Rivaroxaban

Abstract

Haemopericardium and cardiac tamponade: case report An 84-year-old man developed haemopericardium and cardiac tamponade following treatment with rivaroxaban for paroxysmal atrial fibrillation [dosage not stated]. The man, who had various co-moridities including paroxysmal atrial fibrillation, had been receiving oral rivaroxaban. He presented with chest pain. Diagnostic evaluations were unremarkable. He was discharged. He had paused rivaroxaban 72 hours previously as he had undergone gastrointestinal endoscopy. The endoscopy revealed non-obstructive schatzki’s ring, mild diverticulosis, three small polyps in ascending colon, which were resected with follow-up pathology showing tubular adenoma. On the following day (current presentation), he presented with generalised malaise, lightheadedness and dizziness. He did not receive any other medications. On admission to the emergency department, he was tachycardic and hypotensive. Examination revealed he was intermittently drowsy, in addition to jugular venous distension, distant heart sounds, prolonged capillary refill and cool extremities. On admission, platelet counts were normal. Troponin was not elevated significantly. An ECG showed atrial fibrillation with a rate of 87 and T-wave inversions in the inferolateral leads without associated electrical alternans. Chest X-ray demonstrated a right pleural effusion with an enlarged cardiac silhouette increased in size from a previous X-ray. The man was transferred to the ICU following inadequate response to isotonic crystalloid and started receiving multiple vasopressors. Laboratory workup showed elevation in lactate, creatinine, AST, ALT and INR. An echocardiogram showed a large global pericardial effusion with a maximal depth of 30mm with the respiratory collapse of the right ventricle consistent with cardiac tamponade physiology. Due to hypoxia and haemodynamic instability, he underwent immediate INR reversal with prothrombin complex concentrate and then urgent pericardiocentesis via subxiphoid approach, in addition to non-invasive positive pressure ventilation, it showed grossly bloody fluid of 1.5L. The pericardial drain was inserted for the prevention of fluid accumulation. INR level was still elevated. An echocardiogram showed resolution of tamponade physiology, in addition to reduced ejection fraction and severe mitral regurgitation. A significant improvement was observed, and he was discharged without anticoagulation. One month later, cytology of pericardial fluid did not show evidence of malignant cells. Bone marrow biopsy showed no overt dysplasia, only normal cellularity with trilineage haematopoiesis. Four months later, follow-up CT scan did not show the progression of lymphadenopathy or ascending aorta dilation.