Non-vitamin K antagonist oral anticoagulants (NOACs) are paused in 166/189 (88%) of the centers before the procedure, while 23/189 (12%) centers perform interventions on uninterrupted NOAC treatment. Among centers that withhold OAC, 28/166 (17%) pause OAC the day before, 41/166 (25%) pause the evening before and 85/166 (51%) pause on the day of the procedure. 8/166 (5%) centers apply other strategies and 4/166 (2%) do not further specify. Post-intervention OAC is started immediately following the procedure in 26/189 (14%) centers, after defined time ranges in 102/189 (54%) centers (Suppl. Figure 2) and the following day in 42/189 (22%). In 19/189 (10%) centers no information on postinterventional anticoagulation was provided.
An overview of imaging and monitoring modalities as well as the type of diagnostic catheters used for transseptal puncture by the EP centers is provided in Suppl. Figure 3. A total of 111/189 (59%) centers use fluoroscopy alone to guide transseptal puncture, while 56/189 (30%) use transesophageal echocardiography guidance, 12/189 (6%) intracardiac echocardiography and 6/189 (3%) use both imaging modalities; another 4/189 (2%) centers report on other imaging modalities for transseptal puncture (e.g., EP navigation/needle potential). Diagnostic catheters used for transseptal puncture are listed in Suppl. Figure 3B. While 115/189 (61%) of the centers perform transseptal puncture under pressure control, 74/189 (39%) do not.
Details on timing of heparin application and the periinterventional target activated clotting time (ACT) are provided in Suppl. Figure 4. Nineteen out of 189 (10%) centers reported weight-adapted application of heparin before transseptal puncture, and 87/189 (46%) centers thereafter. In 78/189 (41%) centers, only a certain amount of the total body weight-adapted heparin dose is administered prior to and the rest after transseptal puncture. 5/189 (2.6%) centers did not provide any information. The majority (71/78, 91%) of centers state that the amount of heparin before the transseptal puncture is ≤ 5000 units (I.U.), while 4/78 (5%) give > 5000 I.U. and 3/78 (4%) did not further specify. Regarding target ACT levels, 14/189 (7%) centers reported ≤ 250 s, 99/189 (52%) ACT levels > 250–300 s and 72/189 (38%) > 300 s during left atrial/ventricular procedures. No information was provided by 4/189 (2%) centers. Only 32/189 (17%) centers perform ACT measurement before, all others following transseptal puncture. Suppl. Figure 4 shows the intervals of the ACT measurements.
Infrastructure and safety
The survey revealed that 61/189 (32%) of the EP centers have on site cardiac surgery, whereas 128/189 (67%) centers have not. All centers without cardiac surgery stated to collaborate with external cardiac surgery institutions.
Suppl. Figure 5A shows in how many centers and in which kind of procedures invasive blood pressure measurement is performed. Centers and types of procedures with non-invasive blood pressure measurements and the corresponding intervals are shown in Suppl. Figure 5B. The majority of EP centers (180/189, 95%) have echocardiography permanently available on site in the EP laboratory.
Echocardiography to rule out pericardial effusion following EP-procedures is routinely performed directly on the EP table in 151/189 (80%) centers as an institutional standard. Pericardial effusion is primarily or repeatedly ruled out in the recovery room and/or on the ward in 31/189 (16%) centers, 74/189 (39%) centers exclude a pericardial effusion the following day. A total of 26/189 (14%) centers perform an echocardiography again at the day of discharge and 3/189 (2%) centers only if clinically indicated (multiple answers possible). A total of 8/189 (4%) centers use different schemes. Suppl. Figure 6A illustrates postprocedural monitoring modalities and durations, if provided by the centers.
Of note, almost all centers (187/189, 98%) have a dedicated pericardiocentesis set prepared for emergencies in the cath lab and half of the centers (93/189, 49%) have regular trainings with the EP team to prepare for emergency intervention in case of cardiac tamponade.
Management of acute pericardial tamponade
Whenever pericardial tamponade occurs, 49/189 (26%) centers immediately contact an institutional resuscitation team. Another 25/189 (13%) centers always inform a cardiac surgeon in case of pericardial tamponade, whereas more than two-thirds of centers (131/189, 69%) do not. 33/189 (17%) centers inform the cardiac surgeon only in specific situations as listed in Suppl. Figure 6A. If not already present, 131/189 (69%) centers place an arterial line for invasive blood pressure measurement in case of pericardial tamponade, 33/189 (17%) do not. In 25/189 (13%) centers, an upgrade to invasive blood pressure management is only performed in certain instances (Fig. 3B).
Fluoroscopy as the primary imaging modality for pericardiocentesis is used in 53/189 (28%) centers, whereas 16/189 (8%) centers use only echocardiography. 117/189 (62%) centers use both, echocardiography and fluoroscopy and another 3/189 (2%) centers do not use any imaging modality for pericardiocentesis. The fluoroscopic projections used by the centers are shown in Suppl. Figure 7.
While 145/189 (77%) centers insert an additional sheath into the pericardium after successful pericardial access is achieved, pigtail catheter insertion is reported by almost all centers (184/189, 97%) and only 5/189 (3%) do not use a pigtail catheter. The sizes of sheaths and pigtail catheters are provided in Suppl. Figure 8.
When cardiac tamponade occurs, protamine is administered on a routine basis in many centers [163/189 (86%)]. A third of the centers [60/163 (37%)] administers protamine immediately when cardiac tamponade is diagnosed, 31/163 (19%) centers after safe access to the pericardium is achieved and 53/163 (33%) once all blood is aspirated from the pericardial space. In 14/163 (9%) centers, individual factors such as persistent bleeding, high ACT levels, or the amount of effusion are applied criteria for administering protamine. Five out of 163 centers (3%) did not give any information. In case of protamine administration, 68/163 (42%) centers antagonize the previously administered heparin in a 1:1 ratio and 54/163 (33%) adapt the dosing according to the last ACT measured. 27/163 (17%) centers apply 5000 I.U. protamine as a standard dosage, 5/163 (3%) 3000 I.U. and 8/163 (5%) centers use other dosages. One center did not further specify.
Overall, only 5% of the centers ever applied a specific NOAC antidote for adjunct treatment of cardiac tamponade. Accordingly, 179/189 (95%) centers have not used any antidote so far. 56/189 (30%) centers routinely administer clotting factors (PPSB, aPPSB, recombinant FVIIa). Almost two-thirds of the centers (122/189, 65%) do not give a NOAC antidote whereas 17/189 (9%) would do so. 50/189 (26%) centers would only use an antidote in certain instances as illustrated in Fig. 4.
With regard to autotransfusion of aspirated blood, 36/189 (19%) centers responded that they reinfuse blood only before protamine administration, while 34/189 (18%) centers also autotransfuse after protamine administration. However, more than half (101/189, 53%) of the centers do not perform autotransfusion. 15/189 (10%) centers report other approaches. Three centers (2%) did not answer. When autotransfusion is performed, 31/70 (44%) do not use a blood filter, 17/70 (24%) use a blood filter, 4/70 (6%) reinfuse blood via a Cellsafer and 18/70 (26%) did not further specify.
Decision for cardiac surgery
Most of the centers [118/189 (62%)] decide for cardiac surgical treatment if the bleeding does not stop after all conventional treatment options within certain periods of time were applied (Fig. 5A). 34/189 (18%) centers decide after a certain amount of blood was aspirated and bleeding continues (Fig. 5B) and 37/189 (20%) centers have a different approach, not further specified.
Subsequent surveillance and monitoring
Once pericardial tamponade is successfully treated, 151/189 (80%) centers monitor their patients on an Intensive Care Unit (ICU), another 26/189 (14%) centers on an Intermediate Care Unit, and 9/189 (5%) might use both the ICU or the Intermediate Care Unit. Only 2/189 (1%) centers monitor patients after cardiac tamponade on regular wards and one single center did not further specify.
Figure 6 shows the time intervals after which the EP centers remove the pigtail catheter from the pericardium. As the figure illustrates, 52/189 (28%) centers use a different strategy to remove the pigtail catheter. In 16/52 (31%) centers, the pigtail catheter is removed the following day, 36/52 (69%) responded to have other criteria for removing of the pigtail catheter, e.g., aspiration volume, echocardiographic control and catheter flow rate.
Two-thirds of the centers (128/189, 68%) stated that they do not routinely apply NSAIDs, colchicine or cortisone after pericardial tamponade. Medication applied by the other centers is provided in Suppl. Figure 9. A total of 87/189 (46%) centers cover their patients with antibiotics in case of pericardial tamponade and remaining pigtail catheter.
A total of 19/189 (10%) centers restart OAC after a certain number of hours, 48/189 (25%) after a certain time range after pericardial bleeding has stopped, and 84/189 (44%) after a certain number of hours following removal of the pigtail catheter. 35/189 (19%) centers chose a different strategy and 3/189 (2%) centers did not further specify (Suppl. Figure 10).
A total of 108/189 (57%) centers routinely schedule an outpatient follow-up visit in patients after cardiac tamponade, while 81/189 (43%) do not. 22/108 (20%) reported that they schedule their patients at day 7 after discharge. More than half (62/108, 57%) of the centers perform FU visits between day 7 and 14 and 13/108 (12%) centers later than 14 days post discharge. Another 4/108 (4%) centers report individualized approaches and 7/108 (6%) did not provide further information.