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After treating cardiac tamponade arising from atrial fibrillation (Afib) catheter ablation, pericardial drains do not need to be kept in place for an additional 12 to 24 hours, researchers suggested.

Not one of the Afib patients who had the drains taken out early -- in the cath lab -- needed repeat pericardiocentesis before hospital discharge, , of John Radcliffe Hospital in Oxford, England, and colleagues reported online in .

This group also had a moderately shorter length of stay than their peers who had drain removal delayed in case of re-bleeding (3 versus 4 days, standardized difference -0.48). What's more, much fewer patients with early removal needed opiate analgesia (8% versus 72%, standardized difference -1.73).

"Early removal of pericardial drains after tamponade complicating Afib catheter ablation procedures appears to be safe and effective, with re-insertion not required in this cohort. The traditional practice of leaving drains in situ for 12 to 24 hrs may result in more patient discomfort and longer hospitalization," Pedersen's group concluded.

"Additionally, there may be benefits to health economics," they commented.

In cases that employed the early removal strategy, the pericardial space was monitored for reaccumulation for a minimum of 30 minutes (1.5 hours on average) with repeated transthoracic echocardiography. Once it reached dryness, the patient was deemed ready to leave the laboratory and the drain was left to operator discretion for removal.

The delayed group was monitored for an extra 17 hours once no reaccumulation was confirmed.

"We are not aware of any studies or guidelines on the length of monitoring for potential reaccumulation of pericardial bleeding," Pedersen and colleagues wrote, citing the exception of a sole expert consensus statement from 2012 by the Heart Rhythm Society, European Heart Rhythm Association, and the European Cardiac Arrhythmia Society, with the line: "Once the pericardial space has been drained, the patient needs to be monitored for ongoing bleeding with the drainage catheter in place."

While the same cannot be said for those with ongoing bleeding, "it is safe to remove the drain after a 30-minute period without reaccumulation," the authors suggested. "Following drain removal ongoing careful hemodynamic assessment and monitoring is required."

Pedersen and colleagues' study included 25 patients who had pericardial drains removed early and 18 who had a conventional delayed removal following pericardiocentesis for cardiac tamponade complicating Afib catheter ablation. Cardiac tamponade was diagnosed when the pericardial effusion led to hypoperfusion and systolic pressure dropped below 80 mm Hg. Pericardiocentesis was performed under fluoroscopic guidance by a subxiphoid approach.

"The practice of early removal was gradually established between 2008 and 2013, as confidence and experience grew," they wrote.

Baseline characteristics were similar between groups, including mean CHA₂DS₂-VASc score, the proportion of first-time procedures, and the number that had additional procedures tacked onto pulmonary vein isolation.

No deaths occurred in either the early removal or the delayed removal groups.

The early removal group went back on anticoagulation earlier (at day 2 versus day 3, standardized difference -0.75). One patient in the delayed removal group had a major adverse event consisting of prolonged hospital stay due to sepsis and multi-organ failure, whereas no major adverse events occurred in the early pericardial drain removal group (standardized difference -0.34).

Also similar between groups was the likelihood of post-cardiac injury syndrome, with two patients in each group having presented with late pericarditic pain and/or effusion with no evidence of sepsis 2 to 3 weeks after the procedure.

"This was an observational, retrospective, descriptive study in a single centre with multiple operators," the investigators acknowledged. "A randomized prospective study would be more valuable to assess the benefits of early removal of pericardial drains after tamponade during catheter ablation for atrial fibrillation ablation. However, such a study would be protracted and difficult due to low incidence of cardiac tamponade complicating Afib ablation."

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