"BLEEDING MY HEART OUT": WARFARIN-RELATED HEMOPERICARDIUM REQUIRING REPEAT PERICARDIAL WINDOW

TOPIC: Cardiothoracic Surgery TYPE: Medical Student/Resident Case Reports INTRODUCTION: Warfarin–induced hemopericardium is rare outside cardiac surgery and can occur due to excessive anticoagulation and/or uremia from anticoagulant–related nephropathy (ACRN). We present a severe case of recurrent warfarin–related complicated by arrest requiring repeat pericardial window. CASE PRESENTATION: A 71-year-old male with history atrial flutter recently started on warfarin presented the emergency department shortness breath oliguria. Initial labs showed BUN 82 mg/dL, creatinine 5.7 potassium 6.1 mEq/L, arterial blood gas pH 7.23, PCO2 29.3 mmHg, bicarbonate 13 nmol/L. INR was greater than 10. Chest x-ray (CXR) revealed an enlarged silhouette. He received hyperkalemia stabilizing therapies given concern for warfarin-related (WRN), he reversal intravenous (IV) vitamin K prothrombin complex concentrate (PCC) prior initiation emergent hemodialysis. Transthoracic echocardiogram (TTE) large circumferential effusion preserved ventricular systolic function. Given size impending hemodynamic instability, patient underwent window TTE showing resolution effusion. maintained hemodialysis his high stroke risk, decision made continue close monitoring outpatient. re-presented 3 months later dyspnea, hypotension 90s/50s 10 CXR Stat identified right diastolic collapse so taken after addressing supratherapeutic PCC, IV DDAVP. Peri-operatively, lost pulses cardiopulmonary resuscitation massage initiated. Following drainage 800 cc bloody fluid, spontaneous circulation returned hemodynamics improved. No malignancy or infection reported fluid analysis. Due significant bleeding further discontinued monitored in intensive care unit 2 weeks before discharge. DISCUSSION: Although cases have incidence associated anticoagulation, none describe initial nor hemopericardium–induced tamponade. This unique that WRN, elevated renal failure without other identifiable cause, lead which contributed diathesis. CONCLUSIONS: highlights life-threatening risks, such as causing tamponade arrest, especially setting WRN REFERENCE #1: Langdon, S.E., Seery, K. & Kulik, A. Contemporary outcomes surgery: impact operative technique. J Cardiothorac Surg 11, 73 (2016). https://doi.org/10.1186/s13019-016-0466-3 #2: Al-Jundi W, Rubin N. Cardiac secondary haemopericardium warfarin. BMJ Rep. 2010;2010:bcr01.2010.2606. doi: 10.1136/bcr.01.2010.2606. Epub 2010 Apr 9. PMID: 22485118; PMCID: PMC3047169. #3: Golla A, Goli R, Nagalla VK, Kiran BV, Raju DSB, Uppin MS. Warfarin-related Nephropathy. Indian Nephrol. 2018 Sep-Oct;28(5):378-381. 10.4103/ijn.IJN_3_17. 30271000; PMC6146722. DISCLOSURES: relevant relationships Uday Gulati, source=Web Response Prateek Juneja, Anshul Kumar, Ananya Nanduri,