C52-03 Hemopericardium on Apixaban Resolved Post-CPR: An Unusual Case of Pericardial Rupture

Introduction Cardiac tamponade is a life-threatening condition requiring immediate diagnosis and intervention, typically stemming from impaired diastolic ventricular filling due to causes like PCI, malignancies, or inflammation. We present a rare case of cardiac tamponade in a patient on apixaban that resolved following chest compression during cardiopulmonary resuscitation (CPR). Case Presentation A 67-year-old female with hypertension and atrial fibrillation (on apixaban) presented with bradycardia and a large pericardial effusion suggesting impending cardiac tamponade. Shortly after arrival, the patient developed cardiac arrest, and CPR was initiated. Initial transthoracic echocardiogram (TTE) confirmed tamponade. As the patient was on apixaban, hemorrhagic effusion was suspected, and andexanet alfa was started. Before emergent pericardiocentesis could be performed, the patient lost pulse, and CPR resumed. Upon achieving ROSC, a repeat TTE showed no pericardial effusion, though left and right ventricular contractility remained limited. It was presumed that pericardial rupture occurred during CPR, leading to the loss of contained blood into the mediastinum. The initial X-ray showed an enlarged cardiac silhouette, while a repeat X-ray showed a decreased cardiac silhouette with a right-sided opacity, secondary to bleeding into pleural space. Discussion Apixaban, a Factor Xa inhibitor, is associated with bleeding risk. Hemorrhagic pericardial effusion causing tamponade is life-threatening, and its association with apixaban is rarely documented. Tamponade physiology limits diastolic filling. Crucially, CPR-related trauma can cause pericardial rupture, which has been previously reported in only two cases to lead to the resolution of pericardial tamponade. Conclusion This case highlights apixaban-related hemorrhagic pericardial tamponade that unexpectedly resolved after chest compressions during CPR, likely due to pericardial rupture. This demonstrates CPR’s potential to alter management. Clinicians must remain aware of bleeding risks with DOACs and the need for rapid diagnosis and emergent intervention. Further studies on CPR-related injuries are recommended.