CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/effusion-after-laao-teerIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • EchoA new or growing effusion on TEE or ICE during the case, or on the follow up echo 1.
  • MonitorFalling pressure, a rising right atrial pressure and pulsus paradoxus 2.
  • ImageA transseptal needle or sheath outside the fossa or at the appendage tip; contrast in the pericardium 1.
  • PatientChest pain, dyspnea or hypotension hours to days later: late effusions occur after appendage closure 3.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Stop advancing; keep wires and sheaths where they are until the source is clear.
  2. Echo the size and the hemodynamics; call the surgeon and anesthesia.
  3. Fluids and vasopressors while preparing 2.
  4. Drain now if there is any hemodynamic compromise; autotransfusion for brisk bleeding 24.
  5. Reverse heparin with protamine once no large device is in a vulnerable position 1.
  6. If the appendage is the source, completing the device deployment can seal it; decide with the surgeon.
  7. Ongoing bleeding despite drainage and reversal: surgery 12.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

Who to call

The escalation ladder, first call first.

  1. Echo: in the room.
  2. Cardiac surgery: at the event 1.
  3. Anesthesia: already present for TEE cases; tell them now.
  4. Second operator: to drain while you hold position.

The bailout step by step

Drain during a structural case 2

  1. Keep the TEE probe in; subcostal echo or fluoroscopy for the needle path.
  2. Subxiphoid 18 gauge sheathed needle with gentle aspiration 2.
  3. Confirm position with agitated saline or contrast; J wire, sheath, multihole pigtail 2.
  4. Aspirate to dryness; return blood through a venous sheath if bleeding is brisk 4.
  5. Reverse heparin; recheck the effusion on echo after a few minutes without drainage.
  6. Leave the drain until output is under 25 mL a day and echo shows no recurrence 2.

Prevent

  • Know the size of the risk: serious pericardial effusion occurred in 4.8 percent of device patients in the early PROTECT AF trial 6.
  • Imaging guided transseptal puncture in the right location for the procedure 3.
  • Gentle sheath manipulation in the appendage, always over a pigtail or under imaging 3.
  • Echo before the patient leaves the lab and before discharge 3.

After care and documentation

  • Echo the next day and with any symptoms; late effusions occur 3.
  • Document the source, the volume, reversal and drain removal.
  • Report in the LAAO or TVT registry.

Practice

No emergency simulator case for this yet; the structural simulator in the app shows an effusion from the crossing or the sheath through its signs. Browse the case library.

References

  1. Holmes DR Jr, Nishimura R, Fountain R, Turi ZG. Iatrogenic pericardial effusion and tamponade in the percutaneous intracardiac intervention era. JACC Cardiovasc Interv 2009;2:705-717.
  2. Sorajja P. Pericardiocentesis. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 18.
  3. Saw J, Holmes DR, Cavalcante JL, et al. SCAI/HRS expert consensus statement on transcatheter left atrial appendage closure. JSCAI 2023;2:100577.
  4. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 26, Perforation.
  5. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  6. Holmes DR, Reddy VY, Turi ZG, et al. Percutaneous closure of the left atrial appendage versus warfarin therapy for prevention of stroke in patients with atrial fibrillation: a randomised non-inferiority trial. Lancet 2009;374:534-542.

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/effusion-after-laao-teer. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.