Faculty Bibliography

BACKGROUND: Subacute pericardial tamponade can present without signs of cardiogenic shock. Symptoms and signs lack both sensitivity and specificity. METHODS: We conducted a case-control study in consecutive hospitalized patients with moderate-to-large pericardial effusion who had no evidence of hemodynamic compromise upon admission. Patients with pericardial effusion drained for diagnostic and/or therapeutic purposes served as cases, and patients who were not drained served as controls. Demographic, clinical, and laboratory data were obtained by retrospective chart review. Echocardiograms were reviewed by 2 independent observers. Pericardial effusion scoring index was calculated for each patient based on effusion size, echocardiographic assessment of hemodynamics, and clinical factors. RESULTS: A total of 48 patients were included in the study: 27(56%) patients had pericardial effusion drained and 21(44%) had clinical follow-up without drainage. Pericardial effusion drainage was surgical in 60% of the cases with the mean time to drainage of 2.5 days. No significant difference was seen between the groups in terms of clinical hemodynamic parameters such as blood pressure or heart rate upon initial presentation. The mean pericardial effusion scoring index was 6.0 for cases and 3.3 for controls showing a wide separation between the groups (P < 0.01). The area under the curve for receiver operator characteristic was 0.91 (95% confidence interval, 0.82-1.00). CONCLUSIONS: The pericardial effusion scoring index obtained at the initial presentation in patients without immediate hemodynamic compromise showed a high accuracy in identifying patients who required pericardial effusion drainage downstream.

The diagnosis and management of pericardial disease are very challenging for clinicians. The evidence base in this field is relatively scarce compared with other disease entities in cardiology. In this article, we outline a unified, stepwise pathway-based approach for the management of pericardial disease. We used the "CHASER" acronym to define the entry points into the pathway. These include chest pain, hypotension or arrest, shortness of breath, echocardiographic or other imaging finding of pericardial effusion, and right-predominant heart failure. We propose a score for the assessment of pericardial effusion that is composed of the following 3 parameters: the etiology of the effusion, the size of the effusion, and the echocardiographic assessment of hemodynamic parameters. The score is applied to clinically stable patients with pericardial effusion to quantify the necessity of pericardial effusion drainage. A stepwise, pathway-based approach to the management of pericardial disease is intended to provide guidance for clinicians in decision-making and a patient-tailored evidence-based approach to medical and surgical therapy for pericardial disease. The pathway for the management of pericardial disease is the ninth project to be incorporated into the "Advanced Cardiac Admission Program" at Saint Luke's Roosevelt Hospital Center of Columbia University in New York. Further studies should focus on the validation of the feasibility, efficacy, and reliability of this pathway.

We present an adult patient who had an acute myocardial infarction complicated by a ventricular septal defect and had it repaired percutaneously. Real-time three-dimensional echocardiography (RT3D) before and during the closure procedure were performed. RT3D provided anatomical and functional information of the defect as well as real-time guidance during the procedure. This case highlights the utility of three-dimensional echocardiography in guiding transcatheter procedures