Andrew A. Ziskind

Percutaneous balloon pericardiotomy for the treatment of cardiac tamponade and large pericardial effusions: description of technique and report of the first 50 cases.

OBJECTIVES This study describes the technique, clinical characteristics and results of the first 50 patients undergoing percutaneous balloon pericardiotomy as part of a multicenter registry. BACKGROUND Percutaneous balloon pericardiotomy involves the use of a percutaneous balloon dilating catheter to create a nonsurgical pericardial window. METHODS Patients eligible for percutaneous balloon pericardiotomy had either cardiac tamponade (n = 36) or a moderate to large pericardial effusion (n = 14). In addition to clinical follow-up, serial echocardiograms and chest X-ray films were obtained. RESULTS The procedure was considered successful in 46 patients after a mean follow-up period of 3.6 +/- 3.3 months. Two patients required an early operation, one for bleeding from a pericardial vessel and one for persistent pericardial catheter drainage. Two patients required a late operation for recurrent tamponade. Minor complications of the procedure included fever in 6 of the first 37 patients (studied before the prophylactic use of antibiotic agents), thoracentesis or chest tube placement in 8 and a small spontaneously resolving pneumothorax in 2. Despite the short-term success of this procedure, the long-term prognosis of the 44 patients with malignant pericardial disease remained poor (mean survival time 3.3 +/- 3.1 months). CONCLUSIONS Percutaneous balloon pericardiotomy is successful in helping to manage large pericardial effusions, particularly in patients with a malignant condition. It may become the preferred treatment to avoid a more invasive procedure for patients with pericardial effusion and a limited life expectancy.

Ionic contrast agent-mediated endothelial injury causes increased platelet deposition to vascular surfaces☆☆☆

Contrast agent-mediated endothelial injury may be clinically relevant to the development of acute thrombosis after coronary interventions. We sought to investigate the extent to which contrast agents increase platelet deposition by measuring deposition of indium-111 radiolabeled platelets in an isolated perfused rabbit carotid artery model. Carotid artery segments were perfused at physiologic temperature, pressure, and shear. Vessels were subjected to angioplasty or no angioplasty before exposure to either buffer, diatrizoate (high osmolal/ionic), ioxaglate (low osmolal/ionic), or ioversol (low osmolal/nonionic). Subsequent deposition of indium-111 radiolabeled platelets was quantified. In vessels without balloon angioplasty, platelet deposition (platelets/cm2) was 110,000 +/- 95,000 for buffer perfused vessels, 280,000 +/- 210,000 for vessels perfused with diatrizoate, 290,000 +/- 160,000 for vessels perfused with ioxaglate, and 130,000 +/- 98,000 for vessels perfused with ioversol. After balloon angioplasty, platelet deposition was 1,300,000 +/- 590,000 for buffer controls, 1,800,000 +/- 320,000 for diatrizoate-perfused vessels, 1,500,000 +/- 450,000 for ioxaglate-perfused vessels, and 1,000,000 +/- 180,000 for ioversol-perfused vessels. In vessels without balloon angioplasty, diatrizoate and ioxaglate increased platelet deposition 2.5-fold and 2.6-fold, respectively, relative to buffer-perfused vessels (p < 0.05 and p < 0.01), whereas no increase was seen with ioversol. After balloon angioplasty, diatrizoate increased platelet deposition 1.4-fold over control (p < 0.05), whereas ioxaglate and ioversol showed no statistically significant increase. We conclude that ionic contrast media may cause more endothelial injury and associated localized platelet deposition than nonionic contrast media. These findings may be relevant to coronary interventions, specifically with regard to acute closure and chronic restenosis.

Percutaneous pericardial biopsy as an adjunctive technique for the diagnosis of pericardial disease

Abstract In summary, we believe that a complementary strategy of pericardial fluid analysis with percutaneous pericardial biopsy can improve the early diagnosis of effusive pericardial disease while avoiding the morbidity of a surgical approach. A direct comparison of the yield from percutaneous and surgical pericardial biopsies is yet to be done. A reasonable diagnostic approach may be to perform percutaneous pericardial biopsy first, then proceed with a surgical biopsy if it is negative. For selected patients, particularly those without a history of malignancy, it can provide additional diagnostic information not obtained by cytologic analysis of pericardial fluid.

Successful use of education and cost-based feedback strategies to reduce physician utilization of low-osmolality contrast agents in the cardiac catheterization laboratory

Abstract For the more than 1 million cardiac catheterizations performed in the United States annually, the cost of iodinated contrast agents is an important and potentially adjustable factor in overall cost. Low-osmolality contrast agents decrease the incidence of adverse effects, but are 15 to 20 times more expensive. Most adverse reactions to high-osmolality contrast agents are minor and generally do not prolong hospital stay or result in permanent injury. 1–4 A cost-effective solution would be to reserve low-osmolality agents for high-risk patients who are at greatest risk for contrast-related complications. 5–11 Implementation of strategies to promote cost-effective use of resources is often hampered by the difficulty of modifying physician behavior. Most studies looking at methods to alter physician-ordering behavior have been directed at the overuse of laboratory and radiographic tests. Educational strategies alone have a variable effect on test-ordering patterns of physicians. 12–14 Approaches in which physicians are given individual cost feedback information on practice patterns lead to a more consistent reduction in test utilization. 15,16 In this report, we examine the impact of education and cost feedback strategies to modify physician use of low-osmolality contrast agents for cardiac diagnostic and interventional catheterization procedures.

Survey of practicing cardiologists in Maryland on their choice of thrombolytic therapy for acute myocardial infarction.

In November 1990, we surveyed 160 practicing community cardiologists in the state of Maryland and 20 academic cardiologists at the University of Maryland Medical Center to determine each individuals preference for aggressive versus nonaggressive therapy for various presentations of acute myocardial infarction. The survey was repeated in April 1991 following a report of the results of the Third International Study of Infarct Survival. All 100 responding cardiologists chose aggressive therapy to manage an early (less than 2 hours) acute anterior myocardial infarction in a 50-year-old patient. However, less aggressive therapy was chosen by many community cardiologists for management of early inferior acute myocardial infarction or for elderly patients. Most community cardiologists chose tissue plasminogen activator as their thrombolytic drug of choice, whereas university cardiologists favored streptokinase. Although there were substantial shifts in choice of thrombolytic agent on the repeat survey, most community physicians still chose tissue plasminogen activator over the less expensive streptokinase.

759–6 Computerization of the ACC/AHA Guidelines for PTCA and CABG - Use of a Relational Database for Comparison with RAND Expert Panel Ratings and University of Maryland Revascularization Appropriateness Scores (RAS)

With the increased emphasis on determining the need for coronary revascularization, appropriateness scoring systems have been developed. We developed software to apply clinically the complex ACC/AHA Guidelines for PTCA (1993) and CABG (1991). Using 40 on an Apple Macintosh, we designed a relational patient database which captures key clinical information: patient demographics, clinical presentation, medications, comorbidity, exercise test results, left ventricular function, angiographic data, and followup events. Compiled code automatically assigns the patient to the proper clinical subsection, interprets relevant coronary anatomy and calculates the appropriateness classification – Class I (general agreement with indication), Class II (divergence of opinion), and Class III (general agreementthat procedure is not indicated). In addition to providing objective appropriateness scores using the ACC/AHA PTCA and CABG Guidelines, the system automatically compares those scores with RAND Expert Panel Ratings and the University of Maryland RAS. Reports can be produced based on specified search criteria for an individual patient or an entire patient group, thus allowing analysis of patterns of care. The system can also be accessed remotely via modem to permit its use as a revascularization “consultant”. Conclusion This program automatically and objectively determines ACC/AHA, RAND and RAS revascularization appropriateness ratings. It is a useful tool for evaluating appropriateness of PTCA or CABG in individual patients as well as for analyzing patterns of care.

791-4 Prospective Assessment of Revascularization Appropriateness Scoring Systems: A Comparison of RAND Expert Panel Ratings, ACC/AHA Guidelines, and the University of Maryland Revascularization Appropriateness Score

Although different scoring systems have been used to evaluate the appropriateness of PTCA and CABG, they have not been directly compared. For 100 patients referred to the catheterization laboratory, we prospectively compared the RAND Expert Panel Ratings, ACC/AHA Guidelines and the University of Maryland Revascularization Appropriateness Score (RAS). The patient population included stable angina (25%), unstable angina (33%). post-MI (27%), acute MI (7%). asymptomatic with + ETT or pre-op (7%). and sudden death (1%). Pts were treated with PTCA(62%). CABG (19%), or medical therapy(19%). There were significant differences among the 3 systems for PTCA and CABG appropriateness. ACC/AHA and RAS were more definitive in assigning revascularization scores than RAND which yielded uncertain ratings in 17% for CABG and 38% for PTCA. ACC/AHA differed markedly in the Inappropriate/ Class III rating for both CABG and PTCA. Download high-res image (131KB) Download full-size image Conclusion Marked differences are present among these 3 scoring systems. Factors contributing to these differences should be clarified before they are widely applied 10 patient care.

Radiographic contrast waste in cardiac catheterization laboratories

Abstract With the growing emphasis on cost-conscious delivery of medical care, there is an even greater need to identify ways to reduce costs without compromising patient care. One area of interest in the cardiac catheterization laboratory is limiting the use of expensive lowosmolality contrast agents that cost 15 to 20 times more than conventional high-osmolality agents. Studies that have evaluated the safety and cost-effectiveness of both agents suggest that a reasonable approach would be to limit the use of low-osmolality agents to selected high-risk patients. 1–5 In an effort to identify other potential sources of cost savings, we investigated the inefficiency of contrast use by studying the quantity of radiographic contrast discarded in our laboratory.