[Comparison of Costs and Revenues in Conservative and Invasive Treatment in Cardiology: a Contribution Margin Analysis]. / Vergleich der Kosten- und Erlössituation invasiver und konservativer kardiologischer Behandlungsfälle: Modell einer Deckungsbeitragsrechnung.

Aim of the study: Direct costing is a specialized form of cost analysis well suited for medical areas with DRG-orientated flat rate payments. By comparing case-related variable costs and payments, it is possible to compare the economic benefits of different medical treatments. This aim was pursued by developing a direct costing concept and by its application to invasively and non-invasively treated cardiac patients. Methods: The entire database comprised 7 330 cases of a tertiary cardiac center between 2007 and 2011. It was derived from databases of the hospital information system, the materials management department and the catheter laboratory. On the revenue side, DRG payments were included. Costs related to heart catheterization such as material, personnel and maintenance expenses were considered to be variable costs. Contribution margins and relative contribution margins were calculated by introducing the length of hospital stay as a time reference. Results: During the observation period, caseload and annual revenues increased by about 20 percent. Contribution margins were higher in invasively than in non-invasively treated patients (2 097±1 590 vs. 1 614±1 105 €; p<0,001). However, the relative relation of both patient groups was not altered during the observation period. A remarkable shortening of the duration of catheter laboratory examinations was observed between 2007 and 2011 (46,2±39,1 auf 36,7±33,5 min; p<0,001). In the same period, relative contribution margins increased from 461±306 to 530±335 € (p<0,001). Conclusions: Within existing supply structures, direct costing is a useful tool for economic comparison of different treatment services. Furthermore, temporal constraints of an economic bottleneck can be easily monitored and tackled with the help of time management tools.

Left ventricular mass and oxygen uptake in top handball athletes.

The key challenge in athlete's screening is the distinction between abnormal and normal which is hindered by the fact that the adaptation to sports activity in endurance athletes is different to that in power athletes. Especially cardiomyopathies provoke changes in ECG and echocardiography (echo) at an early stage when clinical symptoms are absent. ECG and echo data and their relationship to fitness peculiar to top handball players have never been described. We studied 291 male first league handball players (32 Olympians/47 national players) (25.3±4.4 years). Check up consisted of ECG, spiroergometry and echocardiography. None had T-wave inversions, 3.1% showed early repolarisation abnormalities in the precordial leads. Sokolow-Lyon voltage criterion for left ventricular hypertrophy was positive in 19.3%. Spiroergometry showed a maximum oxygen uptake (peakVO2) of 50.3±7.7 ml/min/kg body weight. LVmass was increased in comparison to normal values. There was a correlation between peakVO2 and LVindex (p<0.001, r=0.341), (LVmass/peak VO2 p=0.053, r=0.125). A relationship between cardiac dimensions and peakVO2 could not be confirmed. In professional handball players early repolarisation abnormalities were less frequent and LVmass was increased when compared with soccer players. The need for normal values for different types of sports is crucial to guarantee a proper evaluation of athletes.

[Congenital left ventricular aneurysm in a 17-year-old competitive athlete]. / Angeborenes linksventrikuläres Aneurysma bei einem 17-jährigen Leistungssportler.

We present the case of a 17-year-old competitive athlete with an asymptomatic left ventricular aneurysm (LVA). Echocardiography demonstrated hypoplasia of the septum and a large apical LVA. Magnetic resonance imaging (MRI) detected a very thin and fibrotic wall of the LVA. Due to the potential risk of rupture the LVA was surgically resected and the apex of the left ventricle was covered with a patch plasty. The patient had an event-free postoperative course. Because of the potential risk of arrhythmia, the patient was recommended not to participate further in competitive sport.

[Echocardiographic tissue Doppler imaging analysis of the systolic and early diastolic velocities of the mitral annulus motion in hypertrophic cardiomyopathy and in top-level athletes]. / Echokardiografische Gewebedoppleranalyse der Mitralringgeschwindigkeiten bei Patienten mit hypertropher Kardiomyopathie und bei Hochleistungssportlern.

BACKGROUND AND OBJECTIVE: Echocardiographic Tissue Doppler Imaging (TDI) has been proposed for the differentiation of pathological left ventricular hypertrophy (e. g. hypertrophic cardiomyopathy, HCM) and physiologic left ventricular hypertrophy (athlete's heart). The aim of this study was the TDI analysis of the systolic (S') and early diastolic (E') velocities in patients (pts.) with non-obstructive hypertrophic cardiomyopathy (HCM) and in top-level athletes in consideration of the previously published cut-off values (S' < 9 cm/s, E' < 9 cm/s). PATIENTS AND METHODS: Pulsed-wave TDI of the systolic and early-diastolic velocities was performed at the lateral and septal mitral annulus in the four-chamber view in 17 HCM pts (12 men; mean age 44 ± 16 years) and 80 consecutive athletes (80 men; mean age 26 ± 5 years). RESULTS: Pts with HCM showed significantly decreased systolic velocities of the septal (S' septal: 5.1 ± 1.2 cm/s versus 9.5 ± 1.5 cm/s, p < 0.001) and lateral mitral annulus (S' lateral: 6.4 ± 2.0 cm/s vs. 10.5 ± 2.1 cm/s, p < 0.001). The early diastolic velocity of the mitral annulus E' was significantly decreased in HCM, too (E' septal: 5.9 ± 2.2 cm/s vs. 13.1 ± 2.9 cm/s, p < 0.001; E' lateral: 8.2 ± 3.0 cm/s vs. 16.5 ± 3.4 cm/s, p < 0.001). CONCLUSION: Tissue Doppler Imaging of the systolic and early diastolic velocity of the mitral annulus might be helpful as a promising additional method for the echocardiographic differentiation between pathological and physiologic left ventricular hypertrophy.

Mitral valve disease as well as uncommon extensive epipericardial and intramyocardial calcification secondary to massive mitral annular calcification.

A 71-year-old woman with a history of childhood pulmonary tuberculosis was admitted to our hospital for exertional dyspnoea (NYHA functional class II). Transthoracic and transoesophageal echocardiography demonstrated moderate to severe mixed mitral valve disease due to massive mitral annular calcification (MAC) and extensive infiltrative calcification of the atrioventricular groove. In addition, a very uncommon intramyocardial calcification of the ventricular septum and the lateral free wall was diagnosed. This case demonstrates a rare combination of mitral valve disease secondary to MAC, and a small hypertrophied left ventricle, as well as epipericardial and myocardial calcification likely due either to the massive MAC with myocardial extension or to former tuberculous perimyocarditis. The multidimensional imaging approach, which has been used in this particularly case, provided an excellent visualization and clinical evaluation of this rare finding.

Papillary fibroelastoma prolapsing into the left ventricular outflow tract: diagnosis using three-dimensional TEE.

A 72-year-old woman was admitted to our hospital with exertional dyspnea and atrial tachycardia due to atypical atrial flutter. Comprehensive three-dimensional transesophageal echocardiography (3D-TEE) with offline reconstruction of the dataset (Siemens Foursight TEE, Erlangen, Germany) allowed visualization of the origin of the tumor and gave important additional information about the tumor: the tumor surface was floppy, it had the appearance of a "sea anemone", and it was attached to the endocardium of the head of the papillary muscle by a short stalk. The tumor was assessed to be 1.9 × 1.4 × 0.9 cm, and a prolapsing of the tumor into the left ventricular outflow tract during systole was demonstrated.A tumor size of 8 × 10 mm and an infiltration of the head of the anterior papillary muscle were found during surgery. The histopathological findings were typical for a papillary fibroelastoma (PFE) with involvement of the head of the papillary muscle.Our case indicates that a PFE might be difficult to distinguish from myxoma by echocardiography. Thus, the multimodal imaging approach and the three-dimensional visualization of the surface, the localization, and the attachment of the tumor to the head of a papillary muscle were very helpful for the identification of a fibroelastoma in this particular case.

Echo-guided percutaneous coil embolization of a symptomatic massive metastasis of a renal cell carcinoma in the right ventricular outflow tract.

We present the case of a 41-year-old woman who was admitted to our centre with progressive symptoms of congestive heart failure (NYHA class III) 5 years after a radical nephrectomy for renal cell carcinoma. Magnetic resonance imaging demonstrated a 5 x 3 cm homogeneous intracardial mass causing right ventricular outflow tract obstruction, not accessible to surgical resection. Serial echo-guided, percutaneous coil embolization of the cardial metastasis was performed with Contour SE Microparticles (150-250 or 300-500 microm) after identification of the target region of the metastasis by contrast injection (Levovist) through the balloon catheter into the coronary artery under transoesophageal echocardiographic control prior to induction of the necrosis, corresponding to the technique which has been described for septal ablation in hypertrophic obstructive cardiomyopathy. Follow-up after serial embolization showed a good haemodynamic and a marked clinical response (dyspnoea NYHA I-II) which lasted during the 19 month of survival after the index procedure.

Prolapsing left atrial myxoma: preoperative diagnosis using a multimodal imaging approach with magnetic resonance imaging and real-time three-dimensional echocardiography.

Real-time three-dimensional echocardiography (RT3DE) is a new promising technique for the evaluation of intracardiac masses. We present the diagnostic work-up using a multimodal-imaging approach in a 74-year-old patient with a prolapsing tumour in the left atrium suggestive of a myxoma, causing severe congestive heart failure attributable to dynamic left ventricular inflow obstruction, and mimicking severe mitral valve stenosis. Real-time three-dimensional echocardiography allowed to accurately image the entire volume of the myxoma, and to analyse the dynamic left ventricular inflow obstruction. The size of the lobulated mass as assessed by RT3DE was 65 x 25 x 22 mm. The mass was surgically removed, histology was diagnostic for myxoma, and the patient had an uneventful recovery. Real-time three-dimensional echocardiography images the entire volume of a mass allowing for accurate measurements in multiple planes, and allowing for real-time evaluation of obstructive effects on ventricular in- or outflow. This case shows how RT3DE and other non-invasive imaging modalities may be used as complementary techniques for evaluation of intracardiac masses.

The in-vivo identification of the MoFe protein (FeMo cofactor) of nitrogenase in Klebsiella pneumoniae and of the Mo-storage protein in Azotobacter vinelandii via the nuclear quadrupole interaction of 99Mo(beta-)99Tc.

The expression of the MoFe protein of nitrogenase in Klebsiella pneumoniae was identified in vivo via the nuclear quadrupole interaction (NQI) of 99Mo(beta-)99Tc using perturbed angular correlations of gamma-rays. The NQI parameters were: omega approx. 360 Mrad/s and eta approx. 1. In addition, the NQI of the 'Mo-storage protein' in Azotobacter vinelandii cells which had been grown in the presence of NH4+ (13 mM), i.e. under conditions of strict repression of nitrogenase synthesis, was determined: omega approx. 190 Mrad/s, eta approx. 0.25. Under these conditions, the characteristic signal of the MoFe protein (FeMo cofactor) was absent.

Ineffectiveness of nickel in augmenting the hepatotoxicity in protein deficient rats.

This study was designed to determine the toxic effects of nickel sulfate on the biochemical and elemental profile of liver in protein deficient rats. Nickel sulfate in the dose of 800mg/l in drinking water was administrated to Sprauge Dawley (S.D) normal control as well as protein deficient rats for a total duration of eight weeks. The effects of nickel treatment and protein deficiency when given separately and in combination were studied on rat liver marker enzymes like Alkaline phosphatase (ALP),Glutamate oxaloacetate transaminase (GOT), Glutamate pyruvate transaminase (GPT) and also on the status of essential elements in rat liver. Protein deficient, Ni treated as well as combined protein deficient and nickel treated rats showed significant reductions in the body weight and hepatic protein contents as compared to normal control rats. Hepatic alkaline phosphatase activity and alanine aminotransferase showed a significant elevation in rats subjected to protein deficiency, nickel treatment and combined protein deficiency and nickel treatment. As regards to hepatic levels of aspartate aminotransferase a significant elevation was observed in protein deficient and nickel treated protein deficient animals. Nickel administration to normal and protein deficient rats has resulted in a significant increase in concentrations of nickel, phosphorus and sulfur in liver tissue. The concentration of zinc and copper in liver tissue decreased significantly in protein deficient, nickel treated and nickel treated protein deficient animals. Tissue iron concentrations were found to be decreased in protein deficient animals, but the concentrations of iron got elevated significantly in nickel treated and nickel treated protein deficient animals. It has been observed that selenium got decreased significantly in protein deficient, nickel treated and nickel treated protein deficient animals when compared to normal animals. The elevation of selenium in nickel treated protein deficient animals was also significantly higher when compared to protein deficient animals.

Role of zinc in regulating the levels of hepatic elements following nickel toxicity in rats.

This study was designed to determine the protective effects of zinc on the hepatotoxicity induced by nickel in rats. Female Sprague-Dawley (SD) rats received either nickel sulfate alone in the dose of 800 mg/L nickel in drinking water, zinc sulfate alone in the dose of 227 mg/L zinc in drinking water, and nickel plus zinc or drinking water alone for a total duration of 8 wk. The effects of different treatments were studied on activities of rat liver marker enzymes like alkaline phosphatase (ALP), alanine aminotransferase (ALT), and aspartate aminotransferases (AST) and on the status of essential elements in rat liver. The study revealed a significant increase in the activities of enzymes ALP and ALT in rats subjected to nickel treatment. Interestingly, zinc supplementation to rats treated with nickel brought back the raised activities of these enzymes to within normal limits. Further, the levels of elements in liver that include zinc, copper, selenium, and potassium were found to be significantly suppressed following nickel treatment, whereas the levels of iron and sulfur were elevated. However, zinc treatment alone did not cause any appreciable change in the concentration of these elements. To the contrary, when zinc was given to nickel-treated rats, the concentrations of zinc, copper, potassium, and phosphorus were not significantly different from that of normal controls, whereas the levels of iron, selenium, and sulfur were improved in comparison to nickel-treated rats but were not within the normal limits. The present study concludes that zinc has the ability to maintain the levels of hepatic elements and has bearing in regulating the liver functions by maintaining the activities of marker enzymes in conditions of nickel toxicity.

Cell analysis with the new Leipzig high-energy ion nanoprobe.

The high-energy ion nanoprobe LIPSION at the University of Leipzig has been in operation since 1998. The ultrastable, 3.5 MV SINLETRON accelerator supplies the H+ or He+ ion beam. A magnetic scanning system moves the focused beam across the sample. At present, a resolution of 41 +/- 4 nm in the low current mode and 300 nm at 5 pA can be achieved. The experimental chamber is equipped with electron-, energy dispersive X-ray-, and particle detectors. They can be used simultaneously to analyse the sample by means of PIXE (particle induced X-ray emission), RBS (Rutherford backscattering), and in the case of thin sections or monolayer samples STIM (scanning transmission ion microscopy). A goniometer allows the application of channeling measurements in single crystals in combination with these methods. In contrast to previous publication describing microbeam facility at LIPSION, the current biomedical research has concentrated on microscopy and tomography on chondrocytes in pig cartilages and fixed single endothelial cells (HUVEC). For the irradiation of single living cells, an external beam facility with irradiation platform, fast beamgate and mini-Petri dishes is under construction.

[Bowel perforation because of ingestion of a blister-wrapped tablet after post-interventional coronary perforation]. / Dünndarm-Perforation durch einen verschluckten Tabletten-Blister nach postinterventioneller Koronarperforation.

HISTORY AND ADMISSION FINDINGS: A 70-year-old woman was admitted to hospital with progressive chest pain. Coronary angiography demonstrated a significant stenosis of the left descending artery (LAD), which was treated by percutaneous coronary intervention (PCI) and stent implantation. During this intervention, a coronary perforation occurred which was remedied immediately. Five days after the intervention, the patient complained about severe atypical chest and abdominal pain with nausea and vomitting, but no fever. Physical examination revealed an acute abdomen of uncertain origin. INVESTIGATIONS: Laboratory tests revealed leukocytosis and elevated levels of C-reactive protein while cardiac enzymes were in normal range. The electrocardiogram showed no signs of acute myocardial ischemia. Abdominal x-ray was performed without any pathological findings. Further diagnostic tests, especially computed tomography of the abdomen, revealed an ingestion of a blister-wrapped tablet which had caused small bowel perforation and peritonitis. DIAGNOSIS, TREATMENT AND COURSE: An acute abdomen due to ingestion of a foreign body was diagnosed and an emergency laparotomy was performed immediately. The blister pack was removed by ileostomy. The further course was uneventful. CONCLUSION: The clinical presentation of abdominal pain is a frequent medical condition in hospital. Determining the cause requires precise assessment and examination and implicates a variety of differential diagnosis including non-cardiac and cardiac pain. Iatrogenic causes must be considered in differential diagnosis.

Two-dimensional strain analysis of the global and regional myocardial function for the differentiation of pathologic and physiologic left ventricular hypertrophy: a study in athletes and in patients with hypertrophic cardiomyopathy.

Two-dimensional strain (2DS) is a novel method to measure strain from standard two-dimensional echocardiographic images by speckle tracking, which is less angle dependent and more reproducible than conventional Doppler-derived strain. The objective of our study was to characterize global and regional function abnormalities using 2DS and strain rate analysis in patients (pts) with pathological left ventricular hypertrophy (LVH) caused by non-obstructive hypertrophic cardiomyopathy (HCM), in top level athletes, and in healthy controls. The hypothetical question was, if 2DS might be useful as additional tool in differentiating between pathologic and physiologic hypertrophy in top-level athletes. We consecutively studied 53 subjects, 15 pts with hypertrophic cardiomyopathy (HCM), 20 competitive top-level athletes, and a control group of 18 sedentary normal subjects by standard echocardiography according to ASE guidelines. Global longitudinal strain (GLS) and regional peak systolic strain (PSS) was assessed by 2DS in the apical four-chamber-view using a dedicated software. All components of strain were significantly reduced in pts with HCM (GLS: -8.1 ± 3.8%; P < 0.001) when compared with athletes (-15.2 ± 3.6%) and control subjects (-16.0 ± 2.8%). In general, there was no significant difference between the strain values of the athletes and the control group, but in some of the segments, the strain values of the control group were significantly higher than those in the athletes. A cut-off value of GLS less than -10% for the diagnosis of pathologic hypertrophy (HCM) resulted in a sensitivity of 80.0% and a specificity of 95.0%. The combination of TDI (averaged S', E') and 2DS (GLS) cut-off values for the detection of pathologic LVH in HCM demonstrated a sensitivity of 100%, and a specificity of 95%. Two-dimensional strain is a new simple and rapid method to measure GLS and PSS as components of systolic strain. This technique could offer a unique approach to quantify global as well as regional systolic dysfunction, and might be used as new additional tool for the differentiation between physiologic and pathologic LVH.

Assessment of myocardial scarring by contrast enhanced magnetic resonance imaging in a patient 11 years after percutaneous transluminal septal myocardial ablation in hypertrophic obstructive cardiomyopathy.

We report on a 60 year-old male who was one of the first patients who underwent percutaneous transluminal septal myocardial ablation (PTSMA) in our institution in 1996. Contrast enhanced cardiac magnetic resonance imaging (MRI) 11 years after the PTSMA demonstrated extensive scarring, in septal and inferior segments of the left ventricle, and an excellent functional result. It has been previously demonstrated that contrast-enhanced MRI allows detailed evaluation of size and location of septal myocardial infarction induced by PTSMA, and that infarction size detected by MRI correlates well with clinical indexes of infarct size. Our case report underlines the importance of ongoing specialized care and reassessment of patients after PTSMA including continuous clinical risk assessment.