Pre-procedural high-pitch coronary CT angiography assessment of patients undergoing transcatheter aortic valve implantation (TAVI) without patient-specific adjustment: analysis of diagnostic performance.

AIM: To evaluate the ability to assess the coronary arteries using pre-procedural computed tomography (CT; high-pitch mode) in patients referred for transcatheter aortic valve implantation (TAVI). METHODS AND MATERIALS: CT and invasive coronary angiography (ICA) were performed pre-TAVI in 100 patients (46 women; 79 ± 5.9 years). CT was performed in prospectively ECG-triggered high-pitch mode after intravenous administration of 70 ml iodinated contrast medium. Image quality was assessed using a four-point scale (graded 0-3). Significant coronary artery stenosis (≥50% diameter) was graded as either present or absent by one observer and in one-third of patients by two observers independently. ICA was the standard of reference. Results were reported per segment and per patient. RESULTS: Twenty-two percent of patients had known coronary artery disease (CAD). In two cases, a coronary anomaly was detected. Diagnostic image quality (grade 1-3) was achieved in 30.3% of segments. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 75%, 80.5%, 16%, and 98.5%, respectively. Significant coronary stenosis could be ruled out completely in all segments in three patients. The interrater agreement per patient was excellent (kappa = 1). CONCLUSION: Relevant coronary findings can frequently be observed in high-pitch TAVI-planning CT. Despite the limitations of the technique and in patients referred to pre-TAVI evaluation (rapid heart rate, coronary calcifications, etc.), a valid evaluation of coronary arteries is possible in a considerable proportion of segments with a high NPV; however, few studies were completely free of motion artefacts to dependably exclude CAD using this technique in this challenging group of patients.

High inter- and intra-observer agreement in mapping sequences compared to classical Lake Louise Criteria assessment of myocarditis by inexperienced observers.

AIM: To investigate the observer agreement for the assessment of chronic myocarditis by native T1 and T2 relaxation times, post-contrast T1 relaxation time, and extracellular volume (ECV) fraction, compared to Lake Louise Criteria: oedema ratio (OR) and early gadolinium enhancement ratio (EGEr). MATERIALS AND METHODS: Data were collected retrospectively on 71 consecutive patients who underwent cardiac magnetic resonance imaging as part of a complete diagnostic work-up according to current guidelines for suspected myocarditis. Thirteen cases were excluded due to previous myocardial infarction or technical issues. To test for intra- and interobserver agreement, the determination of the myocardial native T1 and T2 relaxation times, post-contrast T1 relaxation time, ECV, OR and EGEr was undertaken by two medical school graduates after comprehensive training. Bland-Altman analysis and intraclass correlation coefficient (ICC) were assessed. RESULTS: The final analysis included 27 patients with chronic myocarditis, 21 patients with dilated cardiomyopathy and/or hypertensive heart disease, and 10 patients with unremarkable investigations in the control group. Excellent interobserver agreement was obtained for native T1 and T2 relaxation times, post-contrast T1 relaxation time and ECV, with ICC of 0.982/0.977/0.991/0.994, p < 0.001. Interobserver agreement was lower for OR and EGEr, with ICC of 0.841 and 0.818, p < 0.001, respectively. Mapping parameters (cut-off values: T1 1,070 ms, T2 54 ms, ECV 30%) yield good performance in the diagnosis of chronic myocarditis with the best sensitivity/specificity/accuracy of 93%/80%/88% for ECV, followed by 70%/80%/74% for T2, and 52%/88%/69% for T1. CONCLUSIONS: mapping parameters show excellent agreement between observers in the assessment of myocarditis.

Comparison of volumetric and functional parameters in simultaneous cardiac PET/MR: feasibility of volumetric assessment with residual activity from prior PET/CT.

OBJECTIVE: To compare cardiac left ventricular (LV) parameters in simultaneously acquired hybrid fluorine-18-fluorodeoxyglucose ([18F] FDG) positron emission tomography/magnetic resonance imaging (PET/MRI) in patients with residual tracer activity of upstream PET/CT. METHODS: Twenty-nine patients (23 men, age 58±17 years) underwent cardiac PET/MRI either directly after a non-cardiac PET/CT with homogenous cardiac [18F] FDG uptake (n=20) or for viability assessment (n=9). Gated cardiac [18F] FDG PET and cine MR sequences were acquired simultaneously and evaluated blinded to the cross-imaging results. Image quality (IQ), end-diastolic (LVEDV), end-systolic volume (LVESV), ejection fraction (LVEF) and myocardial mass (LVMM) were measured. Pearson correlation and intraclass correlation coefficient (ICC), regression and a Bland-Altman analysis were assessed. RESULTS: Except LVMM, volumetric and functional LV parameters demonstrated high correlations (LVESV: r=0.97, LVEDV: r=0.95, LVEF: r=0.91, LVMM: r=0.87, each p<0.05), but wide limits of agreement (LOA) for LVEDV (-25.3-82.5ml); LVESV (-33.1-72.7ml); LVEF (-18.9-14.8%) and LVMM (-78.2-43.2g). Intra- and interobserver reliability were very high (ICC≥0.95) for all parameters, except for MR-LVEF (ICC=0.87). PET-IQ (0-3) was high (mean: 2.2±0.9) with significant influence on LVMM calculations only. CONCLUSION: In simultaneously acquired cardiac PET/MRI data, LVEDV, LVESV and LVEF show good agreement. However, the agreement seems to be limited if cardiac PET/MRI follows PET/CT and only the residual activity is used. KEY POINTS: • [ 18 F] FDG PET-MRI is feasible with residual [ 18 F] FDG activity in patients with homogenous cardiac uptake. • Cardiac volumes and function assessed by PET/MRI show good agreement. • LVEDV and LVESV are underestimated; PET overestimates LVMM and LVEF. • Cardiac PET and MRI data correlate better when acquired simultaneously than sequentially. • PET and MRI should not assess LV parameters interchangeably.

[Experience in applying legal conditions according to the nursing insurance regulation--ambulatory rehabilitation, nursing aids and nursing care eligibility]. / Erfahrung in der Umsetzung von Vorgaben nach dem Pflegeversicherungsgesetz--ambulante Rehabilitation, Hilfsmittel und Pflegeeinsatz.

UNLABELLED: The Statutory Health Care (Nursing) Insurance in Germany, called "Pflegeversicherung (PVG)", financially supports nursing care at home and in nursing homes. If suggested by an authorized examining person (MDK), it provides access to ambulatory rehabilitation and to various aids to facilitate nursing care of patients cared for at home. Also, the PVG mandatory requires the visit by a nurse every three to six months (nursing care checkup) if the patient is cared for by family members without support of professional nursing services. Little is known about the realisation of the suggestions given by the examining person from MDK and about the realisation of the nursing care checkup in actual practice. Our study tried to find answers to these questions. For this purpose, we visited 150 patients at home and asked them about rehabilitation efforts, whether the recommended additional aids had been supplied, and whether nursing care checkups had been successfully performed. RESULTS: For 41 patients, rehabilitatory exercises were suggested, but only 7 were actually realised. 89 patients were supposed to receive various aids, but only 31 were actually delivered. Whenever rehabilitation was performed, it was nearly without exception thanks to the initiative of relatives supported by their private doctor. Nursing care checkups should have been performed in 80 patients, but had been realised in only 11 cases. The care providing relatives considered such "care checkups" to be ineffective, costly and useless. CONCLUSION: The nonfinancial services granted by the PVG were not translated into reality in most instances, and if so, it was due to efforts of relatives and private doctors, not to efforts of the statutory bodies. Apparently this task was more than these bodies could handle during this early phase of services by the PVG. Therefore, the private doctors (family doctors) should be informed of the results of the examination done by MDK. The need for the nursing care checkup should be reconsidered.

[Experiences in realization of guidelines of the nursing care insurance regulation--outcome in home care service after expert assessment by medical service personnel]. / Erfahrungen in der Umsetzung von Vorgaben nach dem Pflegeversicherungsgesetz--Erhebungen im häuslichen Bereich nach der Begutachtung durch den MDKN.

The German Pflegeversicherung is a new kind of insurance system for dependence on nursing care (Nursing Care Insurance). Grading into groups according to the intensity of help required, effected by physicians and nurses of the Medical Service of the statutory insurance bodies, as well as the grading system itself have been subjected to severe criticism. However, the emotions in this regard have recently calmed down considerably. The questions are: Do the benefits of the Pflegeversicherung result in improving the financial situation at home? Does it signify increase professional nursing at home? The purpose of our study is to find an answer to these and other questions. We interviewed 150 nursing care dependent persons receiving benefits according to the new system. Senile dementia was the most frequent diagnosis in groups II and III of the official grading scale. Despite of the financial support, a change to more professional nursing care was rarely observed; on the contrary, at times the costly professional services were no longer requested. Deterioration of physical health was seen in every second patient since the first rating by the Medical Service 4 to 6 months ago. Notification of grading and payments to the families took place without delay except in cases of "Kombinationsleistung" (financial support plus financing ambulatory professional nursing-care). We observed major deficits in the counselling of patients or their relatives; there were mostly no courses in nursing care for relatives. Patients and their care-providing relatives usually were satisfied by the benefits provided; relatives felt the financial benefits as an acknowledgement of their engagement. In summary, most care-providing relatives were satisfied by the benefits, but the lack of nonfinancial services (counselling, courses in nursing care, payments for social security) showed up major deficiencies.

[Method and organization of geriatric assessment]. / Zur Methode und Organisation des geriatrischen Assessments.

The intention of a Geriatric Assessment (GA) is a more systematic and exact way to examine a wide range of activities of daily life. This can be achieved by the help of scientifically proved and standardized investigations which complete the medical judgment with objective and comparable results. This type of examination controls the selective observation of the investigator and makes reexamination easier. Moreover, this way of gaining information gives reliable hints about non-apparent or difficult-to-estimate risks of a patient. The methods of GA have to be adapted to different qualities of resources which will be assessed: physical resources should be assessed by standardized ways of observation; the patient's subjective well-being should be examined by standardized interviews. The standardized instruments of measurement are fairly independent from personal qualifications of the investigator.