[The impact of social and institutional characteristics on the appropriateness of invasive cardiologic procedures]. / Der Einfluss sozialer und struktureller Faktoren auf die Angemessenheit invasiver kardiologischer Prozeduren.

BACKGROUND AND PURPOSE: Germany has the highest per capita rate of invasive cardiologic procedures in Europe. An aim of the SULEIKA study was to present a clearer picture of this important area of health care. METHODS: Clinical data along with social characteristics of patients were acquired by means of questionnaires. An additional survey was established to collect data about the treating institution. Clinical information was used to define the appropriateness of coronary angiographies and percutaneous coronary interventions. A possible impact of social or institutional characteristics on the appropriateness was examined. RESULTS: 549 of 709 diagnostic coronary angiographies (77.4%) were rated "appropriate", 54 (7.6%) as "equivocal", and 106 (15%) as "inappropriate". 245 of 317 coronary interventions (77.3%) were rated "appropriate", 40 (12.6%) as "equivocal", and 32 (10.1%) as "inappropriate". Social and institutional impact were found for invasive diagnostics but not for PCI. CONCLUSION: Social characteristics of patients and institutional characteristics have only a marginal impact on the indication of invasive cardiologic procedures. A trend toward "overdiagnostics" within the group of younger patients has been noticed, even in the case of missing hard medical evidence. A serious deficit of health care research can be found. Consented criteria to assess the appropriateness of medical treatments are missing. More research has to be done in the field of concepts and processes controlling the distribution and movement of patients into different sections of the health care system. Validated, standardized and comprehensive data for an international comparison of decisions about medical treatments are needed.

Balloon mitral valvotomy after surgical commissurotomy: clinical and hemodynamic results of a large, single-center study.

BACKGROUND AND AIM OF THE STUDY: Patients with restenosis after open or closed surgical commissurotomy (SC) often demonstrate more severe valve degeneration than patients without prior surgery. This may affect the result of balloon mitral valvotomy (BMV) in this patient group. METHODS: The immediate- and long-term results (maximum 106 months; mean 26 months) of BMV with the Inoue balloon in patients with prior SC were compared with findings in patients without prior surgery. Between February 1989 and July 2001, a total of 1,156 BMV interventions was performed, of which 127 were conducted in patients (106 women, 21 men; mean age 56 +/- 12 years) with prior SC. RESULTS: After BMV, the mitral valve area (MVA) increased from 1.0 +/- 0.2 cm2 to 1.6 +/- 0.4 cm2 after SC compared with 1.0 +/- 0.3 cm2 to 1.8 +/- 0.4 cm2 without SC. After three months, the average MVA was 1.7 +/- 0.3 cm2 in both patient groups. The mean NYHA class improved from 2.8 to 2.0 (after SC) versus 2.7 to 1.8 (no SC) three months after BMV. The main complications were cardiac tamponade in three patients (2.4 %), and more than moderate mitral regurgitation (grade 2+) in six (4.7 %) compared to 5.8% in no-SC patients. CONCLUSION: In view of the satisfactory clinical and hemodynamic results, BMV with the Inoue balloon can be considered the treatment of choice for mitral valve restenosis after SC in selected patients.