[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.

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.

[Paroxysmal and persistent atrial fibrillation: New therapy concepts for pulmonary vein isolation - First clinical experiences with the High Density Mesh Ablator (HDMA)]. / Paroxysmales und persistierendes Vorhofflimmern: Neue Therapiekonzepte der Pulmonalvenen-Isolation - Erste klinische Erfahrungen mit dem High Density Mesh Ablator (HDMA).

BACKGROUND AND OBJECTIVES: Interventional therapy of atrial fibrillation (AF) is often associated with long examination- and fluoroscopy times. The use of mapping catheters in addition to the ablation catheter requires multiple transseptal sheets for left atrial access. The HDMA was introduced in 2007 for the the segmental and circumferentil ablation of paroxysmal atrial fibrillation. In small experimental study groups the new catheter system was validated for its electrophysiological properties. The purpose of this prospective study was to evaluate feasibility and safety of pulmonary vein (PV) isolation using the High Density Mesh Ablator (HDMA), a novel single, expandable electrode catheter for both mapping and radiofrequency (RF) delivery at the left atrium/PV junctions. PATIENTS AND METHODS: 40 patients with highly symptomatic paroxysmal AF (PAF, 23/57,5 %) and persistent AF (CAF, 17/42,5 %) were studied. PV isolation via the HDMA was performed using a customized pulsed RF energy delivery program (target temperature 55 - 60 degrees, power 70 - 100 Watt, 600 - 1000 seconds RF application time/PV). RESULTS: All 158 PV in 40 patients could be mapped and ablated by the HDMA. Segmental PV isolation was achieved with a mean of 3,75 +/- 1,9 RF applications for a mean of 715 +/- 375 sec. Entrance conduction block was obtained in 93,5 % of all PV. Mean total procedure and fluoroscopy time was 152 +/- 34 min and 29 +/- 10 min respectively. None of the patients experienced severe complications. After 3 month 78 % of the patients with PAF and 41 % with CAF respectively were free of AF. CONCLUSIONS: In this first study of PV isolation using the HDMA, our findings suggest that this method is feasible, and yields good primary success rates. Due to single transseptal access the HDMA simplifies the complex procedure of AF ablation, favorably impacting procedure and fluoroscopy times.

Non-determinable defibrillation threshold and inefficacy of implantable cardioverter/defibrillator shocks due to defective connections of the defibrillator lead terminals in the device header port.

Inefficacy of implantable cardioverter/defibrillator (ICD) shocks or inappropriate shocks in ICD patients may occur due to mechanical or technical failure of the device. In our unusual case of ICD defibrillation failure, faulty insertion and configuration of the defibrillation lead in the header port resulted in ineffective shock therapies and a non-determinable defibrillation threshold. In cases of successless defibrillations during or after ICD implantation, this problem should be considered.