Introduction: Idiopathic dilatation of the right atrium (IDRA) is a rare abnormality usually detected by chance at any time between antenatal and adult life. It is defined as isolated enlargement of the right atrium in the absence of other cardiac lesions causing right atrial dilatation. IDRA can be associated with atrial arrhythmia and systemic embolism. The clinical presentation shows high variability ranging from the lack of any symptoms up to cardiac failure. Methods/Results: We describe 2 children with antenatally diagnosed IDRA, the intrauterine course in 1 case, the postnatal management and its long-term follow-up. There has been no need for surgical intervention so far because of the lack of arrhythmias and no further progression of right atrial diameters. Thrombus formation in the right atrium, which is a potential risk for pulmonary embolism, led us to initiate anticoagulation in our cases to prevent such complications. Furthermore, we suggest one possible pathomechanism of congenital right atrial dilatation. Conclusion: Optimal management of severe IDRA depends on the individual case. Long-term follow-up of these patients is necessary to monitor a possible further progression of right atrial size and occurrence of arrhythmias. As a possible pathomechanism, a functional partial anomalous pulmonary venous insertion may imitate a structural abnormal pulmonary vein connection in some idiopathic cases of congenital right atrial dilatation. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

The aneurysma of abdominal aorta is a pathological amplification of the diameter of this artery. It is a serious illness which affects 2 -- 6 % men and 1 -- 2 % women over 60. In the case of a rupture there is the mortality of 80 -- 90 %. If the aneurysma is diagnosed in time it is necessary to solve this state with an adequate treatment. The surgical treatment consists in substitution of the afflected part with a vessel replacement. Thanks to the development of medicinal technologies the aorta aneurysma is more and more often treated by the help of stentgrapth by which the afflicted part of the aorta is set aside from the circulation. The theoretical (the first) part of this work deals with the issues of the aneurysma of abdominal aorta, and it also describes the methods of its treatment. Then the work describes costs analyses used in the medical service. The practical part of the work is dedicated to the cost analysis of the treatment by means of a cost minimalization method. The work processes data of a group of patients being treated during a certain period of time in the Olomouc University Hospital in the Department of Vessel Surgery and in the Department of Interventional Radiology. The aim of this work is to evaluate and compare objectively the costs of abdominal aorta aneurysma treatment by individual methods, and to compare the results with foreign studies.

Infektionen im Bereich der Aorta stellen heute noch eine der gravierendsten Komplikationen der rekonstruktiven Gefäßchirurgie dar. Ziel der vorliegenden Arbeit war es, die Effektivität von kryokonservierten Aortenallografts bei der in situ-Behandlung einer manifesten Infektion im Bereich der Aorta tierexperimentell zu evaluieren. Dessweiteren sollte die Rolle der im Rahmen der Kryokonservierung zum Zwecke der Dekontamination eingesetzten Antibiotika untersucht werden. Zu diesem Zwecke erfolgte im in-vitro Experiment die Untersuchung der Antibiotikakonzentration im Gewebe sowie die der Freisetzungskinetik. Am Modell einer durch Staphylococcus epidermidis RP-62 verursachten Protheseninfektion der infrarenalen Bauchaorta des Hundes konnte eine intrinsische Infektionsresistenz der kryokonservierten Aortenallografts nachgewiesen werden. Jedoch scheint die Antibiotikabehandlung der Allografts für die Optimierung des therapeutischen Effektes essentiell zu sein. Die Ergebnisse der in vivo-Experimente werden durch die in vitro-Untersuchungen, ebenso wie durch die Analyse der eigenen klinischen Ergebnisse und der in der Literatur publizierten Daten belegt. Die vorliegende Arbeit kommt zu dem Schluß, daß die Verwendung von kryokonservierten Allografts das Therapiekonzept der Wahl zur Behandlung von Infektionen im Bereich der Aorta darstellt. / Infections of the aorta remain one of the most dreaded complications in reconstructive vascular surgery. The purposes of this study were to evaluate the efficacy of a cryopreserved aortic allograft to treat an established vascular graft infection by the surgical in situ replacement of the infected segment in an animal model, and to investigate the role of antibiotics to decontaminate the allograft during the cryopreservation process. Furthermore, the tissue concentrations of the antibiotic and the kinetics of desorption were investigated in in vitro experiments. A model of prosthetic graft infection by Staphylococcus epidermidis RP-62 (inserted in the infrarenal aorta) in dogs was developed. By in situ replacement of the infected prosthetic graft with a cryopreserved aortic allograft, this study demonstrated an intrinsic resistance to infection of cryopreserved aortic allografts. However, antibiotic loading of the cryopreserved aortic allografts appeared to be essential to obtain optimal therapeutic effects. The results of these in vivo experiments were supported by the findings of our in vitro studies, as well by analysis of our own clinical results and by clinical data published in the medical literature. We conclude that in situ replacement with a cryopreserved allograft is currently the therapy of choice for an aortic infection.

Background: Scoring models are widely established in the intensive care unit (ICU). However, the importance in patients with ruptured abdominal aortic aneurysm (RAAA) remains unclear. Our aim was to analyze scoring systems as predictors of survival in patients undergoing open surgical repair (OSR) for RAAA. Methods: This is a retrospective study in critically ill patients in a surgical ICU at a university hospital. Sixty-eight patients with RAAA were treated between February 2005 and June 2013. Serial measurements of Sequential Organ Failure Assessment score (SOFA), Simplified Acute Physiology Score II (SAPS II) and Simplified Therapeutic Intervention Scoring System-28 (TISS-28) were evaluated with respect to in-hospital mortality. Eleven patients had to be excluded from this study because 6 underwent endovascular repair and 5 died before they could be admitted to the ICU. Results: All patients underwent OSR. The initial, highest, and mean of SOFA and SAPS II scores correlated significant with in-hospital mortality. In contrast, TISS-28 was inferior and showed a smaller area under the receiver operating curve. The cut-off point for SOFA showed the best performance in terms of sensitivity and specificity. An initial SOFA score below 9 predicted an in-hospital mortality of 16.2% (95% CI, 4.3–28.1) and a score above 9 predicted an in-hospital mortality of 73.7% (95% CI, 53.8–93.5, p < 0.01). Trend analysis showed the largest effect on SAPS II. When the score increased or was unchanged within the first 48 h (score >45), the in-hospital mortality rate was 85.7% (95% CI, 67.4–100, p < 0.01) versus 31.6% (95% CI, 10.7–52.5, p = 0.01) when it decreased. On multiple regression analysis, only the mean of the SOFA score showed a significant predictive capacity with regards to mortality (odds ratio 1.77; 95% CI, 1.19–2.64; p < 0.01). Conclusion: SOFA and SAPS II scores were able to predict in-hospital mortality in RAAA within 48 h after OSR. According to cut-off points, an increase or decrease in SOFA and SAPS II scores improved sensitivity and specificity.

BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms are an uncommon, heterogeneous group of aneurysms with poorer neurological outcomes compared to other intracranial aneurysms. At first, as part A, we conducted a systematic review of the literature to evaluate the safety and efficacy of treatment strategies for PICA-aneurysms. Subsequently, as part B, we performed a multicenter retrospective study to analyze the outcome in a large series of patients treated with contemporary microsurgical and endovascular techniques. METHODS: For the meta-analysis, a systematic search of Medline, EMBASE, Scopus and Web of Science was done for studies published through November 2015. We included studies that described treatment of PICA-aneurysms with ≥10 patients. Random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, periprocedural morbidity/mortality, stroke rates, aneurysm recurrence/rebleed, CN-palsies rates, and long-term neurological morbidity/mortality. As the second part, aiming to report the current trends and results in treatment strategies for PICA-aneurysms, records of 94 patients treated for PICA-aneurysms between 2000 and 2015 at 3 large referral neurovascular centers were retrospectively reviewed. RESULTS: In the meta-analysis, we...

Background: Impaired homocysteine metabolism is associated with a number of vasculopathies including extracranial aneurysms. We analyzed the possible association of nine genetic variants of homocysteine metabolism with the occurrence of intracranial aneurysms. Methods: Caucasian patients (n = 255) treated at two German hospitals for intracranial aneurysms and local controls (n = 348) were genotyped for the following polymorphisms: methionine synthase (MTR) c.2756A→G, methylenetetrahydrofolate reductase (MTHFR) c.677C→T, MTHFR c.1298A→C, cystathionine β-synthase (CBS) c.844_855ins68, CBS c.833T→C, dihydrofolate reductase (DHFR) c.594 + 59del19bp, glutathione S-transferase Ω-1 (GSTO1) c.428C→A, reduced folate carrier 1 (RFC1) c.80G→A and transcobalamin 2 (Tc2) c.776C→G. Results: The G-allele of the missense polymorphism Tc2 c.777C→G was found to be underrepresented in patients, suggesting that this variant may protect from the formation of cerebral aneurysms [odds ratio per two risk alleles (OR) 0.48; 95% confidence interval (CI) 0.30–0.77; p = 0.002]. We obtained borderline results for the G-allele of RFC1 c.80G→A (OR 1.64; 95% CI 1.01–2.65; p = 0.051) and the insertion allele of DHFR c.594 + 59del19bp (OR 1.61; 95% CI 1.00–2.60; p = 0.059), which were found to be overrepresented in patients. Conclusion: Polymorphisms of homocysteine metabolism are possible risk factors for the formation of intracranial aneurysms. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Background: Vascular remodeling generated by reactive oxygen species contributes to aneurysm formation. The NADPH oxidase system is a major source of superoxide anion not only in phagocytes, but also in endothelial and vascular smooth muscle cells. Polymorphisms of p22phox, an essential component of the NADPH oxidase system, are found to be associated with atherosclerosis, while a recent study found a significant association between the 214C>T polymorphism and the occurrence of ischemic cerebrovascular disease. We conducted a case-control study to investigate the relationship of five polymorphisms of the p22phox gene and the occurrence of cerebral aneurysms. Methods: The study population consisted of 113 patients with intracranial aneurysms and 53 control subjects. The 214C>T polymorphism was investigated by restriction fragment length polymorphism analysis, while polymorphisms 381T>C, 480G>A, 521C>T, and *24A>G were analyzed by direct sequencing of exon 6 and adjacent intronic sequences. Results: The analysis of a primary study sample comprising 35 cases and 28 controls failed to show a significant association between any of the five polymorphisms and the occurrence of intracranial aneurysms using both allele frequencies and genotypes (all nominal p > 0.05). Although there was a deviation from Hardy-Weinberg equilibrium in cases at the 521C>T locus (nominal p < 0.05), this could not be confirmed in a second study sample of 78 patients. Haplotypes were constructed regarding three frequent polymorphisms (214C>T, 521C>T, and *24A>G); haplotype frequencies in cases and controls were not significantly different. Conclusion: Although polymorphisms of the p22phox gene located in the coding region and the 3′-untranslated region were reported to be associated with atherosclerosis and cerebrovascular disease, our data provide evidence that there is no association between these polymorphisms and the occurrence of cerebral aneurysms in Caucasians. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

Introduction: Idiopathic dilatation of the right atrium (IDRA) is a rare abnormality usually detected by chance at any time between antenatal and adult life. It is defined as isolated enlargement of the right atrium in the absence of other cardiac lesions causing right atrial dilatation. IDRA can be associated with atrial arrhythmia and systemic embolism. The clinical presentation shows high variability ranging from the lack of any symptoms up to cardiac failure. Methods/Results: We describe 2 children with antenatally diagnosed IDRA, the intrauterine course in 1 case, the postnatal management and its long-term follow-up. There has been no need for surgical intervention so far because of the lack of arrhythmias and no further progression of right atrial diameters. Thrombus formation in the right atrium, which is a potential risk for pulmonary embolism, led us to initiate anticoagulation in our cases to prevent such complications. Furthermore, we suggest one possible pathomechanism of congenital right atrial dilatation. Conclusion: Optimal management of severe IDRA depends on the individual case. Long-term follow-up of these patients is necessary to monitor a possible further progression of right atrial size and occurrence of arrhythmias. As a possible pathomechanism, a functional partial anomalous pulmonary venous insertion may imitate a structural abnormal pulmonary vein connection in some idiopathic cases of congenital right atrial dilatation. / Dieser Beitrag ist mit Zustimmung des Rechteinhabers aufgrund einer (DFG-geförderten) Allianz- bzw. Nationallizenz frei zugänglich.

BACKGROUND: Posterior inferior cerebellar artery (PICA) aneurysms are an uncommon, heterogeneous group of aneurysms with poorer neurological outcomes compared to other intracranial aneurysms. At first, as part A, we conducted a systematic review of the literature to evaluate the safety and efficacy of treatment strategies for PICA-aneurysms. Subsequently, as part B, we performed a multicenter retrospective study to analyze the outcome in a large series of patients treated with contemporary microsurgical and endovascular techniques. METHODS: For the meta-analysis, a systematic search of Medline, EMBASE, Scopus and Web of Science was done for studies published through November 2015. We included studies that described treatment of PICA-aneurysms with ≥10 patients. Random-effects meta-analysis was used to pool the following outcomes: complete occlusion, technical success, periprocedural morbidity/mortality, stroke rates, aneurysm recurrence/rebleed, CN-palsies rates, and long-term neurological morbidity/mortality. As the second part, aiming to report the current trends and results in treatment strategies for PICA-aneurysms, records of 94 patients treated for PICA-aneurysms between 2000 and 2015 at 3 large referral neurovascular centers were retrospectively reviewed. RESULTS: In the meta-analysis, we...

Vorliegende Dissertation untersucht den Einfluss einer leichtgradigen Subarachnoidalblutung (SAB, Hunt & Hess Grad 1-2) auf das Outcome der Patienten nach Clipping intrakranieller Aneurysmen im Vergleich zu elektivem Clipping unrupturierter Aneurysmen. Es wurden insgesamt 588 Patienten aus dem Zeitraum zwischen 2009 und 2020 eingeschlossen (458 Patienten mit einer SAB, darunter 104 Patienten mit einer SAB Hunt & Hess Grad 1-2 und Clipping; 130 Patienten mit elektivem Clipping). Eine Populationsanalyse, Dokumentation des Therapieverlaufs und Evaluation des Outcomes der Patienten zum Entlassungszeitpunkt erfolgte retrospektiv anhand der Patientenakten. Nach etwa 6 Jahren im Median erfolgte eine erneute Abfrage der Lebensqualität bei 53 SAB-Patienten und 67 elektiv geclippten (EC) Patienten via Telefoninterview. Das Outcome der Patienten wurde mittels Glasgow Outcome Scale Extended (GOSE), Modified Rankin Scale (mRS), dem Score der World Federation of Neurosurgical Societies (WFNS), dem Barthel Index und dem Short Form 36 – Fragebogen erfasst. Eine statistische Analyse der Einflussfaktoren auf das Outcome der Patienten erfolgte sowohl uni- als auch multivariat mittels Pearson-Chi-Quadrat Test, Mann-Whitney-U Test und Kruskal-Wallis Test. Die Ergebnisse der vorliegenden Studie zeigten einen signifikanten Unterschied im kurzfristigen, sowie langfristigen Outcome der untersuchten Patienten in mehreren Scores. So erreichten unter den elektiv geclippten Patienten zum Entlassungszeitpunkt in der GOSE (7-8 Punkte) und in der mRS (0-1 Punkt) jeweils etwa 70% der Patienten ein sehr gutes Outcome, wohingegen dies für die Patienten mit leichtgradiger aSAB nur für etwa 40% der Patienten galt (p = < 0,001). Auch im Follow-up konnten diese Ergebnisse bestätigt werden (GOSE 7-8 Punkte: 74,6% vs. 54,7%, p = 0,022). Im Score der WFNS zeigte sich dieser Unterschied unmittelbar postoperativ weniger deutlich (93,8% vs. 80,8%). Beide Patientengruppen gaben die meisten Beschwerden aufgrund physischer Einschränkungen und Schmerzen an, während sie sich aufgrund mangelnder Energie und emotionaler Probleme am wenigsten belastet fühlten. Die mediane Zeit bis zur erneuten Aufnahme der Berufstätigkeit betrug in beiden Gruppen etwa ein halbes Jahr. Unerwünschte Ereignisse im Verlauf wurden seltener unter den EC Patienten dokumentiert, darunter die Entwicklung eines Hydrocephalus (1,5% vs. 48,1%) und Vasospasmen (10% vs. 41,3%) (p = < 0,001). Dagegen stellte das Vorliegen eines Hydrocephlaus für die SAB-Patienten einen unabhängigen Risikofaktor für ein schlechteres Outcome in der GOSE dar (HR 8,026, p = 0,010). Nebenbefundlich wiesen die EC Patienten im Durchschnitt mit 58,2 Jahren ein um 5,3 Jahre signifikant höheres Lebensalter auf als die SAB-Patienten. Ein steigendes Lebensalter erwies sich dabei in beiden Gruppen als unabhängiger Risikofaktor für ein schlechtes Outcome im alltäglichen Leben (GOSE 1-4 Punkte) (SAB: HR 0,924, p = 0,017, EC: HR 0,790, p = 0,049). In beiden Gruppen zeigte sich ein Geschlechterverhältnis von 2:1 Frauen zu Männern, wobei das weibliche Geschlecht für EC Patienten ebenfalls als unabhängiger Risikofaktor für ein schlechteres Outcome in der GOSE (1-4 Punkte) galt. Diese Patientengruppe erreichte außerdem weniger Punkte im SF 36 – Fragebogen mit steigendem Aneurysmavolumen sowohl für ihre körperliche (HR 0,949, p = 0,006), als auch für ihre mentale Gesundheit (HR 0,955, p = 0,015). Abschließend konnten unter den EC Patienten vermehrt Nebendiagnosen dokumentiert werden, darunter am häufigsten ein arterieller Hypertonus (71,5% vs. 45,2%) und Nikotinabusus (37,7% vs. 14,4%). Als unabhängige Risikofaktoren für ein schlechteres Outcome (GOSE 1-4 Punkte) konnten allerdings für diese Patienten ein Diabetes mellitus (HR 6,795, p = 0,022) und eine Niereninsuffizienz (HR 7,304, p = 0,027) evaluiert werden. Das Outcome der Patienten nach neurochirurgischem Clipping wird maßgeblich durch das Vorhandensein einer leichtgradigen SAB beeinflusst. Patienten mit einem Blutungsereignis zeigen auch im späteren Verlauf nach mehreren Jahren noch häufiger kognitive und körperliche Einschränkungen als elektiv geclippte Patienten. Dabei scheinen vor allem ein höheres Lebensalter, das weibliche Geschlecht und die Entwicklung unerwünschter Ereignisse im Therapieverlauf einen signifikanten Einfluss auf die Lebensqualität der Patienten zu nehmen. Komorbiditäten der Patienten, sowie die Anzahl und Lokalisation der Aneurysmen zeigten dagegen keinen relevanten Einfluss auf das Outcome der Patienten.:Abkürzungsverzeichnis I Abbildungsverzeichnis II Tabellenverzeichnis III Inhaltsverzeichnis IV 1 Einleitung 1 1.1 Definition und Inzidenz 1 1.2 Pathophysiologie und Risikofaktoren 5 1.3 Klinische Symptomatik und Diagnostik 7 1.4 Therapie von intrakraniellen Aneurysmen 11 1.5 Patientenoutcome 16 2 Methoden 17 2.1 Patientengut 17 2.2 Datenerhebung 18 2.3 Statistische Auswertung 23 3 Ergebnisse 24 3.1 Populationsanalyse 24 3.2 Patientenstatus bei Aufnahme 26 3.3 Charakteristika der Aneurysmen 29 3.4 Primäres Outcome 30 3.5 Outcome im Langzeit-Follow-up 35 4 Diskussion 38 4.1 Einfluss von Alter und Geschlecht auf das Outcome 44 4.2 Einfluss der Nebendiagnosen auf das Outcome 48 4.2.1 Nikotinabusus 48 4.2.2 arterieller Hypertonus 49 4.2.3 Diabetes mellitus 50 4.2.4 Niereninsuffizienz 51 4.2.5 koronare Herzkrankheit 52 4.3 Einfluss der Aneurysmencharakteristik auf das Outcome 54 4.4 Einfluss der unerwünschten Ereignisse auf das Outcome 58 4.4.1 Hydrocephalus 58 4.4.2 Vasospasmus und Infarkt 59 4.4.3 Hirnödem 60 4.4.4 Restperfusion des Aneurysmas und Nachblutungen 61 4.5 Limitationen der Studie 64 5 Zusammenfassung 65 6 Summary 67 7 Literaturverzeichnis 69 8 Anhang 84 8.1 Glasgow Outcome Scale Extended Fragebogen 84 8.2 Barthel Index 87 8.3 Short Form 36 – Fragebogen 89 Anlage 1: Erklärungen zur Eröffnung des Promotionsverfahrens 95 Anlage 2: Bestätigung über Einhaltung der aktuellen gesetzlichen Vorgaben 96