Impact of 3-Monthly Vitamin D Supplementation Plus Exercise on Survival after Surgery for Osteoporotic Hip Fracture in Adult Patients over 50 Years: A Pragmatic Randomized, Partially Blinded, Controlled Trial.

OBJECTIVE: To determine whether 3-monthly supplementation of an oral vitamin D widely used in Spain (calcifediol) plus daily exercise could influence survival at one and four years after surgery for osteoporotic hip fracture. DESIGN: A pragmatic, randomized, partially single-blind placebo-controlled study. SETTING: Patients admitted to a tertiary university hospital for acute hip fracture. PARTICIPANTS: 675 healthy adult patients undergoing surgery for osteoporotic hip fracture were recruited from January 2004 to December 2007. INTERVENTION: Patients were randomized to receive either 3-monthly oral doses of 3 mg calcifediol (Hidroferol Choque®) or placebo in the 12 months postsurgery. Patients who received calcifediol were also given an exercise programme. The placebo group received standard health recommendations only. MEASUREMENTS: The primary endpoint was survival at 1 year and at 4 year follow-up. We also recorded new fractures, medical complications and anti-osteoporotic treatment compliance. RESULTS: We included a total of 88 patients, aged 62 to 99 years. Mean age was 82 years and 88.6% were women. At 12 months, 10 (11.3%) patients had died, 9 of them, from the non-intervention group. At 4 years after surgery, 20 (22.7%) had died, 3 (3.4%) from the intervention group and 17 (19.3%) from the non-intervention group. At this time, survival curve analysis showed 93% survival in the intervention group and 62% in the non-intervention group (p=0.001). At 12-month follow up, there were 18 new fractures, 9 in each group. The non-intervention group had more medical complications, with significant differences at visit 2 (p = 0.04) and 3 (p = 0.02) but not at visit 4 (p = 0.18). No significant differences between groups were found regarding treatment compliance. CONCLUSION: 3-monthly, oral supplements of 3 mg calcifediol plus daily exercise improved survival at one-year and four-year follow up after surgery for an osteoporotic hip fracture.

Denosumab or Zoledronic Acid in Postmenopausal Women With Osteoporosis Previously Treated With Oral Bisphosphonates.

CONTEXT: Denosumab and zoledronic acid (ZOL) are parenteral treatments for patients with osteoporosis. OBJECTIVE: The objective of the study was to compare the effect of transitioning from oral bisphosphonates to denosumab or ZOL on bone mineral density (BMD) and bone turnover. DESIGN AND SETTING: This was an international, multicenter, randomized, double-blind trial. PARTICIPANTS: A total of 643 postmenopausal women with osteoporosis previously treated with oral bisphosphonates participated in the study. INTERVENTIONS: Subjects were randomized 1:1 to sc denosumab 60 mg every 6 months plus iv placebo once or ZOL 5 mg iv once plus sc placebo every 6 months for 12 months. MAIN OUTCOME MEASURES: Changes in BMD and bone turnover markers were measured. RESULTS: BMD change from baseline at month 12 was significantly greater with denosumab compared with ZOL at the lumbar spine (primary end point; 3.2% vs 1.1%; P < .0001), total hip (1.9% vs 0.6%; P < .0001), femoral neck (1.2% vs -0.1%; P < .0001), and one-third radius (0.6% vs 0.0%; P < .05). The median decrease from baseline was greater with denosumab than ZOL for serum C-telopeptide of type 1 collagen at all time points after day 10 and for serum procollagen type 1 N-terminal propeptide at month 1 and at all time points after month 3 (all P < .05). Median percentage changes from baseline in serum intact PTH were significantly greater at months 3 and 9 with denosumab compared with ZOL (all P < .05). Adverse events were similar between groups. Three events consistent with the definition of atypical femoral fracture were observed (two denosumab and one ZOL). CONCLUSIONS: In postmenopausal women with osteoporosis previously treated with oral bisphosphonates, denosumab was associated with greater BMD increases at all measured skeletal sites and greater inhibition of bone remodeling compared with ZOL.

Estudio mediante densitometría y ergoespirometría de los efectos de un programa de ejercicio físico en pacientes con cirrosis hepática y sobrepeso / Study by densitometry and ergospirometry of the effects of an exercise programme in overweight patients with liver cirrhosis

Objetivo: Estudiar los efectos del programa de ejercicio físico moderado sobre la composición corporal y la capacidad de esfuerzo evaluadas mediante densitometría y ergoespirometría, respectivamente, en pacientes con cirrosis y sobrepeso. Pacientes y metodología: Se incluyeron 14 pacientes con cirrosis y sobrepeso compensados que realizaron un programa de ejercicio físico moderado durante tres meses de una hora, tres días/semana. Se midió la variación antropométrica, la composición corporal mediante densitometría, la capacidad de esfuerzo mediante ergoespirometría y la calidad de vida (SF-36). Resultados: Al final del estudio, respecto al inicio, no hubo diferencias en el índice de masa corporal. Encontramos aumento de la masa muscular total y disminución de la masa grasa total. Aumentó el tiempo de esfuerzo total y el tiempo de esfuerzo aerobio. La presión arterial media y la creatinina sérica disminuyeron. La calidad de vida mejoró en todos los dominios del SF-36 aunque alcanzó significación estadística en la función física. Conclusiones: Un programa de ejercicio físico moderado disminuye la masa grasa y aumenta la masa muscular y la capacidad de esfuerzo en pacientes con cirrosis y sobrepeso (AU)

Objective: To study the effects of a moderate exercise programme on body composition and effort capacity evaluated by means of densitometry and ergospirometry, respectively, in overweight patients with cirrhosis. Patients and methods: Fourteen compensated overweight patients with cirrhosis underwent a moderate exercise programme during 3 months one hour 3 days/week. We analyzed the changes in anthropometric measures, body composition by densitometry, effort capacity by ergospirometry and quality of life by SF-36 questionnaire. Results: At the end of the study there were not differences in body mass index with respect to basal values, but we observed an increase in total body muscle mass evaluated by densitometry and a decrease in total fat body mass. Ergospirometry showed an increase in effort time and in aerobic effort time. Mean arterial pressure and serum creatinine decreased at the end of the study. With respect to quality of life, there was an improvement in all SF-36 domains that reached statistical significance in physical functioning. Conclusions: A moderate exercise programme decreases total body fat and increases total body muscle mass and effort capacity in overweight patients with cirrhosis (AU)

Analgesic use and pain in the hospital settings.

AIM: The aim of this study was to assess the analgesic treatment and the prevalence of pain in patients treated with analgesics in hospitals. METHODS: Adult patients treated with analgesics were selected from a sample of 1,675 patients in a cross-sectional study carried out in 15 Catalonian hospitals (Spain). Patient characteristics, type of analgesics, treatment schedules, patients' pain intensity and clinical ward and hospital characteristics were assessed. Adherence to analgesic use guidelines was established according to the principles and recommendations of internationally recognised guidelines for pain management. Pain was determined by asking patients about pain intensity by means of a visual analogue scale (VAS). RESULTS: Analgesics were prescribed for 1,173 patients (70%; 95% CI: 67.4-72.6), in whom 57% (95% CI: 54.2-59.8) had pain and in whom 30.5% (95% CI: 27.9-33.1) pain intensity was greater than 30 mm. Adherence to analgesic treatment guidelines was judged appropriate in only 26.9% (95% CI: 24.4-29.4%) of all patients. The administered analgesic dose was in the recommended dose range in 42% (95% CI: 54-58) of all analgesics and in 28% (95% CI: 24-32) of opioid analgesics. A minority of patients was treated with a rescue schedule or patient-controlled analgesia (2%; 95% CI: 1.4-2.6). Pain prevalence was higher in those with analgesic treatment that did not adhere to guidelines (63.6%; 95% CI: 60.4-66.8) than in those considered as having appropriate adherence to guidelines (39.3%; 95% CI: 33.8-44.6) (p < 0.001). Adherence to analgesic treatment guidelines was higher in the large hospitals (21%; 95% CI: 18-24) than in medium and small hospitals (13%; 95% CI: 9-16) (p < 0.001). CONCLUSIONS: Although analgesic use is high in the hospital settings, adherence to the principles and recommendations of pain guidelines is low, and pain is usually common in patients treated with analgesics. These results once again emphasise the need to improve analgesic use and pain management in hospitals.

[Multicenter study of pain assessment in hospitals]. / Estudio multicéntrico de la evaluación del dolor en el medio hospitalario.

OBJECTIVE: To evaluate the recording of pain intensity in hospital charts. METHODS: A cross-sectional study was carried out in 15 hospitals in a sample of admitted patients with pain. Clinical data, including pain intensity, were gathered from the hospital records. Multiple analysis of variance was used to identify factors related to the intensity of pain recorded in the patients' charts. RESULTS: A total of 1038 patients with a mean (SD) age of 56.1 (18.9) years were included. Pain intensity was noted in the charts of 47.9% (95% confidence interval [CI], 44.9%-50.9%) of the patients. Pain intensity had been noted for 68.9% (95% CI, 61.4%-76.4%) of the patients with cancer, 43% (95% CI, 38.2%-47.8%) of postoperative patients, 38.2% (95% CI, 35%-41.4%) of trauma patients, and 26.6% (95% CI, 16.9%-36.3%) of postpartum women. There was great interhospital variability. Factors associated with the recording of pain intensity in medical charts were hospital characteristics (large hospitals, teaching hospitals, hospitals and internal medicine and surgical specialities) and type of patient (cancer and trauma cases and patients reporting pain to the staff). CONCLUSION: There is inadequate written recording of intensity of pain in hospitals, even though there is considerable interhospital variation. Pain intensity assessment and recording is an indicator of quality of health care and should become a routine practice in hospital health care.

Estudio multicéntrico de la evaluación del dolor en el medio hospitalario / Multicenter study of pain assessment in hospitals

OBJETIVO: Evaluar el registro de la intensidad del dolor en los hospitales. MÉTODOS: Estudio transversal en 15 hospitales. Se seleccionó una muestra de los pacientes hospitalizados con dolor. Se recogió información clínica de los pacientes y del registro de la intensidad del dolor en las historias clínicas. Se realizó un análisis multivariante para identificar los factores relacionados con el registro de la intensidad del dolor en las historias clínicas. RESULTADOS: Fueron incluidos 1.038 pacientes con una edad media (DE) de 56,1 (18,9) años. Se registró la intensidad del dolor en las historias clínicas de un 47,9% (IC 95%: 44,9-50,9%) de los pacientes. Se anotó la intensidad del dolor en un 68,9% (IC 95%: 61,4-76,4%) de los pacientes neoplásicos, en un 43% (IC 95%: 38,2- 47,8%) de los postoperados, en un 38,2% (IC 95%: 35- 41,4%) de los traumáticos y en un 26,6% (IC 95%: 16,9- 36,3%) de las mujeres postparto. Se observó una amplia variabilidad entre los diferentes hospitales. Los factores relacionados con un mayor registro de la intensidad del dolor en las historias clínicas fueron las características hospitalarias (grandes hospitales, hospitales docentes y servicios de medicina y cirugía) y de los pacientes (neoplásicos, traumáticos y los que comunicaron el dolor al personal sanitario). CONCLUSIÓN: El registro de la intensidad del dolor de los pacientes en los hospitales es insuficiente aunque existe una amplia variabilidad entre los hospitales. El registro de la intensidad del dolor es un indicador de calidad asistencial y debería ser una actividad rutinaria en el proceso asistencial hospitalario

OBJECTIVE: To evaluate the recording of pain intensity in hospital charts. METHODS: A cross-sectional study was carried out in 15 hospitals in a sample of admitted patients with pain. Clinical data, including pain intensity, were gathered from the hospital records. Multiple analysis of variance was used to identify factors related to the intensity of pain recorded in the patients’ charts. RESULTS: A total of 1038 patients with a mean (SD) age of 56.1 (18.9) years were included. Pain intensity was noted in the charts of 47.9% (95% confidence interval [CI], 44.9%-50.9%) of the patients. Pain intensity had been noted for 68.9% (95% CI, 61.4%-76.4%) of the patients with cancer, 43% (95% CI, 38.2%-47.8%) of postoperative patients, 38.2% (95% CI, 35%-41.4%) of trauma patients, and 26.6% (95% CI, 16.9%-36.3%) of postpartum women. There was great interhospital variability. Factors associated with the recording of pain intensity in medical charts were hospital characteristics (large hospitals, teaching hospitals, hospitals and internal medicine and surgical specialities) and type of patient (cancer and trauma cases and patients reporting pain to the staff). CONCLUSION: There is inadequate written recording of intensity of pain in hospitals, even though there is considerable interhospital variation. Pain intensity assessment and recording is an indicator of quality of health care and should become a routine practice in hospital health care

Prevalence of pain in adults admitted to Catalonian hospitals: a cross-sectional study.

OBJECTIVE: To survey the prevalence of pain in patients admitted to different hospitals of Catalonia and to describe which factors are related to pain. METHODS: A cross-sectional study was performed in 1675 patients from fifteen hospitals in Catalonia (Spain). Clinical and demographic data, as well as the existence of pain intensity evaluations and analgesic therapy, were obtained from medical charts. Characteristics of pain were given by patients after being interviewed by trained interviewers. The main-outcome measure was the existence of pain (at the interview, in the previous 24h, at the admission and at any time after admission) that was assessed by a visual analogue scale (VAS). The relationship of prevalence of pain to patients' characteristics was carried out by means of a multiple-logistic-regression model with pain presence as the dependent variable of interest. RESULTS: A great variability in the prevalence and intensity of pain among different hospitals was observed. At the time of the interview, 48.5% (95% CI: 46.1-50.9%) of the patients had pain and the median VAS was 40mm (range: 10-100mm), and the prevalence of pain during the previous 24h was similar (47.6%; 95% CI: 45.2-50%). At admission, 26.7% (95% CI: 24.6-28.8%) of patients were in pain, whereas 62% (95% CI: 59.7-64.3%) reported having pain at some time during their stay. Pain intensity annotations were absent in 51.3% (95% CI: 47.9-54.7%) of the medical records of the patients with pain. The factors associated with pain were younger age, female gender, presence of surgery, orthopaedic surgery wards, large hospital and prescribed analgesics. CONCLUSION: A high prevalence of clinically relevant pain in in-patients was found as well as a great variability according to type of patients, clinical wards and hospitals. This study gives clear evidence of the lack of adequate management of pain in the majority of the hospitals and calls for the implementation of organisational and educational measurements that may settle this epidemic problem.

Calcific retinal embolism as an indicator of severe unrecognised cardiovascular disease.

OBJECTIVE: To describe the association between calcific retinal embolism (CRE) and cardiac valve stenosis. DESIGN AND SETTING: Retrospective chart review of patients with clinical criteria for CRE. PATIENTS: 24 patients with CRE who underwent two dimensional echocardiography between 1976 and 1998. RESULTS: Nine patients (38%) had calcific valve stenosis, which was haemodynamically severe in five patients (four aortic and one mitral), four of whom had no cardiac symptoms. Six patients underwent surgical intervention (aortic valve replacement in three patients, mitral and aortic valve replacement in one patient, removal of calcific cardiac pseudotumour in one patient, and carotid endarterectomy in one patient). CONCLUSIONS: CRE may be the presenting feature of otherwise asymptomatic, clinically important underlying cardiovascular disease and, in particular, haemodynamically severe calcific valve stenosis.

Anatomical basis for acquired intracardiac shunt postaortic valve replacement: Doppler echocardiographic diagnosis.

We report a case of postoperative intracardiac shunts across the membranous septum detected by Doppler echocardiography and discuss the anatomical basis for the development of such a complication.

Influence of parotid-sparing radiotherapy on xerostomia in head and neck cancer patients.

Radiotherapy (RT) for head and neck cancers causes permanent salivary gland dysfunction (SGD) and xerostomia. We have previously demonstrated the effectiveness of parotid-sparing RT on salivary function. The aim of this was to characterize the relationship between radiation dosages to parotid glands, SGD, xerostomia, and impaired quality of life (QOL). Ninety-three patients received unilateral (n=38) and bilateral (n=44) neck RT with parotid-sparing techniques, or standard three-field technique RT (n=11). Unstimulated and stimulated parotid saliva was collected pre-RT and 1 year post-RT. Assessment of QOL and xerostomia was conducted with three questionnaires. The results demonstrated that reduced radiation dosages to parotid glands were strongly associated with percentage of baseline parotid flow rates measured at 1 year post-RT. Unilateral and bilateral neck RT with parotid-sparing techniques were successful in preserving salivary output, compared to standard three beam RT techniques. Lower radiation dose to contralateral parotid glands was associated with greater percentage of baseline salivary flow rates at 1 year post-RT, fewer xerostomic complaints, and an enhanced QOL.

Reoperation for prosthetic aortic valve obstruction in the era of echocardiography: trends in diagnostic testing and comparison with surgical findings.

OBJECTIVES: We sought to: 1) identify trends in the diagnostic testing of patients with prosthetic aortic valve (AVR) obstruction who undergo reoperation and 2) compare diagnostic test results with pathologic findings at surgery. BACKGROUND: It is unclear whether Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have reduced hemodynamic catheterization rates. METHODS: We reviewed 92 consecutive cases ofAVR reoperation at a single center from 1989 to 1998, comparing 49 cases of mechanical AVR obstruction (group A) to 43 cases of bioprosthetic obstruction (group B). Preoperative Doppler TTE was performed in all cases. RESULTS: In group A cases, there was a marginally significant trend towards lower catheterization rates for the Gorlin AVR area, from 36% in 1989 to 1990 to 10% in 1997 to 1998 (p = 0.07), but diagnostic TEE utilization (47% of cases) did not vary. The cause of mechanical AVR obstruction was pannus in 26 cases (53%), mismatch (P-PM) in 19 (39%) and thrombosis in 4 (8%). The mechanism (pannus/thrombus vs. mismatch) was identified in 10% by TTE and 49% by TEE (p < 0.001). In group B cases, hemodynamic catheterization rates (21%) and diagnostic TEE utilization (21%) did not vary with time. Obstruction was caused by structural degeneration in 37 cases (86%), thrombosis in 3 (7%), mismatch in 2 (5%) and pannus in 1 (2%). The mechanism was correctly identified in 63% by TTE and in 81% by TEE (p = 0.18). CONCLUSIONS: Doppler TTE is the primary means to diagnose AVR obstruction; hemodynamic catheterization is not routinely needed. In unselected patients with mechanical AVR obstruction, TEE differentiation of pannus or thrombus from mismatch is challenging.

Fractured occluder disc: a previously unrecognized complication of the Starr-Edwards disc prosthesis.

Fracture of the occluder disc of a low-profile Starr-Edwards prosthesis is a hitherto unrecognized complication. We describe a patient who presented with right heart failure and severe pulmonary hypertension 27 years after mitral valve replacement with a model 6520 caged-disc prosthesis. At surgery, there was a longitudinal split in the occluder disc, and organized thrombus was lodged between the split segments. This case offers a unique opportunity to study the long-term effects of wear on the polyethylene poppet and Stellite cage.

Outcome of reoperation for aortic valve prosthesis-patient mismatch.

We report a single center's 10-year experience with 21 consecutive cases of repeat aortic valve replacement for prosthesis-patient mismatch (P-PM) in which there was no hospital mortality among 12 patients treated for isolated P-PM. With an overall survival of 92% at a median follow-up of 4.5 years and functional class I symptoms in most survivors (73%), we conclude that repeat surgery for isolated P-PM has a relatively low mortality and a good intermediate-term clinical outcome.

Transesophageal echocardiography guided enoxaparin antithrombotic strategy for cardioversion of atrial fibrillation: the ACUTE II pilot study.

BACKGROUND: Patients with atrial fibrillation >2 days' duration for whom immediate cardioversion is desired or required are commonly hospitalized for 4 or more days of antithrombotic therapy with intravenous unfractionated heparin and commencement of oral warfarin. For these early cardioversion patients, self-administered low-molecular-weight heparin (enoxaparin sodium) as "bridge" therapy to warfarin may obviate the need for hospitalization and activated partial thromboplastin time monitoring and thus potentially lower costs and enhance utility. OBJECTIVE: To compare feasibility and safety of a transesophageal echocardiography (TEE)-guided enoxaparin strategy with those of a TEE-guided unfractionated heparin strategy in patients with atrial fibrillation of >2 days' duration undergoing early electrical or chemical cardioversion. DESIGN AND SETTING: This is a randomized, multicenter clinical trial at 11 hospitals in the United States. PATIENTS AND INTERVENTION: Two hundred patients with atrial fibrillation >2 days' duration requiring early chemical or electric cardioversion will be enrolled. TEE-guided intravenous unfractionated heparin bridge therapy will be compared with TEE-guided subcutaneous enoxaparin bridge therapy. OUTCOME MEASURES: Feasibility outcomes are time to hospital discharge, patient quality of life/utility, treatment costs, and sinus rhythm. Safety outcomes are ischemic stroke, transient ischemic attack, systemic embolization, major and minor bleeding, clinical hemodynamic instability, and cardiac and cardioversion-related death for a 5-week period from enrollment. CLINICAL IMPLICATIONS: The results of this pilot study will have important clinical and economic implications for the antithrombotic management of patients with atrial fibrillation undergoing TEE-guided cardioversion.

The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease.

CONTEXT: Acute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting. OBJECTIVE: To assess the presentation, management, and outcomes of acute aortic dissection. DESIGN: Case series with patients enrolled between January 1996 and December 1998. Data were collected at presentation and by physician review of hospital records. SETTING: The International Registry of Acute Aortic Dissection, consisting of 12 international referral centers. PARTICIPANTS: A total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom had type A dissection. MAIN OUTCOME MEASURES: Presenting history, physical findings, management, and mortality, as assessed by history and physician review of hospital records. RESULTS: While sudden onset of severe sharp pain was the single most common presenting complaint, the clinical presentation was diverse. Classic physical findings such as aortic regurgitation and pulse deficit were noted in only 31.6% and 15.1% of patients, respectively, and initial chest radiograph and electrocardiogram were frequently not helpful (no abnormalities were noted in 12.4% and 31.3% of patients, respectively). Computed tomography was the initial imaging modality used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients with type A dissection managed surgically was 26%; among those not receiving surgery (typically because of advanced age and comorbidity), mortality was 58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in 20% of patients with type B dissection; mortality in this group was 31.4%. CONCLUSIONS: Acute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection.

Clinical characteristics and outcome in postinfarction pseudoaneurysm.

The clinical characteristics and outcome in 22 patients with postinfarction pseudoaneurysm were studied. The medium-term outcome was poor (median follow-up 3.6 years), but cardiac rupture was uncommon in patients treated conservatively.

Clinical profile and outcome in 52 patients with cardiac pseudoaneurysm.

BACKGROUND: Cardiac pseudoaneurysm, a contained cardiac rupture, predisposes patients to further rupture. However, knowledge of the clinical profile and natural history of this cardiac complication is limited. OBJECTIVE: To study the clinical features and outcomes of patients with cardiac pseudoaneurysm. DESIGN: Retrospective analysis of patients with cardiac pseudoaneurysm seen between January 1980 and September 1996. SETTING: Mayo Clinic in Rochester, Minnesota; Scottsdale, Arizona; and Jacksonville, Florida. PATIENTS: 52 patients with pseudoaneurysm. RESULTS: Pseudoaneurysm was discovered incidentally in 25 asymptomatic patients (48%). Four patients (8%) presented acutely (3 with acute myocardial infarction and 1 with cardiac tamponade). Other clinical presentations were congestive heart failure in 8 patients (15%), chest pain in 7 (13%), syncope or arrhythmia in 5 (10%), and systemic embolism in 3 (6%). Initial diagnostic tests were echocardiography in 32 patients, cardiac catheterization in 12, magnetic resonance imaging in 4, and computed tomography in 2. Diagnosis was made intraoperatively in two patients. Pseudoaneurysm occurred after cardiac surgery in 30 patients (58%) and after myocardial infarction in 22 (42%). Location of the pseudoaneurysm was primarily related to its cause: Pseudoaneurysm was located in the inferior or posterolateral wall in 18 of 22 patients (82%) after myocardial infarction, in the right ventricular outflow tract in 13 of 15 patients (87%) after congenital heart surgery, in the posterior subannular region of the mitral valve in 4 of 4 patients (100%) after mitral valve replacement, and in the subaortic region in 3 of 3 (100%) after aortic valve replacement. Forty-two patients (81%) had surgical repair (surgical mortality rate, 7%). Ten patients (19%) did not have surgery. Nineteen patients died after a median survival of 2.3 years (range, 3 days to 8.2 years): Eight died of noncardiac cause, 5 of congestive heart failure, 4 of acute myocardial infarction, and 2 of cardiac arrhythmia (ventricular tachycardia). No further cardiac ruptures were documented. CONCLUSIONS: A substantial number of patients with pseudoaneurysm are asymptomatic. Although surgical repair is the treatment of choice, conservative management in selected patients with increased surgical risk seems reasonable because no deaths were caused by further rupture.

Diagnosis of right atrial metastatic melanoma by transesophageal echocardiographic-guided transvenous biopsy.

Traditionally, tissue diagnosis of malignant melanoma metastatic to the heart necessitated thoracotomy or was done at autopsy. More recently, right or left ventricular endomyocardial biopsy under fluoroscopic guidance has been used to confirm metastatic involvement of the heart by various neoplasms including malignant melanoma; results have been excellent, and morbidity has been low. High-quality images of intracardiac masses with excellent anatomic details can be obtained by transesophageal echocardiography. Herein we describe a 73-year-old man with a history of malignant melanoma in whom cardiac metastatic involvement was documented by percutaneous transesophageal echocardiographic-guided transvenous biopsy of a right atrial mass; thus, the need for a more invasive approach to tissue documentation was avoided.