A sixty three years old male was performed total aortic arch replacement under a separate cardiopulmonary bypass with moderate hypothermia and 600-800ml/min in cerebral perfusion flow which had been getting general consent. A brain ischemia was increased during the operation and the patient was sufferd from brain death. Autopsy revealed the brain edema due to a cerebral transverse sinus thrombus originated by right internal jugular vein thrombosis which was caused by intimal injury by repeated puncture of the vein prior to the operation. This is the first case of accident that occured during the aortic arch surgery.

We report a 64-year-old woman with fungal prosthetic valve endocarditis. She underwent the aortic valve replacement (SJM 19 A^®) with annular enlargement using autologous pericardium. She had a persistent fever and congestive heart failure 8 months after surgery. Echocardiogram demonstrated vegetations of the aortic prosthetic valve, perivalvular leakage and third degree mitral valve regurgitation. Double valve replacement was performed concomitant with aortic annular enlargement using a xenograft. The aortic valve prosthesis was found to be detached from the aortic annulus on the side of the left coronary sinus and also from the implanted autologous pericardium. There were vegetations on the aortic prosthesis and the autologous pericardium. Histopathological findings led to the diagnosis of fungal endocarditis of the aortic prosthetic valve and antifungal therapy was started on the second postoperative day. She is in good condition 5 years later without any relapse of inflammation and has been receiving antifungal treatment. The surgical method of aortoatrioplasty with double valve replacement was effective for fungal prosthetic valve endocarditis after aortic valve replacement with annular enlargement.

A 57-year-old woman was admitted with intermittent bleeding and pus discharge from her right anterior chest. She had undergone radical mastectomy (Halsted operation) and irradiation for breast cancer 11 years previously. Skin ulcer with a bleeding fistula had appeared at the right clavicular region 6 months previously. An emergency operation was performed, since angiography revealed brachiocephalic pseudoaneurysm with fistulation to the skin. The brachiocephalic artery was exposed through a right cervical and middle sternal incision. The brachiocephalic artery was interposed with two segments of the great saphenous vein joined to make a proper graft in size. The infected area was filled by the greater omentum. A pedicle flap was used to close the large skin defect after removing the fistula. The postoperative course was uneventful and infection improved soon after the operation. The patient was discharged about one month after the operation. We reported a rare case of infected brachiocephalic pseudoaneurysm with fistulation to the skin after radical mastectomy and irradiation for breast cancer.

1)The factors Japanese residents consider most important in postgraduate clinical training are: "relationship with supervising physicians," "well-developed training programs," and "guidance of supervising physicians."2)Items showing a large discrepancy between their importance to residents and residents' satisfaction were: "well-developed training program," "experiencing a large number of cases,""guidance of supervising physicians," and "guidance of senior residents."3)Multiple regression analysis showed that factors significantly influencing residents' satisfaction with training were "quality of the medical service" (r=0.59) and "consideration for accepted residents" (r=0.42).

We report a case of surgical treatment for mitral valve papillary fibroelastoma which is an uncommon and rare benign tumor. The patient was a 62-year-old woman who had TIA (paralysis of left leg) and was admitted with the diagnosis of cardiac tumor. Before operation, the tumor was detected in the left atrium two-dimensional echocardiography, attached to the anterior leaflet of the mitral valve. At operation, the tumor was 11×8mm in size, with a yellow jelly-like and fragile appearance, attached to the same position as indicated by echocardiography. As the tumor occupied over one third of the leaflet, it was excised including all the anterior leaflet of the mitral valve and a prosthetic valve was replaced leaving the posterior leaflet intact. The tumor was diagnosed as papillary fibroelastoma by pathological examination. The postoperative course was uneventful.