1) Anjo Kosei Hospital has nearly 40 years of history of the post-primary clinical training course.
2) More than 90% of the young doctors, passed through 2 years of the primary clinical training course, have chosen further training at Anjo Kosei Hospital. During this course they began to start the experience for their own career for specialist.
3) This education program is closely coordinated with Medical Colleges such as Nagoya University and Nagoya City College of medicine. After 4 or 5 years of training at Anjo Kosei Hospital, they continued their training at Nagoya University Hospital or Nagoya City College Hospital for the further career.

Pulmonary vein isolation procedure was performed for atrial fibrillation associated with mitral valve disease in twelve patients. This simple procedure consisted of only isolation of the four pulmonary veins. Combined mitral valve surgery consisted of mitral valve plasty, mitral valve replacement with or without aortic valve replacement and tricuspid annuloplasty. Ten patients returned to a sinus rhythm. Two patients required DDD pacemaker implant for sick sinus syndrome. Left atrial contraction was detected in eight cases by trans-esophageal echography. Compared with the maze procedure, this operation was less invasive and preserved atrial appendage, helping to maintain normal secretion of atrial natriuretic peptide. This study suggests that the pulmonary vein isolation procedure may be an effective and simple maneuver for atrial fibrillation associated with mitral valvular disease.

The present study was to evaluate endothelial nitric oxide synthase (eNOS) protein expression and hemodynamics of pulmonary circulation in rats of "Living high and Training low" (LH+TL). The Sprague Dawley strain of male rats were used at the age of 9 weeks. They were divided according to four conditions of a living low (LL) group, living low and training low (LL+TL) group, living high (LH) group and LH+TL group, for 10 days. We assessed the effects of LH+TL on exercise-induced pulmonary arterial pressure and blood lactic acids under sea-level altitude in catheter-implanted conscious rats. Also, we measured the pulmonary artery under anesthesia and analyzed eNOS protein expression by western blot analysis. The blood lactate levels in the LH+TL rats decreased after maximal treadmill running compared to LL, LL+TL and LH rats (p<0.05). The increase in pulmonary arterial blood pressure with exercise was significantly lower in the LH+TL group than in the LL group (p<0.05). The eNOS protein expressions of pulmonary artery were higher in the LH+TL group than in the LL group (p<0.05). This study indicates that LH+TL reduced the increase of pulmonary arterial blood pressure with exercise at below sea-level altitude. In addition, eNOS protein expressions were enhanced in the pulmonary arteries of LH+TL rats. Thus, we conclude that the high altitude training of LH+TL was a useful method for improvement of endurance exercise ability and this improvement may be associated with pulmonary arterial response.

A 75-year-old man who presented with fever and cough was given a diagnosis with active pulmonary valve endocarditis and transferred to our institution. Blood cultures were positive for Enterococcus faecalis, and transthoracic echocardiography showed a mobile vegetation attached to the pulmonary valve. Despite an 8-week treatment with antibiotics, a relapse of the infection required surgery. During the surgical procedure, we found that the vegetation had destroyed all of the pulmonary valve leaflets. After excising the pulmonary valve leaflets, we implanted a bioprosthetic valve and closed the pulmonary artery with autologous pericardium. The patient completed a 6-week course of intravenous antibiotics and was discharged on postoperative day 68. Postoperative transthoracic echocardiography demonstrated an adequate effective orifice area index. Our case report of isolated pulmonary valve endocarditis without predisposing factors is rare. The implantation of a bioprosthetic valve and enlargement with an autologous pericardial patch is an effective option for achieving a satisfactory hemodynamic profile.

A 29-year-old female with aortic regurgitation associated with aortitis syndrome and severe stenosis of bilateral carotid arteries was reported. She had no symptom of brain ischemia, although an aortogram revealed complete occlusion of the left common carotid artery and the left subclavian artery, and severe stenosis of the right common carotid artery. The intracranial major arteries were perfused totally by the right vertebral artery via collaterals. The transcranial Doppler method and perfusion cintigraphy revealed normal cerebral perfusion. Therefore, we performed conventional aortic valve replacement without reconstruction of carotid arteries. During cardiopulmonary bypass, the mean systemic blood pressure was kept higher than 60mmHg under moderate-hypothermic (tympanic temperature: 25°C) pulsatile perfusion with monitoring of the left middle cerebral artery flow velocity. The patient did not develop any cerebral complications during or after the operation.

A 62-year-old woman was admitted to a regional hospital for acute myocardial infarction. Emergency coronary angiography revealed occlusion of the first diagonal branch, and transesophageal echocardiography showed severe mitral regurgitation due to anterior papillary muscle rupture. She was transferred to our hospital in a state of cardiogenic shock despite the use of high-dose catecholamine and intra-aortic balloon pumping. We immediately performed mitral valve replacement. The patient's postoperative course was uneventful and she was ambulatory when transferred to another hospital on foot on postoperative day 19. Physicians should be aware that fatal anterior papillary muscle rupture may be caused by isolated occlusion of the diagonal branch.

Renal damage caused by hemolysis during cardiopulmonary bypass (CPB) was investigated, and the preventive effects of haptoglobin in regard to this condition was also evaluated. Nineteen patients who underwent open heart surgery were divided into two groups: a control group (n=11) and a haptoglobin group (n=8). In the control group, the level of plasma-free hemoglobin increased significantly after CPB (p<0.01), and this level was strongly correlated with renal tubular leaking enzymes: NAG (r=0.76) and γ-GTP (r=0.81), in the Intensive Care Unit or on the first day after surgery. On the contrary, in the haptoglobin group, in which 4, 000 units of haptoglobin was added in the priming solution of CPB, no increased level of plasma free hemoglobin was observed. Furthermore, leak age of renal tubular enzymes were statistically less (p<0.05). It was concluded that free hemoglobin was a cause of renal damage during CPB and the damage was preventable by the administration of haptoglobin.

Quantitative histochemical analysis of the internal thoracic artery (ITA) and right gastroepiploic artery (GEA) was performed using microspectrophotometry. Arterial specimens from eight patients who underwent coronary bypass grafting using both ITA and GEA grafts were examined. There were seven men and one woman with a mean age of 60 years; ranging from 36 to 73 years. Concerning risk factors, 4 patients had hypertension, 3 had hypercholesterolemia and 2 had diabetes mellitus. The degree of intimal hyperplasia was calculated as follows; Intimal hyperplasia (%)=(I/I+M)×100 (I: area of intima, M: area of media). Quantitative histochemical analysis (smooth muscle cells, elastin, collagen and mucopolysaccaride) of arterial graft was measured by means of microspectrophotometry. Pieces of both the ITA and GEA grafts were obtained immediately before grafting. Each sample was stained with Azocarmin G, Weigert, van Gieson and Alcian Blue stains to identify smooth muscle cells, elastin, collagen and mucopolysaccaride, respectively. Intimal hyperplasia was significantly greater in GEA than ITA grafts (25.3 ±8.7% versus 6.8±3.5%, respectively; p<0.01). In quantitative histochemical analysis of the arterial grafts, the volume of smooth muscle cells was also significantly higher in GEA than ITA at both the intima (ITA; 38.8±7.9%E, GEA; 52.5±7.6%E, p<0.01) and media (ITA; 49.6±6. 5%E, GEA; 59.5±8.2%E, p<0.05). No significant differences in elastin, collagen or mucopolysaccaride content were observed. The greater amount of smooth muscle in GEA grafts may be one reason why the magnitude of intimal hyperplasia was greater in GEA than ITA grafts. Long-term follow-up is necessary to determine the course of atherosclerotic change in arterial grafts.

The relationships between physical activity and childhood body size, low physical fitness epidemic are still unclear. The purpose of this study was to examine the relationship between energy expenditure estimated by doubly labeled water (DLW) method and body fatness, physical fitness in children, and the relationship between physical activity levels and percent time spent in activities. 30 healthy Japanese children (20 boys and 10 girls) participated in this study. The total energy expenditure (TEE) and % body fat were measured by the DLW method over a 6-day period. The physical activity-related energy expenditure (PAEE) was calculated as (TEE × 0.90) – basal metabolic rate (BMR). The physical activity level (PAL) was also calculated as TEE/BMR. The physical fitness tests (8 items) were applied to evaluate fitness, and scores of each test were calculated as overall physical fitness score. The TEE was 2009.8 ± 272.6 kcal/day, the PAEE was 558.4 ± 206.1 kcal/day and the PAL was 1.61 ± 0.18. TEE per weight and PAEE per weight (PAEE/wt) was significantly negatively correlated with % body fat (r = - 0.626; r = - 0.400, respectively). These results suggest that increasing energy expenditure is important for achieving adequate body size. The PAEE/wt was most strongly correlated with physical fitness score (r = 0.680). The PAL was associated with percent time spent of inactivity ( r = -0.506), light-moderate activity ( r = 0.450) and vigorous activity ( r = 0.545). It was suggested that physically active lifestyle would be necessary for childhood health.

The purpose of this study was to examine the relationships between patterns of daily physical activities measured by accelerometer and physical activity level (PAL) in children. Firstly, activity intensities during incremental exercise were measured using a tri-axial accelerometer (HJA-350IT) in twenty one children aged 10.6 ± 0.9 years. As a result of receiver-operating characteristic curve analysis, the cut-off value for discrimination between walking and running activity was set at 7.2 METs of HJA-350IT. Secondly, total energy expenditure (TEE) in daily life was measured by doubly labeled water method, and durations of lifestyle, walking, and running activities were measured by the accelerometer in 6^th grade elementary school children (11 boys and 10 girls). TEE and physical activity level (PAL) were 2,021 ± 343 kcal/day and 1.56 ± 0.17, respectively. The average durations of lifestyle, walking and running activities were 188 ± 30 min/day (50.6 ± 6.0 %), 171±28 min/day (45.9 ± 5.0 %) and 13.3 ± 7.6 min/day (3.5 ± 1.8 %), respectively. The proportion of the duration of running activity was positively correlated with PAL (r = 0.615, p < 0.01), and the proportion of the duration of lifestyle activity was negatively correlated with PAL (r = -0.439, p < 0.05). There was no relationship between the proportion of the duration of walking activity and PAL (r = 0.300, n.s.). These results suggest that running activity is important to increase PAL more than ever in primary school children.