An unusual case of a 71-year-old man with massive sinuses of Valsalva presenting with coronary insufficiency was reported. Primarily, he had undergone aortic valve replacement (AVR) with a diagnosis of severe aortic regurgitation (AR) and annulo-aortic ectasia (AAE). Four years after the primary operation, he came to our hospital as an emergency admission complaining of chest pain. Electrocardiography showed sinus rhythm with ST wave elevation in limb leads of II, III and aVF and a diagnosis of acute myocardial infarction was made. Coronary angiography revealed right coronary insufficiency and aortography showed massive sinuses of Valsalva (diameter 8.5cm) with minimal functional AR. At the second operation, the right coronary artery was severely stretched and attenuated over the surface of the right coronary sinus. The ostium was found to be free of atherosclerosis. A composite reconstruction of the aortic root with a new valved conduit and reimplantation of coronary arteries were performed. The postoperative course was uneventful. Aneurysmal change of the sinus of Valsalva is rare, and it is reported that the mean maximal diameter is 5.4cm in this type of AAE. In our case, the unusual dilation of the sinuses of Valsalva resulted in right coronary insufficiency. This case reminded us that aortic root replacement must be applied in patients with AAE as the initial treatment of choice.

A rare case of secundum type atrial septal defect associated with cleft of the anterior mitral leaflet in 63-year-old man is reported. The electrocardiogram showed right bandle branch block and indeterminate QRS axis. Preoperative cardiac catheterization revealed left to right shunt at the atrial level and moderate mitral regurgitation due to a cleft in the anterior mitral leaflet. Marked tricuspid regurgitation due to a dilated annulus concomitantly existed. The valve deficiencies were repaired and the atrial septal defect was closed at operation. Forty cases of secundum type atrial septal defect associated with cleft mitral valve were discussed about their electrocardiograms and operative indications.

Between January, 1975 and June, 1990, 67 patients underwent surgical treatment for infective endocarditis at our hospital. Of 67 patients, 27 patients showed active endocarditis at the time of operation. In these 27 patients, 20 had active endocarditis of the native valve (NVE), and the seven had active prosthetic valve endocarditis (PVE). The interval between onset of infective endocarditis and operation ranged from 7 to 252 days (mean, 36 days). In the operative results, 3 of 20 patients (15%) with NVE and 2 of 5 patients (40.0%) with PVE died before discharge from the hospital. According to analysis of preoperative hemodynamic state and bacteriological data, the determinant factors of operative mortality and morbidity were preoperative NYHA functional classification, the interval between onset of infection and operation, and annular destruction (annular abscess). Patient's age, preoperative renal function, positive blood culture, the site of infection, and positive culture or stain of the surgically excised valve did not play an important role to determine operative mortality and morbidity. It is our conclusion that all patients with infective endocarditis who develop progressive congestive heart failure and echocardigraphical extravalvular infection despite medical treatment, should have prompt valve replacement.

A 72-year-old man suffering from congestive heart failure, swelling of the lower limbs and hematuria was transferred from another hospital with a diagnosis of large aneurysms of the abdominal aorta and the left common iliac artery. Iliac arteriovenous fistula (AVF) was definitively diagnosed preoperatively by contrast-enhanced CT and angiogaphy. At operation, an infrarenal abdominal aortic aneurysm of 8cm and left iliac arterial aneurysm of 12cm were identified. After proximal and distal aortic clamping, the aneurysm was entered and an AVF orifice of 1cm communicating with the left common iliac vein was disclosed at the right posterior wall of the left common iliac artery. Venous blood reflux was controlled by inserting an occlusive balloon catheter to the fistula and intraoperative shed blood was aspirated and returned by an autotransfusion system. The AVF was closed from inside the iliac aneurysm by three interrupted 3-0 monofilament mattress sutures with pledgets. The aneurysms were resected and replaced with a bifurcated Dacron prosthetic graft. The patient had an uncomplicated postoperative recovery; the lower limb edema subsided and heart failure improved rapidly. Preoperative identification of the location of the AVF is mandatory to make surgery safe. Moreover, easy availability or routine use of the devices for controlling undue blood loss such as an autotransfusion system and an occlusive balloon catheter are other important supplementary means to obtain good results of surgical treatment.

1) The study tour was organized by Dr. Hinohara to learn about the medical education in North America and its philosophy to support the method.
2) The McMaster University, which started PBL curriculum in 1969, began COMPASS curriculum which focuses on conceptual thinking and e-learning in which tutorial groups still remain as the key to the learning process.
3) The Duke University, which values the researcher promotion, began a new curriculum including at further integration of basic and clinical medicine and structural clinical training (Intersession).
4) The Washington University, which constructed WWAMI Program that cooperated with the medical institutions in four states surrounding Washington, started College System to support the students and to strengthen their clinical competencies.
5) Common aspects of the innovation of medical education in North America are (1) further integration of the basic and clinical medicine, (2) early exposure to the principle of clinical medicine and (3) promotion of professionalism by Clinical Preceptorship.

A case of 41-year-old man with large candidal vegetation on the tricuspid valve was reported. He was presented with high fever and newly developed heart murmur. Four months before admission, he had suffered from head trauma which required intravenous hyperalimentation and injection of multiple antibiotics through catheter indwelling the superior vena cava. On admission, echocardiogram showed large vegetation on the tricuspid valve, although blood cultures were sterile. At operation, tricuspid valve was replaced with St. Jude Medical prosthesis because large vegetation developed from the anterior tricuspid leaflet was confirmed. Candida albicans was detected by microscopic examination of the vegetation. The total of 1500mg of Amphotericine-B were administered intravenously after operation. His postoperative course was uneventful. We discussed about the availability of echocardiogram for diagnosis and the effectiveness of a combination of chemotherapy and valve replacement for treament of fungal endocarditis.

Cor triatriatum is one of the rare congenital cardiac malformations and once the diagnosis is correctly established, this is amenable to surgical correction. We reported a case of 25-year-old male of cor triatriatum, who had symptomes of easy fatiguability. The diagnosis of cor triatriatum was suspected preoperatively by two-dimensional echocardiogram at first, detecting abnormal diaphragm in the left atrium, and it was confirmed by color Doppler echocardiogram and transesophageal two-dimensional echocardiogram. Cardiac catheterization revealed high pulmonary capillary wedge pressure and the abnormal diaphragm in the left atrium was showed by the pulmonary arteriography. On the operation, the abnormal diaphragm was excised by the trans-septal approach, which had a small fenestration of 8mm in diameter at posterolateral site. Some considerations for clinical diagnosis and surgical treatment are discussed.

A 53 year-old male with mitral valve aneurysm was presented. This patient, who had no episodes of rheumatic fever, was admitted with complaints of general fatigue, dyspnea and continuing high fever. Echocardiographic examination showed an abnormal echo behind the anterior leaflet of mitral valve, protruding into the left atrium during systole. Angiogram showed the same abnormal change of mitral valve and mitral regurgitation (MR) and aortic regurgitation (AR). We diagnosed as mitral valve aneurysm with MR and AR due to infective endocarditis. At operation, it was revealed that the aortic valve was destroyed, resulting in severe AR, and the anterior leaflet of mitral valve was a large aneurysm itself. Both valves were replaced with St. Jude Medical valve prosthesis. Postoperative course was good and with no complications. In Japan, 21 cases of mitral valve aneurysm were reported. We discussed the clinical course and the operative procedure for mitral valve aneurysm in this report.

A 59-year-old man was admitted for treatment of Stanford type B acute dissecting aneurysm with acute renal failure. He had begun hemodialysis one month after onset, because digital subtraction angiography (DSA) revealed that the truelumen was narrowed by a dilated false channel just above the renal artery. Initially axillo-femoral bypass was performed to treat renal failure, and the patients was easily weaned from hemodialysis. Eight months after the first operation, descending thoracic aorta replacement was performed. The patient is doing well one year after operation. In conclusion, axillo-femoral bypass yielded good results because our patient recovered from renal failure and could undergo radical operation safely. Axillo-femoral bypass allowed evaluation of the hemodynamic study before radical operation.

Infra-renal abdominal aortic aneurysms were electively treated by bifurcated endovascular stent grafts (Power Web^TM system, Endologix Co., USA) at 5 Japanese centers. The stent grafting (SG) was applied for candidates nominated by the selection committee after informed consent was obtained according to the IRB in each center. The delivery success rate of 60 patients (53 males) was 96.7%. There were 2 patients with type I endoleaks, resulting in a technical success rate of 93.3%. The operation time of 193±55min and blood loss of 440±240g were significantly shorter and less, respectively in the SG group when compared with 303±88min and 1, 496±2, 025g in 97 patients (83 males) treated by conventional open surgery. Endoleaks were detected in 4 patients (type I: 3, type II: 1) by CT scan taken at the time of discharge or 1 month after SG procedure. Type I endoleak was observed in patients with short and severely angulated SG landing zones. Renal artery obstruction, and temporary buttock pain caused by internal iliac artery occlusion occurred, but there was no hospital death. In 56 patients excluding an SG-unrelated death and a dropout from surveillance, there was no secondary endoleak or marked adverse events at all except 1 SG limb occlusion during a 6-month follow up period. The aneurysm size shrank in 26 patients and remained unchanged in 30 patients. No aneurysm enlargement was observed. The Power Web^TM system is appropriate for minimally invasive surgery for abdominal aortic aneurysms. Long-term follow-up studies will follow.