A 10-day-old male neonate underwent repair of mixed-type total anomalous pulmonary venous connection. The left upper pulmonary vein connected to the left innominate vein by way of a vertical vein. The other veins converged to form a common pulmonary vein and drained to the coronary sinus. As the common pulmonary vein was not stenotic, normal coronary sinus unroofing was undertaken and the postoperative course was uneventful. Five months later pulmonary vein stenosis (PVS) occurred at the junction of the common pulmonary vein and coronary sinus. At reoperation the common pulmonary vein was deeply incised to the point near the pulmonary venous orifice, and the stenotic tissue was resected. Although he was discharged from the hospital on the 10th postoperative day, PVS recurred at age 9 months and a second reoperation was undertaken. This time, the common pulmonary vein was excised and the anterior wall of each pulmonary vein was incised to drain independently and directly to the left atrium without causing turbulence. The left upper pulmonary vein was anastomosed to the left atrial appendage. Pulmonary angiography 18 months after the second reoperation revealed the pulmonary venous pathway to be nonstenotic.

The incidence of ventricular subepicardial aneurysm following myocardial infarction is quite low. We report a case of subepicardial aneurysm that was diagnosed on postoperative pathohistologic examination. A 69-year-old man was admitted to our hospital because of left ventricular aneurysm following myocardial infarction. The patient had left main trunk disease, triple-vessel coronary artery desease and low output syndrome. Under cardiopulmonary bypass with the heart arrested, the aneurysm was resected and the defect was closed. The suture line was reinforced using Teflon felt and GRF glue. A saphenous vein graft was anastmosed to the left anterior descending artery. On pathohistologic examination, the wall of the aneurysm was found to be composed of fibrotic tissue, myocardial fibers, medium-sized pericardial arteries, epicardium and fibrin thrombi. We diagnosed this as subepicardial aneurysm.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.

Under scheduled anticoagulation therapy, surgery for abdominal aortic aneurysm was performed in 4 patients who had undergone heart valve surgery and implantation of a mechanical prosthesis. Warfarin and antiplatelet agents were prescribed in all cases preoperatively. Antiplatelet agents were discontinued from seven to 10 days before operation. Warfarin was stopped from two to three days before operation and heparin (200IU/kg/day) was administered by continuous intravenous infusion to produce an activated clotting time of around 150 seconds. Bolus intravenous heparin of 3, 000 IU was added before aortic crossclamp. Oral anticoagulants were resumed from the beginning of oral intake, and heparin was stopped when the prothrombin time reached therapeutic levels (% PT=40%). In three patients perioperative courses were uneventful. Intraperitoneal hemorrhage occurred in one patient who simultaneously underwent cholecystectomy and aneurysmectomy with Y-grafting. He required blood transfusion and interruption of anticoagulation. Brain thromboembolism occurred in this patient 26 days after the operation. We believe that scheduled anticoagulation for the operation of abdominal aortic aneurysm is safe and useful in patients with prior prosthetic heart valve surgery. However, the coexistence of coagulopathy requires more intensive anticoagulation therapy.

Objective.-To survey a broad sample of Japanese internists regarding the effects of postgraduate training on their ability to provide ambulatory care.
Design.-Analysis of internists trained at university or non-university hospitals (as designated by the Ministry of Health and Welfare) by written questionnaire.
Results.-74.0% of respondents (127 in total) had undergone ambulatory care training. 30.7% were trained in outpatient clinic sessions that were held more than once a week on average. 85.8% of respondents said they recognized the differences between ambulatory care and inpatietn care. Furthermore, the percentage of respondents who understood such differences during their postgraduate training periods was higher in the group that had had ambulatory care training than the group that had not. Many respondents also suggested the necessity of training in non-internal medicine specialties (e. g. dermatology, OB-GYN, otolaryngology, orthopedics, urology and ophthalmology) that were not popular postgraduate training programs.
Conclusion.-Postgraduate training had a large effect on the ability of internists to provide ambulatory care. Japanese postgraduate training is still not sufficient in this regard. Residency training programs should put more emphasis on ambulatory care.

Our previous study concerning evaluation methods of postgraduate clinical training showed a usefulness in improving clinical training, especially in the fields of clinical skills and knowledge. However, it also pointed out the unsolved problem of assessment of those behaviors in which no significant differences were shown throughout the residency period. In order to solve this problem, a feedback system has been introduced, consisting of self-evaluation during the residensy, and appropriate counseling regarding hortcomings.
In the present study, the effect of this feedback system on clinical training, particularly on physician behavior, has been analyzed. The study was performed by comparing evaluation scores, based on a five-point scale, from two groups: 35 residents who did not undergo the feedback system, and 84 residents who had. Clinical skills, knowledge, positiveness, behavior with patients and colleagues, and patients' records, were each evaluated after discussions by the teaching staff.
Our results showed that there was a significant improvement not only in clinical skills and knowledge, but also in physician behavior in the group using the feedback system. Thus, it appears that this feedback system is useful in improving postgraduate clinical training.

Causative factors for thrombi formation in left atria of 38 patients with mitral stenosis who underwent mitral valve surgery (open mitral commissurotomy or mitral valve replacement) alone or in combination with other procedures were studied. There were 9 cases of left atrial thrombosis (LAT). Left atrial diameter was increased in LAT(+) group (6.1±1.6cm) compared with LAT(-) group (4.6±0.7cm). There was significant difference in the left atrial diameter between the two groups of patients (p<0.01). Cardiac output was decreased in LAT(+) group (3.04±0.74l/min) compared with LAT(-) group (3.99±1.07l/min). Cardiac output of LAT (-) group was significantly larger than that of LAT(+) group (p<0.05). Mean transition time of blood through left atrium (MTT_LA) was calculated using left atrial volume and cardiac output. In LAT (+) group, MTT_LA was significantly increased (6.2±3.9sec) compared with LAT(-) group (2.9±1.6sec). It is considered that, in mitral stenosis, prolongation of MTT_LA is one of the risk factors for thrombi formation in the left atrium.

This is a case report of a 57-year-old woman with high aortic occlusion (HAO) who had acute symptoms of severe ischemia of the lower extremities and the intrapelvic organs. Generally, HAO is a chronic ischemic disease of the lower extremities and the intrapelvic organs; therefore, acute HAO is relatively rare. Acute thrombotic occlusion of a major collateral artery might be the cause of acute HAO. Laser Doppler flowmetry of the sigmoid colon was useful to evaluate the ischemia of intrapelvic organs. Thrombectomy of the juxtarenal portion with the suprarenal aortic cross clamp was performed within four minutes, then the clamp was moved to the infrarenal portion. The remaining occluded aorta was replaced with a Y-shaped knitted Dacron graft. She had no symptoms after the surgery except renovascular hypertension. Seventy five percent stenosis of the right renal artery was exacerbated to 99%. Vascular clamping of the right renal artery might have been the cause of severe stenosis. Percutaneous transluminal renal angioplasty was successfully performed after the surgery. Aggressive renal artery reconstruction during surgery is recommended in cases with moderate or severe renal artery stenosis.