In repair of the tricuspid valve (TV) due to Ebstein's anomaly, mobilization of the anterior leaflet associated with longitudinal right ventricle placation (Carpentier's procedure) has provided good results in both short- and long-term follow-up. However, if the anterior leaflet is small or severely deformed, such repair may be ineffective. We report two cases of Ebstein's anomaly (63 and 53 years old) with deformed anterior leaflets of the TV in whom Carpentier's procedure was not feasible. In one patient, the anterior leaflets were broadly plastered on the right ventricle and Carpentier's procedure was tried. However, the repair was converted to valve replacement because of significant residual regurgitation. The other patient had a cleft in the anterior leaflet, therefore Carpentier's procedure was not suitable. The repair restructured the valve mechanism below the true annulus by using the most mobile leaflets for valve closure (modified Hetzer's procedure). This method of repair could be an alternative method to repair of the TV in Ebstein's anomaly, particularly when the anterior leaflet is deformed.

A main symptom of chronic fatigue syndrome (CFS) is fatigue which continues for more than 6 months and does not improve with rest, leading to a marked decrease in quality of life. Other problems include fever, sleep disorder, and headache. Etiologically, a preceding viral infection, immunological disorder, and changes in the central nervous system, especially in hippocampus have been reported. However, the precise pathogenesis of CFS has not been elucidated, and neither diagnostic markers nor effective treatments have yet to be discovered. Here, we report a case of CFS, successfully treated with Kampo medicines.
The patient was a 16-year-old high school student, who had received medical therapy for one year under the diagnosis of CFS. His chief complaint was a continuing fever and strong malaise after influenza infection. At his visit to our outpatient clinic, we confirmed that his symptoms met the criteria for CFS. A combination treatment with Kampo medicine (sanoshashinto) and duloxetine improved his malaise and fatigue in 4 weeks, but fever and anorexia remained. The addition of hochuekkito to the combination dramatically ameliorated his symptoms. This case suggests that Kampo medicines would contribute to the effective treatment of CFS, which is refractory to Western medicines.