We report a rare case of combined valvular disease concomitant with the communication between the coronary and bronchial arteries. A 76-year-old woman was given a diagnosis of chronic heart failure 8 years previously and received medical therapy but recently she had dyspnea. Ultrasound cardiography revealed aortic regurgitation and mitral regurgitation. Cardiac catheterization confirmed the combined valvular disease and also revealed an aberrant coronary artery. Cardiac computed tomography showed coronary to bronchial artery communication, which caused myocardial ischemia. We performed aortic valve replacement with a bioprosthesis, mitral valve repair, and ligation and division of the aberrant coronary artery. Apart from some postoperative bronchial bleeding that ceased spontaneously the postoperative course was uneventful.

Ebstein's anomaly is a rare congenital heart disease. A 51-year-old man was hospitalized due to Ebstein's anomaly with severe congestive heart failure. He underwent Hetzer's procedure for tricuspid valve incompetence and right atrial isolation technique to restore the sinus rhythm. The postoperative course was uneventful, he was discharged from the hospital on the 21st day after the operation. The cardiothoracic ratio reduced from 74% before the operation to 60%. And his New York Heart Association functional class also improved from III to I after discharge. Hetzer's procedure for tricuspid valve repair in Ebstein's anomaly restructures the valve mechanism at the level of the true tricuspid annulus by using the most mobile leaflet for valve closure without placation of the atrialized chamber. We thus conclude that Hetzer's procedure, with anatomical evaluation of the malformed tricuspid valves before or during the operation, is beneficial as a simple and reproducible method for the repair of certain cases of Ebstein's anomaly.

We report possibly the oldest patient in the world with both a ruptured abdominal aortic aneurysm and shock who was saved by accurate diagnosis and immediate treatment by trained medical teams specializing in emergency medicine, radiology, vascular surgery, anesthesiology, and internal medicine. The 96-year-old patient was transferred to our hospital because of sudden left lateral abdominal pain and hypotension that resulted in periods of unconsciousness and shock. An enhanced CT scan showed that the ruptured infrarenal abdominal aortic aneurysm was surrounded by hematoma that was located mainly in the left lateral abdomen, extended above the renal arteries (Fitzgerald type III), and was 7cm at its maximum diameter. Y-graft replacement was successfully performed after a rapid decrease in the patient's blood pressure was quickly restored by clamping the aortic neck by hand. Following the operation the patient developed ischemic colitis and cholecystitis, which were cured by conservative treatment. The patient was discharged 20 days after the operation. We were able to save this nonagenarian patient with both a ruptured abdominal aortic aneurysm and shock by immediate treatment provided by medical teams that are trained and coordinated.

Bradycardia or asystole during epileptic seizure are referred to as ictal bradycardia syndrome. Ictal asystole is very rare, and there is no report about ictal bradycardia syndrome caused by brain metastases. A 62-year old man was diagnosed as having lung cancer and had multiple brain metastases. The patient had no history of epilepsy and syncope. The patient developed cardiac asystole with sinus arrest for up to 16 seconds. The bradycardia was associated with other signs and symptoms, including abdominal pain, nausea, low blood pressure, sinus arrest, decreased level of consciousness, and staring at a single point. Electroencephalograms showed multiple sharp waves. Repeated seizures, ictal asystole, and coexisting symptoms disappeared after improved treatment of brain metastases by radiation therapy. Therefore, a diagnosis of ictal asystole caused by brain metastases was made. There is no recommended treatment for ictal bradycardia syndrome. However, in the case of ictal bradycardia syndrome caused by brain metastases, treatment of the metastatic tumor might be useful. When patients with cancer present with syncope or sick sinus syndrome, we should consider the possibility of cardiac arrest caused by an epileptic seizure.