INTRODUCTION: The sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are the cornerstones of cardiovascular adaptation.Autonomic dysfunction produces symptoms that overlap with hypofunction of the RAAS, namely hypoaldosteronism. The simultaneous presence of both disorders is not uncommon, especially in patients with CAD undergoing CABG surgery. Objective: This is the case of a patient with recurrent episodes of syncope and severe bradycardia, found to have both hyporeninemic hypoaldosteronism and carotid sinus hypersensitivity. We describe those interrelated phenomena and their association with CAD and CABG surgery. Case presentation: Our patient is a 63-year-old male with a history of hypertension (On Bisoprolol, Valsartan and Hydrochlorothiazide) and hyperlipidemia presenting for coronary artery bypass grafting for triple vessel disease. On the day of admission, the patient lost consciousness briefly and was transiently hypotensive (60/30 mm Hg) with a heart rate of 65 bpm. He reported having had similar self resolving episodes in the past at times of emotional stress. The next day, the patient underwent CABG surgery that was uneventful. Four hours later he developed another episode of unprovoked hypotension that resolved with the administration of neosynephrine. On postoperative day 3, while removing the central line from the right IJ vein, he lost consciousness and had a cardiac pause of 5 seconds. His blood pressure was 70/45 mm Hg. He regained consciousness immediately afterwards upon leg elevation. A carotid massage resulted in a 7 seconds cardiac pause, confirming the presence of carotid sinus hypersensitivity, necessitating the insertion of a pacemaker. However the patient lost consciousness again the next morning despite a normal functioning device. Endocrinology work up was initiated to rule out adrenal insufficiency. It revealed an undetectable aldosterone level with a low-normal renin level, ie hyporeninemic hypoaldosteronism.No hyponatremia, hyperkalemia, renal insufficiency or hypocortisolism were noted. Patient was started on fludrocortisone 0.1 mg daily, and his hemodynamics improved.He remained free of symptoms with normal electrolytes and vital signs on follow up since then. Conclusion: This case describes coexistence of hyporeninemic hypoaldosteronism and carotid sinus hypersensitivity. Although both entities might seem unrelated, a review of the literature and the physiology of cardiovascular hemodynamics revealed that CAD leads to autonomic dysfunction, which can present as carotid sinus hypersensitivity as in our case. In turn, the impaired adrenergic function blocks the activation of renin, leading to hypoaldosteronism and hypofunctioning RAAS. CABG surgery unmasked those interrelated entities. Patient was treated successfully with pacemaker placement and fludrocortisone replacement.

The sympathetic nervous system and the renin-angiotensin-aldosterone system (RAAS) are the cornerstones of

Coronary artery fistulas (CAF) are rare but hemodynamically significant anomalies. Although asymptomatic, they can be associated with several cardiorespiratory conditions. Coronary to bronchial fistulas (CBF) account for 0.5% to 0.61% of coronary artery fistulas, with fistulas arising from the right coronary artery being exceedingly rare. These fistulas are known to be associated with bronchiectasis but not lung bullae. The following paper reports a rare case of a coronary to bronchial fistula associated to bronchiectasis and lung bullae. The patient presented for dyspnea and was found to have a large lung bullae, bronchiectasis and a coronary to bronchial artery fistula arising from the right coronary artery and terminating into the left bronchial artery. The CBF was successfully managed first with percutaneous microcoil embolization then the bullae was resected thoracoscopically three days later. However, more case reports are mandatory in order to further understand the etiology and pathophysiology of these fistulas, elucidate their relationship to other pathologies such as bronchiectasis and lung bullae and determine the optimal therapeutic measures.

Classic open ascending aortic replacement is an effective treatment for Stanford type A aortic dissection However it is associated with a mortality ranging between 15 to 60%. This incidence is even higher in recurrent cases. In these patients, hybrid procedures which combine thoracic endovascular aortic repair (TEVAR) with aortic arch vessel bypasses are successfully adopted. This paper reports a successful hybrid management of aortic arch pseudoaneurysm in a 66 year old female patient known to be hypertensive, diabetic,smoker dyslipidemic on dialysis and who underwent one year previously a surgical ascending aortic repair. Aortic arch vessel bypasses-necessary in this case-were facilitated by the presence of an aberrant right subclavian artery known as Arteria Lusoria-This variant, a rare embryologic anomaly of the aortic arch vessels, described by Hunauld in 1735, was used as an inflow artery to the right common carotid allowing the surgeons to avoid a left to right common carotid artery bypass known to be associated with many complications. Although the hybrid management seems a feasible and safe option especially in high risk patients not eligible for open surgical repair, furher clinical studies and development of new devices dedicated to treat ascending aortic diseases are fundamental to improve outcomes.

Mitral valve rupture is a very rare and lethal complication following coronary artery bypass grafting (CABG). We report in this paper a case of mitral valve rupture ninety hours following CABG and coronary endarterectomy and we review the literature for similar cases in order to determine the different etiologies and mechanisms that may precipitate such serious adverse event and to define the measures that will help us diagnosing and treating promptly this complication.