An 80-year-old man with the diagnosis of acute aortic dissection was rushed to the emergency department. Preoperative transthoracic echocardiography showed pericardial effusion and mild aortic regurgitation; however, the mitral valve was not observed. Although the false lumen was thrombosed, emergency surgery was performed because of the patient’s severe hypotension. After induction of general anesthesia, transesophageal echocardiography was performed to evaluate cardiac function. Transesophageal echocardiography showed a thickened basal interventricular septum, severe mitral regurgitation, and anterior systolic motion of the anterior mitral leaflet, in addition to pericardial effusion and mild aortic regurgitation.
  In emergency cardiovascular surgery, there may not be sufficient time to assess cardiac function. Because new findings that have not been diagnosed preoperatively may influence treatment decisions, it is important to evaluate the entire heart by intraoperative transthoracic echocardiography in addition to the sitestargeted for surgical intervention.

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 Severe bradycardia and hypotension during arousal from sedation with dexmedetomidine in a patient with combined spinal and epidural anesthesia is rare. We present a case of a 60-year-old woman who underwent total hip arthroplasty (THA) under combined spinal and epidural anesthesia (CSEA). Severe bradycardia (10 bpm) and hypotension were developed at arousal from sedation with dexmedetomidine prior to the end of the surgery. At that time, she complained of shoulder pain. Cardiac rhythm was restored by the administration of atropine. She was not under high spinal anesthesia. This severe bradycardia was mainly attributed to Bezold-Jarisch reflex (BJR) with decreased preload due to the low concentration of dexmedetomidine and increased inotropic state because of severe pain. BJR may develop during arousal from sedation with dexmedetomidine under combined spinal and epidural anesthesia.

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