Current strategies for pediatric coronary artery bypass surgery have been better clarified through the accumulation of experience and data: 1) Long-term survival rates following pediatric coronary bypass surgery utilizing internal thoracic artery (ITA) grafts are promising, with reported survival rates of 95% up to 40 years post-surgery for patients with Kawasaki disease complications and > 75% for those undergoing coronary transfer operations up to 20 years post-surgery. 2) Bilateral use of ITA grafts in small children can be performed safely and effectively, even during infancy. 3) The increase in the blood supply capacity of ITA grafts occurs more rapidly and effectively than previously thought, allowing for their use in emergency situations involving acute coronary events. 4) Tightening or ligation of the coronary artery distal to the aneurysm combined with ITA grafting to the distal coronary artery can prevent flow competition with careful intraoperative monitoring and care; however, further evidence is needed to establish a definitive surgical strategy. 5) The use of surgical microscopes in pediatric coronary bypass surgery for infants and small children is now accepted by cardiac surgeons.

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Antiplatelet therapy following percutaneous coronary intervention (PCI) has evolved along with the development of antiplatelet agents and coronary stents. The use of P2Y₁₂ inhibitor monotherapy is gradually replacing aspirin monotherapy after PCI, as supported by emerging evidence. Aspirin-free P2Y₁₂ inhibitor monotherapy has also been investigated in several prospective studies as a novel antiplatelet therapy for patients undergoing PCI. This brief review highlights the current status of P2Y₁₂ inhibitor monotherapy and offers future perspectives on its use after PCI.

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The saphenous vein (SV) has been widely used as an aortocoronary bypass graft for coronary artery bypass grafting (CABG) for the past 60 years. However, CABG using the SV as an aortocoronary bypass graft has shown disadvantages of lower long-term graft patency rates and subsequently worse clinical outcomes, compared with CABG using the internal thoracic artery (ITA). Revascularization using an arterial composite graft based on the in-situ ITA increases the length of the arterial graft and allows the extensive use of arterial conduits to revascularize both the left and right coronary territories. In contrast to the arterial conduits which have been commonly used as composite graft configurations in patients exhibiting multi-vessel disease, the SV has not been widely used as a composite graft for CABG because there are concerns when using the SV having disadvantages as a composite graft. In this article, a recent surgical strategy of using the SV as part of a composite graft based on the in-situ ITA will be discussed.

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Coronary artery bypass grafting is a well-established treatment for coronary artery disease, and avoiding cardiopulmonary bypass has attracted attention because of its potential to reduce complications. Japan was an early and extensive adopter of off-pump coronary artery bypass grafting, offering a unique environment to evaluate its outcomes. Using data from the Japanese Cardiovascular Surgery Database, several large-scale observational studies have compared off- and on-pump coronary artery bypass grafting in diverse patient populations. These studies consistently revealed a lower early mortality with the off-pump technique than on-pump, especially in high-risk groups, such as those with severe renal disease or an impaired left ventricular function. However, concerns persist regarding the completeness of revascularization and the higher likelihood of fewer bypass grafts when performing off-pump surgery than on-pump, which may limit the long-term benefits. Analyses focusing on the long-term survival found no definitive advantage of the off-pump strategy, with some evidence suggesting worse outcomes in patients with incomplete revascularization than in others. Furthermore, the experience level of surgeons and hospital procedure volume have emerged as critical factors influencing the success of off-pump surgery, highlighting the importance of technical proficiency. Overall, although the off-pump approach provides meaningful advantages for select high-risk populations, its routine application remains controversial. Future research efforts should target improved selection criteria and broader data integration to establish more definitive conclusions and optimize patient outcomes.

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Reports on bailout stenting for coronary artery occlusion (CAO) after transcatheter aortic valve replacement are limited. This case series proposes a flow chart outlining bailout strategies for CAO, including chimney stenting and orthotopic snorkel techniques, based on coronary occlusion and the risk of stent deformation.

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Ventricular septal rupture is a serious complication of acute myocardial infarction. We encountered a rare case of ventricular septal rupture with intramyocardial dissection extending to the right ventricular free wall. Significant tricuspid valve regurgitation was also observed. The patient underwent a trans-right ventricular double-patch repair for ventricular septal rupture. Intraoperative findings revealed a detached inferior papillary muscle of the tricuspid valve secondary to intramyocardial dissection, which necessitated tricuspid valve replacement. In addition, because the edge of the ventricular septal rupture was extremely close to the mitral valve annulus, concomitant mitral valve replacement was performed to achieve a better fit of the left ventricular side patch. The postoperative course was uneventful, and echocardiography revealed no residual shunt flow. Double valve replacement combined with trans-right ventricular patch repair was useful in addressing this rare situation.

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The right superior septal artery originates from either the right coronary artery or the right sinus of Valsalva and distributes blood to the superior part of the ventricular septum; thus, it can connect to the septal branches of the left anterior descending artery and serve as a collateral source. In the case presented herein, coronary computed tomographic angiography clearly delineated the right superior septal artery, and coronary angiography demonstrated a collateral connection between the right superior septal artery and the septal branch. This collateral artery prevents myocardial infarction in the anterior and septal walls of the left ventricle. The right superior septal artery is clinically important not only as a collateral source to the left anterior descending artery but also as an access route for percutaneous transluminal septal myocardial ablation in hypertrophic cardiomyopathy.

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