The patient is a 47-year-old male who was rushed to the hospital after experiencing fainting during exertion. Head magnetic resonance imaging (MRI) and electroencephalography showed no abnormalities. Elevated myocardial biomarkers indicated cardiogenic syncope. Coronary angiography (CAG) and coronary computed tomography (CT) revealed that the right coronary artery originated above the right-left coronary cusp commissure and coursed between the aorta and pulmonary artery. While no definitive ischemia was observed in various tests, elevated cardiac enzymes upon admission suggested transient ischemia of the right coronary artery as a likely cause of the syncope. Consequently, right coronary reimplantation surgery was performed after thorough discussion with the patient. His recovery has been favorable, with no recurrence of symptoms observed during follow-up. Anomalous origin of the right coronary artery has been reported in asymptomatic cases or cases where ischemia cannot be confirmed, leading to varying treatment approaches. This report describes a case where successful coronary artery reimplantation was performed following syncope which triggered the discovery of anomalous right coronary artery origin. It includes a literature review to further explore this case.

An 82-year-old male patient who had a history of ischemic heart disease (IHD) and Debranching Thoracic Endovascular Aortic Repair (TEVAR) (right axillary artery-left axillary artery-left common carotid artery) was admitted to our hospital due to sudden chest pain. The diagnosis revealed acute coronary syndrome: 2-vessel lesions, including the left main trunk (LMT) (right coronary artery (RCA) #2 75%, #3 90%, LMT #5 50%, and left anterior descending (LAD) branch #7 75%). Plain Old Balloon Angioplasty (POBA) was performed on the responsible lesion, RCA (#2-3). Off-pump Coronary Artery Bypass Grafting (OPCAB) was initially planned for the remaining lesion. However, cardiogenic shock occurred, and an emergency OPCAB (SVG-LAD, SVG-#4PD) was performed via partial sternotomy (inverted L-shaped incision on the left side), using intra-aortic balloon pumping (IABP). The patient underwent revascularization using great saphenous vein grafts due to the potential for postoperative pleuroperitoneal communication in patients undergoing peritoneal dialysis, as well as the risk of impaired internal thoracic artery (ITA) flow caused by debranching in future involving internal shunts for dialysis. It is important to consider not only the graft but also the thoracotomy, taking into account the perspectives of early weaning and the prevention of perioperative complications.

An 84-year-old woman, who had undergone ligation for a coronary pulmonary artery fistula, coronary aneurysmectomy, and coronary artery bypass grafting at the age of 76 years, was referred to another hospital for chest pain and diagnosed with acute myocardial infarction based on coronary angiography results. The day after admission, she was transferred to our hospital after her blood pressure decreased and echocardiography showed left ventricular rupture. The Impella CP was introduced on the same day, and the surgery was performed on day 8 after one week of heart failure management. Intraoperative findings revealed a ruptured site in the lateral wall, which was repaired by patch closure. The patient was transferred for rehabilitation on postoperative day 24. As the patient was elderly with multiple organ failure and at high operative risk, a preoperative period to allow remodeling of the infarcted myocardium was considered crucial for a successful repair procedure. The left ventricle was decompressed using the Impella system to prevent enlargement of the rupture site in this case, and a 7-day preoperative optimization period was sufficient for improving myocardial damage. Thus, preoperative Impella-assisted management for left ventricular rupture might be effective in cases of free wall rupture after cardiac surgery with stable hemodynamic status as in the present case or oozing rupture.

Acute mitral regurgitation caused by papillary muscle rupture (PMR) is a severe complication often associated with acute myocardial infarction. A 41-year-old male developed acute mitral regurgitation due to posterior papillary muscle rupture during catheter ablation for supraventricular tachycardia. The rupture likely occurred when the chordae tendineae became entangled during catheter manipulation. The patient, a Jehovah's Witness, refused blood transfusion but accepted diluted autologous blood, a cell saver, and cardiopulmonary bypass. The ruptured posterior papillary muscle and anterior leaflet (A2) were excised, and mitral valve replacement was performed using a mechanical valve. Postoperatively, the patient recovered without mechanical circulatory support or blood transfusion and was discharged in good condition. This case highlights the rare complication of papillary muscle rupture during catheter ablation.

Cardiac papillary fibroelastoma (PFE) is a benign cardiac tumor that mainly occurs in the valve leaflets of the left heart. The patient was a 72-year-old man diagnosed with cerebral infarction. Contrast-enhanced computed tomography and transesophageal echocardiography revealed a 12-mm mass in the left atrial appendage (LAA), and we decided to undergo emergency cardiac tumor resection due to embolism onset. Postoperative pathological examination revealed an extremely rare cardiac PFE originating in the LAA.

A 73-year-old man, who underwent total esophagectomy and gastric tube reconstruction via the retrosternal route for esophageal cancer 10 years eariler, was referred to our hospital with chest pain. He was suspected of acute coronary syndrome, and coronary artery angiography was performed, showing in-stent restenosis of the proximal site of the right coronary artery, diagnosed as the culprit lesion, and drug-coated ballooning was performed. His symptoms improved, however, the poor expansion of the stent and in-stent stenosis remained, and he was referred to our department for coronary artery bypass surgery. Because the gastric tube was reconstructed just below the sternum and performing sternotomy seemed to be difficult, a left mini-thoracotomy approach using great saphenous vein was planned. Under general anesthesia, an approximately 10-cm skin incision was made on the left fifth rib from the anterior axillary to the midclavicular line, and the chest wall was opened at the fifth and third intercostal spaces from the same skin incision, to secure views of the AV node branch and ascending aorta. First, the great saphenous vein was anastomosed to the ascending aorta from the third intercostal space, using 3.8 mm puncher and Heartstring III (Getinge, Lindholmspiren, Sweden). After that, the graft was guided extrapericardially via the left intrathoracic cavity, and was anastomosed to the AV nodal branch from the fifth intercostal space. The graft blood flow was 48 ml/min. The postoperative course was uneventful and contrast-enhanced CT confirmed the patency of the graft.

An 89-year-old female was referred to her local doctor with persistent chest pain. She was rushed to our hospital because acute coronary syndrome was suspected. Emergency catheterization revealed a severe stenosis in left main trunk. An intra-aortic balloon pump (IABP) was placed, and we planned urgent surgery. During off-pump coronary artery bypass grafting, mitral valve regurgitation due to systolic anterior motion (SAM) occurred, her hemodynamics remained unstable after the operation. We performed tapering of catecholamine, and gave intravenous fluids and use of β-blocker to her. But what most improved her hemodynamics was that we removed the IABP.

Case 1: A 60-year-old female with subarachnoid hemorrhage was diagnosed with infectious endocarditis. The echocardiography showed severe aortic regurgitation due to quadricuspid valve and patent foramen ovale. We performed aortic valve reconstruction using autologous pericardium (Ozaki procedure) and patent foramen ovale direct closure. Case 2: A 54-year-old male was diagnosed with aortic regurgitation. The echocardiography showed severe aortic regurgitation due to quadricuspid valve. We performed the Ozaki procedure. The most common surgical technique for quadricuspid aortic valve is reported to be va1ve replacement. In the present study, we experienced two cases of successful aortic valve reconstruction using autologous pericardium. The Ozaki procedure is often indicated for congenital quadricuspid aortic value because of providing physiological hemodynamics without anticoagulation.

MYH9 disorders are autosomal dominant disorders characterized by thrombocytopenia with giant platelets and leukocyte inclusions. This disease is the most frequent of the congenital macrothrombocytopenia, estimated at about 1 in 100,000. We performed double valve replacement for aortic valve stenosis and mitral valve regurgitation with MYH9 disorder without hemorrhagic complications or infections. A 78-year-old woman was on maintenance hemodialysis, and had no particular subjective symptoms. Chest X-ray showed cardiomegaly. Echocardiography revealed aortic valve stenosis and mitral valve regurgitation. Surgery was performed with perioperative platelet transfusion for thrombocytopenia. To reduce operative time and blood loss, we chose valve replacement instead of valvuloplasty for the mitral valve, and performed double valve replacement of the aortic valve and mitral valve. The postoperative course was good without recognizing hemorrhagic complication and infectious disease in the perioperative period.

A 45-year-old man with no history developed pain and paralysis in his left lower extremity. When he visited his previous physician, CT was performed, which showed Stanford type A aortic dissection with an aberrant right subclavian artery and Kommerell's diverticulum and narrowing of the true lumen of the left common iliac artery. He was accompanied by lower limb symptoms. He was then rushed to our hospital for emergency surgery. The operation was planned and performed in two stages. A median sternotomy was conducted, and cardiopulmonary bypass using the right common femoral artery, left axillary artery, and right atrium was initiated. Deep hypothermic circulatory arrest and antegrade selective cerebral perfusion were performed. The tear's entry was located in the distal arch of the aorta. The aortic arch was transected between the left common carotid and left subclavian arteries. We inserted an open stent graft to cover the diverticulated origin of the right subclavian artery. The left subclavian artery was reconstructed using a fenestration technique. The ascending aorta, aortic arch, and right and left common carotid arteries were reconstructed using a 4-branch prosthesis graft. The right subclavian artery was reconstructed through the thoracic cavity. On the day after the surgery, we performed percutaneous embolization of the right subclavian artery distal to the Kommerell's diverticulum. Postoperative CT showed no endoleakage or blood flow to the Kommerell's diverticulum. The patient's postoperative course was uneventful.

An 80-year-old male patient underwent endovascular aneurysm repair (EVAR) for a 60 mm infrarenal abdominal aortic aneurysm (AAA) at the age of 78. Intraoperative angiography detected an endoleak of indeterminate origin, leading to a decision for postoperative surveillance. Follow-up contrast-enhanced CT imaging revealed proximal main body infolding and a Type 1a endoleak. Despite these findings, the patient declined further intervention at that time, necessitating continued conservative management. Eighteen months postoperatively, the aneurysm diameter had increased from 60 to 63 mm, warranting additional endovascular intervention. Initial attempts to correct the infolding with balloon angioplasty were unsuccessful in eliminating the endoleak. Consequently, a secondary stent graft was deployed within the initial stent graft, successfully resolving the endoleak. At the four-month postoperative follow-up, there was no evidence of recurrent stent graft infolding.

We report on a rare case of a left subclavian artery aneurysm concomitant with Loeys-Dietz Syndrome (LDS) which required us to operate in childhood. A 12-year-old female, who had been diagnosed with LDS by genetic examination one year eariler, was revealed to be suffering from a left subclavian artery aneurysm (25 mm in diameter) by follow up chest MRI scan. Hybrid surgery consisting of coil embolization of aneurysm and surgical revascularization of the left subclavian artery and left vertebral artery was performed successfully. The patient was discharged on postoperative day 8.

This column is a roundtable discussion featuring three U40 members who have been extensively involved in the organization and planning of hands-on training, along with Mr. Park, the CEO of EBM Corporation. The four participants discuss hands-on training in the field of cardiovascular surgery. Drawing on their experiences with programs such as the Cardiovascular Surgery Summer School, Basic Lecture Course (BLC), Online BLC, Advanced Lecture Course (ALC), and the coronary anastomosis competition “Challengers' Live Demonstrations,” they explore the essence of hands-on training, current challenges, and future prospects in this field.