The transition to the new specialist certification system has progressed in cardiovascular surgery, enabling many surgeons to obtain specialist certification earlier than before. This study focuses on conditions that are particularly easy to overlook factors in the application process, namely academic activities, surgical experience, and Off-the-Job Training (OJT). This report summarizes these changes to facilitate efficient specialist certification applications for trainees.

Giant coronary artery aneurysms are relatively rare and are usually associated with Kawasaki disease, atherosclerosis, congenital disease, or trauma. Although a coronary-pulmonary artery fistula is a known complication, clear guidelines for treatment of this condition remain unavailable. We report a case of multiple giant coronary artery aneurysms associated with a coronary-pulmonary artery fistula in a patient who underwent fistulotomy, aneurysmectomy, and coronary artery bypass graft surgery. A 66-year-old woman was initially evaluated by her primary care physician following right breast cancer surgery. She denied any specific symptoms; however, she was referred to our hospital for evaluation of an abnormal shadow detected on chest radiography. Contrast-enhanced computed tomography (CT) performed at our hospital revealed multiple giant coronary artery aneurysms(approximately 45 mm in size), as well as right and left coronary-pulmonary artery fistulas. We performed simultaneous aneurysmectomy, fistula resection, and coronary artery bypass grafting for management of the giant coronary artery aneurysms concomitant with coronary-pulmonary artery fistulas. Threedimensional CT was useful for accurate imaging of the location of the coronary artery aneurysms, fistula vessels, and the left anterior descending, and left circumflex arteries. It is essential to accurately delineate the boundary between the aneurysms and healthy coronary arteries and fistula vessels, and coronary artery bypass graft surgery should be performed if necessary. We report a rare case of the aforementioned clinical condition, together with a literature review.

The patient was a 68-year-old man. In January 2017, he underwent aortic valve replacement (Carpentier-Edwards Perimount Magna, 25 mm, Edwards Lifescience Corporation, Irvine, USA) for aortic stenosis and coronary bypass surgery with two saphenous vein grafts (SVG-#7 and SVG-4PD) for asymptomatic myocardial ischemia. He was treated as an outpatient by a local physician for at least a week during November 2017, with a principal complaint of mild fever, but no other significant symptoms. Transthoracic echocardiography suggested prosthetic valve endocarditis, so he was referred to the author's hospital. The day after admission, he had symptoms of thoracic discomfort, and emergency cardiac catheter examination showed a lesion thought to be due to a thrombus in the left main coronary trunk ; so, thrombus aspiration was carried out. However, no improvement in blood flow was achieved, so balloon angioplasty was carried out, with the aim of improving blood flow in the left circumflex artery, where coronary artery bypass grafting had not been performed. Improvement in blood flow was achieved, and a culture was carried out using the aspirated thrombus. Streptococcus pasteurianus was detected in the culture.