Congenital anomalous anatomy and course of coronary arteries are common however atresia of LMS is extremely a rare condition. Fewer than 50 cases of congenital atresia of left main stem coronary artery have been reported in the literature. The ostium or trunk of the left coronary artery is atretic, and the left coronary artery and its branches are supplied by the right coronary artery via coronary collaterals in a retrograde direction. The pattern of presentation varies depending on the age and anatomy of the patient. According to the literature these cases present at a very early age with signs of heart failure whereas adults may present with angina or shortness of breath. Its clinical signs and symptoms often resemble anomalous origin of the left coronary artery from the pulmonary artery and endomyocardial fibrosis. In literature there are only five adult cases reported with congenital atresia of LMS and an interesting fact is that one out of those five cases was diagnosed on autopsy to have atresia of LMS. That patient was a female at age of 76 years who died of reasons other than heart symptoms. Therefore it may be inferred that the range of symptoms vary from being completely asymptomatic to overt heart failure.

Type A aortic dissection after percutaneous coronary intervention is a rare and life-threatening situation. The reported incidence ranges from 0,02% to 0,6% of all diagnostic and interventional percutaneous procedures. We describe a case of aortic dissection after percutaneous coronary intervention in a patient with acute myocardial infarction from spontaneous coronary artery dissection. The patient was initially treated with primary percutaneous coronary intervention of the affected left coronary artery branches and left main coronary artery. Conservative management for the aortic dissection proved inadequate due to increasing diameter of the false lumen and the patient was referred to our cardiovascular unit for definite surgical management.

Pseudoaneurysms of the aorta are rare complications of cardiac surgery, and sternal re-entry to address the pathology is particularly challenging. In this case, we describe a rare presentation of thoracic aortic pseudoaneurysm due to chronic erosion from a sternal wire, 10 years following the index operation. The patient was treated in two-stages, including carotid-subclavian bypass, followed by sternal re-entry with total arch replacement and frozen elephant trunk, employing cardiopulmonary bypass via femoral and axillary cannulation. Despite the high risks of rupture/haemorrhage associated with sternal re-entry, operative success for aortic pseudoaneurysms can be achieved with careful planning and safe bypass strategies.

At a time where delivering the best quality of care is the raison d’être of the health service, outliers can pose a serious challenge to both clinicians and policy makers. Methods of outlier detection are highly variable. The collection and assimilation of outcome variables can also be very challenging. Despite this, the publication of surgeon specific data has brought the concept of outliers into the public eye and the consequent punitive action affected upon surgeons can be deleterious to clinician psychology and patient perception. Simultaneously, positive outliers are rarely mentioned and never rewarded. Moving forward, the use of more objective outcomes, including novel biomarkers and patient-centred data, as well as innovative statistical strategies and management cultures, can positively evolve the healthcare paradigm for the future.