Coronary artery anomalies (CAAs) are rare congenital variations with a broad spectrum of clinical implications. While certain configurations are associated with myocardial ischemia and sudden cardiac death (SCD), many remain clinically silent and are discovered incidentally. An anomalous origin of the left main coronary artery (LMCA) from the right coronary artery (RCA) represents an exceptionally uncommon variant, particularly when it arises from the proximal RCA and follows a prepulmonic course. We report the case of a 56-year-old female with a history of immune thrombocytopenic purpura who presented with atypical chest discomfort. She underwent coronary computed tomography angiography (CCTA), which revealed an LMCA originating from the proximal RCA with a prepulmonic (anterior) course, consistent with a Lipton right sinus of valsalva, type II, anterior (RIIA) single coronary artery (SCA) pattern. The coronary artery calcium score was zero, and no evidence of obstructive coronary artery disease was identified. Given the absence of ischemia and the benign anatomical course, the patient was managed conservatively. She underwent periodic outpatient surveillance with symptom reassessment and cardiovascular risk factor monitoring, remaining asymptomatic over three years without adverse cardiac events. Single coronary artery anomalies are rare, with reported prevalence estimates of approximately 0.06% in angiographic series, although these data may be influenced by referral bias. Among these, LMCA arising from the RCA accounts for only 0.0024%-0.02% of reported cases. Clinical significance depends on vessel course as well as associated morphological features. Interarterial variants carry higher risk, whereas prepulmonic and retroaortic courses are generally considered lower risk. CCTA is valuable for defining anatomy and guiding individualized risk stratification, while functional testing may be considered selectively when symptoms or uncertain hemodynamic significance are present. This case highlights a rare but benign coronary anomaly and underscores the importance of integrating anatomical findings, clinical presentation, and selective adjunctive testing to guide management while avoiding unnecessary invasive intervention.

BACKGROUND:Pulmonary embolism (PE) and ischemic stroke, particularly when associated with a patent foramen ovale (PFO), present complex management challenges that require careful consideration. CASE SUMMARY:A 64-year-old man experienced recurrent ischemic strokes and acute PE, with complications including right ventricular strain and a small PFO with moderate shunting. He presented with dyspnea, hypoxia, and right-sided weakness. Imaging revealed bilateral PE and right ventricular strain. Initial management included intravenous unfractionated heparin and successful embolectomy, followed by long-term anticoagulation and antiplatelet therapy. Multidisciplinary discussions addressed the potential for PFO closure, which was postponed until Holter monitoring could rule out atrial fibrillation. DISCUSSION:This case highlights the complexity of immediate stabilization with long-term management in patients with concurrent thromboembolic conditions. It underscores the potential importance of PFO closure in selected cases. TAKE-HOME MESSAGES:A multidisciplinary approach is crucial in managing complex thromboembolic conditions, and PFO closure may benefit specific patients.

Intramyocardial dissecting hematoma (IDH) is a rare complication that may emerge from myocardial infarction, thoracic injury, or percutaneous intervention. In the past, IDH was diagnosed through surgical intervention or postmortem autopsy. We present a case of a 70-year-old male with comorbidities who admitted to the intensive care unit after suffering out of hospital pulseless electrical activity cardiac arrest and obtained return of spontaneous circulation after chest compressions. Initial electrocardiogram (ECG) showed ST elevation in the anterolateral leads. Repeated ECG a few minutes later showed junctional rhythm bradycardia with a rate of 27 and serial changes of an anterolateral infarct were present and placed on percutaneous pacing with vasopressors. The troponin I peaked at 1.880. Transthoracic echocardiography (TTE) portrayed a hyperechoic mobile filamentous structure near the cardiac apex, which was thought to be a false left ventricular (LV) tendon initially. A repeat TTE with the use of an ultrasound enhancing agent (sulfur hexafluoride) revealed an apical neocavity with no contrast filling, suggestive of a large apical IDH within the LV. The patient expired because of cardiac arrest secondary to cardiogenic shock refractory to pressor support, with no autopsy performed. This case highlights an uncommon and timelier diagnostic modality of IDH in deference of more costly and prolonged imaging studies.

Patients with severe calcific native aortic valve stenosis (AS) who require valve replacement have two options, surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). TAVR was approved in late 2011 for extremely high-risk patients and was subsequently approved for high-risk (2012), intermediate-risk (2016), and low-risk (2019) patients. In 2019, TAVR procedures surpassed SAVR procedures for the first time in the United States. The approach to anesthesia for this procedure has also evolved. Initially, general anesthesia (GA) was preferred, but currently, conscious sedation (CS) is favored. This review aims to clarify the indications and contraindications for both approaches, as well as the advantages of one approach over the other. Recent studies show that conscious sedation has better outcomes in terms of all-cause mortality, procedure complications such as stroke, myocardial infarction, infection requiring antibiotics, acute kidney injury, and the need for inotropes or vasopressors.

Peripheral artery disease (PAD) is associated with high rates of readmission following endovascular interventions and contributes to a significant hospital readmission burden. Quality metrics like hospital readmissions affect hospital performance, but must adjust to local trends. Our primary goal was to evaluate risk factors and readmission rates post-percutaneous peripheral intervention in a US-Mexico border city, at a single tertiary university hospital. We performed a retrospective review of patients with PAD undergoing first time peripheral intervention from July 2015 to June 2020. Among 212 patients, 58% were readmitted with median 235-day follow-up (inter-quartile range (IQR) 42-924); 35.3% of readmissions occurred within 30 days, and 30.2% of those were within 7 days. Median time to readmission was 62 days. Active smokers had 84% higher risk of readmission (hazard ratio (HR) 1.84, 95% CI 1.23-2.74, P < .01). Other significant factors noted were insurance status-Medicaid or uninsured (HR 1.94, 95% CI 1.22-3.09), prior amputation (HR 1.69, 95% CI 1.13-2.54), heart failure, both preserved (HR 4.35, 95% CI 2.07-9.16) and reduced ejection fraction (HR 1.88, 95% CI 1.14-3.10). Below the knee, interventions were less likely to be readmitted (adjusted HR .64, 95% CI 0.42-.96). Readmission rates were unrelated to medication adherence.

The coronavirus disease (COVID-19 or SARS-CoV-2) pandemic has brought the global community to a halt. A return to normalcy is dependent on effective reopening strategies that encourage herd immunity through the implementation of vaccines. Cardiopulmonary inflammation has been reported in SARS-CoV-2 infection, independent of the severity, mainly amongst the juvenile population. Cardiovascular involvement following SARS-CoV-2 infection is associated with higher mortality and morbidity. Cardiovascular complications following COVID-19 vaccination have been documented as less severe, with no link between cardiovascular injury and death. This case report describes the presentation of an otherwise healthy 18-year-old male who experienced retrosternal chest pain after receiving a first dose of the mRNA-1273 vaccine. The patient had a negative polymerase chain reaction (PCR) test for COVID-19 infection. An electrocardiogram revealed diffuse ST elevation and PR segment depression, with increased inflammatory markers consistent with pericarditis. Elevation of troponin (16 ng/mL), evidence of borderline reduced ejection fraction (50-55%), and global left ventricular hypokinesis were suggestive of myopericarditis. Infectious and autoimmune studies were negative. The patient was treated mainly with non-steroidal anti-inflammatory drugs and colchicine, which resulted in a significant improvement of clinical symptoms. As the administration of emergency COVID-19 vaccines continues worldwide, it is of paramount importance to be aware of possible adverse events, including those affecting the cardiovascular system.

Chronic Kidney Disease (CKD) is a major medical problem that leads to progressive loss of kidney function in approximately 37 million adults in the United States. Currently, kidney transplantation is the only treatment method that restores renal function; however, the shortage of donor kidneys for transplantation remains a problem. Cell-based therapy provides an alternate approach to augment and restore kidney function. In normal kidneys, dedifferentiation and proliferation of resident tubular epithelial cells are potential mechanisms contributing to repair and regeneration in kidneys with ischemic or chronic disease. We hypothesized that human primary renal cells derived from CKD kidneys could be used to delay the progression of CKD. In a previous study, we demonstrated the feasibility of isolating and expanding renal cells from diseased kidneys and showed that primary renal cells derived from CKD kidneys had similar morphological and functional characteristics to their counterparts from normal healthy kidneys (NK) in vitro. The current study examined the functional and structural effects of CKD derived primary human cells in a rat CKD model. We investigated whether CKD cells are as effective as NK cells for cell therapy. Our results show that primary human renal cells from CKD donors retained their normal phenotypic and functional characteristics, indicating that they could be used for cell therapy to provide functional and morphologic protection from the CKD associated damage in rats by enhancing tubular cell proliferation and reducing apoptosis. These findings suggest that autologous cells obtained from CKD patients could potentially be used for treatments.Funding Information: This study was supported by Tengion Inc. through a sponsored research agreement with Wake Forest Institute for Regenerative Medicine. In addition to supporting the study financially, Tengion Inc. was involved in the study design and progress. This study was supported, in part, by a grant from the State of North Carolina. Declaration of Interests: None declared. Ethics Approval Statement: All procedures were approved by the Wake Forest University School of Medicine Institutional Animal Care and Use Committee.

Purpose of Review This review aims to evaluate the major cardiovascular adverse events (MACE) and antithrombotic approaches in concomitant atrial fibrillation (AF) and atherosclerosis. Recent Findings MACE in concomitant AF and atherosclerosis has been evaluated in recent studies. A recent retrospective study of 2670 patients with AF revealed that atherosclerosis burden with AF can be a marker of adverse vascular outcomes with extracranial atherosclerosis as a potent predictor of MACE. Trials to evaluate the antithrombotic approaches in concomitant atherosclerotic disease and AF has been mainly in patients with coronary artery disease (CAD). AFIRE trial demonstrated that in patients with AF and stable CAD rivaroxaban alone is not inferior to rivaroxaban plus aspirin with better safety profile. Atherosclerosis is common in AF and poses additional risk to patients. Antithrombotic management of atherosclerosis in AF is not well investigated and needs further trial to identify the subgroups that benefit from more intensive antithrombotic measures.

Purpose of Review Atherosclerosis is the largest cause of death in the western world with the role of sex yet to be determined. The purpose of this review is to investigate the role sex may play in the development of atherosclerosis. Recent Findings Differences in plaque burden play a role in atherosclerotic outcome. Men have a higher prevalence of plaque burden, while women have less plaque rupture, necrotic core, and calcium. Differences in hormones, vascular anatomy, and overall lifestyle all play a role. Estrogen's cardioprotective effect is well known, but there is a lack of consensus on testosterone's role. There are varying rates of atherosclerosis between the sexes. Studies have also shown varying differences in the progression of plaque and the type of plaques between sexes. Further investigations need to be done to solidify the role sex may play as a variable in the development of atherosclerosis and how that may impact future treatment goals.

Salmonellae foodborne infections are a well described and documented entity, however cardiac complications of Salmonellae foodborne infections including infective endocarditis (IE) are rare. Here we present a case of infective endocarditis as a result of bacteremia caused by multiple species of Salmonella. The patient initially presented with chest pain, fever and altered mental status. Troponin and ECG were unremarkable. The patient was started on empiric antibiotics. Blood cultures grew Salmonella species serotype O&H. Transesophageal echocardiogram (TEE) confirmed aortic valve vegetation. Regional cultural practices suggested possible contamination attributed to ingestion of rattlesnake meat, a practice that has been previously described and well-established in various Hispanic folk practices. Upon further history taking, the patient was found to be regularly consuming dried rattlesnake meat preparations, a rather common practice in Chihuahua desert region. Surgery was not indicated, and the patient was treated with six weeks of antibiotics. This case presents an opportunity to gain insight into such a unique manifestation of Salmonellae, offering a potential facet of information for clinicians to better understand its presentation, susceptibility, and potential adverse outcomes.

Purpose: Drug-induced nephrotoxicity can occur in patients with pre-existing renal dysfunction or renal ischemia, potentially leading to chronic kidney disease (CKD) and end-stage renal disease (ESRD). Prompt treatment of CKD and the related side effects is critical in preventing progression to ESRD. The goal of this study was to demonstrate the therapeutic potential of urine-derived stem cells (USC) to treat chronic kidney disease-induced by nephrotoxic drugs and renal ischemia. Materials and methods: Human USC were collected, expanded and characterized by flow cytometry. A CKD model was induced by creating an ischemia-reperfusion injury and gentamicin administration. Twenty-eight adult immunodeficient rats were divided into three groups: PBS-treated group (n=9), USC-treated group (n=9), and sham group with age-matched control animals (n=10). Cell suspension of USC (5 x 106 / 100µl / kidney) or PBS was injected bilaterally into the renal parenchyma 9 weeks after CKD model creation. Renal function was evaluated by collection blood and urine samples to measure serum creatinine and glomerulus filtration rate. The kidneys were harvested 12 weeks after cell injection. Histologically, the extent of glomerulosclerosis and tubular atrophy, the amount of collagen deposition, interstitial fibrosis, inflammatory monocyte infiltration, and expression of transforming growth factor beta 1 (TGF-ß1), and superoxide dismutase 1 (SOD-1) were examined. Results: USC expressed renal parietal epithelial cells (CD24, CD29 and CD44). Renal function, measured by GFR and serum Cr in USC-treated group were significantly improved compared to PBS-treated animals (p<0.05). The degree of glomerular sclerosis and atrophic renal tubules, the amount of fibrosis, and monocyte infiltration significantly decreased in USC-treated group compared to the PBS group (p<0.05). The level of TGF-ß1 expression in renal tissues was also significantly lower in the PBS group, while the level of SOD-1 expression was significantly elevated in the USC group, compared to PBS group (p<0.05). Conclusions: The present study demonstrates the nephron-protective effect of USC on renal function via anti-inflammatory, anti-oxidative stress, and anti-fibrotic activity in a dual-injury CKD rat model. This provides an alternative treatment for CKD in certain clinical situations, such as instances where CKD is due to drug-induced nephrotoxicity and renal ischemia.

Kidney disease is a major medical problem globally. Chronic kidney disease (CKD) is a progressive loss of kidney function. It causes accumulation of waste and fluid in the body, eventually resulting in kidney failure as well as damaging other organs. Although dialysis and kidney transplantation have been used as primary treatments for renal disease, dialysis does not restore full renal function, and there is a shortage of donor kidneys for transplantation. Recent advances in cell-based therapies have offered a means to augment and restore renal function. Various types of cells have been tested to evaluate their therapeutic effects on injured kidneys. Among various types of cells, amniotic fluid stem cells (AFSCs) share advantages of both embryonic and adult stem cells, such as pluripotent activity, remarkable plasticity, and immunomodulatory effects, which may allow their future therapeutic use as an "off-the-shelf" cell source. AFSC presents advantages of both conventional pluripotent and adult stem cells, such as pluripotent activity, remarkable plasticity, and immunomodulatory effects. This study demonstrates that administration of human-derived AFSC facilitates functional and structural improvement in a rat model of CKD, and suggests that cell therapy with AFSC has potential as a therapeutic strategy to recover renal function in patients with CKD. Impact Statement Patients with chronic kidney disease (CKD) have limited treatment options, and renal transplantation is the only definitive treatment method that restores kidney function. However, challenges associated with transplantation, including donor organ shortage, rejection, and life-long immunosuppression, remain a problem. Recently, stem cell-based therapies have been proposed as an alternative approach to augment and restore renal function. In this study, we used human-derived amniotic fluid stem cells (AFSCs) to treat CKD in a rat model and demonstrated that AFSC treatment facilitated positive effects in terms of improvements of renal function.

Double right coronary artery (RCA) is a very rare coronary artery anomaly (few cases reported in the literature) that might be overlooked during left heart catheterization for chest pain evaluation or other diagnostic purposes. A 46-year-old male presented with exertional chest pain.

Kidney transplantation is currently the only definitive solution for the treatment of end-stage renal disease (ESRD), however transplantation is severely limited by the shortage of available donor kidneys. Recent progress in whole organ engineering based on decellularization/recellularization techniques has enabled pre-clinical in vivo studies using small animal models; however, these in vivo studies have been limited to short-term assessments. We previously developed a decellularization system that effectively removes cellular components from porcine kidneys. While functional re-endothelialization on the porcine whole kidney scaffold was able to improve vascular patency, as compared to the kidney scaffold only, the duration of patency lasted only a few hours. In this study, we hypothesized that significant damage in the microvasculatures within the kidney scaffold resulted in the cessation of blood flow, and that thorough investigation is necessary to accurately evaluate the vascular integrity of the kidney scaffolds. Two decellularization protocols [sodium dodecyl sulfate (SDS) with DNase (SDS + DNase) or Triton X-100 with SDS (TRX + SDS)] were used to evaluate and optimize the levels of vascular integrity within the kidney scaffold. Results from vascular analysis studies using vascular corrosion casting and angiograms demonstrated that the TRX + SDS method was able to better maintain intact and functional microvascular architectures such as glomeruli within the acellular matrices than that by the SDS + DNase treatment. Importantly, in vitro blood perfusion of the re-endothelialized kidney construct revealed improved vascular function of the scaffold by TRX + SDS treatment compared with the SDS + DNase. Our results suggest that the optimized TRX + SDS decellularization method preserves kidney-specific microvasculatures and may contribute to long-term vascular patency following implantation. (C) 2018 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.

Purpose of Review This review aims to clarify the cardiovascular risk of white coat hypertension (WCH). Recent Findings Cardiovascular risk of WCH has been evaluated in multiple meta-analyses and population-based studies. International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes study evaluated the cardiovascular risk in 653 patients with WCH and 5137 normotensive patients. The patients were age-matched and were followed for 10.6 years. The results revealed no increased cardiovascular risk except in older high-risk WCH patients. A recent meta-analysis evaluated the cardiovascular risk in WCH subjects without any antihypertensive treatment (23 cohorts, 20445 individuals), WCH subjects with antihypertensive treatment (11 cohorts, 8656 individuals), and mixed population including both treated and untreated subjects (12 cohorts, 21336 individuals). This study revealed increased cardiovascular risk in untreated and mixed population WCH subjects but not in treated WCH subjects. Summary WCH might have prognostic impact on cardiovascular outcomes; however, this is not true in all WCH subjects. Further studies should identify the subgroups of WCH that are at increased risk and evaluate the effect of therapeutic measures on cardiovascular outcomes.

Patients with inflammatory bowel disease are prone to thromboembolism and infective endocarditis (IE). A 45-year-old man with past medical history of ulcerative colitis presented with chronic abdominal pain and generalized abdominal tenderness. Abdominal computed tomography revealed occlusion of