Research Spotlight

Bejcek, A. and Wenkert, D. (2022). “Hemoglobin Wayne causing a falsely elevated hemoglobin A1c.” Proc (Bayl Univ Med Cent) 35(1): 84-85.

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Hemoglobin A1c (HbA1c) is an important tool for diagnosis and management of patients with diabetes mellitus (DM). However, hemoglobin variants can interfere with laboratory assays and lead to inaccurate results. This study describes a patient who was found to have falsely elevated HbA1c values secondary to hemoglobin Wayne, a rare hemoglobin variant. Although hemoglobin Wayne is often clinically silent, falsely elevated HbA1c results could lead to unnecessary medical interventions that could cause patient harm. This variation in results highlights the importance of utilizing additional measurements such as glucose readings and evaluating for hemoglobin variants when results are discordant.

Bagiella, E., Puskas, J.D., Moskowitz, A.J., Gelijns, A.C., Alexander, J.H., Narula, J., Smith, P.K., Hutcheson, K., Chang, H.L., Gammie, J.S., Iribarne, A., Marks, M.E., Vengrenyuk, Y., Yasumura, K., Raymond, S., Taylor, B.S., Yarden, O., Orion, E., Dagenais, F., Ailawadi, G., Chu, M.W.A., Gupta, L., Levitan, R.G., Williams, J.B., Jr., Crestanello, J.A., Jessup, M., Rose, E.A., Scavo, V., Acker, M.A., Gillinov, M., O’Gara, P.T., Voisine, P., Mack, M.J. and Goldstein, D.J. (2021). “Rationale and Design of a Randomized Trial Evaluating an External Support Device for Saphenous Vein Coronary Grafts.” Am Heart J Dec 19;S0002-8703(21)00482-8. [Epub ahead of print].

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BACKGROUND: Coronary artery bypass grafting (CABG) is the most common revascularization approach for the treatment of multi-vessel coronary artery disease. While the internal mammary artery is nearly universally used to bypass the left anterior descending coronary artery, autologous saphenous vein grafts (SVGs) are still the most frequently used conduits to grafts the remaining coronary artery targets Long-term failure of these grafts, however, continues to limit the benefits of surgery. DESIGN: The Cardiothoracic Surgical Trials Network trial of the safety and effectiveness of a Venous External Support (VEST) device is a randomized, multicenter, within-patient trial comparing VEST-supported versus unsupported saphenous vein grafts in patients undergoing CABG. Key inclusion criteria are the need for CABG with a planned internal mammary artery to the left anterior descending and two or more saphenous vein grafts to other coronary arteries. The primary efficacy endpoint of the trial is SVG intimal hyperplasia (plaque + media) area assessed by intravascular ultrasound at 12 months post randomization. Occluded grafts are accounted for in the analysis of the primary endpoint. Secondary confirmatory endpoints are lumen diameter uniformity and graft failure (>50% stenosis) assessed by coronary angiography at 12 months. The safety endpoints are the occurrence of major adverse cardiac and cerebrovascular events and hospitalization within 5 years from randomization. CONCLUSIONS: The results of the VEST trial will determine whether the VEST device can safely limit SVG intimal hyperplasia in patients undergoing CABG as treatment for coronary atherosclerotic disease.

Arunthamakun, J., Vallabhan, R., Ayad, R. and Roberts, C.C. (2022). “Shotgun recoil causing severe acute aortic regurgitation years after replacement of the aortic valve and ascending aorta.” Proc (Bayl Univ Med Cent) 35(1): 96-97.

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Blunt chest trauma can lead to severe, life-threatening injury to chest organs, including the aorta, heart, lungs, and major airways. We describe a 64-year-old man who had undergone replacement of his aortic valve and ascending aorta 14 years earlier (at age 50) and suddenly developed severe aortic regurgitation after firing his shotgun while hunting. Such an event has not been reported previously.

Alam, A., Doshi, H., Patel, D.N., Patel, K., James, D. and Almendral, J. (2022). “Myocardial infarction and factor VIII elevation in a 36-year-old man.” Proc (Bayl Univ Med Cent) 35(1): 93-95.

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An association has been reported between factor VIII and arterial thrombosis such as ischemic stroke and myocardial infarction. We report a 36-year-old man who had a myocardial infarction despite lacking traditional cardiac risk factors. He developed end-stage heart failure and renal insufficiency necessitating a HeartMate II left ventricular assist device (LVAD). While on the transplant list, he experienced two episodes of LVAD thrombosis 6 months apart, prompting device exchange and escalation of anticoagulation therapy. He eventually underwent a successful heart-kidney transplant before suffering an extensive left lower extremity deep vein thrombosis 6 weeks later. A thrombophilia workup revealed elevated factor VIII activity of 319% (normal range, 50%-150%). He was placed on indefinite anticoagulation with apixaban with no further thrombotic episode in 18 months of follow-up to date.

Agarwal, A., Johannesson, L., Findeis, S.K., Punar, M., Askar, M., Ma, T.W., Pinto, K., Demetris, A.J. and Testa, G. (2022). “Clinicopathological Analysis of Uterine Allografts Including Proposed Scoring of Ischemia Reperfusion Injury and T-cell-mediated Rejection-Dallas UtErus Transplant Study: A Pilot Study.” Transplantation 106(1): 167-177.

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BACKGROUND: Uterus transplantation (UTx) enables pregnancy in infertile women. This study describes the histopathological changes of ischemia reperfusion injury and mostly acute T-cell-mediated rejection (TCMR) in UTx and proposes modification toward a working formulation grading system with associated treatments. METHODS: Protocol and indication biopsies from 11 living and 2 deceased donor UTx recipients were analyzed. Serving as a control were 49 age-matched nontransplanted uteri. All posttransplant histopathological specimens were evaluated in a blinded fashion by 3 pathologists. Response to treatment was assessed by follow-up biopsies. Serial serum donor-specific antibody (DSA) responses were also recorded. RESULTS: Changes attributed to ischemia reperfusion resolved within 2 wk of UTx in most of the patients. For TCMR grading, perivascular inflammation, focal capillary disruption, and interstitial hemorrhage were added to interface inflammation, intercellular edema, stromal inflammation, and epithelial apoptotic bodies. Of the 173 protocol biopsies, 98 were classified as negative for TCMR; 34 as indeterminate-borderline; 35 as mild; 3 as moderate; and 3 as severe, 1 of which occurred in a DSA-positive recipient and also showed microvascular injury. Corticosteroids successfully treated all moderate-to-severe TCMR episodes. Mild TCMR was treated by increasing existing baseline immunosuppression. Indeterminate-borderline episodes were not treated. Neither ischemia-reperfusion injury nor TCMR with DSA adversely affected embryo transfer. CONCLUSIONS: Relying on a modified histopathological grading system, we developed a treatment strategy resulting in resolution of TCMR and successful pregnancies.