Long-term results of percutaneous coronary intervention in no-touch vein grafts are significantly better than in conventional vein grafts.

INTRODUCTION: Conventional vein grafts have a high risk of thrombosis and early atherosclerosis. Percutaneous coronary intervention (PCI) in conventional vein grafts is associated with a higher incidence of late adverse cardiac events. The aim of this study was to evaluate the long-term results after PCI in saphenous vein grafts (SVG) harvested with the no-touch technique compared to the conventional technique. METHODS: This was a single-center, retrospective, cohort study, based on data from the Swedeheart register. The inclusion criterion was individuals who underwent CABG using different vein graft techniques between January 1992 and July 2020, and who required a PCI in SVGs between January 2006 and July 2020. The primary end point was long-term in-stent restenosis. The secondary endpoints were long-term major adverse cardiac events (MACE) and 1-year re-hospitalization rates. The associations between the graft types and the endpoints were evaluated using the Fine and Gray competing-risk regression analysis. RESULTS: The study included 346 individuals (67 no-touch, 279 conventional). The mean clinical follow-up time was 6.4 years with a standard deviation of 3.7 years. The long-term in-stent restenosis rate for the no-touch grafts was 3.2% compared to 18.7% for the conventional grafts (p < .01), with a subdistribution hazard ratio (SHR) of 0.16 (p = .010). The long-term MACE rate was 27.0% in the no-touch group and 48.3% in the conventional group (p < .01) with a SHR of 0.53 (p = .017). The short-term results were similar in both groups. CONCLUSIONS: Percutaneous coronary intervention in a no-touch vein graft was associated with statistically significantly fewer in-stent restenoses and MACE at long-term follow-up compared to a conventional SVG.

The a' velocity by tissue-Doppler echocardiography correlates to invasive mean left atrial pressure in patients with normal ejection fraction.

OBJECTIVES: To evaluate the correlation of a' velocity by tissue-Doppler measurements with invasively measured mean left atrial pressure in patients with normal ejection fraction. DESIGN: In this retrospective study, we evaluated the septal a', lateral a' and average a' velocity by tissue-Doppler echocardiography, in 125 in-hospital patients, 1-12 h before an elective pulmonary vein isolation due to intermittent atrial fibrillation, and compared to invasively measured mean left atrial pressure (LAP) during the invasive procedure. The patients, aged 35-81 years, had to be in sinus rhythm at both examinations, no atrial fibrillation during two procedures, no or mild valve disease and normal ejection fraction (>50%). RESULTS: Invasively measured mean LAP correlated well to septal a' (r = -0.435), lateral a' (r = -0.473) and average a' velocity (r = -0.491). Normal mean LAP (≤12 mmHg) was found in 95 patients and elevated mean LAP (>12 mmHg) in 30 patients. The patients with elevated mean LAP had a lower septal a' velocity (6.5 ± 2.7 vs 8.6 ± 2.3 cm/s; p < .01), lateral a' velocity (5.9 ± 2.3 vs 8.6 ± 2.1 cm/s; p < .01) and average a' velocity (6.2 ± 2.4 vs 8.8 ± 2.1 cm/s; p < .01) compared to patients with normal mean LAP. Septal a', lateral a' and average a' velocity were good predictors of elevated mean LAP with AUC of 0.78, 0.83 and 0.82. Average a' velocity with cut-off < 7.25 cm/s had a sensitivity of 83% and a specificity of 77% to predict elevated mean LAP. CONCLUSION: The a' velocity is a good indicator of mean LAP and might be considered in the evaluation of left ventricle filling pressure in patients with normal ejection fraction.

E/a' ratio is closely related to pulmonary vein flow profile in patients with normal ejection fraction.

Objectives. To compare the ability of the E/a' ratio and the recommended diastolic parameters in the American Society of Echocardiography (ASE) and the European Association of Cardiovascular Imaging (EACVI), in predicting a dominant diastolic pulmonary vein flow in patients with normal ejection fraction. Design. We retrospectively evaluated the diastolic function according to the ASE/EACVI guidelines, the S/D ratio and the septal, lateral and average E/a' ratio in 293 unselected in-hospital patients, aged 39-86 years, in sinus rhythm and with no or mild valve disease, having a normal systolic function (EF > 50%). Results. The S/D ratio had a positive association to septal, lateral and average E/a ratio (R2 = 0.25, 0.35 and 0.32). The association to average E/e' ratio, LA vol index and TR velocity was weak (R2 = 0.037, 0.033 and 0.087) and for e' velocity negatively. In patients with S/D ratio <1, septal, lateral, average E/a' ratio, average E/e ratio, LA vol index (p<.001) and TR velocity (p<.05) were significantly higher compared to patients with S/D ratio ≥1. No significant difference was seen in e' velocity. The septal, lateral and average E/a' ratio were significantly higher in patients with S/D ratio <1 regardless a normal or impaired diastolic function according to the ASE/EACVI guidelines (p<.001). The ASE/EACVI algorithm detected 21 patients with S/D ratio <1 compared to 28 patients using average E/a' ratio with cut-off >14. Conclusion: E/a' ratio might be a useful new diastolic parameter in patients with a normal ejection fraction as it is more closely related to the S/D ratio than the established ASE/EACVI diastolic parameters.

The a´ velocity in the tissue Doppler predicts S/D ratio <1 in patients with a normal ejection fraction.

OBJECTIVES: To compare the ability of the a´ velocity and the e´ velocity in predicting a dominant diastolic pulmonary vein flow (S/D ratio <1) in patients with normal ejection fraction. DESIGN: We retrospectively evaluated the diastolic function according to the ASE/EACVI guidelines, the S/D ratio and the septal, lateral and average a´ velocity in 293 unselected in-hospital patients, aged 39-86 years, in sinus rhythm and with no or mild valve disease, having a normal systolic function (EF >50%). RESULTS: There was a good linear correlation between the S/D ratio and the a´ velocity, but a tendency towards a negative correlation between the S/D ratio and the e´ velocity. S/D ratio <1 was seen in 43 patients. These patients had a significantly lower a´ velocity compared to those with S/D-ratio ≥1, septal (6,1 ± 2,4 v 8,8 ± 2,1 cm/s; p < .001) and lateral (6,0 ± 2,6 v 9,3 ± 2,5 cm/s; p < .001) No significant difference was seen in the septal e´ velocity (6,8 ± 2,4 v 6,8 ± 2,1 cm/s), lateral e´ velocity (9,4 ± 2,6 v 9,1 ± 2,8 cm/s) or in the ejection fraction (58,6 ± 4,4% v 58,7 ± 4,0%). A diastolic dysfunction was present in 62 patients, normal diastolic function in 231 patients. The a´ velocity was significantly lower in patients with S/D ratio <1 in both groups (p < .01). CONCLUSION: The a´ velocity is superior to the e´ velocity in predicting S/D ratio <1 in patients with normal ejection fraction regardless the ASE/EACVI diastolic classification. A failing left atrium seems to be the explanation.

Effects on repetitive 24-hour ambulatory blood pressure in subjects with type II diabetes randomized to liraglutide or glimepiride treatment both in combination with metformin: a randomized open parallel-group study.

In this post hoc study, we aimed to investigate liraglutide treatment on repetitive 24-hour blood pressure (BP) in patients with type II diabetes. Sixty-two individuals with type II diabetes (45 males) were randomized to 1.8 mg liraglutide once daily or 4 mg glimepiride together with 1 g metformin twice daily. Ambulatory 24-hour systolic and diastolic blood pressure (sBP/dBP) was repetitively measured at baseline, 2 weeks, and 18 weeks. Outcomes were evaluated as treatment change from baseline, 2 weeks, and 18 weeks. Baseline clinical characteristics of liraglutide (n = 33) and glimepiride (n = 29) groups were well matched. No statistically significant difference in 24-hour sBP/dBP between three time periods and groups was observed. There was no treatment change for 24-hour sBP at week 2 or after week 18. There was a transient treatment change in 24-hour dBP in the liraglutide group at week 2 (3.2 ± 5.4 vs. -1.2 ± 4.5 mm Hg, P < .01). A treatment change in 24-hour heart rate at week 2 (4.9 ± 6.8 vs. 1.0 ± 6.0 bpm, P = .03) and at week 18 (5.9 ± 7.8 vs. 0.2 ± 6.3 bpm, P < .01) was observed in the liraglutide group. In conclusion, liraglutide treatment did not lower BP. However, a small diurnal variation in dBP without affecting BP variability or nocturnal BP dipping was observed.

Corrigendum: Effects on Subclinical Heart Failure in Type 2 Diabetic Subjects on Liraglutide Treatment vs. Glimepiride Both in Combination with Metformin: A Randomized Open Parallel-Group Study.

[This corrects the article on p. 325 in vol. 8, PMID: 29184539.].

E/a´ ratio a simple detector of left ventricular dysfunction in patients with decreased ejection fraction.

OBJECTIVES: Could a diastolic dysfunction and an increased LV-filling pressure according to ASE/EACVI guidelines be detected or ruled out by the E/a´ratio in patients with decreased ejection fraction. DESIGN: We retrospectively evaluated the diastolic function of 113 unselected in-hospital patients, aged 40-84 years, in sinus rhythm and with no or mild valve disease, having a decreased systolic function (EF ≤50%) using the new ASE/EACVI guidelines and compared these results with the E/a´ratio derived from the E wave in the mitral flow and the a´velocity in the tissue Doppler. RESULTS: The average E/a´ ratio is a strong predictor of a grade II-III diastolic dysfunction and an elevated left atrial pressure according to ASE/EACVI guidelines with an AUC of 0.92. An average E/a´ ratio with a cut-off >10 had a sensitivity of 97.6% and a negative predictive value of 98.2% in detecting or ruling out a grade II-III diastolic dysfunction and an elevated left atrial pressure according to the current guidelines. CONCLUSION: The average E/a´ ratio might be useful as a fast screening tool of a left ventricular dysfunction and an increased left ventricular filling pressure in patients with a decreased ejection fraction.

Effects on Subclinical Heart Failure in Type 2 Diabetic Subjects on Liraglutide Treatment vs. Glimepiride Both in Combination with Metformin: A Randomized Open Parallel-Group Study.

Objective: We aimed to investigate the effect of liraglutide treatment on heart function in type 2 diabetes (T2D) patients with subclinical heart failure. Methods: Randomized open parallel-group trial. 62 T2D patients (45 male) with subclinical heart failure were randomized to either once daily liraglutide 1.8 mg, or glimepiride 4 mg, both add on to metformin 1 g twice a day. Mitral annular systolic (s') and early diastolic (e') velocities were measured at rest and during bicycle ergometer exercise, using tissue Doppler echocardiography. The primary endpoint was 18-week treatment changes in longitudinal functional reserve index (LFRIdiastolic/systolic). Results: Clinical characteristics between groups (liraglutide = 33 vs. glimepiride = 29) were well matched. At baseline left ventricle ejection fraction (53.7 vs. 53.6%) and global longitudinal strain (-15.3 vs. -16.5%) did not differ between groups. There were no significant differences in mitral flow velocities between groups. For the primary endpoint, there was no treatment change [95% confidence interval] for: LFRIdiastolic (-0.18 vs. -0.53 [-0.28, 2.59; p = 0.19]), or LFRIsystolic (-0.10 vs. -0.18 [-1.0, 1.7; p = 0.54]); for the secondary endpoints, there was a significant treatment change in respect of body weight (-3.7 vs. -0.2 kg [-5.5, -1.4; p = 0.001]), waist circumference (-3.1 vs. -0.8 cm [-4.2, -0.4; p = 0.019]), and heart rate (HR) (6.3 vs. -2.3 bpm [-3.0, 14.2; p = 0.003]), with no such treatment change in hemoglobin A1c levels (-11.0 vs. -9.2 mmol/mol [-7.0, 2.6; p = 0.37]), between groups. Conclusion: 18-week treatment of liraglutide compared with glimepiride did not improve LFRIdiastolic/systolic, but however increased HR. There was a significant treatment change in body weight reduction in favor for liraglutide treatment.

The no-touch vein graft for coronary artery bypass surgery preserves the left ventricular ejection fraction at 16†years postoperatively: long-term data from a longitudinal randomised trial.

OBJECTIVES: To assess the left ventricular heart function and the clinical outcome 16 years after coronary artery bypass surgery. DESIGN: In a randomised trial, the no-touch (NT) vein graft in coronary artery bypass surgery has shown a superior patency rate, a slower progression of atherosclerosis and better clinical outcome compared to the conventional (C) vein graft at 8.5 years. All patients at mean time 16 years were offered an echocardiographic and clinical examination. RESULTS: In the NT-group 34 patients and in the C-group 31 patients underwent an echocardiography examination. A significantly better left ventricle ejection fraction was seen in the NT-group compared to the C-group (57.9% vs 49.4%; p=0.011). The size of the left atrium in NT was 21.7 cm(2) compared to 23.9 cm(2) in C; p=0.034. No patient in NT had atrial fibrillation compared to five patients in C (p=0.021). Patients with a brain natriuretic peptide value (BNP) ≥150 was 30% in NT compared to 38% in C. Total mortality was 25% in NT vs 27% in C. Cardiac-related deaths were 8% and 12% in NT and C respectively. CONCLUSIONS: The NT vein graft preserves the left ventricular ejection fraction after 16 years. A smaller left atrium, a lower BNP and no atrial fibrillation indicates an improved diastolic left ventricular function in the NT-group. TRIAL REGISTRATION: The study is registered with clinicaltrials.gov (NCT01686100) and The Research and Development registry in Sweden (no. 102841).

Quality improvement in coronary care: analysis of sustainability and impact on adjacent clinical measures after a Swedish controlled, multicenter quality improvement collaborative.

BACKGROUND: Quality Improvement in Coronary Care, a Swedish multicenter, controlled quality-improvement (QI) collaborative, has shown significant improvements in adherence to national guidelines for acute myocardial infarction, as well as improved clinical outcome. The objectives of this report were to describe the sustainability of the improvements after withdrawal of study support and a consolidation period of 3 months and to report whether improvements were disseminated to treatments and diagnostic procedures other than those primarily targeted. METHODS AND RESULTS: Multidisciplinary teams from 19 Swedish hospitals were educated in basic QI methodologies. Another 19 matched hospitals were included as blinded controls. All evaluations were made on the hospital level, and data were obtained from a national quality registry, Swedish Register of Information and Knowledge About Swedish Heart Intensive Care Admissions (RIKS-HIA). Sustainability indicators consisted of use of angiotensin-converting enzyme inhibitors, lipid-lowering therapy, clopidogrel, low-molecular weight heparin, and coronary angiography. Dissemination indicators were use of echocardiography, stress tests, and reperfusion therapy; time delays; and length of stay. At the reevaluation period of 6 months, the improvements at the QI intervention hospitals were sustained in all indicators but 1 (angiotensin-converting enzyme inhibitor). Between the 2 measurements, the control group improved significantly in all but 1 indicator (angiotensin-converting enzyme inhibitor). However, at the second measurement, the absolute adherence rates of the intervention hospitals were still numerically higher in all 5 indicators, and significantly so in 1 (clopidogrel). No significant changes were observed for the dissemination indicators. CONCLUSIONS: The combination of a systematic QI collaborative with a national, interactive quality registry might lead to substantial and sustained improvements in the quality of acute myocardial infarction care. However, to achieve disseminated improvements in adjacent clinical measures, those adjacent measures probably should be made explicit before any QI intervention. (J Am Heart Assoc. 2012;1:e000737 doi: 10.1161/JAHA.112.000737.).

Slower progression of atherosclerosis in vein grafts harvested with 'no touch' technique compared with conventional harvesting technique in coronary artery bypass grafting: an angiographic and intravascular ultrasound study.

OBJECTIVES: In a long-term randomised coronary artery bypass grafting (CABG) study, the patency rate using a new 'no touch' (NT) vein-graft preparation technique was superior to the conventional (C) technique. This cineangiographic and intravascular ultrasound (IVUS) substudy examined possible mechanisms. METHODS: A total of 45 patients (118 grafts) in the NT group and 46 patients (112 grafts) in the C group had patent grafts at short-term follow-up after 18 months. Thirty-seven patients (91 grafts) in the NT group and 37 patients (77 grafts) in the C group had patent grafts at long-term follow-up after 8.5 years, and were evaluated on a scale from 0 (normal) to 2 (significant stenosis) by cineangiogram. IVUS was performed in 15 NT grafts and 14 C grafts in the short-term follow-up, and 27 NT grafts and 26 C grafts in the long-term follow-up, in grafts considered normal by the cineangiogram. The grafts were evaluated with respect to lumen volume, intimal thickness, incidence of plaque and plaque components. RESULTS: In the short-term follow-up, the cineangiogram showed more normal grafts (89.0% in the NT group compared with 75.0% in the C group), and the number of grafts with stenosis was 11.0% in the NT group compared with 25.0% in the C group (p=0.006). IVUS showed less mean intimal thickness (0.43 (0.07)mm vs 0.52 (0.08)mm; p=0.03), less grafts with considerable intimal hyperplasia (≥ 0.9 mm; 20% vs 78.6%; p=0.011) and fewer patients with considerable hyperplasia (≥ 0.9 mm; 25% vs 100%; p=0.007). In the long-term follow-up, the cineangiogram showed more normal grafts, with 91.2% in the NT group compared with 83.1% in the C group; there were fewer grafts with significant stenosis, with 7.7% in the NT group compared with 15.6% in the C group (p=0.14). IVUS showed fewer grafts containing multiple plaques (14.8% vs 50%; p=0.008), less advanced plaque with lipid (11.8% vs 63.9%; p=0.0004) and less maximal plaque thickness (1.04 (0.23)mm vs 1.32 (0.25)mm; p=0.02) in the NT group compared with the C group. CONCLUSION: The superior long-term patency rate using the NT vein-graft technique at CABG could be explained by a significantly slower progression of atherosclerosis.

No touch vein harvesting technique for CABG improves the long-term clinical outcome.

OBJECTIVES: To investigate the long-term clinical outcome, averaging 8.5 years, of two saphenous vein harvesting techniques for CABG; no touch (NT) versus conventional (C). DESIGN: In a randomized study, 49/52 in group NT and 44/52 in group conventional were evaluated for reangina, myocardial infarction, new revascularization, functional class, risk factors and medical treatment. The vein grafts and the native coronary arteries were correlated to the occurrence of reangina. RESULTS: There were significantly more patients free from angina and in NYHA class I (67.3 versus 43.2%; p =0.02) in group NT compared to group C. No cardiac death was found in group NT versus three in group C. There were trends towards fewer patients with cardiac death or myocardial infarction (3.8 vs. 13.4%; p =0.16), more patients free from angina (75.5 vs. 63.6%; p =0.26) and fewer patients with graft occlusion (24.3 vs. 43.2% (p =0.14) in group NT. CONCLUSIONS: The results of the NT-technique are encouraging with no cardiac deaths, significantly more asymptomatic patients and a trend towards impact on hard clinical endpoints compared to the conventional technique.

Harvesting the saphenous vein with surrounding tissue for CABG provides long-term graft patency comparable to the left internal thoracic artery: results of a randomized longitudinal trial.

OBJECTIVE: Conventional harvesting of the saphenous vein in coronary artery bypass surgery produces vessel damage that contributes to graft failure. A novel "no touch" technique provides high short- and long-term patency rates. METHOD: This randomized longitudinal trial compares graft patency of two patient groups undergoing coronary artery bypass surgery. Conventional: 52 patients had their veins stripped, distended, and stored in saline solution. No-touch: 52 patients had veins removed with surrounding tissue, not distended, and stored in heparinized blood. Angiographic assessment was performed at mean time 18 months after the operation in 46 patients in the conventional group and 45 patients in the no-touch group and repeated at mean time 8.5 years in 37 patients from both groups. RESULTS: The distribution of the grafts to the recipient coronary arteries regarding their size and quality was similar in both groups. The angiographic assessment at 18 months postoperatively showed 89% conventional versus 95% no-touch grafts were patent. Repeated angiography at 8.5 years showed a patency rate for the conventional group of 76% and 90% for the no-touch group (P = .01). The multivariate analysis showed that the most important surgical factors for graft patency were the technique of harvesting (odds ratio= 3.7, P = .007) for the no-touch versus the conventional technique and the vein quality before implantation (odds ratio = 3.2, P = .007) for veins that were of good quality. By comparison the patency of the thoracic artery grafts was 90%. CONCLUSION: Harvesting the saphenous vein with surrounding tissue provides high short- and long-term patency rates comparable to the left internal thoracic artery.

Influence of body size and age on maximal diastolic velocity of mitral annulus motion.

BACKGROUND: Maximal long-axis relaxation velocity (RV(m)), measured from the mitral annulus motion (MAM), has recently been suggested as an index of left ventricular (LV) diastolic function. M-mode recording and pulsed tissue Doppler have been used. Regarding the M-mode method, reference values have not been presented previously. In the current study, therefore, the influence on RV(m) of such variables as age, body size, heart rate, and blood pressure was investigated to obtain adequate reference values. METHODS AND RESULTS: Fifty-seven healthy subjects were included in the study. RV(m) was recorded by M-mode echocardiography from apical 4- and 2-chamber views from 4 sites of the mitral annulus. Multiple regression analysis showed that heart rate ought to be taken into account when reference values are calculated for children and adolescents, and age must be considered in adults. For reference values in children and adolescents, the following equation is suggested: RV(m) = 171 - 0.54 x heart rate (SEE = 18.7). In adults over 18 years, the suggested equation is RV(m) = 163 - 1.29 x age (SEE = 8.4.)