Satisfaction with orthognathic surgery of skeletal Class III patients.

INTRODUCTION: Class III relationships can be corrected with single-jaw or bimaxillary surgery. The purpose of this research was to assess patient satisfaction after bimaxillary surgery, compared with setback surgery alone, for Class III corrections. Identifying patients' relative levels of satisfaction will provide guidance for the selection of surgical options. METHODS: The cephalometric outcomes for 25 patients who underwent 2-jaw surgery were compared with the outcomes in 40 patients who had mandibular setback. Soft and hard tissue changes were evaluated using initial and postsurgical lateral cephalograms. The patients were asked to complete self-administered questionnaires after orthognathic treatment. Correlations between cephalometric improvement and patient satisfaction were evaluated. RESULTS: The patients in the 2-jaw group reported significantly higher satisfaction in the appearance of the mouth (P <0.05), smile (P <0.05), and treatment outcome (P <0.001). These item scores and the changes in ANB, ANS-M, and nasolabial angle showed strong correlations in the 2-jaw group and moderate correlations in the 1-jaw group. CONCLUSIONS: ANS-M and nasolabial angle should be considered in the conventional diagnosis of skeletal Class III orthognathic surgery to obtain adequate correction of facial esthetics and patient satisfaction. Esthetic needs contribute to surgical decisions when treating patients with skeletal Class III malocclusions and dentofacial deformities such as maxillary deficiency and long facial height that causes a turned-up upper lip.

Reduced renal function is associated with combined increases in ventricular-systolic stiffness and arterial load in patients undergoing cardiac catheterization for coronary artery disease.

Although mildly reduced renal function is associated with increased risk for heart failure in patients with coronary artery disease (CAD), mechanisms underlying the association remain unclear. We tested the hypothesis that abnormal ventricular-arterial interaction may occur in mildly reduced renal function. We examined the relationships of the estimated glomerular filtration rate (eGFR) with various indices reflecting ventricular-arterial coupling [effective arterial elastance (the ratio of left ventricular (LV) end-systolic pressure to stroke volume, E (a)], LV end-systolic elastance (the ratio of LV end-systolic pressure to end-systolic volume, E (es)), and the total arterial compliance (the ratio of stroke volume to aortic pulse pressure)] and those of LV systolic and diastolic function [peak systolic and diastolic mitral annular velocities (S' and E') and the ratio of peak early diastolic mitral inflow to annular velocity (E/E')] in 320 consecutive patients who underwent cardiac catheterization for CAD and had normal (≥ 0.50) ejection fractions (EF). As eGFR decreased, E (a) and E (es) increased and total arterial compliance and E' decreased. eGFR did not correlate with E (a)/E (es), S', or E/E'. After adjusting for potential confounders, the findings were generally similar, but the correlation of eGFR with E' did not remain significant. In conclusion, reduced renal function may be associated with combined increases in ventricular-systolic stiffness and arterial load in known or suspected CAD patients with normal EF.

Impact of arterial load on left ventricular diastolic function in patients undergoing cardiac catheterization for coronary artery disease.

BACKGROUND: Although left ventricular (LV) diastolic dysfunction is associated with increased risk for incident heart failure in patients with coronary artery disease (CAD), no specific treatment for diastolic abnormalities has been established. Animal and small human studies have shown that an acute increase in LV afterload adversely impacts on LV early diastolic relaxation, but little is known about its chronic effect on diastolic function. METHODS AND RESULTS: The relationships of various components of arterial load (arterial compliance, total vascular resistance index, and augmentation index [AI] in the ascending aorta) with LV diastolic function indices determined on cardiac catheterization (relaxation time constant [Tau] and end-diastolic pressure [EDP]) and those on tissue Doppler echocardiography (early diastolic mitral annular velocity [E'] and the ratio of early diastolic mitral inflow to annular velocities [E/E']) were investigated in 303 consecutive patients undergoing cardiac catheterization for CAD. All components of arterial load correlated with diastolic function indices, with AI, an index reflecting late-systolic load, having the strongest correlations with diastolic function indices. After adjustment for potential confounders, AI correlated with Tau (standardized beta=0.25, P<0.001), EDP (beta=0.25, P<0.001), E' (beta=-0.21, P<0.001), and E/E' (beta=0.23, P<0.001). CONCLUSIONS: Increased AI is independently associated with LV diastolic function in patients with known or suspected CAD. Late-systolic load may be a therapeutic target to improve LV diastolic abnormalities in this population.

Usefulness of plasma brain natriuretic peptide measurement and tissue Doppler imaging in identifying isolated left ventricular diastolic dysfunction without heart failure.

Left ventricular (LV) diastolic dysfunction carries a substantial risk for the subsequent development of heart failure and reduced survival, even when it is asymptomatic. Plasma brain natriuretic peptide (BNP) level and tissue Doppler imaging indexes provide powerful incremental assessment of LV diastolic function. Accordingly, the aim of this study was to clarify whether these methodologies could identify LV diastolic dysfunction without heart failure in 280 patients with preserved LV ejection fractions (> or =50%) who underwent echocardiography and cardiac catheterization for the evaluation of coronary artery disease. Patients were classified into 2 groups, those with diastolic dysfunction (tau > or =48 ms; n = 91) and those with normal diastolic function (tau <48 ms; n = 189). Plasma BNP > or =22.4 pg/ml, an unexpectedly low value, had sensitivity of 74.7% and specificity of 60.8% for identifying isolated LV diastolic dysfunction; the combined use of BNP > or =22.4 pg/mL and mitral annular velocity during early diastole <7.4 cm/s had relatively low sensitivity of 44.0% but high specificity of 86.8%. In conclusion, using plasma BNP level and with the combination of BNP level and mitral annular velocity during early diastole, invasively proved isolated LV diastolic dysfunction without heart failure could be identified in patients with coronary artery disease.

Relationship between renal function, aortic stiffness and left ventricular function in patients with coronary artery disease.

BACKGROUND: There are plausible reasons to hypothesize that increased aortic stiffness and left ventricular (LV) dysfunction may occur in early renal insufficiency. METHODS AND RESULTS: The correlation of glomerular filtration rate (GFR) with the augmentation index (AI) of ascending aortic pressure and indices of LV systolic and diastolic function (ejection fraction, LV pressure relaxation time constant, LV end-diastolic pressure and mitral inflow (E/A) and annular velocities (S' and E')) was examined in 359 consecutive patients undergoing cardiac catheterization for coronary artery disease (CAD). When patients were stratified according to GFR of 60, 75 and 90 ml x min(-1) x 1.73 m(-2), there was a progressive increase in AI and decreases in E/A and E' with decreasing GFR. There were no linear trends in other indices of systolic or diastolic function across GFR groups. After adjustment for potential confounders, reduced GFR was associated with increased AI, but not with decreased E/A or E'. CONCLUSIONS: Early renal impairment may be partly associated with increased aortic stiffness, but not with LV systolic or diastolic function in CAD patients.

Elevated plasma levels of B-type natriuretic Peptide but not C-reactive protein are associated with higher red cell distribution width in patients with coronary artery disease.

Although higher red cell distribution width (RDW) has recently been reported to be associated with increased mortality independent of anemia in patients with heart failure and those with coronary artery disease (CAD), the mechanism underlying this association is unknown. We hypothesized that higher RDW may reflect neurohumoral activation and a chronic inflammatory state that each contribute to adverse clinical outcomes in these populations. We measured RDW and plasma levels of B-type natriuretic peptide (BNP) and high-sensitive C-reactive protein (hs-CRP) in 226 consecutive patients undergoing cardiac catheterization for CAD (age, 67 +/- 8 years; males, 77%; RDW, 45.8 +/- 3.3 fL; hemoglobin, 13.2 +/- 1.4 g/dL; BNP, median [interquartile range], 26.0 [9.0-58.4] pg/mL; hs-CRP, 679 [345-1920] ng/mL). Plasma BNP (r = 0.21, P < 0.01) but not hs-CRP (r = 0.04, P > 0.1) levels correlated with RDW. After adjustment for potential confounders including age, gender, body mass index, glomerular filtration rate, hemoglobin, and known hemodynamic determinants of BNP, including elevated left ventricular end-diastolic pressure and volume and slow left ventricular relaxation, RDW was independently predicted by BNP (r(2) = 0.058, P < 0.001). In conclusion, elevated BNP levels are independently associated with higher RDW in patients with CAD. Neurohumoral activation may be a mechanistic link between increased RDW and adverse clinical outcomes in this population.

Correlation between left ventricular end-diastolic pressure and peak left atrial wall strain during left ventricular systole.

OBJECTIVE: Left atrial (LA) reservoir function is determined by integration of LA relaxation and left ventricular (LV) systolic function, and LV diastolic dysfunction increases LA volume at end systole. This study investigates the effect of LV end-diastolic pressure on LA wall tension during LV systole. METHODS: A total of 101 stable patients with sinus rhythm undergoing cardiac catheterization were studied. LA wall extension during LV systole was evaluated as LA wall strain in the longitudinal direction obtained using two-dimensional ultrasound speckle tracking imaging. LV end-diastolic pressure and LV end-systolic and end-diastolic volumes were obtained in cardiac catheterization, and LV ejection fraction was determined. RESULTS: Peak LA wall strain during LV systole had a significant inverse correlation with LV end-diastolic pressure (r = - 0.76, P < .0001). This correlation was also significant in patients with preserved LV systolic function (LV ejection fraction > or =50%) (r = - 0.64, P < .0001). In patients with peak LA wall strain during LV systole of less than 30%, 89% had elevated LV end-diastolic pressure (> or =16 mm Hg). CONCLUSION: Elevated LV end-diastolic pressure is associated with a decrease of peak LA wall strain in the longitudinal direction during LV systole. In patients with peak LA wall strain during LV systole of less than 30%, the majority had elevated LV end-diastolic pressure, while most patients with peak LA wall strain during LV systole 45% or higher had normal LV end-diastolic pressures. In patients whose LV ejection fraction is 50% or more, when peak LA wall strain during LV systole is between 30% and 44%, it is not possible to predict LV end-diastolic pressure from peak LA wall strain measures.

Impaired myocardial oxidative metabolism in the remote normal region in patients in the chronic phase of myocardial infarction and left ventricular remodeling.

BACKGROUND: Left ventricular (LV) remodeling occurs in the remote normal region in the LVs after myocardial infarction (MI) and is closely involved in heart failure. METHODS: We assessed myocardial oxygen consumption using a clearance rate constant K (mono) for the time activity curves of (11)C-acetate in 15 patients with a prior anterior wall MI, 8 with a prior inferior wall MI, and 10 age-matched normal control subjects. LV end-systolic volume index (ESVI) was determined by echocardiography. RESULTS: The LVESVI was significantly greater in patients with an anterior and inferior MI than in control subjects. The heart rate systolic pressure product did not differ among the groups. K (mono) in the remote normal region in patients with an anterior MI was significantly less than that in the corresponding area in control subjects (0.055 +/- 0.005 vs 0.065 +/- 0.008 min(-1), P < .001). K (mono) in the remote normal region in those with an inferior MI was also significantly less compared with controls (0.054 +/- 0.007 vs 0.069 +/- 0.010 min(-1), P < .01). CONCLUSION: In patients with a prior MI and LV remodeling, myocardial oxidative metabolism is apparently impaired in the remote normal region where augmented myocardial energy production is needed against the increased end-systolic wall stress caused by LV dilatation.

Mycoplasma hominis meningitis in a neonate: case report and review.

Despite frequent colonization with Mycoplasma hominis, the invasive disease is rare in neonates. This study describes a neonatal case with meningitis in which M. hominis was isolated from a cerebrospinal fluid sample by culture and detected by PCR. The M. hominis infection was confirmed by elevated metabolic inhibition titers against the isolated M. hominis strain and anti-M. hominis antibodies in serum samples. Minocycline and moxifloxacin were effective against M. hominis, which caused meningitis in the patient. However, the patient exhibited left hemiplegia because of massive brain infarction. Based on data of the previously reported 28 cases in addition to our case, the high morbidity and mortality of the M. hominis central nervous system infection were confirmed; it was assumed to result from delayed diagnosis and ineffective initial therapy. Early diagnosis and prompt initiation of appropriate antimicrobial treatment are necessary for a favorable prognosis. Fourth-generation fluoroquinolones, especially moxifloxacin, deserve wider use in such cases.

Peak mitral annular velocity during early diastole and propagation velocity of early diastolic filling flow are not interchangeable as the parameters of left ventricular early diastolic function.

The difference between peak mitral annular velocity during early diastole (Ea) and the propagation velocity of left ventricular (LV) early diastolic filling flow (Vp) obtained using Doppler imaging as LV relaxation parameters was not fully elucidated. Thus, this issue was investigated in 117 patients with suspected coronary artery disease. During cardiac catheterization, LV volumes, the LV relaxation time constant Tp, and inertia force of late systolic aortic flow were obtained. Ea significantly and closely correlated with Tp (r = -0.70, p <0.0001) and significantly but weakly correlated with LV ejection fraction (r = 0.37, p <0.0001) and inertia force (r = 0.34, p = 0.0002). Conversely, Vp significantly and closely correlated with both LV ejection fraction (r = 0.66, p <0.0001) and inertia force (r = 0.72, p <0.0001) and significantly but weakly correlated with Tp (r = - 0.35, p = 0.0001). In conclusion, Ea and Vp reflect different aspects of LV behavior from end-systole to early diastole. Ea can be used to index LV relaxation, whereas Vp might not be a proper parameter of LV intrinsic relaxation because it is significantly dependent on LV systolic function and LV chamber size at end-systole. Both parameters are not interchangeable as those of LV early diastolic function. Vp may be a noninvasive parameter of LV elastic recoil.

Lack of inertia force of late systolic aortic flow is a cause of left ventricular isolated diastolic dysfunction in patients with coronary artery disease.

OBJECTIVES: We investigated whether a lack of inertia force of late systolic aortic flow and/or apical asynergy provoke early diastolic dysfunction in patients with coronary artery disease (CAD). BACKGROUND: Left ventricular (LV) isolated diastolic dysfunction is a well-recognized cause of heart failure. METHODS: We evaluated LV apical wall motion and obtained left ventricular ejection fraction (LVEF) by left ventriculography in 101 patients who underwent cardiac catheterization to assess CAD. We also computed the LV relaxation time constant (Tp) and the inertia force of late systolic aortic flow from the LV pressure (P)-first derivative of left ventricular pressure (dP/dt) relation. Using color Doppler echocardiography, we measured the propagation velocity of LV early diastolic filling flow (Vp). Patients with LVEF > or =50% (preserved systolic function [PSF], n = 83) were divided into 2 subgroups: patients with inertia force (n = 53) and without inertia force (n = 30). No patient with systolic dysfunction (SDF) (LVEF <50%) had inertia force (n = 18). RESULTS: The Tp was significantly longer in patients with SDF (85.7 +/- 21.0 ms) and with PSF without inertia force (81.1 +/- 23.6 ms) than in those with PSF with inertia force (66.3 +/- 12.8 ms) (p< 0.001). The Vp was significantly less in the former 2 groups than in the last group. In patients with PSF, LV apical wall motion abnormality was less frequently observed in those with inertia force than in those without (p < 0.0001). CONCLUSIONS: An absence of inertia force in patients with PSF is one of the causes of isolated diastolic dysfunction in patients with CAD. Normal LV apical wall motion is substantial enough to give inertia to late systolic aortic flow.

Usefulness of plasma brain-type natriuretic peptide level to differentiate left ventricular diastolic dysfunction from preserved diastolic function in patients with systolic dysfunction.

The extent of left ventricular (LV) diastolic dysfunction is related to the finding that some patients with cardiomegaly due to LV systolic dysfunction have good exercise tolerance, although others have limited tolerance. A brain-type natriuretic peptide level of >/=104 pg/ml reliably enables the detection of relatively worse LV diastolic function in patients with systolic dysfunction, and this value may provide clinically useful information for the management of patients with cardiomegaly.

Evaluation of whole left ventricular systolic performance and local myocardial systolic function in patients with prior myocardial infarction using global long-axis myocardial strain.

Left ventricular (LV) global strain along its long axis during systole, which is obtained by dividing mitral annular excursion by the distance from the mitral annulus to the LV apex at end-diastole, can be used to assess whole LV systolic performance. The evaluation of LV wall function using this parameter suggests that previous myocardial infarction (MI) causes long-axis myocardial function in remote normal LV walls, as well as in walls with MI, to deteriorate.