The prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF): a systematic review and meta-analysis.

To date, studies on the prevalence of coronary microvascular dysfunction (CMD) in heart failure with preserved ejection fraction (HFpEF) have not been summarized and analyzed as a whole. We conducted this systematic review and meta-analysis to assess the prevalence of CMD in patients with HFpEF. The PubMed, Cochrane, and Embase databases were searched from dates of inception until May 1, 2023. The primary outcome was the prevalence of CMD in patients with HFpEF, and values of CMD prevalence were pooled using a random-effects model. In total, 10 studies involving 1267 patients, including 822 with HFpEF and 445 without HFpEF, were included. The pooled prevalence of CMD in patients with HFpEF was 71% (95% CI, 0.63-0.79). In the subgroup analysis, the prevalence of CMD was 79% (95% CI, 0.71-0.87) by invasive measurement and 66% (95% CI, 0.54-0.77) by noninvasive measurement and 67% (95% CI, 0.52-0.82) with CFR < 2.0 and 75.0% (95% CI, 0.71-0.79) with CFR < 2.5. The prevalence of endothelium-independent CMD and endothelium-dependent CMD was 62% (95% CI, 0.53-0.72) and 50% (95% CI, 0.19-0.81), respectively. The prevalence of CMD was 74% (95% CI = 0.69-0.79) and 66% (95% CI = 0.41-0.90) in prospective and retrospective studies, respectively. Compared with the control group, patients with HFpEF had a significantly lower CFR (MD = - 1.28, 95% CI = - 1.82 to - 0.74, P < 0.01) and a higher prevalence of CMD (RR = 2.21, 95% CI = 1.52 to 3.20, P < 0.01). Qualitative analysis demonstrated that CMD might be associated with poor clinical outcomes in patients with HFpEF. In conclusion, this is the first systematic review and meta-analysis of all studies reporting the prevalence of CMD in patients with HFpEF. Our study demonstrates that CMD is common in patients with HFpEF and might be associated with poor clinical outcomes in these patients. Clinicians should attach importance to CMD in the diagnosis and treatment of HFpEF. The number of studies in this field is relatively small. Therefore, more high-quality studies are needed to explore the diagnostic and prognostic value of CMD and the potential role of CMD as a therapeutic target in patients with HFpEF.

Quantitative Flow Ratio-Derived Index of Microcirculatory Resistance as a Novel Tool to Identify Microcirculatory Function in Patients with Ischemia and No Obstructive Coronary Artery Disease.

BACKGROUND: Coronary microvascular disease (CMVD) is associated with adverse cardiovascular outcomes. However, there is no reliable and noninvasive quantitative diagnostic method available for CMVD. The use of a pressure wire to measure the index of microcirculatory resistance (IMR) is possible, but it has inevitable practical restrictions. We hypothesized that computation of the quantitative flow ratio could be used to predict CMVD with symptoms of ischemia and no obstructive coronary artery disease (INOCA). METHODS: We retrospectively assessed the diagnostic efficiency of the quantitative flow ratio-derived index of microcirculatory resistance (QMR) in 103 vessels from 66 patients and compared it with invasive IMR using the thermodilution technique. RESULTS: Patients were divided into the CMVD group (41/66, 62.1%) and non-CMVD group (25/66, 37.9%). Pressure wire IMR measurements were made in 103 coronary vessels, including 44 left descending arteries, 18 left circumflex arteries, and 41 right coronary arteries. ROC curve analysis showed a good diagnostic performance of QMR for all arteries (area under the curve = 0.820, 95% confidence interval 0.736-0.904, p < 0.001) in predicting microcirculatory function. The optimal cut-off for QMR to predict microcirculatory function was 266 (sensitivity: 82.9%, specificity: 72.6%, and diagnostic accuracy: 76.7%). CONCLUSION: QMR is a promising tool for the assessment of coronary microcirculation. The assessment of the IMR without the use of a pressure wire may enable more rapid, convenient, and cost-effective assessment of coronary microvascular function.

The triglyceride glucose index was nonlinearly associated with all-cause mortality in diabetic patients.

BACKGROUND AND AIM: The TyG index has been linked with cardiometabolic diseases. Our study aimed to investigate the specific relationship between the triglyceride and glucose index (TyG) and both all-cause and cardiovascular mortality in diabetic patients. METHODS AND RESULTS: We enrolled 3120 participants with diabetes from the National Health and Nutrition Examination Survey. The TyG index was calculated using the formula ln [fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. Hazard ratios (HRs) of TyG associated with mortality risk were assessed using Cox proportional hazard regression models. Over a follow-up period of 10.8 thousand person-years, we observed 768 all-cause deaths and 155 cardiovascular deaths. Compared to the reference quartile, the multivariate-adjusted hazard ratios and 95% confidence intervals for all-cause mortality were 1.02 (1.01-1.05; p = 0.008) in the fourth quartile. Dose-response analysis revealed a non-linear association. However, no significant associations were found between the TyG index and cardiovascular mortality. CONCLUSIONS: The TyG index exhibited a non-linear association with the risk of all-cause mortality in diabetic patients.

Mandibular Body Osteotomy Combined with Sagittal Split Ramus Osteotomy for the Treatment of Severe Skeletal Class â ¢ Malocclusion with Ankylosed Teeth.

This study presents a combination of 2 different surgery procedures performed on the mandible as part of the treatment aiming to improve the facial profile and occlusal function of patients with severe skeletal class Ⅲ malocclusion and bilateral edentulous gaps. The teeth next to the edentulous gaps were found to be ankylosed. Mandibular setback by bilateral sagittal split ramus osteotomies and mandibular body osteotomies, combined with Le Fort Ⅰ level maxillary advancement were performed, since the chief complaint of the patient was a concave profile. As a result, the skeletal class Ⅲ malocclusion had been corrected, a satisfying facial profile had been achieved, and no apparent adverse effect was found. Thus, it has been proved that the combination of sagittal split ramus osteotomy and mandibular body osteotomy is available for correcting skeletal class Ⅲ malocclusion.

Inferior Alveolar Nerve Repositioning With the Computer-Aided Design in Hemimandibular Hyperplasia.

A 34-year-old man presented with facial asymmetry and was diagnosed with left-sided hemimandibular hyperplasia. Orthognathic surgery and mandibular angle osteotomy combined with inferior alveolar nerve repositioning were performed with computer-aided design. The facial asymmetry was successfully corrected with acceptable cosmetic results. Inferior alveolar nerve repositioning provided sufficient space for the osteotomy of the affected side with the abnormal mandibular canal. Inferior alveolar nerve repositioning with computer-aided design can be used as an effective and reliable technique for hemimandibular hyperplasia.

Assessment of Masseter Volume and Postoperative Stability After Orthognathic Surgery in Patients With Skeletal Class III Malocclusion With Facial Asymmetry.

OBJECTIVE: This study aimed to evaluate the effect of orthognathic surgery on masseter volume in patients with skeletal Class III malocclusion with facial asymmetry and the effect of masseter volume on stability in orthognathic surgery. METHODS: This research studied 16 patients with Class III malocclusion with facial asymmetry who received combined orthodontic-orthognathic treatment and underwent craniofacial computed tomography (CT) before (T0), 2 weeks after (T1), and 6 months after (T2) surgery. Three-dimensional (3D) CT images were retrospectively analyzed, using 3D volume reconstruction to obtain the masseter volume and examine the impact of the masseter volume on stability in orthognathic surgery. RESULTS: A statistically significant difference ( P < 0.05) in the volume of the masseter was found up to 6 months after orthognathic surgery compared with the preoperative period, and the reduction in the masticatory muscle volume on the lengthened side is greater than on the shortened side ( P < 0.05). The volume of both masseters differed according to facial asymmetry, and the difference was significantly reduced after orthognathic surgery ( P < 0.05). During the period time (T1-T2), cephalometric maxillary marker points were not significantly different ( P > 0.05), and mandibular marker points were significantly anteriorly shifted ( P < 0.05). There was an association between the masseter volume and anterior shift of point B (R > 0.5, P < 0.05), the upward and anterior shifts of the gonion point differed between the lengthened and shortened sides ( P < 0.05). CONCLUSION: The size of the masseter becomes smaller 6 months after orthognathic surgery, and orthognathic surgery improves both bone and soft tissue symmetry. A larger sagittal relapse of mandibular setback occurred in patients with greater masseter volume. Considering these alterations may be helpful in planning orthognathic surgery.

Using a three-dimensional natural head position precise recording and transferring device to translate the natural head position into a 3-dimensional virtual patient: A dental technique.

As computer-assisted surgical design becomes increasingly popular in maxillofacial surgery, the integration of the natural head position (NHP) of a 3-dimensional virtual patient has become a primary problem that orthognathic surgeons have to solve during virtual surgical planning. The present technique describes a way of transferring the horizon orientation of the NHP into a computer-aided design software program with a recently developed NHP recording and transferring device (Patent No. ZL202110992198.6 China). The device can record NHP using 5 marked points which can be visualized radiographically.

Himi-Lengthening Genioplasty: A Modified Technique for the Correction of Mandibular Asymmetry.

Mandibular asymmetry is among the most common facial anomalies. Traditionally, mandibular asymmetry with malocclusion has been treated with orthognathic surgery and genioplasty. However, routine genioplasty cannot achieve a satisfactory contour. Hence, this study presents a modified technique, himi-lengthening genioplasty, to resolve this matter. By combining this technique with orthognathic surgery, the authors successfully corrected mandibular asymmetry in 1-stage surgery, achieved ideal occlusion, and reconstructed the esthetic contour. No complications occurred during the 6-month follow-up period. Therefore, the authors recommend our modified surgical technique for its effectiveness, security, stability, and simplicity.

Modified Le Fort I Arc Osteotomy Combined With Autologous Bone Grafts to Improve Midface Hypoplasia Combined With Skeletal Class III Malocclusion: A Technical Note.

Midface hypoplasia sometimes appears in patients with skeletal class III malocclusion in the Asian population, often requires additional surgical treatments. The technical note is intended to introduce a modified Le Fort I arc osteotomy combined with autologous bone grafts harvested from proximal segments after bilateral sagittal split ramus osteotomy to improve the profile for skeletal class III malocclusion patients with midface hypoplasia. The benefit of the modified technology is that the size and position of the arc can be adjusted according to the severity of the deformity to suit different patients. In addition, the application of autologous bone grafts increased the extra height of osteotomy line and enhanced the surgical effect, and maintained bone consolidation. More importantly, the osteotomy line of the modified Le Fort I arc osteotomy can be easily designed and this modification will not cause additional injuries. Therefore, we believe that for skeletal class III malocclusion patients with midface hypoplasia in Asia modified Le Fort I arc osteotomy combined with autologous bone grafts will be an efficient surgical method to improve midface hypoplasia.

Application of 3D-printed Surgical Cutting Guide in Anterior Mandibular Body Ostectomy.

Complications in mandibular surgeries involve nerve and root injuries. Due to the variation of the intraosseous pattern of the inferior alveolar nerve and roots among patients, the risk of injury remains high in complex cases of mandibular body surgeries. This technical note aims to introduce a novel design of surgical cutting guide used in anterior mandibular body ostectomy. Roots of neighboring teeth and the inferior alveolar nerve are segmented and visualized in 3-dimension. Osteotomy planes designed in virtual surgical planning provide an accurate safety distance to the nerve and roots. These planes are translated to a bone-based cutting guide to ensure the osteotomy is conducted as planned. Application of the cutting guide offers protection to the neighboring structures and the simplified structure requires limited preoperative design time of the cutting guide. Therefore, the authors believe this surgical cutting guide would bring accuracy and efficiency to mandibular surgeries.

Three-dimensional Reconstruction and Comparison of Temporomandibular Joint Space Volume Before and After Orthognathic Surgery in Patients with Skeletal Class III Malocclusion With Mandibular Deviation.

OBJECTIVE: To look into the association between the degree of deviation and the changing trend in the temporomandibular joint (TMJ) space volume after orthognathic surgery in patients with skeletal Class III malocclusion. METHODS: Twenty patients having combined orthodontic-orthognathic treatment for skeletal Class III malocclusions with mandibular deviation were chosen, and craniofacial spiral CT was performed before (T0), two weeks after (T1), and six months after (T2) surgery. Using 3D volume reconstruction, further partitioning, and analysis of each domain's volume changes over time, the TMJ space volume is to be obtained. The differences in changes between groups A (mild deviation group) and B (severe deviation group) were examined to examine the impact of the degree of deviation on the TMJ space volume. RESULTS: A statistically significant difference ( P <0.05) existed between the postoperative TMJ space volume in group A and the preoperative overall, anterolateral, and anteroinferior space volume; the same difference also existed between the postoperative TMJ space volume in the NDS and the preoperative posterolateral, posteroinferior space volume. In group B, the postoperative TMJ space volume was statistically significant ( P <0.05) compared with the preoperative total and anteroinferior space volume in the DS; the difference between the total volume of the T1 stage on the NDS and the total volume of the T0 stage was statistically significant ( P <0.05). The two groups showed substantial differences in the space volume changes between the T1-T0 phase and the T2-T1 period. CONCLUSION: Patients with skeletal Class III malocclusion and mandibular deviation after orthognathic surgery see a change in the TMJ space volume. All patient types experience a largely consistent space volume change trend two weeks after surgery, and the degree of mandibular deviation is correlated with the intensity and longevity of the alteration.

A Novel Technique for Resection and Reconstruction of the Temporomandibular Joint by Sliding Vertical Ramus Osteotomy using Only Submandibular Approach.

In this paper, an innovative technique for resection and reconstruction of the temporomandibular joint by sliding vertical ramus osteotomy using only a submandibular approach is presented. Before pulling the posterior mandibular border slightly downward to expose parts of the condyle, the vertical ramus osteotomy was performed. With the help of 3D simulation and surgical templates, the condylectomy was carried out using the ultrasonic osteotome through the submandibular approach. Our technique achieved the desired results while preventing complications of facial nerve paralysis, the occurrence of Frey syndrome, and the preauricular scar. Therefore, we suggest that this surgical method represents an alternative treatment option for temporomandibular joint lesions.

Posterior Mandibular Segmental Split Osteotomy: A Novel Technique for Edentulous Space Reconstruction in Patients With Skeletal Class III Malocclusion.

ABSTRACT: This study presents an innovative surgery that successfully improved the facial profile and occlusal function of a patient with a skeletal Class III malocclusion and posterior hypodontia. The patient had chief complaints of missing teeth and a protrudedjaw. A novel 1-stage surgery referred to as posterior mandibular segmental split osteotomy combined with Le Fort i osteotomy and BSSRO was used because the patient wanted to save time and was worried about periodontal complications associated with other treatment methods. As a result, a satisfying facial profile and a Class I occlusion with a normal position of the posterior dentoalveolar segment of the mandible were achieved with no adverse effects. Thus, posterior mandibular segmental split osteotomy can be considered an effective treatment for skeletal Class III malocclusion with posterior hypodontia.

A Novel Forceps for Preventing Mucosal Damage of the Hard Palate in Maxilla Mobilization During Le Fort I Osteotomy.

At present, the most effective and common strategy to mobilize the maxilla is to use Rowe disimpaction forceps. But because of the directed forces on the hard palate, the mucosa of the hard palate will have to receive an ineluctable mechanical injury. Therefore, we introduce a novel forceps (Patent No. 202110966069.X China), which can accurately and steadily clamp the maxilla on the premise of protecting the hard palate mucosa from loss of palatal vascularity and pressure necrosis, and then thoroughly mobilize the maxilla. Complaints and mucosal damage were not observed in the initial 3 patients.

Classification and Clinical Treatments for Unfavorable Fractures of the Proximal Segment in Sagittal Spilt Ramus Osteotomy: A Retrospective Study of 964 Cases.

ABSTRACT: Unfavorable fractures in sagittal split ramus osteotomy are hard to manage. The aim of this study is to develop a new classification method for unfavorable fractures of the proximal segment to guide clinical managements. After reviewing 964 cases of sagittal split ramus osteotomy, we found that the unfavorable fractures can be divided into 3 types: mandibular ramus transverse fractures (Type 1), bad fractures accompanied by free fragments (Type 2), and unexpected separation patterns without free fragments (Type 3). We calculated the incidence of each fracture type and provided instructions for their corresponding treatments. Thirty-six patients suffered from unfavorable fractures (7.4% of patients), among which 32 patients had unilateral fractures and 4 patients had bilateral fractures. There were 2 Type 1 fractures (0.2% of split sites), 8 Type 2 fractures (0.8% of split sites), and twenty-six Type 3 fractures (2.3% of split sites). Type 1 unfavorable fractures are difficult to deal with, but Types 2 and 3 are generally manageable and they have no significant impact on the final outcomes. The new classification can effectively guide treatment strategies for unfavorable fractures. Severe cases of unfavorable fractures are rare, and most unfavorable fracture cases have a positive prognosis if correctly treated in time.

One-Stage Repair of Alveolar Cleft and Nasal Deformities Using Grafts From Nasal Septum: Application of Vomer, Ethmoid, and Septal Cartilage.

BACKGROUND: Patients with alveolar cleft unrepaired suffer from nasal deformities of different magnitude. Bone and cartilage grafts are harvested through several incisions. In this study, we present a method to simultaneously correct nasal deformities and repair alveolar cleft using grafts from the nasal septum. PATIENTS AND METHODS: All 6 patients with unilateral cleft lip and palate have alveolar cleft unrepaired combined with nasal deformity. Computed tomography scans and 3-dimensional-printed models of vomer and ethmoid bone were used for the purpose of preoperative design and for assessing the magnitude of deformity. Grafts of bone and cartilage from deviated septum were harvested by septoplasty through which dorsum deviation was corrected. Bone grafts from vomer and ethmoid were then fixed to the prepared alveolar cleft to repair the defect and elevate the alar base. Septal cartilage was adjusted into different shapes of grafts and deformities of nasal tip, nostrils, and columella were then corrected by rhinoplasty to restore the symmetry of the nose. RESULTS: Symmetry of nostrils was improved. The height of alar base on the cleft side was elevated to the level close to the noncleft side. Deviation of the septum, nasal dorsum, and columella was corrected. Projection of the nasal tip was adjusted to facial midline. Midface aesthetics was generally improved. CONCLUSION: Application of septal grafts reduce the number of incisions. One-stage repair of alveolar cleft and nasal deformities, with the aid of digital design, improves the postoperative experience and the general outcome of the surgery.

Bilateral Sagittal Split Mandibular Ramus Osteotomy Alters the Temporomandibular Joint.

ABSTRACT: In this retrospective analysis, we examined temporomandibular joint space volume and condyle position in 10 patients undergoing bilateral sagittal split mandibular ramus osteotomy plus Le Fort I osteotomy to correct mandibular asymmetry. Cone beam computed tomography was used to map temporomandibular joint prior to (T0), immediately after (T1), and at 1 year after surgery (T2). In the deviated side, we detected significant lateral shift of the condyle in 5 patients at T1, and the shift disappeared at T2. In the non-deviated side, we detected significant medial shift of the condyle in all 10 patients at T1; the shift continued in 9 patients at T2. Temporomandibular joint space volume increased significantly at T1 and returned to presurgical volume at T2. In conclusion, there is significant shift in position of condyle in majority of the patients after bilateral sagittal split mandibular ramus osteotomy. The most consistent and persisting change was medial shift on the nondeviated side.

Simultaneous Orthognathic Surgery and Mandibular Contour Osteoplasty for Treating Mandibular Protrusion With High Gonial Angle.

OBJECTIVE: The purpose of this study was to confirm the effectiveness and feasibility of simultaneous orthognathic surgery and mandibular contour osteoplasty with the help of the accurate surgical templates to treat mandibular protrusion with high gonial angle. METHODS: Ten patients diagnosed as mandibular protrusion with high gonial angle were included in this study. Besides the traditional orthognathic surgery, mandibular contour osteoplasty was performed simultaneously. Models of the mandible were fabricated via 3D printing technology. Accurate surgical templates were produced on the 3D printing model according to preoperative design. Radiographs and medical photographs preoperatively and postoperatively were taken to compare the effectiveness of the operation. Measurement items include gonial angle (Ar-Go-Me), midlines of maxilla and mandible. The clinical manifestation of the temporomandibular joint and condylar process were observed. RESULTS: Radiographs and photographs of the face were taken after surgery showed satisfactory esthetic outcomes. The right gonial angle improved from 128.20°â€Š±â€Š5.67° to 120.35°â€Š±â€Š0.46°, and the left gonial angle improved from 129.91°â€Š±â€Š2.78° to 120.74°â€Š±â€Š0.59°. The midlines of the maxilla and mandibular basically consisted of the facial midline. After surgery, patients' clinical manifestation of the temporomandibular joint was no significant difference compared with the preoperative and the condylar process had no absorption. CONCLUSION: The results of this study showed it was possible to perform orthognathic surgery and mandibular contour osteoplasty simultaneously with the help of surgical templates in the treatment of mandibular protrusion with high gonial angle.

A Modified Cosmetic Genioplasty Can Affect Airway Space Positively in Skeletal Class II Patients: Studying Alterations of Hyoid Bone Position and Posterior Airway Space.

BACKGROUND: Improving the posterior airway space is one of the most important functions of genioplasty. Studies have shown that the posterior airway space (PAS) can play an important role in the evaluation of obstructive sleep apnea syndrome (OSAS). The purpose of this study is to evaluate the airway safety of our modified technology by observing the impact on PAS in skeletal Class II patients without OSAS. METHODS: We have modified a cosmetic genioplasty, which can guarantee the continuity of the lower edge of the bilateral mandible by rotating the chin segment clockwise. Fourteen patients submitted to our modified cosmetic genioplasty alone were included in the study. The facial convexity angle and the ratio of the face were measured by analyzing photographs. The position of the hyoid bone and the width of the PAS were measured by analyzing lateral cephalograms. The volume and the cross-sectional area (CSA) of the PAS were measured using 3D reconstruction. The Wilcoxon signed-rank test and paired samples t test were used to assess the significance of differences of the data (p < 0.05). RESULTS: Soft tissue measurements were statistically different (p = 0.001) and achieved satisfactory results. The position of the hyoid bone moved up (LX: p = 0.004; LML: p = 0.056) and forward (LY: p = 0.001; LCV3: p = 0.016). The increase in the CSA had statistical significance (p < 0.005). There were significant statistical differences in the total airway volume and hypopharynx (p = 0.001), except in the oropharynx (p = 0.096). CONCLUSIONS: Our modified genioplasty not only achieved better cosmetic results by ensuring the continuity of the lower edge of the bilateral mandible but also exerted a significant positive impact on the posterior airway space for patients with skeletal class II, thus helping reduce the prevalence of OSAS. We hence suggest performing this modified cosmetic genioplasty on the skeletal class II patients with/without OSAS if necessary. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Precise Midline Positioning Instrument for Le Fort I Osteotomy.

To reduce the deviations in the horizontal direction of posterior maxilla during the maxilla Le Fort I osteotomy, the authors develop and validate the precise midline positioning instrument for Le Fort I osteotomy, which can guide the precise relocation of the truncated maxillary bone segment. The patent application for the precise midline positioning instrument for Le Fort I osteotomy is already submitted (patent no: 201711245533.6, China). The accuracy of Le Fort I osteotomy can be improved significantly, because of the amplification effect of this patent on the rotation/micro-movement of the posterior maxilla in all directions to achieve the precise movement and pairing of the maxillary bone segment. And this method is simple, efficient, and laborsaving.