Prognostic impact of right ventricular free wall longitudinal strain in tricuspid regurgitation: a systematic review and meta-analysis

INTRODUCTION: Traditional echocardiography is limited in the early assessment of right ventricular (RV) dysfunction, especially in cases of tricuspid regurgitation (TR). In this context, right ventricular free wall longitudinal strain (RVFWLS) has emerged as a promising tool to enhance this evaluation. Hypothesis: We aimed to conduct a systematic review and meta-analysis to investigate whether impaired RVFWLS in patients with moderate to severe TR is associated with an increased risk of all-cause mortality and heart failure (HF) hospitalization. METHODS: We searched Pubmed, Embase and Cochrane for studies that examined our clinical question. Two reviewers performed study selection, data extraction and assessment of bias. RVFWLS was evaluated as a binary variable: normal/near-normal vs. impaired. The latter was defined as a RVFWLS > -17%. Statistical analysis was performed using Review Manager 5.4.1. We calculated pooled hazard ratios (HR) with 95% confidence intervals (CI) under a random effects model. We also performed a subgroup analysis of multivariable analyses to minimize the effect of confounding variables. RESULTS: We included 1,523 patients from 5 cohort studies. The mean follow-up ranged from 2.2 to 3.9 years. Mean age ranged to 62 to 84 years and 1,462 (96%) had functional TR. All-cause mortality (HR 1.06; 95% CI 1.02-1.10; p=0.002) and the composite of all-cause mortality or HF hospitalizations (HR 1.10; 95% CI 1.03-1.18; p=0.006) were significantly higher in patients with impaired RVFWLS compared with normal or near-normal RVFWLS. When considering only the multivariable analyses, patients with reduced RVFWLS also had a higher adjusted risk of all-cause mortality (HR 1.05; 95% CI 1.02-1.08; p=0.003). CONCLUSIONS: Our findings indicate that RVFWLS is an independent prognostic factor for all-cause mortality among patients with moderate to severe TR. The use of RVFWLS to guide management of this population warrants further investigation.

Mandibular exercises improve mandibular advancement device therapy for obstructive sleep apnea.

RATIONALE: Temporomandibular disorder (TMD) has been the most common contraindication for mandibular advancement device (MAD) as a treatment for obstructive sleep apnea syndrome (OSAS). Exercising the mandible is a recommended form of therapy for TMD. OBJECTIVES: To assess the efficacy of mandibular exercises in the control of pain, changes of quality of life and to assess the impact of MAD compliance in OSAS patients with previously diagnosed TMD. METHODS: A blind, randomized, and controlled trial was used to evaluate 29 OSAS patients with TMDs were divided in two groups: the exercise support therapy (ST) and placebo therapy (PT), who were evaluated prior to and 120 days after MAD treatment. Treatment outcomes were measured using the Fletcher and Luckett sleep questionnaire, Epworth sleepiness scale, SF-36 inventory of quality of life, polysomnography, diary of MAD usage, and the research diagnostic criteria for TMD. MEASUREMENTS AND MAIN RESULTS: ST group showed significant improvement in their sleep quality and life quality when compared to the PT group (p < 0.05). Higher number of patients with persistent pain was observed in the PT group (p = 0.01). There was a reduction of pain intensity in the ST group, but not in the PT group (p < 0.05). Higher MAD compliance was observed in the ST group (p < 0.05). CONCLUSIONS: Mandibular exercises enable patients with TMD to use MAD; exercises were found to be effective in reducing pain and increasing MAD compliance and produced a significant improvement in the quality of life and quality of sleep.

Prevalence of temporomandibular disorders in obstructive sleep apnea patients referred for oral appliance therapy.

AIMS: To evaluate the prevalence of pain associated with temporomandibular disorders (TMD) in obstructive sleep apnea syndrome (OSAS) patients referred for oral appliance therapy. METHODS: Eighty-seven patients (46 men and 41 women), between 18 and 65 years of age, with an apnea-hypopnea index (AHI) of > 5 and < 30 (events by sleep hour), and body mass index (BMI) of =or< 30 Kg/m(2) were evaluated according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) to determine the presence of signs and symptoms of TMD. Statistical analyses included correlations assessed by Pearson's test. RESULTS: Fifty-two percent of patients presented symptoms of TMD. Thirty-two patients (average age 47 +/- 11 years, AHI 17.3 +/- 8.7, BMI 25.9 +/- 3.8 kg/m(2)) completed the study. According to the Scoring Protocol for Graded Chronic Pain (Axis II-RDC/TMD), 75% of the patients presented chronic pain related to TMD, categorized as low disability grade I (< 50 points for pain intensity, and < 3 disability points). The most common TMD diagnosis was myofascial pain with and without limited mouth opening and arthralgia (50%). CONCLUSION: The high prevalence of TMD in the current study indicates that patients with OSAS referred for oral appliance therapy require specific evaluation related to TMD.