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Renal Denervation Influences Angiotensin II Types 1 and 2 Receptors. Int J Nephrol 2022; 2022:8731357. [PMID: 36262553 PMCID: PMC9576444 DOI: 10.1155/2022/8731357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 09/05/2022] [Accepted: 09/12/2022] [Indexed: 11/17/2022] Open
Abstract
The sympathetic and renin-angiotensin systems (RAS) are two critical regulatory systems in the kidney which affect renal hemodynamics and function. These two systems interact with each other so that angiotensin II (Ang II) has the presynaptic effect on the norepinephrine secretion. Another aspect of this interaction is that the sympathetic nervous system affects the function and expression of local RAS receptors, mainly Ang II receptors. Therefore, in many pathological conditions associated with an increased renal sympathetic tone, these receptors' expression changes and renal denervation can normalize these changes and improve the diseases. It seems that the renal sympathectomy can alter Ang II receptors expression and the distribution of RAS receptors in the kidneys, which influence renal functions.
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Patel KP, Katsurada K, Zheng H. Cardiorenal Syndrome: The Role of Neural Connections Between the Heart and the Kidneys. Circ Res 2022; 130:1601-1617. [PMID: 35549375 PMCID: PMC9179008 DOI: 10.1161/circresaha.122.319989] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The maintenance of cardiovascular homeostasis is highly dependent on tightly controlled interactions between the heart and the kidneys. Therefore, it is not surprising that a dysfunction in one organ affects the other. This interlinking relationship is aptly demonstrated in the cardiorenal syndrome. The characteristics of the cardiorenal syndrome state include alterations in neurohumoral drive, autonomic reflexes, and fluid balance. The evidence suggests that several factors contribute to these alterations. These may include peripheral and central nervous system abnormalities. However, accumulating evidence from animals with experimental models of congestive heart failure and renal dysfunction as well as humans with the cardiorenal syndrome suggests that alterations in neural pathways, from and to the kidneys and the heart, including the central nervous system are involved in regulating sympathetic outflow and may be critically important in the alterations in neurohumoral drive, autonomic reflexes, and fluid balance commonly observed in the cardiorenal syndrome. This review focuses on studies implicating neural pathways, particularly the afferent and efferent signals from the heart and the kidneys integrating at the level of the paraventricular nucleus in the hypothalamus to alter neurohumoral drive, autonomic pathways, and fluid balance. Further, it explores the potential mechanisms of action for the known beneficial use of various medications or potential novel therapeutic manipulations for the treatment of the cardiorenal syndrome. A comprehensive understanding of these mechanisms will enhance our ability to treat cardiorenal conditions and their cardiovascular complications more efficaciously and thoroughly.
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Affiliation(s)
- Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha (K.P.P.)
| | - Kenichi Katsurada
- Division of Cardiovascular Medicine, Department of Internal Medicine (K.K.), Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.,Division of Clinical Pharmacology, Department of Pharmacology (K.K.), Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Hong Zheng
- Basic Biomedical Sciences, Sanford School of Medicine, University of South Dakota, Vermillion (H.Z.)
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Katsurada K, Nandi SS, Zheng H, Liu X, Sharma NM, Patel KP. GLP-1 mediated diuresis and natriuresis are blunted in heart failure and restored by selective afferent renal denervation. Cardiovasc Diabetol 2020; 19:57. [PMID: 32384887 PMCID: PMC7206815 DOI: 10.1186/s12933-020-01029-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/25/2020] [Indexed: 02/07/2023] Open
Abstract
Background Glucagon-like peptide-1 (GLP-1) induces diuresis and natriuresis. Previously we have shown that GLP-1 activates afferent renal nerve to increase efferent renal sympathetic nerve activity that negates the diuresis and natriuresis as a negative feedback mechanism in normal rats. However, renal effects of GLP-1 in heart failure (HF) has not been elucidated. The present study was designed to assess GLP-1-induced diuresis and natriuresis in rats with HF and its interactions with renal nerve activity. Methods HF was induced in rats by coronary artery ligation. The direct recording of afferent renal nerve activity (ARNA) with intrapelvic injection of GLP-1 and total renal sympathetic nerve activity (RSNA) with intravenous infusion of GLP-1 were performed. GLP-1 receptor expression in renal pelvis, densely innervated by afferent renal nerve, was assessed by real-time PCR and western blot analysis. In separate group of rats after coronary artery ligation selective afferent renal denervation (A-RDN) was performed by periaxonal application of capsaicin, then intravenous infusion of GLP-1-induced diuresis and natriuresis were evaluated. Results In HF, compared to sham-operated control; (1) response of increase in ARNA to intrapelvic injection of GLP-1 was enhanced (3.7 ± 0.4 vs. 2.0 ± 0.4 µV s), (2) GLP-1 receptor expression was increased in renal pelvis, (3) response of increase in RSNA to intravenous infusion of GLP-1 was enhanced (132 ± 30% vs. 70 ± 16% of the baseline level), and (4) diuretic and natriuretic responses to intravenous infusion of GLP-1 were blunted (urine flow 53.4 ± 4.3 vs. 78.6 ± 4.4 µl/min/gkw, sodium excretion 7.4 ± 0.8 vs. 10.9 ± 1.0 µEq/min/gkw). A-RDN induced significant increases in diuretic and natriuretic responses to GLP-1 in HF (urine flow 96.0 ± 1.9 vs. 53.4 ± 4.3 µl/min/gkw, sodium excretion 13.6 ± 1.4 vs. 7.4 ± 0.8 µEq/min/gkw). Conclusions The excessive activation of neural circuitry involving afferent and efferent renal nerves suppresses diuretic and natriuretic responses to GLP-1 in HF. These pathophysiological responses to GLP-1 might be involved in the interaction between incretin-based medicines and established HF condition. RDN restores diuretic and natriuretic effects of GLP-1 and thus has potential beneficial therapeutic implication for diabetic HF patients.
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Affiliation(s)
- Kenichi Katsurada
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA
| | - Shyam S Nandi
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA
| | - Hong Zheng
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, SD, USA
| | - Xuefei Liu
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, SD, USA
| | - Neeru M Sharma
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA
| | - Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, 985850 Nebraska Medical Center, Omaha, NE, 68198-5850, USA.
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Zheng H, Liu X, Katsurada K, Patel KP. Renal denervation improves sodium excretion in rats with chronic heart failure: effects on expression of renal ENaC and AQP2. Am J Physiol Heart Circ Physiol 2019; 317:H958-H968. [PMID: 31490733 DOI: 10.1152/ajpheart.00299.2019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Previously we have shown that increased expression of renal epithelial sodium channels (ENaC) may contribute to the renal sodium and water retention observed during chronic heart failure (CHF). The goal of this study was to examine whether renal denervation (RDN) changed the expressions of renal sodium transporters ENaC, sodium-hydrogen exchanger-3 proteins (NHE3), and water channel aquaporin 2 (AQP2) in rats with CHF. CHF was produced by left coronary artery ligation in rats. Four weeks after ligation surgery, surgical bilateral RDN was performed. The expression of ENaC, NHE3, and AQP2 in both renal cortex and medulla were measured. As a functional test for ENaC activation, diuretic and natriuretic responses to ENaC inhibitor benzamil were monitored in four groups of rats (Sham, Sham+RDN, CHF, CHF+RDN). Western blot analysis indicated that RDN (1 wk later) significantly reduced protein levels of α-ENaC, β-ENaC, γ-ENaC, and AQP2 in the renal cortex of CHF rats. RDN had no significant effects on the protein expression of kidney NHE3 in both Sham and CHF rats. Immunofluorescence studies of kidney sections confirmed the reduced signaling of ENaC and AQP2 in the CHF+RDN rats compared with the CHF rats. There were increases in diuretic and natriuretic responses to ENaC inhibitor benzamil in rats with CHF. RDN reduced the diuretic and natriuretic responses to benzamil in CHF rats. These findings suggest a critical role for renal nerves in the enhanced expression of ENaC and AQP2 and subsequent pathophysiology of renal sodium and water retention associated with CHF.NEW & NOTEWORTHY This is the first study to show in a comprehensive way that renal denervation initiated after a period of chronic heart failure reduces the expression of epithelial sodium channels and aquaporin 2 leading to reduced epithelial sodium channel function and sodium retention.
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Affiliation(s)
- Hong Zheng
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, South Dakota
| | - Xuefei Liu
- Division of Basic Biomedical Sciences, Sanford School of Medicine of the University of South Dakota, Vermillion, South Dakota
| | - Kenichi Katsurada
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
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5
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Jamali HK, Waqar F, Gerson MC. Cardiac autonomic innervation. J Nucl Cardiol 2017; 24:1558-1570. [PMID: 27844333 DOI: 10.1007/s12350-016-0725-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 10/25/2016] [Indexed: 10/20/2022]
Abstract
The autonomic nervous system plays a key role in regulating changes in the cardiovascular system and its adaptation to various human body functions. The sympathetic arm of the autonomic nervous system is associated with the fight and flight response, while the parasympathetic division is responsible for the restorative effects on heart rate, blood pressure, and contractility. Disorders involving these two divisions can lead to, and are seen as, a manifestation of most common cardiovascular disorders. Over the last few decades, extensive research has been performed establishing imaging techniques to quantify the autonomic dysfunction associated with various cardiovascular disorders. Additionally, several techniques have been tested with variable success in modulating the cardiac autonomic nervous system as treatment for these disorders. In this review, we summarize basic anatomy, physiology, and pathophysiology of the cardiac autonomic nervous system including adrenergic receptors. We have also discussed several imaging modalities available to aid in diagnosis of cardiac autonomic dysfunction and autonomic modulation techniques, including pharmacologic and device-based therapies, that have been or are being tested currently.
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Affiliation(s)
- Hina K Jamali
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH, USA
| | - Fahad Waqar
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH, USA
| | - Myron C Gerson
- Division of Cardiovascular Health and Disease, Department of Internal Medicine, University of Cincinnati College of Medicine, P.O. Box 670542, Cincinnati, OH, USA.
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6
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Hopper I, Gronda E, Hoppe UC, Rundqvist B, Marwick TH, Shetty S, Hayward C, Lambert T, Hering D, Esler M, Schlaich M, Walton A, Airoldi F, Brandt MC, Cohen SA, Reiters P, Krum H. Sympathetic Response and Outcomes Following Renal Denervation in Patients With Chronic Heart Failure: 12-Month Outcomes From the Symplicity HF Feasibility Study. J Card Fail 2017. [DOI: 10.1016/j.cardfail.2017.06.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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7
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Vuckovic KM, Puzantian H. Estimated Glomerular Filtration Rate and 6-Minute Walk Distance in African Americans with Mild to Moderate Heart Failure. Cardiorenal Med 2017; 7:227-233. [PMID: 28736563 DOI: 10.1159/000471810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 03/12/2017] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND/AIMS The 6-minute walk test is a measure of functional capacity in patients with heart failure (HF) or chronic kidney disease (CKD). The association between estimated glomerular filtration rate (eGFR) and 6-minute walk distance (6MWD) has not been investigated in African-Americans (AA), despite them having a higher incidence of CKD and chronic HF. Thus, our aim was to determine if eGFR was an independent predictor of 6MWD in AA >50 years of age with HF. METHODS In this cross-sectional study, we examined the relationship between eGFR and 6MWD in 45 AA patients with HF from an urban outpatient HF clinic, using logistic regression with bootstrapping. RESULTS The sample consisted of 53% females; mean age = 64.8 ± 9 years, mean eGFR = 61.6 ± 20 mL/min/1.73 m2, and mean 6MWD = 222 ± 78 m. A decrease in eGFR by 10 mL/min/1.73 m2 was associated with 46% higher odds (p = 0.02) of a 6MWD ≤200 m in an unadjusted model and 39-41% higher odds (p = 0.03) of a 6MWD ≤200 m in adjusted models. CONCLUSION A decrease in eGFR significantly predicted a shorter 6MWD in AA patients with HF. Therefore, a reduction in eGFR may be used as an early marker to identify and manage declining functional capacity in these patients.
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Affiliation(s)
- Karen M Vuckovic
- Department of Biobehavioral Health Science, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
| | - Houry Puzantian
- Department of Biobehavioral Health Science, University of Illinois at Chicago College of Nursing, Chicago, IL, USA
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8
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Sarwar CMS, Papadimitriou L, Pitt B, Piña I, Zannad F, Anker SD, Gheorghiade M, Butler J. Hyperkalemia in Heart Failure. J Am Coll Cardiol 2017; 68:1575-89. [PMID: 27687200 DOI: 10.1016/j.jacc.2016.06.060] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/28/2016] [Indexed: 01/14/2023]
Abstract
Disorders of potassium homeostasis can potentiate the already elevated risk of arrhythmia in heart failure. Heart failure patients have a high prevalence of chronic kidney disease, which further heightens the risk of hyperkalemia, especially when renin-angiotensin-aldosterone system inhibitors are used. Acute treatment for hyperkalemia may not be tolerated in the long term. Recent data for patiromer and sodium zirconium cyclosilicate, used to treat and prevent high serum potassium levels on a more chronic basis, have sparked interest in the treatment of hyperkalemia, as well as the potential use of renin-angiotensin-aldosterone system inhibitors in patients who were previously unable to take these drugs or tolerated only low doses. This review discusses the epidemiology, pathophysiology, and outcomes of hyperkalemia in heart failure; provides an overview of traditional and novel ways to approach management of hyperkalemia; and discusses the need for further research to optimally treat heart failure.
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Affiliation(s)
| | | | - Bertram Pitt
- Cardiology Division, University of Michigan, Ann Arbor, Michigan
| | - Ileana Piña
- Cardiology Division, Albert Einstein College of Medicine; Bronx, New York
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center, Göttingen, Germany
| | - Mihai Gheorghiade
- Center for Cardiovascular Drug Development and Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, New York.
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9
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Zhong M, Kim LK, Swaminathan RV, Feldman DN. Renal Denervation to Modify Hypertension and the Heart Failure State. Interv Cardiol Clin 2017; 6:453-464. [PMID: 28600097 DOI: 10.1016/j.iccl.2017.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sympathetic overactivation of renal afferent and efferent nerves have been implicated in the development and maintenance of several cardiovascular disease states, including resistant hypertension and heart failure with both reduced and preserved systolic function. With the development of minimally invasive catheter-based techniques, percutaneous renal denervation has become a safe and effective method of attenuating sympathetic overactivation. Percutaneous renal denervation, therefore, has the potential to modify and treat hypertension and congestive heart failure. Although future randomized controlled studies are needed to definitively prove its efficacy, renal denervation has the potential to change the way we view and treat cardiovascular disease.
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Affiliation(s)
- Ming Zhong
- Division of Cardiology, Interventional Cardiology and Endovascular Laboratory, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th street, New York, NY 10021, USA
| | - Luke K Kim
- Division of Cardiology, Interventional Cardiology and Endovascular Laboratory, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th street, New York, NY 10021, USA
| | - Rajesh V Swaminathan
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, 2400 Pratt Street, Durham, NC 27705, USA
| | - Dmitriy N Feldman
- Division of Cardiology, Interventional Cardiology and Endovascular Laboratory, Weill Cornell Medical College, New York Presbyterian Hospital, 520 East 70th street, New York, NY 10021, USA.
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10
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Affiliation(s)
- W.H. Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland, Ohio
- Center for Clinical Genomics, Cleveland Clinic, Cleveland, Ohio
| | - Mark E. Dunlap
- Heart & Vascular Center, MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
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11
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Abstract
A key feature of chronic heart failure (HF) is the sustained activation of endogenous neurohormonal systems in response to impaired cardiac pumping and/or filling properties. The clinical use of neurohormonal blockers has revolutionised the care of HF patients over the past three decades. Drug therapy that is active against imbalance in both the autonomic and renin-angiotensin-aldosterone systems consistently reduces morbidity and mortality in chronic HF with reduced left ventricular ejection fraction and in sinus rhythm. This article provides an assessment of the major neurohormonal systems and their therapeutic blockade in patients with chronic HF.
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Affiliation(s)
- Thomas G von Lueder
- Department of Cardiology, Oslo University Hospital UllevÅl, Oslo, Norway.,Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia and Alfred Hospital, Melbourne, Australia
| | - Dipak Kotecha
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia and Alfred Hospital, Melbourne, Australia.,University of Birmingham Institute of Cardiovascular Sciences, Birmingham, UK
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital UllevÅl, Oslo, Norway
| | - Ingrid Hopper
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia and Alfred Hospital, Melbourne, Australia
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12
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Sarwar CMS, Bhagat AA, Anker SD, Butler J. Role of Hyperkalemia in Heart Failure and the Therapeutic Use of Potassium Binders. Handb Exp Pharmacol 2017; 243:537-560. [PMID: 28382468 DOI: 10.1007/164_2017_25] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Hyperkalemia can be a life-threatening disorder, especially for at-risk patients with heart failure, chronic kidney disease, with diabetes, and patients on certain drugs like renin-angiotensin-aldosterone system antagonists and mineralocorticoid receptor antagonists. There are limited therapeutic options available for hyperkalemia, and they have narrow effectiveness because of their unfavorable side effects profile in long-term and high cost utilization requiring inpatient care. Patiromersorbitex calcium and sodium zirconium cyclosilicate are novel potassium-lowering compounds for the treatment and prevention of hyperkalemia in at-risk population. These therapeutic agents have shown encouraging results in early phase II and phase III clinical trials. However, there is need to further study their efficacy and safety in heart failure population in order to establish their clinical use. The focus of this chapter will be to promote better understanding of potassium homeostasis in heart failure patients and the mechanistic overview of novel drugs, with emphasis on heart failure population.
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Affiliation(s)
| | - Aditi A Bhagat
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | - Javed Butler
- Cardiology Division, Stony Brook University, Stony Brook, NY, USA.
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13
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Böhm M, Ewen S, Mahfoud F. Renal Denervation for Chronic Heart Failure: Background and Pathophysiological Rationale. Korean Circ J 2016; 47:9-15. [PMID: 28154583 PMCID: PMC5287193 DOI: 10.4070/kcj.2016.0231] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 07/28/2016] [Indexed: 01/28/2023] Open
Abstract
The activation of the sympathetic nervous system is associated with cardiovascular hospitalizations and death in heart failure. Renal denervation has been shown to effectively reduce sympathetic overdrive in certain patients with uncontrolled hypertension. Pilot trials investigating renal denervation as a potential treatment approach for heart failure were initiated. Heart failure comorbidities like obstructive sleep apnea, metabolic syndrome and arrhythmias could also be targets for renal denervation, because these occurrences are also mediated by the activation of the sympathetic nervous system. Therefore, renal denervation in heart failure is worthy of further investigation, although its effectiveness still has to be proven. Herein, we describe the pathophysiological rationale and the effect of renal denervation on surrogates of the heart failure syndrome.
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Affiliation(s)
- Michael Böhm
- Departments of Internal Medicine III, Cardiology, Angiology, and Intensive Care, Saarland University Hospital, Homburg/Saar, Germany
| | - Sebastian Ewen
- Departments of Internal Medicine III, Cardiology, Angiology, and Intensive Care, Saarland University Hospital, Homburg/Saar, Germany
| | - Felix Mahfoud
- Departments of Internal Medicine III, Cardiology, Angiology, and Intensive Care, Saarland University Hospital, Homburg/Saar, Germany
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14
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Madanieh R, El-Hunjul M, Alkhawam H, Kosmas CE, Madanieh A, Vittorio TJ. A perspective on sympathetic renal denervation in chronic congestive heart failure. Heart Fail Rev 2016; 21:1-10. [PMID: 26563322 DOI: 10.1007/s10741-015-9516-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Medical therapy has indisputably been the mainstay of management for chronic congestive heart failure. However, a significant percentage of patients continue to experience worsening heart failure (HF) symptoms despite treatment with multiple therapeutic agents. Recently, catheter-based interventional strategies that interrupt the renal sympathetic nervous system have shown promising results in providing better symptom control in patients with HF. In this article, we will review the pathophysiology of HF for better understanding of the interplay between the cardiovascular system and the kidney. Subsequently, we will briefly discuss pivotal renal denervation (RDN) therapy trials in patients with resistant hypertension and then present the available evidence on the role of RDN in HF therapy.
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Affiliation(s)
- Raef Madanieh
- Center for Advanced Cardiac Therapeutics, St. Francis Hospital - The Heart Center®, 100 Port Washington Blvd., Roslyn, NY, 11576-1348, USA.
| | | | - Hassan Alkhawam
- Elmhurst Hospital Center, Icahn School of Medicine at Mount Sinai, Elmhurst, NY, USA
| | | | - Abed Madanieh
- Center for Advanced Cardiac Therapeutics, St. Francis Hospital - The Heart Center®, 100 Port Washington Blvd., Roslyn, NY, 11576-1348, USA
| | - Timothy J Vittorio
- Center for Advanced Cardiac Therapeutics, St. Francis Hospital - The Heart Center®, 100 Port Washington Blvd., Roslyn, NY, 11576-1348, USA
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15
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Schlaich MP. What we need to know about renal nerve ablation for treatment of hypertension and other states of sympathetic overactivity. Am J Physiol Renal Physiol 2016; 311:F1267-F1270. [PMID: 27630063 DOI: 10.1152/ajprenal.00058.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 09/12/2016] [Indexed: 01/18/2023] Open
Abstract
Renal nerves are key players in the regulation of kidney function and blood pressure control. Targeting the neurogenic mechanisms underlying hypertension and cardiac and renal disease has been attempted by means of surgical and pharmacologic approaches and most recently by catheter-based interventions aimed at disrupting renal sympathetic nerve traffic. The recent developments in the area and the relevant questions that need to be addressed to advance the field further are briefly reviewed in this article.
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Affiliation(s)
- Markus P Schlaich
- School of Medicine and Pharmacology-Royal Perth Hospital Unit, The University of Western Australia, Perth, Western Australia, Australia; .,Neurovascular Hypertension and Kidney Disease Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia; and.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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16
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Abstract
Cardio-renal syndrome is a commonly encountered problem in clinical practice. Its pathogenesis is not fully understood. The purpose of this article is to highlight the interaction between the cardiovascular system and the renal system and how their interaction results in the complex syndrome of cardio-renal dysfunction. Additionally, we outline the available therapeutic strategies to manage this complex syndrome.
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Affiliation(s)
- Joseph Gnanaraj
- Department of Cardiology, Bridgeport Hospital, Bridgeport, CT, USA
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17
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Zheng H, Patel KP. Integration of renal sensory afferents at the level of the paraventricular nucleus dictating sympathetic outflow. Auton Neurosci 2016; 204:57-64. [PMID: 27527558 DOI: 10.1016/j.autneu.2016.08.008] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 08/01/2016] [Accepted: 08/05/2016] [Indexed: 02/07/2023]
Abstract
The sympathetic nervous system has been identified as a major contributor to the pathophysiology of chronic heart failure (CHF) and other diseases such as hypertension and diabetes, both in experimental animal models and patients. The kidneys have a dense afferent sensory innervation positioning it to be the origin of multimodal input to the central nervous system. Afferent renal nerve (ARN) signals are centrally integrated, and their activation results in a general increase in sympathetic tone, which is directed toward the kidneys as well as other peripheral organs innervated by the sympathetic nerves. In the central nervous system, stimulation of ARN increases the neuronal discharge frequency and neuronal activity in the paraventricular nucleus (PVN) of the hypothalamus. The activity of the neurons in the PVN is attenuated during iontophoretic application of glutamate receptor blocker, AP5. An enhanced afferent renal input to the PVN may be critically involved in dictating sympathoexcitation in CHF. Furthermore, renal denervation abrogates the enhanced neuronal activity within the PVN in rats with CHF, thereby possibly contributing to the reduction in sympathetic tone. Renal denervation also restores the decreased endogenous levels of neuronal nitric oxide synthase (nNOS) in the PVN of rats with CHF. Overall, these data demonstrate that sensory information originating in the kidney excites pre-autonomic sympathetic neurons within the PVN and this "renal-PVN afferent pathway" may contribute to elevated sympathetic nerve activity in hyper-sympathetic disease conditions such as CHF and hypertension.
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Affiliation(s)
- Hong Zheng
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198-5850, United States
| | - Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198-5850, United States.
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18
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Li P, Nader M, Arunagiri K, Papademetriou V. Device-Based Therapy for Drug-Resistant Hypertension: An Update. Curr Hypertens Rep 2016; 18:64. [PMID: 27402013 DOI: 10.1007/s11906-016-0671-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Drug-resistant hypertension (RH) remains a significant and common cardiovascular risk despite the availability of multiple potent antihypertensive medications. Uncontrolled resistant hypertension contributes substantially to excessive cardiovascular and renal morbidity and mortality. Clinical and experimental evidence suggest that sympathetic nervous system over-activity is the main culprit for the development and maintenance of drug-resistant hypertension. Both medical and interventional strategies, targeting the sympathetic over-activation, have been designed in patients with hypertension over the past few decades. Minimally invasive, catheter-based, renal sympathetic denervation (RDN) and carotid baroreceptor activation therapy (BAT) have been extensively evaluated in patients with RH in clinical trials. Current trial outcomes, though at times impressive, have been mostly uncontrolled trials in need of validation. Device-based therapy for drug-resistant hypertension has the potential to provide alternative treatment options to certain groups of patients who are refractory or intolerant to current antihypertensive medications. However, more research is needed to prove its efficacy in both animal models and in humans. In this article, we will review the evidence from recent renal denervation, carotid baroreceptor stimulation therapy, and newly emerged central arteriovenous anastomosis trials to pinpoint the weak links, and speculate on potential alternative approaches.
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Affiliation(s)
- Ping Li
- Washington Veterans Affairs Medical Center, 50 Irving Street, N.W., Washington, DC, 20422, USA
- Georgetown University Hospital, Washington, DC, USA
- George Washington University Hospital, Washington, DC, USA
| | - Mark Nader
- Georgetown University Hospital, Washington, DC, USA
| | | | - Vasilios Papademetriou
- Washington Veterans Affairs Medical Center, 50 Irving Street, N.W., Washington, DC, 20422, USA.
- Georgetown University Hospital, Washington, DC, USA.
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19
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Zheng H, Liu X, Sharma NM, Patel KP. Renal denervation improves cardiac function in rats with chronic heart failure: Effects on expression of β-adrenoceptors. Am J Physiol Heart Circ Physiol 2016; 311:H337-46. [PMID: 27288440 DOI: 10.1152/ajpheart.00999.2015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/03/2016] [Indexed: 11/22/2022]
Abstract
Chronic activation of the sympathetic drive contributes to cardiac remodeling and dysfunction during chronic heart failure (HF). The present study was undertaken to assess whether renal denervation (RDN) would abrogate the sympathoexcitation in HF and ameliorate the adrenergic dysfunction and cardiac damage. Ligation of the left coronary artery was used to induce HF in Sprague-Dawley rats. Four weeks after surgery, RDN was performed, 1 wk before the final measurements. At the end of the protocol, cardiac function was assessed by measuring ventricular hemodynamics. Rats with HF had an average infarct area >30% of the left ventricle and left ventricular end-diastolic pressure (LVEDP) >20 mmHg. β1- and β2-adrenoceptor proteins in the left ventricle were reduced by 37 and 49%, respectively, in the rats with HF. RDN lowered elevated levels of urinary excretion of norepinephrine and brain natriuretic peptide levels in the hearts of rats with HF. RDN also decreased LVEDP to 10 mmHg and improved basal dP/dt to within the normal range in rats with HF. RDN blunted loss of β1-adrenoceptor (by 47%) and β2-adrenoceptor (by 100%) protein expression and improved isoproterenol (0.5 μg/kg)-induced increase in +dP/dt (by 71%) and -dP/dt (by 62%) in rats with HF. RDN also attenuated the increase in collagen 1 expression in the left ventricles of rats with HF. These findings demonstrate that RDN initiated in chronic HF condition improves cardiac function mediated by adrenergic agonist and blunts β-adrenoceptor expression loss, providing mechanistic insights for RDN-induced improvements in cardiac function in the HF condition.
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Affiliation(s)
- Hong Zheng
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Xuefei Liu
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Neeru M Sharma
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
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Boschetti E, Alrashdi Y, Schillaci G. Renal denervation for resistant hypertension: yes. Intern Emerg Med 2016; 11:491-3. [PMID: 26970989 DOI: 10.1007/s11739-016-1429-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/25/2016] [Indexed: 11/29/2022]
Abstract
Sympathetic overactivity may have a role in triggering and maintaining resistant hypertension, and catheter-based renal denervation (RDN) has emerged as a promising treatment in refractory hypertension. Recently, the results of the Symplicity HTN-3, the first randomized, sham-controlled trial, failed to confirm the previously reported BP-lowering effects of RDN, although definitive conclusions cannot be drawn due to a number of study limitations. Consequently, although some centers halted their RDN programs, research continues and both the concept of denervation and treatment strategies are being redefined. A new generation of sham-controlled trials is currently underway with the aim of detecting which patients are expected to achieve the most beneficial effect from RDN. In this article, we examine the current data on RDN and discuss some insights and future opportunities.
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Affiliation(s)
- Enrico Boschetti
- Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
- Struttura Complessa di Cardiologia, Azienda Ospedaliero-Universitaria di Terni, Terni, Italy
| | - Yahya Alrashdi
- Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy
| | - Giuseppe Schillaci
- Dipartimento di Medicina, Università degli Studi di Perugia, Perugia, Italy.
- Struttura Complessa di Medicina Interna, Azienda Ospedaliero-Universitaria di Terni, Piazzale Tristano di Joannuccio, 1, 05100, Terni, Italy.
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21
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Fischell TA, Ebner A, Gallo S, Ikeno F, Minarsch L, Vega F, Haratani N, Ghazarossian VE. Transcatheter Alcohol-Mediated Perivascular Renal Denervation With the Peregrine System. JACC Cardiovasc Interv 2016; 9:589-98. [DOI: 10.1016/j.jcin.2015.11.041] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Revised: 11/22/2015] [Accepted: 11/23/2015] [Indexed: 02/07/2023]
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22
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Skrzypecki J, Ufnal M. Drug resistant hypertension – no simple way out. Kidney Blood Press Res 2016; 40:66-76. [PMID: 25791632 DOI: 10.1159/000368483] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2015] [Indexed: 11/19/2022] Open
Abstract
Hypertension poses growing challenge for health policy-makers and doctors worldwide. Recently published results of Symplicity-III trial (HTN-3), the first blinded, randomized, multicenter study on the efficacy of renal denervation for the treatment of resistant hypertension did not show a significant reduction of BP in patients with resistant hypertension 6 months after renal-artery denervation, as compared with controls. In this paper we review clinical and experimental studies on renal denervation. In order to identify causes of inconsistent results in renal denervation studies we look at basic science support for renal denervation and at designs of clinical trials.
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23
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Liu Q, Zhang Q, Wang K, Wang S, Lu D, Li Z, Geng J, Fang P, Wang Y, Shan Q. Renal Denervation Findings on Cardiac and Renal Fibrosis in Rats with Isoproterenol Induced Cardiomyopathy. Sci Rep 2015; 5:18582. [PMID: 26689945 PMCID: PMC4686968 DOI: 10.1038/srep18582] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 11/23/2015] [Indexed: 12/26/2022] Open
Abstract
Cardio-renal fibrosis plays key roles in heart failure and chronic kidney disease. We sought to determine the effects of renal denervation (RDN) on cardiac and renal fibrosis in rats with isoproterenol induced cardiomyopathy. Sixty male Sprague Dawley rats were randomly assigned to Control (n = 10) and isoproterenol (ISO)-induced cardiomyopathy group (n = 50). At week 5, 31 survival ISO-induced cardiomyopathy rats were randomized to RDN (n = 15) and Sham group (n = 16). Compared with Control group, ejection fraction was decreased, diastolic interventricular septal thickness and left atrial dimension were increased in ISO-induced cardiomyopathy group at 5 week. After 10 weeks, cardio-renal pathophysiologic results demonstrated that the collagen volume fraction of left atrio-ventricular and kidney tissues reduced significantly in RDN group compared with Sham group. Moreover the pro-fibrosis factors (TGF-β1, MMP2 and Collagen I), inflammatory cytokines (CRP and TNF-α), and collagen synthesis biomarkers (PICP, PINP and PIIINP) concentration significantly decreased in RDN group. Compared with Sham group, RDN group showed that release of noradrenaline and aldosterone were reduced, angiotensin-converting enzyme (ACE)/angiotensin II (Ang II)/angiotensin II type-1 receptor (AT1R) axis was downregulated. Meanwhile, angiotensin-converting enzyme 2 (ACE2)/angiotensin-1-7 (Ang-(1-7))/mas receptor (Mas-R) axis was upregulated. RDN inhibits cardio-renal fibrogenesis through multiple pathways, including reducing SNS over-activity, rebalancing RAAS axis.
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Affiliation(s)
- Qian Liu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Qi Zhang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Kai Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Shengchan Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Dasheng Lu
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Zhenzhen Li
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Jie Geng
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Ping Fang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Ying Wang
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
| | - Qijun Shan
- Department of Cardiology, The First Affiliated Hospital of Nanjing Medical University
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Patel HC, Hayward C, Vassiliou V, Patel K, Howard JP, Di Mario C. Renal denervation for the management of resistant hypertension. Integr Blood Press Control 2015; 8:57-69. [PMID: 26672761 PMCID: PMC4675644 DOI: 10.2147/ibpc.s65632] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Renal sympathetic denervation (RSD) as a therapy for patients with resistant hypertension has attracted great interest. The majority of studies in this field have demonstrated impressive reductions in blood pressure (BP). However, these trials were not randomized or sham-controlled and hence, the findings may have been overinflated due to trial biases. SYMPLICITY HTN-3 was the first randomized controlled trial to use a blinded sham-control and ambulatory BP monitoring. A surprise to many was that this study was neutral. Possible reasons for this neutrality include the fact that RSD may not be effective at lowering BP in man, RSD was not performed adequately due to limited operator experience, patients’ adherence with their anti-hypertensive drugs may have changed during the trial period, and perhaps the intervention only works in certain subgroups that are yet to be identified. Future studies seeking to demonstrate efficacy of RSD should be designed as randomized blinded sham-controlled trials. The efficacy of RSD is in doubt, but many feel that its safety has been established through the thousands of patients in whom the procedure has been performed. Over 90% of these data, however, are for the Symplicity™ system and rarely extend beyond 12 months of follow-up. Long-term safety cannot be assumed with RSD and nor should it be assumed that if one catheter system is safe then all are. We hope that in the near future, with the benefit of well-designed clinical trials, the role of renal denervation in the management of hypertension will be established.
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Affiliation(s)
- Hitesh C Patel
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Carl Hayward
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Vassilis Vassiliou
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Ketna Patel
- Department of Cardiology, Royal Free Hospital, London, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College, London, UK
| | - Carlo Di Mario
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
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25
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LI ZZ, JIANG H, CHEN D, LIU Q, GENG J, GUO JQ, SUN RH, ZHU GQ, SHAN QJ. Renal Sympathetic Denervation Improves Cardiac Dysfunction in Rats With Chronic Pressure Overload. Physiol Res 2015; 64:653-62. [DOI: 10.33549/physiolres.932912] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Varied causative and risk factors can lead to cardiac dysfunction. Cardiac dysfunction often evolves into heart failure by cardiac remodeling due to autonomic nervous system disturbance and neurohumoral abnormalities, even if the detriment factors are removed. Renal sympathetic nerve activity plays a pivotal regulatory role in neurohumoral mechanisms. The present study was designed to determine the therapeutic effects of renal sympathetic denervation (RSD) on cardiac dysfunction, fibrosis, and neurohumoral response in transverse aortic constriction (TAC) rats with chronic pressure overload. The present study demonstrated that RSD attenuated myocardial fibrosis and hypertrophy, and structural remodeling of the left atrium and ventricle, up-regulated cardiac β adrenoceptor (β-AR, including β1AR and β2AR) and sarco-endoplasmic reticulum Ca2+-ATPase (SERCA) while down-regulated angiotensin II type 1 receptor (AT1R), and decreased plasma B-type natriuretic peptide (BNP), norepinephrine (NE), angiotensin II (Ang II), and arginine vasopressin (AVP) levels in TAC rats with chronic pressure overload. We conclude that RSD attenuates myocardial fibrosis, the left atrial enlargement, and the left ventricular wall hypertrophy; inhibits the overdrive of the sympathetic nervous system (SNS), renin-angiotensin-aldosterone system (RAAS), and AVP system in TAC rats with chronic pressure overload. RSD could be a promising non-pharmacological approach to control the progression of cardiac dysfunction.
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Affiliation(s)
| | | | | | | | | | | | | | - G.-Q. ZHU
- Key Laboratory of Cardiovascular Disease and Molecular Intervention, Department of Physiology, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Q.-J. SHAN
- Cardiovascular Department, First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
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26
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Ji M, Shen L, Wu YZ, Yao ZF, Yin JS, Chen JH, Jia JG, Qiao LJ, Liu P, Ge JB. Short-term safety and efficiency of cryoablation for renal sympathetic denervation in a swine model. Chin Med J (Engl) 2015; 128:790-4. [PMID: 25758274 PMCID: PMC4833984 DOI: 10.4103/0366-6999.152621] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Renal sympathetic nerves are involved in the reflective activation of the sympathetic nervous system in circulatory control. Catheter-based renal denervation (RDN) ameliorated treatment-resistant hypertension safely, but 10%–20% of treated patients are nonresponders to radiofrequency denervation. The purpose of this study was to investigate the safety and efficiency of cryoablation for sympathetic denervation in a swine model and to explore a new way of RDN. Methods: Seven swines randomly assigned to two groups: Renal cryoablation (CR) group and control group. The control group underwent renal angiogram only. The CR group underwent renal angiogram plus bilateral renal cryoablation. Renal angiograms via femoral were performed before denervation, after denervation and prior to the sacrifice to access the diameter of renal arterial and the pressure of aorta abdominalis. Euthanasia of the swine was performed on 28-day to access norepinephrine (NE) changes of the renal cortex and the changes of renal nerves. Results: Cryoablation did not induce severe complications at any time point. There was no significant change in diameter of renal artery. CR reduced systolic blood pressure (BP) from 145.50 ± 9.95 mmHg at baseline to 119.00 ± 14.09 mmHg. There was a slight but insignificant decrease in diastolic BP. The main nerve changes at 28-day consisted of necrosis with perineurial fibrosis at the site of CR exposure in conjunction with the nerve vacuolation. Compared with the control group, renal tissue NE of CR group decreased by 89.85%. Conclusions: Percutaneous catheter-based cryoablation of the renal artery is safe. CR could effectively reduce NE storing in the renal cortex, and the efficiency could be maintained 28-day at least.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Jun-Bo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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27
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Khan SA, Sattar MZA, Abdullah NA, Rathore HA, Abdulla MH, Ahmad A, Johns EJ. Obesity depresses baroreflex control of renal sympathetic nerve activity and heart rate in Sprague Dawley rats: role of the renal innervation. Acta Physiol (Oxf) 2015; 214:390-401. [PMID: 25846561 DOI: 10.1111/apha.12499] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 03/28/2015] [Indexed: 12/18/2022]
Abstract
AIM This study investigated the role of the renal innervation in arterial and cardiopulmonary baroreflex regulation of renal sympathetic nerve activity (RSNA) and heart rate (HR) in rats fed a high-fat diet to induce obesity. METHODS Rats received either a normal (12% kcal) or high (45% kcal) fat diet for 60 days. On day 61, rats were anesthetized and prepared for recording left RSNA. In one group, the renal nerves remained intact, while in the other, both kidneys were denervated. Baroreflex gain curves for RSNA and HR were generated by increasing and decreasing blood pressure. Low-pressure baroreceptors were challenged by infusing a saline load. RESULTS Mean blood pressure was 135 mmHg in the fat-fed and 105 mmHg (P < 0.05) in normal rats. Weight gain, adiposity index and creatinine clearance were 37, 82 and 55% higher (P < 0.05-0.001), but urine flow rate and fractional sodium excretions were 53 and 65% (both P < 0.001) lower, respectively, in the fat-fed compared to normal rats. In fat-fed rats with innervated kidneys, RSNA and HR arterial baroreflex sensitivities were reduced by 73 and 72% (both P < 0.05) but were normal in renally denervated rats. Volume expansion decreased RSNA by 66% (P < 0.001) in normal rats, but not in the intact fat-fed rats and by 51% (P < 0.01) in renally denervated fat-fed rats. CONCLUSION Feeding a high-fat diet caused hypertension associated with dysregulation of the arterial and cardiopulmonary baroreflexes which was dependent on an intact renal innervation. This suggests that in obese states neural signals arising from the kidney contribute to a deranged autonomic control.
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Affiliation(s)
- S. A. Khan
- Department of Physiology; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
| | - M. Z. A. Sattar
- Department of Physiology; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
| | - N. A. Abdullah
- Department of Pharmacology; Faculty of Medicine; Universiti Malaya; Kuala Lumpur Malaysia
| | - H. A. Rathore
- Department of Physiology; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
| | - M. H. Abdulla
- Department of Physiology; University College Cork; Cork Ireland
| | - A. Ahmad
- Department of Physiology; School of Pharmaceutical Sciences; Universiti Sains Malaysia; Penang Malaysia
| | - E. J. Johns
- Department of Physiology; University College Cork; Cork Ireland
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28
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Fukuda K, Kanazawa H, Aizawa Y, Ardell JL, Shivkumar K. Cardiac innervation and sudden cardiac death. Circ Res 2015; 116:2005-19. [PMID: 26044253 PMCID: PMC4465108 DOI: 10.1161/circresaha.116.304679] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 12/11/2014] [Indexed: 12/14/2022]
Abstract
Afferent and efferent cardiac neurotransmission via the cardiac nerves intricately modulates nearly all physiological functions of the heart (chronotropy, dromotropy, lusitropy, and inotropy). Afferent information from the heart is transmitted to higher levels of the nervous system for processing (intrinsic cardiac nervous system, extracardiac-intrathoracic ganglia, spinal cord, brain stem, and higher centers), which ultimately results in efferent cardiomotor neural impulses (via the sympathetic and parasympathetic nerves). This system forms interacting feedback loops that provide physiological stability for maintaining normal rhythm and life-sustaining circulation. This system also ensures that there is fine-tuned regulation of sympathetic-parasympathetic balance in the heart under normal and stressed states in the short (beat to beat), intermediate (minutes to hours), and long term (days to years). This important neurovisceral/autonomic nervous system also plays a major role in the pathophysiology and progression of heart disease, including heart failure and arrhythmias leading to sudden cardiac death. Transdifferentiation of neurons in heart failure, functional denervation, cardiac and extracardiac neural remodeling has also been identified and characterized during the progression of disease. Recent advances in understanding the cellular and molecular processes governing innervation and the functional control of the myocardium in health and disease provide a rational mechanistic basis for the development of neuraxial therapies for preventing sudden cardiac death and other arrhythmias. Advances in cellular, molecular, and bioengineering realms have underscored the emergence of this area as an important avenue of scientific inquiry and therapeutic intervention.
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Affiliation(s)
- Keiichi Fukuda
- From the Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (K.F., H.K., Y.A.); and UCLA Cardiac Arrhythmia Center, Neurocardiology Research Center of Excellence (J.L.A., K.S.).
| | - Hideaki Kanazawa
- From the Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (K.F., H.K., Y.A.); and UCLA Cardiac Arrhythmia Center, Neurocardiology Research Center of Excellence (J.L.A., K.S.)
| | - Yoshiyasu Aizawa
- From the Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (K.F., H.K., Y.A.); and UCLA Cardiac Arrhythmia Center, Neurocardiology Research Center of Excellence (J.L.A., K.S.)
| | - Jeffrey L Ardell
- From the Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (K.F., H.K., Y.A.); and UCLA Cardiac Arrhythmia Center, Neurocardiology Research Center of Excellence (J.L.A., K.S.)
| | - Kalyanam Shivkumar
- From the Department of Cardiology, Keio University School of Medicine, Tokyo, Japan (K.F., H.K., Y.A.); and UCLA Cardiac Arrhythmia Center, Neurocardiology Research Center of Excellence (J.L.A., K.S.).
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29
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Rajapakse NW, Nanayakkara S, Kaye DM. Pathogenesis and treatment of the cardiorenal syndrome: Implications of L-arginine-nitric oxide pathway impairment. Pharmacol Ther 2015; 154:1-12. [PMID: 25989232 DOI: 10.1016/j.pharmthera.2015.05.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 05/07/2015] [Indexed: 01/11/2023]
Abstract
A highly complex interplay exists between the heart and kidney in the setting of both normal and abnormal physiology. In the context of heart failure, a pathophysiological condition termed the cardiorenal syndrome (CRS) exists whereby dysfunction in the heart or kidney can accelerate pathology in the other organ. The mechanisms that underpin CRS are complex, and include neuro-hormonal activation, oxidative stress and endothelial dysfunction. The endothelium plays a central role in the regulation of both cardiac and renal function, and as such impairments in endothelial function can lead to dysfunction of both these organs. In particular, reduced bioavailability of nitric oxide (NO) is a key pathophysiologic component of endothelial dysfunction. The synthesis of NO by the endothelium is critically dependent on the plasmalemmal transport of its substrate, L-arginine, via the cationic amino acid transporter-1 (CAT1). Impaired L-arginine-NO pathway activity has been demonstrated individually in heart and renal failure. Recent findings suggest abnormalities of the L-arginine-NO pathway also play a role in the pathogenesis of CRS and thus this pathway may represent a potential new target for the treatment of heart and renal failure.
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Affiliation(s)
- Niwanthi W Rajapakse
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Australia; Department of Physiology, Monash University, Melbourne, Australia.
| | | | - David M Kaye
- Heart Failure Research Group, Baker IDI Heart and Diabetes Institute, Melbourne, Australia; Department of Medicine, Monash University, Melbourne Australia; Department of Cardiovascular Medicine, Alfred Hospital, Melbourne, Australia
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30
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McArdle MJ, deGoma EM, Cohen DL, Townsend RR, Wilensky RL, Giri J. Beyond blood pressure: percutaneous renal denervation for the management of sympathetic hyperactivity and associated disease states. J Am Heart Assoc 2015; 4:e001415. [PMID: 25801757 PMCID: PMC4392429 DOI: 10.1161/jaha.114.001415] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Michael J McArdle
- Department of Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (M.J.M.A.)
| | - Emil M deGoma
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (E.M.G., R.L.W., J.G.)
| | - Debbie L Cohen
- Division of Renal, Electrolyte, and Hypertension, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (D.L.C., R.R.T.)
| | - Raymond R Townsend
- Division of Renal, Electrolyte, and Hypertension, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (D.L.C., R.R.T.)
| | - Robert L Wilensky
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (E.M.G., R.L.W., J.G.)
| | - Jay Giri
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (E.M.G., R.L.W., J.G.)
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31
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Xu B, Zheng H, Liu X, Patel KP. Activation of afferent renal nerves modulates RVLM-projecting PVN neurons. Am J Physiol Heart Circ Physiol 2015; 308:H1103-11. [PMID: 25637549 DOI: 10.1152/ajpheart.00862.2014] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 01/26/2015] [Indexed: 02/07/2023]
Abstract
Renal denervation for the treatment of hypertension has proven to be successful; however, the underlying mechanism/s are not entirely clear. To determine if preautonomic neurons in the paraventricular nucleus (PVN) respond to afferent renal nerve (ARN) stimulation, extracellular single-unit recording was used to investigate the contribution of the rostral ventrolateral medulla (RVLM)-projecting PVN (PVN-RVLM) neurons to the response elicited during stimulation of ARN. In 109 spontaneously active neurons recorded in the PVN of anesthetized rats, 25 units were antidromically activated from the RVLM. Among these PVN-RVLM neurons, 84% (21/25) were activated by ARN stimulation. The baseline discharge rate was significantly higher in these neurons than those PVN-RVLM neurons not activated by ARN stimulation (16%, 4/25). The responsiveness of these neurons to baroreflex activation induced by phenylephrine and activation of cardiac sympathetic afferent reflex (CSAR) was also examined. Almost all of the PVN neurons that responded to ARN stimulation were sensitive to baroreflex (95%) and CSAR (100%). The discharge characteristics for nonevoked neurons (not activated by RVLM antidromic stimulation) showed that 23% of these PVN neurons responded to ARN stimulation. All the PVN neurons that responded to ARN stimulation were activated by N-methyl-D-aspartate, and these responses were attenuated by the glutamate receptor blocker AP5. These experiments demonstrated that sensory information originating in the kidney is integrated at the level of preautonomic neurons within the PVN, providing a novel mechanistic insight for use of renal denervation in the modulation of sympathetic outflow in disease states such as hypertension and heart failure.
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Affiliation(s)
- Bo Xu
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Hong Zheng
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Xuefei Liu
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kaushik P Patel
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, Nebraska
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Abstract
Hypertension has wide (30-45 %) prevalence in the general population and is related to important increases in overall cardiovascular morbidity and mortality. Despite lifestyle modifications and optimal medical therapy (three drugs, one being diuretic), about 5-20 % of hypertensives are affected by resistant hypertension. Chronic high blood pressure has adverse effects on the heart and other organs such as the kidneys and vasculature. Renal sympathetic denervation and baroreceptor stimulation are invasive approaches initially investigated to treat resistant hypertension. Their pleiotropic effects appear promising in cardiovascular remodeling, heart failure and arrhythmias and could potentially affect cardiovascular morbidity and mortality.
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Hu W, Zhao QY, Yu SB, Sun B, Chen L, Cao S, Guo RQ. Renal sympathetic denervation inhibits the development of left ventricular mechanical dyssynchrony during the progression of heart failure in dogs. Cardiovasc Ultrasound 2014; 12:47. [PMID: 25416926 PMCID: PMC4255928 DOI: 10.1186/1476-7120-12-47] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Accepted: 11/12/2014] [Indexed: 11/17/2022] Open
Abstract
Background The purpose of this study was to investigate whether transcatheter renal sympathetic denervation (RSD) interfere with the development of left ventricular (LV) mechanical dyssynchrony during the progression of heart failure (HF). Methods Nineteen beagles were randomly divided into sham-operated group (six dogs), control group (seven dogs), and RSD group (six dogs). Sham-operated group were implanted with pacemakers without pacing; Control group were implanted with pacemakers and underwent 3 weeks of rapid right ventricular pacing; and RSD group underwent catheter-based RSD bilaterally and were simultaneously implanted with pacemakers. Both LV strain and LV dyssynchrony were analyzed via 2D speckle-tracking strain echocardiography to evaluate LV function. Longitudinal dyssynchrony was determined as the standard deviation for time-to-peak speckle-tracking strain on apical 4- and 2-chamber views. Radial and circumferential dyssynchrony was determined as the standard deviation for time-to-peak speckle-tracking strain in mid- and base-LV short-axis views. Each myocardial function was also evaluated by averaging the peak systolic strains. LV systolic pressure (LVSP) and LV end-diastolic pressure (LVEDP) were measured. The LV interstitial fibrosis was determined by histological analysis. Plasma angiotensin II (Ang II), aldosterone and norepinephrine (NE) levels were also measured. Results After 3 weeks, all of the dogs in both the control and RSD groups showed greater LV end-diastolic volume compared with the sham-operated group; however, the dogs in the RSD group had a higher LV ejection fraction (LVEF) than the dogs in the control group (p < 0.001). The LV systolic strains were higher in the RSD group than in the control group (p < 0.001 for longitudinal, circumferential and radial strain, respectively). The levels of LV dyssynchrony were lower in the RSD group than in the control group (p < 0.001 for longitudinal, circumferential and radial dyssynchrony, respectively). Compared with dogs with control alone, RSD dogs had lower LV end-diastolic pressures and less fibrous tissue. The levels of plasma Ang II, aldosterone and NE were lower in the RSD group than in the control group. Conclusions RSD inhibites the development of left ventricular mechanical dyssynchrony during the progression of heart failure in dogs.
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Affiliation(s)
| | | | | | | | | | | | - Rui-qiang Guo
- Department of Ultrasound, Renmin Hospital of Wuhan University, Jiefang Road 238#, Wuchang District, Wuhan 430060, China.
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Leong KTG, Walton A, Krum H. Renal sympathetic denervation for the treatment of refractory hypertension. Annu Rev Med 2014; 65:349-65. [PMID: 24422574 DOI: 10.1146/annurev-med-051812-145353] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Resistant hypertension poses significant health concerns. There are strong demands for new and safe therapies to control resistant hypertension while addressing its common causes, specifically poor compliance to lifelong polypharmacy, lifestyle modifications, and physician inertia. The sympathetic nervous system plays a significant pathophysiological role in hypertension. Surgical sympathectomy for blood pressure reduction is an old but extremely efficacious therapeutic concept, now abandoned with the dawn of a safer contemporary pharmacology era. Recently, clinical studies have revealed promising results for safe and sustained blood pressure reduction with percutaneous renal sympathetic denervation. This is a novel, minimally invasive, device-based therapy, specifically targeting and ablating the renal artery nerves with radiofrequency waves without permanent implantation. There are also reported additional benefits in related comorbidities, such as impaired glucose metabolism, renal impairment, left ventricular hypertrophy, heart failure, and others. This review focuses on how selective renal sympathetic denervation works, its present and potential therapeutic indications, and its future directions.
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Huang B, Yu L, Scherlag BJ, Wang S, He B, Yang K, Liao K, Lu Z, He W, Zhang L, Po SS, Jiang H. Left renal nerves stimulation facilitates ischemia-induced ventricular arrhythmia by increasing nerve activity of left stellate ganglion. J Cardiovasc Electrophysiol 2014; 25:1249-56. [PMID: 25066536 DOI: 10.1111/jce.12498] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 07/14/2014] [Accepted: 07/21/2014] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Renal sympathetic nerve (RSN) activity plays a key role in systemic sympathetic hyperactivity. Previous studies have shown that cardiac sympathetic hyperactivity, especially the left stellate ganglion (LSG), contributes to the pathogenesis of ventricular arrhythmias (VAs) after acute myocardial infarction (AMI). METHODS AND RESULTS Twenty-eight dogs received 3 hours of continuous left-sided electrical stimulation of RSN (LRS; Group-1, n = 9), sham RSN stimulation (Group-2, n = 9), or LSG ablation plus 3 hours of LRS (Group-3, n = 10) were included. AMI was induced by ligating the proximal left anterior descending coronary artery. LRS was performed using electrical stimulation on the adventitia of left renal artery at the voltage increasing the systolic blood pressure (BP) by 10%. BP, heart rate variability (HRV), serum norepinephrine (NE) level, and LSG function were measured at baseline and the end of each hour of LRS. C-fos and nerve growth factor (NGF) protein expressed in the LSG were examined in Group-1 and Group-2. Compared with baseline, 3 hours of LRS induced a significant increase in BP, sympathetic indices of HRV, serum NE level, and LSG function. The incidence of VAs in Group-1 was significantly higher than other groups. The expression of c-fos and NGF protein in the LSG was significantly higher in Group-1 than Group-2. CONCLUSION Three hours of LRS induces both systemic and cardiac sympathetic hyperactivity and increases the incidence of ischemia-induced VAs.
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Affiliation(s)
- Bing Huang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, China
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Hu J, Li Y, Cheng W, Yang Z, Wang F, Lv P, Niu C, Hou Y, Yan Y, Ge J. A comparison of the efficacy of surgical renal denervation and pharmacologic therapies in post-myocardial infarction heart failure. PLoS One 2014; 9:e96996. [PMID: 24830442 PMCID: PMC4022500 DOI: 10.1371/journal.pone.0096996] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 04/14/2014] [Indexed: 01/08/2023] Open
Abstract
Objective Although renal denervation (RD) has been shown to be effective in treating post- myocardial Infarction (MI) heart failure (HF) in animal models and clinical trials, its utility as a standalone treatment without traditional drug treatment for post-MI HF still needs to be investigated. Methods Rats were randomly assigned into seven experimental groups: N group (control group with no MI and no RD, n = 10), MI group (MI, n = 20), RD group (renal denervation, n = 10), RD-3d+MI group (RD performed three days before MI, n = 15), β-blocker-3d+MI group (Metoprolol treated three days before MI, n = 15), ACEI-3d+MI group (Perindopril treated three days before MI, n = 15), and ARB-3d+MI group (Losartan treated three days before MI, n = 15). Cardiac function, autonomic nervous system parameters, and neuroendocrine activities were evaluated 8 weeks post MI. Results Compared to β-blockers, ACEIs, and ARBs, RD alone provided significantly better cardiac remodeling and function, enhanced water and sodium excretion, and improved autonomic modulation. Conclusions In this post-MI HF animal model, surgical RD provides effective autonomic modulation, inhibition of the RAAS, improved cardiac remodeling, and preserved renal function, without affecting normal circulation and cardiopulmonary function in normal rats. Compared to β-blocker, ACEI, and ARB single-drug therapies, RD alone is more efficacious. These results suggest that RD may be an effective treatment option for HF, especially in patients who have contraindications to drug therapy.
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Affiliation(s)
- Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yinliang Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wenbo Cheng
- Department of Cardiology, Shanghai Jiaotong University affiliated Sixth People's Hospital South Campus, Shanghai, China
| | - Zhen Yang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fang Wang
- Department of Cardiology, Shanghai Jiaotong University affiliated Sixth People's Hospital South Campus, Shanghai, China
| | - Peng Lv
- Department of Diagnostic Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Conway Niu
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Yuemei Hou
- Department of Cardiology, Shanghai Jiaotong University affiliated Sixth People's Hospital South Campus, Shanghai, China
| | - Yan Yan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
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Krum H, Schlaich M, Sobotka P. Renal sympathetic nerve ablation for treatment-resistant hypertension. Br J Clin Pharmacol 2014; 76:495-503. [PMID: 23819768 DOI: 10.1111/bcp.12171] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 03/01/2013] [Indexed: 12/26/2022] Open
Abstract
Hypertension is a major risk factor for increased cardiovascular events with accelerated sympathetic nerve activity implicated in the pathogenesis and progression of disease. Blood pressure is not adequately controlled in many patients, despite the availability of effective pharmacotherapy. Novel procedure- as well as device-based strategies, such as percutaneous renal sympathetic nerve denervation, have been developed to improve blood pressure in these refractory patients. Renal sympathetic denervation not only reduces blood pressure but also renal as well as systemic sympathetic nerve activity in such patients. The reduction in blood pressure appears to be sustained over 3 years after the procedure, which suggests absence of re-innervation of renal sympathetic nerves. Safety appears to be adequate. This approach may also have potential in other disorders associated with enhanced sympathetic nerve activity such as congestive heart failure, chronic kidney disease and metabolic syndrome. This review will focus on the current status of percutaneous renal sympathetic nerve denervation, clinical efficacy and safety outcomes and prospects beyond refractory hypertension.
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Affiliation(s)
- Henry Krum
- Centre of Cardiovascular Research & Education (CCRE) in Therapeutics, Monash University/Alfred Hospital, Melbourne, Australia
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38
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Zucker IH, Xiao L, Haack KKV. The central renin-angiotensin system and sympathetic nerve activity in chronic heart failure. Clin Sci (Lond) 2014; 126:695-706. [PMID: 24490814 PMCID: PMC4053944 DOI: 10.1042/cs20130294] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
CHF (chronic heart failure) is a multifactorial disease process that is characterized by overactivation of the RAAS (renin-angiotensin-aldosterone system) and the sympathetic nervous system. Both of these systems are chronically activated in CHF. The RAAS consists of an excitatory arm involving AngII (angiotensin II), ACE (angiotensin-converting enzyme) and the AT1R (AngII type 1 receptor). The RAAS also consists of a protective arm consisting of Ang-(1-7) [angiotensin-(1-7)], the AT2R (AngII type 2 receptor), ACE2 and the Mas receptor. Sympatho-excitation in CHF is driven, in large part, by an imbalance of these two arms, with an increase in the AngII/AT1R/ACE arm and a decrease in the AT2R/ACE2 arm. This imbalance is manifested in cardiovascular-control regions of the brain such as the rostral ventrolateral medulla and paraventricular nucleus in the hypothalamus. The present review focuses on the current literature that describes the components of these two arms of the RAAS and their imbalance in the CHF state. Moreover, the present review provides additional evidence for the relevance of ACE2 and Ang-(1-7) as key players in the regulation of central sympathetic outflow in CHF. Finally, we also examine the effects of exercise training as a therapeutic strategy and the molecular mechanisms at play in CHF, in part, because of the ability of exercise training to restore the balance of the RAAS axis and sympathetic outflow.
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Affiliation(s)
- Irving H Zucker
- *Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
| | - Liang Xiao
- *Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
| | - Karla K V Haack
- *Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, U.S.A
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Angle JF, Prince EA, Matsumoto AH, Lohmeier TE, Roberts AM, Misra S, Razavi MK, Katholi RE, Sarin SN, Sica DA, Shivkumar K, Ahrar K. Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel on Renal Sympathetic Denervation. J Vasc Interv Radiol 2014; 25:497-509. [PMID: 24674208 DOI: 10.1016/j.jvir.2013.12.572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 12/27/2013] [Accepted: 12/27/2013] [Indexed: 10/25/2022] Open
Affiliation(s)
- John F Angle
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908.
| | - Ethan A Prince
- Department of Radiology, Division of Vascular and Interventional Radiology, Brown University, Providence, Rhode Island
| | - Alan H Matsumoto
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Virginia Health System, 1215 Lee Street, Charlottesville, VA 22908
| | - Thomas E Lohmeier
- Department of Physiology, University of Mississippi, Jackson, Mississippi
| | - Andrew M Roberts
- Department of Physiology, University of Louisville, Louisville, Kentucky
| | - Sanjay Misra
- Department of Radiology, Division of Vascular and Interventional Radiology, Mayo Clinic, Rochester, Minnesota
| | - Mahmood K Razavi
- Vascular & Interventional Specialists of Orange County, Inc., Los Angeles, California
| | - Richard E Katholi
- Department of Cardiology, Prairie Heart Institute at St. John's Hospital, Springfield, Illinois
| | - Shawn N Sarin
- Department of Radiology, Division of Vascular and Interventional Radiology, George Washington University, Washington, D.C
| | - Domenic A Sica
- Department of Internal Medicine, Division of Nephrology, Virginia Commonwealth University, Richmond, Virginia
| | - Kalyanam Shivkumar
- Department of Internal Medicine, Division of Cardiology, University of California, Los Angeles, Los Angeles, California
| | - Kamran Ahrar
- Department of Radiology, Division of Vascular and Interventional Radiology, University of Texas, MD Anderson Cancer Center, Houston, Texas
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40
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Böhm M, Ewen S, Kindermann I, Linz D, Ukena C, Mahfoud F. Renal denervation and heart failure. Eur J Heart Fail 2014; 16:608-13. [DOI: 10.1002/ejhf.83] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 12/20/2013] [Accepted: 01/17/2014] [Indexed: 01/07/2023] Open
Affiliation(s)
- Michael Böhm
- Universitätsklinikum des Saarlandes; Homburg/Saar Germany
| | - Sebastian Ewen
- Universitätsklinikum des Saarlandes; Homburg/Saar Germany
| | | | - Dominik Linz
- Universitätsklinikum des Saarlandes; Homburg/Saar Germany
| | | | - Felix Mahfoud
- Universitätsklinikum des Saarlandes; Homburg/Saar Germany
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41
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Hubens LEG, Verloop WL, Joles JA, Blankestijn PJ, Voskuil M. Ischemia and reactive oxygen species in sympathetic hyperactivity states: a vicious cycle that can be interrupted by renal denervation? Curr Hypertens Rep 2014; 15:313-20. [PMID: 23754326 DOI: 10.1007/s11906-013-0367-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Renal denervation has developed as a new treatment strategy for patients suffering from resistant hypertension. The success of this therapy is due to the fact that sympathetic hyperactivity is involved in the pathogenesis of elevated blood pressure. However, not only the sympathetic nervous system (SNS), but also the renin angiotensin system (RAS) is known to be involved in hypertension. In addition, RAS is involved in other sympathetic hyperactivity states, such as heart failure, chronic kidney disease, insulin resistance and obstructive sleep apnea. Moreover, renal denervation has a beneficial effect on patients suffering from these disease states. Recent research suggested that the production of reactive oxygen species (ROS) is elevated in sympathetic hyperactivity states, and that ROS are able to activate the SNS and local tissue renin angiotensin system. Therefore, this review discusses the possibility of ROS as a common trigger of SNS and RAS activity in sympathetic hyperactivity states, and the effect of renal denervation on this ROS production.
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Affiliation(s)
- Lisette E G Hubens
- Division of Heart and Lungs, Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, The Netherlands
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Böhm M, Ewen S, Linz D, Reil JC, Schirmer S, Ukena C, Mahfoud F. Renal denervation: a novel non-pharmacological approach in heart failure. J Cardiovasc Transl Res 2014; 7:330-7. [PMID: 24578253 DOI: 10.1007/s12265-014-9549-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 02/11/2014] [Indexed: 01/27/2023]
Abstract
Heart failure is associated with activation of the sympathetic nervous system which presumably results in a progression of the syndrome and thereby in poor outcome. Renal denervation has shown to be effective in conditions with enhanced sympathetic activity like resistant hypertension and metabolic syndrome associated with sleep apnea. The first pilot trials assessing the effect of renal denervation on signs and symptoms of heart failure in patients with both preserved and reduced left ventricular ejection fraction are presently ongoing. The results of these studies will determine whether to proceed with larger prospective outcome trials. Altogether, renal denervation is a promising novel technique that may improve the outcome of patients with sympathetic hyperactivity and cardiovascular diseases.
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Affiliation(s)
- Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III Kardiologie, Angiologie und Internistische Intensivmedizin, Kirrberger Str. 1, DE 66424, Homburg/Saar, Germany,
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43
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Verloop WL, Beeftink MM, Nap A, Bots ML, Velthuis BK, Appelman YE, Cramer MJ, Agema WR, Scholtens AM, Doevendans PA, Allaart CP, Voskuil M. Renal denervation in heart failure with normal left ventricular ejection fraction. Rationale and design of the DIASTOLE (DenervatIon of the renAl Sympathetic nerves in hearT failure with nOrmal Lv Ejection fraction) trial. Eur J Heart Fail 2014; 15:1429-37. [DOI: 10.1093/eurjhf/hft119] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
| | | | - Alex Nap
- Department of Cardiology; VU Medical Centre Amsterdam; The Netherlands
| | - Michiel L. Bots
- Julius Centre for Health Sciences and Primary Care; University Medical Centre Utrecht; The Netherlands
| | | | | | - Maarten-Jan Cramer
- Department of Cardiology; University Medical Centre Utrecht; The Netherlands
| | | | - Asbjorn M. Scholtens
- Department of Nuclear Medicine; University Medical Centre Utrecht; The Netherlands
| | | | - Cor P. Allaart
- Department of Cardiology; VU Medical Centre Amsterdam; The Netherlands
| | - Michiel Voskuil
- Department of Cardiology; University Medical Centre Utrecht; The Netherlands
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Gossios TD, Ziakas A, Doumas M, Katsiki N, Petroglou D, Kouparanis A, Lillis L, Karvounis H. Renal Denervation. Angiology 2014; 65:760-8. [DOI: 10.1177/0003319713517738] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Resistant hypertension, defined as failure to reach blood pressure (BP) goals despite treatment with ≥3 antihypertensive agents, one of which is a diuretic, bears a significant risk of cardiovascular complications. Strong evidence exists, implicating the overactivation of the sympathetic nervous system (SNS) in the pathogenesis of resistant hypertension through complex neurohormonal interactions. Renal denervation is a novel attractive option to achieve adequate blockade of the sympathetic system, with subsequent BP reductions in patients with resistant hypertension. Data have shown promising results regarding the efficacy of the procedure, maintaining a favorable safety profile. As such, the paradigm of resistant hypertension has expanded in other conditions involving a hyperadrenergic state such as the metabolic syndrome, heart failure, arrhythmias, sleep apnea, and renal failure. This review focuses on the pathophysiological rationale of modifying SNS tone and the evidence of the benefits of such intervention beyond BP control.
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Affiliation(s)
- Thomas D. Gossios
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Ziakas
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michalis Doumas
- 2nd Propedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Niki Katsiki
- 2nd Propedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios Petroglou
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Antonios Kouparanis
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Leonidas Lillis
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Fischell TA, Vega F, Raju N, Johnson ET, Kent DJ, Ragland RR, Fischell DR, Almany SL, Ghazarossian VE. Ethanol-mediated perivascular renal sympathetic denervation: preclinical validation of safety and efficacy in a porcine model. EUROINTERVENTION 2013; 9:140-7. [PMID: 23685302 DOI: 10.4244/eijv9i1a20] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIMS We report the use of a novel endovascular approach using chemical neurolysis, via periadventitial injection of dehydrated ethanol (EtOH) to perform renal artery denervation. METHODS AND RESULTS A novel, three-needle delivery device was introduced into the renal arteries of adult swine using fluoroscopic guidance. EtOH was injected bilaterally with one injection per artery, via the three needles into the adventitial and periadventitial space, using EtOH doses 0.15 ml/artery; n=3, 0.30 ml/artery; n=3, and 0.60 ml/artery; n=3, with saline injection as a sham control (0.4 ml/artery; n=3), and naive subjects (n=7) as a true negative control. The renal parenchymal norepinephrine (NE) concentration at two-week follow-up was the primary efficacy endpoint. The mean renal NE reduction was 54%, 78% and 88% at doses of 0.15 ml, 0.30 ml and 0.60 ml, respectively (p<0.0001 vs. controls). Histological examination revealed marked, and deep, circumferential renal nerve injury at depths of 2-8 mm from the intimal surface. There was no evidence of device-related or EtOH-induced injury to the intimal layers. In some samples at the higher EtOH doses, there was focal loss of smooth muscle cells in the outer media. Angiography at 45 days demonstrated normal appearing renal arteries with no detectable stenoses (n=8). CONCLUSIONS Circumferential adventitial delivery of very low doses of EtOH may be a promising alternative to energy-based systems to achieve dose-dependent, and predictable renal denervation. Further study is warranted.
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Affiliation(s)
- Tim A Fischell
- Michigan State University, Borgess Heart Institute, Kalamazoo, MI 49048, USA.
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Ormiston JA, Watson T, van Pelt N, Stewart R, Stewart JT, White JM, Doughty RN, Stewart F, Macdonald R, Webster MWI. Renal denervation for resistant hypertension using an irrigated radiofrequency balloon: 12-month results from the Renal Hypertension Ablation System (RHAS) trial. EUROINTERVENTION 2013; 9:70-4. [PMID: 23685297 DOI: 10.4244/eijv9i1a11] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
AIMS Renal denervation using the point-by-point application of radiofrequency energy delivered by the first-generation Symplicity system is effective in lowering office blood pressure but may be time-consuming. The OneShot Renal Denervation System with a balloon-mounted spiral electrode potentially shortens and simplifies the procedure. This study is a hypothesis-generating first-in-human study to assess feasibility, and to provide preliminary efficacy and safety data. METHODS AND RESULTS Eligible patients had a baseline office systolic blood pressure ≥160 mmHg (or ≥150 mmHg for diabetics) and were on two or more antihypertensive medications. Nine patients were enrolled. The primary endpoint, the insertion of the OneShot balloon into each renal artery and the delivery of radiofrequency energy, was achieved in 8/9 (89%) of patients. The one failure (the first patient) was due to generator high-impedance safety shut-off threshold set too low for humans. Adverse events were minor. No patient developed renal artery stenosis. Baseline BP was 185.67 ± 18.7 mmHg and the reductions at 1, 3, 6 and 12 months were 30.1 ± 13.6 (p=0.0004), 34.2 ± 20.2 (p=0.002), 33.6 ± 32.2 (p=0.021) and 30.6 ± 22.0 (p=0.019). CONCLUSIONS The OneShot renal denervation system successfully delivered radiofrequency energy to the renal arteries in a short and straightforward procedure. Australian New Zealand Clinical Trials Registry - URL: anzctr.org.au. Trial identification: ACTRN12611000987965.
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Patel HC, Rosen SD, Lindsay A, Hayward C, Lyon AR, di Mario C. Targeting the autonomic nervous system: Measuring autonomic function and novel devices for heart failure management. Int J Cardiol 2013; 170:107-17. [DOI: 10.1016/j.ijcard.2013.10.058] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 09/03/2013] [Accepted: 10/19/2013] [Indexed: 01/08/2023]
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Damascelli B, Patelli G, Tichá V, Della Rocca F, Lattuada S, Sala C, Albertoni A, D'Alessio A, Funaro A, Scotti L. Catheter-based radiofrequency renal sympathetic denervation for resistant hypertension. J Vasc Interv Radiol 2013; 24:632-9. [PMID: 23622036 DOI: 10.1016/j.jvir.2013.01.491] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 01/15/2013] [Accepted: 01/18/2013] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To evaluate the feasibility, efficacy, and safety of catheter-based radiofrequency renal sympathetic denervation for treatment of resistant hypertension. MATERIALS AND METHODS Twenty-four patients with essential hypertension unresponsive to at least three antihypertensive agents underwent renal denervation (RDN). Three patients had variant renal anatomy. Comorbidities included diabetes (n = 11), renal failure (n = 4), and obstructive sleep apnea (n = 2). The effect on 24-hour ambulatory blood pressure (BP) was assessed at 6 months. Patients with a decrease in systolic BP of at least 10mm Hg were considered responders. RESULTS RDN was bilateral in 19 patients and single-sided in five. The 19 patients with bilateral RDN showed mean reductions in 24-hour ambulatory BP of 20.7/8.7mm Hg±18.1/9.9 (systolic/diastolic; P = .0001/P = .0012). Sixteen bilaterally treated patients (84.2%) showed a systolic BP reduction of at least 10mm Hg and were considered responders, whereas only one of the five patients with single-sided RDN showed a response. Two responders with sleep apnea showed improvement in polysomnography indices, and one with left concentric ventricular hypertrophy showed complete cardiac remodeling 11 months after the RDN procedure. Renal function remained unchanged in all patients, including those with renal failure. Optical coherence tomography of the renal arteries in one patient showed sporadic endothelial scarring. Renal angiograms at 9 months (one patient) and 12 months (two patients) had normal findings. CONCLUSIONS Catheter-based RDN was carried out safely, even in patients with comorbidities, abnormal renal arteries, or anatomic variants. The response rate for bilateral RDN (84.2%) was comparable to previous reports.
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Affiliation(s)
- Bruno Damascelli
- Department of Interventional Radiology, EMO GVM Centro Cuore Columbus, Milan, Italy.
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Abstract
SNS (sympathetic nervous system) activation is a common feature of arterial hypertension and has been demonstrated to contribute to the development and progression of the hypertensive state. Persuasive evidence suggests a strong association between SNS overactivity and variety of disease states, including chronic renal failure, insulin resistance, congestive heart failure, sleep apnoea, ventricular arrhythmias and others. Although sympatholytic agents are available to target SNS overactivity pharmacologically, they are not widely used in clinical practice, leaving the SNS unopposed in many patients. The recent introduction of catheter-based renal denervation as an alternative approach to target the SNS therapeutically has been demonstrated to result in a clinically relevant blood pressure reduction in patients with resistant hypertension, presumably through its effects on both efferent and afferent renal nerve traffic. Available data on this interventional procedure demonstrate a favourable vascular and renal safety profile. Preliminary data obtained primarily from small and mostly uncontrolled studies in related disease states often characterized by overactivity of the SNS are promising, but require confirmation in appropriately designed clinical trials. In the present paper, we briefly review the physiology of the renal nerves and their role in hypertension and other relevant disease states, summarize the data currently available from clinical studies pertaining to the safety and efficacy of renal denervation in resistant hypertension, discuss potential future implications and the available data supporting such a role for renal denervation, and describe some of the newer devices currently under investigation to achieve improved blood pressure control via renal denervation.
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The role of renal denervation for the treatment of resistant hypertension. J Hum Hypertens 2013; 28:218-23. [PMID: 24088716 DOI: 10.1038/jhh.2013.92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2013] [Accepted: 08/28/2013] [Indexed: 11/09/2022]
Abstract
Hypertension affects more than one-fourth of the adult population worldwide and is a major risk factor for cardiovascular and kidney disease. Currently, the majority of patients with hypertension do not reach goal blood pressure (BP) targets, and cardiovascular risk is increased further for patients with treatment-resistant hypertension, defined as office BP above goal despite pharmacological treatment with three or more antihypertensive medications at optimal doses including a diuretic. Although missed diagnosis of secondary forms of hypertension, physician inertia and non-adherence with prescribed medication are important contributors to the phenomenon of resistant hypertension that need to be addressed, there is a need for alternative therapeutic approaches. Renal sympathetic denervation is a minimally invasive endovascular procedure that disrupts renal efferent and afferent neural connections, both of which are important regulators of BP control. Limited data from recent clinical trials indicate that this approach is safe and effectively lowers BP in patients with treatment-resistant hypertension. Accumulating data is emerging to suggest that renal sympathetic denervation may also have utility beyond treatment-resistant hypertension. This review aims to briefly summarize the existing evidence for the use of renal denervation (RDN) in patients with treatment-resistant hypertension and to explore the potential utility of RDN in other pathological states associated with sympathetic dysfunction.
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