1
|
Xueyuan L, Yanping X, Jiaoqiong G, Yuehui Y. Autonomic nervous modulation: early treatment for pulmonary artery hypertension. ESC Heart Fail 2024; 11:619-627. [PMID: 38108098 DOI: 10.1002/ehf2.14616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
Pulmonary artery hypertension (PAH) is a chronic vascular disease defined by the elevation of pulmonary vascular resistance and mean pulmonary artery pressure, which arises due to pulmonary vascular remodelling. Prior research has already established a link between the autonomic nervous system (ANS) and PAH. Therefore, the rebalancing of the ANS offers a promising approach for the treatment of PAH. The process of rebalancing involves two key aspects: inhibiting an overactive sympathetic nervous system and fortifying the impaired parasympathetic nervous system through pharmacological or interventional procedures. However, the understanding of the precise mechanisms involved in neuromodulation, whether achieved through medication or intervention, remains insufficient. This limited understanding hinders our ability to determine the appropriate timing and scope of such treatment. This review aims to integrate the findings from clinical and mechanistic studies on ANS rebalancing as a treatment approach for PAH, with the ultimate goal of identifying a path to enhance the safety and efficacy of neuromodulation therapy and improve the prognosis of PAH.
Collapse
Affiliation(s)
- Liu Xueyuan
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xu Yanping
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Guan Jiaoqiong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yin Yuehui
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| |
Collapse
|
2
|
Device-based neuromodulation for cardiovascular diseases and patient' s age. J Geriatr Cardiol 2022; 19:876-893. [PMID: 36561057 PMCID: PMC9748266 DOI: 10.11909/j.issn.1671-5411.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The autonomic nervous system plays an important role in the pathogenesis of cardiovascular diseases. With aging, autonomic activity changes, and this impacts the physiological reactions to internal and external signals. Both sympathetic and parasympathetic responses seem to decline, reflecting functional and structural changes in nervous regulation. Although some investigators suggested that both the sympathetic and parasympathetic activities were suppressed, others found that only the parasympathetic activity was suppressed while the sympathetic activity increased. In addition, cardiac innervation progressively diminishes with aging. Therefore, one may suggest that neuromodulation interventions may have different effects, and older age groups can express an attenuated response. This article aims to discuss the effect of device-based neuromodulation in different cardiovascular diseases, depending on the patient's age. Thus, we cover renal denervation, pulmonary artery denervation, baroreceptor activation therapy, vagus nerve stimulation, spinal cord stimulation, ganglionated plexi ablation for the management of arterial and pulmonary hypertension, heart failure, angina and arrhythmias. The results of many clinical studies appeared to be unconvincing. In view of the low rate of positive findings in clinical studies incorporating neuromodulation approaches, we suggest the underestimation of advanced age as a potential contributing factor to poorer response. Analysis of outcomes between different age groups in clinical trials may shed more light on the true effects of neuromodulation when neutral/ambiguous results are obtained.
Collapse
|
3
|
Davies MG, Miserlis D, Hart JP. Current status of pulmonary artery denervation. Front Cardiovasc Med 2022; 9:972256. [PMID: 36262207 PMCID: PMC9573987 DOI: 10.3389/fcvm.2022.972256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 09/02/2022] [Indexed: 11/22/2022] Open
Abstract
Pulmonary hypertension is a progressive disease with a poor long-term prognosis and high mortality. Pulmonary artery denervation (PADN) is emerging as a potential novel therapy for this condition. The basis of pursuing a sympathetic denervation strategy has its origins in a body of experimental translation work that has demonstrated that denervation can reduce sympathetic nerve activity in various animal models. This reduction in pulmonary sympathetic nerve activity is associated with a reduction in pathological pulmonary hemodynamics in response to mechanical, pharmacological, and toxicologically induced pulmonary hypertension. The most common method of PADN is catheter-directed thermal ablation. Since 2014, there have been 12 reports on the role of PADN in 490 humans with pulmonary hypertension (311:179; treated: control). Of these, six are case series, three are randomized trials, and three are case reports. Ten studies used percutaneous PADN techniques, and two combined PADN with mitral and/or left atrial surgery. PADN treatment has low mortality and morbidity and is associated with an improved 6-minute walking distance, a reduction in both mean pulmonary artery pressure and pulmonary vascular resistance, and an improvement in cardiac output. These improved outcomes were seen over a median follow-up of 12 months (range 2–46 months). A recent meta-analysis of human trials also supports the effectiveness of PADN in carefully selected patients. Based on the current literature, PADN can be effective in select patients with pulmonary hypertension. Additional randomized clinical trials against best medical therapy are required.
Collapse
Affiliation(s)
- Mark G. Davies
- Division of Vascular and Endovascular Surgery, The University of Texas Health at San Antonio, San Antonio, TX, United States,*Correspondence: Mark G. Davies
| | - Dimitrios Miserlis
- Division of Vascular and Endovascular Surgery, The University of Texas Health at San Antonio, San Antonio, TX, United States
| | - Joseph P. Hart
- Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| |
Collapse
|
4
|
Goncharova NS, Condori Leandro HI, Vakhrushev AD, Koshevaya EG, Skorik YA, Mitrofanova LB, Murashova LA, Korobchenko LE, Andreeva EM, Lebedev DS, Moiseeva OM, Mikhaylov EN. Transcatheter radiofrequency pulmonary artery denervation in swine: the evaluation of lesion degree, hemodynamics and pulmonary hypertension inducibility. BMC Pulm Med 2021; 21:418. [PMID: 34922518 PMCID: PMC8684280 DOI: 10.1186/s12890-021-01786-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/10/2021] [Indexed: 11/25/2022] Open
Abstract
Background Mechanisms of positive effects of pulmonary artery (PA) denervation (PADN) remain poorly understood. The study aimed to evaluate pulmonary hemodynamic changes after PADN and their association with the extent of PA wall damage in an acute thromboxane A2 (TXA2)-induced pulmonary hypertension (PH) model in swine. Methods In this experimental sham-controlled study, 17 normotensive male white Landrace pigs (the mean weight 36.2 ± 4.5 kg) were included and randomly assigned to group I (n = 9)—PH modeling before and after PADN, group II (n = 4)—PADN only, or group III (n = 4)—PH modeling before and after a sham procedure. Radiofrequency (RF) PADN was performed in the PA trunk and at the proximal parts of the right and left PAs. PA wall lesions were characterized at the autopsy study using histological and the immunohistochemical examination. Results In groups I and II, no statistically significant changes in the mean pulmonary arterial pressure nor systemic blood pressure were found after PADN (−0.8 ± 3.4 vs 4.3 ± 8.6 mmHg, P = 0.47; and 6.0 ± 15.9 vs -8.3 ± 7.5 mmHg, P = 0.1; correspondingly). There was a trend towards a lower diastolic pulmonary arterial pressure after PADN in group I when compared with group III during repeat PH induction (34.4 ± 2.9 vs 38.0 ± 0.8; P = 0.06). Despite the presence of severe PA wall damage at the RF application sites, S100 expression was preserved in the majority of PA specimens. The presence of high-grade PA lesions was associated with HR acceleration after PADN (ρ = 0.68, p = 0.03). No significant correlation was found between the grade of PA lesion severity and PA pressure after PADN with or without PH induction. Conclusions Extended PADN does not affect PH induction using TXA2. Significant PA adventitia damage is associated with HR acceleration after PADN. Possible delayed effects of PADN on perivascular nerves and pulmonary hemodynamics require further research in chronic experiments. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01786-y.
Collapse
Affiliation(s)
- Natalia S Goncharova
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341.
| | - Heber Ivan Condori Leandro
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Aleksandr D Vakhrushev
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Elena G Koshevaya
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Yury A Skorik
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Lubov B Mitrofanova
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Lada A Murashova
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Lev E Korobchenko
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Elizaveta M Andreeva
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Dmitry S Lebedev
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Olga M Moiseeva
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341
| | - Evgeny N Mikhaylov
- Almazov National Medical Research Centre, 2, Akkuratova Str., Saint-Petersburg, Russian Federation, 197341.
| |
Collapse
|
5
|
Li L, Hu Z, Xiong Y, Yao Y. Device-Based Sympathetic Nerve Regulation for Cardiovascular Diseases. Front Cardiovasc Med 2021; 8:803984. [PMID: 34957267 PMCID: PMC8695731 DOI: 10.3389/fcvm.2021.803984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/22/2021] [Indexed: 12/05/2022] Open
Abstract
Sympathetic overactivation plays an important role in promoting a variety of pathophysiological processes in cardiovascular diseases (CVDs), including ventricular remodeling, vascular endothelial injury and atherosclerotic plaque progression. Device-based sympathetic nerve (SN) regulation offers a new therapeutic option for some CVDs. Renal denervation (RDN) is the most well-documented method of device-based SN regulation in clinical studies, and several large-scale randomized controlled trials have confirmed its value in patients with resistant hypertension, and some studies have also found RDN to be effective in the control of heart failure and arrhythmias. Pulmonary artery denervation (PADN) has been clinically shown to be effective in controlling pulmonary hypertension. Hepatic artery denervation (HADN) and splenic artery denervation (SADN) are relatively novel approaches that hold promise for a role in cardiovascular metabolic and inflammatory-immune related diseases, and their first-in-man studies are ongoing. In addition, baroreflex activation, spinal cord stimulation and other device-based therapies also show favorable outcomes. This review summarizes the pathophysiological rationale and the latest clinical evidence for device-based therapies for some CVDs.
Collapse
Affiliation(s)
| | | | | | - Yan Yao
- National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Fu Wai Hospital, Beijing, China
| |
Collapse
|
6
|
An Ovine Model for Percutaneous Pulmonary Artery Laser Denervation: Perivascular Innervation and Ablation Lesion Characteristics. Int J Mol Sci 2021; 22:ijms22168788. [PMID: 34445490 PMCID: PMC8395814 DOI: 10.3390/ijms22168788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 08/10/2021] [Accepted: 08/13/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Pulmonary artery denervation (PADN) is an evolving interventional procedure capable to reduce pulmonary artery (PA) pressure. We aimed to compare PA nerve distribution in different specimens and assess the feasibility of an ovine model for a denervation procedure and evaluate the acute changes induced by laser energy. Methods: The experiment was divided into two phases: (1) the analysis of PA nerve distribution in sheep, pigs, and humans using histological and immunochemical methods; (2) fiberoptic PADN in sheep and postmortem laser lesion characteristics. Results: PA nerve density and distribution in sheep differ from humans, although pigs and sheep share similar characteristics, nerve fibers are observed in the media layer, adventitia, and perivascular tissue in sheep. Necrosis of the intima and focal hemorrhages within the media, adventitia, and perivascular adipose tissue were evidenced post laser PADN. Among the identified lesions, 40% reached adventitia and could be classified as effective for PADN. The use of 20 W ablation energy was safer and 30 W-ablation led to collateral organ damage. Conclusions: An ovine model is suitable for PADN procedures; however, nerve distribution in the PA bifurcation and main branches differ from human PA innervation. Laser ablation can be safely used for PADN procedures.
Collapse
|
7
|
Goncharova NS, Andreeva EM, Vakhrushev AD, Leandro HIC, Murashova LA, Voronin SE, Korobchenko LE, Mitrofanova LB, Skorik YA, Galagudza MM, Moiseeva OM, Mikhaylov EN. Modeling of Acute Pulmonary Arterial Hypertension in Pigs Using a Stable Thromboxane A 2 Analogue (U46619): Dose Adjustment and Assessment of Hemodynamic Reactions. Bull Exp Biol Med 2021; 170:729-733. [PMID: 33893968 DOI: 10.1007/s10517-021-05142-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Indexed: 11/29/2022]
Abstract
U46619, a synthetic analogue of thromboxane A2 was used for modeling acute stable and reversible pulmonary arterial hypertension. Administration of U46619 in high doses led to vascular collapse and inhibition of cardiac function. The doses of U46619 were empirically selected that allow attaining the target level of pulmonary hypertension without systemic hemodynamic disturbances. The possibility of attaining the target level of pulmonary hypertension and reversibility of changes after termination of U46619 infusion make this model attractive for evaluation of the efficiency of different therapeutic methods of treatment of pulmonary hypertension in large animals.
Collapse
Affiliation(s)
- N S Goncharova
- Non-Coronary Heart Diseases Research Department, St. Petersburg, Russia.
| | - E M Andreeva
- Non-Coronary Heart Diseases Research Department, St. Petersburg, Russia
| | - A D Vakhrushev
- Neuromodulation Research Laboratory, St. Petersburg, Russia
| | | | - L A Murashova
- Center for Preclinical and Translational Research, St. Petersburg, Russia
| | - S E Voronin
- Center for Preclinical and Translational Research, St. Petersburg, Russia
| | | | - L B Mitrofanova
- Research Laboratory of Pathomorphology, V. A. Almazov National Medical Research Centre, Ministry of Health the Russian Federation, St. Petersburg, Russia
| | - Y A Skorik
- Center for Preclinical and Translational Research, St. Petersburg, Russia
| | - M M Galagudza
- Center for Preclinical and Translational Research, St. Petersburg, Russia
| | - O M Moiseeva
- Non-Coronary Heart Diseases Research Department, St. Petersburg, Russia
| | - E N Mikhaylov
- Neuromodulation Research Laboratory, St. Petersburg, Russia.,Arrhythmia Research Department, St. Petersburg, Russia
| |
Collapse
|
8
|
Perivascular Innervation of the Pulmonary Artery in Human and Swine: A Comparative Study for the Development of an Experimental Model of Denervation. Bull Exp Biol Med 2020; 170:279-282. [PMID: 33263852 DOI: 10.1007/s10517-020-05051-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Indexed: 10/22/2022]
Abstract
For studying the possibility of using catheter denervation of the pulmonary artery for the treatment of pulmonary hypertension, large animals, such as pigs, are more suitable, because the diameter of the pulmonary artery in this case allows manipulation of the ablation catheter. The study of the perivascular adipose tissue of the trunk and bifurcation of the pulmonary artery in humans and pigs revealed differences in the density and diameter of nerve fibers, but their depth did not differ. Immunohistochemical analysis with different markers of the autonomic nervous system receptors revealed similar receptor profile in human and pigs, though the expression of all studied markers in pigs was less pronounced than in humans. These findings attest to similarity of the innervation of the pulmonary arteries in humans and pigs under normal conditions.
Collapse
|
9
|
Extended Renal Artery Denervation Is Associated with Artery Wall Lesions and Acute Systemic and Pulmonary Hemodynamic Changes: A Sham-Controlled Experimental Study. Cardiovasc Ther 2020; 2020:8859663. [PMID: 33193811 PMCID: PMC7644331 DOI: 10.1155/2020/8859663] [Citation(s) in RCA: 2] [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: 07/16/2020] [Revised: 10/05/2020] [Accepted: 10/18/2020] [Indexed: 11/17/2022] Open
Abstract
Objectives We sought to assess acute changes in systemic and pulmonary hemodynamics and microscopic artery lesions following extended renal artery denervation (RDN). Background RDN has been proposed to reduce sympathetic nervous system hyperactivation. Although the effects of RDN on systemic circulation and overall sympathetic activity have been studied, data on the impact of RDN on pulmonary hemodynamics is lacking. Methods The study comprised 13 normotensive Landrace pigs. After randomization, 7 animals were allocated to the group of bilateral RDN and 6 animals to the group of a sham procedure (SHAM). Hemodynamic measures, cannulation, and balloon-based occlusion of the renal arteries were performed in both groups. In the RDN group, radiofrequency ablation was performed in all available arteries and their segments. An autopsy study of the renal arteries was carried out in both groups. Results The analysis was performed on 12 pigs (6 in either group) since pulmonary thromboembolism occurred in one case. A statistically significant drop in the mean diastolic pulmonary artery pressure (PAP) was detected in the RDN group when compared with the SHAM group (change by 13.0 ± 4.4 and 10.0 ± 3.0 mmHg, correspondingly; P = 0.04). In 5 out of 6 pigs in the RDN group, a significant decrease in systemic systolic blood pressure was found, when compared with baseline (98.8 ± 17.8 vs. 90.2 ± 12.6 mmHg, P = 0.04), and a lower mean pulmonary vascular resistance (PVR) (291.0 ± 77.4 vs. 228.5 ± 63.8 dyn∗sec∗cm−5, P = 0.03) after ablation was found. Artery dissections were found in both groups, with prevalence in animals after RDN. Conclusions Extensive RDN leads to a rapid and significant decrease in PAP. In the majority of cases, RDN is associated with an acute lowering of systolic blood pressure and PVR. Extended RDN is associated with artery wall lesions and thrombus formation underdiagnosed by angiography.
Collapse
|
10
|
Condori Leandro HI, Vakhrushev AD, Goncharova NS, Korobchenko LE, Koshevaya EG, Mitrofanova LB, Andreeva EM, Moiseeva OM, Lebedev DS, Mikhaylov EN. Stimulation Mapping of the Pulmonary Artery for Denervation Procedures: an Experimental Study. J Cardiovasc Transl Res 2020; 14:546-555. [PMID: 33111219 DOI: 10.1007/s12265-020-10079-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/13/2020] [Indexed: 10/23/2022]
Abstract
Transcatheter pulmonary artery denervation (PADN) has been developed for the correction of pulmonary hypertension. We investigated pulmonary artery stimulation mapping and its role in PADN procedures. Artery stimulation was performed in 17 Landrace pigs. Low-frequency stimulation defined areas of ventricular and atrial capture. High-frequency stimulation evoked the following responses: sinus rhythm slowing and/or atrial rhythm acceleration in 59% of animals, phrenic nerve capture in 100%, and laryngeal recurrent nerve capture in 23%. The sites with evoked heart rate responses were marked by discrete radiofrequency ablations (RFA). An autopsy showed nerves in the adventitia and perivascular fat under the RFA sites, and the lack of muscarinic-1, tyrosine hydroxylase, and dopamine-5 receptors' expression. During PADN, areas adjacent to the course of phrenic and recurrent laryngeal nerves should be avoided. RFA at points with heart rate responses leads to the non-reproducibility of evoked reactions and the disappearance of neural markers' expression. Graphical abstract.
Collapse
Affiliation(s)
- Heber Ivan Condori Leandro
- Neuromodulation Laboratory, Almazov National Medical Research Centre, 197341, Akkuratova st.2, Saint Petersburg, Russian Federation
| | - Aleksandr D Vakhrushev
- Neuromodulation Laboratory, Almazov National Medical Research Centre, 197341, Akkuratova st.2, Saint Petersburg, Russian Federation
| | - Natalia S Goncharova
- Non-coronary Heart Disease Department, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Lev E Korobchenko
- Pavlov First Saint Petersburg Medical University, Saint Petersburg, Russian Federation
| | - Elena G Koshevaya
- Pathology Department, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Lubov B Mitrofanova
- Pathology Department, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Elizaveta M Andreeva
- Pavlov First Saint Petersburg Medical University, Saint Petersburg, Russian Federation
| | - Olga M Moiseeva
- Non-coronary Heart Disease Department, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation
| | - Dmitry S Lebedev
- Arrhythmia Department, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation.,Department of Bioengineering Systems, Saint Petersburg Electrotechnical University "LETI", Saint Petersburg, Russian Federation
| | - Evgeny N Mikhaylov
- Neuromodulation Laboratory, Almazov National Medical Research Centre, 197341, Akkuratova st.2, Saint Petersburg, Russian Federation. .,Arrhythmia Department, Almazov National Medical Research Centre, Saint Petersburg, Russian Federation. .,Department of Bioengineering Systems, Saint Petersburg Electrotechnical University "LETI", Saint Petersburg, Russian Federation.
| |
Collapse
|