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Chung WH, Lin YN, Wu MY, Chang KC. Sympathetic Modulation in Cardiac Arrhythmias: Where We Stand and Where We Go. J Pers Med 2023; 13:jpm13050786. [PMID: 37240956 DOI: 10.3390/jpm13050786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 05/28/2023] Open
Abstract
The nuance of autonomic cardiac control has been studied for more than 400 years, yet little is understood. This review aimed to provide a comprehensive overview of the current understanding, clinical implications, and ongoing studies of cardiac sympathetic modulation and its anti-ventricular arrhythmias' therapeutic potential. Molecular-level studies and clinical studies were reviewed to elucidate the gaps in knowledge and the possible future directions for these strategies to be translated into the clinical setting. Imbalanced sympathoexcitation and parasympathetic withdrawal destabilize cardiac electrophysiology and confer the development of ventricular arrhythmias. Therefore, the current strategy for rebalancing the autonomic system includes attenuating sympathoexcitation and increasing vagal tone. Multilevel targets of the cardiac neuraxis exist, and some have emerged as promising antiarrhythmic strategies. These interventions include pharmacological blockade, permanent cardiac sympathetic denervation, temporal cardiac sympathetic denervation, etc. The gold standard approach, however, has not been known. Although neuromodulatory strategies have been shown to be highly effective in several acute animal studies with very promising results, the individual and interspecies variation between human autonomic systems limits the progress in this young field. There is, however, still much room to refine the current neuromodulation therapy to meet the unmet need for life-threatening ventricular arrhythmias.
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Affiliation(s)
- Wei-Hsin Chung
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- UCLA Cardiac Arrhythmia Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA 90024, USA
| | - Yen-Nien Lin
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
| | - Mei-Yao Wu
- School of Post-Baccalaureate Chinese Medicine, China Medical University, Taichung 404333, Taiwan
- Department of Chinese Medicine, China Medical University Hospital, Taichung 40447, Taiwan
| | - Kuan-Cheng Chang
- Division of Cardiovascular Medicine, Department of Medicine, China Medical University Hospital, Taichung 40447, Taiwan
- School of Medicine, China Medical University, Taichung 404333, Taiwan
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Lauder L, Mahfoud F, Azizi M, Bhatt DL, Ewen S, Kario K, Parati G, Rossignol P, Schlaich MP, Teo KK, Townsend RR, Tsioufis C, Weber MA, Weber T, Böhm M. Hypertension management in patients with cardiovascular comorbidities. Eur Heart J 2022:6808663. [DOI: 10.1093/eurheartj/ehac395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 06/23/2022] [Accepted: 07/08/2022] [Indexed: 11/09/2022] Open
Abstract
Abstract
Arterial hypertension is a leading cause of death globally. Due to ageing, the rising incidence of obesity, and socioeconomic and environmental changes, its incidence increases worldwide. Hypertension commonly coexists with Type 2 diabetes, obesity, dyslipidaemia, sedentary lifestyle, and smoking leading to risk amplification. Blood pressure lowering by lifestyle modifications and antihypertensive drugs reduce cardiovascular (CV) morbidity and mortality. Guidelines recommend dual- and triple-combination therapies using renin–angiotensin system blockers, calcium channel blockers, and/or a diuretic. Comorbidities often complicate management. New drugs such as angiotensin receptor-neprilysin inhibitors, sodium–glucose cotransporter 2 inhibitors, glucagon-like peptide-1 receptor agonists, and non-steroidal mineralocorticoid receptor antagonists improve CV and renal outcomes. Catheter-based renal denervation could offer an alternative treatment option in comorbid hypertension associated with increased sympathetic nerve activity. This review summarises the latest clinical evidence for managing hypertension with CV comorbidities.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Michel Azizi
- Université Paris Cité, INSERM CIC1418 , F-75015 Paris , France
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department, DMU CARTE , F-75015 Paris , France
- FCRIN INI-CRCT , Nancy , France
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center, Harvard Medical School , Boston, MA , USA
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine , Tochigi , Japan
| | - Gianfranco Parati
- Department of Medicine and Surgery, Cardiology Unit, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS , Milan , Italy
| | - Patrick Rossignol
- FCRIN INI-CRCT , Nancy , France
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques - Plurithématique 14-33 and INSERM U1116 , Nancy , France
- CHRU de Nancy , Nancy , France
| | - Markus P Schlaich
- Dobney Hypertension Centre, Medical School—Royal Perth Hospital Unit, Medical Research Foundation, The University of Western Australia , Perth, WA , Australia
- Departments of Cardiology and Nephrology, Royal Perth Hospital , Perth, WA , Australia
| | - Koon K Teo
- Population Health Research Institute, McMaster University , Hamilton, ON , Canada
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania , Philadelphia, PA , USA
| | - Costas Tsioufis
- National and Kapodistrian University of Athens, 1st Cardiology Clinic, Hippocratio Hospital , Athens , Greece
| | | | - Thomas Weber
- Department of Cardiology, Klinikum Wels-Grieskirchen , Wels , Austria
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University , Kirrberger Str. 1, 66421 Homburg , Germany
- Cape Heart Institute (CHI), Faculty of Health Sciences, University of Cape Town , Cape Town , South Africa
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Persu A, Maes F, Toennes SW, Ritscher S, Georges C, Wallemacq P, Haratani N, Parise H, Fischell TA, Lauder L, Mahfoud F. Impact of drug adherence on blood pressure response to alcohol-mediated renal denervation. Blood Press 2022; 31:109-117. [PMID: 35575248 DOI: 10.1080/08037051.2022.2074367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
PURPOSE While poor drug adherence is frequent in patients with resistant hypertension, detailed analyses of the impact of drug adherence on the success of renal denervation are scarce. We report drug adherence at baseline, changes in drug adherence, and the influence of these parameters on blood pressure changes at 6 and 12 months in patients treated with alcohol-mediated renal denervation as part of the Peregrine study. MATERIALS AND METHODS Urinary detection of antihypertensive drugs was performed using high-performance liquid chromatography-tandem mass spectrometry. Full adherence, partial adherence, and complete non-adherence were defined as 0, 1, or ≥2 drugs not detected, respectively. RESULTS Renal denervation was performed in 45 patients with uncontrolled hypertension on ≥3 antihypertensive medications (62% men, age 55 ± 10 years). At baseline, the proportion of fully, partially, and non-adherent patients was 62% (n = 28), 16% (n = 7), and 22% (n = 10), respectively. At 6 months, adherence improved by 21% (n = 9), remained unchanged at 49% (n = 21), and worsened by 30% (n = 13). Mean 24-h systolic blood pressure decreased by 10 ± 13, 10 ± 4, and 14 ± 19 mmHg in fully, partially, and non-adherent patients (p = 0.77), and by 14 ± 14, 8 ± 11, and 14 ± 18 mmHg in patients who improved, maintained, or decreased adherence, respectively (p = 0.35). The results at 12 months were similar. CONCLUSION About 40% of patients with apparently treatment-resistant hypertension were not fully adherent at baseline, and adherence decreased further in 30%. Nevertheless, mean blood pressure changes after renal denervation were similar irrespective of drug adherence. Our results suggest that such patients may benefit from alcohol-mediated renal denervation, irrespective of drug adherence. These findings are hypothesis-generating and need to be confirmed in ongoing sham-controlled trials.
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Affiliation(s)
- Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Frédéric Maes
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Stefan W Toennes
- Institute of Legal Medicine, Goethe University, Frankfurt, Germany
| | - Sabrina Ritscher
- Institute of Legal Medicine, Goethe University, Frankfurt, Germany
| | - Coralie Georges
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium.,Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Pierre Wallemacq
- Clinical Chemistry Department, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | | | | | | | - Lucas Lauder
- Department of Internal Medicine III, Saarland University Medical Center, Homburg, Germany
| | - Felix Mahfoud
- Department of Internal Medicine III, Saarland University Medical Center, Homburg, Germany
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Kiuchi MG, Carnagarin R, Nolde JM, Lugo-Gavidia LM, Ward NC, Schlaich MP. Renal denervation as a management strategy for hypertension: current evidence and recommendations. Expert Rev Cardiovasc Ther 2021; 19:825-835. [PMID: 34353197 DOI: 10.1080/14779072.2021.1965878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The concept of targeting the renal sympathetic nerves therapeutically to lower blood pressure (BP) is based on their crucial role in regulating both renal and cardiovascular control. These effects are mainly mediated via three major mechanisms including alteration of renal blood flow, renin-release, and Na+ retention. Initial surgical approaches applying crude and unselected sympathectomy, while rendering significant BP lowering and cardiovascular event reducing properties, where plagued by side effects. More modern selective catheter-based denervation approaches selectively targeting the renal nerves have been shown to be safe and effective in reducing BP in various forms of hypertension and multiple comorbidities. AREAS COVERED This article covers the background relevant for the concept of renal denervation (RDN), the evidence obtained from relevant randomized controlled trials to substantiate the safety and efficacy of RDN, and recently published clinical recommendations. EXPERT OPINION Catheter-based RDN is safe and has now been shown in sham-controlled randomized clinical trials to result in clinically meaningful BP lowering in both drug naïve hypertensive patients and those on concomitant antihypertensive therapy. Real world data from a large global registry further supports the clinical utility of RDN. It now seems time to embed renal denervation into routine clinical care.
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Affiliation(s)
- Márcio Galindo Kiuchi
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit and RPH Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, the University of Western Australia, Perth, Western Australia, Australia
| | - Revathy Carnagarin
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit and RPH Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, the University of Western Australia, Perth, Western Australia, Australia
| | - Janis M Nolde
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit and RPH Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, the University of Western Australia, Perth, Western Australia, Australia
| | - Leslie Marisol Lugo-Gavidia
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit and RPH Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, the University of Western Australia, Perth, Western Australia, Australia
| | - Natalie C Ward
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit and RPH Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, the University of Western Australia, Perth, Western Australia, Australia
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine - Royal Perth Hospital Unit and RPH Research Foundation, Faculty of Medicine, Dentistry & Health Sciences, the University of Western Australia, Perth, Western Australia, Australia.,Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia.,Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth, Australia
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Aorticorenal ganglion as a novel target for renal neuromodulation. Heart Rhythm 2021; 18:1745-1757. [PMID: 34182169 DOI: 10.1016/j.hrthm.2021.06.1192] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 06/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Clinical trials for renal artery (RA) ablation have shown limited efficacy. OBJECTIVE The purpose of this study was to investigate whether the aorticorenal ganglion (ARG) can be targeted for renal denervation. METHODS Twenty-eight pigs were studied under isoflurane or alpha-chloralose to examine hemodynamic responses and catecholamine release in response to RA or ARG stimulation. To assess the efficacy of ARG ablation, we randomized 16 pigs to either sham, RA, or ARG ablation, followed by occlusion of the left anterior descending coronary artery (LAD). Hemodynamic responses, cardiac electrophysiological parameters, and arrhythmias/sudden cardiac death were assessed following LAD occlusion. Absent hemodynamic responses to stimulation confirmed ARG or RA ablation. In vivo stellate ganglion neural activity was recorded to assess cardiac sympathetic signaling. Cadaveric dissections were performed to localize the ARG in humans for comparison to swine. RESULTS The ARG is a purely sympathetic ganglion with cholinergic inputs and pass-through sensory afferent fibers. Compared to RA stimulation, ARG stimulation yielded greater hemodynamic responses during alpha-chloralose anesthesia. However, neither site yielded significant responses under isoflurane. Radiofrequency ablation of the ARG eliminated responses to both RA and ARG stimulation, whereas RA ablation did not eliminate responses to ARG stimulation. Ablation of the ARG did not impact the kidneys or adrenal glands. Compared to control and RA ablation, ARG ablation was protective against ventricular arrhythmias and sudden death. Human and swine ARG are similarly located in the aorticorenal region. CONCLUSION Our findings indicate that the ARG may be a novel target for renal neuromodulation. Further studies are warranted to validate these findings.
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Böhm M, Lauder L. Blood pressure and renal denervation with ultrasound: another step forward. Lancet 2021; 397:2441-2443. [PMID: 34010610 DOI: 10.1016/s0140-6736(21)00989-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/21/2021] [Indexed: 11/23/2022]
Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, 66421 Homburg/Saar, Germany.
| | - Lucas Lauder
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, 66421 Homburg/Saar, Germany
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Baik J, Seo S, Lee S, Yang S, Park SM. Circular Radio-Frequency Electrode With MEMS Temperature Sensors for Laparoscopic Renal Sympathetic Denervation. IEEE Trans Biomed Eng 2021; 69:256-264. [PMID: 34166182 DOI: 10.1109/tbme.2021.3092035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Laparoscopic renal denervation (LRDN) ablates sympathetic nerves on the outer wall of a renal artery to treat autonomic nervous system disorders such as hypertension and arrhythmia. Here, we developed a new circular radio frequency (RF) electrode for LRDN using micro-electro-mechanical systems (MEMS) technology. METHODS The electrode consists of a parallel bipolar MEMS electrode, two MEMS thermocouples, and a shape-memory alloy (SMA) substrate. The electrode is automatically wrapped and unwrapped under actuation controlled by the heat generated by RF energy on the electrode-tissue interface. The electrode was designed through a computational simulation analysis, and its actuation and temperature-sensing performance were tested in laboratory experiments and a porcine animal study. RESULTS In an in-vivo study of porcine renal arteries, the electrode could automatically wrap and unwrap around an artery during LRDN. The bipolar MEMS electrode required 13 Vrms for heat generation up to 60°C, while the two MEMS thermocouples reliably measured the temperature without noise signals (a temperature coefficient of 38.3 or 38.5 µV/°C and an accuracy of ±0.44 or ±0.49°C). As revealed in a histological analysis using hematoxylin and eosin staining and Masson's trichrome staining, the renal artery was intact after LRDN. CONCLUSION The circular RF electrode improves the safety of LRDN by reliably measuring the electrode temperature of the electrode during RDN and enhances the effectiveness of LRDN by reducing the complicated manipulations of the surgical instrument. SIGNIFICANCE The developed circular RF electrode will pave the way for LRDN treatment of autonomic nervous system disorders.
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8
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Mahfoud F, Azizi M, Ewen S, Pathak A, Ukena C, Blankestijn PJ, Böhm M, Burnier M, Chatellier G, Durand Zaleski I, Grassi G, Joner M, Kandzari DE, Kirtane A, Kjeldsen SE, Lobo MD, Lüscher TF, McEvoy JW, Parati G, Rossignol P, Ruilope L, Schlaich MP, Shahzad A, Sharif F, Sharp ASP, Sievert H, Volpe M, Weber MA, Schmieder RE, Tsioufis C, Wijns W. Proceedings from the 3rd European Clinical Consensus Conference for clinical trials in device-based hypertension therapies. Eur Heart J 2021; 41:1588-1599. [PMID: 32211888 PMCID: PMC7174031 DOI: 10.1093/eurheartj/ehaa121] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/19/2019] [Accepted: 02/10/2020] [Indexed: 12/22/2022] Open
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Michel Azizi
- Université de Paris, INSERM CIC1418, F-75015 Paris, France.,APHP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France.,F-CRIN INI-CRCT Network, Nancy, France
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Atul Pathak
- F-CRIN INI-CRCT Network, Nancy, France.,Department of Cardivascular Medicine, INSERM 1048, Princess Grace Hospital (CHPG), Avenue Pasteur, 98000 Monaco, Monaco
| | - Christian Ukena
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | | | - Gilles Chatellier
- Université de Paris, INSERM CIC1418, F-75015 Paris, France.,APHP, Hôpital Européen Georges Pompidou, Clinical Trial Unit, F-75015 Paris, France
| | | | - Guido Grassi
- Clinica Medica, University of Milano Bicocca, Milan, Italy
| | - Michael Joner
- Deutsches Herzzentrum München, Munich, Germany.,Deutsches Zentrum für Herz- und Kreislauf-Forschung (DZHK) e.V. (German Center for Cardiovascular Research), Partner Site Munich, Munich, Germany
| | | | - Ajay Kirtane
- Columbia University Irving Medical Center/NewYork-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY, USA
| | | | - Melvin D Lobo
- William Harvey Research Institute, Centre for Clinical Pharmacology, Barts NIHR Cardiovascular Biomedical Research Centre, Queen Mary University of London, London, UK
| | - Thomas F Lüscher
- Center for Molecular Cardiology, Schlieren Campus, Zürich, Switzerland.,Royal Brompton and Harefield Hospital Trust, Imperial College London, London, UK
| | | | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca-Istituto Auxologico Italiano, IRCCS, Milano, Italy
| | - Patrick Rossignol
- F-CRIN INI-CRCT Network, Nancy, France.,Université de Lorraine, Inserm, Centre d'Investigations cliniques-plurithématique 1433, Inserm U1116, Nancy, France.,CHRU Nancy, Nancy, France
| | - Luis Ruilope
- Institute of Research i+12 and CIBER CV, Hospital 12 de Octubre and Faculty of Sport Medicine, European University, Madrid, Spain
| | - Markus P Schlaich
- Dobney Hypertension Centre, The University of Western Australia-Royal Perth Hospital Campus, Perth, Australia.,Baker Heart and Diabetes Institute, Melbourne, Australia
| | - Atif Shahzad
- National University of Ireland Galway, Galway, Ireland.,Galway University Hospital, Galway, Ireland
| | - Faisal Sharif
- National University of Ireland Galway, Galway, Ireland.,Galway University Hospital, Galway, Ireland
| | - Andrew S P Sharp
- University Hospital of Wales, Cardiff, UK.,University of Exeter, Exeter, UK
| | - Horst Sievert
- CardioVascular Center Frankfurt CVC, Frankfurt, Germany.,Anglia Ruskin University, Chelmsford, UK.,University California San Francisco UCSF, San Francisco, USA.,Yunnan Hospital Fuwai, Kunming, China
| | - Massimo Volpe
- Sapienza University of Rome-Sant'Andrea Hospital Rome and IRCCS Neuromed, Pozzilli, Italy
| | | | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital, Erlangen, Germany
| | - Costas Tsioufis
- First Cardiology Clinic, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece
| | - William Wijns
- The Lambe Institute for Translational Medicine, National University of Ireland Galway, Galway, Ireland
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The Effects of Renal Nerve Denervation on Blood Pressure and Target Organs in Different Hypertensive Rat Models. Int J Hypertens 2021; 2021:8615253. [PMID: 33884205 PMCID: PMC8041559 DOI: 10.1155/2021/8615253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 01/25/2021] [Accepted: 03/02/2021] [Indexed: 11/26/2022] Open
Abstract
Background Hypertension contributes to the progression of cardiac remodeling and renal damage. In turn, renal sympathetic hyperactivation showed elevated sympathetic nervous system activity and led to blood pressure increase in certain patients. The purpose of this study was to observe the effect of renal nerve denervation on blood pressure and target organ changes in two hypertensive rat models. Methods Hypertensive rats were randomly divided into a renal denervation (RDN) group and sham operation group. Wistar–Kyoto (WKY) rats of the same age were set as the baseline control group. In the secondary hypertension model, SD rats were randomly divided into five groups. Blood pressure and bodyweight were measured every week until they were euthanized. Results The two rat models underwent RDN at key timepoints. At these timepoints, the hearts and kidneys were collected for norepinephrine and angiotensin II measurements and histological analysis. Conclusion RDN performed before development of hypertension showed a significant antihypertensive effect on the secondary hypertension model.
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Abstract
In the past decade, efforts to improve blood pressure control have looked beyond conventional approaches of lifestyle modification and drug therapy to embrace interventional therapies. Based upon animal and human studies clearly demonstrating a key role for the sympathetic nervous system in the etiology of hypertension, the newer technologies that have emerged are predominantly aimed at neuromodulation of peripheral nervous system targets. These include renal denervation, baroreflex activation therapy, endovascular baroreflex amplification therapy, carotid body ablation, and pacemaker-mediated programmable hypertension control. Of these, renal denervation is the most mature, and with a recent series of proof-of-concept trials demonstrating the safety and efficacy of radiofrequency and more recently ultrasound-based renal denervation, this technology is poised to become available as a viable treatment option for hypertension in the foreseeable future. With regard to baroreflex activation therapy, endovascular baroreflex amplification, carotid body ablation, and programmable hypertension control, these are developing technologies for which more human data are required. Importantly, central nervous system control of the circulation remains a poorly understood yet vital component of the hypertension pathway and mandates further investigation. Technology to improve blood pressure control through deep brain stimulation of key cardiovascular control territories is, therefore, of interest. Furthermore, alternative nonsympathomodulatory intervention targeting the hemodynamics of the circulation may also be worth exploring for patients in whom sympathetic drive is less relevant to hypertension perpetuation. Herein, we review the aforementioned technologies with an emphasis on the preclinical data that underpin their rationale and the human evidence that supports their use.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany (F.M.)
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology (MIT), Cambridge, MA (F.M.)
| | - Markus P Schlaich
- Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Unit, The University of Western Australia, Australia (M.S.)
- Departments of Cardiology (M.S.), Royal Perth Hospital, Australia
- Nephrology (M.S.), Royal Perth Hospital, Australia
- Neurovascular Hypertension and Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Australia (M.S.)
| | - Melvin D Lobo
- William Harvey Research Institute and Barts NIHR Cardiovascular Biomedical Research Centre, Queen Mary University of London, United Kingdom (M.D.L.)
- Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom (M.D.L.)
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Lauder L, Böhm M, Mahfoud F. The current status of renal denervation for the treatment of arterial hypertension. Prog Cardiovasc Dis 2021; 65:76-83. [PMID: 33587963 DOI: 10.1016/j.pcad.2021.02.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/08/2021] [Indexed: 02/08/2023]
Abstract
Despite the availability of safe and effective antihypertensive drugs, blood pressure (BP) control to guideline-recommended target values is poor. Several device-based therapies have been introduced to lower BP. The most extensively investigated approach is catheter-based renal sympathetic denervation (RDN), which aims to interrupt the activity of afferent and efferent renal sympathetic nerves by applying radiofrequency energy, ultrasound energy, or injection of alcohol in the perivascular space. The second generation of placebo-controlled trials have provided solid evidence for the BP-lowering efficacy of radiofrequency- and ultrasound-based RDN in patients with and without concomitant pharmacological therapy. In addition, the safety profile of RDN appears to be excellent in all registries and clinical trials. However, there remain unsolved issues to be addressed. This review summarizes the rationale as well as the current evidence and discusses open questions and possible future indications of catheter-based RDN.
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Affiliation(s)
- Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany; Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
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12
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Mahfoud F, Böhm M, Schmieder R, Narkiewicz K, Ewen S, Ruilope L, Schlaich M, Williams B, Fahy M, Mancia G. Effects of renal denervation on kidney function and long-term outcomes: 3-year follow-up from the Global SYMPLICITY Registry. Eur Heart J 2020; 40:3474-3482. [PMID: 30907413 PMCID: PMC6837160 DOI: 10.1093/eurheartj/ehz118] [Citation(s) in RCA: 159] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 11/01/2018] [Accepted: 02/20/2019] [Indexed: 12/12/2022] Open
Abstract
Aims Several studies and registries have demonstrated sustained reductions in blood pressure (BP) after renal denervation (RDN). The long-term safety and efficacy after RDN in real-world patients with uncontrolled hypertension, however, remains unknown. The objective of this study was to assess the long-term safety and efficacy of RDN, including its effects on renal function. Methods and results The Global SYMPLICITY Registry is a prospective, open-label registry conducted at 196 active sites worldwide in hypertensive patients receiving RDN treatment. Among 2237 patients enrolled and treated with the SYMPLICITY Flex catheter, 1742 were eligible for follow-up at 3 years. Baseline office and 24-h ambulatory systolic BP (SBP) were 166 ± 25 and 154 ± 18 mmHg, respectively. SBP reduction after RDN was sustained over 3 years, including decreases in both office (−16.5 ± 28.6 mmHg, P < 0.001) and 24-h ambulatory SBP (−8.0 ± 20.0 mmHg; P < 0.001). Twenty-one percent of patients had a baseline estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2. Between baseline and 3 years, renal function declined by 7.1 mL/min/1.73 m2 in patients without chronic kidney disease (CKD; eGFR ≥60 mL/min/1.73 m2; baseline eGFR 87 ± 17 mL/min/1.73 m2) and by 3.7 mL/min/1.73 m2 in patients with CKD (eGFR <60 mL/min/1.73 m2; baseline eGFR 47 ± 11 mL/min/1.73 m2). No long-term safety concerns were observed following the RDN procedure. Conclusion Long-term data from the Global SYMPLICITY Registry representing the largest available cohort of hypertensive patients receiving RDN in a real-world clinical setting demonstrate both the safety and efficacy of the procedure with significant and sustained office and ambulatory BP reductions out to 3 years. ![]()
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Affiliation(s)
- Felix Mahfoud
- Department of Internal Medicine, Saarland University Hospital, Geb. 41, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine, Saarland University Hospital, Geb. 41, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Roland Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Maximilianspl. 2, 91054 Erlangen, Germany
| | - Krzysztof Narkiewicz
- Department of Hypertension and Diabetology, Medical University of Gdansk, Marii Skłodowska-Curie 3a, 80-210 Gdansk, Poland
| | - Sebastian Ewen
- Department of Internal Medicine, Saarland University Hospital, Geb. 41, Kirrberger Strasse 1, 66421 Homburg/Saar, Germany
| | - Luis Ruilope
- Department of Cardiovascular Risk, Hypertension Unit and Cardiorenal Translational Research Laboratory, Institute of Research i + 12, Hospital Universitario 12 de Octubre and CIBERCV, School of Doctoral Studies and Research, Universidad Europea de Madrid, Av. Cordoba, s/n, 28041 Madrid, Spain
| | - Markus Schlaich
- Department of Medicine, Dobney Hypertension Centre, School of Medicine-Royal Perth Hospital Unit, The University of Western Australia, 197 Wellington St, Perth, WA 6000, Australia
| | - Bryan Williams
- Department of Medicine, Institute of Cardiovascular Sciences, University College London, National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, Gower St, Bloomsbury, London WC1E 6BT, UK
| | - Martin Fahy
- Coronary and Structural Heart Division, Medtronic PLC, 3576 Unocal Place, Santa Rosa, CA 95403, USA
| | - Giuseppe Mancia
- Professor Emeritus, University of Milano-Bicocca, P.za dei Daini, 4 - 20126 Milano, Italy
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Los registros de denervación renal, ¿completan la evidencia? Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2020.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Evaluation of Transcatheter Alcohol-Mediated Perivascular Renal Denervation to Treat Resistant Hypertension. J Clin Med 2020; 9:jcm9061881. [PMID: 32560164 PMCID: PMC7356226 DOI: 10.3390/jcm9061881] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 06/06/2020] [Accepted: 06/09/2020] [Indexed: 12/27/2022] Open
Abstract
Catheter-based renal denervation (RDN) has been investigated for hypertension (HTN) treatment with variable success. One of the novel approaches to RDN is the delivery of micro-doses of dehydrated alcohol to the adventitial space of the renal artery to perform perivascular ablation of the sympathetic nerves. We sought to assess the safety and efficiency of transcatheter alcohol-mediated perivascular renal denervation in patients with resistant hypertension. Fifty adult patients who had been referred for resistant HTN were screened. To qualify for the study, the patients had to have a mean 24 h systolic pressure ≥ 135 mmHg based upon ambulatory blood pressure monitoring (ABPM) and acceptable renal artery anatomy confirmed by the contrast computer tomography (AngioCT) and nephrologist consultation. Ten patients were eligible for chemical RND. There were no safety issues throughout the 24 months of follow-ups. The mean decrease in the office BP (OBP) was significant during 24 months of follow-up (p < 0.01). The difference in the BP in the ABPM was statistically significant in the 1st, 3rd and 12th months (p < 0.01), whereas during the 3-month follow-up, a trend was observed. The modifications of anti-hypertension drugs throughout the follow-up period were minimal. This study has shown that transcatheter alcohol-mediated renal denervation in patients with resistant hypertension is feasible and safe. Nevertheless, it is a hypothesis-generating study.
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Millenaar D, Emrich I, Mahfoud F. Registries in renal denervation-completing the picture? ACTA ACUST UNITED AC 2020; 73:605-607. [PMID: 32199804 DOI: 10.1016/j.rec.2020.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 02/10/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Dominic Millenaar
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany.
| | - Insa Emrich
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
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Mahfoud F, Renkin J, Sievert H, Bertog S, Ewen S, Böhm M, Lengelé JP, Wojakowski W, Schmieder R, van der Giet M, Parise H, Haratani N, Pathak A, Persu A. Alcohol-Mediated Renal Denervation Using the Peregrine System Infusion Catheter for Treatment of Hypertension. JACC Cardiovasc Interv 2020; 13:471-484. [DOI: 10.1016/j.jcin.2019.10.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/15/2019] [Accepted: 10/22/2019] [Indexed: 12/20/2022]
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Kunz M, Lauder L, Ewen S, Böhm M, Mahfoud F. The Current Status of Devices for the Treatment of Resistant Hypertension. Am J Hypertens 2020; 33:10-18. [PMID: 31570933 DOI: 10.1093/ajh/hpz161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 09/23/2019] [Accepted: 09/29/2019] [Indexed: 12/22/2022] Open
Abstract
Arterial hypertension is associated with increased cardiovascular morbidity and mortality. Although blood pressure-lowering therapies significantly reduce the risk of major cardiovascular events, blood pressure control remains unsatisfactorily low. Several device-based antihypertensive therapies have been investigated in patients with treatment-resistant hypertension and in patients unable or unwilling to adhere to antihypertensive medication. As the field of device-based therapies is subject to constant change, this review aims at providing an up-to-date overview of different device-based approaches for the treatment of hypertension. These approaches target the sympathetic nervous system (renal denervation, baroreflex amplification therapy, baroreflex activation therapy, and carotid body ablation) or alter mechanical arterial properties by creating an iliac arteriovenous fistula. Notably, the use of all of these treatment options is not recommended for the routine treatment of hypertension by current guidelines but should be investigated in the context of controlled clinical studies.
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Affiliation(s)
- Michael Kunz
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Lucas Lauder
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
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Stereotactic Radiotherapy for Renal Denervation: To Beam, or Not to Beam? J Am Coll Cardiol 2019; 74:1710-1713. [PMID: 31558255 DOI: 10.1016/j.jacc.2019.07.054] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 07/10/2019] [Accepted: 07/17/2019] [Indexed: 01/08/2023]
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Kalman JM, Lavandero S, Mahfoud F, Nahrendorf M, Yacoub MH, Zhao D. Looking back and thinking forwards - 15 years of cardiology and cardiovascular research. Nat Rev Cardiol 2019; 16:651-660. [PMID: 31570832 DOI: 10.1038/s41569-019-0261-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/24/2022]
Abstract
The first issue of Nature Reviews Cardiology was published in November 2004 under the name Nature Clinical Practice Cardiovascular Medicine. To celebrate our 15th anniversary in 2019, we invited six of our Advisory Board members to discuss what they considered the most important advances in their field of cardiovascular research or clinical practice in the past 15 years and what changes they envision for cardiovascular medicine in the next 15 years. Several practice-changing breakthroughs are described, including advances in procedural techniques to treat arrhythmias and hypertension and the development of novel therapeutic strategies to treat heart failure and pulmonary arterial hypertension, as well as those that target risk factors such as inflammation and elevated LDL-cholesterol levels. Furthermore, these key opinion leaders predict that machine learning technology and data derived from wearable devices will pave the way towards the coveted goal of personalized medicine.
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Affiliation(s)
- Jonathan M Kalman
- Department of Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia. .,Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia.
| | - Sergio Lavandero
- Advanced Center for Chronic Diseases (ACCDiS), Faculty of Chemical and Pharmaceutical Sciences & Faculty of Medicine, University of Chile, Santiago, Chile. .,Department of Internal Medicine (Cardiology Division), University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Felix Mahfoud
- Department of Internal Medicine III, Saarland University Hospital, Homburg (Saar), Germany. .,Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA.
| | - Matthias Nahrendorf
- Center for Systems Biology, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA. .,Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Magdi H Yacoub
- National Heart and Lung Institute, Heart Science Centre, Harefield Hospital, London, UK. .,The Magdi Yacoub Foundation, Aswan Heart Centre, Aswan, Egypt.
| | - Dong Zhao
- Capital Medical University, Beijing Anzhen Hospital, Beijing, China.
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20
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Effects of renal denervation on 24-h heart rate and heart rate variability in resistant hypertension. Clin Res Cardiol 2019; 109:581-588. [DOI: 10.1007/s00392-019-01543-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Accepted: 08/23/2019] [Indexed: 12/12/2022]
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21
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Electrical stimulation-based renal nerve mapping exacerbates ventricular arrhythmias during acute myocardial ischaemia. J Hypertens 2019; 36:1342-1350. [PMID: 29621066 DOI: 10.1097/hjh.0000000000001712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Blood pressure elevation in response to transient renal nerve stimulation (RNS) has been used to determine the ablation target and endpoint of renal denervation. This study aimed to evaluate the safety of transient RNS in canines with normal or ischaemic hearts. METHODS In ten normal (Group 1) and six healed myocardial infarction (HMI) (Group 2) canines, a large-tip catheter was inserted into the left or right renal artery to perform transient RNS. The left stellate ganglion neural activity (LSGNA) and ventricular electrophysiological parameters were measured at baseline and during transient RNS. In another 20 acute myocardial infarction (AMI) canines, RNS (Group 3, n = 10) or sham RNS (Group 4, n = 10) was intermittently (1 min ON and 4 min OFF) performed for 1 h following AMI induction. The LSGNA and AMI-induced ventricular arrhythmias were analysed. RESULTS In normal and HMI canines, although transient RNS significantly increased the LSGNA and facilitated the action potential duration (APD) alternans, it did not induce any ventricular arrhythmias and did not change the ventricular effective refractory period, APD or maximum slope of the APD restitution curve. In AMI canines, transient RNS significantly exacerbated LSG activation and promoted the incidence of ventricular arrhythmias. CONCLUSION Transient RNS did not increase the risk of ventricular arrhythmias in normal or HMI hearts, but it significantly promoted the occurrence of ventricular arrhythmias in AMI hearts. Therefore, electrical stimulation-based renal nerve mapping may be unsafe in AMI patients and in patients with a high risk for malignant ventricular arrhythmias.
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Kiuchi MG, Nolde JM, Villacorta H, Carnagarin R, Chan JJSY, Lugo-Gavidia LM, Ho JK, Matthews VB, Dwivedi G, Schlaich MP. New Approaches in the Management of Sudden Cardiac Death in Patients with Heart Failure-Targeting the Sympathetic Nervous System. Int J Mol Sci 2019; 20:E2430. [PMID: 31100908 PMCID: PMC6567277 DOI: 10.3390/ijms20102430] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 05/10/2019] [Accepted: 05/12/2019] [Indexed: 12/11/2022] Open
Abstract
Cardiovascular diseases (CVDs) have been considered the most predominant cause of death and one of the most critical public health issues worldwide. In the past two decades, cardiovascular (CV) mortality has declined in high-income countries owing to preventive measures that resulted in the reduced burden of coronary artery disease (CAD) and heart failure (HF). In spite of these promising results, CVDs are responsible for ~17 million deaths per year globally with ~25% of these attributable to sudden cardiac death (SCD). Pre-clinical data demonstrated that renal denervation (RDN) decreases sympathetic activation as evaluated by decreased renal catecholamine concentrations. RDN is successful in reducing ventricular arrhythmias (VAs) triggering and its outcome was not found inferior to metoprolol in rat myocardial infarction model. Registry clinical data also suggest an advantageous effect of RDN to prevent VAs in HF patients and electrical storm. An in-depth investigation of how RDN, a minimally invasive and safe method, reduces the burden of HF is urgently needed. Myocardial systolic dysfunction is correlated to neuro-hormonal overactivity as a compensatory mechanism to keep cardiac output in the face of declining cardiac function. Sympathetic nervous system (SNS) overactivity is supported by a rise in plasma noradrenaline (NA) and adrenaline levels, raised central sympathetic outflow, and increased organ-specific spillover of NA into plasma. Cardiac NA spillover in untreated HF individuals can reach ~50-fold higher levels compared to those of healthy individuals under maximal exercise conditions. Increased sympathetic outflow to the renal vascular bed can contribute to the anomalies of renal function commonly associated with HF and feed into a vicious cycle of elevated BP, the progression of renal disease and worsening HF. Increased sympathetic activity, amongst other factors, contribute to the progress of cardiac arrhythmias, which can lead to SCD due to sustained ventricular tachycardia. Targeted therapies to avoid these detrimental consequences comprise antiarrhythmic drugs, surgical resection, endocardial catheter ablation and use of the implantable electronic cardiac devices. Analogous NA agents have been reported for single photon-emission-computed-tomography (SPECT) scans usage, specially the 123I-metaiodobenzylguanidine (123I-MIBG). Currently, HF prognosis assessment has been improved by this tool. Nevertheless, this radiotracer is costly, which makes the use of this diagnostic method limited. Comparatively, positron-emission-tomography (PET) overshadows SPECT imaging, because of its increased spatial definition and broader reckonable methodologies. Numerous ANS radiotracers have been created for cardiac PET imaging. However, so far, [11C]-meta-hydroxyephedrine (HED) has been the most significant PET radiotracer used in the clinical scenario. Growing data has shown the usefulness of [11C]-HED in important clinical situations, such as predicting lethal arrhythmias, SCD, and all-cause of mortality in reduced ejection fraction HF patients. In this article, we discussed the role and relevance of novel tools targeting the SNS, such as the [11C]-HED PET cardiac imaging and RDN to manage patients under of SCD risk.
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Affiliation(s)
- Márcio Galindo Kiuchi
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Janis Marc Nolde
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Humberto Villacorta
- Cardiology Division, Department of Medicine, Universidade Federal Fluminense, Niterói, Rio de Janeiro 24033-900, Brazil.
| | - Revathy Carnagarin
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Justine Joy Su-Yin Chan
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Leslie Marisol Lugo-Gavidia
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Jan K Ho
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Vance B Matthews
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
| | - Girish Dwivedi
- Harry Perkins Institute of Medical Research and Fiona Stanley Hospital, The University of Western Australia, Perth 6150, Australia.
| | - Markus P Schlaich
- Dobney Hypertension Cenre, School of Medicine-Royal Perth Hospital Unit, Faculty of Medicine, Dentistry & Health Sciences, The University of Western Australia Level 3, MRF Building, Rear 50 Murray St, Perth 6000, MDBP: M570, Australia.
- Departments of Cardiology and Nephrology, Royal Perth Hospital, Perth 6000, Australia.
- Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne 3004, Australia.
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Relevance of Targeting the Distal Renal Artery and Branches with Radiofrequency Renal Denervation Approaches-A Secondary Analysis from a Hypertensive CKD Patient Cohort. J Clin Med 2019; 8:jcm8050581. [PMID: 31035604 PMCID: PMC6572309 DOI: 10.3390/jcm8050581] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 02/07/2023] Open
Abstract
We searched for an association between changes in blood pressure (BP) at 12 and 24 months after renal denervation (RDN) and the different patterns of ablation spots placement along the renal artery vasculature. We performed a post-hoc analysis of a 24-month follow-up evaluation of 30 patients who underwent RDN between 2011 and 2012 using our previous database. Patients who had (i) resistant hypertension, as meticulously described previously, and (ii) Chronic kidney disease (CKD) stages 2, 3 and 4. Correlations were assessed using the Pearson or Spearman correlation tests as appropriate. The mean change in systolic ambulatory BP monitoring (ABPM) compared to baseline was −19.4 ± 12.7 mmHg at the 12th (p < 0.0001) and −21.3 ± 14.1 mmHg at the 24th month (p < 0.0001). There was no correlation between the ABPM Systolic Blood Pressure (SBP)-lowering effect and the total number of ablated spots in renal arteries (17.7 ± 6.0) either at 12 (r = −0.3, p = 0.1542) or at 24 months (r = −0.2, p = 0.4009). However, correlations between systolic BP-lowering effect and the number of ablation spots performed in the distal segment and branches were significant at the 12 (r = −0.7, p < 0.0001) and 24 months (r = −0.8, p < 0.0001) follow-up. Our findings indicate a substantial correlation between the numbers of ablated sites in the distal segment and branches of renal arteries and the systolic BP-lowering effect in the long-term.
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Böhm M, Ewen S, Wolf M. Renal Denervation Halts Left Ventricular Remodeling and Dysfunction in Heart Failure: New Shores Ahead. J Am Coll Cardiol 2018; 72:2622-2624. [PMID: 30466520 DOI: 10.1016/j.jacc.2018.09.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/01/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg-Saar, Germany.
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg-Saar, Germany
| | - Milan Wolf
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Homburg-Saar, Germany
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Kataoka Y, Delacroix S, Sidharta S, Andrews J, Nicholls SJ, Tsioufis CP, Papademetriou V, Worthley SG. Serial changes in vessel walls of renal arteries after catheter-based renal artery denervation: insights from volumetric computed tomography analysis. Int J Nephrol Renovasc Dis 2018; 11:259-266. [PMID: 30310302 PMCID: PMC6166743 DOI: 10.2147/ijnrd.s161313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim Radiofrequency ablation of peri-arterial renal autonomic nerves has been studied as a potential therapeutic option for resistant hypertension. While recent clinical trials have reported its efficacy, there is paucity of data addressing the effects of the procedure on renal arteries, such as changes in vessel and lumen areas. Herein, the effect of atheroma burden on renal arteries after renal denervation was assessed using computed tomography (CT) imaging. Materials and methods Serial renal artery CT imaging was conducted in 38 patients from the EnligHTN™ I study, a prospective, multicenter study evaluating the efficacy of the EnligHTN multi-electrode radiofrequency ablation catheter in resistant hypertensive subjects. Cross-sectional images of renal arteries at 1 mm intervals were acquired using commercially available software (3mensio Structural Heart version 5.1). Vessel and lumen areas were manually traced in each image. Vessel wall volume (VWV) and percent vessel wall volume (P-VWV) were calculated. The measurements within the ablation (first 30 mm segments) and the non-ablation (subsequent 30 mm segment after the first bifurcation of renal arteries) zones were compared. Results On serial evaluation, greater increase in P-VWV and VWV was observed in the ablation zone (change in P-VWV, 6.7%±5.1% vs 3.6%±2.8%, P=0.001; change in VWV, 106.3±87.4 vs 23.0±18.2 mm3, P=0.001). Receiver-operating characteristic analysis demonstrated baseline P-VWV in the ablation zone >37.1% as an optimal cutoff value to predict its substantial progression after the procedure (area under the curve=0.88, sensitivity 89.8%, specificity 79.1%). Conclusion Change in vessel wall was greater within the segments receiving renal artery denervation. Baseline VWV predicted its substantial increase after the procedure. These observations suggest that atheroma burden within the renal arteries is a potential contributing factor to vascular changes after renal sympathetic denervation.
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Affiliation(s)
- Yu Kataoka
- Vascular Research Center, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Sinny Delacroix
- Department of Medicine, Cardiovascular Research Center, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia,
| | - Samuel Sidharta
- Department of Medicine, Cardiovascular Research Center, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia,
| | - Jordan Andrews
- Vascular Research Center, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Stephen J Nicholls
- Vascular Research Center, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, SA, Australia
| | - Costas P Tsioufis
- 1st Department of Cardiology, University of Athens, Hippokration Hospital, Athens, Greece
| | - Vasilios Papademetriou
- Center for hypertension, kidney and vascular research, VA and Georgetown University Medical Centers, Washington DC, USA
| | - Stephen G Worthley
- Department of Medicine, Cardiovascular Research Center, Royal Adelaide Hospital, University of Adelaide, Adelaide, SA, Australia,
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Selejan SR, Linz D, Tatu AM, Hohl M, Speer T, Ewen S, Mahfoud F, Kindermann I, Zamyatkin O, Kazakov A, Laufs U, Böhm M. Sympathoadrenergic suppression improves heart function by upregulating the ratio of sRAGE/RAGE in hypertension with metabolic syndrome. J Mol Cell Cardiol 2018; 122:34-46. [PMID: 30096408 DOI: 10.1016/j.yjmcc.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Revised: 07/16/2018] [Accepted: 08/05/2018] [Indexed: 11/16/2022]
Abstract
Receptors-for-Advanced-Glycation-End-products (RAGE) activate pro-inflammatory programs mediated by carboxymethyllysine (CML) and high-mobility-group-box1 protein (HMGB1). The soluble isoform sRAGE neutralizes RAGE-ligands preventing cardiovascular complications in conditions associated with increased sympathetic activation like hypertension and diabetes. The effects of sympathetic modulation on RAGE/sRAGE-balance and end-organ damage in metabolic syndrome on top of hypertension remains unknown. We hypothesized that increased sympathoadrenergic activity might lead to an unfavourable RAGE/sRAGE regulation. Renal denervation (RDN) was used to modulate sympathetic activation in obese spontaneously hypertensive rats (SHRobRDN) versus sham-operated obese spontaneously hypertensive rats (SHRob), their hypertensive lean controls (SHR) and non-hypertensive controls. Cardiac fibrosis was assessed by histological analysis and sRAGE/RAGE and ligand levels by Western blotting. Levels of CML and HMGB1 were highest in SHRob and were significantly lowered by RDN in serum (-44% and -45%) and myocardium (-25% and -52%). Myocardial RAGE was increased in SHR (+72% versus controls) and in SHRob (+68% versus SHR) while sRAGE decreased (-50% in SHR versus controls and -51% in SHRob versus SHR). RDN reduced myocardial RAGE expression. (-20%) and increased sRAGE levels in heart (+80%) and serum (+180%) versus sham-operated SHRob. Myocardial fibrosis correlated inversely with myocardial sRAGE content (r = -0.79; p = .004; n = 10). Myocardial sRAGE shedding active A-Disintegrin-And-Metalloprotease-10 (ADAM-10) was decreased in SHR (-33% versus controls) and in SHRob (-54% versus SHR), and was restored after RDN (+129% versus SHRob). Serum ADAM-10 activity was also decreased in SHRob (-66% versus SHR) and restored after RDN (+150% versus SHRob). In vitro, isoproterenol induced a ß1-adrenergic receptor mediated increase of RAGE expression in splenocytes (+200%) and decreased sRAGE secretion of splenocytes and cardiac fibroblasts (-50% and -49%) by ß2-adrenergic receptor stimulation mediated suppression of ADAM-10 activity. In conclusion, sympathetic activity affects sRAGE/RAGE-balance, which can be suppressed through sympathetic modulation by RDN, preventing RAGE-induced cardiac damage in hypertension with metabolic syndrome.
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Affiliation(s)
- Simina-Ramona Selejan
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany.
| | - Dominik Linz
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Anna-Maria Tatu
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Mathias Hohl
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Thimoteus Speer
- Klinik für Innere Medizin IV (Nieren- und Hochdruckkrankheiten), Universität des Saarlandes, Homburg, Saar, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Felix Mahfoud
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Ingrid Kindermann
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Olesja Zamyatkin
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Andrey Kazakov
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Ulrich Laufs
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universität des Saarlandes, Homburg, Saar, Germany
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Hypertension: history and development of established and novel treatments. Clin Res Cardiol 2018; 107:16-29. [DOI: 10.1007/s00392-018-1299-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 06/11/2018] [Indexed: 01/08/2023]
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Mahfoud F, Bakris G, Bhatt DL, Esler M, Ewen S, Fahy M, Kandzari D, Kario K, Mancia G, Weber M, Böhm M. Reduced blood pressure-lowering effect of catheter-based renal denervation in patients with isolated systolic hypertension: data from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. Eur Heart J 2018; 38:93-100. [PMID: 28158510 PMCID: PMC5381589 DOI: 10.1093/eurheartj/ehw325] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 04/27/2016] [Accepted: 06/29/2016] [Indexed: 12/26/2022] Open
Abstract
Aims Catheter-based renal artery denervation (RDN) has been shown to lower blood pressure (BP) in certain patients with uncontrolled hypertension. Isolated systolic hypertension (ISH) (systolic BP [SBP] ≥140 mmHg and diastolic BP <90 mmHg), characterized by increased vascular stiffness, is the predominant hypertensive phenotype in elderly patients. This study compared baseline characteristics and SBP change at 6 months between patients with ISH and combined systolic–diastolic hypertension (CH). Methods and results This study pooled data from 1103 patients from SYMPLICITY HTN-3 and the Global SYMPLICITY Registry. A total of 429 patients had ISH, and 674 had CH. Patients with ISH were significantly older than those with CH (66 vs. 55 years), had more type 2 diabetes mellitus (52.9 vs. 34.6%), and a lower estimated glomerular filtration rate (71.8 vs. 78.6 mL/min/1.73 m2); all P < 0.001. At 6 months, the SBP drop for CH patients was −18.7 ± 23.7 mmHg compared with a reduction of −10.9 ± 21.7 mmHg for ISH patients −7.8 mmHg, 95% confidence interval, CI, −10.5, −5.1, P < 0.001). The change in 24-h SBP at 6 months was −8.8 ± 16.2 mmHg in patients with CH vs. −5.8 ± 15.4 mmHg in ISH (−3.0 mmHg, 95% CI −5.4, −0.6, P = 0.015). Presence of ISH at baseline but not age was associated with less pronounced BP changes following the procedure. The strongest predictor of office SBP reduction at 6 months was CH, followed by aldosterone antagonist use and non-use of vasodilators. Conclusion The reduction in BP among patients with ISH following RDN was less pronounced than the reduction in patients with CH. Clinical.Trials.gov identifiers NCT01534299 and NCT01418261.
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Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
- Corresponding author. Tel: +49 6841 16 15911, Fax: +49 6841 16 15910,
| | | | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
| | | | | | - Kazuomi Kario
- Jichi Medical University School of Medicine, Tochigi, Japan
| | - Giuseppe Mancia
- University of Milano-Bicocca and Istituto Auxologico Italiano, Milan, Italy
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Saarland University Hospital, Kirrberger Str., Geb. 40, Homburg/Saar 66421, Germany
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Ye E, Baik J, Lee S, Ryu SY, Yang S, Choi EK, Song WH, Yuk HD, Jeong CW, Park SM. Design and simulation of novel laparoscopic renal denervation system: a feasibility study. Int J Hyperthermia 2018; 35:9-18. [PMID: 29772927 DOI: 10.1080/02656736.2018.1468037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
Abstract
PURPOSE In this study, we propose a novel laparoscopy-based renal denervation (RDN) system for treating patients with resistant hypertension. In this feasibility study, we investigated whether our proposed surgical instrument can ablate renal nerves from outside of the renal artery safely and effectively and can overcome the depth-related limitations of the previous catheter-based system with less damage to the arterial walls. METHOD We designed a looped bipolar electrosurgical instrument to be used with laparoscopy-based RDN system. The tip of instrument wraps around the renal artery and delivers the radio-frequency (RF) energy. We evaluated the thermal distribution via simulation study on a numerical model designed using histological data and validated the results by the in vitro study. Finally, to show the effectiveness of this system, we compared the performance of our system with that of catheter-based RDN system through simulations. RESULTS Simulation results were within the 95% confidence intervals of the in vitro experimental results. The validated results demonstrated that the proposed laparoscopy-based RDN system produces an effective thermal distribution for the removal of renal sympathetic nerves without damaging the arterial wall and addresses the depth limitation of catheter-based RDN system. CONCLUSIONS We developed a novel laparoscope-based electrosurgical RDN method for hypertension treatment. The feasibility of our system was confirmed through a simulation study as well as in vitro experiments. Our proposed method could be an effective treatment for resistant hypertension as well as central nervous system diseases.
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Affiliation(s)
- Eunbi Ye
- a Department of Creative IT Engineering , POSTECH , Pohang , Republic of Korea
| | - Jinhwan Baik
- a Department of Creative IT Engineering , POSTECH , Pohang , Republic of Korea
| | - Seunghyun Lee
- a Department of Creative IT Engineering , POSTECH , Pohang , Republic of Korea
| | - Seon Young Ryu
- a Department of Creative IT Engineering , POSTECH , Pohang , Republic of Korea
| | - Sunchoel Yang
- b Department of Prototype Production , Osong Medical Innovation Foundation , Chungbuk , Republic of Korea
| | - Eue-Keun Choi
- c Department of Internal Medicine , Seoul National University Hospital , Seoul , Republic of Korea
| | - Won Hoon Song
- d Department of Urology , Seoul National University Hospital , Seoul , Republic of Korea
| | - Hyeong Dong Yuk
- d Department of Urology , Seoul National University Hospital , Seoul , Republic of Korea
| | - Chang Wook Jeong
- d Department of Urology , Seoul National University Hospital , Seoul , Republic of Korea
| | - Sung-Min Park
- a Department of Creative IT Engineering , POSTECH , Pohang , Republic of Korea
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Linz D, Hohl M, Elliott AD, Lau DH, Mahfoud F, Esler MD, Sanders P, Böhm M. Modulation of renal sympathetic innervation: recent insights beyond blood pressure control. Clin Auton Res 2018; 28:375-384. [PMID: 29429026 DOI: 10.1007/s10286-018-0508-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 01/29/2018] [Indexed: 02/06/2023]
Abstract
Renal afferent and efferent sympathetic nerves are involved in the regulation of blood pressure and have a pathophysiological role in hypertension. Additionally, several conditions that frequently coexist with hypertension, such as heart failure, obstructive sleep apnea, atrial fibrillation, renal dysfunction, and metabolic syndrome, demonstrate enhanced sympathetic activity. Renal denervation (RDN) is an approach to reduce renal and whole body sympathetic activation. Experimental models indicate that RDN has the potential to lower blood pressure and prevent cardio-renal remodeling in chronic diseases associated with enhanced sympathetic activation. Studies have shown that RDN can reduce blood pressure in drug-naïve hypertensive patients and in hypertensive patients under drug treatment. Beyond its effects on blood pressure, sympathetic modulation by RDN has been shown to have profound effects on cardiac electrophysiology and cardiac arrhythmogenesis. RDN can display anti-arrhythmic effects in a variety of animal models for atrial fibrillation and ventricular arrhythmias. The first non-randomized studies demonstrate that RDN may promote the maintenance of sinus rhythm following catheter ablation in patients with atrial fibrillation. Registry data point towards a beneficial effect of RDN to prevent ventricular arrhythmias in patients with heart failure and electrical storm. Further large randomized placebo-controlled trials are needed to confirm the antihypertensive and anti-arrhythmic effects of RDN. Here, we will review the current literature on anti-arrhythmic effects of RDN with the focus on atrial fibrillation and ventricular arrhythmias. We will discuss new insights from preclinical and clinical mechanistic studies and possible clinical implications of RDN.
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Affiliation(s)
- Dominik Linz
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia. .,Centre for Heart Rhythm Disorders, Department of Cardiology, New Royal Adelaide Hospital, Adelaide, 5000, Australia.
| | - Mathias Hohl
- Kardiologie, Angiologie und Internistische Intensivmedizin, Universität des Saarlandes, Saarbrücken, Germany
| | - Adrian D Elliott
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Dennis H Lau
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Felix Mahfoud
- Kardiologie, Angiologie und Internistische Intensivmedizin, Universität des Saarlandes, Saarbrücken, Germany.,Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Murray D Esler
- Human Neurotransmitters Laboratory, Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Prashanthan Sanders
- Centre for Heart Rhythm Disorders (CHRD), South Australian Health and Medical Research Institute (SAHMRI), University of Adelaide and Royal Adelaide Hospital, Adelaide, Australia
| | - Michael Böhm
- Kardiologie, Angiologie und Internistische Intensivmedizin, Universität des Saarlandes, Saarbrücken, Germany
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31
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Autonomic Control of the Heart. Neuromodulation 2018. [DOI: 10.1016/b978-0-12-805353-9.00104-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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33
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Mahfoud F, Schmieder RE, Azizi M, Pathak A, Sievert H, Tsioufis C, Zeller T, Bertog S, Blankestijn PJ, Böhm M, Burnier M, Chatellier G, Durand Zaleski I, Ewen S, Grassi G, Joner M, Kjeldsen SE, Lobo MD, Lotan C, Lüscher TF, Parati G, Rossignol P, Ruilope L, Sharif F, van Leeuwen E, Volpe M, Windecker S, Witkowski A, Wijns W. Proceedings from the 2nd European Clinical Consensus Conference for device-based therapies for hypertension: state of the art and considerations for the future. Eur Heart J 2017; 38:3272-3281. [PMID: 28475773 PMCID: PMC5837218 DOI: 10.1093/eurheartj/ehx215] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 03/13/2017] [Accepted: 04/06/2017] [Indexed: 01/31/2023] Open
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Saarland University Hospital, Angiologie und Internistische Intensivmedizin, 66421 Homburg, Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Roland E Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | - Michel Azizi
- Paris-Descartes University, Paris, France
- Assistance Publique-Hôpitaux de Paris, Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France
- INSERM, CIC1418, and FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), F-75015 Paris, France
| | - Atul Pathak
- Department of Cardiovascular Medicine, Hypertension, Risk Factors and Heart Failure Unit, Clinique Pasteur, Avenue de Lombez, Toulouse, France
- INSERM 1048, and FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Toulouse, France
| | - Horst Sievert
- CardioVascular Center (CVC), Seckbacher Landstraße, Frankfurt, Germany
- Anglia Ruskin University, Chelmsford, UK
| | - Costas Tsioufis
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Greece
| | - Thomas Zeller
- Klinik Kardiologie und Angiologie II, Universitaets-Herzzentrum Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Stefan Bertog
- CardioVascular Center (CVC), Seckbacher Landstraße, Frankfurt, Germany
| | - Peter J Blankestijn
- Department of Nephrology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michael Böhm
- Klinik für Innere Medizin III, Saarland University Hospital, Angiologie und Internistische Intensivmedizin, 66421 Homburg, Saar, Germany
| | - Michel Burnier
- Service of Nephrology and Hypertension, University Hospital, Lausanne, Switzerland
| | | | - Isabelle Durand Zaleski
- ECEVE, UMR 1123, AP HP URCEco Ile de France Hopital de l’Hotel Dieu, Paris, France
- Sante Publique Hopital Henri Mondor, Creteil, France
| | - Sebastian Ewen
- Klinik für Innere Medizin III, Saarland University Hospital, Angiologie und Internistische Intensivmedizin, 66421 Homburg, Saar, Germany
| | - Guido Grassi
- Clinica Medica, Università Milano-Bicocca, Italy
- IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Michael Joner
- Deutsches Herzzentrum München, Klinik für Kardiologie, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung e.V., Standort München, Germany
| | - Sverre E Kjeldsen
- ECEVE, UMR 1123, AP HP URCEco Ile de France Hopital de l’Hotel Dieu, Paris, France
- University of Oslo, Institute for Clinical Medicine, Oslo, Norway
| | - Melvin D Lobo
- William Harvey Research Institute, Barts NIHR Cardiovascular Biomedical Research Unit, Queen Mary University of London, London, UK
| | - Chaim Lotan
- Clinica Medica, Università Milano-Bicocca, Italy
| | | | | | - Patrick Rossignol
- INSERM, Centre d’Investigations Cliniques Plurithématique 1433 & U1116, Université de Lorraine, CHRU de Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Luis Ruilope
- Institute of Investigation imas12 and Hypertension Unit, Hospital 12 de Octubre; Department of Preventive Medicine and Public Health, Universidad Autonoma and Department of Postdoctoral Studies and Investigation, Universidad Europea de Madrid, Madrid, Spain
| | - Faisal Sharif
- CURAM, Cardiovascular Research Centre (CVRC) and BioInnovate Ireland, National University of Ireland Galway, Ireland
| | - Evert van Leeuwen
- Department IQ healthcare, section Ethics, Radboudumc, Nijmegen, The Netherlands
| | - Massimo Volpe
- Cardiology, Department of Clinical and Molecular Medicine, University of Rome Sapienza, Rome and IRCCS Neuromed, Pozzilli, Italy
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Bern, Switzerland
| | - Adam Witkowski
- Department of Interventional Cardiology & Angiology, Institute of Cardiology, Warsaw, Poland
| | - William Wijns
- The Lambe Institute for Translational Medicine and Curam, National University of Ireland, Galway, Ireland
- Saolta University Healthcare Group, Galway, Ireland
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Tang X, Shi L, Cui X, Yu Y, Qi T, Chen C, Tang X. Renal denervation decreases susceptibility of the heart to ventricular fibrillation in a canine model of chronic kidney disease. Exp Physiol 2017; 102:1414-1423. [PMID: 28833735 DOI: 10.1113/ep086370] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 08/18/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Xiaotie Tang
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
| | - Lang Shi
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
| | - Xuebin Cui
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
| | - Yang Yu
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
| | - Ting Qi
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
| | - Cheng Chen
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
| | - Xianglei Tang
- Department of Nephrology, Puren Hospital of Wuhan; Wuhan University of Science and Technology; Wuhan China
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Catheter-based radio-frequency renal nerve denervation lowers blood pressure in obese hypertensive swine model. J Hypertens 2017; 34:1854-62. [PMID: 27379536 DOI: 10.1097/hjh.0000000000001021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Radio-frequency renal denervation (RDN) therapy is under investigation for the treatment of uncontrolled hypertension. Data in hypertensive, drug-naïve large animal models using RDN is limited. METHODS A cohort of Ossabaw swine (N = 9) was implanted with telemetry monitors, enrolled on a high calorie-feed regimen and randomly assigned to RDN. Blood pressure (BP) data were separated and analyzed according to the following epoch definitions: 24-h (h), most-active-h, light-h, and dark-h. RESULTS The mean weight increased by 45% from 86.5 ± 2.5 kg at telemetry implant (day 87) to 125.2 ± 4.5 kg at time of RDN therapy (day 227). Hypertension developed in all swine (24-h BP: 169.5/128.3 ± 5.8/5.1 mmHg pre-RDN). RDN resulted in significant reductions in noradrenaline kidney tissue concentration by 63%. Significant BP reductions were documented at 45 days post-RDN in all defined interday epochs, except for the dark-h period. The most pronounced SBP/DBP reduction was 12.4/11.2 mmHg (P < 0.05), observed during the most-active-h period. Animals continued to gain weight after the RDN procedure to the end of the study at 90 days (125.2 ± 4.5-138.5 ± 6.6 kg, P < 0.001). At 90 days post-RDN, the mean 24-h BP returned near pre-RDN baseline values. Given the strong relationship of BP to weight (R = 0.87, P < 0.001), group mean SBP/DBP was normalized by weight resulting in significant and continued reductions at both 45 and 90 days post-RDN across all intradaily epochs. CONCLUSION Catheter-based RDN, using a multielectrode system, resulted in a significant reduction in 24-h BP in this drug-naïve, hypertensive animal model.
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Liu Z, Shen L, Huang W, Zhao X, Fang W, Wang C, Yin Z, Wang J, Fu G, Liu X, Jiang J, Zhang Z, Li J, Lu Y, Ge J. Efficacy and safety of renal denervation for Chinese patients with resistant hypertension using a microirrigated catheter: study design and protocol for a prospective multicentre randomised controlled trial. BMJ Open 2017; 7:e015672. [PMID: 28864691 PMCID: PMC5588951 DOI: 10.1136/bmjopen-2016-015672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Available data show that approximately 8%-18% of patients with primary hypertension will develop resistant hypertension. In recent years, catheter-based renal denervation (RDN) has emerged as a potential treatment option for resistant hypertension. A number of observational studies and randomised controlled trials among non-Chinese patients have demonstrated its potential safety and efficacy. METHODS AND ANALYSIS This is a multicentre, randomised, open-label, parallel-group, active controlled trial that will investigate the efficacy and safety of a 5F saline-irrigated radiofrequency ablation (RFA) used for RDN in the treatment of Chinese patients with resistant hypertension. A total of 254 patients who have failed pharmacological therapy will be enrolled. Eligible subjects will be randomised in a 1:1 ratio to undergo RDN using the RFA plus antihypertensive medication or to receive treatment with antihypertensive medication alone. The primary outcome measure is the change in 24 hours average ambulatory systolic blood pressure from baseline to 3 months, comparing the RDN-plus-medication group with the medication-alone group. Important secondary endpoints include the change in office blood pressure from baseline to 6 months after randomisation. Safety endpoints such as changes in renal function will also be evaluated. The full analysis set, according to the intent-to-treat principle, will be established as the primary analysis population. ETHICS AND DISSEMINATION All participants will provide informed consent; the study protocol has been approved by the Independent Ethics Committee for each site. This study is designed to investigate the efficacy and safety of RDN using a 5F saline microirrigated RFA. Findings will be shared with participating hospitals, policymakers and the academic community to promote the clinical management of resistant hypertension in China. TRIAL REGISTRATION ClinicalTrials.gov ID: NCT02900729; pre-results.
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Affiliation(s)
- Zongjun Liu
- Department of Cardiology, Putuo Hospital affiliated to Shanghai Traditional Chinese Medicine University, Shanghai, China
| | - Li Shen
- Department of Cardiology, Zhongshan Hospital affiliated to Fu Dan University, Shanghai, China
| | - Weijian Huang
- Department of Cardiology, The First Hospital affiliated to Wenzhou Medical College, Wenzhou, China
| | - Xianxian Zhao
- Department of Cardiology, Changhai Hospital affiliated to Second Military Medical University, Shanghai, China
| | - Weiyi Fang
- Department of Cardiology, Shanghai Chest Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Changqian Wang
- Department of Cardiology, Shanghai Ninth People’s Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Zhaofang Yin
- Department of Cardiology, Shanghai Ninth People’s Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Jianan Wang
- Department of Cardiology, The Second Hospital affiliated to Zhejiang University, Hangzhou, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital affiliated to Zhejiang University, Hangzhou, China
| | - Xuebo Liu
- Department of Cardiology, Tongji Hospital affiliated to Tongji University, Shanghai, China
| | - Jianjun Jiang
- Department of Cardiology, Taizhou Hospital, Taizhou, China
| | - Zhihui Zhang
- Department of Cardiology, The Third Xiangya Hospital of Central South University, China
| | - Jingbo Li
- Department of Cardiology, Shanghai Sixth People’s Hospital affiliated to Shanghai Jiao Tong University, Shanghai, China
| | - Yingmin Lu
- Department of Cardiology, Xinhua Hospital affiliated to Shanghai Jiao Tong University School of Medicine Chongming Branch, Shanghai, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital affiliated to Fu Dan University, Shanghai, China
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Mahfoud F, Pipenhagen CA, Boyce Moon L, Ewen S, Kulenthiran S, Fish JM, Jensen JA, Virmani R, Joner M, Yahagi K, Tsioufis C, Böhm M. Comparison of branch and distally focused main renal artery denervation using two different radio-frequency systems in a porcine model. Int J Cardiol 2017; 241:373-378. [DOI: 10.1016/j.ijcard.2017.04.057] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/18/2017] [Accepted: 04/19/2017] [Indexed: 12/31/2022]
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Huang J, Huang H, Pan W, Ou D, Dai W, Lin Y, Wu J, Xie W, Chen X. Renal denervation attenuates cardiac hypertrophy in spontaneously hypertensive rats via regulation of autophagy. Mol Med Rep 2017. [PMID: 28627693 PMCID: PMC5562017 DOI: 10.3892/mmr.2017.6790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
It has been suggested that renal denervation (RD) may attenuate left ventricular (LV) hypertrophy. However, the role that autophagy serves in this process is currently unclear. In the present study, utilizing a model of hypertension-induced cardiac hypertrophy in spontaneous hypertensive rats, it was demonstrated that RD was significantly associated with a reduction in LV hypertrophy. Furthermore, a decrease in the myocardial mRNA of hypertrophy-associated genes was demonstrated in RD rats compared with sham controls. In addition, RD in hypertension-induced LV hypertrophy rats was associated with the attenuation of cellular autophagic response over activation at a physiological level. This was indicated by a reduction in the expression of Beclin-1, autophagy related 9A and microtubule-associated protein 1A/1B-light chain 3 II/I in RD rats to physiological levels that are observed in control rats. Furthermore, the number of autophagosomes was restored to physiological levels in the cardiomyocytes of RD rats. The results of the current study suggest that RD may attenuate LV hypertrophy via the regulation of autophagic responses.
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Affiliation(s)
- Jionghua Huang
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - He Huang
- Department of Cardiology, The First Affiliated Hospital of Gannan Medical College, Ganzhou, Jiangxi 341000, P.R. China
| | - Wei Pan
- Department of Cardiology, Nanhai Hospital Affiliated to Southern Medical University, Foshan, Guangdong 528200, P.R. China
| | - Dejin Ou
- Department of Laboratory Medicine, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Wenjun Dai
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Yuhui Lin
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Jinlei Wu
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Wenjie Xie
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
| | - Ximing Chen
- Department of Cardiology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 510150, P.R. China
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Mahfoud F, Edelman ER. Renal denervation for treatment of hypertension - will 2017 be the year of enlightenment? EUROINTERVENTION 2017; 12:e2163-e2165. [PMID: 28391220 PMCID: PMC5967398 DOI: 10.4244/eijv12i18a355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Felix Mahfoud
- Klinik für Innere Medizin III, Saarland University Hospital, Homburg/Saar, Germany
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Elazer R. Edelman
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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40
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van Zandvoort L, van Kranenburg M, Karanasos A, Van Mieghem N, Ouhlous M, van Geuns RJ, van Domburg R, Daemen J. Serial quantitative magnetic resonance angiography follow-up of renal artery dimensions following treatment by four different renal denervation systems. EUROINTERVENTION 2017; 12:e2271-e2277. [DOI: 10.4244/eij-d-16-00097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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41
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da Silva Gonçalves Bos D, Happé C, Schalij I, Pijacka W, Paton JFR, Guignabert C, Tu L, Thuillet R, Bogaard HJ, van Rossum AC, Vonk-Noordegraaf A, de Man FS, Handoko ML. Renal Denervation Reduces Pulmonary Vascular Remodeling and Right Ventricular Diastolic Stiffness in Experimental Pulmonary Hypertension. JACC Basic Transl Sci 2017; 2:22-35. [PMID: 29034356 PMCID: PMC5628179 DOI: 10.1016/j.jacbts.2016.09.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 09/17/2016] [Accepted: 09/20/2016] [Indexed: 01/20/2023]
Abstract
Neurohormonal overactivation plays an important role in pulmonary hypertension (PH). In this context, renal denervation, which aims to inhibit the neurohormonal systems, may be a promising adjunct therapy in PH. In this proof-of-concept study, we have demonstrated in 2 experimental models of PH that renal denervation delayed disease progression, reduced pulmonary vascular remodeling, lowered right ventricular afterload, and decreased right ventricular diastolic stiffness, most likely by suppression of the renin-angiotensin-aldosterone system.
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Key Words
- AT1, angiotensin II type 1
- Ea, right ventricular afterload
- Eed, right ventricular stiffness
- Ees, right ventricular contractility
- MCT, monocrotaline model
- PH, pulmonary hypertension
- RAAS, renin angiotensin-aldosterone system
- RD, renal denervation
- SNS, sympathetic nervous system
- SuHx, sugen combined with hypoxia model
- pulmonary hypertension
- renin angiotensin system
- right ventricular failure
- sympathetic nervous system
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Affiliation(s)
- Denielli da Silva Gonçalves Bos
- Department of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands.,Department of Physiology VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - Chris Happé
- Department of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands.,Department of Physiology VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - Ingrid Schalij
- Department of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands.,Department of Physiology VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - Wioletta Pijacka
- School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences, University of Bristol, Bristol, United Kingdom
| | - Julian F R Paton
- School of Physiology, Pharmacology & Neuroscience, Biomedical Sciences, University of Bristol, Bristol, United Kingdom
| | - Christophe Guignabert
- University of Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Ly Tu
- University of Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Raphaël Thuillet
- University of Paris-Sud, Faculté de Médecine, Université Paris-Saclay, Le Kremlin Bicêtre, France.,INSERM UMR_S 999, Hôpital Marie Lannelongue, Le Plessis-Robinson, France
| | - Harm-Jan Bogaard
- Department of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - Albert C van Rossum
- Department of Cardiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - Anton Vonk-Noordegraaf
- Department of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - Frances S de Man
- Department of Pulmonology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands.,Department of Physiology VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
| | - M Louis Handoko
- Department of Physiology VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands.,Department of Cardiology, VU University Medical Center, Institute for Cardiovascular Research, Amsterdam, the Netherlands
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Targeting Neurohormonal Activation in Pulmonary Arterial Hypertension. JACC Basic Transl Sci 2017; 2:36-38. [PMID: 30167553 PMCID: PMC6113518 DOI: 10.1016/j.jacbts.2016.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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43
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Pinkham MI, Loftus MT, Amirapu S, Guild SJ, Quill G, Woodward WR, Habecker BA, Barrett CJ. Renal denervation in male rats with heart failure improves ventricular sympathetic nerve innervation and function. Am J Physiol Regul Integr Comp Physiol 2017; 312:R368-R379. [PMID: 28052866 DOI: 10.1152/ajpregu.00313.2016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 12/14/2016] [Accepted: 01/02/2017] [Indexed: 01/19/2023]
Abstract
Heart failure is characterized by the loss of sympathetic innervation to the ventricles, contributing to impaired cardiac function and arrhythmogenesis. We hypothesized that renal denervation (RDx) would reverse this loss. Male Wistar rats underwent myocardial infarction (MI) or sham surgery and progressed into heart failure for 4 wk before receiving bilateral RDx or sham RDx. After additional 3 wk, left ventricular (LV) function was assessed, and ventricular sympathetic nerve fiber density was determined via histology. Post-MI heart failure rats displayed significant reductions in ventricular sympathetic innervation and tissue norepinephrine content (nerve fiber density in the LV of MI+sham RDx hearts was 0.31 ± 0.05% vs. 1.00 ± 0.10% in sham MI+sham RDx group, P < 0.05), and RDx significantly increased ventricular sympathetic innervation (0.76 ± 0.14%, P < 0.05) and tissue norepinephrine content. MI was associated with an increase in fibrosis of the noninfarcted ventricular myocardium, which was attenuated by RDx. RDx improved LV ejection fraction and end-systolic and -diastolic areas when compared with pre-RDx levels. This is the first study to show an interaction between renal nerve activity and cardiac sympathetic nerve innervation in heart failure. Our findings show denervating the renal nerves improves cardiac sympathetic innervation and function in the post-MI failing heart.
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Affiliation(s)
| | - Michael T Loftus
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Satya Amirapu
- Department of Anatomy and Radiology, University of Auckland, Auckland, New Zealand
| | - Sarah-Jane Guild
- Department of Physiology, University of Auckland, Auckland, New Zealand
| | - Gina Quill
- Department of Medicine, University of Auckland, Auckland, New Zealand; and
| | - William R Woodward
- Department of Physiology and Pharmacology, Oregon Health & Science University, Portland, Oregon
| | - Beth A Habecker
- Department of Physiology and Pharmacology, Oregon Health & Science University, Portland, Oregon
| | - Carolyn J Barrett
- Department of Physiology, University of Auckland, Auckland, New Zealand
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44
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Chen HH, Cheng PW, Ho WY, Lu PJ, Lai CC, Tseng YM, Fang HC, Sun GC, Hsiao M, Liu CP, Tseng CJ. Renal Denervation Improves the Baroreflex and GABA System in Chronic Kidney Disease-induced Hypertension. Sci Rep 2016; 6:38447. [PMID: 27917928 PMCID: PMC5137107 DOI: 10.1038/srep38447] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Accepted: 11/07/2016] [Indexed: 12/18/2022] Open
Abstract
Hypertensive rats with chronic kidney disease (CKD) exhibit enhanced gamma-aminobutyric acid (GABA)B receptor function and regulation within the nucleus tractus solitarii (NTS). For CKD with hypertension, renal denervation (RD) interrupts the afferent renal sympathetic nerves, which are connecting to the NTS. The objective of the present study was to investigate how RD improves CKD-induced hypertension. Rats underwent 5/6 nephrectomy for 8 weeks, which induced CKD and hypertension. RD was induced by applying phenol to surround the renal artery in CKD. RD improved blood pressure (BP) by lowering sympathetic nerve activity and markedly restored the baroreflex response in CKD. The GABAB receptor expression was increased in the NTS of CKD; moreover, the central GABA levels were reduced in the cerebrospinal fluid, and the peripheral GABA levels were increased in the serum. RD restored the glutamic acid decarboxylase activity in the NTS in CKD, similar to the effect observed for central treatment with baclofen, and the systemic administration of gabapentin reduced BP. RD slightly improved renal function and cardiac load in CKD. RD may improve CKD-induced hypertension by modulating the baroreflex response, improving GABA system dysfunction and preventing the development and reducing the severity of cardiorenal syndrome type 4 in CKD rats.
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Affiliation(s)
- Hsin-Hung Chen
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Yuh-Ing Junior College of Health Care &Management, Kaohsiung, Taiwan
| | - Pei-Wen Cheng
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Yuh-Ing Junior College of Health Care &Management, Kaohsiung, Taiwan
| | - Wen-Yu Ho
- Division of General Internal Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Pei-Jung Lu
- Graduate Institute of Clinical Medicine, National Cheng-Kung University, Tainan, Taiwan
| | - Chi-Cheng Lai
- Cardiovascular Center, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yang-Ming Tseng
- Department of Pathology and Laboratory Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Hua-Chang Fang
- Division of Nephrology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Gwo-Ching Sun
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Michael Hsiao
- Genomics Research Center, Academia Sinica, Taipei, Taiwan
| | - Chun-Peng Liu
- Department of Administration, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Section of Cardiology, Department of Medcine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ching-Jiunn Tseng
- Department of Medical Education and Research, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan.,Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
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45
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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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46
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Imnadze G, Balzer S, Meyer B, Neumann J, Krech RH, Thale J, Franz N, Warnecke H, Awad K, Hayek SS, Devireddy C. Anatomic Patterns of Renal Arterial Sympathetic Innervation: New Aspects for Renal Denervation. J Interv Cardiol 2016; 29:594-600. [DOI: 10.1111/joic.12343] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Guram Imnadze
- Schüchtermann Clinic; Bad Rothenfelde; Germany
- University Witten/Herdecke; Witten; Germany
| | | | - Baerbel Meyer
- Institute for Pathology; Klinikum Osnabrück; Germany
| | - Joerg Neumann
- Institute for Pathology; Klinikum Osnabrück; Germany
| | | | | | - Norbert Franz
- Schüchtermann Clinic; Bad Rothenfelde; Germany
- University Witten/Herdecke; Witten; Germany
| | - Henning Warnecke
- Schüchtermann Clinic; Bad Rothenfelde; Germany
- University Witten/Herdecke; Witten; Germany
| | - Khaled Awad
- Schüchtermann Clinic; Bad Rothenfelde; Germany
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47
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Abstract
Cardiac control is mediated via a series of reflex control networks involving somata in the (i) intrinsic cardiac ganglia (heart), (ii) intrathoracic extracardiac ganglia (stellate, middle cervical), (iii) superior cervical ganglia, (iv) spinal cord, (v) brainstem, and (vi) higher centers. Each of these processing centers contains afferent, efferent, and local circuit neurons, which interact locally and in an interdependent fashion with the other levels to coordinate regional cardiac electrical and mechanical indices on a beat-to-beat basis. This control system is optimized to respond to normal physiological stressors (standing, exercise, and temperature); however, it can be catastrophically disrupted by pathological events such as myocardial ischemia. In fact, it is now recognized that autonomic dysregulation is central to the evolution of heart failure and arrhythmias. Autonomic regulation therapy is an emerging modality in the management of acute and chronic cardiac pathologies. Neuromodulation-based approaches that target select nexus points of this hierarchy for cardiac control offer unique opportunities to positively affect therapeutic outcomes via improved efficacy of cardiovascular reflex control. As such, understanding the anatomical and physiological basis for such control is necessary to implement effectively novel neuromodulation therapies. © 2016 American Physiological Society. Compr Physiol 6:1635-1653, 2016.
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Affiliation(s)
- Jeffrey L Ardell
- Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA.,UCLA Neurocardiology Research Center of Excellence, David Geffen School of Medicine, Los Angeles, California, USA
| | - John Andrew Armour
- Los Angeles (UCLA) Cardiac Arrhythmia Center, David Geffen School of Medicine, University of California, Los Angeles, California, USA.,UCLA Neurocardiology Research Center of Excellence, David Geffen School of Medicine, Los Angeles, California, USA
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48
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Ukena C, Mahfoud F, Ewen S, Bollmann A, Hindricks G, Hoffmann BA, Linz D, Musat D, Pavlicek V, Scholz E, Thomas D, Willems S, Böhm M, Steinberg JS. Renal denervation for treatment of ventricular arrhythmias: data from an International Multicenter Registry. Clin Res Cardiol 2016; 105:873-9. [PMID: 27364940 DOI: 10.1007/s00392-016-1012-y] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 06/13/2016] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Ventricular arrhythmias (VAs) in patients with chronic heart failure (CHF) are sometimes refractory to antiarrhythmic drugs and cardiac ablation. This study aimed to investigate catheter-based renal sympathetic denervation (RDN) as antiarrhythmic strategy in refractory VA. METHODS These are the first data from a pooled analysis of 13 cases from five large international centers (age 59.2 ± 14.4 years, all male) with CHF (ejection fraction 25.8 ± 10.1 %, NYHA class 2.6 ± 1) presented with refractory VA who underwent RDN. Ventricular arrhythmias, ICD therapies, clinical status, and blood pressure (BP) were evaluated before and 1-12 months after RDN. RESULTS Within 4 weeks prior RDN, a median of 21 (interquartile range 10-30) ventricular tachycardia (VT) or fibrillation (VF) episodes occurred despite antiarrhythmic drugs and prior cardiac ablation. RDN was performed bilaterally with a total number of 12.5 ± 3.5 ablations and without peri-procedural complications. One and 3 months after RDN, VT/VF episodes were reduced to 2 (0-7) (p = 0.004) and 0 (p = 0.006), respectively. Four (31 %) and 11 (85 %) patients of these 13 patients were free from VA at 1 and 3 months. Although BP was low at baseline (116 ± 18/73 ± 13 mmHg), no significant changes of BP or NYHA class were observed after RDN. During follow-up, three patients died from non-rhythm-related causes. CONCLUSIONS In patients with CHF and refractory VA, RDN appears to be safe concerning peri-procedural complications and blood pressure changes, and is associated with a reduced arrhythmic burden.
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Affiliation(s)
- Christian Ukena
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg, Saar, Germany.
| | - Felix Mahfoud
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg, Saar, Germany
| | - Sebastian Ewen
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg, Saar, Germany
| | - Andreas Bollmann
- Abteilung für Rhythmologie, Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig, Leipzig, Germany
| | - Gerhard Hindricks
- Abteilung für Rhythmologie, Klinik für Innere Medizin/Kardiologie, Herzzentrum Leipzig, Leipzig, Germany
| | - Boris A Hoffmann
- Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Linz
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg, Saar, Germany
| | - Dan Musat
- Arrhythmia Institute, Valley Health System, University of Rochester School of Medicine and Dentistry, New York, NY, USA
| | - Valerie Pavlicek
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg, Saar, Germany
| | - Eberhard Scholz
- Innere Medizin III (Kardiologie, Angiologie, Pneumologie), Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Dierk Thomas
- Innere Medizin III (Kardiologie, Angiologie, Pneumologie), Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Stephan Willems
- Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes, Kirrberger Str. 1, 66421, Homburg, Saar, Germany
| | - Jonathan S Steinberg
- Arrhythmia Institute, Valley Health System, University of Rochester School of Medicine and Dentistry, New York, NY, USA
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49
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Emschermann F, Zuern CS, Patzelt J, Rizas KD, Jäger G, Eick C, Meuth SG, Gawaz M, Bauer A, Langer HF. Resistance to renal denervation therapy — Identification of underlying mechanisms by analysis of differential DNA methylation. IJC HEART & VASCULATURE 2016; 11:80-86. [PMID: 28616530 PMCID: PMC5462630 DOI: 10.1016/j.ijcha.2016.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 04/10/2016] [Indexed: 11/18/2022]
Abstract
Background Factors causing resistance to renal denervation (RDN) for treatment of arterial hypertension are not known. In the current study, we sought to determine mechanisms involved in responsiveness to renal denervation therapy in patients with difficult-to-control and resistant hypertension. Methods and results We evaluated the differential CpG methylation of genes in blood samples isolated from patients of a recently described cohort of responders or non-responders to renal denervation using microarray technique and measured protein levels of identified downstream effectors in blood samples of these patients by ELISA. Our analysis revealed up to 6103 methylation sites differing significantly between non-responders and responders to renal denervation therapy. Software based analysis showed several of these loci to be relevant for arterial hypertension and sympathetic nervous activity. Particularly, genes involved in glutamate synthesis, degradation and glutamate signaling pathways were differently methylated between both groups. For instance, genes for glutamate dehydrogenase 1 and 2 central to glutamate metabolism, genes for ionotropic (AMPA, NMDA) and metabotropic glutamate receptors as well as glutamate transporters revealed significant differences in methylation correlating with responsiveness to RDN. To underline their potential relevance for responsiveness to RDN, we measured plasma protein levels of norepinephrine, a downstream effector of the glutamate receptor pathway, which were significantly lower in non-responders to RDN. Conclusions The present study describes novel molecular targets potentially contributing to reduction of blood pressure after RDN in some patients. Identifying patients with a high responsiveness to RDN could contribute to an individualized therapy in drug resistant hypertension.
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50
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Mahfoud F, Ewen S, Böhm M. Renal denervation in patients with heart failure with preserved ejection fraction: end of the beginning? Eur J Heart Fail 2016; 18:713-5. [DOI: 10.1002/ejhf.553] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 03/25/2016] [Indexed: 01/01/2023] Open
Affiliation(s)
- Felix Mahfoud
- Klink für Innere Medizin III Saarland University Hospital Homburg/Saar Germany
| | - Sebastian Ewen
- Klink für Innere Medizin III Saarland University Hospital Homburg/Saar Germany
| | - Michael Böhm
- Klink für Innere Medizin III Saarland University Hospital Homburg/Saar Germany
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