1
|
Agwuegbo CC, Antia AU, Shamaki GR, Bob-Manuel T. Controversies related to renal artery denervation and devices. Curr Opin Cardiol 2024; 39:244-250. [PMID: 38567924 DOI: 10.1097/hco.0000000000001146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
PURPOSE OF REVIEW This review article discusses the controversies, strengths, and limitations of the current literature on renal artery denervation in the management of resistant hypertension, as well as the future directions of this intervention. RECENT FINDINGS There have been conflicting data from the different randomized control trials assessing the efficacy of renal artery denervation in the management of resistant hypertension. SUMMARY Renal artery denervation is achieved by ablating the sympathetic nerves surrounding the renal arteries using endovascular ultrasound, radiofrequency, or alcohol. Our review article highlights that renal artery denervation is generally effective in improving blood pressure in patients with resistant hypertension. The Food and Drug Administration (FDA) has recently approved the ReCor Medical Paradise system, and the Symplicity Spyral RDN systems for renal artery denervation.
Collapse
Affiliation(s)
| | | | | | - Tamunoinemi Bob-Manuel
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| |
Collapse
|
2
|
Wang J, Yin Y, Lu C, Lu Z, Hu J, Wang Y, Ge J, Jiang H, Yao C, Yan X, Ma W, Qi X, Dang Y, Chen S, Zhu J, Wang D, Ding C, Wang W, Liu J, Wang Y, Li H, Pan Z, Cui K, Li C, Liang X, Chen W, Sobotka PA, Zhang J, Esler M, Sun N, Chen M, Huo Y. Efficacy and safety of sympathetic mapping and ablation of renal nerves for the treatment of hypertension (SMART): 6-month follow-up of a randomised, controlled trial. EClinicalMedicine 2024; 72:102626. [PMID: 38756107 PMCID: PMC11096821 DOI: 10.1016/j.eclinm.2024.102626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Background Previous trials of renal denervation (RDN) have been designed to investigate reduction of blood pressure (BP) as the primary efficacy endpoint using non-selective RDN without intraoperatively verified RDN success. It is an unmet clinical need to map renal nerves, selectively denervate renal sympathetic nerves, provide readouts for the interventionalists and avoid futile RDN. We aimed to examine the safety and efficacy of renal nerve mapping/selective renal denervation (msRDN) in patients with uncontrolled hypertension (HTN) and determine whether antihypertensive drug burden is reduced while office systolic BP (OSBP) is controlled to target level (<140 mmHg). Methods We conducted a randomized, prospective, multicenter, single-blinded, sham-controlled trial. The study combined two efficacy endpoints at 6 months as primary outcomes: The control rate of patients with OSBP <140 mmHg (non-inferior outcome) and change in the composite index of antihypertensive drugs (Drug Index) in the treatment versus Sham group (superior outcome). This design avoids confounding from excess drug-taking in the Sham group. Antihypertensive drug burden was assessed by a composite index constructed as: Class N (number of classes of antihypertensive drugs) × (sum of doses). 15 hospitals in China participated in the study and 220 patients were enrolled in a 1:1 ratio (msRDN vs Sham). The key inclusion criteria included: age (18-65 years old), history of essential HTN (at least 6 months), heart rate (≥70 bpm), OSBP (≥150 mmHg and ≤180 mmHg), ambulatory BP monitoring (ABPM, 24-h SBP ≥130 mmHg or daytime SBP ≥135 mmHg or nighttime SBP ≥120 mmHg), renal artery stenosis (<50%) and renal function (eGFR >45 mL/min/1.73 m2). The catheter with both stimulation and ablation functions was inserted in the distal renal main artery. The RDN site (hot spot) was selected if SBP increased (≥5 mmHg) by intra-renal artery (RA) electrical stimulation; an adequate RDN was confirmed by repeated electronic stimulation if no increase in BP otherwise, a 2nd ablation was performed at the same site. At sites where there was decreased SBP (≥5 mmHg, cold spot) or no BP response (neutral spot) to stimulation, no ablation was performed. The mapping, ablation and confirmation procedure was repeated until the entire renal main artery had been tested then either treated or avoided. After msRDN, patients had to follow a predefined, vigorous drug titration regimen in order to achieve target OSBP (<140 mmHg). Drug adherence was monitored by liquid chromatography-tandem mass spectrometry analysis using urine. This study is registered with ClinicalTrials.gov (NCT02761811) and 5-year follow-up is ongoing. Findings Between July 8, 2016 and February 23, 2022, 611 patients were consented, 220 patients were enrolled in the study who received standardized antihypertensive drug treatments (at least two drugs) for at least 28 days, presented OSBP ≥150 mmHg and ≤180 mmHg and met all inclusion and exclusion criteria. In left RA and right RA, mapped sites were 8.2 (3.0) and 8.0 (2.7), hot/ablated sites were 3.7 (1.4) and 4.0 (1.6), cold spots were 2.4 (2.6) and 2.0 (2.2), neutral spots were 2.0 (2.1) and 2.0 (2.1), respectively. Hot, cold and neutral spots was 48.0%, 27.5% and 24.4% of total mapped sites, respectively. At 6 M, the Control Rate of OSBP was comparable between msRDN and Sham group (95.4% vs 92.8%, p = 0.429), achieved non-inferiority margin -10% (2.69%; 95% CI -4.11%, 9.83%, p < 0.001 for non-inferiority); the change in Drug Index was significantly lower in msRDN group compared to Sham group (4.37 (6.65) vs 7.61 (10.31), p = 0.010) and superior to Sham group (-3.25; 95% CI -5.56, -0.94, p = 0.003), indicating msRDN patients need significantly fewer drugs to control OSBP <140 mmHg. 24-hour ambulatory SBP decreased from 146.8 (13.9) mmHg by 10.8 (14.1) mmHg, and from 149.8 (12.8) mmHg by 10.0 (14.0) mmHg in msRDN and Sham groups, respectively (p < 0.001 from Baseline; p > 0.05 between groups). Safety profiles were comparable between msRDN and Sham groups, demonstrating the safety and efficacy of renal mapping/selective RDN to treat uncontrolled HTN. Interpretation The msRDN therapy achieved the goals of reducing the drug burden of HTN patients and controlling OSBP <140 mmHg, with only approximately four targeted ablations per renal main artery, much lower than in previous trials. Funding SyMap Medical (Suzhou), LTD, Suzhou, China.
Collapse
Affiliation(s)
- Jie Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
- Division of Cardiology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, NY, 10032, USA
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Chengzhi Lu
- Department of Cardiology, Tianjin First Central Hospital, Tianjin, 300190, China
| | - Zhibing Lu
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
- Department of Cardiology, Zhongnan Hospital, Wuhan University, Wuhan, 430071, China
| | - Jialu Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Yue Wang
- The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Chen Yao
- Peking University Health Science Center, Beijing, 100034, China
| | - Xiaoyan Yan
- Peking University Health Science Center, Beijing, 100034, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
| | - Xiaoyong Qi
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Yi Dang
- Department of Cardiology, Hebei General Hospital, Shijiazhuang, 050057, China
| | - Shaoliang Chen
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Jiancheng Zhu
- Department of Cardiology, Nanjing First Hospital, Nanjing, 210012, China
| | - Dongmei Wang
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Chao Ding
- Department of Cardiology, Norman Bethune International Peace Hospital, Shijiazhuang, 050082, China
| | - Weimin Wang
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Jian Liu
- Department of Cardiology, Peking University People's Hospital, Beijing, 100044, China
| | - Yanbin Wang
- Department of Cardiology, Taiyuan Central Hospital, Taiyuan, 030009, China
| | - Hui Li
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Zhenhua Pan
- Department of Cardiology, Daqing Oilfield General Hospital, Daqing, 163458, China
| | - Kaijun Cui
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, 332001, China
| | - Chengzong Li
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 221002, China
| | - Xinjian Liang
- Department of Cardiology, Shenzhen People's Hospital, Shenzhen, Guangdong, 430060, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Paul A. Sobotka
- Department of Cardiology, The Ohio State University College of Medicine, Columbus, OH, 43210, USA
| | | | - Murray Esler
- Baker IDI Heart and Diabetes Institute, Melbourne, Australia
| | - Ningling Sun
- Department of Hypertension, Heart Center, Peking University People's Hospital, Beijing, 100044, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, 210029, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, 100034, China
| |
Collapse
|
3
|
Hu X, Zhou H, Chen W, Li D, Du H, Xia T, Yin Y. Current problems in renal denervation and a hope to break the stage. Hypertens Res 2023; 46:2654-2660. [PMID: 37500716 DOI: 10.1038/s41440-023-01380-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/28/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
Renal denervation (RDN) is currently confronted with the considerable heterogeneity of different post-procedural blood pressure responses. The challenges predominantly arise from not only the lack of selection of appropriate responders but also the absence of detection for the successful endpoints of intervention. In this paper, we summarize the significant characteristics of potentially appropriate hypertensive patients and propose a hopeful way to improve the accuracy of RDN, that is, the application of three-dimensional reconstruction technology combined with electrical renal nerve stimulation to guide the radiofrequency catheter ablation, which may promote the development of selective and accurate RDN in real-world clinical practice. This paper focuses on two current critical concerns of renal denervation (RDN): appropriate patient selection and the improvement in the accuracy of selective RDN. A hopeful way of accurate RDN may be the combination of 3D electroanatomic mapping systems for the renal artery with modified renal nerve stimulation (RNS) techniques and technology for appropriate hypertensive candidates.
Collapse
Affiliation(s)
- Xinyu Hu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Department of Cardiology, Chongqing University Fuling Hospital, Chongqing, China
| | - Hao Zhou
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Dan Li
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Huaan Du
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Tianli Xia
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China.
- Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China.
- Chongqing Key Laboratory of Arrhythmias, Chongqing, China.
| |
Collapse
|
4
|
Wagener M, Dolan E, Arnous S, Galvin J, Murphy AW, Casserly I, Eustace J, O’Connor S, McCreery C, Shand J, Wall C, Matiullah S, Sharif F. Renal Denervation as a Complementary Treatment Option for Uncontrolled Arterial Hypertension: A Situation Assessment. J Clin Med 2023; 12:5634. [PMID: 37685701 PMCID: PMC10488551 DOI: 10.3390/jcm12175634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/20/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
Uncontrolled arterial hypertension is a major global health issue. Catheter-based renal denervation has shown to lower blood pressure in sham-controlled trials and represents a device-based, complementary treatment option for hypertension. In this situation assessment, the authors, who are practicing experts in hypertension, nephrology, general practice and cardiology in the Republic of Ireland, discuss the current evidence base for the BP-lowering efficacy and safety of catheter-based renal denervation with different modalities. Although important questions remain regarding the identification of responders, and long-term efficacy and safety of the intervention, renal denervation has the potential to provide much-needed help to address hypertension and its adverse consequences. The therapeutic approach needs to be multidisciplinary and personalised to take into account the perspective of patients and healthcare professionals in a shared decision-making process.
Collapse
Affiliation(s)
- Max Wagener
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
| | - Eamon Dolan
- Stroke and Hypertension Unit, Connolly Hospital, D15 X40D Dublin, Ireland
| | - Samer Arnous
- University Hospital Limerick, V94 F858 Limerick, Ireland
| | - Joseph Galvin
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | - Andrew W. Murphy
- Turloughmore Medical Centre, University of Galway, H91 TK33 Galway, Ireland
| | - Ivan Casserly
- The Mater Misericordiae University Hospital, D07 R2WY Dublin, Ireland
| | | | | | | | - James Shand
- St. Vincent’s University Hospital, D04 T6F4 Dublin, Ireland
| | | | | | - Faisal Sharif
- University Hospital Galway, University of Galway, H91 TK33 Galway, Ireland
| |
Collapse
|
5
|
Wang J, Sun N, Ge J, Jiang H, Yin Y, Chen M, Wang Y, Yao C, Yan X, Sobotka PA, Huo Y. Rationale and Design of Sympathetic Mapping/Ablation of Renal Nerves Trial (SMART) for the Treatment of Hypertension: a Prospective, Multicenter, Single-Blind, Randomized and Sham Procedure-Controlled Study. J Cardiovasc Transl Res 2023; 16:358-370. [PMID: 36042146 DOI: 10.1007/s12265-022-10307-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
Abstract
Renal denervation (RDN) is proposed as a durable and patient compliance independent treatment for hypertension. However, 20-30% non-responder after RDN treatment weakened the therapeutic effect, which may be due to blind ablation. The renal nerve mapping/selective ablation system developed by SyMap Medical Ltd (Suzhou), China, has the function of mapping renal sympathetic/parasympathetic nerve sites and selectively removing renal sympathetic nerves and is expected to meet the urgent unmet clinical need of targeted RDN. The "Sympathetic Mapping/Ablation of Renal Nerves Trial" (SMART) is a prospective, multicenter, randomized, single-blinded, sham procedure-controlled trial, to evaluate the safety and efficacy of targeted renal sympathetic denervation in patients with essential and uncontrolled hypertension. The study is the first clinical registry trial using a targeted RDN for the treatment of uncontrolled hypertension; the dual-endpoint design can answer the question of how many antihypertensive drugs can be reduced in patients after RDN. The trial is registered on clinicaltrials.gov NCT02761811.
Collapse
Affiliation(s)
- Jie Wang
- Division of Cardiology, Department of Medicine, College of Physician and Surgeons, Columbia University, New York, NY, 10032, USA.
- Academy of Clinical and Translational Research Jiangsu Province, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China.
| | - Ningling Sun
- Department of Hypertension, Heart Center, Peking University People's Hospital, Beijing, 100044, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Hong Jiang
- Department of Cardiology, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Minglong Chen
- Department of Cardiology, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China
| | - Yue Wang
- Academy of Clinical and Translational Research Jiangsu Province, The First Affiliated Hospital With Nanjing Medical University, Nanjing, 210029, China
| | - Chen Yao
- Peking University Clinical Research Institute, Beijing, 100191, China
- Department of Biostatistics, Peking University First Hospital, Beijing, 100034, China
| | - Xiaoyan Yan
- Peking University Clinical Research Institute, Beijing, 100191, China
| | | | - Yong Huo
- Division of Cardiology, Peking University First Hospital, Beijing, 100034, China.
| |
Collapse
|
6
|
Xiong B, Chen S, Chen W, Yin Y, Ling Z. Advances in Renal Denervation in the Treatment of Hypertension. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2023. [DOI: 10.15212/cvia.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
Hypertension significantly increases the risk of cardiovascular events and it is associated with high rates of disability and mortality. Hypertension is a common cause of cardiovascular and cerebrovascular accidents, which severely affect patients’ quality of life and lifespan. Current treatment strategies for hypertension are based primarily on medication and lifestyle interventions. The renal sympathetic nervous system plays an important role in the pathogenesis of hypertension, and catheter-based renal denervation (RDN) has provided a new concept for the treatment of hypertension. In recent years, studies on RDN have been performed worldwide. This article reviews the latest preclinical research and clinical evidence for RDN.
Collapse
|
7
|
Katsurada K, Kario K. Emerging topics on renal denervation in hypertension: anatomical and functional aspects of renal nerves. Hypertens Res 2023:10.1038/s41440-023-01266-2. [PMID: 36991064 DOI: 10.1038/s41440-023-01266-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/27/2023] [Indexed: 03/31/2023]
Abstract
Inappropriate sympathetic activation is closely associated with the development and progression of hypertension. Renal denervation (RDN) is a neuromodulation therapy performed using an intraarterial catheter in patients with hypertension. Recent randomized sham-operated controlled trials have shown that RDN has significant antihypertensive effects that last for at least 3 years. Based on this evidence, RDN is nearly ready for general clinical application. On the other hand, there are remaining issues to be addressed, including elucidation of the precise antihypertensive mechanisms of RDN, the appropriate endpoint of RDN during the procedure, and the association between reinnervation after RDN and the long-term effects of RDN. This mini review focuses on studies implicating anatomy of the renal nerves, which consist of afferent or efferent and sympathetic or parasympathetic nerves, the response of blood pressure to renal nerve stimulation, and reinnervation of renal nerves after RDN. A comprehensive understanding of the anatomical and functional aspects of the renal nerves and the antihypertensive mechanisms of RDN, including its long-term effects, will enhance our ability to incorporate RDN into strategies to treat hypertension in clinical practice. This mini review focuses on studies implicating anatomy of the renal nerves, which consist of afferent or efferent and sympathetic or parasympathetic nerves, the response of blood pressure to renal nerve stimulation, and reinnervation of renal nerves after renal denervation. Whether the ablation site is sympathetic dominant or parasympathetic dominant, and afferent dominant or efferent dominant, would in turn determine the final output of renal denervation. BP: blood pressure.
Collapse
Affiliation(s)
- Kenichi Katsurada
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
- Division of Clinical Pharmacology, Department of Pharmacology, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan.
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Internal Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| |
Collapse
|
8
|
Liu H, Li Y, Zhou H, Chen W, Xu Y, Du H, Zhang B, Xia T, Li D, Ou Z, Tang R, Chen Q, Zhao B, Yin Y. Renal nerve stimulation identifies renal innervation and optimizes the strategy for renal denervation in canine. J Transl Med 2023; 21:100. [PMID: 36759871 PMCID: PMC9912587 DOI: 10.1186/s12967-023-03919-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Renal denervation (RDN) was still performed without any intra-procedural method for nerve mapping. Whether renal nerve stimulation (RNS) is an efficient way to identify renal autonomic innervation and optimize the strategy for RDN remain to be worthy for further exploration. METHODS The characteristics of renal autonomic innervation at the sites with different blood pressure (BP) responses to RNS were explored. Then, dogs anatomically eligible for RDN were randomly assigned into elevated BP response ablation group, reduced BP response ablation group, and RNS-control group. The postoperative outcomes were measured at baseline and after 4 weeks follow-up. RESULTS The proportion of afferent sensory nerve was higher at elevated BP response sites (ERS) than reduced BP response sites (RRS) and non-response sites (NRS) (P = 0.012 and P = 0.004). Conversely, the proportion of parasympathetic nerve at RRS was the highest (RRS vs. ERS, P = 0.017; RRS vs. NRS, P = 0.023). More importantly, there was a significant correlation between systolic blood pressure changes and the area ratios of afferent sensory and parasympathetic nerve (R = 0.859; P < 0.001). In addition, ablation at BP-elevation sites can result in a significant decrease in BP and plasma norepinephrine (NE) after 4 weeks (P = 0.002; P = 0.008), while ablation at BP-reduction sites can lead to significant increases in BP and plasma NE (P = 0.016; P = 0.033). CONCLUSIONS RNS is an effective method to identify renal autonomic innervation. It could not only help to identify optimal target sites, but also avoid ablation of sympathetic-inhibitory areas during RDN.
Collapse
Affiliation(s)
- Hang Liu
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yidan Li
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Hao Zhou
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Weijie Chen
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yanping Xu
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Huaan Du
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Bo Zhang
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Tianli Xia
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Dan Li
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Zhenhong Ou
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Ruotian Tang
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Qingsong Chen
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Binyi Zhao
- grid.412461.40000 0004 9334 6536Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China ,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China. .,Chongqing Cardiac Arrhythmias Therapeutic Service Center, Chongqing, China. .,Chongqing Key Laboratory of Arrhythmia, Chongqing, China.
| |
Collapse
|
9
|
Intrarenal neurohormonal modulation by renal denervation: benefits for chronic kidney disease and heart failure. Hypertens Res 2023; 46:518-520. [PMID: 36400846 DOI: 10.1038/s41440-022-01104-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/31/2022] [Accepted: 11/01/2022] [Indexed: 11/19/2022]
|
10
|
Lai Y, Zhou H, Chen W, Liu H, Liu G, Xu Y, Du H, Zhang B, Li Y, Woo K, Yin Y. The intrarenal blood pressure modulation system is differentially altered after renal denervation guided by different intensities of blood pressure responses. Hypertens Res 2023; 46:456-467. [PMID: 36202981 DOI: 10.1038/s41440-022-01047-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 02/07/2023]
Abstract
The aim of this study was to investigate alterations in the intrarenal blood pressure (BP) regulation system after renal denervation (RDN) guided by renal nerve stimulation (RNS). Twenty-one dogs were randomized to receive RDN at strong (SRA group, n = 7) or weak (WRA group, n = 7) BP-elevation response sites identified by RNS or underwent RNS only (RNS-control, RSC, n = 7). After 4 weeks of follow-up, renal sympathetic components, the main components of renin-angiotensin system (RAS) and the major transporters involved in sodium and water reabsorption were assessed by immunohistochemical analysis. Compared with RSC treatment, RDN therapy significantly reduced renal norepinephrine and tyrosine hydroxylase levels, decreased the renin content and inhibited the onsite generation of angiotensinogen. Moreover, the expression of exciting axis components, including angiotensin-converting enzyme (ACE), angiotensin II and angiotensin II type-1 receptor, was downregulated, while protective axis components for the cardiovascular system, including ACE2 and Mas receptors, were upregulated in both WRA and SRA groups. Moreover, RDN reduced the abundance of aquaporin-1 and aquaporin-2 in kidneys. Although RDN had a minimal effect on overall NKCC2 expression, its activation (p-NKCC2) and directional enrichment in the apical membrane (mNKCC2) were dramatically blunted. All these changes were more obvious in the SRA group than WRA group. Selective RDN guided by RNS effectively reduced systemic BP by affecting the renal neurohormone system, as well as the sodium and water transporter system, and these effects at sites with a strong BP response were more superior.
Collapse
Affiliation(s)
- Yinchuan Lai
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
- Department of Cardiology, the Second People's Hospital of Yibin & West China Hospital, Sichuan University Yibin Hospital, Yibin City, Sichuan, China
| | - Hao Zhou
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Hang Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Guangliang Liu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Yanping Xu
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Huaan Du
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Bo Zhang
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Yidan Li
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China
| | - Kamsang Woo
- Institute of Future Cities, the Chinese University of Hong Kong, Hong Kong, China
| | - Yuehui Yin
- Department of Cardiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing Cardiac Arrhythmia Therapeutic Service Center, Chongqing Key Laboratory of Arrhythmia, Chongqing, China.
| |
Collapse
|
11
|
Guber K, Kirtane AJ. Renal Sympathetic Denervation for Hypertension. Kidney Int Rep 2022; 7:2129-2140. [PMID: 36217529 PMCID: PMC9546727 DOI: 10.1016/j.ekir.2022.06.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/16/2022] [Accepted: 06/27/2022] [Indexed: 12/01/2022] Open
Abstract
Arterial hypertension is the most prevalent global modifiable risk factor for cardiovascular morbidity and mortality. Despite the availability of numerous pharmacologic treatments, many patients do not achieve guideline-recommended blood pressure targets. Therefore, renal sympathetic denervation (RDN), a process in which catheter-directed techniques are used to ablate portions of the renal artery to reduce sympathetic activity, has been extensively investigated as a complementary and nonpharmacologic approach for the treatment of arterial hypertension. This review seeks to discuss the pathophysiological rationale of this strategy, to survey its history and development, and to highlight the current clinical evidence and possible future directions of its employment. In sum, RDN has demonstrated itself to be a safe and well-tolerated endovascular intervention that can reliably contribute to improved blood pressure control and, perhaps ultimately, significant cardiovascular prognosis.
Collapse
Affiliation(s)
- Kenneth Guber
- Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ajay J. Kirtane
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York, USA
- Cardiovascular Research Foundation, New York, New York, USA
| |
Collapse
|
12
|
Huang H, Cheng H, Chia Y, Li Y, Van Minh H, Siddique S, Sukonthasarn A, Tay JC, Turana Y, Verma N, Kario K, Wang T. The role of renal nerve stimulation in percutaneous renal denervation for hypertension: A mini-review. J Clin Hypertens (Greenwich) 2022; 24:1187-1193. [PMID: 36196464 PMCID: PMC9532907 DOI: 10.1111/jch.14554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 07/11/2022] [Accepted: 07/18/2022] [Indexed: 11/19/2022]
Abstract
Recent trials have demonstrated the efficacy and safety of percutaneous renal sympathetic denervation (RDN) for blood pressure (BP)-lowering in patients with uncontrolled hypertension. Nevertheless, major challenges exist, such as the wide variation of BP-lowering responses following RDN (from strong response to no response) and lack of feasible and reproducible peri-procedural predictors for patient response. Both animal and human studies have demonstrated different patterns of BP responses following renal nerve stimulation (RNS), possibly related to varied regional proportions of sympathetic and parasympathetic nerve tissues along the renal arteries. Animal studies of RNS have shown that rapid electrical stimulation of the renal arteries caused renal artery vasoconstriction and increased norepinephrine secretion with a concomitant increase in BP, and the responses were attenuated after RDN. Moreover, selective RDN at sites with strong RNS-induced BP increases led to a more efficient BP-lowering effect. In human, when RNS was performed before and after RDN, blunted changes in RNS-induced BP responses were noted after RDN. The systolic BP response induced by RNS before RDN and blunted systolic BP response to RNS after RDN, at the site with maximal RNS-induced systolic BP response before RDN, both correlated with the 24-h ambulatory BP reductions 3-12 months following RDN. In summary, RNS-induced BP changes, before and after RDN, could be used to assess the immediate effect of RDN and predict BP reductions months following RDN. More comprehensive, large-scale and long term trials are needed to verify these findings.
Collapse
Affiliation(s)
- Hui‐Chun Huang
- Cardiovascular Center and Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
- Graduate Institute of Epidemiology and Preventive MedicineCollege of Public HealthNational Taiwan UniversityTaipeiTaiwan
| | - Hao‐min Cheng
- Department of MedicineTaipei Veterans General HospitalMedical Education and ResearchNational Yang‐Ming UniversityTaipeiTaiwan
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Healthcare and Medical SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Yan Li
- Department of Cardiovascular MedicineShanghai Institute of HypertensionShanghai Key Laboratory of HypertensionState Key Laboratory of Medical GenomicsNational Research Centre for Translational MedicineRuijin HospitalShanghai Jiaotong University School of MedicineShanghaiChina
| | - Huynh Van Minh
- Department of CardiologyUniversity of Medicine and PharmacyHue UniversityHue CityThua Thien‐HueVietnam
| | - Saulat Siddique
- Department of CardiologyFatima Memorial HospitalLahorePakistan
| | - Apichard Sukonthasarn
- Cardiology DivisionDepartment of Internal MedicineFaculty of MedicineChiang Mai UniversityChiang MaiThailand
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Yuda Turana
- Faculty of Medicine and Health SciencesAtma Jaya Catholic University of IndonesiaJakartaIndonesia
| | - Narsingh Verma
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineShimotsukeTochigiJapan
| | - Kazuomi Kario
- Department of PhysiologyKing George's Medical UniversityLucknowIndia
| | - Tzung‐Dau Wang
- Cardiovascular Center and Division of CardiologyDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
- Division of Hospital MedicineDepartment of Internal MedicineNational Taiwan University HospitalNational Taiwan University College of MedicineTaipeiTaiwan
| |
Collapse
|
13
|
Present Evidence of Determinants to Predict the Efficacy of Renal Denervation. Int J Hypertens 2022; 2022:5694127. [PMID: 35992203 PMCID: PMC9391193 DOI: 10.1155/2022/5694127] [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: 04/29/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
Sympathetic overactivation is one of the main contributors to development and progress of hypertension. Renal denervation (RDN) has been evidenced by series of clinical trials for its efficacy and safety to treat overactivated sympathetic nervous system induced diseases. However, the results were inconsistent and not all patients benefited from RDN. Appropriate patient selection and intraoperative factors to improve the efficacy of RDN need to be solved urgently. Over the decade, research studies on the correlations between indicators and the antihypertensive effects have been conducted and made a fairly well progress. Herein, we comprehensively reviewed the research studies on how to make RDN more predictable or improve the efficacy of RDN and summarized these potential indicators or devices which might be applied in clinical settings.
Collapse
|
14
|
Brain-heart communication in health and diseases. Brain Res Bull 2022; 183:27-37. [PMID: 35217133 DOI: 10.1016/j.brainresbull.2022.02.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 12/19/2022]
Abstract
Tight connections between the brain and heart have attracted a considerable amount of attention. This review focuses on the anatomical (extrinsic cardiac autonomic nervous system and intrinsic cardiac autonomic nervous system) and functional (neuroendocrine-heart axis and neuroimmune-heart axis) connections between the brain and heart, the linkage between central nervous system diseases and cardiovascular diseases, the harm of sympathetic hyperactivity to the heart, and current neuromodulation therapies. Depression is a comorbidity of cardiovascular diseases, and the two are causally related. This review summarizes the mechanisms and treatment of depression and cardiovascular diseases, providing theoretical evidence for basic research and clinical studies to improve treatment options.
Collapse
|
15
|
Xia Z, Han L, Pellegrino PR, Schiller AM, Harrold LD, Lobato RL, Lisco SJ, Zucker IH, Wang HJ. Safety and efficacy of renal denervation in patients with heart failure with reduced ejection fraction (HFrEF): A systematic review and meta-analysis. Heliyon 2022; 8:e08847. [PMID: 35141435 PMCID: PMC8814903 DOI: 10.1016/j.heliyon.2022.e08847] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 12/02/2021] [Accepted: 01/24/2022] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION A systematic analysis of clinical trials was performed in order to assess the effectiveness and risks of bilateral renal denervation (RDN) in patients with chronic heart failure with reduced ejection fraction (HFrEF). METHODS A systematic review was conducted of all clinical trials exploring the effectiveness of RDN in patients with HF who had reduced (<50%) EF. Primary outcomes were NYHA class, 6-min walk test, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, left ventricular ejection fraction (LVEF) and other cardiac parameters including left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVEDD), and left atrium diameter (LAD). Secondary outcomes were systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), glomerular filtration rate (GFR), and creatinine. RESULTS Seven studies were included in this analysis. From baseline to 6 months after RDN, the pooled mean NYHA class was decreased (mean difference [MD], -0.9; 95% confidence interval [CI], -1.6 to -0.2; P = 0.018), the mean 6-min walk test was increased (MD, 79.5 m; 95% CI, 26.9 to 132.1; P = 0.003), and the average NT-proBNP level was decreased (MD, -520.6 pg/mL; 95% CI, -1128.4 to 87.2; P = 0.093). Bilateral RDN increased the LVEF (MD, 5.7%; 95% CI, 1.6 to 9.6; P = 0.004), decreased the LVESD (MD, -0.4 cm; 95% CI, -0.5 to -0.2; P < 0.001), decreased the LVEDD (MD, -0.5 cm; 95% CI, -0.6 to -0.3; P < 0.001), and decreased the LAD (MD, -0.4 cm; 95% CI, -0.8 to 0; P = 0.045). In addition, RDN significantly decreased systolic BP (MD, -9.4 mmHg; 95% CI, -16.3 to -2.4; P = 0.008) and diastolic BP (MD, -4.9 mmHg; 95% CI, -9.5 to -0.4; P = 0.033), and decreased HR (MD, -4.5 bpm; 95% CI, -8.2to -0.9; P = 0.015). RDN did not significantly change GFR (MD, 7.9; 95% CI, -5.0 to 20.8; P = 0.230), or serum creatinine levels (MD, -7.2; 95% CI, -23.7 to 9.4; P = 0.397). CONCLUSION Bilateral RDN appears safe and well-tolerated in patients with HF. RDN improved the signs and symptoms of HF and slightly decreased systolic and diastolic BP without affecting renal function in the clinical trials performed to date.
Collapse
Affiliation(s)
- Zhiqiu Xia
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Li Han
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- College of Veterinary Medicine, Huazhong Agricultural University, Wuhan 430070, China
| | - Peter R. Pellegrino
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Alicia M. Schiller
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Logan D. Harrold
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Robert L. Lobato
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Steven J. Lisco
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Irving H. Zucker
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
| | - Han-Jun Wang
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Department of Cellular and Integrative Physiology, University of Nebraska Medical Center, Omaha, NE 68198, USA
- Corresponding author.
| |
Collapse
|
16
|
Kandzari DE. Catheter-Based Renal Denervation Therapy: Evolution of Evidence and Future Directions. Circ Cardiovasc Interv 2021; 14:e011130. [PMID: 34903035 DOI: 10.1161/circinterventions.121.011130] [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: 11/16/2022]
Abstract
Motivated by the persistence of uncontrolled blood pressure and its public health impact, the development and evaluation of device-based therapies for hypertension has advanced at an accelerated pace to complement pharmaceutical and lifestyle intervention strategies. Countering widespread interest from early studies, the lack of demonstrable efficacy for renal denervation (RDN) in a large, sham-controlled randomized trial motivated revision of trial design and conduct to account for confounding variables of procedural technique, medication variability, and selection of both patients and end points. Now amidst varied trial design and methods, several sham-controlled, randomized trials have demonstrated clinically meaningful reductions in blood pressure with RDN. With this momentum, additional studies are underway to position RDN as a potential part of standard therapy for the world's leading cause of death and disability. In parallel, further studies will address unresolved issues including durability of blood pressure lowering and reduction in antihypertensive medications, late-term safety, and impact on clinical outcomes. Identifying predictors of treatment effect and surveys of patient-reported outcomes and treatment preferences are also evolving areas of investigation. Aside from confirmatory studies of safety and effectiveness, these additional studies will further inform patient selection, expand experience with RDN in broader populations with hypertension, and provide guidance to how RDN may be incorporated into treatment pathways.
Collapse
|
17
|
Li L, Hu Z, Xiong Y, Yao Y. Device-Based Sympathetic Nerve Regulation for Cardiovascular Diseases. Front Cardiovasc Med 2021; 8:803984. [PMID: 34957267 PMCID: PMC8695731 DOI: 10.3389/fcvm.2021.803984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 11/22/2021] [Indexed: 12/05/2022] Open
Abstract
Sympathetic overactivation plays an important role in promoting a variety of pathophysiological processes in cardiovascular diseases (CVDs), including ventricular remodeling, vascular endothelial injury and atherosclerotic plaque progression. Device-based sympathetic nerve (SN) regulation offers a new therapeutic option for some CVDs. Renal denervation (RDN) is the most well-documented method of device-based SN regulation in clinical studies, and several large-scale randomized controlled trials have confirmed its value in patients with resistant hypertension, and some studies have also found RDN to be effective in the control of heart failure and arrhythmias. Pulmonary artery denervation (PADN) has been clinically shown to be effective in controlling pulmonary hypertension. Hepatic artery denervation (HADN) and splenic artery denervation (SADN) are relatively novel approaches that hold promise for a role in cardiovascular metabolic and inflammatory-immune related diseases, and their first-in-man studies are ongoing. In addition, baroreflex activation, spinal cord stimulation and other device-based therapies also show favorable outcomes. This review summarizes the pathophysiological rationale and the latest clinical evidence for device-based therapies for some CVDs.
Collapse
Affiliation(s)
| | | | | | - Yan Yao
- National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Fu Wai Hospital, Beijing, China
| |
Collapse
|
18
|
Cai X, Shen Y, Yang Y, Wang W, Qian L, Cai J, Chi R, Yu S, Li K, Wei Z, Chen T, Fei Y, Han Y, Chen X, Liu M, Liu Y, Wang D, Jiang M, Li YG. Renal Denervation by Noninvasive Stereotactic Radiotherapy Induces Persistent Reduction of Sympathetic Activity in a Hypertensive Swine Model. J Am Heart Assoc 2021; 10:e020068. [PMID: 34369204 PMCID: PMC8475062 DOI: 10.1161/jaha.120.020068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background We have previously reported the feasibility of noninvasive stereotactic body radiotherapy (SBRT) as a novel approach for renal denervation. Methods and Results Herein, from a translational point of view, we assessed the antihypertensive effect and chronological evolution of SBRT‐induced renal nerve injury within 6 months in a hypertensive swine model. Hypertension was induced in swine by subcutaneous implantation of deoxycorticosterone acetate pellets in combination with a high‐salt diet. A single dose of 25 Gy with SBRT was delivered for renal denervation in 9 swine within 3.4±1.0 minutes. Blood pressure levels at baseline and 1 and 6 months post‐SBRT were comparable to control (n=5), whereas renal norepinephrine was significantly lower at 6 months (P<0.05). Abdominal computed tomography, performed before euthanasia and renal function assessment, remained normal. Standard semiquantitative histological assessment showed that compared with control (1.4±0.4), renal nerve injury was greater at 1 month post‐SBRT (2.3±0.3) and peaked at 6 months post‐SBRT (3.2±0.8) (P<0.05), along with a higher proportion of active caspase‐3–positive nerves (P<0.05). Moreover, SBRT resulted in continuous dysfunction of renal sympathetic nerves and low level of nerve regeneration in 6 months by immunohistochemistry analysis. Conclusions SBRT delivering 25 Gy for renal denervation was safe and related to sustained reduction of sympathetic activity by aggravating nerve damage and inhibiting nerve regeneration up to 6 months; however, its translation to clinical trial should be cautious because of the negative blood pressure response in the deoxycorticosterone acetate–salt hypertensive swine model.
Collapse
Affiliation(s)
- Xingxing Cai
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yichen Shen
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yuli Yang
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Wei Wang
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Li Qian
- Department of Pathology Affiliated Hospital of Nantong University China
| | - Jing Cai
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Runmin Chi
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Shunxuan Yu
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Keke Li
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Zhixing Wei
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Taizhong Chen
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yudong Fei
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yaqin Han
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Xiu Chen
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Ming Liu
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yifei Liu
- Department of Pathology Affiliated Hospital of Nantong University China
| | - Dengbin Wang
- Department of Radiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Mawei Jiang
- Department of Oncology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| | - Yi-Gang Li
- Department of Cardiology Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine China
| |
Collapse
|
19
|
Kandzari DE, Townsend RR, Bakris G, Basile J, Bloch MJ, Cohen DL, East C, Ferdinand KC, Fisher N, Kirtane A, Lee DP, Puckrein G, Rader F, Vassalotti JA, Weber MA, Willis K, Secemsky E. Renal denervation in hypertension patients: Proceedings from an expert consensus roundtable cosponsored by SCAI and NKF. Catheter Cardiovasc Interv 2021; 98:416-426. [PMID: 34343406 DOI: 10.1002/ccd.29884] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 07/15/2021] [Indexed: 12/19/2022]
Affiliation(s)
- David E Kandzari
- Interventional Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Raymond R Townsend
- Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - George Bakris
- Hypertension, University of Chicago Medicine, Chicago, Illinois, USA
| | - Jan Basile
- Cardiology, Medical University of South Carolina and Ralph H. Johnson VA Medical Center to Medical University of South Carolina, Charleston, South Carolina, USA
| | - Michael J Bloch
- Vascular Care, Renown Institute for Heart and Vascular Health, University of Nevada, Reno School of Medicine, Reno, Nevada, USA
| | - Debbie L Cohen
- Hypertension, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Cara East
- Cardiology, Baylor Heart & Vascular Hospital, Dallas, Texas, USA.,Vascular Intervention, Soltero CV Research Center, Texas A&M College of Medicine
| | - Keith C Ferdinand
- Preventive Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Naomi Fisher
- Hypertension, Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ajay Kirtane
- Interventional Vascular Therapy, Columbia University Irving Medical Center, New York, New York, USA
| | - David P Lee
- Interventional Cardiology, Stanford University, Stanford, California, USA
| | - Gary Puckrein
- The National Minority Quality Forum, Washington, District of Columbia, USA
| | - Florian Rader
- Hypertension Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Joseph A Vassalotti
- Clinical Professor, Icahn School of Medicine at Mount Sinai, National Kidney Foundation, New York, New York, USA
| | - Michael A Weber
- Cardiovascular Medicine, SUNY Downstate Medical Center, New York, New York, USA
| | - Kerry Willis
- National Kidney Foundation, New York, New York, USA
| | - Eric Secemsky
- Vascular Intervention, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| |
Collapse
|
20
|
Zhou H, Li Y, Xu Y, Liu H, Lai Y, Tan K, Liu X, Ou Z, Chen W, Du H, Liu Z, Yin Y. Mapping Renal Innervations by Renal Nerve Stimulation and Characterizations of Blood Pressure Response Patterns. J Cardiovasc Transl Res 2021; 15:29-37. [PMID: 34282540 DOI: 10.1007/s12265-021-10149-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/14/2021] [Indexed: 12/18/2022]
Abstract
Increased sympathetic nervous activity is one of main contributors to pathogenesis and progression of hypertension. Renal denervation (RDN) has been demonstrated as a potential therapy for treatment of hypertension; however, lack of indicators of intra-/post-procedure results in inconsistent clinical outcomes. Renal nerve stimulation (RNS), a simple and promising method, could evoke elevated blood pressure as an intraoperative indicator for RDN. But related researches on patterns of blood pressure responses to RNS are still incomplete. To investigate and categorize the phenotypes of blood pressure response to RNS and heart rate alteration before and after RNS, 24 Chinese Kunming dogs were used to perform RNS from bifurcation to ostium of renal arteries after angiography, and a total of 483 stimulated sites were complete. We identified five different patterns of blood pressure response to RNS in 483 stimulated sites, (1) continuous ascending and finally keeping steady above baseline (26.9%), (2) declining and then rising over baseline (11.8%), (3) declining and then rising but below baseline (14.5%), (4) fluctuating in the vicinity of baseline (39.5%), and (5) continuous declining and finally keeping steady below baseline (7.2%), and found no difference in RR intervals among five blood pressure responses before and after renal nerve stimulation. Renal nerve stimulation could elicit different patterns of blood pressure response, which could potentially assist in distinguishing sympathetic-excitatory sites and sympathetic-inhibitory sites from mixed nerve components, which might help to improve the efficacy of RDN.
Collapse
Affiliation(s)
- Hao Zhou
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Yidan Li
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Yanping Xu
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Hang Liu
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Yinchuan Lai
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Kunyue Tan
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Xueyuan Liu
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Zhenhong Ou
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Weijie Chen
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Huaan Du
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Zengzhang Liu
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China
| | - Yuehui Yin
- Department of Cardiology, Chongqing Cardiac Arrhythmias Therapeutic Service Center, The Second Affiliated Hospital of Chongqing Medical University, No. 288 Tianwen Avenue, Nan'an District, Chongqing, China.
| |
Collapse
|
21
|
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.
Collapse
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.)
| |
Collapse
|
22
|
Xue Q, Wang R, Wang L, Xiong B, Li L, Qian J, Hao L, Wang Z, Liu D, Deng C, Rong S, Yao Y, Jiang Y, Zhu Q, Huang J. Downregulating the P2X3 receptor in the carotid body to reduce blood pressure via acoustic gene delivery in canines. Transl Res 2021; 227:30-41. [PMID: 32554072 DOI: 10.1016/j.trsl.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 06/01/2020] [Accepted: 06/09/2020] [Indexed: 01/26/2023]
Abstract
The purinergic P2X3 receptor in the carotid body (CB) is considered a new target for treating hypertension, although approaches for targeted regulating P2X3 receptor expression are lacking. Here, we explored the feasibility of targeted P2X3 receptor down-regulation in CBs by localized low-intensity focused ultrasound (LIFU)-mediated gene delivery to reduce the blood pressure. Thirty-two Kunming canines were randomly assigned to the treatment group (n = 14), negative control group (n = 10), LIFU + cationic microbubbles group (n = 4), and LIFU-only group (n = 4). Plasmid-loaded cationic microbubbles were injected and bilateral CBs were irradiated with a LIFU-based transducer. Flow cytometry showed that 33.15% of transfected cells expressed the green fluorescent protein reporter gene. T7 endonuclease I assays showed an insertion-deletion rate of 8.30%. The P2X3 receptor mRNA- and protein-expression levels in CBs decreased by 56.31% and 45.10%, respectively, in the treatment group. Mean systolic (152.5 ± 3.0 vs 138.0 ± 2.9 mm Hg, P = 0.003) and diastolic (97.8 ± 1.5 vs 87.2 ± 2.3 mm Hg, P= 0.002) blood pressures reduced on day 14 in the treatment group, compared with the baseline values, whereas no effects were observed with LIFU treatment or cationic microbubbles injection alone. Canines treated with this strategy exhibited no local or systemic adverse events. Thus, LIFU-mediated gene delivery to CBs successfully modulated CB function and reduced blood pressure in a canine model, suggesting a new possibility for treating hypertension and further clinical translation.
Collapse
Affiliation(s)
- Qian Xue
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Ruiyu Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Liang Wang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Xiong
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lingjiao Li
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jun Qian
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Lan Hao
- Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing Medical University, Chongqing, China
| | - Zhigang Wang
- Chongqing Key Laboratory of Ultrasound Molecular Imaging, Chongqing Medical University, Chongqing, China
| | - Dichuan Liu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Changming Deng
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shunkang Rong
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yuanqing Yao
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yonghong Jiang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Que Zhu
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jing Huang
- Department of Cardiology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China; Institute of Ultrasound Imaging, Department of Ultrasound, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
| |
Collapse
|
23
|
DeLalio LJ, Sved AF, Stocker SD. Sympathetic Nervous System Contributions to Hypertension: Updates and Therapeutic Relevance. Can J Cardiol 2020; 36:712-720. [PMID: 32389344 DOI: 10.1016/j.cjca.2020.03.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 12/15/2022] Open
Abstract
The sympathetic nervous system plays a pivotal role in the long-term regulation of arterial blood pressure through the ability of the central nervous system to integrate neurohumoral signals and differentially regulate sympathetic neural input to specific end organs. Part 1 of this review will discuss neural mechanisms of salt-sensitive hypertension, obesity-induced hypertension, and the ability of prior experiences to sensitize autonomic networks. Part 2 of this review focuses on new therapeutic advances to treat resistant hypertension including renal denervation and carotid baroactivation. Both advances lower arterial blood pressure by reducing sympathetic outflow. We discuss potential mechanisms and areas of future investigation to target the sympathetic nervous system.
Collapse
Affiliation(s)
- Leon J DeLalio
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alan F Sved
- Department of Neuroscience, University of Pittsburgh, Pennsylvania, USA
| | - Sean D Stocker
- Department of Medicine, Renal-Electrolyte Division, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
| |
Collapse
|
24
|
Paton JFR. Denervated or Not? That Remains the Question for Renal Denervation. Hypertension 2019; 74:493-494. [PMID: 31327273 DOI: 10.1161/hypertensionaha.119.12779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Julian F R Paton
- From the Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland
| |
Collapse
|