Renal denervation as a synergistic tool for the treatment of polymorphic ventricular ectopic beats: A case report

INTRODUCTION

Ventricular ectopic beats (VEBs) are very common and often occur in hypertensive or obese individuals, as well as in patients presenting with either sleep apnea or structural cardiac disease. Sympathetic overactivity plays a crucial role in the development, continuation, and exacerbation of ventricular arrhythmias. Recent studies have reported the relevance of sympathetic activation in patients with ventricular arrhythmias and suggested a potential role for catheter-based renal denervation (RDN) in reducing the arrhythmic burden.

PATIENT CONCERNS

We describe a 38-year-old female symptomatic patient that at the time of presentation was complaining of fatigue in response to minor and medium efforts and not tolerating any physical activity, and episodes of tachycardia associated with dyspnoea, pre-syncope, and syncope.

DIAGNOSIS

She had a high incidence of polymorphic VEBs on 24-hour-Holter monitoring who also presented with left ventricular (LV) hypertrophy for which she was treated with bisoprolol 10 mg/d. The 24-hour-Holter on bisoprolol at baseline showed sinus rhythm with an average heart rate of 92 bpm. There were 44,743 isolated VEBs. A total of 2538 nonsustained ventricular tachycardia events were registered. Her cardiac magnetic resonance imaging showed an increase in LV diastolic diameter and impairment of the right ventricle.

INTERVENTIONS

The patient underwent endocardial ablation of the right ventricular outflow tract and the LV free lateral wall, and concomitantly underwent bilateral RDN.

OUTCOMES

Three months post-procedure, her 24-hour-Holter off medication demonstrated an average heart rate 72 bpm and a substantially reduced number of 2823 isolated monomorphic VEBs. Thus far, 18-months follow-up, she has been asymptomatic and doing physical exercises.

CONCLUSION

In our current patient, we used RDN as a synergistic method to attenuate the sympathetic overactivity, which is narrowly linked to VEBs appearance. Our case report highlighted that RDN may become a potential adjuvant treatment for VEBs in the future.

The Prevalence of Japanese Outpatients with Hypertension Who Meet the Definition of Treatment Resistant Hypertension and Are Eligible for Enrolment in Clinical Trials of Endovascular Ultrasound Renal Denervation

Objective A clinical trial (REQUIRE) was started to investigate the use of an ultrasound renal denervation system in the treatment of resistant hypertension (RHT). We analyzed the prevalence of patients who were eligible for inclusion in this cross-sectional study at the time of screening. Methods Nine-hundred ninety-nine consecutive hypertension (HT) patients who were treated in our hospital as outpatients were classified into the following categories: patients treated with at least 3 types of antihypertensive drugs including diuretic agents who were eligible for enrolment in SYMPLICITY HTN-Japan (SH-J) with an office systolic blood pressure (SBP) of ≥160 mmHg, who were ≤80 years of age, and an estimated glomerular filtration rate (eGFR) of ≥45 mL/min/1.73 m² (RHT-S); and patients who were treated similar medications and who were eligible for enrolment in REQUIRE, with an SBP of ≥150 mmHg, ≤75 years of age, and an eGFR of ≥40 mL/min/1.73 m² (RHT-R). We investigated the proportion of patients in each category. We also investigated HT patients (1,423 cases) who were enrolled in the Chikushi Anti-Hypertension Trial (CHAT), a research network that includes general practitioners. Results Eleven patients (1.1%) with RHT-S and 18 patients (1.8%) with RHT-R were identified. After the exclusion of patients with secondary HT and a diastolic blood pressure (DBP) of <90 mmHg (applied in REQUIRE), 5 patients (0.5%) with RHT-S and 4 patients (0.4%) with RHT-R remained. In the analysis of the CHAT study, only 2 (0.1%) patients with RHT-R remained. Conclusion The number of eligible patients in the REQUIRE trial was decreased, largely due to the strict age restriction and the new DBP limitation. The prevalence of eligible patients in REQUIRE was estimated to be approximately 0.5 to 0.8 times that in SH-J. Since patient enrollment will be difficult, drastic measures may be required to recruit eligible patients.

Clinical Outcome Following Radiofrequency Denervation for Refractory Sacroiliac Joint Dysfunction Using the Simplicity III Probe: A 12-Month Retrospective Evaluation

BACKGROUND

Sacroiliac joint syndrome (SIJ) is diagnosed in 10% to 25% of cases of lower back pain. The response to traditional radiofrequency (RF) denervation of the SIJ has being inconsistent. The Simplicity III RF probe (Neruotherm. Inc.) offers a novel treatment option.

OBJECTIVE

To evaluate the long-term clinical outcome (12 months) refractory SIJ syndrome in terms of pain intensity and functional improvement. A 50% reduction in intensity pain intensity (VAS) at 12 months was deemed clinically significant.

STUDY DESIGN

A 12-month retrospective observational evaluation all of adults treated with RF for refractory SIJ.

SETTING

Chronic pain management center.

METHODS

The medical records of all adults treated with this technique was retrospectively reviewed. The primary outcome was pain intensity scores (VAS) over a 12 months period; Secondary outcomes included Roland-Morris Functional scores (RMF), Brief Pain Inventory (BPI), general health assessment (Sf12), and patient satisfaction scores (GPI), which were recorded pre and post denervation.

REULTS

Pain Intensity improved by 4.7 points compared to pre-treatment representing a 61% reduction in pain at 12 months (n=11, P < 0.001). Significant improvements in (a) RMF (P < 0.01, W2 = 0.63 (large effect size); (b) BPI (P < 0.001, W2 = 0.72 (strong effect size); and (c) Sf12 (P < 0.01) were noted. Overall patients were satisfied with the outcome (GPI = 77.7%).

LIMITATIONS

The retrospective in nature of the study and the small sample size are limitations. As it was our policy to monitor the progress of the individuals since the introduction of this technique a reliable method of recording the baseline and outcome variables at each point of contact was in place. Access to a complete set of variables in all individuals over a 12-month period was therefore possible, which we feel contributes to the quality of the dataset.

CONCLUSION

By creating a consistent radiofrequency lesion between the sacral foramen and the SIJ will reliably capture the innervation to the SIJ with significant long-term clinical improvement. This technique should be considered earlier in the treatment algorithm of individuals suffering from SIJ symptoms.

Renal denervation for the treatment of hypertension: the Dutch consensus

Since 2010, renal denervation (RDN) is being performed in the Netherlands. To make sure RDN is implemented with care and caution in the Netherlands, a multidisciplinary Working Group has been set up by the Dutch Society of Cardiology (NVVC). The main aim of this Working Group was to establish a consensus document that can be used as a guide for implementation of RDN in the Netherlands. This consensus document was prepared in consultation with the Dutch Association of Internal Medicine (NIV) and the Dutch Society of Radiology (NVVR).

The efficacy and complications of laparoscopic presacral neurectomy in pelvic pain

OBJECTIVE

To evaluate the efficacy and complications of laparoscopic presacral neurectomy in pelvic pain.

METHODS

We reviewed records of 655 patients receiving laparoscopic conservative surgery and laparoscopic presacral neurectomy for diagnoses including adenomyosis with dysmenorrhea (n = 55), moderate and severe endometriosis with dysmenorrhea (n = 127), minimal and mild endometriosis with dysmenorrhea (n = 208), primary dysmenorrhea (n = 99), and chronic pelvic pain with or without pathologic disease (n = 166). Pain relief was evaluated at least 12 months postoperatively.

RESULTS

Pain relief was evaluated in 527 patients. Significant pain relief (no pain or mild pain requiring no medication) was found in 22 (52%) of 42 women with adenomyosis, in 75 (73%) of 103 with moderate to severe endometriosis with dysmenorrhea, in 123 (75%) of 164 with minimal to mild endometriosis with dysmenorrhea, in 64 (77%) of 83 with primary dysmenorrhea, and in 84 (62%) of 135 with chronic pelvic pain. There were four major complications (0.6%) that required further surgery, including injury of the right internal iliac artery (n = 1) and chylous ascites (n = 3). Three cases (0.5%) had laceration of the middle sacral vein controlled during laparoscopy. In addition, 485 (74%) of the 655 patients complained of constipation after laparoscopic presacral neurectomy, which was relieved easily by medication.

CONCLUSION

Presacral neurectomy can be performed safely and efficiently by laparoscopy and is a valuable alternative treatment for pelvic pain.

Comparison of laparoscopic presacral neurectomy and laparoscopic uterine nerve ablation for primary dysmenorrhea

OBJECTIVE

To compare laparoscopic presacral neurectomy and laparoscopic uterine nerve ablation for primary dysmenorrhea.

STUDY DESIGN

Sixty-eight patients with primary dysmenorrhea and a poor response to medical treatment were randomized into two groups. One group (33 patients) had laparoscopic presacral neurectomy (LPSN) and the other group (35 patients), laparoscopic uterine nerve ablation (LUNA).

RESULTS

There were no complications, and all the patients left the hospital within 24 hours after surgery. The efficacy of both surgical methods was almost equal (87.9% vs. 82.9%) at the 3-month postoperative follow-up visit, but the efficacy of LPSN was significantly better than that of LUNA (81.8% vs 51.4%) at the 12-month visit.

CONCLUSION

LPSN is a valid option for treating primary dysmenorrhea.

[Denervation of the wrist]

Fifty patients with wrist arthritis mainly secondary to a scaphoid pseudarthrosis (44%) or a Kienböck disease (22%) were operated on by one surgeon by "total" denervation. With a post-operative follow up of 5 years, pain, strength and range of movement were reviewed. Four complications are by means of stressed: one painful neuroma and three radial nerve paresthesiae. 72% of the patients had pain improvement with an average of 72 points on a scale of 100 points. Strength and range of movement were not significantly improved.

Changes in open-field behavior of rats following spinal nerve root sectioning

The open-field behavior of of 30 laboratory albino rats was measured after selective unilateral sectioning of either the L2, L3, L4 or L5 spinal nerve root using a novel abdominal entry. Although treated subjects displayed observable motor dysfunction of the operated limb, no differences were found in open-field ambulation, rearing, defecation or urination based either on the level of the sectioned nerve root or on the day the behavior was measured, suggesting that there was an effect of the treatment not measurable by standard statistical procedures, quite possibly due to the small sample size.