Successful single-sided renal denervation in drug-resistant hypertension and ventricular tachycardia

Renal denervation for the treatment of ventricular arrhythmias: A systematic review and meta-analysis

INTRODUCTION

Ventricular arrhythmias (VAs) are a major cause of morbidity and mortality in patients with heart disease. Recent studies evaluated the effect of renal denervation (RDN) on the occurrence of VAs. We conducted a systematic review and meta-analysis to determine the efficacy and safety of this procedure.

METHODS AND RESULTS

A systematic search of the literature was performed to identify studies that evaluated the use of RDN for the management of VAs. Primary outcomes were reduction in the number of VAs and implantable cardioverter-defibrillator (ICD) therapies. Secondary outcomes were changes in blood pressure and renal function. Ten studies (152 patients) were included in the meta-analysis. RDN was associated with a reduction in the number of VAs, antitachycardia pacing, ICD shocks, and overall ICD therapies of 3.53 events/patient/month (95% confidence interval [CI] = -5.48 to -1.57), 2.86 events/patient/month (95% CI = -4.09 to -1.63), 2.04 events/patient/month (95% CI = -2.12 to -1.97), and 2.68 events/patient/month (95% CI = -3.58 to -1.78), respectively. Periprocedural adverse events occurred in 1.23% of patients and no significant changes were seen in blood pressure or renal function.

CONCLUSIONS

In patients with refractory VAs, RDN was associated with a reduction in the number of VAs and ICD therapies, and was shown to be a safe procedure.

Renal Afferents

Purpose of Review

The etiology of hypertension, a critical public health issue affecting one in three US adults, involves the integration of the actions of multiple organ systems, including the renal sympathetic nerves. The renal sympathetic nerves, which are comprised of both afferent (sensory input) and efferent (sympathetic outflow) arms, have emerged as a major potential therapeutic target to treat hypertension and disease states exhibiting excess renal sympathetic activity.

Recent Findings

This review highlights recent advances in both clinical and basic science that have provided new insight into the distribution, function, and reinnervation of the renal sympathetic nerves, with a focus on the renal afferent nerves, in hypertension and hypertension-evoked disease states including salt-sensitive hypertension, obesity-induced hypertension, and chronic kidney disease.

Summary

Increased understanding of the differential role of the renal afferent versus efferent nerves in the pathophysiology of hypertension has the potential to identify novel targets and refine therapeutic interventions designed to treat hypertension.

The impact of renal sympathetic denervation on cardiac electrophysiology and arrhythmias: A systematic review of the literature

INTRODUCTION

Increased central sympathetic activity has a central role in the pathophysiology of cardiac arrhythmias. Despite the recently published negative results regarding the impact of renal sympathetic denervation (RDN) on resistant hypertension treatment, the beneficial effects of this intervention on cardiac arrhythmias seems to be promising. The aim of this systematic review is to analyze the existing data regarding the impact of RDN on atrial and ventricular arrhythmias.

METHODS

We systematically searched MEDLINE/PubMed database until January 2016 by using the algorithm "renal denervation AND (arrhythmias OR atrial OR ventricular)" without limitations. Additionally, the reference lists of the included studies and the relevant review studies were also manually searched.

RESULTS

Of the 467 studies yielded from the initial search, 34 were finally included in the systematic review (15 human studies, 18 animal studies and 1 study with both experimental and clinical data). The critical analysis of data from both human and animal studies indicates that RDN can modulate atrial and ventricular electrophysiological properties and exerts favorable effects in the development and recurrence of atrial and ventricular arrhythmias.

CONCLUSION

In this systematic review we showed that RDN reduces the burden of atrial and ventricular arrhythmias in various experimental and clinical settings. Appropriately designed randomized sham controlled trials are needed in order to elucidate the exact impact of RDN on arrhythmia management.

Renal denervation for treatment of ventricular arrhythmias: data from an International Multicenter Registry

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.

Renal artery sympathetic denervation: observations from the UK experience

Background

Renal denervation (RDN) may lower blood pressure (BP); however, it is unclear whether medication changes may be confounding results. Furthermore, limited data exist on pattern of ambulatory blood pressure (ABP) response—particularly in those prescribed aldosterone antagonists at the time of RDN.

Methods

We examined all patients treated with RDN for treatment-resistant hypertension in 18 UK centres.

Results

Results from 253 patients treated with five technologies are shown. Pre-procedural mean office BP (OBP) was 185/102 mmHg (SD 26/19; n = 253) and mean daytime ABP was 170/98 mmHg (SD 22/16; n = 186). Median number of antihypertensive drugs was 5.0: 96 % ACEi/ARB; 86 % thiazide/loop diuretic and 55 % aldosterone antagonist. OBP, available in 90 % at 11 months follow-up, was 163/93 mmHg (reduction of 22/9 mmHg). ABP, available in 70 % at 8.5 months follow-up, was 158/91 mmHg (fall of 12/7 mmHg). Mean drug changes post RDN were: 0.36 drugs added, 0.91 withdrawn. Dose changes appeared neutral. Quartile analysis by starting ABP showed mean reductions in systolic ABP after RDN of: 0.4; 6.5; 14.5 and 22.1 mmHg, respectively (p < 0.001 for trend). Use of aldosterone antagonist did not predict response (p > 0.2).

Conclusion

In 253 patients treated with RDN, office BP fell by 22/9 mmHg. Ambulatory BP fell by 12/7 mmHg, though little response was seen in the lowermost quartile of starting blood pressure. Fall in BP was not explained by medication changes and aldosterone antagonist use did not affect response.

Electronic supplementary material

The online version of this article (doi:10.1007/s00392-015-0959-4) contains supplementary material, which is available to authorized users.

Effects of catheter-based renal denervation on cardiac sympathetic activity and innervation in patients with resistant hypertension

OBJECTIVES

To investigate, whether renal denervation (RDN) has a direct effect on cardiac sympathetic activity and innervation density.

BACKGROUND

RDN demonstrated its efficacy not only in reducing blood pressure (BP) in certain patients, but also in decreasing cardiac hypertrophy and arrhythmias. These pleiotropic effects occur partly independent from the observed BP reduction.

METHODS

Eleven patients with resistant hypertension (mean office systolic BP 180 ± 18 mmHg, mean antihypertensive medications 6.0 ± 1.5) underwent I-123-mIBG scintigraphy to exclude pheochromocytoma. We measured cardiac sympathetic innervation and activity before and 9 months after RDN. Cardiac sympathetic innervation was assessed by heart to mediastinum ratio (H/M) and sympathetic activity by wash out ratio (WOR). Effects on office BP, 24 h ambulatory BP monitoring, were documented.

RESULTS

Office systolic BP and mean ambulatory systolic BP were significantly reduced from 180 to 141 mmHg (p = 0.006) and from 149 to 129 mmHg (p = 0.014), respectively. Cardiac innervation remained unchanged before and after RDN (H/M 2.5 ± 0.5 versus 2.6 ± 0.4, p = 0.285). Cardiac sympathetic activity was significantly reduced by 67 % (WOR decreased from 24.1 ± 12.7 to 7.9 ± 25.3 %, p = 0.047). Both, responders and non-responders experienced a reduction of cardiac sympathetic activity.

CONCLUSION

RDN significantly reduced cardiac sympathetic activity thereby demonstrating a direct effect on the heart. These changes occurred independently from BP effects and provide a pathophysiological basis for studies, investigating the potential effect of RDN on arrhythmias and heart failure.

Neuropeptide Y as an indicator of successful alterations in sympathetic nervous activity after renal sympathetic denervation

BACKGROUND

Renal sympathetic denervation (RSD) represents a safe and effective treatment option for certain patients with resistant hypertension and has been shown to decrease sympathetic activity. Neuropeptide Y (NPY) is a neurotransmitter that is co-released with norepinephrine and is up-regulated during increased sympathetic activity. The aim of the present study was to examine the effect of RSD on NPY and to analyze the association between changes in NPY levels and blood pressure reduction after RSD.

METHODS

A total of 150 consecutive patients (age 64.9 ± 10.2 years) from three clinical centers undergoing RSD were included in this study. Response to RSD was defined as an office systolic blood pressure (SBP) reduction of >10 mmHg 6 months after RSD. Venous blood samples for measurement of NPY were collected prior to and 6 months after RSD.

RESULTS

BP and NPY levels were significantly reduced by 23/9 mmHg (p = 0.001/0.001) and 0.24 mg/dL (p < 0.01) 6 months after RSD. There was a significant correlation between baseline SBP- and RSD-related systolic BP reduction (r = -0.43; p < 0.001) and between serum NPY baseline values and NPY level changes (r = -0.52; p < 0.001) at the 6-month follow-up. The BP response to RSD (>10 mmHg) was associated with a significantly greater reduction in NPY level when compared with BP non-responders (p = 0.001).

CONCLUSION

This study demonstrates an effect of RSD on serum NPY levels, a specific marker for sympathetic activity. The association between RSD-related changes in SBP and NPY levels provides further evidence of the effect of RSD on the sympathetic nervous system.

Retinal microperfusion after renal denervation in treatment-resistant hypertensive patients

BACKGROUND

High pulsatile pressure and flow in the arteries causes microvascular damage, and hence increased cardio-, and cerebrovascular complications. With advanced stages of hypertensive disease, an exaggerated pulsatile retinal capillary flow (RCF) has been shown, but data about interventional effect are missing.

METHODS

Fifty-one patients with true treatment-resistant hypertension (TRH) underwent renal denervation (RDN) using the Symplicity Flex(™) catheter and were followed for 12 months. RCF was assessed non-invasively using Scanning laser Doppler flowmetry (SLDF) before, 6 (6 M), and 12 (12 M) months after RDN. RCF was measured in systole and diastole and pulsed RCF (difference of RCF in systole minus diastole) was calculated. In addition, flicker light-induced vasodilation (representing vasodilatory capacity) was assessed.

RESULTS

Systolic and diastolic office blood pressure (BP) as well as 24-h ABPM decreased significantly 6 M and 12 M after RDN, compared to baseline values (all p < 0.001). There was a significant reduction of pulsed RCF 6 M (231 ± 81 versus 208 ± 68 AU, p = 0.046) and 12 M (194 ± 72 AU, p = 0.001) after RDN, whereas the mean RCF was unchanged. Moreover, there was a significant increase of flicker light-induced vasodilation after RDN (p = 0.043).

CONCLUSION

In hypertensive patients with TRH, we observed a decrease of pulsed RCF 6 M and 12 M after RDN and an increase of vasodilatory capacity, in parallel to decreases in BP and heart rate. The reduction of pulsed RCF after RDN implies a decrease of shear stress on the vascular wall by the pulsed blood flow. This and the increment of vasodilatory capacity suggest an improvement of retinal (and potentially cerebral) microcirculation.

Renal sympathetic denervation for treatment of ventricular arrhythmias: a review on current experimental and clinical findings

Ventricular arrhythmias (VAs) remain the major cause of mortality and sudden cardiac death (SCD) in almost all forms of heart disease. Despite so many therapeutic advances, such as pharmacological therapies, catheter ablation, and arrhythmia surgery, management of VAs remains a great challenge for cardiologists. Evidence from histological studies and from direct nerve activity recordings have suggested that increased sympathetic nerve density and activity contribute to the generation of VAs and SCD. It is well known that renal sympathetic nerve (RSN), either afferent component or efferent component, plays an important role in modulation of central sympathetic activity. We have recently shown that RSN activation by electrical stimulation significantly increases cardiac and systemic sympathetic activity and promotes the incidence of acute ischemia-induced VAs, suggesting RSN has a role in the development of VAs. Initial experience of RSN denervation (RDN) in patients with resistant hypertension showed that this novel and minimally invasive device-based approach significantly reduced not only kidney but also whole-body norepinephrine spillover. In addition, experimental studies find that left stellate ganglion nerve activity is significantly decreased after RDN. Based on these observations, it is reasonable to conclude that RDN may be an effective therapy for the management of VAs. Indeed, RDN has provided a protection against VAs in both animal models and patients. In this article, we review the role of the RSN in the generation of VAs and SCD and the role of RDN as a potential treatment strategy for VAs and SCD.

Neuraxial modulation for treatment of VT storm

In the hyperadrenergic state of VT storm where shocks are psychologically and physiologically traumatizing, suppression of sympathetic outflow from the organ level of the heart up to higher braincenters plays a significant role in reducing the propensity for VT recurrence. The autonomic nervous system continuously receives input from the heart (afferent signaling), integrates them, and sends efferent signals to modify or maintain cardiac function and arrhythmogenesis. Spinal anesthesia with thoracic epidural infusion of bupivicaine and surgical removal of the sympathetic chain including the stellate ganglion has been shown to decrease recurrences of VT. Excess sympathetic outflow with catecholamine release can be modified with catheter-based renal denervation. The insights provided from animal experiments and in patients that are refractory to conventional therapy have significantly improved our working understanding of the heart as an end organ in the autonomic nervous system.