Effects of Renal Denervation vs Sham in Resistant Hypertension After Medication Escalation: Prespecified Analysis at 6 Months of the RADIANCE-HTN TRIO Randomized Clinical Trial

Importance

Although early trials of endovascular renal denervation (RDN) for patients with resistant hypertension (RHTN) reported inconsistent results, ultrasound RDN (uRDN) was found to decrease blood pressure (BP) vs sham at 2 months in patients with RHTN taking stable background medications in the Study of the ReCor Medical Paradise System in Clinical Hypertension (RADIANCE-HTN TRIO) trial.

Objectives

To report the prespecified analysis of the persistence of the BP effects and safety of uRDN vs sham at 6 months in conjunction with escalating antihypertensive medications.

Design, Setting, and Participants

This randomized, sham-controlled, clinical trial with outcome assessors and patients blinded to treatment assignment, enrolled patients from March 11, 2016, to March 13, 2020. This was an international, multicenter study conducted in the US and Europe. Participants with daytime ambulatory BP of 135/85 mm Hg or higher after 4 weeks of single-pill triple-combination treatment (angiotensin-receptor blocker, calcium channel blocker, and thiazide diuretic) with estimated glomerular filtration rate (eGFR) of 40 mL/min/1.73 m2 or greater were randomly assigned to uRDN or sham with medications unchanged through 2 months. From 2 to 5 months, if monthly home BP was 135/85 mm Hg or higher, standardized stepped-care antihypertensive treatment starting with aldosterone antagonists was initiated under blinding to treatment assignment.

Interventions

uRDN vs sham procedure in conjunction with added medications to target BP control.

Main Outcomes and Measures

Six-month change in medications, change in daytime ambulatory systolic BP, change in home systolic BP adjusted for baseline BP and medications, and safety.

Results

A total of 65 of 69 participants in the uRDN group and 64 of 67 participants in the sham group (mean [SD] age, 52.4 [8.3] years; 104 male [80.6%]) with a mean (SD) eGFR of 81.5 (22.8) mL/min/1.73 m2 had 6-month daytime ambulatory BP measurements. Fewer medications were added in the uRDN group (mean [SD], 0.7 [1.0] medications) vs sham (mean [SD], 1.1 [1.1] medications; P = .045) and fewer patients in the uRDN group received aldosterone antagonists at 6 months (26 of 65 [40.0%] vs 39 of 64 [60.9%]; P = .02). Despite less intensive standardized stepped-care antihypertensive treatment, mean (SD) daytime ambulatory BP at 6 months was 138.3 (15.1) mm Hg with uRDN vs 139.0 (14.3) mm Hg with sham (additional decreases of -2.4 [16.6] vs -7.0 [16.7] mm Hg from month 2, respectively), whereas home SBP was lowered to a greater extent with uRDN by 4.3 mm Hg (95% CI, 0.5-8.1 mm Hg; P = .03) in a mixed model adjusting for baseline and number of medications. Adverse events were infrequent and similar between groups.

Conclusions and Relevance

In this study, in patients with RHTN initially randomly assigned to uRDN or a sham procedure and who had persistent elevation of BP at 2 months after the procedure, standardized stepped-care antihypertensive treatment escalation resulted in similar BP reduction in both groups at 6 months, with fewer additional medications required in the uRDN group.

Trial Registration

ClinicalTrials.gov Identifier: NCT02649426.

Stereotactic radiosurgery for ablation of ventricular tachycardia in the setting of electrical storm

Funding Acknowledgements

Type of funding sources: None.

Introduction

Stereotactic body radiotherapy (SBRT) has been reported as a safe and efficient therapy to treat refractory VT despite optimal medical treatment and/or catheter ablation (CA). However data in the setting of ES are lacking.

Objectives

The aim of this study was to assess the clinical outcomes associated with SBRT in the setting of ES.

Methods

This retrospective study included patients who underwent SBRT in the setting of ES from March 2019 to March 2021 in one tertiary center (CHU Lille). Target volume was delineated according to a predefined workflow. The efficacy was assessed with the following endpoints: sustained VT recurrence, VT reduced with ATP or ICD shock.

Results

17 patients underwent SBRT to treat refractory VT in the setting of ES (Mean age: 67±12.8, 59% presenting ischemic heart disease, mean LVEF: 33.7± 9.7%). After a median follow-up of 7 [5; 16] months, a reduction in VT burden was observed in all patients after a 6-week blanking period. 6 patients presented an increase of the VT burden from week 2 to week 6 following SBRT despite an initial reduction of VT burden. No patient experienced ICD shocks beyond 6 weeks.

Conclusion

SBRT is efficient in treating recurrent VT in the setting of ES with failure and/or contraindication to CA. One third of patient present a transient increase in VT burden during a 6 weeks blanking period. Therefore, VT tolerance should be integrated as part of an action plan defined upstream to SBRT for each patient.

Pulmonary Valve Replacement and Redo Pulmonary Valve Replacement via Ministernotomy - How to do it

Minimally invasive cardiac surgery is mainly dedicated to acquired left-sided valve diseases. Ministernotomy is widely used for aortic valve repair or replacement, whereas pulmonary valve repair via this approach has been reported only recently. This article aims to describe the use of ministernotomy for pulmonary valve replacement in adult congenital patients.

The natural history of a family with aortic dissection associated with a novel ACTA2 variant

Disease-causing heterozygous variants in the ACTA2 gene cause an autosomal dominant heritable thoracic aortic disease (HTAD) with thoracic aortic aneurysm and dissection as main phenotype, and occasional extravascular abnormalities such as livedo reticularis. ACTA2-HTAD accounts for an important part of non-syndromic HTAD, with detection rates varying between 1.5-21% according to different studies. A consensus statement for the screening and management of patients with pathogenic ACTA2 variants has been recently published by the European reference network for rare vascular diseases (VASCERN). However, management of ACTA2 patients is often challenged by extremely variable inter- and intra-familial clinical courses of the disease. Here we report a family harboring a disease-causing ACTA2 variant. The proband and two siblings presented with acute type A aortic dissection and rupture involving nondilated aortic segments before the age of 30. Their mother died at 49 years-old from type B aortic dissection and rupture. Genetic testing revealed the heterozygous novel p.(Pro335Arg) variant in the ACTA2 gene in the proband and in the affected siblings. The clinical history of this family highlights the difficulty of adopting effective prevention strategies in ACTA2 patients.

Assessment of aortic regurgitation mechanism with cardiac magnetic resonance: an echocardiography comparative study

Funding Acknowledgements

Type of funding sources: None.

Background

Aortic regurgitation (AR) quantification still remains challenging and requires an integrated approach. AR mechanism is one key parameter to take into account to assess its severity and repairability, and thus help to guide surgical decision. Although Cardiac Magnetic Resonance (CMR) has a growing interest in AR quantification, its performance to identify aortic AR mechanism has never been studied.

Purpose

We intended to define CMR Performance in this setting, by using echocardiography as reference.

Methods

AR mechanism was systematically evaluated in sixty-seven patients (81% male, mean age 46 ± 20 years) with chronic AR using CMR, and compared to transthoracic (TTE) and transesophageal (TEE) echocardiography as gold standard. AR were categorized as follows: type 1, aortic dilatation; type 2, Cusp prolapse; type 3, restrictive cusp motion. Jet direction, number of cusps and calcification (1 = no calcification, 2 = spots, 3 = big calcification interfering with cusp motion and 4 = Extensive with restricted cusp motion) were also evaluated.

Results

At TTE/TEE, mechanisms of AR were type 1 in 56 (83.5%), type 2 in 33 (49.2%), type 3 in 24 (35%). Agreement between TTE/TEE and CMR was modest, with respectively 74.6% (k= 0.4), 79.1% (k = 0.58) and 74.6% (k = 0.44). Bicuspid aortic valve was found in 44 (65.7%) patients at TTE/TEE, agreement with CMR was excellent, 98.5% (k = 0.97).  Jet was directed to the mitral valve in 42 (62.7%), at the inter ventricular septum in 12 (17.9%), and central in 13 (19.4%). Agreement with CMR was correct, respectively 80% (k = 0,6), 88% (k = 0.62) and 83.5% (K= 0.52). Calcification extension was 1 in 26 (38.8%), 2 in 25 (37.3%), 3 in 11 (16.4%) and 4 in 5 (7.5%). Agreement with CMR was poor, 44.7% (K= 0.28).

Conclusion

Accuracy between CMR and TTE/TEE to evaluate chronic AR mechanism and repairability was modest, with lower performance to define calcification extension.

Abstract Figure. AR classification TTE/TEE vs CMR

Utility of 3-dimensional transoesophageal echocardiography for mitral annular sizing in transcatheter mitral valve replacement procedures: a cardiac computed tomography comparative study

Funding Acknowledgements

Type of funding sources: None.

Background.  3-dimensional transoesophageal echocardiography (3D-TEE) is frequently used as an initial screening tool in the evaluation of patients who are candidates to Transcatheter Mitral Valve Replacement (TMVR). However, little is known about the imaging correlation with the gold-standard computed tomography (CT) imaging. We aimed at testing the quantitative differences between these two modalities and finding the best 3D-TEE parameters for TMVR screening.

Methods. We included 57 patients referred to our Heart Valve Clinic for TMVR with prostheses specifically designed for the mitral valve. Mitral annulus (MA) analyses were performed using commercially available software in 3D-TEE and CT.

Results. 3D-TEE was feasible in 52 patients (91%). Although 3D-TEE measurements were slightly lower than in CT, both measurements of projected MA area and perimeter showed excellent correlation with small differences between the two modalities (r = 0.88 and r = 0.92 respectively, p < 0.0001). Correlations were significant but lower for MA diameters (r = 0.68 to 0.72, p < 0.0001) and mitro-aortic angle (r = 0.53, p = 0.0001). ROC curve analyses showed that 3D-TEE had a good ability to predict TMVR screening success defined by constructors based on CT measurements with a range of 12.9 to 15cm² for MA area (AUC = 0.88-0.91, p < 0.0001), 128 to 139mm for MA perimeter (AUC = 0.85-0.91, p < 0.0001), 35 to 39mm for anteroposterior diameter (AUC = 0.79-0.84 p < 0.0001) and 37 to 42mm for posteromedial-anterolateral diameter (AUC = 0.81-0.89, p < 0.0001) (Figure 1). Conclusion. 3D-TEE measurements of MA dimensions display strong correlation with CT measurements in patients undergoing TMVR screening process. 3D-TEE should be proposed as a reasonable alternative to CT in this vulnerable population.

Abstract Figure.