Renal Denervation for Patients With Heart Failure

HomeCirculation: Heart FailureVol. 14, No. 3Renal Denervation for Patients With Failure Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBRenal FailureMaking a Full Circle Marat Fudim, MD, MHS Paul A. Sobotka, MD Jonathan P. Piccini, Manesh R. PatelMD FudimMarat Fudim Correspondence to: MHS, Duke Clinical Research Institute, Durham, NC 27715. Email E-mail Address: [email protected] https://orcid.org/0000-0002-8671-7007 Division of Cardiology, Department Medicine, University, (M.F., J.P.P., M.R.P.). Search more papers by this author , SobotkaPaul Sobotka The Ohio State Columbus (P.A.S.). PicciniJonathan Piccini https://orcid.org/0000-0003-0772-2404 PatelManesh Patel Originally published12 Mar 2021https://doi.org/10.1161/CIRCHEARTFAILURE.121.008301Circulation: Failure. 2021;14:e008301This article is commentary on the followingRenal Sympathetic in Preserved Ejection FractionSee Article Kresoja and Rommel et alThe evolution renal denervation (RDN) has now come full circle. When catheter-based RDN was first conceived, it explored as treatment overcome diuretic resistance patients with heart failure (HF). In fact, HF identified primary target population original patent.1 Indeed, first-in-man study Australia 2007 selected an elevated blood pressure. Elevated pressure chosen safety purposes given antihypertensive effect observed surgical sympathectomies. While mild observed, most dramatic acute drop arterial (unpublished data from Howard Levin 2007.). As result, company pivoted hypertension instead (ARDIAN, Inc, later Medtronic).The procedure (irrespective applied technique) leads destruction nerves surrounding vasculature. Renal connect central nervous system kidney (efferent) back (afferent). early days, uncoupling kidneys efferent sympathetic seen therapeutic mechanism resultant improved sodium water handling benefit. Understanding complex interplay between since evolved, evidence suggests that afferent play important role than previously realized pathophysiology various cardiometabolic diseases. It likely majority reduce cardiovascular risk derived nerve ablation (Figure). improves tone through fibers (measured reduced noradrenalin spillover), but also reduces global via effects modulation autonomic muscle activity, baroreflex sensitivity, rate variability).2Download figureDownload PowerPointFigure. Contribution preserved ejection fraction (HFpEF). induces number detrimental processes increased tone. output augmented input kidneys. consequence flow includes venous constriction, cardiac hypertrophy arrhythmias, endothelial dysfunction, insulin skeletal muscle, contributing development diabetes metabolic syndrome. sum total these does enable HFpEF.Over last 2 decades, shown be effective hypertension,3 accumulating benefits other sympathetically mediated conditions. Beneficial physiology associated pathologies include reduction rate, decreased resistance, function, improvement sleep apnea, burden tachyarrhythmia.4,5 conceivable additionally structural functional changes studies set up successful strategy HF.6 particular, (HFpEF) might especially attractive vast HFpEF defined driven comorbidities such hypertension, atrial fibrillation, chronic disease, diabetes, etc To date, efforts have focused fraction, totality function biomarker profile.In present issue Circulation: Failure, al7 best date. authors compared hemodynamic physiological who underwent at their center without European Society Cardiology diagnostic criteria (clinical, laboratory, echocardiographic). Of 164 left ventricular ≥50% available natriuretic peptide level, 99 (60%) met plus HFpEF. That remarkably high number, suggesting was/is commonly performed under disguise hypertension. detailed phenotyping echocardiography magnetic resonance imaging before after RDN, which allowed investigation myocardial/vascular specific parameters 6 months (radiofrequency or ultrasound based).Patients had worse phenotype aortic distendibility, higher variability, diastology, myocardial work indices. After dropped similarly (−9 [−17 −2] mm Hg) no-HFpEF (−8 [−16 Hg; P=0.47). greater NT-proBNP (N-terminal pro-B-type peptide) New York Association class symptoms. Despite overall comparable change systolic diastolic saw distendibility (cardiac power output) direct measures were not obtained, many are attributed activity control (ventriculo-arterial coupling). noted authors, some if could potentially explained volume loading vasculature rest increase splanchnic vascular pooling.8 There notable limitations. Observational nonrandomized regression mean bias. Regression bias affects only HFpEF-specific end points evaluated authors. Further, evaluation lacked invasive (rest exercise), key point based validated yet fully reliable single beat estimation pressure-volume relationship.Despite limitations analysis, al provides encouraging suggest appears safe (no excessive hypotension) positive performance potential improvement. improvements those appeared independent pressure, underscores inadequacy solitary marker technical success plurality mechanisms systemic effects.As current investigations fibrillation wrapping up, particular appear next frontier RDN. Hypertension remains common comorbidity both fibrillation. Thus, unreasonable underlying impact disease states. However, protection may differ disorders. HFpEF, extend beyond facilitating loss drive, decongestion signals recurrent arrhythmia improve rates when occur. clinical overlap favorably all 3 overlapping conditions.The challenges hand will toSelect right patient: (and profile) benefit RDN? One hypothesize redistribution (ambulatory significant fluid overload) overload (more hospitalized failure).9–11Select design: one reasons initial therapy because relatively easy measure BP surrogate closely linked outcomes. Unfortunately, selection so simple task even less Careful objective subjective help determine ideal design minimize need large, traditional outcomes trial.12Select intervention: choice modality versus ultrasound, etc) question selective Our understanding anatomy variability fiber composition evolving concepts/technologies targeted approach ablation.13 Accumulating presence subpopulations stimulated raise, change, lower Unselective (global) blunt benefits. Whether element incomplete either safer beneficial deliberate circumferential interesting question. Proper assessment adverse events mode critical future trials upstream exhibit profound predominant blockade.14,15In summary, predominantly studied physiologically there large unmet need, paired clear path toward regulatory approval. once efficacy established HF(pEF) possibly promise.Disclosures Dr supported American Grant 17MCPRP33460225, NIH T32 grant 5T32HL007101, Mario Family Award, Translating Health Award receives consulting fees AxonTherapies, Daxor, Galvani. consults V-Flow Medical. reports receiving research grants Boston Scientific Abbott Medtronic Abbvie. HeartFlow, Bayer, Janssen, National Heart, Lung, Blood Institute being advisory board Janssen.FootnotesThe opinions expressed necessarily editors Association.For Disclosures, see page 310.Correspondence marat.[email protected]eduReferences1. 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Boortz-Marx RL, Ganesh DeVore Rogers JG, Coburn Johnson I, Coyne BJ, Splanchnic block failure.JACC 8:742–752. 10.1016/j.jchf.2020.04.010CrossrefMedlineGoogle Scholar15. WS, Green CL, Hernandez AF, MR. failure.Circulation. 138:951–953. 10.1161/CIRCULATIONAHA.118.035260LinkGoogle Scholar Previous Back top Next FiguresReferencesRelatedDetailsRelated articlesRenal FractionKarl-Patrik Kresoja, al. 2021;14 March 2021Vol Issue 3Article InformationMetrics Download: 1,130 © 2021 Association, Inc.https://doi.org/10.1161/CIRCHEARTFAILURE.121.008301PMID: 33706548 publishedMarch 12, Keywordsheart failureEditorialskidneyblood pressurePDF download SubjectsCardiomyopathyHeart