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DCS Årsmøde 2011 Renal nerve ablation in the management of systemic hypertension Henning Kelbæk DSC 2011 History - Cutting of the great splanchnic nerve (renal denervation) induced ipsilateral diurese (Bernard 1859) Electric stimulation of the peripheral cut end (renal sympathetic stimulation) induced ipsilateral anti-diurese - Renal denervation is associated with increased renal blood flow (Starling 1908) - Renal sympathetic nerve activity: decreases renal blood flow increases Renin secretion rate increases tubular sodium reabsorption Hypertension An insidious disease Background - Increased SA is common in essential hypertension - Sympathectomy reduces blood pressure efficiently - The prevalence of hypertension is appr 10% in DK - Long-term complications are stroke, MI, renal failure - In >95% of all cases the hypertension is essential - In some patients the blood pressure cannot be controlled despite treatment with 5 different drugs N Engl J Med 2009:361;9 Renal Nerve Ablation team, Rigshospitalet - Cardiology Clinic: Lia E Bang, Mikael Sander, Jesper Hastrup Svendsen, Henning Kelbæk - Nephrology Clinic Anne-Lise Kamper, Bo Feldt-Rasmussen Renal Denervation • Catheter based transmural ablation • Disruption of renal sympathetic nervous innervation Symplicity Catheter • Can be introduced percutaneously into the renal arteries • Delivers radiofrequency energy • Can ablate both efferent and afferent renal nerves Targeting Renal Nerves • Nerves arise from T10-L2 • The nerves arborize around the artery and primarily lie within the adventitia Vessel Lumen Media Adventitia 10 Renal Nerves Lancet 2009:373;1275-81 Inclusion criteria: - BP (office) > 160 on 3 drugs (incl. one diuretic) or - Intolerance to medication Exclusion criteria: Secondary cause of hypertension GFR < 45 ml/min/1.73m2 Type 1 DM PM/ICD Medical treatment (such as warfarin) Renovascular disease Lancet 2009;373:1275-81 50 patients (5 excluded due to renal vascular causes) Office blood pressure prior: 177/101 Mean 4.7 anti-hypertension medications - 96 % ACEI or AT2A or both - 76 % betablocker - 69 % calcium antagonist - 18 % direct vasodilators - 96 % diuretics Lancet 2009;373:1275-81 Trial profile Lancet 2009;373:1275-81 BP at 1 month: -14/-10 BP at 3 month: -21/-10 BP at 6 month: -22/-11 BP at 12 month: -27/-17 13 % non-responders Lancet 2009;373:1275-81 Ablation lesions: 4.2 (right) and 3.7 (left Renal Artery) Pain while energy administration Mean reduction of renal NA spillover: 47 % (n = 10) Angiogram (day 14-30; n 18): no stenosis MRI (6 month; n = 14): no irregularities 1 renal artery dissection (prior to ablation) 1 femoral artery pseudoaneurysm Lancet 2009;373:1275-81 Case report Change in kidney NE N Engl J Med 2009:361;932-4 Case report Change in whole-body NE N Engl J Med 2009:361;932-4 Case report Change in sympathetic activity N Engl J Med 2009:361;932-4 24 centres: 190 patients screened 106 included: - 52 renal denervation - 54 controls Lancet 2010;376:1903-09 Trial profile Lancet 2010;376:1903-09 Lancet 2010;376:1903-09 Change in blood pressure Lancet 2010;376:1903-09 Change in renal function Lancet 2010;376:1903-09 Data analysers were not masked to treatment assignment Primary endpoint: Change in seated office-based measurement of systolic blood pressure at 6 months Lancet 2010;376:1903-09 Symplicity Catheter Catheter Tip Features 5mm Flexible Tip (self-orienting) 12mm Deflectable Shaft Catheter Handle Features Deflect tip by pulling lever towards back of handle Straighten tip by pushing lever towards front of handle Shaft & electrode can rotate independent from handle body Renal Angiogram 29 Eligible Anatomy: • Absence of flow limiting obstructions • Diameter ≥ 4mm in targeted area Targeting Renal Nerves • Treat distal to proximal • 4-6 focal treatments • 2 min per treatment • ≥ 5 mm between locations • Stable, unique locations • Circumferential coverage • Common strategy (dependent on renal anatomy): • Distal: Inferior and inferolateral locations • Proximal: Superior and superolateral locations • Avoid purely lateral treatments (possible electrode movement with respiration) • PULL, ROTATE, ASSESS new location and prior treatment site 30 Case 20-år gammel HF-elev henvist til renal ablation for hypertension Disp: Farmor har hypertension. Ingen med hypertension i ungdommen Anamnese: Essentiel hypertension siden 11-års-alderen Problemer med bivirkninger af diverse præpararter Dårlig medicin compliance Medicin: Centyl m/KCl 2.5 mg x 1 Adalat Oros 60 mg x 1 Corodil 20 mg x 1 Objektivt:: Blodtryk 160/100 på begge arme St.c. & p. : i.a. Normale femoralispulse EKG: i.a. Patienter med essentiel hypertension - hvis blodtryk ikke kan kontrolleres trods med mindst 3 antihypertensiva behandling - som har uacceptable bivirkninger af den behandling medicinske kan henvises til Hjertecentrets visitation, Rigshospitalet med angivelse af - Kort anamnese med indikation - Døgn-blodtryk monitorerings svar - P-kreatinin - Medicin liste Spørgsmål: Hvad er det sikreste tegn på forår ? Spørgsmål: At pigerne går Hvad er sandaler det sikreste med tegn på forår ?