经导管去肾交感神经治疗顽固性高血压——附两例报告

目的探讨经导管去肾交感神经治疗顽固性高血压的疗效。方法入选2例典型顽固性高血压患者,于全麻下使用Symplicity导管及射频仪对患者行经导管去肾交感神经术,螺旋式消融肾动脉内膜4～6个点,术中消融指标:每点消融时间2min,消融功率8W,消融阻抗250～350Ω,消融温度50～60℃。结果经过术后短期随访,两例患者血压控制良好。病例1患者血压由术后163/102mm Hg缓慢下降,术后第2天晨起血压125/90mm Hg,逐渐减少降压药,术后1个月行动态血压监测全天血压均值为129/82mm Hg。病例2患者血压由术后151/102mm Hg缓慢下降,术后第2天晨起血压120/78mm Hg,逐渐减少降压药,术后1个月行动态血压监测全天血压均值为130/81mm Hg。结论使用Symplicity导管及射频仪进行经导管去肾交感神经术,是治疗顽固性高血压有效的新方法。     

经导管去肾脏交感神经治疗顽固性高血压的研究进展

<正>顽固性高血压是指经过生活方式改善,同时服用3种不同作用机制的降压药物(其中一种为利尿剂),或至少需要4种药物才能将收缩压和舒张压控制在目标水平(140/90 mm Hg)[1](1 mm Hg=0.133k Pa)。此类患者约占高血压病的10%左右,有较高的致残率和死亡率。因此,临床上一直在寻找新的治疗手段,希望能简单、安全、有效地控制顽固性高血压。肾脏交感神经系统在高血压中的作用已经被动物实验     

经皮导管射频消融去肾脏交感神经术治疗顽固性高血压的治疗现状

对于顽固性高血压患者,药物治疗不能较好地控制血压。肾脏交感神经活性增强是高血压发生、发展和靶器官损害的重要危险因素。近年来研究表明,经皮导管射频消融去肾交感神经术有助于治疗顽固性高血压。     

经导管肾交感神经去除术治疗顽固性高血压“无反应”原因

经导管肾交感神经去除术（renal sympathetic denervation,RSD）是近年兴起的一种治疗顽固性高血压的新方法.其基本原理是通过导管技术在肾动脉内膜用消融能量将肾动脉外膜的交感神经传入、传出纤维损伤,降低肾脏局部和全身交感神经活性,减少肾素释放,降低肾素-血管紧张素-醛固酮系统（RAAS）的活性,达到降低血压的目的.2013年4月欧洲心脏病学会首先将RSD治疗顽固性高血压列入专家共识,随后我国、美国、加拿大等相继发表专家共识来规范、指导该术在顽固性、难治性高血压患者中的应用[1-4].多中心临床研究发现,RSD可显著降低大部分顽固性高血压患者的收缩压、舒张压,在降压药物不变的情况下,RSD术后随访收缩压降低10 mm Hg（1mm Hg=0.133 kPa）以上为有效的标准,其有效率可达83％～93％以上[5].     

顽固性高血压获得革命性突破——肾动脉去交感神经消融(ARDN)新闻发布会

2012年3月3日,在第15届全国介入心脏病学论坛新闻发布会上,大会主席霍勇教授表示,治疗难治性高血压获得了新突破。"经皮导管肾脏交感神经射频消融术"通过射频消融术切断肾脏交感神经,且不影响其他腹部、骨盆或下肢神经支配,达到了在降压的同时避免严重并发症的发生。这一新技术是第一次在全国性心血管学术会议上发布的。通过微创去除部分肾动脉交感神经,用来治疗难治性高血压,是高血压治疗领域革命性的突破。     

经“子母”导管行去肾交感神经治疗顽固性高血压二例

目的 探讨经“子母冶导管行肾动脉交感神经治疗顽固性高血压的方法及疗效。方法 2例顽固性高血压患者,于局麻下使用7F肾动脉指引导管套5F消融导管对其行经导管去肾交感神经术,螺旋式消融肾动脉内膜4~ 6个点,术中消融指标：每点消融时间累积120 s,消融功率8 W,消融阻抗150 ~250 赘,消融温度45益。结果 2例血压由术前170 /100,175/98 mmHg降至术后出院时的130/82,134/84 mm Hg,术后4个月随访期间平均血压分别为130/82,134/84 mm Hg。 2例患者术后降压药的用量和种类减少。结论 使用“子母冶导管行经导管去肾交感神经术治疗顽固性高血压安全、有效。     

经导管射频消融去肾交感神经术的现状

许多研究已证实肾交感神经活动参与高血压的发病与维持,尤其在顽固性高血压中,因此选择性肾交感神经阻断被认为是治疗顽固性高血压的一个重要手段。经导管射频消融去肾交感神经术采用血管介入方法高选择性阻断支配肾脏传入和传出交感神经,从而降低肾交感活性达到降压的目的。该操作创伤小、并发症少、不影响生理性心肺功能,不损伤机体应激反应能力。经动物实验及临床实践发现其除了对于顽固性高血压有显著而持续的降压作用外,还有改善心功能、糖代谢、左室质量等效益。现就经导管射频消融去肾交感神经术的现状做一综述。     

肾脏交感神经射频消融术临床效应研究进展

肾脏交感神经射频消融术是一种新型的、选择性降低肾脏交感神经活性的介入治疗手段,最新研究证实不仅可显著降低顽固性高血压患者血压水平,而且临床研究发现还具有逆转左心室肥厚、改善心功能、改善胰岛素抵抗、降低尿蛋白等临床效应;现主要对肾脏交感神经射频消融术的临床效应及应用前景进行综述。     

经导管射频消融去肾脏交感神经术治疗难治性高血压研究现状

经导管射频消融去肾脏交感神经术是一种治疗难治性高血压的新兴非药物手段,作为一种微创手术,可以选择性消融肾交感神经纤维,阻断中枢交感神经和肾脏之间神经冲动的传递,从而达到控制血压的目的。目前关于经导管射频消融去肾脏交感神经术治疗难治性高血压的研究较多,但具有一定的争议性,现就经导管射频消融去肾脏交感神经术治疗高血压开展的有关研究现状做一综述。     

肾脏神经射频消融与心脏代谢综合征的研究进展

越来越多的研究证实,肾脏去交感神经化治疗可以降低顽固性高血压病患者的血压水平.顽固性高血压病患者常常伴随着一系列代谢障碍性疾病,如胰岛素抵抗、糖耐量异常及糖尿病等,构成了所谓的心脏代谢综合征.新近研究探讨了肾脏神经射频消融术治疗顽固性高血压病患者过程中,肾脏去交感神经化对心脏代谢综合征的影响.现就肾脏神经射频消融与心脏代谢综合征的研究进展做一综述.     

Interventionelle Therapiestrategien bei resistenter Hypertonie

For some years it has been possible to offer two new interventional treatment options to patients with resistant hypertension, stimulation of the carotid baroreceptors and radiofrequency ablation of the activated renal sympathetic nerve (renal denervation). With the first method the baroreceptors in the carotid sinus are stimulated after prior implantation of electrodes and a programmable pulse generator system. In the second method the renal sympathetic nerve fibers of the renal arteries are severed by minimally invasive catheter-aided radiofrequency ablation. Both therapy options achieve a systolic blood pressure reduction of at least 10?mmHg in 70?C90% of patients. With carotid sinus stimulation the average blood pressure was reduced on average by approximately 30?C35/15?C20?mmHg 12 months after implantation. Comparable data but with a slightly less pronounced tendency, have been published for renal denervation. Contraindications for carotid sinus stimulation are carotid stenosis of more than 50% or large carotid plaques and for radiofrequency ablation of renal sympathetic activity renal artery stenosis or a history of renal artery stenting and additionally patients with an estimated glomerular filtration rate (eGFR) under 45?ml/min.     

经皮肾交感神经射频消融术治疗难治性高血压:附2例报告

目的初步观察和探索经皮肾交感神经射频消融术治疗难治性高血压的疗效及操作方法。方法对2例难治性高血压患者实施经皮肾交感神经射频消融术并随访半年至一年,观察其血压及用药水平的变化。结果术后患者的血压较术前明显下降,降压药物种类及剂量亦减少。随访结果显示2例患者的高血压药物使用剂量和种类均有减少,其中1例患者血压控制在目标水平,1例未达到目标水平。结论难治性高血压患者通过经皮肾交感神经射频消融术使血压持续下降,用药剂量和种类减少。     

Modulation of Sympathetic Overactivity to Treat Resistant Hypertension

Purpose of Review

To review the role and evidence for sympathetic overactivity in resistant hypertension and review the therapies that have been studied to modulate the sympathetic nervous system to treat resistant hypertension, with a focus on non-pharmacologic therapies such as renal denervation, baroreflex activation therapy, and carotid body ablation.

Recent Findings

Based on the two best current techniques available for assessing sympathetic nerve activity, resistant hypertension is characterized by increased sympathetic nerve activity. Several device therapies, including renal denervation baroreflex activation therapy and carotid body ablation, have been developed as non-pharmacologic means of reducing blood pressure in resistant hypertension. With respect to renal denervation, the technologies for renal denervation have evolved since the unfavorable results from the HTN-3 study, and the revised technologies are being actively studied. Data from the first phase of the SPYRAL HTN Clinical Trial Program have been published. Results from the SPYRAL HTN-OFF MED trial suggest that ablating renal nerves can reduce blood pressure in patients with untreated mild-to-moderate hypertension. The SPYRAL HTN-ON MED trial demonstrated the safety and efficacy of catheter-based renal denervation in patients with uncontrolled hypertension on antihypertensive treatment. Interestingly, there was a high rate of medication non-adherence among patients with hypertension in this study. One attractive alternative to radiofrequency ablation is the use of ultrasound for renal denervation. Proof of concept data for the Paradise endovascular ultrasound renal denervation system was recently published in the RADIANCE-HTN SOLO trial. The results of this trial indicate that, among patients with mild to moderate hypertension on no medications, renal denervation with the Paradise system results in a greater reduction in both SBP and DBP at 2months compared with a sham procedure. Overall reductions were similar in magnitude to those noted in the SPYRAL HTN-OFF MED study. With respect to carotid body ablation, there is an ongoing proof of concept study that is investigating the safety and feasibility of ultrasound-based endovascular carotid body ablation in 30 subjects with treatment-resistant hypertension outside of the USA.

Summary

The sympathetic nervous system is an important contributor to resistant hypertension. Modulation of sympathetic overactivity should be an important goal of treatment. Innovative therapies using non-pharmacologic means to suppress the sympathetic nervous system are actively being studied to treat resistant hypertension.

     

Renal sympathetic nervous system and the effects of denervation on renal arteries

Resistant hypertension is associated with chronic activation of the sympathetic nervous system resulting in various comorbidities. The prevalence of resistant hypertension is often under estimated due to various reasons. Activation of sympathetic nervous system at the renal-as well as systemic-level contributes to the increased level of catecholamines and resulting increase in the blood pressure. This increased activity was demonstrated by increased muscle sympathetic nerve activity and renal and total body noradrenaline spillover. Apart from the hypertension, it is hypothesized to be associated with insulin resistance, congestive heart failure and obstructive sleep apnea. Renal denervation is a novel procedure where the sympathetic afferent and efferent activity is reduced by various techniques and has been used successfully to treat drug-resistant hypertension improvement of various metabolic derangements.Renal denervation has the unique advantage of offering the denervation at the renal level, thus mitigating the systemic side effects. Renal denervation can be done by various techniques including radiofrequency ablation, ultrasound guided ablation and chemical ablation. Various trials evaluated the role of renal denervation in the management of resistant hypertension and have found promising results. More studies are underway to evaluate the role of renal denervation in patients presenting with resistant hypertension in different scenarios. Appropriate patient selection might be the key in determining the effectiveness of the procedure.     

Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months

Renal sympathetic hyperactivity is seminal in the maintenance and progression of hypertension. Catheter-based renal sympathetic denervation has been shown to significantly reduce blood pressure (BP) in patients with hypertension. Durability of effect beyond 1 year using this novel technique has never been reported. A cohort of 45 patients with resistant hypertension (systolic BP ≥160 mm Hg on ≥3 antihypertension drugs, including a diuretic) has been originally published. Herein, we report longer-term follow-up data on these and a larger group of similar patients subsequently treated with catheter-based renal denervation in a nonrandomized manner. We treated 153 patients with catheter-based renal sympathetic denervation at 19 centers in Australia, Europe, and the United States. Mean age was 57±11 years, 39% were women, 31% were diabetic, and 22% had coronary artery disease. Baseline values included mean office BP of 176/98±17/15 mm Hg, mean of 5 antihypertension medications, and an estimated glomerular filtration rate of 83±20 mL/min per 1.73 m(2). The median time from first to last radiofrequency energy ablation was 38 minutes. The procedure was without complication in 97% of patients (149 of 153). The 4 acute procedural complications included 3 groin pseudoaneurysms and 1 renal artery dissection, all managed without further sequelae. Postprocedure office BPs were reduced by 20/10, 24/11, 25/11, 23/11, 26/14, and 32/14 mm Hg at 1, 3, 6, 12, 18, and 24 months, respectively. In conclusion, in patients with resistant hypertension, catheter-based renal sympathetic denervation results in a substantial reduction in BP sustained out to ≥2 years of follow-up, without significant adverse events.     

心房颤动导管消融联合肾交感神经消融——心房颤动合并高血压治疗的新策略？

心房颤动是临床上最常见的一种心律失常,它可以影响血流动力学和增加脑卒中的风险。近年来心房颤动导管消融发展迅速,但是导管消融治疗心房颤动仍可能复发房性心律失常,目前单纯导管消融治疗心房颤动长期维持窦性心律的成功率还不尽如人意。肾交感神经消融通过抑制交感神经系统及肾素-血管紧张素-醛固酮系统活性从而达到治疗顽固性高血压的目的,现已成为一种有效、安全的新型手术方法。原发性高血压、心房颤动和交感神经系统三者之间有着密不可分的关系,肾交感神经消融可能通过抑制交感神经系统和肾素-血管紧张素-醛固酮系统活性减少心房颤动复发,也许将会成为心房颤动合并高血压治疗的新策略。现就导管消融联合肾交感神经消融治疗心房颤动的相关内容进行综述。     

Renale Denervierung

Hypertension is a well-known risk factor for major cardiovascular events. Despite advances in medical therapy, sufficient treatment of hypertension remains unsatisfying in a substantial number of patients and is therefore one of the main challenges in modern medicine. In Germany 5–15?% of patients with hypertension suffer from resistant hypertension with elevated blood pressure despite the use of at least three antihypertensive drugs. Additionally patients often suffer from side effects. In patients with resistant hypertension the important role of the sympathetic nervous system with increased sympathetic activity is well known. In the past surgical sympathectomy with extended removal of sympathetic ganglia was performed to reduce blood pressure in patients with malignant hypertension. The positive effect of this highly invasive procedure on blood pressure led to the development of new strategies for the treatment of uncontrolled hypertension. One of the novel procedures includes catheter-based renal sympathetic denervation. The most common system is the radiofrequency ablation catheter (Symplicity?, Medtronic, Minneapolis, USA) which ablates the nerve fibers in the adventitia of the renal arteries by using high-frequency energy. As the results of the Symplicity trials (HTN-1 and HTN-2) showed significant reduction of systolic and diastolic blood pressure after renal denervation there is growing interest in this novel procedure. Moreover, by reducing the sympathetic activity after renal denervation early results indicate a positive impact on glucose metabolism, sleep apnea syndrome, as well as heart and renal failure. These effects led to the development of many different devices for renal denervation; however, trials with a higher number of patients and longer follow-up need to confirm these initially promising results and the value of newer devices. Until then renal denervation should not be regarded as standard therapy for arterial hypertension or an alternative to medical antihypertensive treatment and should be reserved for selected patients with resistant hypertension and specialized medical centres.     

Renal Nerves in the Maintenance of Hypertension: A Potential Therapeutic Target

Renal sympathetic efferent and afferent nerves, which lie within and immediately adjacent to the wall of the renal arteries, contribute to the maintenance of hypertension. Because the causative factors of hypertension change over time, denervation of both efferent and afferent renal nerves should result in long-term attenuation of hypertension. The importance of the renal nerves in hypertensive patients can now be defined with the novel development of percutaneous, minimally invasive renal denervation from within the renal artery using radiofrequency energy as a therapeutic strategy. Studies thus far show that catheter-based renal denervation in patients with resistant essential hypertension lowers systolic blood pressure 27 mm Hg by 12 months, with the estimated glomerular filtration rate remaining stable. The decrease in arterial pressure after renal denervation is associated with decreased peripheral sympathetic nervous system activity, suggesting that the kidney is a source of significant central sympathetic outflow via afferent renal nerve activity.     

肾交感神经消融治疗高血压及其研究进展

肾交感神经的过度激活可能是高血压的产生和维持的关键因素,肾交感神经消融属选择性的去交感神经化治疗,为高血压的治疗提供了新途径,本文对肾交感神经消融治疗高血压的安全性、有效性及其适应症的进一步拓展作一综述。