射频消融去肾交感神经治疗顽固性高血压

1. 射频消融去肾交感神经治疗顽固性高血压 河南科技大学第一附属医院 心内科 杨旭明

2. # 高血压病的流行趋势# 交感神经过度激活与高血压病# 顽固性高血压治疗的新亮点# 去肾交感神（DRN）经令人鼓舞的临床疗效# 对DRN的基本认识# 展望与期待

3. Global burden of hypertension is substantial and growing

4. More than one quarter of adults in developed societies are affected by hypertension

5. Global burden of hypertension is substantial and growing Total Hypertensive Population (M)

6. Hypertension leads to an increased risk ofdeath from stroke and heart disease Systolic BP / Diastolic BP (mmHg) CV mortality risk doubles for every 20 mmHg increase in systolic blood pressure.1,2

7. 1 in 3 Patients Cannot Control Their Blood Pressure Despite Optimal Treatment over 5 Years Medication use and blood pressure control in ALLHAT (33,357 patients)

8. 交感神经过度激活与高血压病

9. The hyperactive sympathetic nervous system is Activated in arterial hypertension

11. Chronology Of anti-hypertensive treatment

12. Nerves Lumen Endothelium Media Adventitia Fat 3 mm Renal Nerves • Arise from T10 - L1 • Follow the renal artery to the kidney • Primarily lie within the adventitia

13. Surgical interruption of the sympathetic nervous System (sympathectomy) Used to treat hypertension 75 years ago Blood pressure levels 10 years after Sympathectomy in 31-year-old patient Although effective, this procedure led to many adverse events: •Prolonged hospitalization •Syncope •Impotence • Hypotension • Difficulty walkingSmithwick. JAMA. 1953

14. Renal Sympaticus DeNervationNew Break throughNew Hot Spot

18. 1ESC： DRN适应症共识 $ Office Systolic BP≥ 160 mmHg(≥150mmHg T2-DM) $ ≥3 Antihypertensive medications -Adequate dose /combination including a $ Following lifestyle modification $ Exclusion of secondary HT or pseudoresistance $ GFR ≥45ml/min/1.73m2 $ Appropriate renal artery anatomy

19. RDN - Encouraging Results

20. Symplicity I TrialSustained office BP reduction at 36 months

21. Responder rate increased over time in Symplicity I

25. DRN------Associated Benefits

28. RSDN: Effect on Glucose Metabolism Mahfoud et al. Circulation 2011;123:1940-1946.

29. Therapy Expansion

30. RDN for Sleep Apnea Witkowski et al. Hypertension 58:559-565 (2011)

31. Early data show that Renal Denervation •Reduces systemic sympathetic activation •Improves hypertension •Reduces fluid overload •Reverse LVH & remodeling （Heart Failure） •May improve renal function （CKD） •Reduces some arrhythmias （Electric Storm） •Improves sleep apnoea •Improves diabetic control （Obesity）

32. BASIC VIEWPOINT ABOUT DRN 综上所述，目前发表的文献显示RDN的初步结果鼓舞人心！作为抑制交感神经过度激活的一种新方法，不仅操作简单，降压作用显著，不良事件少，而且有可能改善胰岛素抵抗，减轻阻塞性呼吸暂停综合症，改善慢性心衰和终末期肾病临床转归，为这些疾病的治疗提供了全新的思路。

33. RDN is effective and safe but ......there are still open questions 1.没有即刻评价RDN技术成功指标，成功与否要看随访过程中血压下降程度,故需要研究客观科学的疗效评价指标。 2.RDN技术的适宜人群不够清楚。按文献的入选标准，约10％-20％的患者治疗无效，因此，进一步研究并规范入选标准，提高RDN的有效率是关键问题之一。 3.远期疗效和安全性问题。肾神经有重要的生理功能，去神经的中远期影响尚不清楚；自分泌或全身交感反馈机制可能使降压效果不能持久；传入神经不能再生，但传出神经再生是否会影响长期效果？目前的研究样本量小，统计效能有限，中远期疗效是否真正减少心脑血管事件及死亡未明。

34. PROSPECT

35. New Technologies A number of different energy sources can cause ablation of renal nerves------- Renal nerves more susceptible to damage and have limited recovery potential-------

36. Radiofrequency Thermally induced tissue damage Cooling Profound cooling can produce cell death May have higher recurrence rate Ultrasound Can cause thermally mediated tissue damage Injection of neurotoxic drugs

38. Renal Nerve Anatomy Allows a Catheter-Based Approach Medtronic • Standard interventional technique • 4-6 two-minute treatments per artery • Proprietary RF Generator • Automated • Low-power • Built-in safety algorithms

39. St. Jude Boston Scientific

40. Vessix Bipolar RF Generator • Custom RF Generator controls temperature at precisely 68◦C and delivers RF energy to all electrodes simultaneously. • Very low power (typically <1.0 Watt) needed to get to and maintain temperature. • Confirms apposition via impedance; electrodes not properly apposed to tissue do not fire. • Bipolar technology obviates need for grounding pad. • Battery operated (rechargeable).

41. Occluding RF Balloon Catheter for Renal Denervation • Low pressure non-compliant balloon (3 atm) mitigates barotrauma. • Offset helical electrode pattern optimized for delivery of thermal energy to adventitia. • Sensors at each electrode allow precise temperature measurement; independent titration of power based on temperature. • Gold electrodes - maximize thermal and electrical conductivity and radiopacity. • Balloons sized for 3 mm to 7 mm vessels; capable of treating small main renal arteries and accessory renal arteries. 41

48. Take Home Message • Resistant HTN should be thoroughly investigated and aggressively treated • RDN is almost ready for prime time • surely Simple! but too expensive • Effective ! but need more evidence • Safe!? need toimprove technology • Long term clinical benefit ? still observation • Strict adherence to indications and protocols is mandatory to prevent Procedure Abuse

49. THANK YOU !