Márcio Galindo Kiuchi

Effects of renal denervation with a standard irrigated cardiac ablation catheter on blood pressure and renal function in patients with chronic kidney disease and resistant hypertension

AIMS Evaluation of the safety and efficacy of renal denervation with a standard irrigated cardiac ablation catheter (SICAC) in chronic kidney disease (CKD) patients with refractory hypertension. METHODS AND RESULTS Twenty-four patients were included and treated with a SICAC. Denervation was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n = 16), 3 (n = 4), and 4 (n = 4). Data were obtained at baseline and monthly until 180th day of follow-up. Baseline values of blood pressure (mean ± SD) were 186 ± 19 mmHg/108 ± 13 mmHg in the office, and 151 ± 18 mmHg/92 ± 11 mmHg by 24 h ambulatory blood pressure monitoring (ABPM). Office blood pressure values at 180th day after the procedure were 135 ± 13 mmHg/88 ± 7 mmHg (P < 0.0001, for both comparisons). The mean ABPM decreased to 132 ± 15 mmHg/85 ± 11 mmHg at the 180th day after the procedure (P < 0.0001 for systolic and P = 0.0015 for diastolic). Estimated glomerular filtration (mean ± SD) increased from baseline (64.4 ± 23.9 mL/min/1.73 m(2)) to the 180th day (85.4 ± 34.9 mL/min/1.73 m(2), P < 0.0001) of follow-up. The median urine albumin:creatinine ratio decreased from baseline (48.5, IQR: 35.8-157.2 mg/g) to the 180th day after ablation (ACR = 15.7, IQR: 10.3-34.2 mg/g, P = 0.0017). No major complications were seen. CONCLUSION The procedure using SICAC seemed to be feasible, effective, and safe resulting in a better control of BP, a short-term increase in estimated glomerular filtration rate, and reduced albuminuria. Although encouraging, our data are preliminary and need to be validated in the long term.

Paced QRS duration as a predictor for clinical heart failure events during right ventricular apical pacing in patients with idiopathic complete atrioventricular block: results from an observational cohort study (PREDICT-HF)

The aim of this study was to investigate the predictive ability of paced QRS duration (pQRSd) for heart failure events among patients receiving right ventricular apical pacing (RVAP).

Long‐Term Effects of Renal Sympathetic Denervation on Hypertensive Patients With Mild to Moderate Chronic Kidney Disease

Thirty patients who underwent percutaneous renal denervation, which was performed by a single operator following the standard technique, were enrolled in this study. Patients with chronic kidney disease (CKD) stage 2 (n=19), 3 (n=6), and 4 (n=5) were included. Data were obtained at baseline and at monthly intervals for the first 6 months. At 7 months, follow‐up data were collected bimonthly until month 12, after which data were collected on a quarterly basis. Baseline blood pressure values (mean±standard deviation) were 185±18/107±13 mm Hg in the office and 152±17/93±11 mm Hg through 24‐hour ambulatory blood pressure monitoring (ABPM). Three patients with stage 4 CKD required chronic renal replacement therapy (one at the 13‐month follow‐up and two at the 14‐month follow‐up) after episodes of acute renal injury; their follow‐up was subsequently discontinued. The office blood pressure values at the 24‐month follow‐up were 131±15/87±9 mm Hg (P<.0001, for both comparisons); the corresponding ABPM values were 132±14/84±12 mm Hg (P<.0001, for both comparisons). The mean estimated glomerular filtration rate increased from 61.9±23.9 mL/min/1.73 m2 to 88.0±39.8 mL/min/1.73 m2 (P<.0001). The urine albumin:creatinine ratio decreased from 99.8 mg/g (interquartile range, 38.0–192.1) to 11.0 mg/g (interquartile range, 4.1–28.1; P<.0001 mg/g). At the end of the follow‐up period, 21 patients (70% of the initial sample) were no longer classified as having CKD.

Renal Sympathetic Denervation in Patients With Hypertension and Chronic Kidney Disease: Does Improvement in Renal Function Follow Blood Pressure Control?

Twenty‐seven patients with resistant hypertension and chronic kidney disease were treated by renal sympathetic denervation (RSD) and followed for 12 months. Patients were retrospectively divided into controlled and uncontrolled blood pressure (BP) groups. Increases in mean estimated glomerular filtration rate (eGFR) were found at months 1, 3, 6, and 12 in the controlled group (P<.0001, for every time point). The mean change in eGFR after 12 months was 18.54±8.15 mL/min/1.73m2 higher in the controlled group (P=.0318). In patients in the controlled group with baseline eGFR <45 mL/min/1.73 m2, responders (with an increase in eGFR >6.2%) corresponded to 50% at 6 months and 83% at 12 months. In the patients with baseline eGFR ≥45 mL/min/1.73 m2, all patients were labeled as responders at months 6 and 12. Median albumin:creatinine ratio after 12 months was lower than baseline only in the controlled group (P=.0003). Our results suggest that patients with this profile who reached BP control by RSD also experienced a significant improvement in renal function.

The efficacy and safety of cardiac resynchronization therapy combined with implantable cardioverter defibrillator for heart failure: a meta-analysis of 5674 patients

AIMS The purpose of this study was to evaluate the efficacy and safety of cardiac resynchronization plus implantable cardioverter defibrillator (CRT-D) therapy and implantable cardioverter defibrillator (ICD) therapy in treating heart failure by systematically reviewing randomized controlled trials. METHODS AND RESULTS Databases of Medline, Embase, and Cochrane Library were searched for published studies up to 31 May 2012. Clinicaltrials.gov and US Food and Drug Administration websites were searched as well. Only randomized controlled trials comparing the efficacy of CRT-D therapy with ICD therapy were enrolled in meta-analysis. Eight randomized controlled trials characterizing 5674 patients were finally included. Meta-analysis found that CRT-D therapy was associated with significant improvement in clinical conditions [odds ratio (OR): 1.66; 95% confidence interval (CI):1.33-2.07] and a reduction in hospitalization (OR: 0.7; 95% CI: 0.6-0.81) and all-cause mortality (OR: 0.8; 95% CI: 0.67-0.95). Although advantages of CRT-D therapy over ICD therapy were obvious, the peri-implantation adverse events of CRT-D therapy remained to be concerns. CONCLUSION Compared with ICD therapy, patients receiving CRT-D therapy have favourable outcomes regarding improvement in clinical conditions, hospitalization rate, and overall survival, but at a significantly higher risk of peri-implantation adverse events. Future studies are warranted to optimize the clinical application of CRT-D.

Proof of concept study: Improvement of echocardiographic parameters after renal sympathetic denervation in CKD refractory hypertensive patients.

AIM Evaluation of the effectiveness of the renal sympathetic denervation (RSD) in reducing lesions of target organs such as the heart and kidneys, in resistant hypertensive CKD patients. METHODS AND RESULTS Forty-five patients were included and treated with an ablation catheter with open irrigated tip. RSD was performed by a single operator following the standard technique. Patients included with CKD were on stages 2 (n=22), 3 (n=16), and 4 (n=7). Data were obtained at baseline and monthly until the 6th month of follow-up. Twenty-six out of the 45 patients had LVH and nineteen did not present LVH. The LV mass index decreased from 123.70±38.44g/m(2) at baseline to 106.50±31.88g/m(2) at the 6th month after RSD, P<0.0001. The end-diastolic left ventricular internal dimension (LVIDd) reduced from 53.02±6.59mm at baseline to 51.11±5.85mm 6months post procedure, P<0.0001. The left ventricular end-diastolic posterior wall thickness (PWTd) showed a reduction from 10.58±1.39mm at baseline to 9.82±1.15mm at the 6th month of follow-up, P<0.0001. The end-diastolic interventricular septum thickness (IVSTd) also decreased from 10.58±1.39mm at baseline to 9.82±1.15mm 6months post procedure, P<0.0001. The left ventricular ejection fraction (LVEF) improved from 58.90±10.48% at baseline to 62.24±10.50% at the 6th month of follow-up, P<0.0001. When the ∆ between baseline and the 6th month post RSD in LVH patients and non LVH patients were compared to the same parameters no significant difference was found. CONCLUSIONS The RSD seemed to be feasible, effective, and safe resulting in an improvement of echocardiographic parameters in LVH and non LVH CKD refractory hypertensive patients.

Acute effect of renal sympathetic denervation on blood pressure in refractory hypertensive patients with chronic kidney disease

a Renal Division, Department of Medicine, Universidade Federal Fluminense, Niteroi, RJ, Brazil b Hospital Regional Darcy Vargas, Rio Bonito, RJ, Brazil c Department of Cardiology, Shanghai First Peoples Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China d Fellowship of European Heart Rhythm Association/European Society of Cardiology, Department of Cardiology, Elisabethinen University Teaching Hospital Linz, Linz, Austria e Abteilung Elektrophysiologie, Herzzentrum, Universitat Leipzig, Leipzig, Sachsen, Germany

Effects of renal sympathetic denervation in left ventricular hypertrophy in CKD refractory hypertensive patients

Article history: Received 26 July 2015 Received in revised form 22 August 2015 Accepted 26 August 2015 Available online 29 August 2015 formed consent was obtained from every patient. In the period from June 2011 to December 2012, thirty consecutive patients underwent RSD. All of them had resistant hypertension and CKD (stages 2, 3 and 4), as shown in Table 1. They underwent laboratory tests and assessment of renal function at baseline and 24 h post-procedure, before discharge. The procedures were performed in the catheterization laboratory with direct visualization using fluoroscopy and radiopaque contrast. In

The effects of different physical activities on atrial fibrillation in patients with hypertension and chronic kidney disease

Background Atrial fibrillation (AF) is highly common, and is most frequently observed in individuals with hypertension and structural cardiac disease. Sympathetic hyperactivity plays a fundamental role in the progression, maintenance and aggravation of arrhythmia. Endurance exercise training clearly lowers sympathetic activity in sympathoexcitatory disease states, and is well-tolerated by patients with chronic kidney disease (CKD). Methods We assessed 50 CKD patients with hypertension. Each patient provided a complete medical history and underwent a physical examination. We used an implantable cardiac monitor over a 3-year follow-up period to evaluate the effects of high-intensity interval training (HIIT) and moderate exercise (ModEx) physical activity protocols on AF occurrence, and determined the effectiveness of these protocols in improving renal function. Subjects were followed up every 6 months after the beginning of the intervention. Results During the 3-year follow-up, AF onset was higher in CKD patients who engaged in HIIT (72%) than in those who engaged in ModEx (24%) (hazard ratio, 3.847; 95% confidence interval, 1.694–8.740, P = 0.0013 by log-rank test). Both groups exhibited significant intra-group changes in the mean systolic 24-hour ambulatory blood pressure measurements (ABPM) between baseline and 12, 24, and 36 months. There were also significant differences in the mean systolic 24-hour ABPM between the groups at the same time points. Conclusion In CKD patients with hypertension, improvements in AF onset, renal function and some echocardiographic parameters were more evident in subjects who engaged in ModEx than in those who engaged in HIIT during 3 years of follow-up.

Feasibility of catheter ablation renal denervation in “mild” resistant hypertension

Renal denervation (RDN) has been proposed as a novel interventional antihypertensive technique. However, existing evidence was mainly from patients with severe resistant hypertension. The authors aimed to evaluate the efficacy of RDN in patients with resistant hypertension with mildly elevated blood pressure (BP). Studies of RDN in patients with mild resistant hypertension (systolic office BP 140–160 mm Hg despite treatment with three antihypertensive drugs including one diuretic, or mean systolic BP by 24‐hour ambulatory BP measurement [ABPM] 135–150 mm Hg) were included. Two observational and one randomized cohort were identified (109 patients in the RDN group and 36 patients in the control group). Overall, the mean age of patients was 62±10 years, and 69.7% were male. Before‐after comparison showed that RDN significantly reduced ABPM as compared with the baseline systolic ABPM, from 146.3±13 mm Hg at baseline to 134.6±14.7 mm Hg at 6‐month follow‐up and diastolic ABPM from 80.8±9.4 mm Hg at baseline to 75.5±9.8 mm Hg at 6‐month follow up (both P<.001). This significant effect was not observed in the control group. Between‐group comparison showed a greater change in ABPM in the RDN group as compared with that in the control group (change in systolic ABPM: −11.7±9.9 mm Hg in RDN vs −3.5±9.6 mm Hg in controls [P<.001]; change in diastolic ABPM: −5.3±6.3 mm Hg in RDN vs −2.1±5.5 mm Hg in control [P=.007]). RDN was also associated with a significantly decreased office systolic/diastolic BP and reduced number of antihypertensive medications. No severe adverse events were found during follow‐up. RDN seems feasible to treat patients with mild resistant hypertension.