Stefan Bertog

Renal Artery Stenosis After Renal Sympathetic Denervation

To the Editor: Renal sympathetic denervation (RDN) has been adopted in a number of countries as an additional treatment option to supplement antihypertensive therapy in patients with resistant hypertension. Concerns have been raised with regard to the possible occurrence of renal artery stenosis (

Long-term results of a randomized trial comparing three different devices for percutaneous closure of a patent foramen ovale

AIMS Percutaneous patent foramen ovale (PFO) closure for secondary stroke prevention is discussed controversially. Long-term data comparing different closure devices are limited. The objective is the prospective comparison of procedural complications and long-term results after PFO closure in patients with cryptogenic stroke randomized to three different closure devices. METHODS AND RESULTS Between January 2001 and December 2004, 660 patients with cryptogenic stroke were randomized to three different closure devices (Amplatzer, CardioSEAL-STARflex, and Helex occluder, 220 patients per group). The primary endpoint was defined as recurrent cerebral ischaemia [stroke, transient ischaemic attacks (TIA), or Amaurosis fugax], death from neurological cause, or any other paradoxical embolism within 5 years after the index procedure. Device implantation was technically successful in all interventions (n = 660; 100%). The procedure was complicated by pericardial tamponade requiring surgery in one patient (Amplatzer group) and device embolization in three patients (all Helex group). Thrombus formation on the device was detected in 12 cases (11 CardioSEALSTARflex, 1 Helex, 0 Amplatzer; P < 0.0001), of which 2 required surgery. Complete closure after single device implantation was more common with the Amplatzer and with the CardioSEAL-STARflex than with the Helex occluder: Amplatzer vs. Helex vs. CardioSEAL-STARflex: n = 217 (98.6%) vs. n = 202 (91.8%) vs. n = 213 (96.8%; P = 0.0012). Within 5 years of follow-up, the primary endpoint occurred in 25 patients (3.8%; 10 TIAs, 12 strokes and 3 cases of cerebral death). Compared with the CardioSEAL-STARflex (6%; 6 TIAs, 6 strokes, 1 cerebral death) and Helex groups (4%; 4 TIAs, 4 stroke, 1 cerebral death), significantly fewer events (P = 0.04) occurred in the Amplatzer group (1.4%; 2 strokes, 1 cerebral death). CONCLUSION Although procedural complications and long-term neurological event rates are low regardless of the device used, the recurrent neurological event rate was significantly lower after Amplatzer than after CardioSEAL-STARflex or Helex implantation. This has important implications regarding the interpretation of trials comparing PFO closure with medical management.

Renal sympathetic denervation as second-line therapy in mild resistant hypertension: A pilot study

Catheter‐based renal sympathetic denervation (CRD) is associated with significant blood pressure (BP) reductions in patients with severe therapy‐resistant hypertension (office systolic BP ≥ 160 mm Hg or ≥ 150 mm Hg in diabetic patients). Effects of renal denervation on BP in patients with milder forms of therapy‐resistant hypertension have not been examined. We sought to investigate the feasibility, safety, and effectiveness of CRD in patients with longstanding mild hypertension despite treatment with ≥ 3 antihypertensive drugs.

Does the presence of accessory renal arteries affect the efficacy of renal denervation

OBJECTIVES This study sought to assess the efficacy of catheter-based renal sympathetic denervation in patients with accessory renal arteries and to compare the blood pressure (BP)-lowering effect with that observed in patients with bilateral single renal arteries after renal denervation. BACKGROUND Catheter-based renal sympathetic denervation causes significant BP reductions in patients with resistant hypertension. METHODS Seventy-four patients were included in this study. Patients were assigned to 2 main groups: a bilateral single renal arteries group I (n = 54) and an accessory renal arteries group II (n = 20). Group II consisted of 9 patients whose accessory renal arteries were all denervated (group IIa), and 11 patients whose accessory renal arteries were not, or only incompletely, denervated (group IIb). The primary endpoint was the change in office systolic BP after 6 months. RESULTS The procedure was successful in all patients. Group I: mean BP at baseline was 166.2/89.4 ± 20.5/14.6 mm Hg and decreased by -16.6 (p < 0.001)/-6.7 (p = 0.016) ± 16.4/11 mm Hg at 6-month follow-up. Group II: mean BP at baseline was 164.2/89.1 ± 19.9/15.4 mm Hg and decreased by -6.2 (p = 0.19)/-0.2 (p = 0.5) ± 19.7/11.3 mm Hg at 6-month follow-up. Patients in group IIa had an office BP reduction of -8.8 (p = 0.2)/1.1 ± 17.9/10.8 mm Hg and patients in group IIb of -4.1 (p = 0.55)/-1.3 ± 20.8/11.6 mm Hg. Similarly, significant improvements in 24-h mean systolic BP were seen in group I (-8.3 ± 17.4 mm Hg, p < 0.01), whereas none were seen in group II (-3.7 ± 8.3 mm Hg, p = 0.38). CONCLUSIONS BP reduction achieved after renal denervation in patients with accessory renal arteries is less pronounced than in patients with bilateral single renal arteries.

Proceedings from the 2nd European Clinical Consensus Conference for device-based therapies for hypertension: state of the art and considerations for the future

Abstract

Left atrial appendage closure using the amulet device: An initial experience with the second generation amplatzer cardiac plug

Aim of this study was to demonstrate the feasibility, safety, and short‐term outcome of left atrial appendage (LAA) closure with a new generation LAA closure device.

Renal denervation in a patient with prior renal artery stenting.

This is a case report of a 69‐year‐old female with treatment‐resistant severe arterial hypertension despite prior successful percutaneous intervention to both renal arteries for significant renal artery stenoses (stenting of the right and balloon angioplasty of the left renal artery). The office blood pressure was 221/108 mm Hg at baseline. Secondary hypertension was ruled out and catheter‐based renal denervation performed (distal to the stent in the right renal artery and in the usual fashion in the left renal artery) without complications. The office blood pressure decreased at 1‐ and 3‐month follow‐up to 185/93 mm Hg and 182/95 mm Hg, respectively. This case illustrates the feasibility and potential efficacy of catheter‐based renal denervation in patients with a renal artery stent, an important finding as persistent hypertension is common in patients despite successful renal artery stenting and currently available trials examining renal denervation have excluded patients with prior renal artery stents.

Left atrial appendage occlusion in octogenarians: short-term and 1-year follow-up.

To determine the procedural safety, safety, and efficacy of left atrial appendage (LAA) occlusion in octogenarians.

Mechanical antithrombotic intervention by LAA occlusion in atrial fibrillation

Stroke in patients with atrial fibrillation (AF) is often associated with substantial morbidity and mortality. Oral anticoagulation remains the first-line approach to stroke prevention in such individuals; however, for a considerable proportion of patients, traditional treatment using warfarin is limited by a number of factors, such as the inconvenience of frequent therapeutic monitoring and the risk of haemorrhage. The development of new oral anticoagulants with improved efficacy and safety profiles has provided viable options for oral anticoagulation therapy in patients with nonvalvular (nonrheumatic AF). Nonetheless, in patients who have an increased risk of major haemorrhage, a nonpharmacological approach to antithrombotic therapy remains an attractive alternative. The left atrial appendage (LAA) has been found to be the source of >90% of thrombi in patients with nonvalvular AF; thus, prevention of thrombus formation via transcatheter mechanical LAA occlusion is a novel therapeutic target for stroke prevention in this patient population. In this Review, we present the rationale for LAA occlusion in patients with AF, the available occlusion devices and their clinical evidence to date. We also discuss the roles of various imaging techniques in device implantation and the management strategy for associated procedural complications.

Incomplete left atrial appendage occlusion and thrombus formation after Watchman implantation treated with anticoagulation followed by further transcatheter closure with a second-generation Amplatzer Cardiac Plug (Amulet device)

We report a case of incomplete left atrial appendage (LAA) closure after Watchman device (Atritech, Boston Scientific, Natrick, MA) implantation which subsequently developed a thrombus 3 years after the initial procedure. The thrombus resolved after a short period of anticoagulation with warfarin, and the LAA was successfully occluded with a second‐generation Amplatzer Cardiac Plug (Amulet device, AGA, St Jude Medical, Minneapolis, MN). Incomplete LAA closure may be associated with increased risk of thrombus formation and further closure with a second device after a course of anticoagulation may be a reasonable and feasible strategy.