New directions for sympathetic denervation

Renal artery denervation (RAD) as a procedure for patients with resistant forms of hypertension was initially described in 2010 and was quickly followed by the Renal Sympathetic Denervation in Patients With Treatment-resistant Hypertension-2 (Symplicity HTN-2) trial, 1 Esler M.D. Krum H. Sobotka P.A. et al. Renal sympathetic denervation in patients with treatment-resistant hypertension (the Symplicity HTN-2 trial): a randomised controlled trial. Lancet. 2010; 376: 1903-1919 Abstract Full Text Full Text PDF PubMed Scopus (1802) Google Scholar showing a mean reduction of systolic pressure by as much as 32 mm Hg even for follow-up periods of 2–3 years. Symplicity HTN-3 as a multicenter trial enrolled 530 patients to confirm the European experience. 2 Bhatt D.L. Kandzari D.E. O’Neill W.W. et al. A controlled trial of renal denervation for resistant hypertension. N Engl J Med. 2014; 370: 1393-1401 Crossref PubMed Scopus (1507) Google Scholar One important difference in Symplicity HTN-3 was the inclusion of a sham control group, which is common in pharmacological trials but unusual for a procedural study owing to potential ethical reservations. The Symplicity HTN-3 trial did not show a significant reduction of systolic blood pressure 6 months after RAD compared with sham controls. Incomplete or inefficient denervation and the lack of reliable biomarkers of RAD are widely considered to be the causes of the negative results. The former was corroborated by a recently published trial, Effect of Renal Denervation and Catheter Ablation vs Catheter Ablation Alone on Atrial Fibrillation Recurrence Among Patients With Paroxysmal Atrial Fibrillation and Hypertension (ERADICATE-AF), in which 302 hypertensive patients with atrial fibrillation (AF) were 1:1 randomized to pulmonary vein isolation (PVI) vs PVI + RAD. 3 Steinberg J.S. Shabanov V. Ponomarev D. et al. Effect of renal denervation and catheter ablation vs catheter ablation alone on atrial fibrillation recurrence among patients with paroxysmal atrial fibrillation and hypertension: the ERADICATE-AF randomized clinical trial. JAMA. 2020; 323: 248-255 Crossref PubMed Scopus (57) Google Scholar At the end of 12-month follow-up, patients in the PVI + RAD group had a better ablation outcome (72.1% vs 56.5%) despite similar effective reduction of mean systolic blood pressure. This trial indicates that with experienced operators using standard ablation catheters, RAD can be successfully achieved. Aorticorenal ganglion as a novel target for renal neuromodulationHeart RhythmVol. 18Issue 10PreviewClinical trials for renal artery (RA) ablation have shown limited efficacy. Full-Text PDF