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Renal denervation as an option for difficult to treat hypertension has been a concept for several decades, with recent U.S. FDA approval of new, minimally invasive devices. However, while renal denervation has the potential to improve hypertension management, several challenges require consideration prior to widespread adoption. The effect relative to sham control is modest, and generally similar to addition of a single blood pressure lowering medication. It is possible that with additional technique refinement greater effects may be possible. Key factors to consider beyond the direction, strengths, and limitations of the renal denervation technologies themselves, are an understanding of patient groups that derive greatest benefit and phenotypes or biomarkers that predict greater response. This review provides an update on these challenges in addition to the current state and future of renal denervation within the context of hypertension management and treatment.
RESUMEN
AIMS: Left ventricular (LV) restoring forces are primed by ventricular deformation during systole and contribute to cardiac relaxation and early diastolic suction. Systolic-diastolic coupling, the relationship between systolic contraction and diastolic recoil, is a novel marker of restoring forces, but the effect of left atrial pressure (LAP) is unknown. We tested preliminary methods of systolic-diastolic coupling comparing mitral annular velocities versus excursion distances and hypothesized a recoil/contraction distance ratio would remain unaffected across varying LAP, providing a surrogate for quantifying LV restoring forces. METHODS AND RESULTS: Healthy subjects (n = 61, age 52 ± 5 years) underwent manipulation of LAP with lower body negative pressure (LBNP) and rapid normal saline (NS) infusion. Pulmonary capillary wedge pressure (PCWP; pulmonary artery catheter) and tissue Doppler imaging of the mitral annulus were measured. Two models of systolic-diastolic coupling--early diastolic excursion (EDexc )/systolic contraction (Sexc ) distances and e'/systolic (s') velocities were compared. Velocity (e'/s') coupling ratios varied significantly (mean e'/s', slope = 0.022, p < 0.001) in relationship with PCWP (5-20 mmHg). Excursion (EDexc /Sexc ) coupling ratio did not vary in relationship with PCWP (EDexc /Sexc : slope = -0.001, p = 0.19). CONCLUSIONS: Systolic-diastolic coupling using mitral annular distance ratios to standardize early diastolic recoil to systolic contraction was not significantly impacted by LAP, in contrast to coupling ratios using velocities. The pressure invariance of annular distance coupling ratios suggests this metric quantifies the efficiency of LV restoring forces by isolating systolic contributions to early diastolic restoring forces independent from changes in LAP.
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Diástole/fisiología , Sístole/fisiología , Función Ventricular Izquierda/fisiología , Ecocardiografía , Femenino , Hemodinámica/fisiología , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: Age-related changes to left ventricular (LV) early diastolic recoil confound the diagnostic value of e' velocity in heart failure with preserved ejection fraction (HFpEF). Systolic-diastolic coupling quantifies passive left ventricular elastic recoil and may be superior to e' in differentiating abnormal diastolic recoil in HFpEF from healthy aging. This study aims to determine the effect of healthy aging and HFpEF on systolic-diastolic coupling. METHODS: Healthy adults (n = 141, aged 20-90 years) underwent right heart catheterization (RHC) to quantify LV filling pressure and tissue Doppler echocardiography to define peak velocities and excursion (velocity time integral) of the mitral annulus. Separately, HFpEF patients (n = 12, age 67 ± 5 years) and controls (n = 12, age 68 ± 5 years) underwent RHC and echocardiography. Systolic-diastolic coupling was measured as early diastolic excursion (EDexc ) divided by systolic excursion (Sexc ). RESULTS: In healthy adults, EDexc / Sexc declined by 15% per decade of life (r2 = 0.53, P < .001). EDexc /Sexc was significantly lower in HFpEF compared with controls (0.43 ± 0.11 vs 0.56 ± 0.11, P = .011), while e' was similar (6.2 ± 1.5 vs 6.8 ± 1.3 cm/s, P = .33). Using ROC analysis, EDexc /Sexc had an AUC to detect HFpEF of 0.82 (0.61-0.95, P = .007), which was superior to e' alone (AUC 0.60(0.39-0.80), P = .39; P = .026 for difference). CONCLUSIONS: Systolic-diastolic coupling, quantified by the EDexc /Sexc ratio, declined linearly with healthy aging. The EDexc /Sexc ratio was further reduced in HFpEF and able to predict HFpEF more accurately than e' alone. Systolic-diastolic coupling may be a useful diagnostic tool to detect HFpEF.
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Envejecimiento Saludable , Insuficiencia Cardíaca , Disfunción Ventricular Izquierda , Adulto , Anciano , Diástole , Insuficiencia Cardíaca/diagnóstico por imagen , Humanos , Persona de Mediana Edad , Volumen Sistólico , Sístole , Disfunción Ventricular Izquierda/diagnóstico por imagen , Función Ventricular IzquierdaRESUMEN
PURPOSE: To evaluate effectiveness of the polytetrafluoroethylene-covered nitinol mesh microvascular plug (MVP) and compare it with other devices in pulmonary arteriovenous malformation (PAVM) embolization in patients with hereditary hemorrhagic telangiectasia (HHT). MATERIALS AND METHODS: Twenty-five patients (average age 35 y; range, 15-56 y) with hereditary hemorrhagic telangiectasia (HHT) and de novo PAVM embolization with at least 1 MVP between November 2015 and May 2017 were retrospectively evaluated. Retrospective data were also obtained from prior embolization procedures in the same patient population with other embolic devices dating back to 2008. Technical success, complications, PAVM persistence rates, and category of persistence were analyzed. RESULTS: In 25 patients, 157 PAVMs were treated: 92 with MVP, 35 with AMPLATZER vascular plug (AVP), 6 with AVP plus coils, and 24 with coils. The per-PAVM technical success rates were 100% with MVP; 97%, AVP; 100%, AVP plus coils; and 100%, coils. PAVM persistence rates and median follow-up were as follows: MVP, 2% (1/92) (510 d); AVP, 15% (3/20) (1,447 d); AVP plus coils, 20% (1/5) (1,141 d); coils, 46.7% (7/15) (1,141 d). Persistence owing to recanalization for MVP, AVP, AVP plus coils, and coils was 2%, 15%, 0%, and 33%. No difference was found between persistence rates of MVP vs AVP (P = .098). Embolization with a vascular plug (MVP or AVP) with or without coils had a statistically significant lower persistence rate (5.4%) than embolization with coils alone (46.7%) (P = .022). CONCLUSIONS: PAVM embolization with MVP had a high technical success rate and a low persistence rate comparable to AVP and lower than coil embolization alone.