Renal denervation.

PURPOSE OF REVIEW: Renal denervation (RDN) has, within recent years, been suggested as a novel treatment option for patients with resistant hypertension. This review summarizes the current knowledge on this procedure as well as limitations and questions that remain to be answered. RECENT FINDINGS: The Symplicity HTN-1 (2009) and HTN-2 (2010) studies re-introduced an old treatment approach for resistant hypertension and showed that catheter-based RDN was feasible and resulted in substantial blood pressure (BP) reductions. However, they also raised questions of durability of BP reduction, correct patient selection, anatomical and physiological effects of RDN as well as possible beneficial effects on other diseases with increased sympathetic activity. The long awaited Symplicity HTN-3 (2014) results illustrated that the RDN group and the sham-group had similar reductions in BP. SUMMARY: Initial studies demonstrated that RDN in patients with resistant hypertension was both feasible and safe and indicated that RDN may lead to impressive reductions in BP. However, recent controlled studies question the BP lowering effect of RDN treatment. Large-scale registry data still supports the favorable BP reducing effect of RDN. We suggest that, in the near future, RDN should not be performed outside clinical studies. The degree of denervation between individual operators and between different catheters and techniques used should be clarified. The major challenge ahead is to identify which patients could benefit from RDN, to clarify the lack of an immediate procedural success parameter, and to establish further documentation of overall effect of treatment such as long-term cardiovascular morbidity and mortality.

High incidence of secondary hypertension in patients referred for renal denervation--the Copenhagen experience.

Percutaneous renal denervation is a new treatment option for patients with resistant hypertension and little is known about the eligibility of patients referred. 100 consecutive patients were referred for renal denervation from March 2011 through September 2012. Clinical data were prospectively extracted from letters and documents from referring clinics and from our physical examination. Of the 100 patients included, 68 were men and the mean age was 60 (± 12) years. Office blood pressure was 176 (± 28)/99 (± 19) mmHg and 24-h ambulatory blood pressure 156 (± 20)/88 (± 13) mmHg. The mean number of antihypertensive agents was 4.0 (± 1.6). Nearly four-fifths (82%) of the patients were categorized as having resistant hypertension based on the criteria stated by The American Heart Association's stated criteria. Nine patients declined interest in renal denervation before completing the clinical workup program. Thus, 91 patients were screened, and of those 51 were found to be candidates for renal denervation. Forty patients were not candidates, of which secondary hypertension was the most common cause (n = 10). Only 51% of patients referred for renal denervation were eligible for treatment. The prevalence of secondary hypertension was 10% of the referred population. Secondary hypertension should therefore be considered in the evaluation of candidates for renal denervation.

Transcatheter valve-in-valve implantation due to severe aortic regurgitation in a degenerated aortic homograft.

Transcatheter aortic valve implantation (TAVI) in severe aortic stenosis has proven to be a feasible and effective treatment modality for inoperable patients. Until now, neither aortic regurgitation nor degenerated bioprostheses has been an indication for TAVI. However, this article reports a successful valve-in-valve implantation of a CoreValve aortic valve prosthesis through the right subclavian artery in a case of severe aortic regurgitation within a degenerated aortic homograft. The case exemplifies the possibilities of expanding the indications for TAVI, as well as other vascular access options than the femoral arteries.

When operable patients become inoperable: conversion of a surgical aortic valve replacement into transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is a relatively new treatment option for inoperable patients with severe aortic stenosis (AS). This case describes how a planned conventional surgical aortic valve replacement (AVR) on a 73-year-old woman was successfully converted to a TAVI procedure. On extracorporal circulation it was reconized that the aortic annulus, the coronary ostiae and the proximal part of the ascending aorta were severely calcified making valve implantation impossible. Surgical closure without valve substitution was estimated to be associated with a high risk of mortality due to the imparied left ventricular function. Consequently, TAVI was performed with a CoreValve ReValving System prosthesis. The delivery of the valve prosthesis was made through the ascending part of aorta, proximal of the cannulation of aorta. Positioning of the valve prosthesis was made under visual guidance, and the prosthesis was sutured to the ascending aorta. With some manipulation of the prosthesis it was possible to suture the aorta circumferentially around the fully expanded upper part of the prosthesis. Post-procedurally the patient recovered successfully, with improved function capacity, aortic valve area and left ventricle function.

[Percutaneous aortic valve replacement - initial experience and results]. / Perkutan indsaettelse af aortaklap - initiale erfaringer og resultater.

INTRODUCTION: Aortic stenosis (AS) is the most common heart valvular disease and with progressive disease morbidity and mortality are substantial. The standard treatment in symptomatic patients is surgical valve replacement. However, one third of the patients with severe AS are inoperable due to advanced age and comorbidity. The aim of this study was to evaluate the results of percutaneous aortic valve replacement - a new treatment modality for patients with inoperable AS. MATERIAL AND METHODS: A total of 20 patients were treated with CoreValve ReValving System valve prosthesis at the Copenhagen University Hospital in the period November 2007 to September 2008. RESULTS: The procedural success was 100% and 30-day mortality was 5%, none of which was due to cardiac death. The treatment resulted in a considerable relief of symptoms. The aortic valve area showed a significant increase from 0.8 +/- 0.2 cm(2) to 1.9 +/- 0.6 cm(2) (p < 0.01). There was a significant decrease in the peak pressure gradient across the aortic valve from 75 +/- 38 mm Hg to 18 +/- 8 mm Hg (p < 0.01). Permanent pacemaker due to AV block was the most common complication with an incidence of 25% during the 30-day follow-up. CONCLUSION: Implantation of a percutaneous aortic valve can be achieved in patients with inoperable AS and may become a very important therapeutic modality for this group of patients. These first results from Copenhagen University Hospital are promising and in concordance with international experience.

[Transcatheter replacement of the aortic valve--a novel treatment modality for high-risk patients]. / Transkateterindsaettelse af aortaklap--en ny behandlingsmodalitet til højrisikopatienter.

Aortic stenosis is the most common valve disease and in line with the rising life expectancy, the population of patients with this disease is expected to rise in years to come. About one third of the patients evaluated for conventional surgical replacement of the aortic valve are dismissed due to high risk of complication as a result of age and occurrence of comorbidity. For this group of inoperable patients, a new treatment can be offered in the form of transcatheter replacement of the aortic valve. This article describes the method and the current experiences.