Endoscopic Thoracic Sympathectomy in the Treatment of Vasospastic Angina Resistant to Medical Therapy.

BACKGROUND: In this study, we aimed to investigate the clinical follow-up results of endoscopic thoracic sympathectomy (ETS) in the treatment of vasospastic angina (VSA) resistant to maximal medical therapy. METHODS: A total of 80 patients with VSA who presented to our hospital between 2010 and 2022 were included in our study. Among them, 6 patients who did not respond to medical therapy underwent ETS. In-hospital and long-term clinical outcomes of patients who underwent ETS were recorded. RESULTS: The median age of the patients with VSA was 57 [48-66] years, and 70% of the group were males. In the ETS group, compared to the non-ETS group, higher numbers of hospital admissions and coronary angiographies were observed before ETS (median 6 [5-6] versus 2 [1-3], P <.001; median 5 [3-6] versus 2 [1-3], P =.004, respectively). Additionally, while 2 patients (33.3%) in the ETS group had implantable cardioverter defib-rillator (ICD), only 2 patients (2.7%) in the non-ETS group had ICD (P =.027). Out of the 6 patients who underwent ETS, 2 were females, with a median age of 56 [45-63] years. Four patients underwent successful bilateral ETS, while 2 patients underwent unilateral ETS. During the follow-up period after ETS, only 3 patients experienced sporadic attacks (once in 28 months, twice in 41 months, and once in 9 years, respectively), while no attacks were observed in 3 patients during their median follow-up of 7 years. CONCLUSION: It appears that ETS is effective in preventing VSA attacks without any major complications.

Coronary artery spasm treated with intracoronary bioresorbable scaffold implantation under the guidance of treadmill test and optical coherence tomography: A case report.

Coronary artery spasm (CAS) can cause unstable angina, and the treatment of this disease is controversial. We report an elderly male patient who was admitted to hospital due to chest tightness. CAG showed that 70% stenosis in the middle of the right coronary artery (RCA). A bioresorbable scaffold (BRS) was implanted in the lesion under the guidance of optical coherence tomography (OCT). One year later, the patient's symptoms were relieved. The repeated CAG showed that the stent was good. BRS implantation under the guidance of treadmill test and OCT is one of treatment options for CAS patients.

Renal Denervation Exacerbates LPS- and Antibody-induced Acute Kidney Injury, but Protects from Pyelonephritis in Mice.

BACKGROUND: Renal denervation (RDN) is an invasive intervention to treat drug-resistant arterial hypertension. Its therapeutic value is contentious. Here we examined the effects of RDN on inflammatory and infectious kidney disease models in mice. METHODS: Mice were unilaterally or bilaterally denervated, or sham operated, then three disease models were induced: nephrotoxic nephritis (NTN, a model for crescentic GN), pyelonephritis, and acute endotoxemic kidney injury (as a model for septic kidney injury). Analytical methods included measurement of renal glomerular filtration, proteinuria, flow cytometry of renal immune cells, immunofluorescence microscopy, and three-dimensional imaging of optically cleared kidney tissue by light-sheet fluorescence microscopy followed by algorithmic analysis. RESULTS: Unilateral RDN increased glomerular filtration in denervated kidneys, but decreased it in the contralateral kidneys. In the NTN model, more nephritogenic antibodies were deposited in glomeruli of denervated kidneys, resulting in stronger inflammation and injury in denervated compared with contralateral nondenervated kidneys. Also, intravenously injected LPS increased neutrophil influx and inflammation in the denervated kidneys, both after unilateral and bilateral RDN. When we induced pyelonephritis in bilaterally denervated mice, both kidneys contained less bacteria and neutrophils. In unilaterally denervated mice, pyelonephritis was attenuated and intrarenal neutrophil numbers were lower in the denervated kidneys. The nondenervated contralateral kidneys harbored more bacteria, even compared with sham-operated mice, and showed the strongest influx of neutrophils. CONCLUSIONS: Our data suggest that the increased perfusion and filtration in denervated kidneys can profoundly influence concomitant inflammatory diseases. Renal deposition of circulating nephritic material is higher, and hence antibody- and endotoxin-induced kidney injury was aggravated in mice. Pyelonephritis was attenuated in denervated murine kidneys, because the higher glomerular filtration facilitated better flushing of bacteria with the urine, at the expense of contralateral, nondenervated kidneys after unilateral denervation.

Successful Management of Unremitting Spasm after Myocardial Revascularization Exclusively with Bilateral Internal Thoracic Arteries in Y-graft Configuration: A Case Report.

Coronary artery spasm (CAS) after coronary artery bypass grafting (CABG) is rare, and in time may be fatal for the patient if undiagnosed. The purpose of the present study is to report the case of a patient who survived after experiencing a persistent spasm of all native coronary arteries following successful arterial myocardial revascularization. Furthermore, we aimed to discuss the therapeutic strategies which may prevent the occurrence of a coronary artery spasm in settings of myocardial revascularization, in the context of reviewed specific literature evidences.

The hemodynamic effects of a central iliac arteriovenous anastomosis at 6 months in patients with resistant and uncontrolled hypertension.

A central iliac arteriovenous anastomosis, termed the "coupler" (ROX Medical), results in a significant reduction in blood pressure (BP) in hypertensive patients. This study assessed functional and hemodynamic changes induced by the device. Twenty-one patients with resistant and/or uncontrolled hypertension underwent stress echocardiography and cardiopulmonary exercise testing (CPET) at baseline and 6 months post-coupler implantation. End points were selected to best evaluate cardiac function including Doppler stroke volume (SV), septal and lateral E/E', and right ventricular systolic velocity S' (RV S'). CPET VO2 peak demonstrated total cardiopulmonary performance. SV increased from 76.4 SD12.2 mL to 92.1 SD22.7 mL 6 months post-coupler insertion; P = .002. No changes in RV S', septal or lateral E/E', or VO2 peak were observed. Five patients experienced increased diuretic requirement ≥3 times baseline. RV S' fell from 19.0 SD1.87 cm/s to 16.80 SD3.43 cm/s in these patients (P > .05). A significant increase in SV 6 months post-coupler insertion was observed. In patients with increased diuretic requirement, the device was associated with a lower RV S' suggesting occult RV dysfunction as the mechanism of this pre-specified adverse outcome.

Sympathectomy versus conventional treatment for refractory coronary artery spasm.

BACKGROUND: There is no clear consensus on the potential efficacy and indications for sympathectomy to prevent recurrence of vasospasm in patients with refractory coronary artery spasm (CAS). OBJECTIVE: To compare the clinical outcomes of sympathectomy with those of conventional treatment in patients with refractory CAS. PATIENTS AND METHODS: Patients with refractory CAS were randomly assigned to sympathectomy group (n = 37) or conventional treatment group (n = 42). The primary end point was a composite of major adverse cardiac event (MACE) episodes (including cardiac death, nonfatal myocardial infarction, unstable angina, heart failure, and life-threatening arrhythmia), and the secondary end point was death from any cause within 24 months after randomization. RESULTS: During the follow-up period of 24 months, the incidence of MACE in the sympathectomy and conventional treatment groups was 16.22 and 61.90%, respectively (P = 0.0001). All-cause death as the secondary end point occurred in zero and six (14.29%) patients, respectively (P = 0.0272). The Kaplan-Meier curve for MACE and all-cause death showed a significant between-group difference (log-rank test, P = 0.0013 and 0.0176, respectively). CONCLUSION: Compared with conventional treatment, sympathectomy significantly reduced the composite end point of MACE episodes and death from any cause in patients with refractory CAS by effectively preventing recurrence of vasospasm.

Identification of Coronary Vasospasm as a Cause of Recurrent Acute Coronary Syndrome.

A case highlighting the importance of nitrate administration, as routinely performed during coronary arteriography.

Application of a central iliac arteriovenous coupler device in severe treatment-resistant hypertension: a 3.5-year follow-up.

OBJECTIVE: In patients with resistant hypertension, percutaneous placement of an iliac arteriovenous coupler device leads to a reduction of blood pressure (BP) via decreased total vascular resistance and improved arterial compliance. However, long-term efficacy and safety need to be further explored. We report on the first case of 3.5-year follow-up in a patient who underwent implantation of an iliac arteriovenous coupler device. RESULTS: A patient with resistant hypertension was admitted to hospital. Despite treatment with six anti-hypertensive drugs, his BP was poorly controlled. Previously, he had undergone renal denervation, which did not cause a significant BP decrease. Therefore, an arteriovenous coupler device was implanted, leading to an immediate and significant BP decrease. The patient was discharged with an office BP of 122/71 mmHg. After 3 months, there was a sustained BP decrease (-14/9 mmHg), whereas later, it was fluctuant (office BP: 147-173/85-95 mmHg, ABPM: 153-166/81-94 mmHg) probably due to medication non-adherence confirmed by a urinary toxicological screening test. Follow-up right heart catheterization showed changes in hemodynamic parameters related to volume congestion, which were accompanied by progressive dyspnea and weight gain. This was controlled by an optimized diuretic therapy. Additionally, an invasive closure maneuver was performed, leading to an immediate BP increase after closure and a similar decrease after re-opening of the anastomosis, verifying its proper long-term function. CONCLUSION: The implantation of an iliac arteriovenous coupler device appears to be a promising and effective method to decrease BP and therefore reduce cardiovascular risk in patients with severe, treatment-resistant hypertension.

[Renal artery stenosis long time after renal denervation for resistant hypertension]. / Sténose de l'artère rénale à distance d'une dénervation rénale pour HTA résistante.

The onset of renal artery stenosis following a renal denervation is rare and occurs in the first few months after renal denervation. We report the onset of renal artery stenosis a long time after the renal denervation for resistant hypertension. This is a 74 year-old patient who stopped smoking in 1980 and who was treated for dyslipidemia with a revascularized coronary artery disease in 2011, a well-stabilized peripheral arterial disease since 2001, a stable asymptomatic carotid atheroma and a good kidney function. His hypertension known since 1995 became resistant. After the control of renal arteries by angio-CT scan, he had a renal denervation in October 2012. His blood pressure decreased 3 months later confirmed by self-blood pressure monitoring (SBPM) and ambulatory blood pressure monitoring (ABPM) with a CT scan with a non-significant renal artery stenosis in January 2014. He remained normotensive under treatment until July 2015 but his hypertension became uncontrolled at the end of 2015 then resistant and severe confirmed by SBPM in April 2017, despite a 5-drug antihypertensive treatment associated to atorvastatin and clopidogrel confirmed by SBPM in April 2017. A left post-ostial renal artery stenosis with decrease in size of left kidney and cortex as compared to 2011 was detected at CT and treated by angioplasty. It was associated with a rapid decrease in blood pressure but unfortunately a new increase related to a restenosis occurred at the end of 2017, which justified a new angioplasty. Discussion about the etiology and the management of this renal post-denervation late stenosis.

Atherothrombotic out-of hospital cardiac arrest: watch out for a second train.

A 63-year-old man presented with an out-of-hospital cardiac arrest. The coronary angiogram with intravascular imaging was performed and showed a mid-left anterior descending artery atherosclerotic cap rupture with thrombus burden treated with drug-eluting stent (DES) implantation. During the hospitalisation in the intensive care unit, the patient experienced recurrent ventricular fibrillations and asystole with transient ST-segment elevation in the inferior leads with normal coronary angiography. A methylergonovine provocative test was therefore performed and showed an occlusive right coronary artery (RCA) spasm. Due to recurrent RCA spasm, the patient was treated with DES implantation with favourable results at 3-month follow-up.

Abnormal coronary vasoreactivity in transient left ventricular apical ballooning (tako-tsubo) syndrome.

BACKGROUND: The exact etiology and pathophysiologic mechanisms of tako-tsubo syndrome (TTS) remain controversial. OBJECTIVE: To further evaluate the abnormal coronary vasoreactivity and its possible anatomical substrate in TTS. METHODS: We studied 47 patients (46 women; age 67±12years) who underwent diagnostic cardiac catheterization and evaluation of coronary vasoreactivity by sequential acetylcholine (Ach), nitroglycerine and adenosine testing with angiographic and intracoronary pressure-Doppler flow monitoring. Coronary artery wall morphology was also evaluated by intravascular ultrasound (IVUS) imaging in 45 vessels of 43 patients. RESULTS: Abnormal coronary vasoconstriction to Ach stimulation was elicited in 40 patients (85%) involving the LAD artery and its branches in 39 (83%). Abnormal microvascular function was seen in 39 (83%) patients. Overall, hyperemic microvascular resistance index (HMR) was higher and Doppler coronary flow velocity reserve (CFVR) was lower in the LAD artery territory as compared to the reference territories (2.64±1.23 vs 2.05±0.56; p=0.008 and 1.95±0.7 vs 2.3±0.6; p=0.018, respectively). IVUS revealed no plaque rupture, dissection or thrombosis but occult plaque formation and myocardial bridging were found as a possible anatomical substrate of endothelial dysfunction in 67% and 48.8% patients respectively. CONCLUSIONS: A global failure of coronary vasomotor function was demonstrated in most TTS patients. These findings implicate abnormal vasoconstrictive response to the activation of the sympathetic system as a potential mechanism involved in the pathogenesis of myocardial stunning in TTS. PERSPECTIVES: Competency in medical knowledge: Abnormal coronary vasoconstriction secondary to endothelial dysfunction may actively contribute to the clinical manifestation of acute coronary syndromes in patients with non-obstructive coronary disease. Translational outlook 1: TTS patients reveal a global failure of vasomotor function with both vasoconstrictive response to acetylcholine and increased hyperemic microvascular resistances in the territory of myocardial stunning. They may also show occult coronary atherosclerosis and myocardial bridging as the anatomic substrates of endothelial dysfunction. Translational outlook 2: The cardiac phenotype of TTS includes a high prevalence of coronary vasomotor disturbances. These findings implicate abnormal vasoconstrictive response to the activation of the sympathetic system as a potential mechanism involved in the pathogenesis of TTS in post-menopausal women. Thus, a systematic evaluation of coronary vasoreactivity could better characterize the syndrome.

Clinical value of ST-segment change after return of spontaneous cardiac arrest and emergent coronary angiography in patients with out-of-hospital cardiac arrest: Diagnostic and therapeutic importance of vasospastic angina.

BACKGROUND: We investigated the association between initial ST-segment change after return of spontaneous circulation (ROSC) and the incidence of acute coronary lesions in patients with out-of-hospital cardiac arrest (OHCA), and clinical outcomes of patients with OHCA caused by vasospastic angina pectoris (VSA). METHODS: Among 2779 OHCA patients in our institution, all patients with ROSC underwent emergent coronary angiography (CAG) except for those with an obvious extra-cardiac cause of OHCA. Initial ST-segment changes after ROSC were reviewed, and 30-day survival and neurological outcome (Cerebral Performance Category) were evaluated. RESULTS: Of the 155 patients, 52 (34%) had ST-segment elevation (STE) and 103 (66%) had non-STE. Significant coronary culprit lesions were present in 81% of patients with STE and in 33% of patients with non-STE ( P<.001). Percutaneous coronary intervention (PCI) was successful in 60 patients (93.8%) and failed in 4 patients (6.2%). Among 155 patients, 74 patients (47.7%) had favorable neurological prognosis, and 104 patients (67.1%) were alive at 30 days. ST-segment analysis showed good positive predictive value (81%) but low negative predictive value (68%) in diagnosing the presence of acute coronary lesions. VSA was found in 5 patients (9.6%) in the STE group and in 12 patients (11.7%) in the non-STE group. Of these 17 patients, 9 (52.9%) had favorable neurological outcome and 14 (82.4%) were alive at 30 days. CONCLUSION: An acute culprit lesion may be the cause of OHCA even in the absence of STE. In survivors of OHCA with normal coronary arteries, spasm provocation testing should be performed to detect VSA as a cause of the arrest.

Catastrophic catheter-induced coronary artery vasospasm successfully rescued using intravascular ultrasound imaging guidance.

A 46-year-old man underwent coronary angiography for stable angina. He developed inferior ST-segment myocardial infarction during the angiography. Intravascular ultrasound (IVUS) findings suggested coronary vasospasm. Intracoronary administration of isosorbide dinitrate restored the coronary flow. This case illustrates the essential role IVUS imaging played in establishing the diagnosis of catheter-induced coronary vasospasm.

Severe and resistant hypertension in an older woman with claudication.

Coarctation of the aorta is an uncommon cause of treatment-resistant hypertension in adults. It is typically detected and treated in infancy or childhood with surgical or endovascular procedures. Most cases of recurrence of coarctation after repair occur in childhood or early adulthood; recurrence in older persons (>70 years) has rarely been reported. A 73-year-old woman was referred to us for the management of treatment-resistant hypertension accompanied by symptoms of claudication and headaches, which had resulted in multiple emergency room visits. Of note, 58 years earlier, a graft from the left subclavian artery had been used to bypass an aortic coarctation. During a hospitalization for severe hypertension accompanied by acute kidney injury and heart failure, diagnostic angiography revealed a complete thrombotic occlusion of the left subclavian-artery-to-descending-aorta bypass graft and a tight coarctation in the descending thoracic aorta. Balloon angioplasty and stenting across the coarctation was only transiently effective; subsequently, an ascending-to-descending graft was placed distal to the coarctation, and within a few days, the blood pressure levels and claudication improved markedly. This case demonstrates that hypertension specialists should suspect the possibility of recurrence of a coarctation in older patients who present with resistant hypertension and have a remote history of coarctation repair. Although such late recurrences are not common, as illustrated in our patient, surgical intervention may contribute to significant improvement in blood pressure control and prevent future complications.

Individualised renal artery denervation improves blood pressure control in Kazakhstani patients with resistant hypertension.

BACKGROUND: The prevalence of hypertension in Kazakhstan is high, and the majority of patients are not adequately controlled. Treatment with renal artery denervation (RAD) could represent a useful therapeutic option for a subset of patients in Kazakhstan with resistant hypertension. AIM: To assess the impact of RAD in a cohort of patients from Kazakhstan with resistant hypertension. METHODS: Between March 2012 and December 2013, 63 patients underwent RAD at our tertiary care centre. Eligibility criteria were office blood pressure more than 160 mm Hg systolic (SBP) or more than 90 mm Hg diastolic (DBP) despite being treated with three or more antihypertensive medications, including a diuretic. Ambulatory blood pressure was measured at baseline and at month 12, and monitoring also included impact on insulin resistance and renal function. RESULTS: There were significant decreases of 25 ± 24 mm Hg for ambulatory SBP during the daytime and of 26 ± 23 mm Hg for ambulatory SBP during the nighttime (p < 0.0001). We observed significant decreases of 12 ± 14 mm Hg for ambula-tory daytime DBP and of 11 ± 14 mm Hg in ambulatory nighttime DBP (p < 0.0001). A decrease in creatinine clearance was observed from 100.2 ± 33.6 mL/min at baseline to 90.2 ± 22.8 mL/min at month 12 (p < 0.001). Homeostasis model assessment-insulin resistance (HOMA-IR) decreased from 3.0 ± 4.6 at baseline to 2.5 ± 3.7 at 12 months (p = 0.007). CONCLUSIONS: In this population RAD resulted in statistically and clinically significant blood pressure reduction at 12 months with minimal adverse events.

Denervation of the distal renal arterial branches vs. conventional main renal artery treatment: a randomized controlled trial for treatment of resistant hypertension.

BACKGROUND: Effective treatment of uncontrolled hypertension using catheter-based percutaneous renal denervation may depend strongly on the anatomic strategy applied when delivering therapy. We hypothesized that concentering renal denervation treatment in the distal region of the artery would improve clinical response. METHODS AND RESULTS: We conducted a single-center, double-blind, randomized, controlled, and parallel group study (ClinicalTrials.gov NCT02667912). Fifty-one treatment-resistant hypertensive patients meeting guideline indications were randomized either to 'conventional' treatment restricted to the main renal artery (n = 26) or to 'distal' treatment applied mainly in the distal branches beyond the main bifurcation (n = 25). Computer-based treatment assignment was performed in the catheterization laboratory at the time of the procedure by the interventional radiologist and remained unknown to patients, investigators, and other outcomes assessors for the entire study period. Six months after randomization, the distal therapy group (n = 24) had a significantly greater decrease in the primary outcome, 24-h mean ambulatory SBP, as compared with the conventionally treated group (n = 21): -22.6 ±â€Š20.0 vs -9.4 ±â€Š18.7 mmHg; P less than 0.05. No major safety issues were observed in either group. CONCLUSION: Percutaneous renal denervation treatment was significantly less effective at lowering 24-h blood pressure in treatment-resistant hypertensive patients when therapy was applied conventionally in the trunk of renal artery as compared with when applied to distal segmental branches. This observation is in accordance with previous surgical and anatomical findings showing that most renal nerve fibers are distant from the lumen proximally and become available for endovascular treatment mainly in the distal portion of the vessel.

Renal denervation for uncontrolled hypertension: critical review of the evidence.

PURPOSE OF REVIEW: Hypertension (HTN) is a major global public health problem. Endovascular catheter-based radiofrequency ablation of renal sympathetic nerve endings (renal denervation) is a novel treatment option for uncontrolled HTN. RECENT FINDINGS: Early clinical studies primarily in Australia and Europe established renal denervation as a well tolerated and feasible procedure that resulted in a sustained reduction in blood pressure among individuals with severe resistant HTN. A recent randomized controlled trial in the United States using a sham procedure in the control arm, however, did not show a significant additional benefit in blood pressure lowering from renal denervation. This review summarizes and critically examines the evidence for renal denervation in HTN management and identifies areas for future research. SUMMARY: Renal denervation is a potentially promising treatment option for drug-resistant uncontrolled HTN. Future efforts should focus on refining the denervation technology and identifying individuals who are most likely to benefit from the denervation procedure.