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经皮导管去肾动脉交感神经射频消融术治疗难治性高血压的研究进展

2017-09-26 MedSci MedSci原创

难治性高血压对患者危害极大,可导致严重的靶器官损伤和心血管风险,难治性高血压的治疗在近几年取得了巨大进步,去肾动脉交感神经术(RDN)是目前治疗难治性高血压的一大突破,射频消融术通过导管头端温度及阻抗传感监测射频能量释放,透过肾动脉的内、中膜选择性破坏外膜的肾动脉交感神经纤维来降低肾动脉交感神经活性,从而抑制交感神经过度兴奋达到降压目的。现将关于RDN治疗难治性高血压最新进展的综述文章总结如下

难治性高血压对患者危害极大,可导致严重的靶器官损伤和心血管风险,难治性高血压的治疗在近几年取得了巨大进步,去肾动脉交感神经术(RDN)是目前治疗难治性高血压的一大突破,射频消融术通过导管头端温度及阻抗传感监测射频能量释放,透过肾动脉的内、中膜选择性破坏外膜的肾动脉交感神经纤维来降低肾动脉交感神经活性,从而抑制交感神经过度兴奋达到降压目的。现将关于RDN治疗难治性高血压最新进展的综述文章总结如下。

Joana Delgado Silva等2016年在美国高血压学会会刊上发表review。其中指出,自2014年Symplicity HTN-3结果(大样本、前瞻性、假手术对照试验)显示RDN对难治性高血压的降压效果并不优于药物治疗之后,一些中心停止了他们的RDN项目,但研究仍在继续,有几项研究评估了该手术的安全性和疗效,其中DENERHTN是一项法国多中心前瞻性开放标签RCT,这项研究不同于HTN-3在于RDN之外还使用标准化的阶梯降血压疗法(SSAHT),在4周的标准化三联治疗后,难治性高血压患者被随机分为RDN+ SSAHT组或SSAHT组,主要有效性终点是基线到6个月白天动态收缩压的平均变化。使用问卷评估并发症。6个月后 RDN组的白天动态收缩压、夜间血压、24小时平均血压下降明显大于SSAHT组。此外还有GSR研究,该研究不仅纳入难治性高血压患者,还包括与交感神经活化相关的其他疾病如心力衰竭,结果显示6个月时收缩压、24小时收缩压显著下降,安全性上RDN发生CV、肾脏、围手术期并发症的比例低(<1%)。目前尚在进行中的还有由美敦力发起的SPYRAL HTN全球临床试验项目,这包括2个全球前瞻性随机假手术对照试验,旨在调查RDN对吃药和不吃药的难治性高血压患者的作用。欧洲高血压和心脏病学会最新指南指出难治性高血压、药物依赖、肾脏解剖合适(无肾动脉狭窄、之前没有接受过支架介入、肾动脉直径合适)的患者可以接受RDN治疗。

在美国,FDA已经适当授权RDN作为调查性手术。鉴于射频消融术治疗反应异质性较大,随机试验的结果多有冲突,内在手术和临床方面的局限性,目前射频消融的替代方式正在研究中,这其中包括:

1.冷冻消融术,即在靶器官中利用极低温使得细胞死亡,并由纤维化替代,目前冷冻消融去肾动脉交感神经正在动物实验阶段。

2.超声能量:利用高频声波穿透周围组织,产生热量导致深层温度升高。

3.化学法去交感神经:利用乙醇侵蚀神经达到去交感的目的。

Ming Zhong等今年在Intervent Cardiol Clin发表综述文章,文中指出对于Symplicity HTN-3射频消融治疗难治性高血压的阴性结果,目前有不同学者提出质疑,这其中包括难治性高血压对患者危害极大,可导致严重的靶器官损伤和心血管风险,难治性高血压的治疗在近几年取得了巨大进步,去肾动脉交感神经术(RDN)是目前治疗难治性高血压的一大突破,射频消融术通过导管头端温度及阻抗传感监测射频能量释放,透过肾动脉的内、中膜选择性破坏外膜的肾动脉交感神经纤维来降低肾动脉交感神经活性,从而抑制交感神经过度兴奋达到降压目的。现将关于RDN治疗难治性高血压最新进展的综述文章总结如下。

Joana Delgado Silva等2016年在美国高血压学会会刊上发表review。其中指出,自2014年Symplicity HTN-3结果(大样本、前瞻性、假手术对照试验)显示RDN对难治性高血压的降压效果并不优于药物治疗之后,一些中心停止了他们的RDN项目,但研究仍在继续,有几项研究评估了该手术的安全性和疗效,其中DENERHTN是一项法国多中心前瞻性开放标签RCT,这项研究不同于HTN-3在于RDN之外还使用标准化的阶梯降血压疗法(SSAHT),在4周的标准化三联治疗后,难治性高血压患者被随机分为RDN+ SSAHT组或SSAHT组,主要有效性终点是基线到6个月白天动态收缩压的平均变化。使用问卷评估并发症。6个月后 RDN组的白天动态收缩压、夜间血压、24小时平均血压下降明显大于SSAHT组。此外还有GSR研究,该研究不仅纳入难治性高血压患者,还包括与交感神经活化相关的其他疾病如心力衰竭,结果显示6个月时收缩压、24小时收缩压显著下降,安全性上RDN发生CV、肾脏、围手术期并发症的比例低(<1%)。目前尚在进行中的还有由美敦力发起的SPYRAL HTN全球临床试验项目,这包括2个全球前瞻性随机假手术对照试验,旨在调查RDN对吃药和不吃药的难治性高血压患者的作用。欧洲高血压和心脏病学会最新指南指出难治性高血压、药物依赖、肾脏解剖合适(无肾动脉狭窄、之前没有接受过支架介入、肾动脉直径合适)的患者可以接受RDN治疗。

在美国,FDA已经适当授权RDN作为调查性手术。鉴于射频消融术治疗反应异质性较大,随机试验的结果多有冲突,内在手术和临床方面的局限性,目前射频消融的替代方式正在研究中,这其中包括:

1.冷冻消融术,即在靶器官中利用极低温使得细胞死亡,并由纤维化替代,目前冷冻消融去肾动脉交感神经正在动物实验阶段。

2.超声能量:利用高频声波穿透周围组织,产生热量导致深层温度升高。

3.化学法去交感神经:利用乙醇侵蚀神经达到去交感的目的。

Ming Zhong等今年在Intervent Cardiol Clin发表综述文章,文中指出对于Symplicity HTN-3射频消融治疗难治性高血压的阴性结果,目前有不同学者提出质疑,这其中包括:

1.由于单头导管的设计,一些试验参与者是否达到了次优去神经;

2.参与者是否为真正的难治性高血压患者,试验期间增加口服降压药物是否掩盖了去神经的降压作用;

3.该试验旨在评估血压的降低,而没有提供其他的信息包括RDN对心容积、心室舒张末期和动脉压、尿钠排泄、糖耐量、心律失常等。尽管目前美国心脏病协会/美国高血压学会指南不推荐RDN用于治疗难治性高血压,很多学者认为HTN-3的结果不能证明或否认RDN的疗效,而是需要进一步的大规模研究。而直到有研究可以明确证实RDN对难治性高血压的疗效,它将一直被视为一个有希望但未被证明的疗法。:

1.由于单头导管的设计,一些试验参与者是否达到了次优去神经;

2.参与者是否为真正的难治性高血压患者,试验期间增加口服降压药物是否掩盖了去神经的降压作用;

3.该试验旨在评估血压的降低,而没有提供其他的信息包括RDN对心容积、心室舒张末期和动脉压、尿钠排泄、糖耐量、心律失常等。尽管目前美国心脏病协会/美国高血压学会指南不推荐RDN用于治疗难治性高血压,很多学者认为HTN-3的结果不能证明或否认RDN的疗效,而是需要进一步的大规模研究。而直到有研究可以明确证实RDN对难治性高血压的疗效,它将一直被视为一个有希望但未被证明的疗法。


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    2017-09-28 freve
  7. [GetPortalCommentsPageByObjectIdResponse(id=1737185, encodeId=7ddc1e371854d, content=<a href='/topic/show?id=c17a8249897' target=_blank style='color:#2F92EE;'>#肾动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82498, encryptionId=c17a8249897, topicName=肾动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=fc5934261565, createdName=江川靖瑶, createdTime=Thu Apr 26 18:12:00 CST 2018, time=2018-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1694710, encodeId=92f51694e10cd, content=<a href='/topic/show?id=471d4682409' target=_blank style='color:#2F92EE;'>#射频消融术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46824, encryptionId=471d4682409, topicName=射频消融术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=febc29728754, createdName=zhmscau, createdTime=Thu Jan 04 11:12:00 CST 2018, time=2018-01-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1279927, encodeId=7d1312e99276a, content=<a href='/topic/show?id=0b0546822fd' target=_blank style='color:#2F92EE;'>#射频消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46822, encryptionId=0b0546822fd, topicName=射频消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dc7a157, createdName=jinweidong, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1380870, encodeId=065b13808e0c5, content=<a href='/topic/show?id=9281e34519b' target=_blank style='color:#2F92EE;'>#研究进展#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73451, encryptionId=9281e34519b, topicName=研究进展)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f13d475, createdName=mashirong, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421684, encodeId=cd1414216848c, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1528390, encodeId=db841528390e9, content=<a href='/topic/show?id=74b798601a1' target=_blank style='color:#2F92EE;'>#难治性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=98601, encryptionId=74b798601a1, topicName=难治性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a1ef11916292, createdName=freve, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1560254, encodeId=8a00156025498, content=<a href='/topic/show?id=a9fd65826da' target=_blank style='color:#2F92EE;'>#消融术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65826, encryptionId=a9fd65826da, topicName=消融术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1c4415117207, createdName=dingxiaobo, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1566263, encodeId=f8b61566263f3, content=<a href='/topic/show?id=a9fd65826da' target=_blank style='color:#2F92EE;'>#消融术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65826, encryptionId=a9fd65826da, topicName=消融术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1c4415117207, createdName=dingxiaobo, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=247884, encodeId=4a2524e884c2, content=学习了.获益匪浅!感谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/17/0ed05bbc4eb124766d2a39104932ec4e.jpg, createdBy=5afd2091871, createdName=情途末路, createdTime=Tue Sep 26 13:18:45 CST 2017, time=2017-09-26, status=1, ipAttribution=)]
  8. [GetPortalCommentsPageByObjectIdResponse(id=1737185, encodeId=7ddc1e371854d, content=<a href='/topic/show?id=c17a8249897' target=_blank style='color:#2F92EE;'>#肾动脉#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=89, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=82498, encryptionId=c17a8249897, topicName=肾动脉)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=fc5934261565, createdName=江川靖瑶, createdTime=Thu Apr 26 18:12:00 CST 2018, time=2018-04-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1694710, encodeId=92f51694e10cd, content=<a href='/topic/show?id=471d4682409' target=_blank style='color:#2F92EE;'>#射频消融术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=102, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46824, encryptionId=471d4682409, topicName=射频消融术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=febc29728754, createdName=zhmscau, createdTime=Thu Jan 04 11:12:00 CST 2018, time=2018-01-04, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1279927, encodeId=7d1312e99276a, content=<a href='/topic/show?id=0b0546822fd' target=_blank style='color:#2F92EE;'>#射频消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=76, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=46822, encryptionId=0b0546822fd, topicName=射频消融)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=dc7a157, createdName=jinweidong, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1380870, encodeId=065b13808e0c5, content=<a href='/topic/show?id=9281e34519b' target=_blank style='color:#2F92EE;'>#研究进展#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=66, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=73451, encryptionId=9281e34519b, topicName=研究进展)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=f13d475, createdName=mashirong, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1421684, encodeId=cd1414216848c, content=<a href='/topic/show?id=4bc865819d2' target=_blank style='color:#2F92EE;'>#消融#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65819, encryptionId=4bc865819d2, topicName=消融)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1a193676008, createdName=xiangyuzhou972, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1528390, encodeId=db841528390e9, content=<a href='/topic/show?id=74b798601a1' target=_blank style='color:#2F92EE;'>#难治性#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=67, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=98601, encryptionId=74b798601a1, topicName=难治性)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=a1ef11916292, createdName=freve, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1560254, encodeId=8a00156025498, content=<a href='/topic/show?id=a9fd65826da' target=_blank style='color:#2F92EE;'>#消融术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=60, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65826, encryptionId=a9fd65826da, topicName=消融术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1c4415117207, createdName=dingxiaobo, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1566263, encodeId=f8b61566263f3, content=<a href='/topic/show?id=a9fd65826da' target=_blank style='color:#2F92EE;'>#消融术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=65826, encryptionId=a9fd65826da, topicName=消融术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=1c4415117207, createdName=dingxiaobo, createdTime=Thu Sep 28 04:12:00 CST 2017, time=2017-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=247884, encodeId=4a2524e884c2, content=学习了.获益匪浅!感谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=112, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/07/17/0ed05bbc4eb124766d2a39104932ec4e.jpg, createdBy=5afd2091871, createdName=情途末路, createdTime=Tue Sep 26 13:18:45 CST 2017, time=2017-09-26, status=1, ipAttribution=)]
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    2017-09-26 情途末路

    学习了.获益匪浅!感谢分享

    0

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