Safety and efficacy of renal sympathectomy in ablation of hypertension complicated with atrial fibrillation

At present, there is limited data on the effect of renal sympathectomy combined with pulmonary vein isolation on hypertensive patients with atrial fibrillation. The purpose of this study was to explore the efficacy and safety of renal sympathectomy combined with ablation in the treatment of hypertension with atrial fibrillation. A comprehensive literature search was conducted on the treatment of hypertension complicated with atrial fibrillation. Comparing the clinical data of renal sympathetic denervation (RSDN)+pulmonary vein isolation (PVI) with that of PVI alone, we analyzed recurrence of postoperative atrial fibrillation (AF) as main outcome. Classification variables were represented by risk ratio (RR), continuous variables as average difference (MD) and 95% confidence interval (CI). A total of 7 eligible studies were included, including 734 patients (RSDN+PVI group: 340 cases; PVI group: 394 cases). The follow-up period was one year or more. Compared with the separate PVI (56%), the recurrence rate of AF in RSDN+PVI group (32%) decreased significantly (RR: 0.60, 95% CI: 0.50, 0.71, p < 0.001). RSDN+PVI increased the operation time (Weighted Mean Difference (WMD): 24.92, 95% CI: 20.27, 29.57, p < 0.001), but did not increase the fluoroscopy time (WMD: 1.58, 95% CI: −7.50, 10.66, p = 0.73). Six months after operation, the glomerular filtration rate in RSDN+PVI group was significantly higher than that in PVI group (WMD: 6.17, 95% CI: 3.09, 9.24, p < 0.001). The control of systolic blood pressure and diastolic blood pressure in RSDN+PVI group was significantly better than that in PVI group (WMD: −9.55, 95% CI: −16.27, −2.84, p = 0.005; WMD: −6.11, 95%CI: −10.72, −1.50, p = 0.009). There was no significant difference in complications between the two groups (RR: 0.85, 95% CI: 0.32, 2.21, p = 0.73). The heterogeneity of clinical outcome was very low in atrial fibrillation and complications (I2 = 0). PVI combined with RSDN is a feasible and safe interventional therapy option for patients with hypertension complicated with atrial fibrillation, which can effectively reduce the burden of atrial fibrillation and improve the control of blood pressure and prevent further renal damage.

Hypertensive; Atrial fibrillation; Ablation; Renal sympathectomy

[1] Jahangir A, Lee V, Friedman PA, Trusty JM, Hodge DO, Kopecky SL, et al. Long-term progression and outcomes with aging in patients with lone atrial fibrillation: a 30-year follow-up study. Circulation. 2007; 115: 3050–3056.

[2] Pokushalov E, Romanov A, Katritsis DG, Artyomenko S, Bayramova S, Losik D, et al. Renal denervation for improving outcomes of catheter ablation in patients with atrial fibrillation and hypertension: early experience. Heart Rhythm. 2014; 11: 1131–1138.

[3] Mahfoud F, Schmieder RE, Azizi M, Pathak A, Sievert H, Tsioufis C, et al. Proceedings from the 2nd European Clinical Consensus Conference for device-based therapies for hypertension: state of the art and considerations for the future. European Heart Journal. 2017; 38: 3272–3281.

[4] Linz D, Ukena C, Mahfoud F, Neuberger HR, Böhm M. Atrial autonomic innervation: a target for interventional antiarrhythmic therapy? Journal of the American College of Cardiology. 2014; 63: 215–224.

[5] Chen PS, Chen LS, Fishbein MC, Lin SF, Nattel S. Role of the autonomic nervous system in atrial fibrillation: pathophysiology and therapy. Circulation Research. 2014; 114: 1500–1515.

[6] Menzies D. Systematic reviews and meta-analyses. The International Journal of Tuberculosis and Lung Disease. 2011; 15: 582–593.

[7] Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLos Medicine. 2009; 6: e1000097.

[8] Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsis-tency in meta-analyses. The BMJ. 2003; 327: 557–560.

[9] Pokushalov E, Romanov A, Corbucci G, Artyomenko S, Baranova V, Turov A, et al. A randomized comparison of pulmonary vein isolation with versus without concomitant renal artery denervation in patients with refractory symptomatic atrial fibrillation and resistant hypertension. Journal of the American College of Cardiology. 2012; 60: 1163–1170.

[10] Romanov A, Pokushalov E, Ponomarev D, Strelnikov A, Shabanov V, Losik D, et al. Pulmonary vein isolation with concomitant renal artery denervation is associated with reduction in both arterial blood pressure and atrial fibrillation burden: Data from implantable cardiac monitor. Cardiovascular Therapeutics. 2017; 35: e12264.

[11] Kiuchi MG, Chen S, Hoye NA, Pürerfellner H. Pulmonary vein isolation combined with spironolactone or renal sympathetic denervation in patients with chronic kidney disease, uncontrolled hypertension, paroxysmal atrial fibrillation, and a pacemaker. Journal of Interventional Cardiac Electrophysiology. 2018; 51: 51–59.

[12] Kiuchi MG, Chen S, E Silva GR, Paz LM, Kiuchi T, de Paula Filho AG, et al. Pulmonary vein isolation alone and combined with renal sympathetic denervation in chronic kidney disease patients with refractory atrial fibrillation. Kidney Research and Clinical Practice. 2016; 35: 237–244.

[13] Kiuchi MG, Chen S, E Silva GR, Rodrigues Paz LM, Kiuchi T, de Paula Filho AG, et al. The addition of renal sympathetic denervation to pulmonary vein isolation reduces recurrence of paroxysmal atrial fibrillation in chronic kidney disease patients. Journal Of Interventional Cardiac Electrophysiology. 2017; 48: 215–222.

[14] Steinberg JS, Shabanov V, Ponomarev D, Losik, D, Ivanickiy, E, Kropotkin E, 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.

[15] Kallistratos MS, Poulimenos LE, Manolis AJ. Atrial fibrillation and arterial hypertension. Pharmacological Research. 2018; 128: 322–326.

[16] Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, et al. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace. 2016; 18: 1609–1678.

[17] Gulati R, Raphael CE, Negoita M, Pocock SJ, Gersh BJ. The rise, fall, and possible resurrection of renal denervation. Nature Reviews Cardiology. 2016; 13: 238–244.

[18] Chen S, Kiuchi MG, Acou WJ, Derndorfer M, Wang J, Li R, et al. Feasibility of catheter ablation renal denervation in “mild” resistant hypertension. The Journal of Clinical Hypertension. 2017; 19: 361–368.

[19] Chen S, Kiuchi MG, Schmidt B, Hoye NA, Acou WJ, Liu S, et al. Renal denervation for mild-moderate treatment-resistant hypertension: a timely intervention? Herz. 2019; 44: 412–418.

[20] Kiuchi MG, Mion D, Graciano ML, de Queiroz Carreira MA, Kiuchi T, Chen S, et al. Proof of concept study: improvement of echocardiographic parameters after renal sympathetic denervation in CKD refractory hypertensive patients. International Journal of Cardiology. 2016; 207: 6–12.

[21] Kiuchi MG, Graciano ML, Carreira MA, Kiuchi T, Chen S, Lugon JR. Long-Term effects of renal sympathetic denervation on hypertensive patients with mild to moderate chronic kidney disease. Journal of Clinical Hypertension. 2016; 18: 190–196.

[22] Kiuchi MG, Graciano ML, de Queiroz Carreira MA, Kiuchi T, Chen S, Andrea BR, et al. Effects of renal sympathetic denervation in left ventricular hypertrophy in CKD refractory hypertensive patients. International Journal of Cardiology. 2016; 202: 121–123.

[23] Wang Z, Chen S, Zhou T, Su L, Ling Z, Fan J, et al. Comparison of saline-irrigated catheter vs. temperature-controlled catheter for renal denervation in a canine model. American Journal of Hypertension. 2015; 28: 1434–1443.

[24] Kiuchi MG, Chen S, Andrea BR, Kiuchi T, Carreira MA, Graciano ML, et al. Renal sympathetic denervation in patients with hypertension and chronic kidney disease: does improvement in renal function follow blood pressure control? Journal of Clinical Hypertension. 2014; 16: 794–800.

[25] Lu J, Ling Z, Chen W, Du H, Xu Y, Fan J, et al. Effects of renal sympathetic denervation using saline-irrigated radiofrequency ablation catheter on the activity of the renin-angiotensin system and endothelin-1. Journal of the Renin-Angiotensin-Aldosterone System. 2014; 15: 532–539.

[26] Kiuchi MG, Maia GL, de Queiroz Carreira MA, Kiuchi T, Chen S, Andrea BR, et al. Effects of renal denervation with a standard irrigated cardiac ablation catheter on blood pressure and renal function in patients with chronic kidney disease and resistant hypertension. European Heart Journal. 2013; 34: 2114–2121.