顽固性高血压的介入治疗肾神经消融ppt课件

顽固性高血压的介入治疗经皮经导管肾神经消融术需要积极稳妥开展临床研究,1,2,历史回顾降压药物问世前，上世纪20-50年代，尝试外科切除内脏交感神经治疗高血压，虽然降压有效，中/远期生存率明显提高，但围术期的致死、致残率高，中/远期并发症多。,3,尽管当代降压药物有长足发展，但仍有部分规范服药的患者血压不能达标,此外：交感神经抑制剂、直接肾素抑制剂、非特异性血管扩张剂、抗高血压疫苗,高血压是全球公共卫生的难题，难治性高血压约占10%-20%，有更高心血管事件风险Resistanthypertension:Circulation2008;117:e51026,4,理论基础的启示：寻找解决办法,Sympatheticnervoussystemandthekidneyinhypertension.,Carotidbaroreflexandhypertension,肾交感神经阻断？,颈动脉体迷走神经兴奋？,5,经导管肾交感神经消融术,6,7,8,9,SymplicityHTN-1ThreeYearandSymplicityHTN-2OneYearSummary,SustainedBPReductionstoThreeYearsFirstSymplicityHTN-1patienttreatedJune2007ThreeyearreportingshowsnodiminishmentofeffectandimpressivelongtermsafetyForpatientsthathavecompleted3yearfollowup,100%havebeenclassifiedasresponders(10mmHgreduction),whileat6months71%ofpatientswereclassifiedasresponders.SuperiorResultsConfirmedinRandomisedStudySymplicityHTN-2treatmentpopulationshowssustainedtreatmenteffectat12monthfollow-upControlcross-overpatientsalsoshowsignificantBPreduction,OnlytheSymplicityrenaldenervationsystemhasprovensafe,superiorandsustainedBPreductions,10,Significant,SustainedBloodPressureReductionstoatLeast3Years,ExpandedresultspresentedattheAmericanCollegeofCardiologyAnnualMeeting2012(Krum,H.),p0.01forfrombaselineforalltimepoints,11,ImpressiveSafetyRecordContinuesinLongTermFollow-up,81patientswith6-monthrenalCTA,MRAorduplexNovascularabnormalitiesatanysiteofRFdeliveryOneprogressionofapre-existingstenosisunrelatedtoRFtreatment(stentedwithoutfurthersequelae)Onenewmoderatestenosiswhichwasnothemodynamicallyrelevantandnottreated3deathswithinthefollow-upperiod;allunrelatedtothedeviceortherapyNohypotensiveeventsthatrequiredhospitalizationTherewerenoobservedchangesinmeanelectrolytesoreGFR,ExpandedresultspresentedattheAmericanCollegeofCardiologyAnnualMeeting2012(Krum,H.),12,PercentageRespondersIncreasesOverTime,ResponderwasdefinedasanofficeSBPreduction10mmHg,(n=143),(n=148),(n=144),(n=130),(n=107),(n=59),(n=24),(n=24),ExpandedresultspresentedattheAmericanCollegeofCardiologyAnnualMeeting2012(Krum,H.),13,SymplicityHTN-2:RDNSuperiortoMedicalManagement,ReductionsSustainedto12M,fromBaselineto6Months(mmHg),PrimaryEndpoint:84%ofRDNpatientshad10mmHgreductioninSBP10%ofRDNpatientshadnoreductioninSBP,Systolic,Diastolic,Systolic,Diastolic,ExpandedresultspresentedattheAmericanCollegeofCardiologyAnnualMeeting2012(Esler,M.),RDN(n=49),fromBaselineto12Months(mmHg),Systolic,Diastolic,PrimaryEndpoint(6MpostRandomisation),LatestFollow-up(12MpostRandomisation),LatestFollow-up:Controlcrossover(n=35):-24/-8mmHg(AnalysisonpatientswithSBP160mmHgat6M),p0.01forfrombaseline,p0.01fordifferencebetweenRDNandControl,14,MedicationChangesat6and12MonthsPost-RenalDenervation,PhysicianswereallowedtomakechangestomedicationsOncethe6monthprimaryendpointwasreached*,*FurtheranalysisofMedicationsisongoing,15,SymplicityRDNSafetyRecordContinuestobeStronginExpandedResults,SymplicityHTN-2Investigators.TheLancet.2010.,RDNN=47,CrossoverN=35,TreatedatRandomisation,Treatedafter6-mofollow-up,16,First-in-Man(AU),SeriesofPilotStudies(EU,US&AU),SymplicityHTN-2InitialRCT(EU&AU),SYMPLICITYHTN-3USPivotalTrial(US),GlobalSYMPLICITYRegistry(ApprovedRegions),ExpandHTNIndication(ApprovedRegions),Post-MarketRegistry(US),SYMPLICITYHF,SymplicityHTN-1（n=153),PilotStudiesinNewIndications(ApprovedRegions),Trialsunderway,ComprehensiveSYMPLICITYClinicalTrialProgramfollowsover5000patientsacrossmultipleindications,Thisreport,17,目前的初步结果鼓舞人心作为抑制交感神经过度激活的一种新方法，可能有潜在巨大的临床应用前景。但仍有许多问题尚不明了，积极稳妥的开展相关的临床研究很有必要。,18,没有即刻评价神经消融技术成功指标SymplicityHTN-1中仅39%消融患者血压控制达标，即达到BP250秒(2)止疼:射频前经静脉予吗啡和/或芬太尼(3)血管扩张:射频中如发现肾动脉收缩明显,予硝酸甘油100-200ug经导管给药(4)降压:如血压明显升高,予硝普钠经静脉泵入(5)心动过缓/血压下降:阿托品0.5mg和/或多巴胺2-3mg经静脉推注,术中用药与监护,30,射频导管头端自肾动脉远端至开口，螺旋型后撤，每隔5mm选一个点消融，射频导管头端充分贴壁后，每点传递能量8w,2分钟，一般一条肾动脉要消融5-6个点,31,术后观察与随访,术后重点观察血压变