Percutaneous Renal Sympathetic Denervation for the Treatment of Resistant Hypertension with Heart Failure: First Experience in Korea
Optimal BP could not be achieved in a 44-yr-old man with a seven-year history of hypertension despite antihypertensive therapy with four different drugs. He had a 30-pack-year smoking history with a body mass index of 33.4 kg/m2, no history of diabetes, and a family history of early coronary artery disease. The patient first visited to our hospital with chronic headache on september 1, 2008. His antihypertensive medications consisted of hydrochlorothiazide 12.5 mg and felodipine 5 mg once a day, and carvedilol 25 mg and valsartan 160 mg twice a day. His average office BP was 170/115 mmHg and his 24 hr-ambulatory BP was 167/113 mmHg with a non-dipping profile ().\nThe patient underwent the established clinical and laboratory evaluation to identify essential hypertension, and he did not have any secondary causes of hypertension (). A physical examination revealed no abnormal findings. Resting electrocardiography revealed a normal sinus rhythm with left ventricular hypertrophy diagnosed using voltage criteria. N-terminal probrain natriuretic peptide, renin activity, aldosterone were 47.8 pg/mL (normal < 88 pg/mL), 0.5 ng/mL/hr (0.15 to 3.95 ng/mL/hr) and aldosterone was 4.0 ng/dL (1.0 to 27.3 ng/dL), respectively. In addition, other laboratory and his transthoracic echocardiographic findings were shown in . Computed tomography showed bilateral renal artery length > 20 mm, lumen diameter > 4 mm, and no significant atherosclerotic plaques.\nHe underwent percutaneous RDN under local anesthesia with midazolam and fentanyl. First, a 6 French sheath was inserted into the right femoral artery and 5000 units of heparin were injected intravenously. Renal angiography was performed through a 5 French pigtail catheter (Cordis, Miami Lakes, FL, USA). Then, a 6 French renal double curve guide catheter (Cordis, Miami Lakes, FL, USA) was inserted to engage the left renal artery. Using an ablation catheter (Symplicity, Ardian, Medtronic), five radiofrequency ablations () were delivered to the left renal artery and six () were delivered to the right renal artery. Final angiographic findings were acceptable, and did not experience any complications such as significant stenosis, dissection, or spasm ().\nAfter four weeks of follow-up, his average office BP was 144/90 mmHg and his 24 hr-ambulatory BP was 145/94 mmHg. Six months post-procedure, an average office BP of 121/78 mmHg and 24-hr ambulatory BP of 147/95 mmHg were noted (). Moreover, the patient did not complain of chronic headaches anymore and his microalbuminuria was decreased with an albumin to creatinine ratio of 17.5 µg/mgCr. Renal Doppler ultrasound showed no significant stenosis in either renal artery, but there was no change in his left ventricular ejection fraction, diastolic function and right ventricular systolic function ().