Interventional and Device-Based Autonomic Modulation in Heart Failure

Abstract

Abstract/SummaryHeart failure is an increasingly prevalent disease with high mortality and public health burden. It is associated with autonomic imbalance characterized by sympathetic hyperactivity and parasympathetic hypoactivity. Evolving novel interventional and device-based therapy has sought to restore autonomic balance by neuromodulation.Results of preclinical animal studies and early clinical trials have demonstrated its safety and efficacy in heart failure. In this review article, we will discuss specific neuromodulatory treatment modalities individually-spinal cord stimulation, vagus nerve stimulation, baroreceptor activation therapy and renal sympathetic nerve denervation. Key Points (3-5)• Heart failure (HF) is a disease categorized by sympathetic hyperactivity, parasympathetic withdrawal and impaired baroreflex control of sympathetic activation.• Several measures of autonomic modulation either by implanted devices or interventions seek to restore the autonomic balance in HF and improve outcomes. These measures include spinal cord stimulation, vagus nerve 3 stimulation, baroreceptor activation therapy and renal sympathetic nerve denervation.• Preclinical work and the majority of early clinical trials demonstrate the benefits of these modalities in HF. Additional larger, well-designed, outcome-based clinical trials are warranted to verify the results and determine whether these evolving, innovative neuromodulation approaches can be recommended to the growing population of HF patients.4

Bilateral sympathectomy improves postinfarction left ventricular remodeling and function

“…New nonpharmacologic treatments of heart failure have focused on increasing parasympathetic activity via the use of different stimulation approaches or sympathetic blockade with renal sympathetic denervation and left cardiac sympathectomy. 1,2 The preclinical results of these procedures are encouraging, but initial clinical trials have been unpredictable and harmful. [1][2][3] A preliminary study reported modest efficacy of left cardiac sympathetic denervation in patients with dilated cardiomyopathy, 4 and this procedure has been shown to modify favorably the incidence of life-threatening arrhythmia.…”

“…1,2 The preclinical results of these procedures are encouraging, but initial clinical trials have been unpredictable and harmful. [1][2][3] A preliminary study reported modest efficacy of left cardiac sympathetic denervation in patients with dilated cardiomyopathy, 4 and this procedure has been shown to modify favorably the incidence of life-threatening arrhythmia. 5 Besides the decrease of sympathetic activity, several mechanisms of neuromodulation in these new interventional modalities probably contribute to their favorable effect, including reduced apoptosis, metalloproteinase inhibition, and augmentation of the anti-inflammatory effect of vagal activity.…”

Eficácia da denervação simpática renal como tratamento para a insuficiência cardíaca

“…9 Outro resultado destacado na pesquisa, apresentado em 4 trabalhos, foi o aumento da tolerância ao exercício no teste de caminhada de 6 minutos 22,25,26,29 . Ademais, os pacientes com IC submetidos à DSR apresentaram melhora do quadro clínico, como a redução de arritmias e de disfunções metabólicas, essa melhora do quadro clínico é relatada em pelo menos 8 trabalhos 8,10,19,20,21,24,28,34 .…”

Influence of Clonidine on Antihypertensive Selective Afferent Vagal Nerve Stimulation in Rats

“…In the last years, bipolar unselective vagal neuromodulation has been investigated for several indications like sepsis, autoimmune‐diseases, obesity, headaches, obsessive‐compulsive‐disorders, and depression . By influencing the—supposed to be dysfunctional—parasympathetic cardiac activity, neuromodulation techniques like VNS seem to have positive effects especially on heart failure and—preclinically investigated—on atrial fibrillation . Significant changes in BP during unselective VNS have not been reported.…”