Splanchnic Nerve Block for Acute Heart Failure
2018; Lippincott Williams & Wilkins; Volume: 138; Issue: 9 Linguagem: Inglês
10.1161/circulationaha.118.035260
ISSN1524-4539
AutoresMarat Fudim, W. Schuyler Jones, Richard L. Boortz-Marx, Arun Ganesh, Cynthia L. Green, Adrian F. Hernandez, Manesh R. Patel,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 138, No. 9Splanchnic Nerve Block for Acute Heart Failure Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBSplanchnic Nerve Block for Acute Heart Failure Marat Fudim, MD, W. Schuyler Jones, MD, Richard L. Boortz-Marx, MD, MS, Arun Ganesh, MD, Cynthia L. Green, PhD, Adrian F. Hernandez, MD, MHS and Manesh R. Patel, MD Marat FudimMarat Fudim Department of Medicine, Division of Cardiology (M.F., W.S.J., A.F.H., M.R.P.) , W. Schuyler JonesW. Schuyler Jones Department of Medicine, Division of Cardiology (M.F., W.S.J., A.F.H., M.R.P.) , Richard L. Boortz-MarxRichard L. Boortz-Marx Duke Clinical Research Institute, and Department of Anesthesiology, Division of Pain Medicine (R.L.B.-M., A.G.), Duke University School of Medicine, Durham, NC. , Arun GaneshArun Ganesh Duke Clinical Research Institute, and Department of Anesthesiology, Division of Pain Medicine (R.L.B.-M., A.G.), Duke University School of Medicine, Durham, NC. , Cynthia L. GreenCynthia L. Green Department of Biostatistics and Bioinformatics (C.L.G.) , Adrian F. HernandezAdrian F. Hernandez Department of Medicine, Division of Cardiology (M.F., W.S.J., A.F.H., M.R.P.) and Manesh R. PatelManesh R. Patel Manesh R. Patel, MD, Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27705. E-mail E-mail Address: [email protected] Department of Medicine, Division of Cardiology (M.F., W.S.J., A.F.H., M.R.P.) Originally published1 Jan 2018https://doi.org/10.1161/CIRCULATIONAHA.118.035260Circulation. 2018;138:951–953Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2018: Ahead of Print The abdominal vascular compartment is the main storage of intravascular blood volume, and decreased abdominal vascular capacitance has been proposed as a major contributor to the complex pathophysiology of heart failure (HF) in animals and humans.1,2 In HF, as a result of a neurohormonal imbalance, the vascular capacitance (storage space) is decreased and acute sympathetic nerve activation can result in acute volume redistribution3 from the abdominal compartment to the thoracic compartment (heart and lungs), which increases intracardiac pressures and precipitates HF symptoms (Figure A). The sympathetic nervous system controls the splanchnic compartment via branches from the sympathetic thoracic ganglia (T6 through T11).4 We have identified the splanchnic nerves as a potential target for treating HF.Download figureDownload PowerPointFigure. Splanchnic nerve block in heart failure.A, Concept for fluid redistribution in heart failure. B, Splanchnic nerve block procedure. C, Effects of the splanchnic nerve block on hemodynamics. * indicates a P<0.05 for a pairwise comparison with the baseline value. D, Effect of the splanchnic nerve block on laboratory and functional outcomes. For Likert scale, P 15 mm Hg (>12 mm Hg if on inotropes).Before and immediately after the splanchnic nerve block (SNB), all patients were tested for catecholamine levels and N-terminal pro-B-type natriuretic peptide levels, transthoracic echocardiogram, aortic pulse wave velocity (SphygmoCor, AtCor Medical), 6-minute walk test, and Likert shortness of breath questionnaires. After the baseline evaluation, all patients underwent a right heart catheterization (via the internal jugular vein) in the supine position, followed by bilateral SNB (15 mL of 1% lidocaine on each side), at the level of T11–T12, in the prone position using fluoroscopic guidance (Figure B). Expected duration of sympatholytic effects were ≤90 minutes. All pressures were recorded in the supine position.Statistical methods included paired t tests or Wilcoxon rank sum tests. Repeated measures analyses (0, 15, 30, 45, 60, 75, and 90 minutes) with a mixed-effects model were used to compare pulmonary arterial mean, pulmonary capillary wedge pressure, cardiac index, and systemic vascular resistance. Tukey's method was used to adjust for multiple pairwise comparisons of each postprocedure time point to baseline.Five patients underwent the SNB. The average age was 56 years, 4/5 patients were male, and ischemic cardiomyopathy was observed in 2 cases. All patients had acute advanced systolic HF with a left ventricular ejection fraction of ≤20% as assessed by transthoracic echocardiogram.No procedural or hemodynamic complications were observed for 48 hours. Bilateral SNB resulted in a temporary reduction of intracardiac pressures such as mean pulmonary arterial pressures and pulmonary capillary wedge pressure (Figure C). Cardiac index increased from 1.92 L/min/m2 (95% confidence interval [CI], 1.55–2.29) at baseline to 2.54 L/min/m2 (95%C, I 2.17–2.91; P<0.008) at 30 minutes before starting to return to baseline values at 90 minutes. Furthermore, SNB resulted in a decrease in mean right atrial pressure from 21 mm Hg (95% CI, 13–28) at baseline to 16 mm Hg at 90 minutes (95% CI, 8–23; P=0.034). Mean arterial pressure decreased from 89 mm Hg (95% CI, 77–102) at baseline to 72 mm Hg (95% CI, 59–84; P<0.001) at 30 minutes after SNB and systemic vascular resistance decreased from 1407 dynes·sec·cm−5 (95% CI, 1041–1772) at baseline to 808 dynes·sec·cm-5 (95% CI, 442–1173; P<0.001) at 30 minutes. Acute hemodynamic effects peaked at 30 minutes after SNB and mostly recovered toward the end of the acute monitoring phase (90 minutes).We assessed changes in biomarkers and symptoms after SNB. Levels of serum norepinephrine were baseline (median, interquartile range: 1202 pg/dL, 892 to 3045, versus postprocedure: minute 90: 936 pg/dL, 462 to 2095 [P=0.125). Serum epinephrine levels were baseline: 250 pg/dL, <25 to 616 versus postprocedure 56.5, 27.5 to 73 (P=0.5). Similarly, we observed a nonsignificant decrease in median N-terminal pro-B-type natriuretic peptide levels of 362 pg/dL within 6 hours after the procedure (P=0.19) (Figure D) as well as a nonsignificant change in central vascular pulse wave velocity, an index of vascular stiffness, from 7.8±2.4 meters to 6.8±1.5 meters (P=0.153). Finally, patients reported an acute improvement in symptoms during the procedure (Figure D). The average 6-minute walk distance was +31.2±34.5 meters from immediately before to after the procedure (P=0.11).In this first-in-man study, we tested a new therapeutic approach to the treatment of acute HF. The procedure, which aimed to modulate the splanchnic sympathetic tone through a minimally invasive regional nerve block, resulted in a marked reduction in intracardiac filling pressures and increase in cardiac output, primarily driven by a significant reduction in systemic vascular resistance and improved arterial vascular capacitance. The splanchnic vascular compartment may be a key player in the volume dysregulation in acute and chronic HF, even in the absence of increases of total body fluid volume.1,2The observed temporary hemodynamic effects are possibly the result of a reduced splanchnic autonomic and vascular tone, leading to a redistribution of blood volume from the chest to the abdomen.5 Hemodynamic changes could also have been modulated by sympatholysis/vasodilation outside of the splanchnic vascular bed. Acute hemodynamic changes were associated with improved self-reported shortness of breath. These findings suggest that continued research into the therapeutic use of SNB for the treatment of acute and potentially chronic HF is of interest. Lack of a control group is a major limitation of this study. Further testing for safety and efficacy is needed before potential clinical application.Sources of FundingThis study was supported by American Heart Association grant 17MCPRP33460225 to M.F. Dr Fudim received American Heart Association grant 17MCPRP33460225 and National Institutes of Health T32 grant 5T32HL007101.DisclosuresDr Fudim consults for AxonTherapies and Coridea. The other authors report no conflicts of interest.Footnoteshttps://www.ahajournals.org/journal/circData sharing: The data, analytic methods, and study materials will be made available to other researchers for purposes of reproducing the results or replicating the procedure by e-mailing the corresponding author.Manesh R. Patel, MD, Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Durham, NC 27705. E-mail manesh.[email protected]eduReferences1. Fudim M, Hernandez AF, Felker GM. Role of volume redistribution in the congestion of heart failure.J Am Heart Assoc. 2017; 6:e006817. doi: 10.1161/JAHA.117.006817.LinkGoogle Scholar2. Fallick C, Sobotka PA, Dunlap ME. Sympathetically mediated changes in capacitance: redistribution of the venous reservoir as a cause of decompensation.Circ Heart Fail. 2011; 4:669–675. doi: 10.1161/CIRCHEARTFAILURE.111.961789.LinkGoogle Scholar3. Fudim M, Yalamuri S, Herbert JT, Liu PR, Patel MR, Sandler A. Raising the pressure: Hemodynamic effects of splanchnic nerve stimulation.J Appl Physiol (1985). 2017; 123:126–127. doi: 10.1152/japplphysiol.00069.2017.CrossrefMedlineGoogle Scholar4. Greenway CV. Blockade of reflex venous capacitance responses in liver and spleen by hexamethonium, atropine, and surgical section.Can J Physiol Pharmacol. 1991; 69:1284–1287.CrossrefMedlineGoogle Scholar5. Fujita Y. Splanchnic circulation following coeliac plexus block.Acta Anaesthesiol Scand. 1988; 32:323–327.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kamat I, Hajduczok A, Salah H, Lurz P, Sobotka P and Fudim M (2022) Catheter-Based Management of Heart Failure, Interventional Cardiology Clinics, 10.1016/j.iccl.2022.01.005, 11:3, (267-277), Online publication date: 1-Jul-2022. Fudim M, Kaye D, Borlaug B, Shah S, Rich S, Kapur N, Costanzo M, Brener M, Sunagawa K and Burkhoff D (2022) Venous Tone and Stressed Blood Volume in Heart Failure, Journal of the American College of Cardiology, 10.1016/j.jacc.2022.02.050, 79:18, (1858-1869), Online publication date: 1-May-2022. Kaye D, Wolsk E, Nanayakkara S, Mariani J, Hassager C, Gustafsson F, Moller J, Sunagawa K and Burkhoff D (2021) Comprehensive Physiological Modeling Provides Novel Insights Into Heart Failure With Preserved Ejection Fraction Physiology, Journal of the American Heart Association, 10:19, Online publication date: 5-Oct-2021. Sorimachi H, Burkhoff D, Verbrugge F, Omote K, Obokata M, Reddy Y, Takahashi N, Sunagawa K and Borlaug B (2021) Obesity, venous capacitance, and venous compliance in heart failure with preserved ejection fraction, European Journal of Heart Failure, 10.1002/ejhf.2254, 23:10, (1648-1658), Online publication date: 1-Oct-2021. Fudim M, Abraham W, von Bardeleben R, Lindenfeld J, Ponikowski P, Salah H, Khan M, Sievert H, Stone G, Anker S and Butler J (2021) Device Therapy in Chronic Heart Failure, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.06.040, 78:9, (931-956), Online publication date: 1-Aug-2021. Jorbenadze A, Fudim M, Mahfoud F, Adamson P, Bekfani T, Wachter R, Sievert H, Ponikowski P, Cleland J and Anker S (2021) Extra‐cardiac targets in the management of cardiometabolic disease: Device‐based therapies, ESC Heart Failure, 10.1002/ehf2.13361, 8:4, (3327-3338), Online publication date: 1-Aug-2021. Málek F, Gajewski P, Zymliński R, Janczak D, Chabowski M, Fudim M, Martinca T, Neužil P, Biegus J, Mates M, Krüger A, Skalský I, Bapna A, Engelman Z and Ponikowski P (2021) Surgical ablation of the right greater splanchnic nerve for the treatment of heart failure with preserved ejection fraction: first‐in‐human clinical trial, European Journal of Heart Failure, 10.1002/ejhf.2209, 23:7, (1134-1143), Online publication date: 1-Jul-2021. Fudim M, Ponikowski P, Burkhoff D, Dunlap M, Sobotka P, Molinger J, Patel M, Felker G, Hernandez A, Litwin S, Borlaug B, Bapna A, Sievert H, Reddy V, Engelman Z and Shah S (2021) Splanchnic nerve modulation in heart failure: mechanistic overview, initial clinical experience, and safety considerations, European Journal of Heart Failure, 10.1002/ejhf.2196, 23:7, (1076-1084), Online publication date: 1-Jul-2021. Fudim M, Patel M, Boortz-Marx R, Borlaug B, DeVore A, Ganesh A, Green C, Lopes R, Mentz R, Patel C, Rogers J, Felker G, Hernandez A, Sunagawa K and Burkhoff D (2021) Splanchnic Nerve Block Mediated Changes in Stressed Blood Volume in Heart Failure, JACC: Heart Failure, 10.1016/j.jchf.2020.12.006, 9:4, (293-300), Online publication date: 1-Apr-2021. Fudim M, Neuzil P, Malek F, Engelman Z and Reddy V (2021) Greater Splanchnic Nerve Stimulation in Heart Failure With Preserved Ejection Fraction, Journal of the American College of Cardiology, 10.1016/j.jacc.2021.02.048, 77:15, (1952-1953), Online publication date: 1-Apr-2021. Doimo S and Pavan D (2021) Novelties in Therapy of Chronic Heart Failure, Heart Failure Clinics, 10.1016/j.hfc.2021.01.006, 17:2, (255-262), Online publication date: 1-Apr-2021. Fudim M, Sobotka P, Piccini J and Patel M (2021) Renal Denervation for Patients With Heart Failure, Circulation: Heart Failure, 14:3, Online publication date: 1-Mar-2021. Kaiser D, Platzer P, Miyashiro K, Canfield J, Patel R, Liu D, St. Goar F and Kaiser C (2021) First-in-Human Experience of Mechanical Preload Control in Patients With HFpEF During Exercise, JACC: Basic to Translational Science, 10.1016/j.jacbts.2020.12.007, 6:3, (189-198), Online publication date: 1-Mar-2021. Harrison N, Pang P, Collins S and Levy P (2021) Blood Pressure Reduction in Hypertensive Acute Heart Failure, Current Hypertension Reports, 10.1007/s11906-021-01127-8, 23:2, Online publication date: 1-Feb-2021. Shiraishi Y, Kawana M, Nakata J, Sato N, Fukuda K and Kohsaka S (2020) Time‐sensitive approach in the management of acute heart failure, ESC Heart Failure, 10.1002/ehf2.13139, 8:1, (204-221), Online publication date: 1-Feb-2021. Husain‐Syed F, Gröne H, Assmus B, Bauer P, Gall H, Seeger W, Ghofrani A, Ronco C and Birk H (2020) Congestive nephropathy: a neglected entity? Proposal for diagnostic criteria and future perspectives, ESC Heart Failure, 10.1002/ehf2.13118, 8:1, (183-203), Online publication date: 1-Feb-2021. Bombardini T (2021) The venous contribution to cardiovascular performance: From systemic veins to left ventricular function: A review, Scripta Medica, 10.5937/scriptamed52-35083, 52:4, (299-308), . Lim S and Kim S (2021) Pathophysiology of Cardiorenal Syndrome and Use of Diuretics and Ultrafiltration as Volume Control, Korean Circulation Journal, 10.4070/kcj.2021.0996, 51:8, (656) Fudim M, Sobotka P and Dunlap M (2021) Extracardiac Abnormalities of Preload Reserve, Circulation: Heart Failure, 14:1, Online publication date: 1-Jan-2021.Fudim M, Brooksbank J, Giczewska A, Greene S, Grodin J, Martens P, Ter Maaten J, Sharma A, Verbrugge F, Chakraborty H, Bart B, Butler J, Hernandez A, Felker G and Mentz R (2020) Ultrafiltration in Acute Heart Failure: Implications of Ejection Fraction and Early Response to Treatment From CARRESS‐HF, Journal of the American Heart Association, 9:24, Online publication date: 15-Dec-2020. Ibrahim A, Ghaleb R, Mansour H, Hanafy A, Mahmoud N, Abdelfatah Elsharef M, Kamal Salama M, Elsaughier S, Abdel-Wahid L, Embarek Mohamed M, Ibrahim A and Abdel-Galeel A (2020) Safety and Efficacy of Adding Dapagliflozin to Furosemide in Type 2 Diabetic Patients With Decompensated Heart Failure and Reduced Ejection Fraction, Frontiers in Cardiovascular Medicine, 10.3389/fcvm.2020.602251, 7 Kaye D, Byrne M, Mariani J, Nanayakkara S and Burkhoff D (2020) Identification of physiologic treatment targets with favourable haemodynamic consequences in heart failure with preserved ejection fraction, ESC Heart Failure, 10.1002/ehf2.12908, 7:6, (3685-3693), Online publication date: 1-Dec-2020. Tang W and Kiang A (2020) Acute Cardiorenal Syndrome in Heart Failure: from Dogmas to Advances, Current Cardiology Reports, 10.1007/s11886-020-01384-0, 22:11, Online publication date: 1-Nov-2020. Boorsma E, ter Maaten J, Damman K, Dinh W, Gustafsson F, Goldsmith S, Burkhoff D, Zannad F, Udelson J and Voors A (2020) Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment, Nature Reviews Cardiology, 10.1038/s41569-020-0379-7, 17:10, (641-655), Online publication date: 1-Oct-2020. Boucher L, Benz R, Pierotty M, de Melo R and Valenti D (2020) Nerve Block Options for Pain Control during Hepatic and Upper Abdominal Minimally Invasive Procedures, Digestive Disease Interventions, 10.1055/s-0040-1717079, 04:03, (237-247), Online publication date: 1-Sep-2020. Fudim M, Boortz-Marx R, Ganesh A, DeVore A, Patel C, Rogers J, Coburn A, Johnson I, Paul A, Coyne B, Rao S, Gutierrez J, Kiefer T, Kong D, Green C, Jones W, Felker G, Hernandez A and Patel M (2020) Splanchnic Nerve Block for Chronic Heart Failure, JACC: Heart Failure, 10.1016/j.jchf.2020.04.010, 8:9, (742-752), Online publication date: 1-Sep-2020. Bouabdallaoui N, Beaubien-Souligny W, Oussaïd E, Henri C, Racine N, Denault A and Rouleau J (2020) Assessing Splanchnic Compartment Using Portal Venous Doppler and Impact of Adding It to the EVEREST Score for Risk Assessment in Heart Failure, CJC Open, 10.1016/j.cjco.2020.03.012, 2:5, (311-320), Online publication date: 1-Sep-2020. Costanzo M (2020) Novel Devices for the Cardiorenal Syndrome in Heart Failure, Current Treatment Options in Cardiovascular Medicine, 10.1007/s11936-020-00823-z, 22:9, Online publication date: 1-Sep-2020. Rao V, Fudim M, Mentz R, Michos E and Felker G (2020) Regional adiposity and heart failure with preserved ejection fraction, European Journal of Heart Failure, 10.1002/ejhf.1956, 22:9, (1540-1550), Online publication date: 1-Sep-2020. Bapna A, Adin C, Engelman Z and Fudim M (2019) Increasing Blood Pressure by Greater Splanchnic Nerve Stimulation: a Feasibility Study, Journal of Cardiovascular Translational Research, 10.1007/s12265-019-09929-7, 13:4, (509-518), Online publication date: 1-Aug-2020. Morgan T, Zhang Y, Pace N, Cai H, Shen B, Wang J, Roppolo J, de Groat W and Tai C (2020) Thermal block of mammalian unmyelinated C fibers by local cooling to 15–25°C after a brief heating at 45°C, Journal of Neurophysiology, 10.1152/jn.00133.2020, 123:6, (2173-2179), Online publication date: 1-Jun-2020. Rosenblum H, Kapur N, Abraham W, Udelson J, Itkin M, Uriel N, Voors A and Burkhoff D (2020) Conceptual Considerations for Device-Based Therapy in Acute Decompensated Heart Failure, Circulation: Heart Failure, 13:4, Online publication date: 1-Apr-2020. Gronda E, Vanoli E, Sacchi S, Grassi G, Ambrosio G and Napoli C (2019) Risk of heart failure progression in patients with reduced ejection fraction: mechanisms and therapeutic options, Heart Failure Reviews, 10.1007/s10741-019-09823-z, 25:2, (295-303), Online publication date: 1-Mar-2020. Deis T, Balling L, Rossing K, Boesgaard S, Kistorp C, Wolsk E, Gøtze J, Rehfeld J and Gustafsson F (2020) Plasma Somatostatin in Advanced Heart Failure: Association with Cardiac Filling Pressures and Outcome, Cardiology, 10.1159/000510284, 145:12, (769-778), . Zhen Z, Liao S, Zhu Z, Sijia S, Au K, Lai W, Tsang A, Hai J and Tse H (2019) Catheter-Based Splanchnic Denervation for Treatment of Hypertensive Cardiomyopathy, Hypertension, 74:1, (47-55), Online publication date: 1-Jul-2019. Antohi E, Ambrosy A, Collins S, Ahmed A, Iliescu V, Cotter G, Pang P, Butler J and Chioncel O (2019) Therapeutic Advances in the Management of Acute Decompensated Heart Failure, American Journal of Therapeutics, 10.1097/MJT.0000000000000919, 26:2, (e222-e233), Online publication date: 1-Mar-2019. Mullens W, Damman K, Harjola V, Mebazaa A, Brunner-La Rocca H, Martens P, Testani J, Tang W, Orso F, Rossignol P, Metra M, Filippatos G, Seferovic P, Ruschitzka F and Coats A (2019) The use of diuretics in heart failure with congestion - a position statement from the Heart Failure Association of the European Society of Cardiology, European Journal of Heart Failure, 10.1002/ejhf.1369, 21:2, (137-155), Online publication date: 1-Feb-2019. Fudim M, Ganesh A, Green C, Jones W, Blazing M, DeVore A, Felker G, Kiefer T, Kong D, Boortz-Marx R, Hernandez A and Patel M (2018) Splanchnic nerve block for decompensated chronic heart failure: splanchnic-HF, European Heart Journal, 10.1093/eurheartj/ehy682, 39:48, (4255-4256), Online publication date: 21-Dec-2018. Fudim M, Parikh K, Dunning A, DeVore A, Mentz R, Schulte P, Armstrong P, Ezekowitz J, Tang W, McMurray J, Voors A, Drazner M, O'Connor C, Hernandez A and Patel C (2018) Relation of Volume Overload to Clinical Outcomes in Acute Heart Failure (From ASCEND-HF), The American Journal of Cardiology, 10.1016/j.amjcard.2018.07.023, 122:9, (1506-1512), Online publication date: 1-Nov-2018. August 28, 2018Vol 138, Issue 9 Advertisement Article InformationMetrics © 2018 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.118.035260PMID: 29804067 Originally publishedJanuary 1, 2018 Keywordsacute heart failuresplanchnic nerve blockcongestionPDF download Advertisement SubjectsHeart FailureHemodynamicsPathophysiologyPhysiologyTranslational Studies
Referência(s)