Future Direction for RDN: From Hypertension to AFib and Beyond

In this video from CRT 2025, JIC speaks with Dr Eric Secemsky of the Beth Israel Deaconness Medical Center about the future of renal denervation in atrial fibrillation treatment.

Transcript:

Hi, I'm Eric Secemsky. I'm an interventional cardiologist at the Beth Israel Deaconess Medical Center in Boston, Massachusetts.

Can you please briefly explain the physiological link between the renal system and AFib?

We've learned a lot about the provocation of atrial fibrillation and the substrate that maintains atrial fibrillation based on the sympathetic nervous system. As such, we know that the sympathetic nervous system is key in activating many of the triggers for atrial fibrillation, and also through the mechanism of hypertension, results in remodeling of the cardio-pulmonary system that serves as the substrate to propagate atrial fibrillation.

How do you see renal denervation fitting into the current treatment paradigm for atrial fibrillation? Could it be a standalone therapy, or would it likely serve an adjunct role?

Right now, we are looking at this as an adjunct treatment for pulmonary vein isolation, PVI, procedures. We've seen in randomized trial data, one of such was published in JAMA just a few years ago, demonstrating that the burden of AFib is reduced when PVI is performed with renal denervation versus PVI performed in isolation. Whether we can reduce the burden or occurrence of atrial fibrillation with renal denervation as a standalone procedure (ie without PVI), is not proven yet, although it's an important question for us to continue to evaluate over the long term.

Is there a particular subgroup of AFib patients do you believe would benefit the most from renal denervation over more established therapies?

I think that patients who are hypertensive in general at baseline tend to have greater adrenergic activity and can be one of the mechanisms where atrial fibrillation might occur more frequently. Thus, I think having baseline uncontrolled hypertension plus atrial fibrillation might be a particular group that could benefit from both procedures.

Based on your experience so far, how do the outcomes of renal denervation in managing AFib compare with other treatments?

Right now, we are performing renal denervation just for blood pressure management alone, and we've seen very effective outcomes in our own institutional practice; we've done more than 20-plus cases commercially since approval in  November 2023. And we've seen average blood pressure reductions of 20/10mmHg through 6 months. So, we're definitely seeing the hypertension management part being effective. We're not doing this right now with PVI, that's primarily investigational, and we're still learning more about what AFib incidence looks like in this population after renal denervation. However, from a standalone treatment for hypertension, renal denervation is an effective adjunct to pharmacotherapy.

You've spoken about challenges in regard to reimbursement for RDN for hypertension. Do you foresee this as an obstacle for AFib as well? How can we make this financially viable for patients?

We're finally in a year where we can hopefully be optimistic about the coverage for renal denervation as we just had a national coverage announcement from Medicare and, hopefully, we'll have a full determination in this calendar year of 2025. The nice thing also is that atrial fibrillation treatment with PVI is still a well-reimbursed procedure, so having these adjunctively together can still be a viable option and economically feasible if the candidate is appropriate.

Are there any upcoming clinical trials or studies that you can share with us?

There’s a number of clinical trials. Recor Medical has an atrial fibrillation/PVI trial with renal denervation that is being run out of Mount Sinai, New York, and will be a really important future trial to confirm prior studies demonstrating the rold of renal denervation as an adjunct to PVI. We need more data here, and although early trials have been supportive, it is important that we should continue to investigate this link between renal denervation and improved AFib outcomes.

The transcript has been lightly edited for clarity.