WO2020097428A1 - Systèmes et méthodes de décharge ventriculaire gauche dans le traitement de l'infarctus du myocarde - Google Patents

Systèmes et méthodes de décharge ventriculaire gauche dans le traitement de l'infarctus du myocarde Download PDF

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Publication number
WO2020097428A1
WO2020097428A1 PCT/US2019/060411 US2019060411W WO2020097428A1 WO 2020097428 A1 WO2020097428 A1 WO 2020097428A1 US 2019060411 W US2019060411 W US 2019060411W WO 2020097428 A1 WO2020097428 A1 WO 2020097428A1
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minutes
patient
heart
myocardial infarction
pump
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PCT/US2019/060411
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English (en)
Inventor
Navin K. Kapur
Richard H. Karas
Noam JOSEPHY
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Tufts Medical Center, Inc.
Abiomed, Inc.
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Priority claimed from US16/244,998 external-priority patent/US20190216995A1/en
Application filed by Tufts Medical Center, Inc., Abiomed, Inc. filed Critical Tufts Medical Center, Inc.
Publication of WO2020097428A1 publication Critical patent/WO2020097428A1/fr

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    • A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
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Definitions

  • AMI Acute myocardial infarction
  • DTB heart failure
  • IRT ischemia-reperfusion injury
  • Prior attempts to limit IRI include vascular conditioning approaches to activate reperfusion injury salvage kinase (RISK) pathway activity and pharmacologic approaches, but the clinical benefit of those approaches has not necessarily been optimal.
  • RISK reperfusion injury salvage kinase
  • a critical barrier to these cardioprotective strategies is the requirement for rapid coronar reperfusion - they potentially leave insufficient time for any therapeutic impact on myocardial injury.
  • Support devices include percutaneously delivered transvalvular axial-flow pumps (TV-Pumps), intra-aortic balloon pumps, intra-corporeal axial flow catheters and extracorporeal membrane oxygenation (ECMO) pumps, and have become popular in the treatment of myocardial injury in the case of TV-pumps, such devices assist with the mechanical pumping of blood out of the left ventricle of the heart and thereby unload tire heart, rapidly reducing left ventricular (LV) wail stress, stroke work, and myocardial oxygen demand, while augmenting systemic mean arterial pressure without the need for surgery.
  • TV-Pumps percutaneously delivered transvalvular axial-flow pumps
  • intra-aortic balloon pumps intra-corporeal axial flow catheters
  • ECMO extracorporeal membrane oxygenation
  • a preliminary swine model of AMI model has been studied to compare primary reperfusion therapy with therapy that delays reperfusion therapy until after unloading the left atrium using a percutaneously delivered extracorporeal, centrifugal pump, with initial indications that delaying coronary reperfusion (P-unloading) may reduce myocardial injury.
  • Another study has applied a percutaneously delivered transvalvular pump directly into the left ventricle of an animal and observed unloading implications when delaying coronary reperfusion for 60 min. The implications for treating MI in humans has not been well understood.
  • the present disclosure relates to an improved method of supporting a human patient’s heart that has sustained myocardial infarction, with the surprising result that the sequence and timing of applying support to the heart prior to reperfusion can improve the heart and reduce the impact of an infarction.
  • the technology can be further applied to prevent or limit the effects of heart failure in a human patient. This can be done by, for example, reducing maladaptive cardiac remodeling in the patient.
  • the method (and systems configured for application) stabilizes or reduces the size of the infarct, which is beneficial to tire patient’s heart. Certain applications include applying a mechanical circulatory support device to reduce the size of an infarct; some application include applying reperfusion therapy after a period of delay wherein tire heart is supported with a mechanical circulatory device.
  • the method is applied by taking a counter approach to conventional modes and theories in the field - rather than immediately applying reperfusion therapy to a patient that has suffered a heart attack, the method (and systems) first supports the heart by reducing myocardial oxygen demand (e.g., by unloading the heart) for a period of time and then, after that support period, restores the oxygen supply to the affected area of the heart (e.g., by reperfusion).
  • the methods thus seek to reduce the time between an AMI and the initiation of mechanical circulatory support, such period referred to conveniently, as the“door to unload.” It has been found that taking such an approach can increase the myocardial salvage of the human heart and reduce the size of the infarct in the human heart. Additionally, such an approach has the surprising effect of preventing or limiting the effects of heart failure in a human patient by, for example, reducing maladaptive cardiac remodeling in the patient.
  • Tire method comprises the steps of (I) inserting a mechanical circulatory support device into the human patient after the myocardial infarction, (ii) prior to re-perfusing the heart, operating the mechanical circulatory support device for a defined support time (the support period), and (iii) after the support period, applying reperfusion therapy to the heart (e.g., inserting a stent, or applying drug therapy to free a narrowed or occluded area in the coronary vasculature).
  • the support period is preferably longer than 15 minutes.
  • the support period may be least 30 minutes and less than 60 minutes.
  • the mechanical circulatory' support device is a cardiac assist device that operates to pump at a rate of at least 2.5 L/min of blood flow.
  • a method of supporting a patient’s heart that has sustained myocardial infarction.
  • the method comprises the step of percutaneously inserting a transva!vular blood pump into the patient and positioning the pump across the aortic valve of the patient’s heart, with a distal end of the pump located in the left ventricle of the heart. Then, prior to re-perfusing the heart, the method proceeds with the step of operating the positioned pump to unload the left ventricle at a pumping rate of at least 2 5 L/min of blood flow for a pumping period of greater than 15 minutes. After the pumping period, the method then comprises the step of treating the heart with re-perfusion therapy.
  • a method of reducing the size of a myocardial infarction scar in a patient’s heart comprises the step of percutaneously inserting a trans val vular microaxial blood pump into the patient, and positioning the pump across the aortic valve of the patient’s heart with a distal end of the pump located in the left ventricle of the heart.
  • the method then comprises, prior to re-perfusing the heart, operating the positioned pump to unload the left ventricle for a pumping period of longer than 15 minutes at a pumping rate of at least 2.5 L/min of blood flow. After the pumping period, the method comprises applying reperfusion therapy to the heart.
  • a method of supporting a myocardial infarcted heart comprises percutaneously inserting a mechanical circulatory support device into the patient after myocardial infarction of the patient’s heart, prior to re-perfusing tire heart, operating the device to unload the left ventricle at a rate of at least 2.5 L/min of blood flow (e.g., 3.5 L/min) for an unloading period of longer than 15 minutes, and after the unloading period, applying reperfusion therapy to the heart.
  • a mechanical circulatory support device into the patient after myocardial infarction of the patient’s heart, prior to re-perfusing tire heart, operating the device to unload the left ventricle at a rate of at least 2.5 L/min of blood flow (e.g., 3.5 L/min) for an unloading period of longer than 15 minutes, and after the unloading period, applying reperfusion therapy to the heart.
  • a method of supporting a patient’s heart with a myocardial infarction comprises the steps of (i) reducing levels of BAX protein and active Caspase-3 antibody in patient cardiac tissue in the myocardial infarction area (the area at risk), and (li) increasing levels of BCL-2 and BCL-XL proteins in patient cardiac tissue in the myocardial infarction area.
  • a method of supporting a patient’s heart with a myocardial infarction comprising at least one of (i) reducing levels of BAX protein and active Caspase-3 antibody in patient cardiac tissue near the myocardial infarction, (ii) increasing levels of BCL-2 and BCL-XL proteins in
  • a method of supporting a patient’s heart with a myocardial infarction comprising increasing stromal derived factor la (SDF-la) protein levels in patient cardiac tissue near the myocardial infarction.
  • Tire method may comprise maintaining activity levels of MMP-2 and MMP-9 enzymes in patient cardiac tissue in the myocardial infarction area.
  • the method may also comprise limiting upregulation of DPP -4 protein expression and activity in patient cardiac tissue in the myocardial infarction area.
  • Such methods may be performed with a mechanical circulatory support device, such as a transvalvuiar or extracorporeal pump.
  • a method of supporting a patient’s heart with a myocardial infarction comprising reducing circulating levels of brain natriuretic peptide (BNP) in the patient’s blood.
  • the method also comprises increasing mRNA levels of SERCA expression in patient cardiac tissue in the myocardial infarction area.
  • the method further comprises reducing levels of calcineurin activity and Type I collagen in patient cardiac tissue near the myocardial infarction while maintaining levels of b-MHC in the non-infarct region of the patient’s heart.
  • a method of supporting a patient’s heart with a myocardial infarction comprising (i) reducing levels of BAX protein and active Caspase-3 antibody in patient cardiac tissue in the myocardial infarction area, (ii) increasing levels of BCL-2 and BCL-XL proteins in patient cardiac tissue in the myocardial infarction area, (iii) increasing stromal derived factor la (SDF-l a) protein levels in patient cardiac tissue in the myocardial infarction area, (iv) maintaining activity levels of MMP-2 and MMP-9 enzymes in patient cardiac tissue in the myocardial infarction area, (v) limiting upregulation of DPP-4 protein expression and activity in patient cardiac tissue in the myocardial infarction area, (vi) reducing circulating levels of brain natriuretic peptide (BNP) in the patient s blood, (vii) increasing mRNA levels of SERCA expression in patient cardiac ceils in the myo
  • a cardioprotective system for supporting a patient’s heart that has sustained myocardial infarction.
  • the system comprises a mechanical circulatory support device configured to be inserted into the patient, and a reperfusion therapy device.
  • the system is configured such that prior to operating the reperfusion therapy device, the mechanical circulator ⁇ ' support device is configured to operate for a support period of greater than 15 minutes at a rate of at least 2.5 L/min of blood flow'.
  • a cardioprotective system for supporting a patient’s heart that has sustained myocardial infarction.
  • the system comprises a blood pump configured to be percutaneously inserted into the patient after the myocardial infarction, the pump sized and shaped to be positioned across the aortic valve of the patient’s heart, with a distal end of the pump configured to be located in the left ventricle of the heart.
  • the system also comprise a reperfusion therapy device.
  • the system is configured such that the blood pump is programmed to be operated prior to operating the reperfusion therapy device and thereafter pump blood at a rate of at least 2.5 L/min of blood flow for a pumping period of longer than 15 minutes.
  • a method of treating a human heart that has sustained myocardial infarction comprising reducing the infarct size.
  • a method of prev enting or limiting the effects of heart failure in a human patient that has sustained myocardial infarction by reducing maladaptive cardiac remodeling in the patient comprise percutaneously inserting a transvalvular blood pump, comprising a rotor and a cannula, into the patient’s vasculature and positioning the cannula across the aortic valve of the patient’s heart, with a distal end of the cannula located in the left ventri cl e of the heart and a proximal end of the pump located in the aorta.
  • the method Prior to reperfusing the heart, the method then comprises the step of operating the positioned pump to unload the left ventricle at a pumping rate of at least 2.5 L/min of blood flow for a support period between at least 30 minutes and less than 60 minutes. After the support period, the method then comprise the step of applying coronary reperfusion therapy to the heart.
  • Maladaptive cardiac remodeling includes, but is not limited to, one or more of: changes in the size, shape, structure, and function of the heart.
  • a system for preventing or limiting the effects of heart failure in a human patient that has sustained myocardial infarction by reducing maladaptive cardiac remodeling in the patient comprises a blood pump, comprising a rotor and a cannula, the blood pump configured to he percutaneously inserted into the patient’s vasculature such that the cannula is positioned across the aortic valve of the patient’s heart, with a distal end of the cannula located in die left ventricle of the heart and a proximal end of the pump located in the aorta.
  • the system may additionally comprise a controller coupled to the pump so as to control the operation of the pump.
  • the system also comprises a coronary reperfusion therapy device.
  • the controller programs the blood pump to unload die left ventricle at a pumping rate of at least 2.5 L/min of blood flow for a support period between at least 30 minutes and less than 60 minutes prior to operating the coronary reperfusion therapy device.
  • the support period is about 30 minutes, or may be between 15 and 30 minutes. In some implementations, the support period is longer than 30 minutes or longer than 45 minutes. In some implementations, the mechanical circulatory support device pumps at a rate of at least 3.5 L/min of blood flow. In certain
  • die device provides a cannula placed into the patient’s heart and pumps blood through the cannula.
  • the device is a microaxial blood pump with a motor and an onboard rotor and stator that mechanically operates to pump blood from die heart; in some implementations the device operates by an external motor and may deploy die pump motor external to the patient and rely on a long cannula extending through the patient’s vasculature to the heart.
  • a suitable mechanical circulatory ' support device is a transvalvular microaxial pump (e.g., an Impella ⁇ blood pump, such as the Impella CP, or a similar device), where the pump is inserted percutaneously or surgically into the aorta and across the aortic valve, allowing the pump to pump blood out of the left ventricle and thereby“unload” the left ventricle.
  • a transvalvular microaxial pump e.g., an Impella ⁇ blood pump, such as the Impella CP, or a similar device
  • the method includes percutaneously inserting a transvalvular micro axial pump blood pump (TV pump), comprising a rotor and a cannula, into the patient’s vasculature and positioning the cannula across the aortic valve of the patient’s heart, with a distal end of the cannula located in the left ventricle of the heart and a proximal end of the pump located in the aorta.
  • TV pump transvalvular micro axial pump
  • An extracorporeal pump may also be used (e.g., Tandem Heart) to unload a heart chamber (such as an atria or ventricle) according to methods disclosed herein. Left or right atria may be unloaded, as may the right ventricle.
  • the heart is unloaded by the mechanical circulatory support device concurrently with reperfusion (for example, after unloading the heart).
  • the period of unloading can be at least 30 minutes, 3 hours, or longer.
  • Various mechanical circulatory support devices may be used in the method of the present disclosure, either alone or in combination.
  • an intra-aortic balloon pump may be used to provide support to the heart after a period of delay.
  • a combination of devices is used.
  • a TV -pump may be used to unload the left ventricle while also using an extracorporeal membrane oxygenation (ECMQ) pump, or intra-aortic balloon pump, or other mechanical circulatory support system in combination.
  • ECMQ extracorporeal membrane oxygenation
  • the reperfusion therapy in the method of the present disclosure comprises at least one of primary percutaneous coronary ' intervention (PCI) and fibrinolysis.
  • methods comprise one or more of the following steps: (i) reducing levels of BAX protein and active Caspase-3 antibody in patient cardiac tissue near a myocardial infarction; (ii) increasing levels of BCL-2 and BCL-XL proteins in patient cardiac tissue near a myocardial infarction; (iii) increasing stromal derived factor la (SDF-la) protein levels in patient cardiac tissue near a myocardial infarction; (iv) maintaining activity levels of MMP-2 and MMP-9 enzymes in patient cardiac tissue near a myocardial infarction; (v) limiting upregulation of DPP-4 protein expression and activity in patient cardiac tissue near a myocardial infarction; (vi) reducing circulating levels of brain natriuretic peptide (BNP in the patient’s blood; (vii) increasing mRNA levels of SERCA expression in patient cardiac cells near a myocardial infarction; and (viii) reducing levels of calcineurin activity and Type
  • the methods may be applied so that any combination (or all) of the foregoing steps are performed.
  • Implementation of one or more of steps (i)-(viii) in any of the methods of the aforementioned embodiments has the surprising result of preventing or limiting the effects of heart failure in a human patient. This can he done by, for example, reducing maladaptive cardiac remodeling in the patient.
  • the methods may be applied to reduce infarct size in patients having elevated ⁇ STE levels.
  • the method may be applied by unloading the left ventricle of a patient having an Ml and an ⁇ STE level of at least 4 (e.g., 5 or 6 or greater than 6), and reducing the infarct size in that patient.
  • the methods may be applied to reduce the infarct size and the left ventricle scar size.
  • the method also comprises increasing blood flow from the left ventricle of the patient’s heart by applying mechanical circulatory support to the patient.
  • the increased blood flow is provided at a rate of at least 2.5 L/min of blood flow for an unloading period of longer than 15 minutes.
  • the method also comprises the step of applying reperfusion therapy to the patient cardiac tissue near the myocardial infarction after applying mechanical circulatory support.
  • the system comprises one or more of the following devices that are operated after or during operation of the mechanical circulatory support device: an intra aortic balloon pump, and an extracorporeal membrane oxygenation (ECMO) pump.
  • reducing the infarct size is done by reducing myocardial oxygen demand of the heart in the portion of the heart containing the infarction, followed by restoring oxygen supply to the portion of the heart containing the infarction.
  • the method comprises reducing levels of at least one of BAX protein and active Caspase-3 in cardiac tissue.
  • the method comprises increasing levels of at least one of BCL-2 and BCL-XL.
  • the method comprises increasing a myocardial sal vage index (MSI) of the heart.
  • MSI myocardial sal vage index
  • the method also comprises the steps of (i) inserting a blood pump into the patient’s vasculature, (ii) prior to applying reperfusion therapy to the heart, actuating the pump during a support period to adjust blood flow within the vasculature, and (iii) after the support period, applying reperfusion therapy to the heart.
  • the support period is at least 15 minutes. In other implementations, the support period is at least 30 minutes, between about 20 minutes and about 40 minutes, or at least 45 minutes.
  • the method also comprises the step of unloading the heart’s left ventricle at a pumping rate of at least 2.5 L/minute during the support period.
  • the blood pump is a micro axial blood pump
  • unloading the left ventricle of the heart comprises inserting a distal end of the pump into the left ventricle and a proximal end of the pump in the aorta, and actuating the pump to pump blood from the left ventricle into the aorta.
  • the method comprises the steps of (i) inserting a balloon pump into the aorta of the heart, and (ii) inflating and deflating the balloon to adjust blood flow within the aorta.
  • the pump is a catheter-based intravascular blood pump.
  • the method comprises at least one of (i) increasing the left ventricular ejection fraction of the heart, (ii) decreasing microvascular obstruction in the heart, (iii) reducing the left ventricular end systolic volume of the heart, and (iv) reducing the left ventri cular end diastolic volume of the heart.
  • the method comprises reducing myocardial oxygen demand of the heart in the portion of the heart containing the infarction for a period of at least 15 minutes, followed by restoring oxygen supply to the portion of the heart containing the infarction.
  • the heart is unloaded by the mechanical circulatory support device concurrently with performing reperfusion therapy on the heart.
  • reperfusion therapy comprises at least one of primar ' percutaneous coronaiy intervention (PCI) and fibrinolysis.
  • the method also comprises the steps of (i) reducing circulating levels of brain natriuretic peptide (BNP) in the patient’s blood, (ii) increasing mRNA levels of SERCA expression in patient cardiac cells near the myocardial infarction, and (iii) reducing levels of calcineurin activity and Type I collagen in patient cardiac tissue near the myocardial infarction while maintaining levels of b-MHC in the non-infarct region of the patient’s heart.
  • the method also comprises removing the blood pump from the patient’s heart after applying the reperfusion therapy.
  • the method also comprises increasing blood flow to patient cardiac tissue near the myocardial infarction.
  • the methods according to any of the foregoing embodiments may comprise continuing the operation of the pump in parallel with the application of coronary reperfusion.
  • the pump is operated in parallel with the application of coronary reperfusion for a total support period of at least 3 hours.
  • the methods may comprise operating the pump so as to sufficiently unload the heart to change genetic expression in cells within the myocardial infarct zone. Unloading the heart is such a manner has the advantage of preventing or limiting the effects of heart failure in a human patient. This can be done by, for example, reducing maladaptive cardiac remodeling in the patient.
  • the methods may comprise providing the patient with drug therapy in combination with operating the pump.
  • the drug therapy may comprise providing the patient with medicament comprising at least one of: beta blockers, afterload reduction agents, neurohonnonal agents, and ace inhibitors.
  • FIG. 1 shows an illustrative cardioprotective system according to an implementation of the present disclosure
  • FIG. 2 show's an illustrative method of supporting a patient’s heart that has sustained myocardial infarction
  • FIG. 3 shows a flow chart outlining the methodology of the study in Example 1 using the method of FIG. 2;
  • FIG 4 shows an unload to balloon time scatter plot for the study in Example I using the method of FIG. 2;
  • FIGS. 5A-5C show' CMR box-whisker plots stratified by ST-elevation sum for the results of the study in Example 1 using the method of FIG. 2;
  • FIG. 6A shows a flowchart illustrating the effect of reperfusion alone (group 1 ), left ventricular unloading for 15 rain (group 2) or 30 min (group 3) before reperfusiom, or left ventricular unloading after reperfusion (group 4) in the study of Example 2 using the method of FIG. 2;
  • FIG. 7B shows a graph illustrating further results of the study referenced in FIG. 3, showing relative messenger ribonucleic acid levels of representative genes from key components of the electron transport chain from within the infarct zone of group 1 (blue) or group 3 (orange) of FIG. 7A, *p ⁇ 0.05 versus sham control; #p ⁇ 0.05 versus primary reperfusion;
  • FIG . 7C shows representative transmission electron micrographs of cardiomyocyte mitochondria from sham controls and from within the infarct zone of group 1 and group 3 of FIG. 7A;
  • DPP4 dipeptidyl peptidase-4
  • LGE late gadolinium enhancement
  • CMR cardiac magnetic resonance imaging
  • FIG. 10B shows regression plot showing correlation between LGE-CMR and anatomic pathologic quantification of LV scar size
  • FIGS. 10C and 10D show representative CMR images showing LV scar within die blue or red circles
  • FIG. 10G shows regression plot showing the correlation between LV scar size as a percentage of die total left ventricle versus plasma SDF-la levels 28 days after myocardial infarction *p ⁇ 0.05 versus sham; ⁇ p ⁇ 0.05 versus P-reperfusion;
  • FIGS. 11A-11C show circulating levels, mRNA levels, and protein levels of B-type natriuretic peptide (BNP) from LV tissue (noninfarct zone) 28 days after primary reperfusion or primary unloading using die method of FIG. 2;
  • BNP B-type natriuretic peptide
  • FIGS. 1 1D-11G show messenger ribonucleic acid (mRNA) levels of sarcoplasmic/ endoplasmic reticulum calcium ATPase (SERCA), calc eurin, type 1 collagen (COL I), and beta-myosin heavy chain (b-MHC) from LV tissue (noninfarct zone) 28 days after primary reperfusion or primary unloading using the method of FIG. 2; and
  • mRNA messenger ribonucleic acid
  • FIG. 12 illustrates schematically the effect of mechanically unloading the left ventricle for a minimum of 30 min before reperfusion which limits expression of proteolytic enzymes that degrades stromal -derived factor-la (SDFla), thereby increasing cardioprotective signaling improving cell survival, and reducing both acute infarct size and subsequent myocardial scar size 28 days after acute myocardial infarction.
  • FIG. 1 illustrates a system 100 for providing a combination of mechanical support and Primary Reperfusion according to an implementation of the present disclosure.
  • System 100 aims to limit myocardial damage in a human patient 110 who has experienced AMI in the heart 120.
  • the system 100 comprises a circulatory' unit 130 and a device (or other source) for providing reperfusion therapy 140.
  • the circulatory unit 130 is in communication with a control unit 150.
  • Control unit 150 may monitor signals issued by the circulatory unit 130 and, accordingly, control the operation of the devices (or other source) comprising the circulatory unit 130. These signals may be indicative of any one of the following: the operational state of the circulatory unit 130, the position and state of the device for reperfusion therapy 140, and the state of the patient’s heart.
  • Samples from the AMI patient may be obtained from either the circulator ' unit 130 or the device for reperfusion therapy 140, or from a biopsy or other source, for characterization and further testing. This may be done via a testing kit or a laboratory' to extract various indicia from these samples so that they can be monitored by a clinician.
  • Such indicia may include, for example, the myocardial infarction scar size, and associated parameters that will be detailed in the following sections.
  • the circulatory unit 130 comprises a mechanical circulatory support device that can be inserted, for example, in the left ventricle of the patient’s heart.
  • a mechanical circulator ⁇ ' support device is capable of changing the blood flow above and beyond the actual cardiac output of the heart.
  • the mechanical circulatory support device may be inserted into the left ventricle of the heart of a patient with AMI and actuated to unload the heart by pumping blood out of the ventricle. This can assist the heart in several possible ways. For example, the myocardium wail stress is reduced. This is beneficial as the mechanism of unloading may assist in myocardial salvage and repair.
  • the mechanical circulatory ' support device may comprise a transvalvular microaxiai blood pump.
  • blood pumps include, but are not limited to, Impella 2.5TM and Impel la CP® by Abiomed, Inc., Danvers, MA
  • extracorporeal pumps may be used to assist the heart, such as extracorporeal pumps.
  • extracorporeal membrane oxygenation (ECMO) or intraaortic balloon pumps may be used in some adaptations a transvalvular pump is used in combination with another such device.
  • ECMO extracorporeal membrane oxygenation
  • intraaortic balloon pumps may be used in some adaptations a transvalvular pump is used in combination with another such device.
  • the circulatory unit 130 may also comprise additional pump devices that assist with the unloading of the heart.
  • Examples of such pump assist devices include, but are not limited to, any one of the following: an intra-aortic balloon pump, and an extracorporeal membrane oxygenation (ECMO) pump.
  • a transvalvular pump may unload the heart while a balloon pump or ECMO device is applied to further assist the patient.
  • the circulatory device may comprise a cannula portion in fluid communication with a pump in which the distal end of the cannula may be positioned within the heart of the patien t, and the pump may be positioned at any one of: (a) within the heart with the cannula, (b) outside the heart but within the patient, and (e) outside the patient.
  • the device 140 is used to administer reperfusion therapy to the patient undergoing AMI.
  • reperfusion therapy includes, for example, primary percutaneous coronary ' intervention (PCI). These procedures may involve the use of a coronary stent delivered into the distal left anterior descending artery (LAD).
  • LAD left anterior descending artery
  • coronary' stents include, but are not limited to, the Promus PREMIERTM and the REBELTM bare-metal Platinum Chromium Coronary Stents, and the SYNERGYTM Bioabsorbable Polymer Stent, all by Boston Scientific, Marlborough, MA.
  • reperfusion therapy 140 rnay comprise drug or medicament that is capable of assisting in fibrinolysis, thereby providing reperfusion therapy either in combination with or as an alternative to a stent or other device.
  • a kit or laboratory is capable of generating the following clinical indicia relevant to myocardial infarction : BAX, BCL-2, BCL-XL, DPP-4 and stromal derived factor la (SDF- la) protein levels, active Caspase-3 antibody levels, MMP-2 and MMP-9 enzyme levels in patient cardiac tissue near or in tire zone of the myocardial infarction site: mRNA levels of SERCA expression in patient cardiac cells near or in the zone of the myocardial infarction; calcineurin activity levels and Type I collagen levels near or in the zone of the myocardial infarction; brain natriuretic peptide (BNP) levels in blood taken from the left ventricl e of the patient’s heart; myocardial salvage index; and ST elevation surn(s) from an
  • FIG. 2 shows a flowchart of an illustrative method 200 for unloading the left ventricle of the heart in a patient with AMI.
  • the method starts at step S210 where a circulatory device, such as the mechanical circulatory device of the circulatory unit 130 in FIG. 1, is inserted into tire patient after myocardial infarction.
  • a circulatory device such as the mechanical circulatory device of the circulatory unit 130 in FIG. 1
  • Such insertion may be achieved by using a vascular access sheath deployed into the right internal jugular vein, left carotid artery, and one or more offemoral arteries and veins of the patient. Further clinical details of such insertion procedures, and associated exemplary supportive data for method 200, are detailed in Examples 1 and 2 in the following sections.
  • step S220 the circulatory' device is operated in step S230 to support the heart, for example by unloading the patient ’ s heart after myocardial infarction.
  • the circulatory device is operated to achieve a pumping rate of at least 2.5 1./min of blood flow from the left ventricle of the heart.
  • the circulatory de vice is operated to achieve a blood flow' rate from the left ventricle of the heart of at least 3.5 L/min of blood flow per cardiac output.
  • Hie unloading is performed for a period (the support period t_sp) that is sufficiently long so as to facilitate a reduction in infarct size.
  • operation of the circulatory device is terminated after tire support period t sp has elapsed.
  • the support period is merely- used as a marker to indicate the elapse of time t sp since the circulatory device has commenced operation, and operation of the circulatory device need not be stopped after t_sp has elapsed.
  • Example 1 provides supportive data for the step of unloading a patient’s heart after myocardial infarction using the method 200 of the present disclosure.
  • the support period t_sp is longer than 15 mins. In other implementations, the support period t_sp is longer than 30 mins
  • step S240 in which a reperfusion therapy is applied to the patient’s heart.
  • Reperfusion therapy is administered using a reperfusion device, drug, or other technique
  • FIG. 1 applies a reperfusion device 140.
  • Clinical details of such reperfusion therapy procedures, and associated exemplary supportive data for method 200, are provided in Examples 1 and 2 below.
  • reperfusion therapy may be applied to the patient’s heart after unloading the left ventricle of the heart.
  • reperfusion therapy may be applied to a patient’s heart while the left ventricle is still being unloaded by the circulator unit.
  • the parallel use of the reperfusion device and the circulatory' device is only earned out after the heart is unloaded with the circulatory' device for the length of the support period t__sp.
  • One or more benefits may be detected in tissue or blood samples taken from the patient. Such benefits may include one or more of the following results: reducing levels of BAX protein and active Caspase-3 antibody in patient cardiac tissue near the myocardial infarction; increasing levels of BCL-2 and BCL-XL proteins in patient cardiac tissue near the myocardial infarction; increasing stromal derived factor la (SDF-l a) protein levels in patient cardiac tissue near the myocardial infarction; maintaining activity' levels of MMP-2 and MMP-9 enzymes in patient cardiac tissue near the myocardial infarction; limiting
  • Examples 1 and 2 detailed below illustrate the results of studies performed by applying an inventive method to patients who had suffered a heart attack.
  • the studies were conducted by inserting a blood pump into the patient’s vasculature after the patient suffered AMI, but prior to applying reperfusion therapy to the heart, actuating the pump during a support period to adjust blood flow within the vasculature, and then after the support period, applying reperfusion therapy to the heart.
  • the results indicate that infarct size was reduced and myocardial salvage index vras increased as compared to conventional methods that apply reperfusion therapy immediately (or as soon as possible) after infarction.
  • EXAMPLE 1 DTU-STEMI pilot study
  • the DTU-STEMI study was a prospective, multicenter, randomized pilot trial involving 14 centers in the United States to explore the feasibility, safety and potential benefit of mechanical unloading prior to coronary reperfusion in patients presenting with anterior STEMI. All patients received acute mechanical unloading with the Impella CP system (Abiomed Inc., Danvers, MA) and were then randomized to one of two arms: LV unloading followed by immediate reperfusion (U-IR) or LV unloading with a 30-minute delay to reperfusion (U-DR). The process flow for U-IR and U-DR methodologies is shown in FIG. 3. This comparison was specifically designed to precondition the myocardium for 30 minutes before reperfusion by comparing infarct sizes in the U-DR versus U-IR arms.
  • Impella CP was placed prior to diagnostic coronary angiography and operators were instructed to perform percutaneous coronary intervention (PCI) using second-generation drug eluting stents and to follow' guideline-directed post-AMI care. In the U-DR group, operators were allowed to shorten the time between unloading and reperfusion if deemed clinically necessary. After PCI, the Impe!la CP was explanted after a min imum of 3 hours of LV support.
  • PCI percutaneous coronary intervention
  • the primary safety outcome was a composite of major adverse cardiovascular and cerebrovascular events (MACCE) including cardiovascular mortality, reinfarction, stroke, or major vascular events at 30 days.
  • Table 1 contains definitions used to adjudicate each component of MACCE. Additional safety parameters included all-cause mortality, hemolysis, acute renal dysfunction, hospitalization for heart failure, ventricular arrhythmias, LV thrombus, bleeding and minor vascular events.
  • the primary efficacy endpoint was an assessment of infarct size as percent of total LV mass at 30 days using CMR. Secondar - efficacy endpoints included infarct size by CM at 3-5 days and 30 days. Exploratory endpoints included a comparison of infarct size normalized to area at risk at 3-5 days between groups.
  • ⁇ STE ST Segment Elevation Sum
  • Baseline Characteristics [0079] Baseline demographic and clinical variables were summarized for the two treatment groups. The study was powered to detect a large difference in infarct size assuming a large standard deviation that may be expected in a small STEMI study. Specifically, a power of 0.88 and an alpha of 0.05 was used to detect an absolute difference in infarct size of 10% with an assumed standard deviation of 10%. All continuous variables were summarized as means with standard deviations as well as medians and interquartile ranges and compared between treatment groups using the appropriate parametric or non-parametric tests.
  • Impella CP was successfully implanted in all 50 patients with a mean power (P-level) of 7.6 ⁇ 1.0 and mean device flow of 2.8 ⁇ 0.4 L/min during the 3 hours of support required by the study protocol, indicating successful unloading of the LV.
  • One patient randomized to the U-DR arm did not have any coronary lesions requiring PCI. All patients undergoing PCI received a P2Y12 inhibitor prior to PCI. 8% of patients received bivalirudin and 94% received unfractionated heparin . Among these, one patient received both bivalirudin and unfractionated heparin. 8% of patients received a glycoprotein 2b/3a receptor inhibitor in addition to dual antiplatelet therapy prior to PCI. Coronary angiography was performed after LV unloading w3 ⁇ 4s initiated.
  • TIMI Myocardial Infarction
  • the DTU-STEMI safety and feasibility pilot study represents the first human experience of mechanically unloading the LV and intentionally delaying coronary reperfusion (Primary Unloading) in anterior STEMI using the method 200 of die present disclosure.
  • CV mortality was observed in one patient for each arm of the study and approaches national benchmarks for 30-day STEM! mortality ' rates.
  • One patient was diagnosed with an acute exacerbation of pulmonary fibrosis on post-op day 3 and expired 10 days later from respiratory' failure, the second mortality was a patient who presented in cardiogenic shock which was detected only after enrollment.
  • Major vascular event rates in the DTU-STEMI study were comparable to the pump arm of the Intra-aortic Balloon Counterp ulsation and Infarct Size in Patients with Acute Anterior Myocardial Infarction Without Shock (CRISP- AMI) study.
  • RISK activation promotes cell survival by limiting cardiomyocyte apoptosis and maintains mitochondrial integrity by preventing opening of the mitochondrial trans-permeability pore.
  • the mechanisms underlying the cardioprotective benefit of P-unloading and whether the acute decrease in infarct size results m a durable reduction in left ventricular (LV) scar and improvement in cardiac function are further explained herein. This study tested the importance of delayed myocardial reperfusion, explored cardioprotective mechanisms, and determined the late-term impact on myocardial function associated with P-unloading.
  • LAD left anterior descending artery
  • Boston Scientific 3.0 x 8 mm bare-metal stent
  • Boston Scientific 3.0 x 8 mm angioplasty balloon
  • Coronary angiography also performed immediately after reperfusion and again after the end of the study protocol confirmed patency of the LAD.
  • LAD stents w'ere used in the acute animal study to mark the exact location for repeat balloon occlusion during Evans blue counterstaining. Animals were then euthanized with pentobarbital and phenytoin after 120 min of reperfusion.
  • TV-pump impella CP, Abiomed, Danvers, Massachusetts
  • an over-the-wire coronary angioplasty balloon was used to deliver a pharmacological inhibitor of the SDF- la receptor, CXCR4 (known as AMDS 100), into the area at risk while maintaining occlusion of the LAD m a closed-chest animal model of AMI.
  • AMDS 100 pharmacological inhibitor of the SDF- la receptor
  • Absolute LV volumes were measured by subtracting parallel conductance from total conductance volumes. Stroke volume is calculated as the difference in conductance volumes at +dP/dtmax and - P/dtmin. LV stroke w'ork was calculated as the product of peak LV peak systolic pressure and stroke volume.
  • LV scar size 28 days after ML the left ventricle was sectioned into five 1-cm slices and then incubated in triphenyltetrazolium chloride without Evans blue. LV slices were then photographed, and 3 blinded reviewers used digitized planimetry to quantify the total myocardial area, area-at-risk, and infarct zone.
  • LGE images were acquired 10 to 15 mm after intravenous administration of 0.2 mmol/kg gadolinium-diethylenetriamine penta-acetic acid with breath-hold 2-dimensional, phase -sensitive inversion recovery- sequences in identical places as in cine images.
  • LGE regions were defined by using full width at one-half maximum (>50% of maximum myocardial signal intensity) with manual adjustment when needed. Areas with LGE were summed to generate a total volume of LGE and are expressed as a proportion of total LV myocardium (%LGE).
  • RNA ribonucleic acid
  • GSE Gene Expression Omnibus accession number 108644.
  • PCR Quantitative polymerase chain reaction
  • Western blot analysis confirmed expression of significan tly regulated genes and their activation in altered pathways.
  • LV tissue samples were obtained from the center of the infarct zone, washed and fixed with 3% glutaraldehyde in phosphate buffer, and then embedded in epoxy resin.
  • Electron micrographs were acquired and analyzed for cardiomyocyte injury, including mitochondrial swelling and integrity.
  • Total protein was extracted from tissue homogenates, isolated as previously described (22-24).
  • SDF-1 a protein levels were quantified in LV tissue isolated from sham- operated animals and infarct zones using Western blot analysis and an enzyme-linked immunosorbent assay. Circulating serum levels of SDF-1 a were quantified by using an enzyme -linked immunosorbent assay (R&D Systems, Minneapolis, Minnesota).
  • CXCR4 levels in LV tissue isolated from sham-operated animals and infarct zones were quantified by Western blot analysis (Abeam, Cambridge, United Kingdom). Immunoblot analysis was then performed as previously described.
  • MMP-2 and MMP-9 activities in homogenates of heart tissues were determined by zymography as previously described. Briefly, gelatin zymography was performed with sodium dodecyl sulfate polyacrylamide gel electrophoresis gels containing 1 mg/ml of porcine gelatin. Samples were prepared under nonreducing conditions. Gel electrophoresis was performed at 150 V for 1 h. After electrophoresis, the gel was washed in 2.5% Triton X- 100 solution with gentle agitation for 6 h at room temperature, followed by replacement with developing buffer containing 5QmM Tris-HCl (pH 7.5), 0.2 M NaCl, 5 mM CaC12, and 0.2% Brij-35.
  • the gel was agitated at room temperature for 30 min, placed into fresh developing buffer, and incubated at 37°C overnight. The following morning, gels were stained with 0.5% Coomassie Brilliant Blue R-250 in 40% methanol and 10% acetic acid for 2 to 4 h and destained 40% methanol and 10% acetic acid at room temperature. Gelatinolytic bands were quantified by scanning densitometry with Image! software (National Institutes of Health, Bethesda, Maryland). DPP-4 protein levels were quantified by immunoassay, and activity levels were measured by using a commercially available activity assay kit (MilliporeSigma, Burlington, Massachusetts).
  • easpase-3 Cell Signaling Technology
  • glyceraldehyde-3-phosphate dehydrogenase Expression of apoptosis regulatory protein levels were normalized to both total protein levels and giyceraldehyde-3-phosphate dehydrogenase.
  • TUNEL staining was performed by using !Q-mm thick sections obtained from the peri-infarct zone fixed in 4% paraformaldehyde/phosphate-buffered saline for 20 min. Slides were permeabilized on ice with 0.1% Triton X-100 in 0.1 % sodium citrate, and sections were labeled in the dark at 37°C for 60 min.
  • Results are presented as mean ⁇ SD.
  • An unpaired Student s t-test or one-way analysis of variance was used to compare continuous variables between groups. All data within groups over time were analyzed by using nonparametric 2-way repeated measures analysis of variance. Simple linear regression analysis was used to evaluate for a correlation between two parameters. All statistical analyses were performed with GraphPad Prism (GraphPad Software, La Jolla, California). An alpha-level of p ⁇ 0.05 was considered to indicate a significant effect or between-group difference.
  • LV unloading for 30 min before reperfusion reduced myocardial infarct size compared with reperfusion alone (33.3 ⁇ 5% vs. 62.2 ⁇ 1.7% infarct/area-at-risk, group 3 vs. group 1 , respectively; p ⁇ 0.01) (see FIG 6B).
  • LV unloading followed by rapid reperfusion within 15 min (group 2) or after reperfusion (group 4) failed to reduce myocardial infarct size compared to P-reperfusion alone.
  • LV unloading for 30 min before reperfusion limited up-regulation of DPP-4 expression and activity. These data suggest that LV unloading for 30 min before reperfusion may preserve SDF-Ia protein levels by limiting the activity of proteases known to degrade SDF-l a.
  • BNP B-type natriuretic peptide
  • P-unloading increased mRNA levels of sarcoplasmic/endoplasmic reticulum calcium ATPase and reduced levels of calcineurin and type 1 collagen without affecting levels from the noninfarct region of the left ventricle (see FIGS. 1 I D to 11 F).
  • P-unloading reduced LV scar size and improved cardiac function 28 days after AMI.
  • P-unloading reduces LV scar size and improved cardiac function 28 days after AMI.
  • P-unloading reduces activity levels of proteases known to degrade SDF-Ia
  • P-unloading reduces LV scar size, preserves cardiac output, reduces BNP expression, and limits expression of genes and proteins associated with maladaptive remodeling within the noninfarct zone 28 days after AMI.
  • Tins data identifies P-unloading as a novel approach to enhance cardioprotective mechanisms that
  • AMI AMI.
  • P-unloading reduced infarct scar size as blindly quantified by LGE- CMR, which tightly correlated with anatomic measurements of myocardial scar size.
  • Well- established molecular markers of maladaptive remodeling in the noninfarct zones were then quantified where the bulk of compensatory ' remodeling would occur in response to a large anterior MI. It was observed that compared with P-reperfusion, P-unloading reduced calcineurin, beta myosin heavy chain, and BNP levels, while preserving

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Abstract

L'invention concerne une méthode de prévention ou de limitation des effets de l'insuffisance cardiaque chez un patient humain qui présente un infarctus du myocarde prolongé par la réduction du remodelage cardiaque mésadapté chez le patient. La méthode consiste à insérer de manière percutanée une pompe d'assistance circulatoire transvalvulaire, comprenant un rotor et une canule, dans le système vasculaire du patient et à positionner la canule à travers la valve aortique du cœur du patient, une extrémité distale de la canule étant située dans le ventricule gauche du cœur et une extrémité proximale de la pompe étant située dans l'aorte. La méthode consiste ensuite à faire fonctionner la pompe positionnée, avant la reperfusion du cœur, pour décharger le ventricule gauche à une vitesse de pompage d'au moins 2,5 L/min de flux sanguin pendant une période d'assistance comprise entre au moins 30 minutes et moins de 60 minutes. Ensuite, après la période d'assistance, la méthode consiste à appliquer une thérapie de reperfusion coronaire au cœur.
PCT/US2019/060411 2018-11-09 2019-11-08 Systèmes et méthodes de décharge ventriculaire gauche dans le traitement de l'infarctus du myocarde WO2020097428A1 (fr)

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US16/244,998 US20190216995A1 (en) 2018-01-10 2019-01-10 Systems and methods for left ventricular unloading in treating myocardial infarction
US16/244,998 2019-01-10
PCT/US2019/013025 WO2019140073A1 (fr) 2018-01-10 2019-01-10 Systèmes et procédés de déchargement ventriculaire gauche dans le traitement d'un infarctus du myocarde

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