WO2020217194A1 - Shunts interauriculaires contenant un matériau biodégradable et leurs procédés de fabrication et d'utilisation - Google Patents

Shunts interauriculaires contenant un matériau biodégradable et leurs procédés de fabrication et d'utilisation Download PDF

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Publication number
WO2020217194A1
WO2020217194A1 PCT/IB2020/053832 IB2020053832W WO2020217194A1 WO 2020217194 A1 WO2020217194 A1 WO 2020217194A1 IB 2020053832 W IB2020053832 W IB 2020053832W WO 2020217194 A1 WO2020217194 A1 WO 2020217194A1
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WIPO (PCT)
Prior art keywords
biodegradable
flared end
drug
biocompatible material
layer
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PCT/IB2020/053832
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English (en)
Inventor
Yaacov Nitzan
Menashe Yacoby
Neal Eigler
James Whiting
Erez Rozenfeld
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V-Wave Ltd.
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Priority claimed from US16/395,209 external-priority patent/US11135054B2/en
Application filed by V-Wave Ltd. filed Critical V-Wave Ltd.
Publication of WO2020217194A1 publication Critical patent/WO2020217194A1/fr

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • 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
    • A61F2/82—Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
    • A61F2/86—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure
    • A61F2/90—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure
    • A61F2/91—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure made from perforated sheet material or tubes, e.g. perforated by laser cuts or etched holes
    • A61F2/915—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure made from perforated sheet material or tubes, e.g. perforated by laser cuts or etched holes with bands having a meander structure, adjacent bands being connected to each other
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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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
    • A61F2/02—Prostheses implantable into the body
    • A61F2/04—Hollow or tubular parts of organs, e.g. bladders, tracheae, bronchi or bile ducts
    • A61F2/06—Blood vessels
    • A61F2/07—Stent-grafts
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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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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    • A—HUMAN NECESSITIES
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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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    • A61F2/915—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure made from perforated sheet material or tubes, e.g. perforated by laser cuts or etched holes with bands having a meander structure, adjacent bands being connected to each other
    • A61F2002/9155—Adjacent bands being connected to each other
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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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    • A61F2/915—Stents in a form characterised by the wire-like elements; Stents in the form characterised by a net-like or mesh-like structure characterised by a net-like or mesh-like structure made from perforated sheet material or tubes, e.g. perforated by laser cuts or etched holes with bands having a meander structure, adjacent bands being connected to each other
    • A61F2002/9155—Adjacent bands being connected to each other
    • A61F2002/91583—Adjacent bands being connected to each other by a bridge, whereby at least one of its ends is connected along the length of a strut between two consecutive apices within a band
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    • A61F2210/00—Particular material properties of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
    • A61F2210/0004—Particular material properties of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof bioabsorbable
    • A—HUMAN NECESSITIES
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    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2230/00—Geometry of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
    • A61F2230/0002—Two-dimensional shapes, e.g. cross-sections
    • A61F2230/0004—Rounded shapes, e.g. with rounded corners
    • A61F2230/001—Figure-8-shaped, e.g. hourglass-shaped
    • A—HUMAN NECESSITIES
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    • A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
    • A61F2230/00—Geometry of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
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    • A61F2250/0014—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis
    • A61F2250/003—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis differing in adsorbability or resorbability, i.e. in adsorption or resorption time
    • A—HUMAN NECESSITIES
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    • A61F2250/00—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
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    • A61F2250/003—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis differing in adsorbability or resorbability, i.e. in adsorption or resorption time
    • A61F2250/0031—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis differing in adsorbability or resorbability, i.e. in adsorption or resorption time made from both resorbable and non-resorbable prosthetic parts, e.g. adjacent parts
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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    • A61F2250/00—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
    • A61F2250/0014—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis
    • A61F2250/0039—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof having different values of a given property or geometrical feature, e.g. mechanical property or material property, at different locations within the same prosthesis differing in diameter
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    • A61F2250/00—Special features of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
    • A61F2250/0058—Additional features; Implant or prostheses properties not otherwise provided for
    • A61F2250/0067—Means for introducing or releasing pharmaceutical products into the body

Definitions

  • This application generally relates to devices and methods for reducing left atrial pressure, particularly in subjects with heart pathologies such as congestive heart failure (CHF), pulmonary hypertension, or myocardial infarction (MI), using an interatrial shunt that may include a drug eluting material that reduces neoplasia.
  • CHF congestive heart failure
  • MI myocardial infarction
  • the human heart is comprised of four major chambers with two ventricles and two atria.
  • the right-side heart receives oxygen-poor blood from the body into the right atrium and pumps it via the right ventricle to the lungs.
  • the left-side heart receives oxygen-rich blood from the lungs into the left atrium and pumps it via the left ventricle to the aorta for distribution throughout the body.
  • Heart failure is the physiological state in which cardiac output is insufficient to meet the needs of the body and the lungs. CHF occurs when cardiac output is relatively low and the body becomes congested with fluid. There are many possible underlying causes of CHF, including myocardial infarction, coronary artery disease, valvular disease, and myocarditis.
  • Chronic heart failure is associated with neurohormonal activation and alterations in autonomic control.
  • these compensatory neurohormonal mechanisms provide valuable support for the heart under normal physiological circumstances, they also have a fundamental role in the development and subsequent progression of CHF.
  • one of the body’s main compensatory mechanisms for reduced blood flow in CHF is to increase the amount of salt and water retained by the kidneys. Retaining salt and water, instead of excreting it into the urine, increases the volume of blood in the bloodstream and helps to maintain blood pressure.
  • the larger volume of blood also stretches the heart muscle, enlarging the heart chambers, particularly the ventricles. At a certain amount of stretching, the heart’s contractions become weakened, and the heart failure worsens.
  • Another compensatory mechanism is vasoconstriction of the arterial system. This mechanism, like salt and water retention, raises the blood pressure to help maintain adequate perfusion.
  • the heart weakens as a result of the high pressures, aggravating the disorder.
  • Pressure in the left atrium may exceed 25 mmHg, at which stage, fluids from the blood flowing through the pulmonary circulatory system flow out of the interstitial spaces and into the alveoli, causing pulmonary edema and lung congestion.
  • Table 1 lists typical ranges of right atrial pressure (RAP), right ventricular pressure (RVP), left atrial pressure (LAP), left ventricular pressure (LVP), cardiac output (CO), and stroke volume (SV) for a normal heart and for a heart suffering from CHF.
  • RVP right atrial pressure
  • RVP right ventricular pressure
  • LAP left atrial pressure
  • LVP left ventricular pressure
  • CO cardiac output
  • SV stroke volume
  • RVP (mmHg) 15-25 20-40
  • CHF is generally classified as either systolic heart failure (SHF) or diastolic heart failure (DHF).
  • SHF systolic heart failure
  • DHF diastolic heart failure
  • ejection fraction is a function of the blood ejected out of the left ventricle (stroke volume), divided by the maximum volume remaining in the left ventricle at the end of diastole or relaxation phase.
  • stroke volume blood ejected out of the left ventricle
  • a normal ejection fraction is greater than 50%.
  • stolic heart failure has a decreased ejection fraction of less than 50%.
  • a patient with SHF may usually have a larger left ventricle because of a phenomenon called cardiac remodeling that occurs secondarily to the higher ventricular pressures.
  • the heart In DHF, the heart generally contracts normally, with a normal ejection fraction, but is stiffer, or less compliant, than a healthy heart would be when relaxing and filling with blood.
  • DHF is more common in patients older than 75 years, especially in women with high blood pressure.
  • assist devices such as mechanical pumps have been used to reduce the load on the heart by performing all or part of the pumping function normally done by the heart.
  • Chronic left ventricular assist devices (LVAD), and cardiac transplantation often are used as measures of last resort.
  • LVAD left ventricular assist devices
  • Such assist devices are typically intended to improve the pumping capacity of the heart, to increase cardiac output to levels compatible with normal life, and to sustain the patient until a donor heart for transplantation becomes available.
  • Such mechanical devices enable propulsion of significant volumes of blood (liters/min), but are limited by a need for a power supply, relatively large pumps, and the risk of hemolysis, thrombus formation, and infection.
  • Temporary assist devices, intra-aortic balloons, and pacing devices have also been used.
  • U.S. Pat. No. 6,120,534 to Ruiz is directed to an endoluminal stent for regulating the flow of fluids through a body vessel or organ, for example for regulating blood flow through the pulmonary artery to treat congenital heart defects.
  • the stent may include an expandable mesh having lobed or conical portions joined by a constricted region, which limits flow through the stent.
  • the mesh may comprise longitudinal struts connected by transverse sinusoidal or serpentine connecting members. Ruiz is silent on the treatment of CHF or the reduction of left atrial pressure.
  • U.S. Pat. No. 6,468,303 to Amplatz et al. discloses a collapsible medical device and associated method for shunting selected organs and vessels.
  • the device may be suitable to shunt a septal defect of a patient’s heart, for example, by creating a shunt in the atrial septum of a neonate with hypoplastic left heart syndrome (HLHS).
  • HLHS hypoplastic left heart syndrome
  • Amplatz discloses that increasing mixing of pulmonary and systemic venous blood improves oxygen saturation.
  • the shunting passage can later be closed by an occluding device. Amplatz is silent on the treatment of CHF or the reduction of left atrial pressure, as well as on means for regulating the rate of blood flow through the device.
  • U.S. Patent Publication No. 2005/0165344 to Dobak, III discloses an apparatus for treating heart failure that includes a conduit positioned in a hole in the atrial septum of the heart, to allow flow from the left atrium into the right atrium. Dobak discloses that the shunting of blood will reduce left atrial pressures, thereby preventing pulmonary edema and progressive left ventricular dysfunction, and reducing LVEDP.
  • the conduit may include a self-expandable tube with retention struts, such as metallic arms that exert a slight force on the atrial septum on both sides and pinch or clamp the valve to the septum, and a one-way valve member, such as a tilting disk, bileaflet design, or a flap valve formed of fixed animal pericardial tissue.
  • a valved design may not be optimal due to a risk of blood stasis and thrombus formation on the valve, and that valves can also damage blood components due to turbulent flow effects. Dobak does not provide any specific guidance on how to avoid such problems.
  • a significant drawback of previous devices is the susceptibility to narrow or close during the post-implantation healing period.
  • neoendocardial tissue overgrowth referred to as pannus
  • pannus grows from the underlining tissue to cover the mesh and narrow or partially occlude the shunt orifice.
  • pannus neoendocardial tissue overgrowth
  • This response entails activation of an inflammatory process, attracting lymphocytes and macrophages to the area of tissue injury.
  • inflammatory cells in turn release a variety of cytokines that signal fibroblasts and smooth-muscle cells from the wound margins to dedifferentiate, migrate, proliferate and encapsulate affected portions of the implanted device.
  • the fibroblasts and smooth muscle cells then secrete extracellular matrix material composed of collagen and proteoglycans, which extracellular matrix forms the bulk of the pannus.
  • the duration of this healing phase in humans is typically up to 6-9 months, but may be longer if there is a chronic source for tissue injury such as device compression or erosion of adjacent tissue.
  • this pannus is covered with neoendothelial cells, causing the pannus growth to stop or stabilize.
  • the collagen of the pannus remodels, but generally retains its space occupying properties.
  • tissue overgrowth typically spreads over the surfaces of the implant’s struts, and may substantially narrow the orifice lumen or even entirely occlude the shunt. Narrowing or occlusion of the shunt prevents FA decompression and limits any positive effect for the patient.
  • Embodiments of the present invention provide hourglass-shaped devices for reducing left atrial pressure having a drug-eluting material that reduces neoplasia, and methods of making and using the same. As elaborated further herein, such reductions in left atrial pressure may increase cardiac output, relieve pulmonary congestion, and lower pulmonary artery pressure, among other benefits.
  • the inventive devices are configured for implantation through the atrial septum, and particularly through the middle of the fossa ovalis, away from the surrounding limbus, inferior vena cava (IVC), and atrial wall.
  • IVC inferior vena cava
  • the devices are configured to provide blood flow between the left atrium and the right atrium, e.g., when the pressure in the left atrium exceeds the pressure in the right atrium, and thus decompress the left atrium.
  • the devices may include a biodegradable material that gradually biodegrades over time to increase the cross- sectional flow area of the device, so as to offset a flow rate decrease caused by tissue overgrowth and thus maintain a suitable flow rate over time.
  • lowering the left atrial pressure using the inventive devices may offset abnormal hemodynamics associated with CHF, for example, to reduce congestion as well as the occurrence of acute cardiogenic pulmonary edema (ACPE), which is a severe manifestation of CHF in which fluid leaks from pulmonary capillaries into the interstitium and alveoli of the lung.
  • ACPE acute cardiogenic pulmonary edema
  • lowering the left atrial pressure may improve the cardiac function by:
  • LVEDP left ventricular end-diastolic pressure
  • PAP pulmonary artery pressure
  • inventive devices for regulating blood pressure between a patient’s left atrium and right atrium to treat a cardiovascular condition include a stent having a first flared end region, a second flared end region, a neck region disposed between the first and second flared end regions, where the neck region is sized and shaped to engage a fossa ovalis of the patient’s atrial septum.
  • the stent may be formed of a plurality of rings interconnected by a plurality of longitudinally extending struts.
  • the stent has a passageway extending from an inlet of the first flared end region through the neck region and out an outlet of the second flared end region, such that blood is shunted between the left atrium and the right atrium through the passageway.
  • the stent may transition between a collapsed state suitable for percutaneous delivery and an expanded state when deployed across the patient’s fossa ovalis.
  • the stent has an hourglass configuration in the expanded state.
  • the stent has a biocompatible material disposed on the stent to define a continuous sheath that channels blood flow through the passageway.
  • the stent may be formed of a shape memory metal coated with the biocompatible material from the neck region to the second flared end region.
  • the biocompatible material may be disposed in the neck region, the second flared end region, and a portion of the first flared end region of the stent.
  • the biocompatible material may include ultra-high-molecular-weight-polyethylene (UHMWPE), expanded-polytetrafluoroethylene (ePTFE), polyurethane, DACRON (polyethylene
  • the biocompatible material disposed on the stent may inhibit excessive tissue overgrowth.
  • the stent further includes a biodegradable material disposed on the device adjacent to the inlet of the first flared end region and/or the outlet of the second flared end region, wherein the biodegradable material inhibits tissue overgrowth across the biodegradable material.
  • the biodegradable material may include collagen-terpolymer, polylactic acid (PLA), poly L-lactic acid (PLLA), polyglycolic acid (PGA), poly(lactic-co-glycolic) acid copolymer (PLGA), poly(s- caprolactone), methacrylated dextran-aminoethyl methacrylate copolymer (Dex-MA/AEMA), polydiaxanone, poly(glycerol sebacate) (PGS), polysialic acid (PSA), collagen type Fill, chitosan, or chitin, or any combination thereof.
  • PLA polylactic acid
  • PLLA poly L-lactic acid
  • PGA polyglycolic acid
  • PLGA poly(lactic-co-glycolic) acid copolymer
  • Dex-MA/AEMA methacrylated dextran-aminoethyl methacrylate copolymer
  • PES poly(glycerol sebacate)
  • PSA polysi
  • the biodegradable material may include a drug, e.g., an“-olimus” drug such as sirolimus (rapamycin), deposited within the biodegradable material, wherein the drug inhibits tissue overgrowth such that the biodegradable material biodegrades after implantation to release the drug to inhibit tissue overgrowth across the biodegradable material.
  • a drug e.g., an“-olimus” drug such as sirolimus (rapamycin
  • biodegradable material may include a first biodegradable layer having a first concentration of the drug, and a second biodegradable layer having a second concentration of the drug different from the first concentration of the drug.
  • the biodegradable material may be formed of a first biodegradable layer having a first biodegradable rate and a second biodegradable layer having a second biodegradable rate different from the first biodegradable rate.
  • At least one of the plurality of rings of the stent includes one or more depressions formed on a surface of the ring(s).
  • the biodegradable material may be disposed within the one or more depressions.
  • the biocompatible material may include a first biocompatible material layer and a second biocompatible material layer, and the biodegradable material may be sandwiched between the first and second biocompatible material layers.
  • the first and/or second biocompatible material layers may include a plurality of nodal pores sized and shaped to permit the drug to be released via the nodal pore(s) as the biodegradable material biodegrades.
  • the biodegradable material may include one or more biodegradable rings disposed on a surface of the biocompatible material adjacent to the inlet of the first flared end region and/or the outlet of the second flared end region.
  • the one or more biodegradable rings inhibit tissue overgrowth across biodegradable ring(s).
  • the biodegradable rings may be disposed on the biocompatible material on an inner surface of the stent and/or and outer surface of the stent.
  • the biocompatible material may include one or more cavities extending through a surface of the biocompatible material, such that one or more biodegradable rings are disposed within the one or more cavities.
  • the stent may have a biodegradable substance layer disposed on the biocompatible material at an inner surface of the neck region to define a cross-sectional area of a blood flow path, wherein the biodegradable substance layer biodegrades after implantation to increase the cross-sectional area of the blood flow path at the neck region over time.
  • the biodegradable substance layer may biodegrade after implantation to increase diameter of the blood flow path cross-sectional area at the neck region from an initial diameter of 5 mm to a diameter of 6 mm over at least a month.
  • the biodegradable substance layer biodegrades responsive to application of an external stimulus, e.g., heat or a biocompatible degradation activating material.
  • the biodegradable substance layer may include a first biodegradable substance layer that biodegrades responsive to application of a first external stimulus, and a second biodegradable substance layer that biodegrades responsive to application of a second external stimulus different from the first external stimulus.
  • a method of treating a subject with a cardiovascular condition e.g., pulmonary hypertension, heart failure, or myocardial infarction, the subject having a heart with an atrial septum having a fossa ovalis therein, is provided.
  • a cardiovascular condition e.g., pulmonary hypertension, heart failure, or myocardial infarction
  • the method includes selecting a stent having a neck region between first and second flared end regions and a passageway extending from an inlet of the first flared end region through the neck region and out an outlet of the second flared end region, the stent further having a biocompatible material disposed on the stent and a biodegradable material disposed on the biocompatible material adjacent to at least the inlet of the first flared end region and the outlet of the second flared end region.
  • the method further includes deploying the stent at a puncture through the fossa ovalis such that the neck region is positioned in the puncture, the first flared end region is disposed in the right atrium, and the second flared end region is disposed in the left atrium.
  • the method also includes shunting blood between the left atrium and the right atrium through the passageway, wherein the biodegradable material inhibits tissue overgrowth across the biodegradable material.
  • the biodegradable material may include a drug, e.g., an“-olimus” drug, deposited within the biodegradable material, wherein the drug inhibits tissue overgrowth. Accordingly, the method further includes biodegrading the biodegradable material to release the drug such that tissue overgrowth is inhibited across the biodegradable material.
  • a drug e.g., an“-olimus” drug
  • the stent may further include a biodegradable substance layer disposed on the biocompatible material at an inner surface of the neck region, such that the method further includes biodegrading the biodegradable substance layer after implantation to increase a cross- sectional area at the neck region.
  • FIG. 1A illustrates an exemplary hourglass-shaped device, according to some embodiments of the present invention.
  • FIGS. IB- ID illustrate the hourglass-shaped device of FIG. 1A having one or more drug-eluting biodegradable rings disposed thereon, according to some embodiments of the present invention.
  • FIGS. IE- IF illustrate the hourglass-shaped device of FIG. 1 A having a drug-eluting biodegradable material disposed within the biocompatible material of the device, according to some embodiments of the present invention.
  • FIGS. 1G-1H illustrate the hourglass-shaped device of FIG. 1A having a drug-eluting biodegradable material embedded within the stent of the device, according to some embodiments of the present invention.
  • FIGS. II- 1 J illustrate exemplary drug-eluting biodegradable materials having multiple layers, according to some embodiments of the present invention.
  • FIG. IK illustrates the hourglass-shaped device of FIG. 1A having a biodegradable substance layer disposed thereon, according to some embodiments of the present invention.
  • FIG. IF is a plot schematically illustrating changes in flow rate over time through the device of FIG. 1 K caused by tissue overgrowth, change in shunt cross-sectional area, and the overall effective flow rate through the device, and a plot schematically illustrating changes of thickness of the biodegradable material and tissue overgrowth on the device of FIG. 1 K over time, and the sum of the thickness.
  • FIG. 1M illustrates the hourglass-shaped device of FIG. 1 A having one or more drug eluting biodegradable rings as well as a biodegradable substance layer disposed thereon, according to some embodiments of the present invention.
  • FIG. 2A schematically illustrates a plan view of the right atrial side of the atrial septum, including a site for implanting an hourglass-shaped device through the middle of the fossa ovalis.
  • FIG. 2B schematically illustrates a perspective view of the hourglass-shaped device of FIGS. 1A-1E positioned in the fossa ovalis of the atrial septum, according to some embodiments of the present invention.
  • FIG. 3 is a flow chart of steps in a method of making an hourglass-shaped device, according to some embodiments of the present invention.
  • FIG. 4 is a flow chart of steps in a method of percutaneously implanting the hourglass-shaped device of FIGS. 1A-1E in a puncture through the fossa ovalis, according to some embodiments of the present invention.
  • FIGS. 5A-5D schematically illustrate steps taken during the method of FIG. 4, according to some embodiments of the present invention.
  • FIGS. 6A and 6B illustrate the hourglass-shaped device of FIG. 1 A having a layer of degradable components disposed thereon, according to some embodiments of the present invention.
  • FIGS. 7A and 7B illustrate the hourglass-shaped device of FIG. 1 A having multiple layers of degradable components disposed thereon, according to some embodiments of the present invention.
  • Embodiments of the present invention are directed to devices that reduce left atrial pressure, and thus may be useful in treating subjects suffering from congestive heart failure
  • the inventive device includes an hourglass or“diabolo” shaped stent, preferably formed of a shape memory metal.
  • the stent is configured to lodge securely in the atrial septum, preferably in the fossa ovalis, and to allow blood to flow between the left atrium and the right atrium when blood pressure in the left atrium exceeds that on the right.
  • the inventive devices are configured so as to reduce blood pressure in the left atrium even when the pressure differential therebetween is relatively low; to provide a smooth flow path, thus inhibiting turbulence and high shear stresses that would otherwise promote thrombus formation; and to have a relatively small implantation footprint so as to inhibit tissue overgrowth and inflammatory response.
  • inventive devices include a biodegradable material that releases a drug that reduces neoplasia so as to reduce tissue overgrowth and thus maintain a suitable flow rate through the device.
  • inventive devices also may include a biodegradable material that modifies the characteristics of blood flow through the device over time, specifically by increasing the cross-sectional area of the flow path so as to offset decreases in the flow path caused by tissue overgrowth. As such, the overall flow rate of the device may be maintained within a desired range over time, notwithstanding tissue overgrowth.
  • FIGS. 1A-1J illustrate various views of illustrative embodiments of the inventive device.
  • device 100 includes an hourglass-shaped stent 110 and biocompatible material 120.
  • Device 100 has three general regions: first flared or funnel-shaped end region 102, second flared or funnel-shaped end region 106, and neck region 104 disposed between the first and second flared end regions.
  • Neck region 104 is configured to lodge in a puncture formed in the atrial septum, preferably in the fossa ovalis, using methods described in greater detail below.
  • First flared end region 102 is configured to engage the right side of the atrial septum
  • second flared end region 106 is configured to flank the left side of the atrial septum, when implanted.
  • neck region 104 and first and second flared end regions 102, 106 may be selected so as to inhibit the formation of eddy currents when implanted, and thus inhibit thrombus formation; to inhibit tissue overgrowth in selected regions; to promote tissue overgrowth in other selected regions; and to provide a desirable rate of blood flow between the left and right atria.
  • a biodegradable material may be disposed on the interior and/or exterior surface of the biocompatible material, within the biocompatible material, and/or embedded in the stent, such that the biodegradable material biodegrades to release a drug for inhibiting tissue overgrowth.
  • FIG. 1B-1J a biodegradable material
  • Hourglass-shaped stent 110 is preferably formed of a shape memory metal, e.g., NITINOL, or any other suitable material known in the art.
  • Stent 110 includes a plurality of rings, e.g., sinusoidal rings 112-116, interconnected by longitudinally extending struts 111.
  • Rings 112-116 and struts 111 may be of unitary construction, that is, entire stent 110 may be laser cut from a tube of shape memory metal.
  • neck region 104 and second flared end region 106 are covered with biocompatible material 120, for example a sheet of a polymer such as expanded polytetrafluoroethylene (ePTFE), silicone, polycarbonate urethane, DACRON (polyethylene terephthalate), or polyurethane, or of a natural material such as pericardial tissue, e.g., from an equine, bovine, or porcine source.
  • ePTFE expanded polytetrafluoroethylene
  • silicone silicone
  • polycarbonate urethane polycarbonate urethane
  • DACRON polyethylene terephthalate
  • polyurethane or of a natural material such as pericardial tissue, e.g., from an equine, bovine, or porcine source.
  • pericardial tissue e.g., from
  • Material 120 preferably is generally smooth so as to inhibit thrombus formation, and optionally may be impregnated with carbon so as to promote tissue ingrowth, i.e., ingrowth of tissue into the porous biocompatable fabric (neointima formation).
  • tissue ingrowth i.e., ingrowth of tissue into the porous biocompatable fabric (neointima formation).
  • portions of stent 110 associated with first flared end region 102 are not covered with the biocompatible material, but are left as bare metal, so as to inhibit the formation of stagnant flow regions in the right atrium, so as to inhibit significant tissue overgrowth on device 100, i.e., undesireable overgrowth of pannus into the shunt lumen.
  • first flared end region 102 also may be covered with biocompatible material 120 such that the region extending approximately from sinusoidal ring 112 to sinusoidal ring 116 is covered with biocompatible material 120.
  • hourglass-shaped stent 110 includes a biodegradable material disposed thereon adjacent to at least the outlet end or inlet end of hourglass-shaped device 100, which biodegrades over time to inhibit or reduce tissue overgrowth over the biodegradable material.
  • the biodegradable material may comprise any suitable material that the body will gradually bioresorb or biodegrade, for example a hydrogel (e.g., polyethylene glycol hydrogel), synthetic polymer, or biological polymer.
  • suitable synthetic polymers may include collagen-terpolymer; poly(lactic-co-glycolic) acids such as polylactic acid (PLA), poly L-lactic acid (PLLA), polyglycolic acid (PGA), and poly(lactic- co-glycolic) acid copolymer (PLGA); poly(8-caprolactone); methacrylated dextran-aminoethyl methacrylate copolymer (Dex-MA/AEMA); polydiaxanone; and poly(glycerol sebacate) (PGS).
  • suitable biological polymers may include polysialic acid (PSA), collagen type PHI, chitosan, and chitin. These materials are meant to be purely illustrative, and it should be appreciated that any suitable biodegradable or bioresorbable material may be used.
  • the biodegradable material is designed to bioresorb or biodegrade gradually over time to thereby inhibit tissue overgrowth.
  • the biodegradable material may have a drug, e.g., an -olimus drug, embedded therein that is released over time as the biodegradable material bioresorb or biodegrade. As the drug is released, tissue overgrowth is inhibited across the biodegradable material.
  • the biodegradable material of device 100 may be in the form of one or more biodegradable rings for inhibiting tissue overgrowth.
  • Hourglass shaped device 100 includes one or more biodegradable rings 117 disposed circumferentially along the surface of biocompatible material 120, preferably adjacent to at least the outlet end or inlet end of hourglass-shaped device 100. As biodegradable rings 117 bioresorb or biodegrade over time, the drug therein is released, which inhibits tissue overgrowth across the biodegradable rings.
  • one or more biodegradable rings 117 may be positioned adjacent to at least the inlet end of second flared end region 106 or outlet end of first flared end region 102 of device 100, and/or adjacent neck region 104 such that tissue overgrowth from the atrial septum is limited.
  • the tissue overgrowth from the atrial septum may assist in anchoring device 100 to the atrial septum, while not excessively expanding so as to interfere with the patency of device 100.
  • FIG. IB illustrates one or more biodegradable rings 117 disposed on the outer surface of biocompatible material 120
  • FIG. 1C illustrates one or more biodegradable rings 117 disposed on the inner surface of biocompatible material 120.
  • any combination of one or more biodegradable rings 117 may be utilized to effectively reduce tissue overgrowth to preserve longevity and patency of device 100.
  • one or more biodegradable rings 117 may be disposed on the inner and/or outer surface of biocompatible material 120 adjacent neck region 104 of device 100.
  • any of the shunts described above may utilize the biodegradable rings described herein for limiting tissue overgrowth across the biodegradable rings.
  • biocompatible material 120 may include one or more cavities 118, e.g., holes or grooves, disposed circumferentially along a surface of biocompatible material 120 such that one or more biodegradable rings 117 are disposed at least partially within the one or more cavities.
  • FIG. ID illustrates one or more cavities 118 disposed circumferentially along an outer surface of biocompatible material 120, as described above, any combination of one or more biodegradable rings 117 may be utilized to effectively reduce tissue overgrowth to preserve longevity and patency of device 100, and thus one or more cavities 118 may be disposed circumferentially along either or both an outer and/or inner surface of biocompatible material 120 to accommodate the biodegradable rings positioned along biocompatible material 120.
  • one or more cavities 118 may include a plurality of individual cavities of various shapes and sizes disposed in a circumferential pattern along the inner and/or outer surface of biocompatible material 120, such that the biodegradable material is disposed within the cavities and biodegrade to release the tissue overgrowth inhibiting drug in a ring-like manner.
  • the biodegradable material of device 100 may be in the form of a biodegradable material layer embedded within biocompatible material 120.
  • biocompatible material 120 may include first biocompatible material layer 121 and second biocompatible material layer 122 such that biodegradable material layer 119 is sandwiched in between the first and second biocompatible material layers of biocompatible material 120.
  • first biocompatible material layer 121 and/or second biocompatible material layer 122 illustratively includes a plurality of nodal pores 123 sized and shaped to permit the drug to be released from biodegradable material layer 119, as biodegradable material layer 119 biodegrades, to permeate therethrough for inhibiting tissue overgrowth across nodal pores 123.
  • Nodal pores 123 may be disposed in a circumferential pattern along first biocompatible material layer 121 and/or second biocompatible material layer 122 of biocompatible material 120 such that the tissue overgrowth inhibiting drug is released from biodegradable material 119 in a ring-like manner.
  • nodal pores 123 may be disposed within first biocompatible material layer 121, as will be understood by a person ordinarily skilled in the art, nodal pores 123 may be disposed within second biocompatible material layer 122, or a combination of both first and second biocompatible material layers.
  • the biodegradable material of device 100 may be embedded in stent 110.
  • ring 115 may include one or more depressions 124 formed on its surface, such that biodegradable material 125 is disposed within one or more depressions 124.
  • One or more depressions 124 may include a plurality of individual cavities of various shapes and sizes disposed in a circumferential pattern along a ring of stent 110, such that biodegradable material 125 is disposed within the cavities and biodegrades to release the tissue overgrowth inhibiting drug in a ring-like manner about device 100.
  • one or more depressions 124 may be circular cavities disposed circumferentially along ring 115. Accordingly, the tissue overgrowth inhibiting drug may be released from
  • biodegradable material 125 in a ring-like manner about device 100.
  • one or more depressions 124 may include a single groove extending circumferentially along the surface of the ring, such that biodegradable material 125 is disposed within the groove in a closed ring shape about stent 110.
  • FIGS. 1G and 1H illustrate one or more depressions 124 disposed along a surface of ring 115, as will be understood by a person ordinarily skilled in the art, one or more depressions 124 may be disposed on any of the rings of stent 110, e.g., rings 112, 113, 114, 115, or 116, to inhibit tissue overgrowth across the respective ring.
  • one or more depressions 124 may be disposed along any one of longitudinal struts 111 of stent 110, such that the biodegradable material is disposed within the one or more depressions within the longitudinal struts.
  • the biodegradable material of device 100 may include multiple layers of biodegradable materials.
  • the biodegradable material includes first biodegradable layer 126 and second biodegradable layer 127.
  • First biodegradable layer 126 includes a first biodegradable material and a first concentration of drug 128 embedded therein such that the first concentration of drug 128 is released as the first biodegradable material biodegrades.
  • Second biodegradable layer 127 includes a second biodegradable material and a second concentration of drug 126 embedded therein such that the second concentration of drug 126 is released as the second biodegradable material biodegrades.
  • the drug in the first biodegradable material may be the same type of drug as the drug in the second biodegradable material or they may be different.
  • the first and second biodegradable materials making up first biodegradable layer 126 and second biodegradable layer 127 may be the same.
  • the second concentration of drug 128 is different from the first concentration of drug 128. Therefore, the concentration of drug 128 released from the biodegradable material may be selectively controlled.
  • more than two layers of biodegradable materials may be used, e.g., three or four or more layers, such that each respective layer may include its own unique concentration and/or type of drug.
  • the biodegradable material includes first biodegradable layer 129 and second biodegradable layer 130.
  • biodegradable layer 130 may have the same concentration of drug 128; however, first biodegradable layer 129 may be selected such that it biodegrades at a first biodegradable rate, and second biodegradable layer 130 may be selected such that it biodegrades at a second biodegradable rate different from the first biodegradable rate of first biodegradable layer 129. Accordingly, the rate of drug 128 released may be selectively controlled.
  • biodegradable materials having multiple layers of biodegradable materials as described with reference to FIGS. II and 1 J may be used in any of the embodiments disclosed above with referenced to FIGS. 1B- 1H.
  • device 100 may include one or more biodegradable components that increase the cross-sectional area of the device so as to compensate for tissue overgrowth, which may occur over the first several weeks to months following implantation.
  • device 100 may include a layer of biodegradable substance 129 disposed on the inner surface of biocompatible material 120, in the neck and second flared end regions of device 100.
  • Biodegradable substance layer 129 biodegrades or is bioresorbed gradually, for example over a period of a few weeks to a few months, thus increasing the cross- sectional flow area of device 100.
  • tissue may overgrow on the interior surface of device 100 and thus may decrease the cross-sectional flow area of the device.
  • the rate at which biodegradable substance layer 129 degrades is
  • FIG. 1L includes a plot schematically illustrating changes in flow rate (and cross-sectional area) through device 100 that are respectively caused by tissue overgrowth and biodegradation of layer 129, as well as the total effective flow rate through device 100.
  • the effective flow rate (cross-sectional flow area) 190 has an initial value of 191, which reflects that there is substantially no reduction in flow rate (cross-sectional flow area) caused by tissue overgrowth 160 (point 161), but a significant reduction in flow rate (cross-sectional flow area) caused by the layer of biodegradable substance 170 (point 171).
  • the body resorbs or biodegrades the layer of
  • tissue overgrowth causes a gradual decrease in flow rate attributable to this overgrowth 160, until the tissue overgrowth reaches a steady-state level (point 163).
  • the collective effect of these two changes preferably is that the flow rate (and cross-sectional flow area) is maintained within a desired range over the first few weeks or months following device implantation, as well as thereafter.
  • FIG. 1L further includes a plot schematically illustrating changes of the thickness of biodegradable material 180 and the thickness of tissue overgrowth 181 on device 100 over the same time period discussed above, as well as the sum of the thickness of the biodegradable material and the tissue overgrowth 182 over that time.
  • the thickness of biodegradable material 180 has an initial maximum value of 183
  • the thickness of tissue overgrowth 181 has a minimum value 185, e.g., 0 mm.
  • the sum of the thickness of the biodegradable material and the tissue overgrowth 182 has an initial value of 184, which is equal to the initial thickness of biodegradable material 183.
  • the body resorbs or biodegrades the layer of biodegradable substance, causing a gradual decrease in the thickness of biodegradable material 180, until substantially all of the biodegradable material is gone (point 186).
  • tissue overgrowth increases causing an increase in the thickness of tissue overgrowth 181 until the tissue overgrowth reaches a steady-state level (point 187).
  • the collective effect of these two changes preferably is that the sum of the thickness of the biodegradable material and the tissue overgrowth 182 is essentially constant over the first few weeks or months following device implantation, as well as thereafter.
  • tissue overgrowth and material biodegradation may vary from subject to subject and even over time for the same subject, and that such rates need not be exactly equal to each other at all times (or even at any time), so long as the effective flow rate (cross-sectional area) of the device remains within acceptable parameters. For example, in some embodiments, beginning approximately one month after implantation the biodegradable material layer 129 illustrated in FIG.
  • IK is gradually replaced by tissue overgrowth (e.g., epithelial tissue or a neointimal layer), maintaining neck region 104 at a substantially constant diameter (e.g., tissue overgrowth causing a neck diameter decrease of about 0.4 mm and degradation of biodegradable substance causing a neck diameter increase of about 0.4 mm).
  • tissue overgrowth e.g., epithelial tissue or a neointimal layer
  • neck region 104 at a substantially constant diameter (e.g., tissue overgrowth causing a neck diameter decrease of about 0.4 mm and degradation of biodegradable substance causing a neck diameter increase of about 0.4 mm).
  • biodegradable substance layer 129 may be formed of the same material as the biodegradable material described above with reference to FIGS. 1B-1J.
  • biodegradable substance layer 129 may comprise any suitable material that the body will gradually bioresorb or biodegrade, for example a hydrogel (e.g., polyethylene glycol hydrogel), synthetic polymer, or biological polymer.
  • suitable synthetic polymers may include collagen-terpolymer; poly(lactic-co-glycolic) acids such as polylactic acid (PLA), poly L-lactic acid (PLLA), polyglycolic acid (PGA), and poly(lactic-co-glycolic) acid copolymer (PLGA); poly(8-caprolactone); methacrylated dextran-aminoethyl methacrylate copolymer (Dex- MA/AEMA); polydiaxanone; and poly(glycerol sebacate) (PGS).
  • suitable biological polymers may include polysialic acid (PSA), collagen type I/III, chitosan, and chitin.
  • Biodegradable substance layer 129 may have a thickness of 0.10 to 0.50 mm, e.g., 0.20 to 0.40 mm, e.g., about 0.30 mm, that reduces the rate of flow through device 100 to about 50-70% of what the flow rate would be without layer 129.
  • biodegradable substance layer 129 may have a drug, e.g., an -olimus drug, embedded therein that is released over time as the biodegradable substance layer bioresorbs or biodegrades. As the drug is released, tissue overgrowth is inhibited across the biodegradable substance layer.
  • any combination of the biodegradable materials described above with reference to FIGS. 1B-1J, e.g., one or more biodegradable rings 117, and biodegradable substance layer 129 may be utilized to effectively reduce tissue overgrowth to preserve longevity and patency of device 100.
  • FIG. 1B-1J any combination of the biodegradable materials described above with reference to FIGS. 1B-1J, e.g., one or more biodegradable rings 117, and biodegradable substance layer 129 may be utilized to effectively reduce tissue overgrowth to preserve longevity and patency of device 100.
  • FIG. 1B-1J any combination of the biodegradable materials described above with reference to FIGS. 1B-1J, e.g., one or more biodegradable rings 117, and biodegradable substance layer 129 may be utilized to effectively reduce tissue overgrowth to preserve longevity and patency of device 100.
  • FIG. 1B-1J any combination of the biodegradable materials described above with reference to FIGS. 1B-1J, e.g., one
  • 1M illustrates one or more holes 118 disposed on the outer surface of biocompatible material 120 adjacent the outlet end of first flared end region 102 of device 100, one or more holes 118 having one or more biodegradable rings 117 disposed therein, as well as biodegradable substance layer 129 disposed on the inner surface of biocompatible material 120, in the neck and second flared end regions of device 100.
  • biodegradable substance layer 129 may further enhance the functionality of the inventive devices by further improving control over the flow characteristics of the devices over time, e.g., by compensating for changes in flow caused by tissue overgrowth.
  • hourglass-shaped device 100 preferably is configured for
  • the fossa ovalis is a thinned portion of the atrial septum caused during fetal development of the heart, which appears as an indent in the right side of the atrial septum and is surrounded by a thicker portion of the atrial septum. While the atrial septum itself may be several millimeters thick and muscular, the fossa ovalis may be only approximately one millimeter thick, and is formed primarily of fibrous tissue.
  • the fossa ovalis comprises predominantly fibrous tissue
  • that region of the atrial septum is not expected to undergo significant tension or contraction during the cardiac cycle, and thus should not impose significant radial stresses on stent 110 that could lead to stress- induce cracking.
  • the composition of the fossa ovalis as primarily fibrous tissue is expected to avoid excessive endothelialization after implantation.
  • hourglass-shaped device 100 is asymmetrically shaped to take advantage of the natural features of atrial septum 210 near the fossa ovalis, and to provide suitable flow characteristics.
  • FIG. 2A illustrates a plan view of the right atrial side of the atrial septum 210, including an implantation site 201 through the fossa ovalis 212.
  • the implantation site 201 is through the middle of the fossa ovalis 212, so that the device may be implanted at a spaced distance from the surrounding limbus 214, inferior vena cava (IVC) 216, and atrial wall 210.
  • IVC inferior vena cava
  • first flared end region 102 is configured to be implanted in right atrium 204 and may be tapered so as to have a more cylindrical shape than does second flared end region 106, which is configured to be implanted in left atrium 202.
  • the more cylindrical shape of first flared end region 102 may reduce or inhibit contact between first flared end region 102 and the limbus 214 of the fossa ovalis 212, that is, between first flared end region 102 and the prominent margin of the fossa ovalis, while still anchoring device 100 across atrial septum 210.
  • first flared end region 102 further may reduce or inhibit contact between first flared end region 102 and the right atrial wall, as well as the ridge 218 separating the coronary sinus from the inferior vena cava (IVC) (shown in FIG. 2A but not FIG. 2B). Additionally, in some embodiments the first flared end region 102 substantially does not extend beyond the indent of the fossa ovalis in the right atrium, and therefore substantially does not restrict blood flow from the IVC 216.
  • IVC inferior vena cava
  • device 100 preferably is configured so as to avoid imposing significant mechanical forces on atrial septum 210 or atria 202, 204, allowing the septum to naturally deform as the heart beats.
  • muscular areas of septum 210 may change by over 20% between systole and diastole. It is believed that any significant mechanical constraints on the motion of atrial septum 210 in such areas would lead to the development of relatively large forces acting on the septum and/or on atrial tissue that contacts device 100, which potentially would otherwise cause the tissue to have an inflammatory response and hyperplasia, and possibly cause device 100 to eventually lose patency.
  • the hourglass shape of device 100 is expected to be sufficiently stable so as to be retained in the septum, while reducing mechanical loads on the surrounding atrial septum tissue 210.
  • tissue overgrowth from atrial septum 210 in regions 230 may further enhance binding of device 100 to the septum.
  • neck region 104 of device 100 is significantly narrower than flared end regions 102, 106, facilitating device 100 to“self-locate” in a puncture through atrial septum 210, particularly when implanted through the fossa ovalis.
  • neck region 104 may have a diameter suitable for implantation in the fossa ovalis, e.g., that is smaller than the fossa ovalis, and that also is selected to inhibit blood flow rates exceeding a predetermined threshold.
  • the smallest diameter of neck 104 may be between about 3 and 6 mm, e.g., between about 4.5 mm and 5.5 mm, preferably between about 4.5 mm and 5.5 mm.
  • diameters of less than about 4.5 mm may in some circumstances not allow sufficient blood flow through the device to decompress the left atrium, and may reduce long-term patency of device 100, while diameters of greater than about 5.5 mm may allow too much blood flow.
  • flow rates of greater than 1.2 liters/minute, or even greater than 1.0 liters/minute are believed to potentially lead to remodeling of the right atrium.
  • the effective diameter at the narrowest point in device 100 i.e., the narrowest diameter provided by the combination of neck 104 and biocompatible material 120 is about 4.5 mm to 4.8 mm.
  • Such a diameter range is expected to provide a flow rate of about 0.80 liters/minute or less following overgrowth of septal tissue, which may anchor device 100 in place, and which may result in an overall diameter reduction of about 1.0 mm over time.
  • first flared end region 102 also may be selected to protrude into the right atrium by a distance selected to inhibit tissue overgrowth that may otherwise interfere with the operation of device 100.
  • distance R between the narrowest portion of neck region 104 and the end of first flared region 102 may be approximately 5.0 to 9.0 mm, for example about 5.5 to about 7.5 mm, or about 6 mm, so as not to significantly protrude above the limbus of fossa ovalis 212.
  • Second flared end region 106 preferably does not significantly engage the left side of atrial septum 210, and distance L may be between 2.0 and 6.0 mm, for example about 2.5 to 7 mm, or about 3.0 mm.
  • first and second flared end regions 102, 106 may reduce blockage of flow from the inferior vena cava (I VC) in the right atrium and from the pulmonary veins in the left atrium.
  • I VC inferior vena cava
  • distance R is about 6.0 mm and distance L is about 3.0 mm.
  • the overall dimensions of device 100 may be 10-20 mm long (L+R, in FIG. 2B), e.g., about 12- 18 mm, e.g., about 14-16 mm, e.g., about 15 mm.
  • first and second flared end regions further may be selected to stabilize device 100 in the puncture through atrial septum 210, e.g., in the puncture through fossa ovalis 212.
  • first flared end region 102 may have a diameter of 10-15 mm at its widest point, e.g., about 9.0-13 mm; and second flared end region 106 may have a diameter of 10-20 mm at its widest point, e.g., about 13-15 mm.
  • the largest diameter of first flared end region 102 may be selected so as to avoid mechanically loading the limbus of the fossa ovalis 212, which might otherwise cause inflammation.
  • the largest diameter of second flared end region 106 may be selected so as to provide a sufficient angle between first and second flared end regions 102, 106 to stabilize device 100 in the atrial septum, while limiting the extent to which second flared end region 106 protrudes into the left atrium (e.g., inhibiting interference with flow from the pulmonary veins), and providing sufficient blood flow from the left atrium through neck region 104.
  • the angle between the first and second flared end regions is about 50-90 degrees, e.g., about 60 to 80 degrees, e.g., about 70 degrees. Such an angle may stabilize device 100 across the fossa ovalis, while inhibiting excessive contact between the device and the atrial septum.
  • the first flared end region subtends an angle of approximately 80 degrees, that is, the steepest part of the outer surface of the first flared end region is at an angle of approximately 40 degrees relative to a central longitudinal axis of the device.
  • the second flared end region may subtend an angle of approximately 75 degrees, that is, the steepest part of the outer surface of the second flared end region is at an angle of approximately 37.5 degrees relative to the central longitudinal axis of the device.
  • left atrial pressures may be regulated in patients having congestive heart failure (CHF).
  • CHF congestive heart failure
  • device 100 may reduce pressure in the left atrium by about 2-5 mmHg immediately following implantation. Such a pressure reduction may lead to a long-term benefit in the patient, because a process then begins by which the lowered left atrial pressure reduces the
  • the pulmonary capillaries may self-regulate to accept high blood volume if needed, without increasing pressure.
  • the left atrial pressure is high, the pulmonary capillaries constrict to maintain the transpulmonary gradient, but as the left atrial pressure decreases, and there is more blood coming from the right atrium, there are actually higher flow rates at lower pressures passing through the pulmonary circulation.
  • the pulmonary circulation has been observed to function at lower pressures, while the systemic circulation maintains higher pressures and thus adequate perfusion.
  • Such small decreases in afterload may dramatically increase the cardiac output (CO) in heart failure, resulting in increased ejection fraction (EF).
  • CO cardiac output
  • EF ejection fraction
  • the right atrial pressure decreases over time as well. Following myocardial infarction, the effect is even more pronounced, because the period after the infarction is very important for the remodeling of the heart. Specifically, when the heart remodels at lower pressures, the outcome is better.
  • tissue growth In the region of contact between device 100 and atrial septum 210, preferably there is limited tissue growth.
  • the connective tissue of atrial septum 210 is non-living material, so substantially no nourishing of cells occurs between the septum and device 100.
  • tissue growth in regions 230 may anchor device 210 across atrial septum 210.
  • Excessive tissue growth beyond regions 230 on device 100 may be inhibited via one or more drug-eluting biodegradable rings disposed adjacent neck region 104 of device 100.
  • tissue growth may cause the flow between the external surface of device 100 and atrial septum 210 to become smoother and more continuous, thus reducing or inhibiting further cell accumulation and tissue growth in regions 230.
  • Flow reductions caused by such tissue growth may be offset by providing in the device a biodegradable substance that biodegrades over time, as discussed above with respect to FIGS. 1K-1L.
  • first flared end region 102 of stent 110 preferably is bare metal. This configuration is expected to inhibit formation of stagnation points in blood flow in right atrium 204, that otherwise may lead to excessive tissue growth on device 100.
  • a method 300 of making device 100 illustrated in FIGS. 1A-1K and FIG. 2B will now be described with respect to FIG. 3.
  • a tube of shape-memory material e.g., a shape- memory metal such as nickel titanium (NiTi), also known as NITINOL
  • NiTi nickel titanium
  • NITINOL nickel titanium
  • suitable materials known in the art of deformable stents for percutaneous implantation may alternatively be used, e.g., other shape memory alloys, polymers, and the like.
  • the tube has a thickness of 0.25 mm.
  • the tube is laser-cut to define a plurality of rings, e.g., sinusoidal rings, connected by longitudinally extending struts (step 302).
  • rings e.g., sinusoidal rings
  • struts 111 and sinusoidal rings 112-116 illustrated in FIG. 1A may be defined using laser cutting a single tube of shape- memory metal, and thus may form an integral piece of unitary construction.
  • struts 111 and sinusoidal rings 112-116 may be separately defined from different pieces of shape- memory metal and subsequently coupled together.
  • the laser-cut tube then is expanded on a mandrel to define first and second flared end regions and a neck therebetween, e.g., to define first end region 102, second end region 106, and neck region 104 as illustrated in FIG. 1A; the expanded tube then may be heated to set the shape of stent 110 (step 303).
  • the tube is formed of NITINOL, shaped using a shape mandrel, and placed into an oven for 11 minutes at 530 C to set the shape.
  • the stent thus defined also may be electropolished to reduce
  • the neck and second flared end region of the stent then may be coated with a biocompatible material (step 304).
  • suitable biocompatible materials include expanded polytetrafluoroethylene (ePTFE), polyurethane, DACRON (polyethylene terephthalate), silicone, polycarbonate urethane, and animal pericardial tissue, e.g., from an equine, bovine, or porcine source.
  • the stent is coated with the biocompatible material by covering the inner surface of the stent with a first sheet of ePTFE, and covering the outer surface of the stent with a second sheet of ePTFE.
  • the first and second sheets first may be temporarily secured together to facilitate the general arrangement, e.g., using an adhesive, suture, or weld, and then may be securely bonded together using sintering to form a strong, smooth, substantially continuous coating that covers the inner and outer surfaces of the stent. Portions of the coating then may be removed as desired from selected portions of the stent, for example using laser-cutting or mechanical cutting. For example, as shown in FIG.
  • biocompatible material 120 may cover stent 110 between sinusoidal ring 113 and sinusoidal ring 116, i.e., may cover neck region 104 and second flared end region 106, but may be removed between sinusoidal ring 113 and sinusoidal ring 112, i.e., may be removed from (or not applied to) first flared end region 102.
  • a plurality of cavities e.g., holes or grooves, may be carved into at least one of sinusoidal rings 112, 113,
  • a biodegradable material may be disposed therein.
  • the biocompatible material facilitates funneling of blood from the left atrium to the right atrium by providing a substantially smooth hemodynamic profile on both the inner and outer surfaces of device 100.
  • this configuration is expected to inhibit the formation of eddy currents that otherwise may cause emboli to form, and facilitates smooth attachment of the device to the atrial septum, e.g., fossa ovalis.
  • Biocompatible material 120 preferably is configured so as to direct blood flow from the left atrium through neck region 104 and into the right atrium.
  • Biocompatible material 120 preferably also is configured so as to inhibit tissue growth from atrial septum 210 and surrounding tissue into device 100.
  • the biocompatible material 120 has a porosity that is preselected to allow limited cell growth on its surface; the cells that grow on such a surface preferably are endothelial cells that are exposed to blood and inhibit blood from coagulating on the biocompatible material.
  • the material preferably is substantially inert and thus not rejected by the body.
  • the biocompatible material may be impregnated with a second material that facilitates tissue ingrowth, e.g., carbon. Such impregnation may be performed before or after applying the biocompatible material to the stent.
  • biocompatible material 120 may have a biodegradable material layer embedded therein, wherein biocompatible material 120 has a plurality of nodal pores disposed on either or both upper and lower surfaces of biocompatible material 120.
  • one or more biodegradable rings may be disposed on the interior and/or exterior surface of biocompatible material 120, such that the rings bioresorb or biodegrade over time to release a drug that inhibits tissue overgrowth across the rings (step 305).
  • a plurality of cavities e.g., holes or grooves, may be carved into biocompatible material 120 such that the one or more biodegradable rings are disposed at least partially in the plurality of holes or grooves. Such carving may be performed before or after applying the biocompatible material to the stent.
  • biodegradable substance layer 129 may be disposed on biocompatible material 120 using any suitable technique, for example, using deep molding, spraying, or electrospinning. Note that if deep molding is used, any surfaces on which it is not desired to apply biodegradable substance layer 129 may be masked to avoid inadvertent deposition on such surfaces.
  • a method 400 of using device 100 illustrated in FIGS. 1 A- IK to reduce left atrial pressure in a subject, for example, a human having CHF, will now be described with reference to FIG. 4. Some of the steps of method 400 may be further elaborated by referring to FIGS. 5A-5D.
  • a biodegradable material e.g., one or more drug-eluting biodegradable rings, and optionally a biodegradable substance layer, is provided (step 401).
  • a biodegradable material e.g., one or more drug-eluting biodegradable rings, and optionally a biodegradable substance layer.
  • the device is collapsed radially to a contracted delivery state, and loaded into a loading tube (step 402).
  • device 100 may be loaded into loading tube 510 using pusher 520 having“star”-shaped end 521.
  • Loading tube 510 includes tapered loading end 511, which facilitates radial compression of device 100 into lumen 512 having a suitable internal diameter.
  • pusher 520 is retracted.
  • device 100 is loaded into loading tube 510 shortly before implantation, so as to avoid unnecessarily compressing device 100 or re-setting of the closed shape of leaflets 132, which may interfere with later deployment or operation of the device.
  • some embodimentsening tube 510 is loaded into loading tube 510 shortly before implantation, so as to avoid unnecessarily compressing device 100 or re-setting of the closed shape of leaflets 132, which may interfere with later deployment or operation of the device.
  • loading tube 510 has a diameter of 16 F or less, or 14 F or less, or 10 F or less, or 6 F or less, e.g., about 5 F
  • device 100 has a crimped diameter of 16 F or less, or 14 F or less, or 10 F or less, or 6 F or less, e.g., about 5 F.
  • loading tube has a diameter of 15 F and device 100 has a crimped diameter of 14 F.
  • the device then is implanted, first by identifying the fossa ovalis of the heart septum, across which device 100 is to be deployed (step 403).
  • a BROCKENBROUGH needle may be percutaneously introduced into the right atrium via the subject’s venous vasculature, for example, via the femoral artery. Then, under fluoroscopic or echocardiographic visualization, the needle is pressed against the fossa ovalis, at a pressure insufficient to puncture the fossa ovalis. As illustrated in FIG.
  • the pressure from needle 530 causes“tenting” of fossa ovalis 541, i.e., causes the fossa ovalis to stretch into the left atrium.
  • Other portions of atrial septum 540 are thick and muscular, and so do not stretch to the same extent as the fossa ovalis.
  • fossa ovalis 541 may be identified, and in particular the central portion of fossa ovalis 541 may be located.
  • the fossa ovalis (particularly its central region) may be punctured with the BROCKENBROUGH needle, and a guidewire may be inserted through the puncture by threading the guidewire through the needle and then removing the needle (step 404, not illustrated in FIG. 5).
  • the puncture through the fossa ovalis then may be expanded by advancing a dilator over the guidewire.
  • a dilator may be advanced over the BROCKENBROUGH needle, without the need for a guidewire.
  • the dilator is used to further dilate the puncture and a sheath then is advanced over the dilator and through the fossa ovalis; the dilator and guidewire or needle then are removed (step 405, not illustrated in FIG. 5).
  • the device then is advanced out of the loading tube and into the sheath using a pusher, and then partially advanced out of the sheath, such that the second flared end of the device protrudes out of the sheath and into the left atrium, and expands to its deployed state (step 407).
  • pusher 550 may be used to partially advance device 100 out of sheath 512 and into left atrium 502, which causes the second flared end region to expand in the left atrium.
  • the pusher may be configured such that it cannot advance the device 100 completely out of the sheath, but instead may only push out the side of the device to be disposed in the left atrium, that is, the second flared end region.
  • the pusher may be mechanically locked from advancing the device out any further.
  • an expanded region may be disposed on the end of the pusher proximal to the physician that abuts the sheath and prevents further advancement of the pusher after the second flared end region is advanced out of the sheath.
  • the device then may be fully deployed by pulling the sheath back, causing the second flared end region of the device to engage the left side of the atrial septum. Such a feature may prevent accidentally deploying the entire device in the left atrium.
  • the sheath then is retracted, causing the second flared end region to flank the left side of the atrial septum and the neck of the device to lodge in the puncture through the fossa ovalis, and allowing expansion of the first flared end of the device into the right atrium (step 408, see also FIG. 2B). Any remaining components of the delivery system then may be removed, e.g., sheath, and loading tube (step 409).
  • the device Once positioned in the fossa ovalis, the device shunts blood from the left atrium to the right atrium when the left atrial pressure exceeds the right atrial pressure (step 410), thus facilitating treatment and/or the amelioration of symptoms associated with CHF.
  • Tissue overgrowth may be reduced or inhibited on the device by biodegrading the biodegradable material, e.g., the one or more biodegradable rings or any of the biodegradable materials described above, to release an -olimus drug, for example as discussed above with reference to FIGS. 1B-1D.
  • the cross-sectional flow area (flow rate) of the device then may be maintained within a desired range by biodegrading the biodegradable substance layer to offset a decrease in the cross-sectional flow area (flow rate) caused by tissue overgrowth, for example as discussed above with reference to FIGS. 1K-1L.
  • the cross- sectional flow area (flow rate) of the device then may be gradually increased by biodegrading the biodegradable substance layer over time.
  • device 100 may include one or more layers of degradable components that may activated to selectively increase the cross-sectional area of the device to adapt to the needs of the patient based on the necessary flow pattern required for the patient. For example, when the clinical condition of the patient at some point after initial implantation of the interatrial shunt requires a greater flow pattern, e.g., from the left atrium to the right atrium, the diameter of the neck region of the shunt may be increased by causing the one or more layers of degradable components at the neck region to degrade, e.g., via applying heat or a degradation activating material to the one or more layers of degradable components, without having to increase the hole within the fossa ovalis.
  • the diameter of the neck region of the shunt may be increased by causing the one or more layers of degradable components at the neck region to degrade, e.g., via applying heat or a degradation activating material to the one or more layers of degradable components, without having to increase the hole within the fossa
  • device 100 may include a layer of degradable components 132 disposed on the inner surface of biocompatible material 120, in the neck region of device 100.
  • the diameter at the neck region of device 100 e.g., the diameter of the distance between the inner surface of biocompatible material 120 on the stent frame, is 6.0 mm, and with the layer of degradable components 132 disposed thereon, the diameter of the passageway through device 100 at its neck region is 5.0 mm.
  • the layer of degradable components 132 may have a thickness of 1.0 mm.
  • the layer of degradable components 132 is made of a degradable material that stays intact until exposed to an external stimulus. Thus, upon interaction with the stimulus, the layer of degradable components 132 will degrade, thereby increasing the cross-sectional area of the passageway through device 100 at its neck region.
  • a delivery balloon may be delivered and positioned within the passageway of device 100 adjacent to the layer of degradable components 132, and a heated contrast-water mixture may be delivered to the balloon to transmit heat to the layer of degradable components 132.
  • the layer of degradable components 132 will degrade in response to the transmitted heat.
  • a biocompatible degradation activating material may be ejected adjacent to the layer of degradable components 132, thereby causing the layer of degradable components 132 to degrade.
  • the diameter of the passageway through device 100 at its neck region will be 6.0 mm.
  • any combination of the biodegradable materials described above with reference to FIGS. 1B-1J, e.g., one or more biodegradable rings 117, and the layer of degradable components 132 may be utilized to effectively reduce tissue overgrowth to preserve longevity and patency of device 100.
  • device 100 may have two or more layers of degradable components, e.g., layer 132a and 132b, disposed on its neck region. Like the layer of degradable components 132, layers 132a and 132b may remain intact until exposed to external stimuli. Layers 132a may be made of degradable material that is different from the degradable material that form layer 132b, such that each of layers 132a and 132b are degradable in response to different stimuli. For example, as shown in FIG.
  • the diameter at the neck region of device 100 e.g., the diameter of the distance between the inner surface of biocompatible material 120 on the stent frame, is 6.0 mm
  • the layer of degradable components 132b disposed thereon the diameter of the passageway through device 100 at its neck region is 5.5 mm
  • the layer of degradable components 132a disposed thereon the diameter of the passageway through device 100 at its neck region is 5.0 mm.
  • the layer of degradable components 132b may have a thickness of 0.5 mm
  • the layer of degradable components 132a may have a thickness of 0.5 mm.
  • the layer of degradable components 132a will degrade, thereby increasing the cross-sectional area of the passageway through device 100 at its neck region from 5.0 mm to 5.5 mm.
  • a second stimulus may be introduced to cause the layer of degradable components 132b to degrade, thereby increasing the cross-sectional area of the passageway through device 100 at its neck region from 5.5 mm to 6.0 mm.
  • more than two layers of degradable components may be disposed at the neck region of device 100, each having a preselected thickness and each responding to the same or different stimuli, such that upon exposure to the corresponding stimulus, each layer of degradable components will degrade to selectively increase the cross-sectional area of the passageway through device 100 at its neck region.
  • the devices and methods described herein may be used to regulate left atrial pressures in patients having a variety of disorders, including congestive heart failure (CHF), as well as other disorders such as patent foramen ovale (PFO), or atrial septal defect (ASD).
  • CHF congestive heart failure
  • PFO patent foramen ovale
  • ASD atrial septal defect
  • the devices and methods also may be used to reduce symptoms and complications associated with such disorders, including myocardial infarction. It is believed that patients receiving the device may benefit from better exercise tolerance, less incidence of hospitalization due to acute episodes of heart failure, and reduced mortality rates.
  • Devices constructed and implanted according to the present invention may provide for significantly improved mortality rates in subjects suffering from heart failure.
  • the devices may significantly enhance ejection fraction, fractional shortening, and/or cardiac output in subjects who would otherwise have significantly diminished cardiac function as a result of excessive left atrial and left ventricular pressures.
  • subjects may be classified under the New York Heart Association (NYHA) classification system as having Class II (Mild) heart failure, who have slight limitation of physical activity and are comfortable at rest, but for whom ordinary physical activity results in fatigue, palpitation, or dyspnea; Class III (Moderate) heart failure, who have marked limitation of physical activity, may be comfortable at rest, and may experience fatigue, palpitation, or dyspnea if they engage in less than normal activity; or as having Class IV (Severe) heart failure, who are unable to carry out any physical activity without discomfort, exhibit symptoms of cardiac insufficiency at rest, and have increased discomfort if they undertake any physical activity.
  • NYHA New York Heart Association
  • the present devices may significantly increase the cardiac output of such class III or class IV subjects, particularly those with low ejection fraction, enabling them to engage in significantly more physical activity than they otherwise could.
  • the present devices further may decrease pulmonary artery pressure in subjects with left heart failure, and additionally may reduce or inhibit pulmonary congestion in patients with pulmonary congestion resulting from such heart failure, for example by inhibiting episodes of acute pulmonary edema.
  • the inventive device may reduce LAP and PAP significantly relative to what those pressures would otherwise be; such pressure reductions may not only provide immediate relief from acute symptoms, but further may facilitate cardiac remodeling over the weeks following implant and thus provide for enhanced cardiac function.
  • the devices may in some embodiments include means for measuring the various parameters of interest, e.g., means such as discussed above with respect to the animal trials. Furthermore, it is believed that disposing one or more drug-eluting biodegradable rings on the interior and/or exterior surface of the biocompatible material covering the stent, such as one or more biodegradable rings 117 illustrated in FIGS. IB- ID, will enhance the functionality of the device by reducing tissue overgrowth. Additionally, it is believed that providing a biodegradable substance layer, such as layer 129 illustrated in FIG. IK, may further enhance the functionality of the device by improving control over flow rate e.g., by compensating for changes in flow caused by tissue overgrowth.
  • the inventive devices also may be used with patients having disorders other than heart failure.
  • the device may be implanted in a subject suffering from myocardial infarction, for example in the period immediately following myocardial infarction (e.g., within a few days of the event, or within two weeks of the event, or even within six months of the event).
  • the heart remodels to compensate for reduced myocardial function.
  • such remodeling may cause the function of the left ventricle to
  • Implanting an inventive device during the period immediately following myocardial infarction may inhibit such deterioration in the left ventricle by reducing LAP and LVEDP during the remodeling period.
  • heart failure was induced in the sheep by injecting microspheres that block the coronary artery and induce myocardial infarction. Following the myocardial infarction, the sheep developed heart failure.
  • implanting the inventive device even a week following the myocardial infarction inhibited degradation of the heart and yielded significantly improved mortality rates and cardiac functioning both immediately and over time as the subjects’ hearts remodeled.
  • implanting an inventive device for even a few weeks or months following myocardial infarction may provide significant benefits to the subject as their heart remodels. The device optionally then may be removed.
  • device 100 illustrated in FIGS. 1A-1K may be implanted so as to shunt blood from the right atrium to the left atrium, thus decreasing right atrial pressure; such a feature may be useful for treating a high right atrial pressure that occurs in pulmonary hypertension.
  • device 100 may be implanted across the ventricular septum, in an orientation suitable to shunt blood from the left ventricle to the right ventricle, or in an orientation suitable to shunt blood from the right ventricle to the left ventricle.

Abstract

L'invention concerne un dispositif de régulation de la pression sanguine entre l'atrium gauche et l'atrium droit d'un patient comprenant un stent en forme de sablier doté d'une région de col et des première et seconde régions d'extrémité évasées, la région de col étant disposée entre les première et seconde régions d'extrémité et configurée pour venir en prise avec la fosse ovale du septum interauriculaire du patient, et un matériau biodégradable d'élution de médicament qui se dégrade biologiquement au avec le temps pour libérer un médicament qui restreint l'hypertrophie tissulaire. Selon l'invention, le dispositif peut comprendre un matériau biodégradable qui se biodégrade pour compenser des changements d'écoulement provoqués par une interposition de tissu. Selon l'invention, le dispositif peut réduire la pression auriculaire gauche et la pression artérielle diastolique ventriculaire gauche, et peut augmenter le débit cardiaque, augmenter la fraction d'éjection ventriculaire, soulager la congestion pulmonaire et faire baisser la pression artérielle pulmonaire, entre autres avantages.
PCT/IB2020/053832 2019-04-25 2020-04-23 Shunts interauriculaires contenant un matériau biodégradable et leurs procédés de fabrication et d'utilisation WO2020217194A1 (fr)

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