Patent Application
20210196459
The invention relates to replacement heart valve prostheses with advantageous sealing properties and advantageous properties for loading into a delivery system, e.g. a catheter.
In the last decades minimally invasive techniques have advanced and are now feasible in many medical fields.
In some medical fields, it is now possible to treat patients by minimally invasive techniques allowing for the treatment of such patients who could otherwise not be adequately taken care of due to their physical condition and the risks connected with surgery. Many of such minimally invasive methods apply delivery systems, e.g. catheters, for implanting the medical device to a desired target site.
In recent years the treatment of heart valve diseases and defects has become more and more successful. Examples are transapical, transjugular and transfemoral procedures for heart valve replacement therapies, e.g. aortic or mitral heart valve treatments.
In many cases a stent-based prosthesis with a tissue based replacement valve is used and implanted to replace the native heart valve. The replacement heart valve is placed into the patient at the target site in a controlled and coordinated manner by way of a catheter delivery system.
The replacement heart valve has to be crimped and loaded onto the catheter system. The delivery system is then introduced into the patient's vasculature, e.g. transfemorally, and directed to the target site. At the target site the replacement heart valve prosthesis has to be positioned precisely before its final release from the catheter in order to achieve a correct deployment.
Equally important for a correct functioning of the replacement heart valve prosthesis is that the prosthesis is tight and no paravalvular leakage occurs (PVL).
Hence there exists a need for a replacement heart valve prosthesis which exhibits good sealing features avoiding back flow of blood during function.
Known problem with replacement heart valves is a lack of sufficient sealing of the implanted replacement heart valve to create PVL (para valvular leakage) and an improper functioning of the replacement heart valve prosthesis.
In particular, replacement heart valve prostheses composed of a double wall or a stent-in-stent design wherein the replacement heart valve prosthesis is composed of a first stent connected to a second stent and attached to each other by suitable means face a greater challenge to provide for a sufficient sealing characteristic of the device.
In aortic replacement heart valve prostheses the annulus and surrounding tissue is relatively firm. The prosthesis' radial force and a simple sealing feature will often provide for sufficient sealing.
In contrast, anatomical requirements of other heart valves e.g. the mitral and tricuspid heart valve, make valve replacement heart valve procedures more complex and challenging.
The size of the native annulus in these heart valves is relatively large. Moreover, the native implantation site in addition may be enlarged, which causes issues especially for treatment of tricuspid regurgitation and pulmonary pathologies. Also, the large annulus diameter and valve diameter of the necessary replacement heart valve prosthesis induces longer profiles, which may reach into the ventricular cavity or within the pulmonary outflow tract.
In addition, the large replacement heart valves are composed of large leaflets which exhibit some resistance, however, they have to be opened and closed properly which is affected by the endogenous blood flow. PVL issues will interfere with a proper valve opening and closing and thus it will interfere with a correct replacement heart valve function. The opening and closing phase requires thus a higher amount of energy. Hence, it is of utmost importance that the hemodynamic characteristics of the replacement heart valve prosthesis and in site positioning is optimal.
Unfortunately, the native heart valve annulus of the above mentioned heart valves often have a non-circular shape, especially the atrio-ventricular heart valve annulus of mitral and tricuspid heart valves.
The implantation site also does not provide an entire surface of contact but mostly only a line of contact. It is not circular and not planar. The tricuspid annulus has, for example, a saddle shape. Consequently, the implantation sites may not provide a sufficient surface contact due to the lack of matching with the tubular replacement heart valve support.
This lack of surface and contact makes the device anchoring and sealing difficult by solely using direct contact with the cylindrical valve support.
Finally, due to the extensive soft tissue of the surrounding tissue of the above mentioned heart valves, e.g. tricuspid and mitral valves, sealing cannot be achieved solely by application of radial force and a simple sealing.
In contrast with calcified aortic valve/root, the pulmonary/tricuspid/mitral valves show different pathologies. Consequently, the implantation sites of e.g. the mitral and tricuspid heart valves are not stiffened by calcium and may not provide rigid and sustainable supports for stent anchoring. Thus, radial force is not sufficient to anchor and seal the replacement device within the soft tissue of the target site.
Moreover, the soft tissue surrounding the target site of the replacement heart valve is sensitive to surrounding stress and movement, like blood pressure variations and muscle contraction. Consequently, the implantation site may have large dimensions variations, especially during the cardiac cycle.
Additionally, if multiple part replacement heart valve systems are used, the anchoring system (outermost section) should comply with the soft tissue of the implantation site, its dynamics, and its irregular anatomy.
Thus the stent configuration is changing during the cardiac cycle implying issues for a proper sealing and avoidance of PVL.
Accordingly, it is one object of the current disclosure to provide a means allowing for better sealing of a replacement heart valve prosthesis, or at least to reducing the disadvantages of the prior art or essentially avoiding these disadvantages.
It is another object of the current disclosure to furnish a heart valve replacement prosthesis providing for sealing means supporting advantageous sealing characteristics and maintaining a sufficiently tight sealing after the implantation and thereafter, or at least reducing the disadvantages of the prior art or essentially avoiding these disadvantages.
It is another object of the current disclosure to furnish a heart valve replacement prosthesis showing sealing characteristics which serve to support an advantageous replacement heart valve opening and closing during the heart beating and heart function.
In one aspect the disclosure relates to a sealing feature for improved sealing characteristics of replacement heart valve prostheses.
In another aspect the disclosure relates to a replacement heart valve prosthesis exhibiting advantageous sealing characteristics or/and blood flow characteristics or/and valve functionality.
In another aspect the disclosure relates to a replacement heart valve prosthesis comprising at least two sealing features.
In another aspect the disclosure relates to an advantageous sealing characteristics or sealing solution useful in double wall, e.g. two part or multiple part stent prostheses, or/and in replacement stent prostheses exhibiting a discontinued stent design.
In another aspect the disclosure relates to a heart valve replacement prosthesis showing sealing characteristics which serve to support an advantageous replacement heart valve opening and closing during heart beating and heart function.
In another aspect the disclosure relates to a replacement heart valve prosthesis having advantageous properties for loading into a delivery system, e.g. a catheter, combined with advantageous replacement heart valve functionality and/or durability.
In the following
Preferably, the position of the point K has to be determined so that the crimped stent length IJ is equal to the tissue length IKJ, to prevent tissue folds and then ease the prosthesis loading.
In the following additional stent design Figures (indicated as Figures B including reference signs also indicated with “B” according to the “Reference Number List B”) will be described which can be combined with the advantageous sealing features of the current disclosure as described herein above and in the above Figures and in the claims.
a and B1b illustrate an example of a replacement heart valve prosthesis of the prior art composed of an laser cut tube inner stent (2) meant to carrying the valve and a braided outer stent (1), also denoted outer mesh stent, combined therewith for positioning and fixation of the prosthesis at the target site (two-part stent).
a and B2b illustrate one aspect of the disclosure, i.e. a two-part stent as of
a and B3b illustrate one aspect of the disclosure, i.e. a two-part stent as of
a and B5b illustrate one aspect of the disclosure, i.e. loops (4) are positioned in the distal area of the braided outer stent (mesh stent); the outer stent is connected with the inner laser cut stent at the middle area; the outer stent is not connected with the inner stent at the distal area; the outer mesh (5) and inner mesh (6) of the outer mesh stent form in the middle or/and distal area a double layer which provides for stability or/and axial force which can be engineered as to the requirements of the particular case; in certain embodiments a stabilizer feature (like additional wires or/and twisted wires below the v-groove) are not present while in other embodiments according to the disclosure can be added to engineer stent stability and stent axial force.
a and B6b illustrate one aspect of the disclosure, i.e. a double stent prosthesis, wherein distally the outer stent (2) is not connected to the inner stent (1). The inner mesh (6) and outer mesh (5) are folded and oriented close to each other in the distal area. Moreover, the inner mesh (6) and outer mesh (5) form an angle (“angle structure” by way of two accessory lines drawn into the outer stent for illustration purposes) wherein the angle is marked as “alpha”. “Alpha” is the area between the two arrow heads marked at the accessory lines in the Figure in direction axial to central in direction to the connection of inner stent (2) where both inner stent (2) and outer stent (1) are connected. The inner mesh (6) and outer mesh (5) thus form an angle which can be chosen depending on the stability and dimension requirements. The close orientation of the inner mesh (6) and outer mesh (5) in combination with the “angle alpha” imply a number of advantages as depicted in
a, b, c illustrates one aspect of the disclosure, wherein the sequence of closing of clipping means (19) is depicted.
In
In
c) illustrates the final connection of the connecting struts (12, 12′) of the two laser cut stents. Sleeve (10) is pushed over the interlocked parts (18) and (9) wherein the sleeve (10) secures the fixation by interaction with the distal part of interlocking yoke (18). The sleeve (10) can be released when the two distal parts of interlocking yoke (18) are pushed together and thus the sleeve (10) can be pushed again over one connecting strut (12′). At the end of part (18) a stop means prevents that sleeve (10) from moving too far over the interlocking means (18) and (9). The interlocking yoke end prevents movement of the sleeve, at least in one or in both directions along the connecting struts.
a) and b) illustrate a variation of the clipping means (19). The interlocking yoke (18) varies in its design on its distal end. Interlocking yoke (18) is characterized by a different stop design and interaction with sleeve (10) and as regards its release mechanism. In one design in
As depicted in both
a illustrates one aspect of the disclosure, i.e. a laser cut stent in a mesh stent of a replacement heart valve prosthesis according to the disclosure re-loaded into a cathether. The advantage of the loop design according to the disclosure is the flexibility of the loops (4) and their special design allowing for retrievabilty into the catheter shaft by way of flipping over during the retrieval or re-loading procedure.
b illustrates one aspect of the disclosure, i.e. a laser cut stent connected to a mesh stent of a replacement heart valve prosthesis according to the disclosure is depicted loaded into a catheter (7). The wire braided outer stent (1) with inner mesh (6) and outer mesh (5) connected to inner stent (2) is illustrated wherein a Z-ring (27) is connected to outer mesh (5). Furthermore, it is apparent from this Figure that the wire braided outer stent (1) elongates during loading and the Z-ring (27) is not superimposed with inner stent (2) but arrives at a position distal from the inner stent (2) which advantageously helps to reducing the catheter diameter.
a to B29f illustrate one aspect of the disclosure, wherein a cut stent in cut stent replacement heart valve prosthesis is depicted.
a to B29c illustrate the three parts of a prosthesis according to the disclosure, i.e. proximal laser cut stent (11a), distal laser cut stent (11b) including anchoring cells (15) and connecting strut guides (17) and inner stent (2) with connecting struts (12).
In
e depicts a replacement heart valve prosthesis according to the disclosure wherein a laser cut outer stent parts (11a, 11b), a V groove (16), an anchoring cell (15), a connecting means (19), connecting struts (12), and connecting strut guides (17) are shown. The laser cut outer stent parts (11a, 11b) are shown, i.e. a proximal part (11a) which will be placed in the atrium of patient and a distal part (11b) which will be placed in the annulus/ventricle of the patient during implantation. Accordingly, the prosthesis concerns a three-part stent. The three stents parts (2, 11a, 11b), respectively, are connected by way of connecting means (19) and connecting strut guide (17). Of particular interest in this Figure is the area illustrating the interconnection of the different stents or/and of the different stent parts around reference sign (19). This area is depicted and further described in
The blow up detail
In the following certain terms of the disclosure will be defined. Otherwise technical terms in the context of the disclosure shall be understood as by the applicable skilled person.
The term “prosthesis” or “medical device” or “implant” in the sense of the disclosure is to be understood as any medical device that can be delivered in a minimally invasive fashion. The terms can be used interchangeably. It can be e.g. a stent or stent-based prosthesis or stent-based replacement heart valve like an aortic heart valve, a mitral heart valve or a tricuspid heart valve.
The term “catheter” or “delivery device” in the sense of the disclosure is to be understood as the device used to deploy a prosthesis in a patient at a determined site, e.g. to replace a heart valve like an aortic heart valve, a mitral heart valve or a tricuspid heart valve.
A “mesh stent” or “braided mesh stent” or “braided stent” in the sense of the disclosure is a stent composed of wires in contrast to a e.g. laser cut nitinol tube.
A “cut stent” or “laser cut stent” in the sense of the disclosure is a stent which is laser cut from a nitinol tube.
A “stent area” or “stent areas” in the sense of the disclosure is a defined area of the outer stent, mesh stent or the replacement heart valve prosthesis and in particular it is a longitudinal section or an outer section defined as proximal, middle or distal area.
A “proximal area”, “middle area”, “distal area” in the sense of the disclosure denotes areas of the stent or prosthesis in relation to the operator performing implantation by use of a catheter wherein proximal is close to the operator and distal is away from the operator. “Middle area” denotes in a stent or prosthesis in the sense of the disclosure the area between the distal and proximal area. The “proximal area” can also be denoted inflow end or inflow area and the “distal area” can also be denoted outflow end or outflow area with regards to the natural blood flow in situ, i.e. in vivo, in an individual (person or patient).
An “annulus area” in the sense of the disclosure is either the respective area of an endogenous heart valve or it defines the respective area in the replacement heart valve or stent which is to be positioned in the implantation site and it meant to align with the endogenous annulus.
A “sub-annular area” in the sense of the disclosure is the area of the prosthesis which is in distal direction (or in outflow direction) of the annulus of the endogenous heart valve. The prosthesis may cover the “sub-annular area” with the groove area and the distal area.
A “groove” in the sense of the disclosure describes an area of the stent or of the prosthesis exhibiting a smaller diameter than other areas and wherein distally and proximally of said groove other areas of the stent or prosthesis having a larger diameter are in neighborhood to said groove; said groove can have a V- or U shape of combinations thereof or other useful geometries.
A “two-part stent” in the sense of the disclosure is composed of an inner and outer stent wherein the inner stent is carrying the heart valve attached to the inner stent, and wherein the inner and outer stents are connected by one or more sutures, a specific mechanism like a click mechanism or any other suitable connecting means forming the replacement heart valve prosthesis. Such a prosthesis in the sense of the disclosure can be suitable or implanted to treat, i.e. to replace, a malfunctioning endogenous heart valve wherein the heart valve is a mitral valve or a tricuspid valve.
In a “multiple-part stent” in the sense of the disclosure the outer stent is composed of two, three or more parts, e.g. made of a laser cut tube, wherein the parts are connected with the laser cut inner stent carrying the valve by way of a connecting means and a connecting guide; a “multiple-part stent” prosthesis can contain at least three or more, e.g. 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, the connecting means and the connecting guides. The connecting guides can advantageously be positioned essentially proximal from the inner stent and prevent or limit longitudinal movement of the inner stent. The definition of the “two-part stent” above forms part and falls under this definition here.
A “target site” in the sense of the disclosure is the location or place where the replacement heart valve prosthesis is to be implanted and where a dysfunction or malfunction shall be treated.
A “connection” of the stents in the sense of the disclosure is the way of fixation of two or more stents to each other by way of suturing, by way of a clipping or clicking mechanism or any other useful manner or means to attach the stents to each other.
A “connection means” or “connecting means” in the sense of the disclosure is a mechanical or physical connection of two struts or two parts in a mesh stent or laser cut stent wherein two stents are connected to form a stable unit. The connecting means can be by e.g. welding, coupling, suturing, gluing or any other known procedure or process or means. A connecting means can also be an attachment or clipping means which exhibits a special design and geometry for releasable or non-releasable connection.
“Connection struts” or “connecting struts” in the sense of the disclosure are the struts of two different stents or two different laser cut stents which are used to connect the two stents together. It relates to the struts of the laser cut stent or stents which function is to connect the laser cut inner and outer stent. The connection can be releasable or non-releasable by way of a non-releasable connection or by way of a connection means.
An “anchoring cell” in the sense of the disclosure is a combination of a loop and a stent cell of a laser cut stent wherein the loop is radially moveable and formed in an atraumatic geometry. The “anchoring cell” can be formed as a single unity wherein a stent cell of a laser cut stent or part thereof forms a loop which is radially moveable and formed in an atraumatic geometry.
A “connection strut guide” in the sense of the disclosure is used to support or assist in the connection of a three-part stent; the connecting strut guide interacts with the connecting struts. Preferably the connecting struts and the connecting strut guides are positioned in the groove (V or U groove), e.g. about the middle and the proximal area of the distal area. The connecting strut guide ends can be formed as eyelets or in another way to allow a connecting strut to pass through and be connected with its connecting strut counter part. In this manner the proximal part of the stent (prosthesis), the distal part of the stent (prosthesis) and the inner stent will be connected. The middle and distal stent parts of the prosthesis can thus freely move and easily align with the ventricular tissue and its geometry; in this manner the inner stent carrying the valve is decoupled from the outer stent parts of the prosthesis and deformations due to heart beating impact to the outer stent parts of the prosthesis will not reach the inner stent. Thus the inner stent round geometry which is advantageous for a proper valve coaptation and functioning, i.e. correct opening and closing of the valve leaflets, is advantageously guaranteed.
A “S strut” or “U or V strut” in the sense of the disclosure is a stent strut of a laser cut stent, e.g. a nitinol stent, wherein the strut comprises or is composed of a repeated number of S, U or V units and thus forms a specific geometry which exhibits other characteristics as compared to a straight strut. An exemplary S strut is depicted in
A “loop” in the sense of the disclosure is a means useful for an improved fixation of a stent or prosthesis wherein a loop is fixed to or connected with or forms part of or is an integral part of the outer stent. The “loop” or “loops” in the sense of the disclosure can have different shapes like round, square etc. and are located in a defined area in a defined pattern. A “loop” in the sense of the disclosure will exhibit a defined angle with regard to the outer stent surface and it may be designed that it may flip over when the stent or prosthesis is retrieved into the catheter after an initial and possibly partial deployment. A loop in the sense of the disclosure can be contained in an anchoring cell.
A “stabilizer” in the sense of the disclosure is a structure which aids for supporting an improved fixation of a stent or replacement heart valve prosthesis at a target site, i.e. at an endogenous heart valve, which is to be replace. A “stabilizer” can also be understood as a re-enforcement means. The “stabilizer” can support certain characteristics of a stent or prosthesis in the sense of the disclosure, like flexibility or axial force etc., entirely or in a defined area. It can be e.g. an additional wire or stent layer; the “stabilizer” is e.g. at least one nitinol ring, preferably attached inside or outside of the mesh stent, or combined with or introduced into the mesh of the mesh stent, preferably wherein the at least one nitinol ring has an undulating, or a V or U geometry, or zigzag geometry, or the “stabilizer” can be designed as a Z-ring.
A “Z-ring” in the sense of the disclosure provides for a fixation functionality, or it combines stabilizer and loop functionalities. Moreover, the fixation or loop functionality advantageously provides for interference with heart structures, e.g. the chordae of the target site and thus an improved fixation of the prosthesis in the target site is achieved. The prosthesis according to the disclosure may comprise 1, 2, or 3 Z-rings. Such Z-rings may be interconnected with each other or they may be independently connected with the outer stent, preferably with the outer mesh stent. The Z-ring can be composed of 10 to 30 cells, or 15 to 25 cells and/or the strut length of each cell may be in the range of 5 to 12 mm, preferably 8 to 10 mm. The Z-ring may be positioned at any middle or distal area or portion thereof, e.g. it may be positioned at the distal area and preferably at the distal end of the outer mesh stent. The Z-ring can be made of any material combinable with the outer mesh stent, and e.g. made of laser cut nitinol, a wire, a nitinol wire. The Z-ring can also have any useful geometry like Z, V, U, or zigzag geometry. The Z-ring is preferably a laser cut part and made of nitinol. The Z-ring is place outside the outer mesh stent and may be connected therewith with known means, e.g. suturing, welding, weaving, clipping, or braiding into the mesh stent.
The Z-ring may be placed circumferentially around the outer stent. It may also be feasible to design a Z-ring which does not represent a single ring circumferentially around the outer stent but which is composed of single units or parts which are placed around the outer stent. It is also feasible that single Z-ring units or parts are positioned in defined areas of the outer stent in order to be placed in preferred areas vis-à-vis endogenous structures prone for interaction and improved fixation functionality. An important aspect of the Z-ring is that the end parts which are essentially directed distally or proximally are free and unconnected with the outer stent in order to exhibit their fixation function.
An “angle structure” or “angle” in the sense of the disclosure is an angle between two accessory lines drawn at a certain area or stent layer in order to define a certain geometry of said stent layer with regard to other stent structures like the inner stent.
“Angle alpha” or “angle α” in the sense of the disclosure is the angle encompassing two accessory drawing lines of the outer mesh stent each aligned to one outer or inner layer of a mesh stent.
A “spring” or “spring function” or “absorption” in the sense of the disclosure relates to the function of the outer mesh stent when folded as two layers and exhibiting a certain radial force and flexibility which will allow to absorb e.g. movements and shocks from the beating heart and which supports an improved fixation in a soft tissue environment like a tricuspid or mitral valve. The same advantageous effect can be achieved when a laser cut outer stent is used.
A “radial force” in the sense of the disclosure is the force exhibited by a stent or prosthesis in radial outward direction, more particularly the force exhibited by the outer stent of the prosthesis which may be a mesh or a laser cut stent, e.g. a nitinol stent. The radial force depends on the particular mesh or cut stent design and relates to the material density, e.g. the density of wires per square area in a mesh stent, or the number of cells and size of said cells circumferentially in a certain laser cut stent level or area, e.g. the proximal, middle or distal area. The radial force in a replacement heart valve prosthesis according to the disclosure will be chosen for each area in a magnitude to provide for good contact with the surrounding tissue and to provide good contact therewith. On the other it will be chosen in a magnitude in order to avoid interference with the implantation site and endogenous tissue and function. The radial force may be supported for its fixation function by other means, e.g. loops for fixation.
A “fixation improvement” in the sense of the disclosure describes a better fixation in situ or in vivo as compared to a stent or replacement heart valve which does not exhibit the respective design feature, or in general means in a stent or replacement heart valve supporting the stable and long term implantation at a desired implantation site.
The term “loading” in the sense of the disclosure is to be understood as positioning a prosthesis onto a catheter in a manner so that the catheter is ready to initiate a delivery and deployment procedure to a patient.
The “target area” in the sense of the disclosure is the three dimensional space surrounding or being within the native organ like a native heart valve which can be e.g. a tricuspid heart valve.
An “atraumatic design” of the loops in the sense of the disclosure is wherein the loops or other means or parts of a stent or a prosthesis are designed to avoid any or essentially any damage of the surrounding tissue or tissue in contact with said parts or at least parts manufactured in a manner to minimize damaging or/and injuring the tissue which they contact.
“Compliance” of the stent or replacement heart valve prosthesis, e.g. comprising an inner laser cut stent within an outer mesh stent, or a laser cut inner stent within a laser cut outer stent, in the sense of the disclosure relates to a positive interference with the target tissue. “Compliance” relates to a design which exhibits good geometry adaptation of the stent or prosthesis to the implantation site and wherein the stent or prosthesis exhibits advantageous fixation characteristics, good functionality as concerns valve function and at the same a minimal interference with the endogenous heart structures and heart function.
“Crush resistance” of a stent or a replacement heart valve prosthesis or a prosthesis in the sense of the disclosure relates to the maintenance of the geometry of the inner stent or/and to the maintenance of the functionality of the replacement valve function due to the design of the outer stent, e.g. a mesh stent or a laser cut nitinol stent, which provides for a decoupling of inner and outer stent in relation to the impact of the endogenous heart beating to the outer stent of the prosthesis. The positive “crush resistance” of the prosthesis according to the disclosure achieves advantageously the maintenance of the geometry of the inner stent and an essentially correct replacement heart valve function. Particularly advantageous is a radial force of the outer stent to provide for fixation force to the target site and at the same time not to interfere with the endogenous tissue and function. A prosthesis according to the disclosure, e.g. comprising an outer mesh stent, will exhibit punctual deformability while in its entirety still exhibiting radial outward force. At the same time it is deformable to provide advantageous compliance with the ventricular heart tissue. Thus a prosthesis according to the disclosure, e.g. comprising an outer mesh stent, exhibits circumferential outward radial force and punctual deformability for providing advantageous compliance. Thus the crush resistance shall be small which outward radial force is in a magnitude to provide a support and fixation functionality. The advantage crush resistance of the outer stent advantageously achieves the distribution and reduction of a punctual stress impact in the target area.
A “frame” or “stent” in the sense of the disclosure is a part of a replacement heart valve prosthesis which can be crimped and delivered by way of a delivery system or catheter to a target site within an individual. A certain part of the frame carries a valve and sealing features wherein the valve replaces the function of the endogenous heart valve and the sealing feature(s) serve to prevent PVL (paravalvular leakage).
A “single frame” in the sense of the disclosure is a frame made of one part or assembled to from one functional part before delivery into the individual.
A “multiple frame” or “stent in stent” design in the sense of the disclosure forms part of the replacement heart valve prosthesis wherein two or more parts form one single frame which carries the valve and sealing features. The stent in stent design may comprise two or more stents, e.g. one or two or three laser cut nitinol stents or a braided stent combined with one, two or more laser cut stent, e.g. made of nitinol.
A “valve” or “replacement heart valve” in the sense of the disclosure is connected to the frame or stent part of the replacement heart valve prosthesis and serves to allow blood flow in a first direction and to prevent blood flow in a second direction. The valve may be made or comprising any useful material known to the skilled person. The materials may be chosen from e.g. pericardium tissue, bovine or porcine, or polymer tissue.
A “sealing feature” in the sense of the disclosure is a means to prevent undesired blood flow in a certain direction or area. A sealing feature may prevent blood flow in one or several directions or it may prevent blood flow in one direction and allow for blood flow in another direction and in particular in coordinated function with the valve of the replacement heart valve prosthesis as disclosed herein. The sealing feature can be one, two, or several and each sealing feature can have a specific functionality and each sealing feature can have a functionality different from the other. Each sealing feature can in turn be divided in different areas. One sealing feature may be located on the outer part of the replacement heart valve prosthesis in the proximal or inflow area, another sealing feature may be located in the annular or middle area, another sealing feature may be located in the distal or outflow area. The materials may be chosen from e.g. pericardium tissue, bovine or porcine, or polymer tissue.
In coordinated function with a minimally invasive heart valve prosthesis, a sealing feature may be attached to the two- or multiple stent frame by different means of attachment, e.g. suturing, gluing, encapsulating, or any other known procedure or process or means.
The stent and sealing features can be made out of a number of materials which are compatible with the other replacement heart valve components and preferably biocompatible. The stent or frame in the sense of the disclosure can be made of or comprise nitinol. It may also comprise one or more polymer materials, e.g. PLLA, or/and one or more metals, e.g. stainless steel or cobalt chromium, platinum-chromium alloy, magnesium. The sealing feature can be made e.g. of bovine or porcine pericardium.
An “attachment point” in the sense of the disclosure defines the connection of the sealing feature with the frame of the replacement heart valve prosthesis; the “attachment point” is in connection with the sealing features other characteristics supports or/and provides for advantageous sealing characteristics and advantageous crimping characteristics the replacement heart valve prosthesis. The “attachment points” may be denoted e.g. I, E, J, K. Other reference points in this context can be defined further. The attachment points define a distance between two attachment points and a ratio of two attachment points to two other attachment points. The defined distances and ratios in combination with the specific attachment point location within the replacement heart valve prosthesis and in particular its locations on the prosthesis frame provide for an advantageous functionality with regards to sealing characteristics or/and its ability to be well crimped. The distances of I to K and K to J can be adapted to different stent designs and may depend on the crimped stent dimensions and stent design like nitinol cut tube stent in mesh stent or nitinol cut tube in nitinol cut tube.
The distance of K to E can be adapted to different stent designs and may depend on the crimped stent dimensions and stent design like nitinol cut tube stent in mesh stent or nitinol cut tube in nitinol cut tube. For sealing and crimping purposes in one aspect the distances J to K and K to J have equidistance.
An “attachment area” in the sense of the disclosure relates to the area of an attachment point within the stent of the replacement heart valve prosthesis.
In the following additional stent designs will be described which can be combined with the advantageous sealing features of the current disclosure as described above and in the figures and claims. The following description relates to the “B” reference list and “B” figures in particular. These features can be combined with each other and with the features as outlined above and such combinations will imply a number of advantages which will be appreciated by the skilled person.
In one aspect the additional stent design can be a mesh stent wherein the stent comprises one or more re-enforced areas.
In one aspect the additional stent design can be a mesh stent comprising one or more fixation loops.
In one aspect the additional stent design can be a combination of a stent comprising one or more re-enforced areas and one or more fixation loops. Possibly a specific outer stent design exhibiting advantageously the capacity of an alignment with the natural tissue of the transplantation site may support an improved fixation in addition.
The above described additional stent designs can be combined with the sealing features as described herein.
In one aspect the additional stent design can thus provide for a stent or/and a replacement heart valve prosthesis exhibiting advantageous fixation characteristics and improved sealing characteristics.
In another aspect the additional stent design relates to a mesh stent as described above wherein the one or more fixation loops are characterized by a wire extending from and returning to the stent forming a loop extending outwardly from the stent, preferably in an angle of 30°-90°, preferably 50°-60° in proximal direction (in inflow direction), preferably located in the sub-annular area of the stent (ventricular area), preferably wherein a number of loops is located circumferentially of the stent with the same or different distances between each other, or/and are positioned in several rows or levels, or/and are positioned in different rows or/and in alternating positions.
The loops according to the disclosure can be formed in any useful manner and geometry, preferably they are formed as oval, round, open, closed, or/and tapered geometry. Advantageously, the loops have a dimension in the range of 2 mm-15 mm in length, or/and the loops are in the range of 2 mm-10 mm in diameter.
Preferably in the mesh stent according to the disclosure the loops are formed in an atraumatic design. Accordingly, the loops are designed to avoid any damage or essentially any damage of the surrounding tissue or at least manufactured in a manner to minimize damaging or/and injuring the tissue which they contact.
The loops can be positioned as is most useful to increase the fixation characteristics of the prosthesis. Accordingly, the loops can form an angle with regard to the mesh stent in either the proximal or distal direction. In one aspect the mesh stent according to the disclosure exhibits loops designed to flip over in distal direction (in outflow direction) during reloading of the stent into the catheter in situ.
In a preferred aspect the mesh stent according to the disclosure is characterized by a combination of inventive features of the disclosure and wherein the re-enforced area is supported by a stabilizer and/or one, two or more additional mesh layers. The stabilizer can be one, two, three or more stabilizers attached or combined with the mesh stent and preferably the stabilizer is at least one or two nitinol rings or wires, preferably attached inside or outside of the mesh stent, or combined with or introduced into the mesh of the mesh stent. The stabilizer can exhibit a geometry in different areas or circumferentially the mesh stent, preferably wherein the at least one nitinol ring has an undulating, or a V or U geometry, or a zigzag geometry.
In one aspect the disclosure relates to an embodiment wherein the outer stent comprises a Z-ring which is positioned outside in the distal area of the outer stent (e.g. a mesh stent), and preferably at the distal end of the outer stent. The Z-ring will advantageously combine a re-enforcement or stabilizer functionality and with its tips protruding essentially in proximal and distal direction it is also characterized by a loop functionality, or a functionality which serves to interfere with heart structures, e.g. the chordae, and thus contributes to an improved fixation characteristics of the replacement heart valve prosthesis as disclosed herein.
In one aspect the disclosure relates to a Z-ring or a number of Z-ring parts useful for supporting or improving a stable fixation of a stent, a two-part stent, a three-part stent of a replacement heart valve prosthesis comprising said stents in a target site, preferably in a heart. The Z-ring or Z-ring parts are characterized by at least two bars and at least one peak or tip in one direction and essentially in counter direction at least two peaks or tips. The number of bars, tips/peaks will vary depending on the overall size of the prosthesis and functional requirements as regards required fixation features. Such a Z-ring or Z-ring parts are connected to an outer stent of e.g. a replacement heart valve prosthesis in a manner to keep the tips or peaks essentially unconnected with the outer stent and allow their interaction with endogenous structures or tissue which will support improved fixation of the prosthesis. The outer stent may be a mesh stent to which the Z-ring or Z-ring part(s) are connected or interwoven.
The Z-ring or Z-ring parts can be advantageously positioned in the middle or distal area of the outer stent or sub-areas thereof. Preferred are all the bent areas of the outer stent.
In one aspect it is also advantageous if the Z-ring or Z-ring parts are positioned in the distal area of the outer stent of a replacement heart valve prosthesis because such a positioning also implies advantages for catheter diameter because of an advantageous placement of the replacement prosthesis parts, e.g. inner stent, Z-ring or Z-ring parts and the remaining prosthesis parts significant to loading and crimped prosthesis diameter in a catheter (see also in the
In one aspect the use of a Z-ring or Z-ring parts will support the concept of an inner stent exhibiting a relative high radial force combined with an outer stent exhibiting relative low radial force and providing a very good compliance with the target site and providing improved or advantageous fixation characteristics of a prosthesis comprising said parts. The Z-ring or Z-ring parts thus make it possible to maintain a relatively low radial force in the outer stent while providing advantageous fixation characteristics.
In an advantageous manner the mesh stent according to the disclosure exhibits reinforced areas wherein the reinforced area(s) is a combination of loops attached to or being an integral part of the outer stent and wherein the mesh stent is reinforced by way of a double, triple or quadruple layer or/and being not connected with the inner stent.
The above features may be combined with an outer mesh stent design wherein the stent area which, when deployed in the target site, will be compliant essentially with the annular or sub-annular area or ventricular area of the target site. Accordingly, the mesh stent will not only well align with the endogenous heart tissue but the contact area of mesh stent and endogenous tissue will be increased. In this way the mesh stent and prosthesis according to the disclosure achieves in improved fixation due to an improved friction because more surface of the stent or replacement heart valve is thus in contact with the endogenous surface of the endogenous valve surrounding tissue. The mesh stent according to the disclosure may advantageously achieve an adaptation of the a priori round mesh stent to an oval shaped endogenous heart valve geometry, and thus the stent or replacement heart valve prosthesis will exhibit improved fixation characteristics in situ. Improved fixation characteristics can also be achieved if the stent or replacement heart valve prosthesis achieves only a partial alignment with the endogenous tissue or endogenous ventricular tissue. Moreover, an interference of the loops with the cordae can contribute to an improved fixation characteristics of the prosthesis.
In one aspect the mesh stent according to the disclosure exhibit one or more reinforced areas, preferably wherein the reinforced area is located on the mesh stent area which, when deployed in the target site, will align essentially with the ventricular area of the target site, preferably in the context of a replacement heart valve of a tricuspid or mitral heart valve) or wherein the reinforced area is located on the mesh stent area which, when deployed in the target site, will align essentially with the aortic or pulmonary area of the target site, preferably in the context of a replacement heart valve of a aortic or pulmonary heart valve.
In one aspect in the mesh stent according to the disclosure the reinforced area is located on the mesh stent area in the outflow area of the mesh stent.
A mesh stent according to the disclosure can exhibit one or more reinforced areas wherein in one aspect the re-enforced area is characterized by a mesh double or triple layer, preferably made of a one part mesh, preferably characterized by back-loops. A back-loop is specifically formed. In a re-loading procedure the loop will flip over and thus can be pulled back into the catheter. and which forms an integral part of the mesh stent. A one part mesh can be used, preferably wherein the layers of the outer stent have the same three dimensional geometry and form a superimposed layer structure; in such a superimposed stent structure the various layers can contribute to the definition and design of the radial force in a particular stent area and thus contribute to a positive and advantageous spring or absorbing effect. The layers of the mesh stent can be connected to each other by useful means like sutures etc.
In one aspect the re-enforced area is characterized by a mesh double or triple layer which is further characterized by a space between the mesh layers or/and by a conical geometry of the two or three mesh layers, preferably wherein the conical geometry and/or the distance increases between the mesh layers in the proximal (inflow) direction.
The flexibility characteristics of the mesh stent according to the disclosure can be designed and adapted by way of the or a combination of the re-enforcement features wherein the re-enforced area is characterized by a reduced flexibility compared to a non-re-enforced mesh stent area or/and is characterized by an increased radial force compared to a non-re-enforced mesh stent area.
A mesh stent according to the disclosure can be characterized by three areas defined as a proximal area or atrium area or inflow area, a middle area or annulus area (or a sub-groove area), and a distal area or ventricular area or outflow area.
The invention advantageously can achieve a particular behavior of the prosthesis by way of defining and choosing the design features of the disclosure as a single feature or a combination of features and thus one can achieve a particular radial force distribution and thus achieve an improved fixation of the prosthesis at the implantation site.
In prior art replacement heart valve prostheses designs may exhibit a radial force distribution (over the length of the prosthesis) in the different area which is unfavorable for an optimized prosthesis fixation, particularly in the context of mitral or tricuspid replacement therapy. Prostheses according to the state of the art may exhibit distally a radial force being too high. This may thus lead—in situ after implantation and when the heart is beating—to the prosthesis being pushed gradually in proximal direction (i.e. in inflow direction) and a dislocation of the prosthesis.
The prosthesis according to the disclosure may now achieve by way of its re-enforcement features, e.g. a re-enforced area or a design wherein the distal part of the mesh is not connected with the inner stent, a different and improved radial force distribution and an improved fixation of the replacement heart valve prosthesis at the desired implantation site.
The additional design features like loops or/and an improved alignment of the outer mesh stent with the endogenous heart tissue in the ventricular area may contribute to such an improved fixation.
The mesh stent according to the disclosure will be designed in its dimensions as suitable for a particular patient or patient group, and the dimensions of the three prosthesis areas will be chosen as is most appropriate. In one aspect the prosthesis according to the disclosure will have prosthesis dimensions wherein the proximal area has a longitudinal dimension of 1 to 25 mm, preferably 1 to 5 mm, the middle area has a longitudinal dimension of 1 to 25 mm, preferably 4 to 10 mm, and the distal area has a longitudinal dimension of 1 to 25 mm, preferably 4 to 10 mm.
In another aspect the disclosure relates to a heart valve prosthesis comprising a mesh stent as described above (which is the first stent) and a second stent, wherein the first stent is the mesh stent (outer stent) and the second stent is the inner stent comprising a valve fixed thereto, preferably by one or more sutures.
In the heart valve prosthesis according the disclosure the inner stent is a laser cut nitinol tube, wherein the inner stent has preferably an inner diameter of between 8 mm to 40 mm, or/and the inner stent has an outer diameter of between 15 mm to 41 mm or/and the inner stent has a longitudinal dimension of 8 to 35 mm in its expanded configuration. The inner stent may be comprised of two, three, four, five or six rows of cells.
In the heart valve prosthesis according to the disclosure the two stents may be connected by suitable and generally known means by the skilled person. The inner stent may be connected with the outer stent preferably by one or more sutures or by way of one or more connecting structures. Such connecting structures may be clips or otherwise two part means which will remain stable once connected to each other.
In the heart valve prosthesis according to the disclosure the inner and outer stents can be connected and fixed to each other as is appropriate and useful for the function of the prosthesis and in addition as may be useful for the crimping procedure. In certain embodiments the inner stent is connected to the outer stent preferably on its distal area (the outflow area) and proximal area (the inflow area) or essentially on its proximal area or/and wherein the distal area of the outer stent is not connected with the inner stent.
In one aspect the heart valve prosthesis according to the disclosure is advantageous wherein the distal area (outflow area) of the outer mesh stent is not connected with the inner stent and wherein the angle of the outer mesh stent in relation to the inner stent is particularly chosen. In addition the angle alpha can be chosen in a specific dimension. All three design features will contribute to an improved fixation of the mesh stent and heart valve prosthesis at the implantation site. In a particular embodiment according to the disclosure the outer stent forms an angle with the inner stent of preferably of 25 to 50°, more preferably of 35 to 45°.
The heart valve prosthesis according to the disclosure may be deployed by way of a catheter system. It is usually desirable to achieve a low profile of the heart valve prosthesis loaded onto the catheter. Accordingly, in the heart valve prosthesis according to the disclosure in the crimped configuration in one embodiment the loops are positioned on the mesh stent in the ventricular area and so to be located on the mesh stent in the area wherein the mesh stent does not overlap with itself or/and in the area wherein the prosthesis exhibits one stent layer less in its crimped configuration. See e.g.
In the mesh stent according to the disclosure or heart valve prosthesis according to the disclosure it was described above that the dimension can be chosen as will be most suitable for the use and an advantageous implantation and fixation. It was also described that the mesh areas can be adapted in their longitudinal dimensions. It is also possible to adapt the diameter of the mesh stent or heart valve prosthesis for improved fixation characteristics. Accordingly, the three areas of the mesh stent or heart valve prosthesis may exhibit different outer diameters, preferably the three outer diameters are in the range of 40 to 90 mm or of 20 to 90 mm in the expanded state of the stent. The outer diameters can be equal or different.
In one aspect the mesh stent according to the disclosure or heart valve prosthesis according to the disclosure is designed wherein the middle area exhibits an essentially smaller outer diameter than the other two areas and preferably forming a groove. Such a groove can be shaped essentially as V- or U-groove or any combination of such geometry in order to achieve an improved alignment with the endogenous heart tissue and geometry.
The overall mesh stent and heart valve prosthesis design according to the disclosure will lead to a specific radial force distribution in longitudinal dimension. In a particular embodiment the radial force in the sub-annular area is essentially equal or higher compared to the ventricular or outflow area of the mesh stent or prosthesis. The radial force over the prosthesis as disclosed herein is preferably as follows: proximal area (inflow area) to middle area to distal area (outflow area) equals 1-2 to 0.5-1 to 2-3.
In one aspect the mesh stent or heart valve prosthesis according to the disclosure exhibits a radial force in the annulus area in the range of 2 to 20 N. In the area of the Z-ring it can be 15 to 40 N.
In another aspect the disclosure relates to a heart valve prosthesis as described above wherein the outer stent is a laser cut stent, preferably a nitinol stent.
In one aspect the disclosure relates to a stent or a replacement heart valve prosthesis comprising or consisting of two laser cut nitinol stents—an inner and outer stent—preferably connected by way of one or more connecting means or by way of a physical method like welding, and preferably having attached a valve to the inner stent.
A laser cut inner stent connected to a laser cut outer stent according to the disclosure advantageously achieves a good long time fixation at the target site and at the same time provides for a good replacement heart valve function. Advantageously longitudinal motion of the inner stent with regard to the outer stent is avoided. Also longitudinal motion of the replacement heart valve prosthesis is essentially avoided which contributes to a correct functionality of the replacement heart valve prosthesis.
The combination of the two laser cut stents according to the disclosure advantageously provides for an advantageous crush resistance of the prosthesis and thus superior functionality of the replacement heart valve.
An issue of replacement heart valve prostheses is a folding of stent parts during deployment at the target site. The particular design of the replacement heart valve prosthesis according to the disclosure achieves to essentially avoid said problem.
The replacement heart valve prosthesis can be divided longitudinally into three areas: firstly, a proximal area or inflow area or atrium area. Secondly, a middle area or preferably a groove area or annular area. Thirdly, a distal area or outflow area or sub-annular area. The different areas will be designed to best fit a particular endogenous heart valve geometry and its dimensions. The three areas can have the following dimensions:
In one aspect the disclosure relates to a heart valve prosthesis as described above wherein the laser cut outer stent is characterized by at least 4 loops and/or anchoring cells, preferably 6 to 18, 8 to 12 or 10 loops and/or anchoring cells. The laser cut outer stent may be characterized circumferentially by a defined number of cells in the different stent areas. The laser cut outer stent according to the disclosure may be characterized by 14 to 22 or 16 to 18 cells (also denoted support cells) in the proximal area and by 14 to 22 or 16 to 18 cells in the distal area. The distal area may comprise or be composed of one, two, three, four or five rows of cells. In embodiments wherein the distal area is composed of two or more rows of cells the number of circumferential cells is 16 to 34 or 18 to 28 to cells.
The laser cut inner stent may be characterized by two, three, four, five, or six rows of cells. Circumferentially the inner stent may comprise or be composed of 10 to 30 or 14 to 20 or 16 to 18 cells in each row.
The laser cut outer stent may comprise eyelets at the proximal end of one or more or all cells which may serve for easier loading into the catheter for deployment.
A laser cut outer stent according to the disclosure distally not connected with the inner stent also contributes to the advantageous compliance functionality of the prosthesis according to the disclosure.
A replacement heart valve prosthesis according to the disclosure will be characterized in situ by advantageous radial force distribution which leads to an advantageous fixation in the implantation site. A prosthesis according to the disclosure will be characterized by essentially no or by only little movement in the atrium area. In the ventricular area it will be characterized by a advantageous flexibility and/or compliance contributing to an improved fixation and long term functioning.
The designs according to the above disclosure also imply the advantage that stent areas prone to potential stent breaks and damages are avoided. E.g. the distal outer part or/and end exhibits an open geometry. Thus, in the prosthesis according to the disclosure in comparison to a closed design wherein the outer distal stent is connected with the inner distal part of the inner stent no stent breaks may occur.
Replacement heart valve prostheses as described above exhibit advantageous fixation characteristics wherein the outer stent comprises loops in the outflow area, preferably on the cells on its outflow end (distal end). In an embodiment the prosthesis is preferably characterized by at least two anchoring cell, e.g. 4 to 20 anchoring cells. The prosthesis can also comprise in addition loops as integral part of the laser cut stent or fixed thereto in any useful manner.
In replacement heart valve prostheses as described above the loops may be positioned in the most distal cells and the loops may protrude outwardly and exhibit flexibility in inward direction.
An embodiment according to the disclosure comprising anchoring is depicted in
An advantage of the integrality of the anchoring cells and loops comprised therein is that no addition of material or means is necessary to be added in an addition production step and also in terms of durability of the prosthesis it lifespan may be increased and not be prone to potential stent breaks.
The loop according to the above disclosure can be formed in a manner that in addition the loops point outwardly and thus support its fixation purpose.
The outer stent can comprise e.g. 4 to 20, 8 to 16 or 10 to 12 anchoring cells wherein the anchoring cells are either positioned in one row circumferentially at the distal area or outflow end of the prosthesis. The anchoring cells can also be positioned in e.g. two rows in alternating positions in the outer stent.
One anchoring cell according to the above disclosure can have a diameter of 3 to 5 mm.
A replacement heart valve prosthesis as described above may have the inner and outer stent connected with a connecting means or in a direct manner using e.g. a physical method like welding, or by way of one or more sutures, one or more screws, or one or more clipping means.
The outer stent can also comprise in defined areas or positions S struts. The S struts may be combined with the connecting means and one or two S struts may be positioned at each side of a connecting means. The S struts and connecting means are positioned so that the commissures of the replacement heart valve is not in the same level but displaced by an angle B. Two connecting means or/and two or four S struts are located in between the commissures of the replacement heart valve. Thus they contribute to an advantageous crush resistance. Also the disfavored folding of the stent may thus be prevented. Finally, also the coaptation functionality of the valve leaflets of the replacement heart valve is thus improved or maintained.
The S strut element implies various advantages. It may provide for easier form shaping during production and also imply advantages during the crimping procedure when loading the prosthesis onto the catheter for delivery. Moreover, materials tensions within the prosthesis are reduced, punctual stress is reduced and the fatigue behavior is improved.
Heart valve prosthesis as described above wherein the clipping means is characterized by interconnecting means and a securing means like a sleeve.
The connection of inner and outer stent by use of one or more clipping means was not obvious nor the advantages and the particular positioning of said clipping means in the area of the atrium. The finding of the inventors to place said clipping means in this area has the advantage that during heart beat and when the implanted prosthesis is exposed to stress the environment where the clipping means are positioned is exposed to less stress as compared to the e.g. the ventricular environment of the heart. This it could be achieved that the clipping means is subject to less stress and thus less the life span and fatigue of the implanted prosthesis is positively influenced. Moreover, the clipping means represent relatively much and dense material which facilitated to visualize the area of the prosthesis which is meant to be positioned in the annulus area. Thus it is possible to direct and position the prosthesis correctly without the need of opaque markers like gold, tantalum, platinum-iridium.
In an advantageous embodiment the valve commissures (or posts carrying the valve or connected to the valve) of the replacement heart valve prosthesis located in the inner stent are positioned between the connecting struts or/and connecting means, like the clipping means.
These prosthesis structures may advantageously be positioned in a certain distance or angle. Thus it can advantageously be achieved to have an optimized coaptation of the valve leaflets of the prosthesis and to avoid inefficient replacement heart valve prosthesis function. Moreover, in this manner the deformation of the inner stent carrying the valve due to the heart beating and tissue movement is reduced and kept at a possible minimum. This also contributes to a correct replacement heart valve prosthesis function after implantation.
Thus and by way of this structural design feature a cooperative or synergistic effect with regards to inner stent stability and reduction of shape change can be achieved supporting a correct opening and closure of the valve leaflets connected to the inner stent.
The crush resistance should be optimized with regard to the endogenous heart structures and functionally related behavior of the implanted prosthesis. One goal achieved with the prosthesis as disclosed herein is that the implanted prosthesis cooperates or/and shows an advantageous compliance with the endogenous tissue and the heart beat requirements and thus the prosthesis as disclosed herein is safely positioned and fixed for long term correct functioning and at the same time as little as possible interference with the endogenous heart structures.
The replacement heart valve prosthesis comprising two laser cut stents connected to each other, preferably by a connecting means, advantageously achieves to providing a combination of an inner stent with high crush resistance with a good valve function, and wherein the outer stent exhibits particularly in the outflow region a low crush resistance and thus advantageously does only little interfere with the ventricular heart areas. Thus the prosthesis as disclosed herein exhibits a high crush resistance in the inner stent and a low crush resistance in the outer stent. In fact by way of the inventive design of the prosthesis of the disclosure the outer stent adapts to the natural endogenous ventricular geometry without too much of an impact on the ventricular geometry.
This positive interaction with the endogenous heart tissue and structure and even be improved by the above described elements like S struts which may be combined with the connecting struts and the clipping means. These elements together with the specific placement and orientation of the commissures provides for an advantageous functionality. The inclusion of anchoring cells in the distal area of the prosthesis and their atraumatic design reduce or avoid tissue damage and at the same time allow for improved fixation and long term fixation of the prosthesis after implantation. The combination and positioning of the connecting means will advantageously avoid or limit the longitudinal movement of the inner stent as described herein.
Moreover, the prosthesis as disclosed herein will exhibit advantageous fixation features and characteristics and in a three-part stent the specific combination of connecting struts and connecting strut guide will provide for a longitudinal movement limitation during systolic contraction of the heart. The three-way connection of connecting struts and connecting strut guide and connecting means and its positioning proximal from the inner stent will essentially prevent or limit longitudinal movement of the inner stent when the valve is closed. The connecting strut guide can have a eyelet, V or U shape wherein the eyelet shape is preferred. An eyelet shape will advantageously keep all parts in a predefined position allowing only little movement and maintaining a predefined geometry during replacement heart valve function.
One aspect of the disclosure is also a replacement heart valve prosthesis as described above wherein the inner and outer stent is connected with 4 to 20 connecting means, preferably with 6 to 14, or 8 to 18, or 8 to 12.
In a replacement heart valve prosthesis as described above the prosthesis can be crimped to a diameter of 16 to 35 French, or of 20 to 35 French, or of 25 tor 35 French.
The replacement valve is connected to the inner stent and usually is composed of three leaflets produced according to the state of the art in one or three pieces and sutured into the inner stent. The material can be chosen form any known and useful materials as e.g. bovine or porcine pericard, polymer materials etc. which do not need to be described in more detail here as the materials and their preparation are well known in the art. The prosthesis may comprise covers and sealing as it is appropriate for its functioning.
It is an advantage that in any prosthesis size wherein the outer stent size may vary, the inner stent carrying the replacement valve may always have the same diameter and dimensions which facilitates the production and reduces production cost.
One advantageous concept in common to all variations and embodiments as disclosed herein is an outer stent with improved fixation characteristics which at the same time decouples or isolates or protects the inner stent essentially from deformation or impact with regard to the inner stent or/and valve geometry and thus combines improved fixation characteristics with improved replacement valve functionality.
One advantage of a laser cut stent in laser cut stent of a replacement heart valve prosthesis according to the disclosure is that there exist very advanced know how as to production and thus such a prosthesis can be manufactured in a very cost efficient manner.
Also the production process is easily controllable when manufacturing a laser cut stent and thus from a cost and quality control aspect it implies advantages.
The disclosure relates to various stent embodiments wherein the stent can be a two-part stent characterized by a laser cut inner stent connected to an outer mesh stent or a laser cut inner stent connected to a laser cut outer stent (two-part or three-part stent) wherein the outer stent may comprise additional features. In all embodiments and variations as described herein the goal of an improved fixation at the target site is achieved with a varying number of features or combinations of features.
Thus the current disclosure provides a variation of different advantageous solution solving the same problem of an improved fixation of a replacement heart valve, preferably in the context of a tricuspid or mitral heart valve. Moreover the current disclosure relates to providing a number of means useful for the improved fixation of a replacement heart valve prosthesis at its target site.
In another aspect the disclosure relates to the use of the described replacement heart valve for use in a replacement heart valve therapy or a method of implantation thereof. The replacement heart valve prosthesis as described herein can be delivered and implanted with known catheter techniques to a desired target site, e.g. to replace a tricuspid heart valve, in a patient. A route of delivery and deployment is e.g. a transfemoral (percutaneous) catheter implantation.
In another aspect the disclosure relates to a method for implantation of a heart valve prosthesis as described above wherein the prosthesis is delivered, e.g. transfemoral, using a catheter comprising the steps of loading the prosthesis onto the catheter, introducing the catheter in an individual, moving the catheter tip to the target site and deploying the prosthesis.
In another aspect the disclosure relates to a connecting means for stents characterized by an interlocking yoke, an interlocking nail or teeth and a sleeve wherein the interlocking yoke, nail or/and teeth, preferably a connecting strut guide, connect two or three connecting struts, preferably in a releasable manner.
The additional stent designs as described above in combination with the sealing features as described herein achieve the additional advantage that improved fixation in combination with an improved sealing characteristics can be provided with the prostheses as described herein.
It shall be understood that each of the single features as described herein above are meant to be combinable in any possible manner or combination, and that specific embodiments as described in the figures or in the above description in a certain feature combination shall not be interpreted as being limiting solely to said combination and that the specific embodiments as describe herein are not meant to be limiting for the scope of the disclosure.
The basic concept of the disclosure relates to a special sealing concept and design in replacement heart valves, e.g. tricuspid, mitral or pulmonary replacement heart valves. This novel sealing concept is characterized by two or more sealing features working in a coordinated manner and essentially preventing systolic and diastolic PVL (paravalvular leakage). Specific attachment points I, J, E, and/or K for one or more sealing features provide for an advantageous and coordinated sealing during systolic and diastolic heart contraction and at the same time improve the replacement valve function.
This advantageous sealing concept can be applied to a number of stent design as outlined herein. Reference is in particular made to the Figures and the stent design described therein as well as the “B” Figures providing for alternative stent design which are well within the gist of the invention when combined with the sealing features as described herein.
Thus the inventive concept achieves an advantageous replacement valve functioning and durability of the replacement heart valve prosthesis. The novel sealing concept according to the disclosure furthermore exhibits advantageous crimping characteristics when loaded into a catheter for delivery.
The general concept of the sealing features according to the disclosure can be combined with any of the stent designs as described herein.
The object underlying the application is solved by a heart valve prosthesis comprising a frame, a valve attached thereon and a sealing means wherein the sealing means comprises or consists of one or more sealing features.
In principle the advantageous sealing features can be combined with different stent designs and types known in the art wherein an advantageous sealing is desirable. In particular, the prosthesis according to the disclosure can comprise or consists of a frame wherein the frame is a single frame, a double frame or a stent in stent design.
The skilled person will appreciate that different materials like metal, nitinol, plastic, polymers etc. can be applied and combined with the advantageous sealings according to the disclosure. In an embodiment the prosthesis according to the disclosure has a frame wherein the frame is made of or comprises a polymer material, a metal, or/and a nitinol material. In particular the prosthesis according to the disclosure has a frame material which is cast, laser cut, or/and a braided mesh.
In the prosthesis according to the disclosure the frame can be composed of an inner frame and an outer frame, preferably attached to each other, preferably by sutures, wherein the inner frame is a laser cut nitinol tube and the outer frame is a braided nitinol mesh, or the inner and the outer stent is a laser cut nitinol stent.
The valve of the prosthesis according to the disclosure can be made or any useful material and material combinable with the other features and materials of the prosthesis, e.g. the valve is made of or comprises pericardium tissue, preferably of bovine or porcine origin.
In particular important are the multiple sealing features and their interaction with one another and the stent components and their positioning within the frame of the prosthesis. In one aspect the prosthesis according to the disclosure comprises or contains sealing features wherein the first sealing feature is a sealing cover at the inflow area of the prosthesis, e.g. atrium area, and the second sealing feature is a sealing cover at the outflow, e.g. ventricular area of the prosthesis.
The inflow and outflow sealing features can be multiple separate parts, attached to each other or made as one unit.
The prosthesis according to the disclosure has multiple sealing features wherein the multiple sealing features are characterized by specific attachment points or areas for attachment to the frame.
It has been shown to be advantageous if the prosthesis according to the disclosure has the multiple sealing parts which are attached to the frame at specific attachment points or areas, e.g. denoted in the figures as I, E, J or/and K.
The interplay of the multiple sealing features and their special design and dimensions have been proven to be advantageous for the functionality of the prosthesis, the sealing characteristics thereof and for an easy loading functionality into the catheter and to avoid damage of the sealing features during leading. In one aspect the prosthesis according to the disclosure is designed so that the distance of the attachment points I to K is in the range of 12 to 30 mm, e.g. about 15 to 26 mm, and the distance of the attachment points K to J is in the range of 12 to 30 mm, e.g. about 15 to 26 mm, preferably the distances IK and JK are essentially equal.
In the prosthesis according to the disclosure the sealing characteristics are advantageous due to the combination and positioning of the multiple sealing features within the frame of the prosthesis. It is advantageous and can be designed with ratios of the sealing feature length and defined distances from one to the other fixation points, e.g. wherein the ratio of the distance I to K: distance K to J is about 0.5 to 1.2, preferably 1.
The sealing features of the prosthesis according to the disclosure can be applied in different valve types wherein the prosthesis can be an aortic, a mitral, a pulmonary or a tricuspid heart valve prosthesis.
The prosthesis according to the disclosure is also characterized by an advantageous crimping behavior and the prosthesis can thus be crimped to an advantageous diameter wherein the prosthesis can have an outer diameter in its crimped state of 13 to 35, 15 to 30 French, preferably 16 to 18 French. It is advantageous if the prosthesis has an outer diameter in its crimped state of equal to or less than 35 French.
In the prosthesis according to the disclosure the sealing features essentially prevent PVL during systole and diastole which advantageously supports a proper and long-term valve function and prosthesis durability.
In another aspect the disclosure relates to a heart valve prosthesis as disclosed herein for use in the treatment of a heart valve disease or disorder, for example a heart valve insufficiency, a heart valve stenosis or a regurgitation.
In another aspect the disclosure relates to a method for minimally invasive implantation of a prosthesis as disclosed herein wherein the prosthesis is loaded onto a delivery system and the delivery system is introduced transapically, transfemorally, transjugularly, transatrially in a patient and the prosthesis is deployed at a target site.
The disclosure provides for replacement heart valve prostheses with advantageous sealing characteristics and advantageous replacement valve function. It furthermore implies the advantage of less risk of thrombosis and better long-time functionality due to a better hemodynamics. The replacement heart valve prosthesis as disclosed reduces possible swirls, turbulences and sheer forces and shear stress which occur in known devices due to sub-optimal blood flow during heart function which will have a positive impact on the occurrence of thrombosis. Moreover, the impact of the prosthesis according to the disclosure on the patient will also be observed due to a better replacement function as such and essentially avoiding PVL.
The improvement in overall replacement valve function and avoidance of essentially PVL by the replacement heart valve prosthesis according to the disclosure will positively impact not only on the replacement heart valve prosthesis but on the overall heart condition and physiological parameters. Thus the prosthesis as disclosed provides for improvements inter alia with regards to valve opening and closing, pressure gradient, overall valve function, overall heart condition and replacement heart valve prosthesis durability.
It shall be understood that each of the single features as described herein are meant to be combinable in any possible manner or combination, and that specific embodiments as described in the figures or in the above description in a certain feature combination shall not be interpreted as being limiting solely to said combination and that the specific embodiments as describe herein are not meant to be limiting for the scope of the disclosure.
1 braided nitinol stent (mesh stent)
2 laser cut nitinol stent
3 inflow sealing cover
4 outflow sealing cover
5 replacement valve
6 Sutures to hold stents together
7 stabilizer
8 loop
9 catheter sheet
10 crimped diameter
11 inflow (proximal) flange
12 prosthesis part aligning to annulus
13 Z-ring
14 connecting means
A aortic valve
P pulmonary valve
M mitral valve
T tricuspid valve
AN annulus
MA mitral annulus
AVN atrioventricular node
S septum
CS coronary sinus
po posterior
an anterior
Co compliance of braided stent to cardiac cycle wall movement
CW cardiac wall
NL native leaflet
Ch chordae
PVL paravalvular leakage
S surface of contact between outer stent (braided mesh stent) and implantation site
S1 surface 1
S2 surface 2
BF blood flow
SBF systolic blood flow
DBF diastolic blood flow
SPS sealing pressure during systole
SPD sealing pressure during diastole
I, J, E sealing cover attachment points with stent (outer/braided stent)
K sealing cover attachment point (possibly if one cover connected between I and J)
A, B, C, D, F defined stent points
1—wire braided outer stent (mesh stent)
2—laser cut inner stent
3—stabilizer (e.g. additional wires and/or twisted wires below v-groove)
4—loops
5—outer mesh
6—inner mesh
7—catheter
8—S-strut
9—interlocking nail
10—sleeve
11—laser cut outer stent
11
a—proximal laser cut outer stent (stent part)
11
b—distal laser cut outer stent (stent part)
12, 12′—connecting struts
13—connection inner/outer stent
14—interlocking teeth
15—anchoring cell
16—v-groove
17—connecting strut guide
18—interlocking yoke
19—connecting means
20—proximal area
21—commissure
22—distal area
23—middle area
24—valve leaflet
25—loop struts
26—RF-struts
27—Z-ring
28—folding
29—right ventricle
30—tricuspid heart valve
31—annulus
32—chordae
| Number | Date | Country | Kind |
|---|---|---|---|
| 18193122.1 | Sep 2018 | EP | regional |
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/EP2019/073768 | 9/5/2019 | WO | 00 |
