Patent Application
20050288722
1. Field of the Invention
This invention relates generally to systems and methods for optimizing the performance and minimizing complications related to implanted sensors, such as pressure sensors, for the purposes of detecting, diagnosing and treating cardiovascular disease in a medical patient.
2. Description of the Related Art
There are approximately 60 million people in the U.S. with risk factors for developing chronic cardiovascular diseases, including high blood pressure, diabetes, coronary artery disease, valvular heart disease, congenital heart disease, cardiomyopathy, and other disorders. Another 10 million patients have already suffered quantifiable structural heart damage but are presently asymptomatic. Still yet, there are about 5 million patients with symptoms relating to underlying heart damage defining a clinical condition known as congestive heart failure (CHF). Although survival rates have improved, the mortality associated with CHF remains worse than many common cancers. The number of CHF patients is expected to grow to 10 million within the coming decade as the population ages and more people with damaged hearts survive.
CHF is a condition in which a patient's heart works less efficiently than it should, and a condition in which the heart fails to supply the body sufficiently with the oxygen-rich blood it requires, either during exercise or at rest. To compensate for this condition and to maintain blood flow (cardiac output), the body retains sodium and water such that there is a build-up of fluid hydrostatic pressure in the pulmonary veins that drain the lungs, which is generally equivalent to the left atrial pressure. As hydrostatic pressure exceeds oncotic pressure and lymph flow, fluid transudates from the pulmonary veins into the pulmonary interstitial spaces, and eventually into the alveolar air spaces. This complication of CHF is called pulmonary edema, which can cause shortness of breath, hypoxemia, acidosis, respiratory arrest, and death. Although CHF is a chronic condition, the disease often requires acute hospital care. Patients are commonly admitted for acute pulmonary congestion accompanied by serious or severe shortness of breath.
One relatively new approach for treating cardiovascular disease is to implant sensors, such as pressure sensors in various chambers of the heart or adjacent vasculature such as the pulmonary arteries or veins, for the purposes of detecting early cardiac decompensation and prevention of pulmonary congestion and edema. Another potential advantage of implanted pressure transducers is that they may be useful in preventing overtreatment with resultant hypoperfusion of vital organs such as the kidneys. Such an approach utilizing a left atrial pressure transducer coupled with a medical therapy optimization system is described by Eigler et al. in U.S. Pat. No. 6,328,699, herein incorporated by reference.
One particular type and method of sensor placement is known as transmural placement where the sensor device enters the desired location by perforation of the tissue wall separating the outside the structure to inside the structure. Generally the sensor device resides on both sides and within a wall separating parts of the body, parts of an organ such as the heart, or separating a body structure form the rest of the body (the wall of a blood vessel). Sensor packages can be transmurally placed in the left atrium of the heart by a minimally invasive percutaneous catheter based procedure known as transseptal catheterization as originally described by Ross (Ross, J., Jr.: Transseptal left heart catheterization: A new method of left atrial puncture. Ann. Surg. 1949:395, 1959) and Cope in 1959 (Cope, C.: Technique for transseptal catheterization of the left atrium: Preliminary report. J. Thorac. Surg. 37:482, 1959), and modified by Brockenbrough and Braunwald in 1960 (Brockenbrough E C, Braunwald E: A new technique for left ventricular angiocardiography and transseptal left heart catheterization. Am J Cardiol 6:1062, 1960) and subsequently by Ross in 1966 (Ross J Jr.: Considerations regarding the technique for transseptal left heart catheterization. Circulation 34:391, 1966), all herein incorporated by reference. More invasive surgical procedures can transmurally place sensor devices in any cardiac chamber or blood vessel of sufficient size including the pulmonary arteries and veins.
Implantable pressure transducers are known in the art. For example, U.S. Pat. Nos. 4,023,562, 4,407,296, 4,407,296, 4,485,813, 4,432,372, 4,774,950, 4,899,751, 4,899,752, 4,986,270, 5,027,816, 4,353,800, 4,846,191, and 6,379,308 describe various types of pressure sensors. However, pressure sensors that are currently described in the art are not suitable for chronic implantation in the body for several reasons. For example, some pressure transducers are not hermetically sealed, or otherwise properly protected, and thus susceptible to degradation by bodily fluids. Other transducers are constructed such that their specific geometries or components cause thrombus formation, a potentially life threatening condition. Several transducers are constructed in a manner that result in significant “drift” of the pressure sensor, either due to tissue overgrowth or some other mechanism, thus resulting in inaccurate pressure measurements, which in many cases cannot be properly or easily recalibrated. Thus, there still remains a need in the art for an implantable sensor, such as a pressure transducer, that is stable, safe, effective, accurate, and, if needed, easily recalibrated.
Several embodiments of the present invention relate generally to implantable physiological sensors. In one embodiment, a pressure sensor, or pressure transducer, that is suitable for chronic implantation in the body is provided. In another embodiment, a pressure transducer system that exhibits long-term stability following chronic implantation in the cardiovascular system is provided. In one embodiment, the pressure transducer remains stable despite the biological reactions that these systems induce. The sensors and methods described in some of the embodiments facilitate optimal healing and subsequent stability of transmurally implanted pressure sensors. Several embodiments of the current invention are particularly advantageous because they reduce the risk of thrombus formation and are not as susceptible to tissue overgrowth that causes drift of the pressure sensor. Other embodiments of the invention are designed to optimize performance. In one embodiment, deployment devices, anchoring means and/or retrieval tools are provided in conjunction with the sensor. In another embodiment, the sensor is at least partially enclosed in protective packaging. In another embodiment, the sensor is designed to minimize viscoelastic drift. In yet another embodiment, temperature compensation is provided. In a further embodiment, the effects of output artifacts, or side loading, are minimized.
In some embodiments, the implantable pressure sensing system, comprises one or more sensing interfaces. The phrase “sensing interface” as used herein shall be given its ordinary meaning and shall also include one or more materials or structures that protects a sensor from direct exposure to the environment (e.g., blood, tissue, etc.) while still preserving the sensor's sensing function. Sensing interfaces include, but are not limited to, diaphragms, hydrogels, metallic foils, plastics, membranes and other materials. In several embodiments, at least a portion of the sensing interface is configured to minimize thrombosis. As used herein the phrase “reduce thrombosis” shall be given its ordinary meaning and shall also include the partial prevention, reduction, hindrance or destruction of a blood clot or thrombus by, for example: (1) pharmacological agents that affect clot or thrombus formation, growth, or dissolution; (2) the promotion of neoendothelial overgrowth by, for example, providing growth channels or biological agents that facilitate tissue growth; and/or (3) comprising a thrombosis resistant coating or a coating that reduces platelet (or other blood component) activation or aggregation.
In one embodiment, a sensor is designed to minimize viscoelastic drift. The thickness of epoxy adhesive attaching strain gauges to diaphragm may be minimized by growing a silicon dioxide or other insulating layer on the bottom of the silicon strain gauges or the metallic diaphragm, so that adhesive does not also have to serve as an insulating layer.
In one embodiment, viscoelastic drift is calibrated, predicted, and corrected. In one embodiment, viscoelastic properties of the pressure transducer are characterized during pre-implant calibration. In one embodiment, known viscoelastic properties are used in combination with the recorded pressure variations over time to obtain pressure measurements that are corrected for viscoelastic drift. In one embodiment, a software algorithm is used to automatically correct for viscoelastic drift due to varying average pressure.
In one embodiment, effects of side loading on the sensor are minimized. In one embodiment, at least a portion of the casing adjacent to the diaphragm is made substantially inflexible and non-distortable such that the diaphragm is not distorted by side-load forces under physiologic conditions. In one embodiment, a fixation anchor attachment to the housing is located as far as possible from the portion of the housing that supports the diaphragm, so that forces exerted by the anchor legs cause less distortion of the diaphragm. In one embodiment, strain gauges are oriented 90° from each other rather than the standard 180° orientation, and connected in a Wheatstone bridge configuration such that differential resistance changes between the strain gauges substantially cancel, while common-mode changes in resistance are additive. Any feature mentioned above may be used in combination with others.
In one embodiment, thrombogenicity of the sensor is minimized by polishing, including electropolishing, coating, including parylene, a small surface area, a low profile, a profile configured to reduce flow disruption and/or encouraging rapid tissue overgrowth/ingrowth.
In one embodiment, materials that promote rapid tissue coverage, heal without chronic inflammation, and develop a thin covering of neointima are provided. These may include alloys of stainless steel, Nitinol, titanium alloys, cobalt chromium and/or tantalum.
In one embodiment, pressure artifacts due to atrial wall stresses are minimized by providing features on the sensor housing that reduce the coupling of these stresses to the sensor diaphragm. In one embodiment, the sensor housing comprises grooves, threads, or tabs generally around its distal circumference to anchor tissue overgrowth, reducing the coupling of stress within the tissue to the sensor diaphragm. In one embodiment, the sensor housing comprises a cylindrical rim that extends distally beyond and surrounding the sensor diaphragm, providing a barrier protecting the diaphragm from the transmission of tissue stresses.
In another embodiment, coupling of wall stresses is minimized by providing for drug delivery from a ring or band about the distal circumference of the sensor housing. The drug may include an antiproliferative agent such as paclitaxel or sirolimus, as is known in the field of drug eluting stents to prevent restenosis. Other bioactive drugs to reduce proliferation, thrombosis or inflammation, as are known to those skilled in the medical arts may also be used. In one embodiment, a source of ionizing radiation is provided in a band around the distal circumference of the sensor. It is known by those skilled in the art that ionizing radiation reduces or prevents tissue proliferation following tissue injury. In one embodiment, the sensor diaphragm comprises a radioactive source such as Phosphorus-32 or Strontium-90, which are known to emit beta particles that can reduce tissue proliferation.
In one embodiment, improved sensor reliability and accuracy is provided.
In one embodiment, improved sensor positioning stability is provided.
In one embodiment, elution of one or more drugs to reduce neointimal thickness is provided.
In one embodiment, slow release of low doses over longer periods is provided.
In one embodiment, slots, grooves, or holes in distal anchor legs to minimize path lengths for tissue ingrowth are provided.
In one embodiment, an implantable pressure monitor is provided, said monitor comprising distal anchors, said anchors comprising one or more legs, said legs configured with one or more slots for the purpose to advantageously promote more rapid tissue overgrowth in a deployed position, which will advantageously aid in securement of the device to the septum wall and prevent thrombus formation. In another embodiment, the slots in the legs can vary in width. In another embodiment, the slots in the legs can be curved or serpentine. In another embodiment, the slots in the legs may be replaced by one or more holes of equal or diverse diameters. In yet another embodiment, the legs can be keyed or slotted at right angles to their long axes from one or both sides.
In one embodiment, surface grooves are formed on the diaphragm to promote rapid tissue ingrowth. The shape of groove long axis may be linear, serpentine, circumferential or any other beneficial groove shape. The cross-sectional shape of groove may be rectangular, triangular (“Vee”), semi-round or any other beneficial shape. The grooves may be filled with or coated by bio-stable or bio-erodable polymer or other coating agents, including one or more drugs that control tissue growth rate or thrombus formation
In one embodiment, biocompatible coatings such as parylene are provided. Such coatings may minimize platelet adhesion and aggregation, provide electrical insulation (for pacing) and/or prevent corrosion of metallic components.
In one embodiment, the invention comprises a coating on the diaphragm surface and/or on anchor surfaces that inhibits or minimizes the formation of undesirable fibrous tissue, while not preventing the beneficial growth of an endothelial covering.
In one embodiment, a plurality of small indentations or holes in the device or anchor surfaces are provided to serve as depots for controlled release of antiproliferative substances
In one embodiment the invention, a pressure transducer is provided that isdesigned so that calibration parameters are minimally affected by tissue overgrowth, and may include a very low compliance diaphragm compared with tissue overgrowth, and/or diaphragm thickness maximized to minimize compliance, consistent with sufficient compliance to derive adequate transducer signal. In one embodiment, the 2.5 mm diameter diaphragm is between about 0.001 to 0.003 inches (25 to 76 microns) thick. In another embodiment, the diaphragm thickness is between about 0.003 to 0.005 inches (76 to 127 microns). In one embodiment, a 2.5 mm diameter by 50-micron thick titanium foil diaphragm has a displacement at its center of only about 4 nm per mm Hg pressure change. In one embodiment, a pressure transducer diaphragm constructed of Ti 6-4 with material properties comprising of approximately R0=1.1 mm, v=0.31, t=0.05 mm, and E=100 GPa is provided. In another embodiment, a low compliance pressure transducer is fabricated from, for example, silicon, using micro electromechanical systems (MEMS) techniques. In one embodiment, a diaphragm is manufactured to maximize flatness, which maximizes gain for a given diaphragm thickness, is provided.
In one embodiment, a pressure sensor includes temperature compensation so that pressure measurements will be minimally affected by temperature change is provided. In one embodiment, an apparatus to measure temperature at the site of the sensor is provided. In one embodiment, the temperature compensation or modulation is achieved by using multiple resistive strain gauges arranged in a Wheatstone bridge, such that the electrical voltage output of the bridge is proportional to the ratio of two or more resistances, all of which depend on temperature in a similar way, thus reducing the affect of temperature on the pressure reading. It can also be achieved by selecting resistive strain gauges with essentially identical temperature coefficients, and connecting the strain gauges in a Wheatstone bridge configuration.
In one embodiment, an internal thermometer that is independent of pressure is provided where prior to implantation calibrating the temperature coefficient of the pressure reading based on this measured temperature. After implantation the measured temperature is used to select the appropriate pressure calibration coefficients. In one embodiment, a band-gap voltage reference is used to create a current proportional to absolute temperature that is then compared to the temperature-independent voltage reference, thereby deriving a measure of temperature.
In one embodiment, the device can be easily recalibrated using non-invasive method, such as a Valsalva maneuver and/or offset calibration, where the gain is not affected by tissue.
In one embodiment, complete encasement of system within hermetic housing is provided to protect against the damaging effects of bodily fluids. The sensor may be enclosed in metal packaging. Environmental pressure may be coupled to sensor through a diaphragm bonded to the metal housing.
In one embodiment, a delivery catheter permits simultaneous measurement of fluid pressure from the catheter tip during transducer package transit and deployment. The delivery catheter is configured to be sufficiently large in diameter to allow the catheter to be filled with a continuous cylindrical column of fluid surrounding the sensor module and its lead. The delivery catheter permits injection of radiographic contrast material with the transducer system in its lumen to localize positioning during transducer system deployment. Positioning can be determined under fluoroscopy by contrast injection and pressure measurement thought side arm port the delivery catheter. In one embodiment, after the distal anchor legs expand to assume their expanded state on a distal side of the septum wall, contrast material is injected to assure correct positioning in the left atrium. The catheter is further retracted while holding the stylet and sensor assembly in place until the distal edge of the catheter is coincident with the proximal end of the sensor assemble, which can be verified by visualizing the alignment of the radiopaque markers on the sensor assembly and the delivery catheter under fluoroscopy. Further contrast is injected while the entire catheter, stylet and sensor assembly are retracted in 1 to 2 mm increments until contrast material is fluoroscopically observed exiting the tip of the catheter into the right atrium. At this point further retraction of the catheter will expose the proximal anchor, allowing it to relax to its expanded state on a proximal side of the septum wall.
In one embodiment, the proximal portion of the catheter may contain a hemostatic assembly or adapter to prevent back bleeding through the catheter around the pressure transducer system and to prevent the entrainment of air during transducer insertion and advancement. In one embodiment, the introducer sheath is made of transparent tubing, such as acrylic, advantageously allowing the operator to verify that all air bubbles have been flushed from the introducer sheath before it is inserted through the hemostatic adapter of the delivery sheath.
In one embodiment, the transducer module and/or its fixation anchors may have radiographic markers to enhance visualization during deployment. The legs of the distal anchor may be positioned at the distal end of the delivery catheter, which can be visually verified under fluoroscopy by noting the alignment of the distal radiopaque marker on the distal end of the delivery catheter with that on the distal end of the sensor assembly.
In one embodiment, the sensor lead is configured to accept a stylet that is preferably configured to provide sufficient column strength to allow the anchor and sensor assembly to be held in place relative to the septum during deployment, while the catheter is retracted to expose and deploy the distal anchor legs. Alternatively, the catheter can be held in place and the stylet and sensor assembly can be advanced to deploy the distal anchor legs.
In one embodiment, a physiological sensing device optimized for placement in the left atrium of the heart by a percutaneous catheter-based procedure that traverses the intra-atrial septum is provided.
In one embodiment, a physiological sensing device optimized for placement in a pulmonary vein by an open surgical procedure is provided.
In one embodiment, a transducer system optimized for placement through the free wall of the left atrium, or through the wall of the left atrial appendage, or across the right atrial free wall or right atrial appendage or transmurally into the main or branch pulmonary arteries by a minimally invasive thorascopic surgical procedure or by a traditional open surgical approach is provided.
In one embodiment, intrathoracic pressure may be monitored by placement of the pressure transducer system through the chest wall or diaphragmatic respiratory muscles by local puncturing techniques, under direct or fiberoptic endoscopic vision, or by robotic surgical manipulation.
In one embodiment, a physiological sensing device is provided, wherein internal transducer components comprising a transducer, power, and communications components are enclosed in a hermetic casing or housing called a transducer module. The casing comprises metal, ceramic, or glass, alone or in combination, or other constituents known to skilled artisans for constructing hermetic packaging. The distal end of the module comprises at least one hermetic diaphragm designed to translate or flex in response to pressure changes at the desired location. The diaphragm or membrane is mechanically coupled to enclosed transducer components. The sensor package may be provided in a wide range of sizes and shapes. The sensor package is cylindrical in shape with a distal end and a proximal end. In one embodiment, the module is between about 1 mm and 5 mm long, and 3 mm in diameter. In another embodiment, the module is between about 5 mm and about 15 mm long. In another embodiment, the package is about 8 mm long, and about 3 mm in diameter. In one embodiment, the package is less than about 1 mm in diameter. In another embodiment, the package is less than about 10 mm long. In one embodiment, the package may be rectangular, square, spherical, oval, elliptical or any other shape suitable for implantation. In one embodiment, the sensor package is rigid, and in another embodiment, the sensor package is flexible. In one embodiment, the sensor module includes a cylindrical housing comprising one or more component pieces of titanium CP, titanium 6-4, or other suitable biocompatible metallic alloy or other material suitable for making a hermetic package such as ceramic material like alumina or zirconia. One embodiment of the invention comprises a titanium cylindrical housing, and a diaphragm comprising a titanium foil that is diffusion bonded or otherwise hermetically affixed to the titanium housing. In another embodiment, the diaphragm and housing may be machined, lapped, or otherwise manufactured from titanium bar or rod stock so that part of the cylindrical housing and the diaphragm are one piece.
In one embodiment, enclosed transducer components are provided, comprising semiconductors that control power, pressure signal transduction, local signal processing, and data telemetry. Resistive strain gauges are bonded, or otherwise coupled, to the inside surface of the diaphragm.
In one embodiment, a titanium cylindrical housing comprising an application-specific integrated circuit (ASIC) or “measurement electronics” is provided. Measurement electronics are contained within the housing and electrically connected to the strain gauges by fine gold wires or other means of electrical connection. In one embodiment, the proximal end of the housing is sealed by a zirconia ceramic feed-through that is brazed to a titanium cylinder. In one embodiment, the housing contains a gaseous atmosphere. In one embodiment, a gaseous atmosphere is provided, which may comprise helium, argon, or any other advantageous gas or combination of gases known to skilled artisans. In one embodiment, a moisture-absorbant material is included within the housing. In one embodiment, the housing is evacuated prior to sealing. An electrical insulating liquid such as an oil or other electrically insulating liquids known to skilled artisans may be contained within the housing. In one embodiment, the implanted module contains an internal power source, such as a battery. In another embodiment, the module is powered transcutaneously by induction of radio frequency current in an implanted wire coil connected directly to the module or connected by a flexible lead containing electrical conductors, to charge an internal power storage device such as a capacitor. In one embodiment, the pressure sensor is fabricated by micro electro-mechanical systems (MEMS) techniques.
In one embodiment, a method for hermetically sealing a silicon device is provided. The silicon device is coupled to a sensor, such as a pressure transducer, which benefits from having direct contact with its environment (the body). In one embodiment, a method to hermetically seal the non-sensing portion of a silicon device while allowing the sensing portion (e.g. the pressure transducer) to have direct contact with the body is provided. A silicon chip, a gold preform and a metallic housing are each primed for sealing and are assembled. The assembly is then heated to react the gold preform to the silicon chip and to form a molten gold-silicon alloy in-situ to bind said metallic housing to the non-sensing portion of the silicon chip. In this way, the non-sensing portion of the silicon chip is hermetically sealed, while still permitting exposure of the sensing portion of the silicon chip to the environment
In one embodiment, a physiological sensor system is provided with a configuration similar to a cardiac pacemaker, with a hermetically sealed housing implanted under the patient's skin (subcutaneous) and a flexible lead containing signal conductors with a hermetically sealed pressure transducer module at its distal end. The signal conductors may be electrical, fiber optic, or any other means of signal conduction known to skilled artisans. The lead may have a stylet lumen to aid with transducer deployment in the body of a medical patient. The lead may have a lumen for connection of the sensor module to a reference pressure. In one embodiment, the housing contains a battery, microprocessor and other electronic components, including transcutaneous telemetry means for transmitting programming information into the device and for transmitting physiological data out to an external programmer/interrogator.
In one embodiment, an implanted pressure sensor-lead combination is provided that is an integral part of a cardiac rhythm management system such as a pacemaker or defibrillator or various other implantable cardiovascular therapeutic systems known to skilled artisans.
In one embodiment, a physiologic sensor system is provided, in which the signal processing, and patient signaling components are located in a device external to the patient's body in communication with an implanted subcutaneous housing via any one or more of the various forms of telemetry well known in the art, such as two-way radio frequency telemetry. The subcutaneous housing can comprise only a tuned electrical coil antenna, or a coil antenna in conjunction with other components. Other designs for antennae are well known to those skilled in the art and are can be used in accordance with several embodiments of the present invention. In still another embodiment, the sensor module is directly connected to a coil antenna by short lead or lead of zero length such that the entire system resides in the heart. Such a system may have a small internal battery or power could be delivered transcutaneously by magnetic inductance or electromagnetic radiation of a frequency suitable for penetrating the body and inducing a voltage in the implanted coil antenna. In one embodiment, radiofrequency electromagnetic radiation is used with a frequency of about 125 MHz. In one embodiment, an implantable pressure sensing module that also comprises one or more sensors in addition to the pressure transducer is provided.
In one embodiment, a physiologic sensor system is provided, comprising a plurality of pressure transducers to measure pressures in the transmural space or locations proximal to the transmural space, or to measure differential pressure between the distal diaphragm and another location.
In one embodiment, a physiologic sensor system is provided, comprising a pressure transducer and one or more other types of sensors, said sensors including accelerometers, temperature sensors, electrodes for measuring electrical activity such as the intracardiac electrogram (IEGM), oxygen partial pressure or saturation, colorimetric sensors, chemical sensors for glucose or for sensing other biochemical species, pH sensors, and other sensor types that may be advantageous for diagnostic purposes, or for controlling therapy.
In one embodiment, pressure sensors with a frequency response of between about 500 and 2000 Hz are provided.
In one embodiment, pressure sensors with a frequency response of less than about 500 Hz and greater than 2000 Hz are provided.
In one embodiment, an implantable pressure sensor module comprising a separate hydrophone sensor is provided.
In one embodiment, an implantable sensor module that serves dual diagnostic and therapeutic functions is provided. Said sensor module contains at least one electrode for stimulating the organ in which it is placed. Said electrode or electrodes may be used for electrical pacing the left atrium
In one embodiment, a method for generating a signal indicative of pressure in the left atrium is provided, based on components of a pressure waveform that are relative to each other and therefore do not have to be compensated for atmospheric pressure and are not subject to offset drift. In one embodiment, a method for generating a signal is provided, wherein the components of a pressure waveform comprise the pressure differential between the mean and respirator minima of the left atrial pressure waveform. The components of a pressure waveform comprise the relative heights and/or shapes of the left atrial “a,” “c,” and “v” waves. Decreased left ventricular compliance is the diagnosis when the “a” wave increases without shortening of the atrioventricular (AV) delay or in the presence of mitral stenosis. Increases in the “v” wave amplitude and merging with the “c” wave to produce a “cv” wave is usually indicative of acute mitral valve regurgitation. In another embodiment, atrial fibrillation and atrial flutter are detected by analysis of the LAP waveform. In another embodiment, spectral analysis of the LAP versus time signal is performed.
In one embodiment, a physiologic sensor system comprising components to obtain a signal indicative of pressure relative to atmospheric pressure is provided. An implanted apparatus for measuring absolute pressure at a location within the body is provided as above, which further communicates this information, as either an analog or digital signal, to an external signal analyzer/communications device. The external signal analyzer/communications device further contains a second pressure transducer configured to measure the atmospheric (barometric) pressure. The analyzer/communications device performs a calculation using the absolute pressure from the implanted module and the atmospheric pressure to obtain the internal pressure relative to atmospheric pressure, that is, difference between the absolute pressure at the location within the body and the absolute barometric pressure outside the body. In one embodiment, gauge pressure measurements are performed only when the implanted apparatus is queried by the external analyzer/communications device. In one embodiment, this is accomplished by having the external device supply operating power to the implant module to make the measurement. In another embodiment, this is accomplished by requiring a proximity RF link to be present between the external and implantable modules, immediately before, after and/or during the measurement. In another embodiment, differential pressure is obtained by the lead containing a lumen that communicates a reference pressure to the sensor module as well known to skilled artisans.
In one embodiment, an implantable pressure sensor module is provided, wherein the module is associated with proximal and distal anchoring systems that assure localized fixation of the distal end of the module and transducer diaphragm essentially coplanar with the plane of the blood contacting surface of the desired chamber or vessel. The anchoring device is configured to cross the septum between the right and left atrium and trap itself between the two chambers such that a pressure-sensing member is exposed to the left atrium. In one embodiment, the distal anchor legs bend outwards until they are substantially perpendicular to the longitudinal axis of the cylindrical base portion of the sensor module. In alternative embodiments, the distal anchor legs bend proximally until they are oriented at more than 90° to the longitudinal axis of the cylindrical base portion of the sensor module. In such embodiments, the angle θ (which represents the amount beyond a perpendicular to the longitudinal axis that the distal anchor legs can bend) can be between about 0° and about 20°. In some embodiments, the angle θ can be between about 5° and about 15°. In one specific embodiment, the angle θ can be about 10°. In one embodiment, the angle θ will preferably be reduced to zero degrees when the distal anchor is deployed on a distal side of a septum wall with a proximal anchor on the proximal side of the wall due to the opposing force of the proximal anchor. In one embodiment, the angle θ is selected along with a spring constant of the distal anchor legs such that an opposing force applied by the proximal anchor through a septum wall of a particular thickness will cause the angle θ to be substantially reduced to zero or to deflect a small amount in the distal direction so as to conform with a substantially concave left atrial septal surface. In one embodiment, the distal anchor legs are configured such that when both the distal and the proximal anchors are deployed, contact between the distal anchors and the septal wall is distributed over the entire proximal side surface area of the distal anchor legs to minimize pressure-induced necrosis of the septum. The device is configured in a manner that will allow it to position the pressure-sensing member at a desired location relative to the septal wall while conforming to anatomical variations. In one embodiment, the diaphragm is essentially coplanar with the left atrial side of the intra-atrial septum. In one embodiment, the term “essentially coplanar” is defined as the plane defined by the outer surface of the diaphragm is within about ±0.5 mm distance of the plane tangential to the left atrial side of the intra-atrial septum at the location it is traversed by the pressure-monitoring module. In another embodiment, this distance is defined as about ±1 mm. In yet another embodiment of the present invention, this distance is defined as about ±2 mm. In one embodiment, the device is designed such that the diaphragm will not be recessed within the septal wall. In one embodiment the device is designed so that the surface of the diaphragm is positioned between 1 mm and 3 mm distally into the left atrium from the left atrial side of the intra-atrial septum.
According to one embodiment, the sensor system comprises a proximal anchor having one or more helical legs extending between a proximal ring and a distal ring. In one embodiment, the helical path of the proximal anchor legs passes through 360 degrees between the proximal ring and the distal ring. In alternative embodiments, the proximal anchor can be longer and/or the legs can pass through 720 degrees. In one embodiment, the legs pass through a substantially whole number of complete circles between the proximal and distal rings.
In one embodiment, an implantable sensor module is provided, comprising a proximal anchor having anchor legs, wherein the at least one of the anchor legs is configured to bend outwards and distally until in their fully expanded state, each leg forms a loop with a distal most edge that is positioned substantially distally from the distal edge of the distal ring. In one embodiment of the proximal anchor, the anchor assembly is configured such that, in a free space (i.e. with no tissue or material between the proximal and distal anchors), the distal edge of the proximal anchor leg loops and the proximal tissue-contacting surface of the distal anchor can actually overlap by up to about 0.06″. In some embodiments the overlap can be between about 0.03″ and about 0.05″, and in one embodiment, the distance is about 0.04″. In some non-overlapping embodiments, the distance between the distal edge of the proximal anchor leg loops and the distal edge of the distal ring of the proximal anchor can be between about 0.040″ and about 0.070″. In some embodiments, the distance is between about 0.050″ and about 0.060″, and in one particular embodiment, the distance is about 0.054″
In one embodiment, an implantable sensor module is provided, comprising a proximal anchor having anchor legs with sufficient resilience that they relax to positions that overlap the plane of the relaxed distal anchors, assuring that the assembly will be securely anchored to even the thinnest of septum walls. In one embodiment, an implantable sensor module comprises a proximal anchor, wherein the material and dimensions of the proximal anchor legs are selected such that the elasticity of the legs is matched to that of the tissue wall with which it is to be in contact, minimizing pressure-induced tissue necrosis and erosion of the device through the septum. In one embodiment, the device also comprises a distal anchor having one or more legs.
In one embodiment, an implantable sensor module is provided, comprising a proximal anchor with one or more barbs oriented such that the sensor module can be pulled proximally through an opening in a septal wall, but such that the barbs prevent the module from being pushed distally through such opening. In one embodiment, the barbs comprise angled metallic tabs.
In one embodiment, an implantable pressure sensor module is provided, wherein the module comprises a hermetically sealed pressure transducer module configured to be supported by the proximal and distal anchors. The proximal and distal anchors of this embodiment are configured to be movable between a collapsed delivery position and an expanded position in which the proximal and distal anchors secure the module to a wall of an organ within a patient. Said implantable pressure sensor module wherein the forward orientation of the distal anchors legs project distally beyond the pressure-sensing diaphragm, and protect the diaphragm from being damaged during handling or catheter passage into the body.
In one embodiment, a system for diagnosing and/or treating a medical condition in a patient is provided, using a device to measure pressure comprising a pressure-sensing module configured to be implanted within a patient, a proximal anchor comprising at least one helical leg configured to expand from a compressed state to a relaxed state, and a distal anchor comprising at least one leg configured to expand from a compressed state to an expanded state. In one embodiment, said proximal anchor and said distal anchor are configured to sandwich an atrial septum wall (or the left atrial free wall, the pulmonary vein wall, or any other suitable wall of a heart or a blood vessel) between the proximal anchor leg and the distal anchor leg and to support the module in the septum wall. In one embodiment, said system further comprises a delivery system, such as a catheter, configured to deploy the sensor, the proximal anchor and the distal anchor in the septum wall.
In one embodiment, a system for monitoring a patient for congestive heart failure is provided, comprising an implantable pressure transducer and a means for contacting a proximal side or wall and a distal side or wall of an organ to anchor said pressure transducer to the organ wall. Said system for monitoring a patient for congestive heart failure may further comprise a means for delivering said implantable transducer and means for contacting to said organ wall.
In one embodiment, a method of monitoring congestive heart failure in a patient is provided, comprising providing a pressure sensor secured to a proximal anchor and a distal anchor, and delivering the pressure sensor through a hole in an atrial septum of the patient's heart. The method further comprises deploying the pressure sensor with the proximal anchor on a proximal side of the septum, and the distal anchor on a distal side of the septum, and monitoring a fluid pressure in the left atrium of the patient's heart.
In one embodiment, a method of monitoring congestive heart failure within a patient is provided, comprising providing an implantable pressure transducer and coupling said implantable pressure transducer to a means for anchoring said pressure transducer in an organ wall. The method may further comprise delivering said pressure transducer and said means for anchoring to said organ wall, and causing said means for anchoring said pressure transducer in said organ wall to expand, thereby capturing said organ wall and anchoring said pressure transducer thereto.
In one embodiment, a method of anchoring a device in the heart of a patient is provided, comprising providing an implantable cardiac anchoring device comprising a proximal anchor having at least one helical leg and a distal anchor having at least one linear leg, attaching an implantable pressure-sensing module to the implantable cardiac anchoring device, positioning a tubular delivery catheter in a wall of a patient's heart, and inserting the implantable module and the implantable cardiac anchoring device into the tubular delivery catheter. The method further includes deploying the sensor and the implantable cardiac anchoring device such that the sensor is retained in a transverse orientation relative to the wall.
In one embodiment, an implantable sensor module is provided, comprising a substantially cylindrical body connected to the distal end of a lead, and a lead-attachment interface comprises a series of annular notches which can be engaged by a tightly-wound coil. The lead-attachment mechanism can be welded in place, such as by laser welding, on the sensor. The lead-attachment interface can comprise screw threads.
In one embodiment, an implantable sensor module having a substantially cylindrical body is provided, to which is attached a distal anchor assembly, wherein the distal anchor assembly is secured to the sensor by struts or locking tabs on the anchor, which engage an angled annular groove which circumscribes a distal portion of the sensor, and comprises locking tabs extending distally from the distal anchor that are bent slightly radially inwards such that they will engage the distal annular groove in the sensor.
In one embodiment, an implantable sensor module having a substantially cylindrical body is provided, to which is attached a proximal anchor assembly, wherein the proximal anchor assembly comprises locking tabs configured to engage a proximal annular groove in the sensor module body.
In one embodiment, an implantable sensor module having a substantially cylindrical body is provided, to which is attached a proximal and/or distal anchor assembly, wherein the proximal and/or distal anchor assembly is secured to the sensor by struts or locking tabs on the anchor, which engage an angled annular groove which circumscribes a proximal and/or distal portion of the sensor, and wherein the proximal and/or distal anchor tabs are spot-welded to their respective annular flange to prevent rotation of the anchors relative to the sensor module.
In one embodiment, an implantable sensor module having a substantially cylindrical body is provided, to which is attached a proximal and/or distal anchor assembly, wherein the proximal and/or distal anchor assembly is secured to the sensor by struts or locking tabs on the anchor, which engage angled notches that receive the locking tabs in a single rotational orientation on the sensor, effectively preventing rotation of the anchors with respect to the module.
In one embodiment, an implantable sensor module with a distal sensor membrane and a distal anchor is provided, wherein the distal anchor is configured to position the plane of the sensor membrane at a predetermined distance from the plane of the distal anchor. In one embodiment, the distance is preferably zero, i.e., the pressure-sensing face is preferably substantially co-planar with the distal-most point of a deployed distal anchor. In alternative embodiments, the sensor is moved distally such that the pressure-sensing face extends distally outwards from the distal anchor. Alternatively still, the sensor is supported within the distal anchor such that the sensor face is recessed within the distal anchor. The location of the sensor face relative to the distal anchor is varied by changing the location of the distal annular groove and/or by varying a size of the locking tabs.
In one embodiment, an implantable sensor module having a substantially cylindrical body is provided, said module having proximal and distal anchor assemblies, wherein the components are attached to one another with interlocking mechanical fasteners. The proximal anchor, the distal anchor, and the sensor may include interlocking structures configured to mechanically interconnect the assembly components in such a way as to limit both axial and rotational movement of the components relative to one another. The distal anchor comprises a plurality of fingers that extend proximally from the cylindrical base portion, each finger comprising a narrow neck section and a wider proximal tab section. The proximal anchors may comprise correspondingly shaped slots in the distal ring to receive the fingers of the distal anchor. The sensor also includes corresponding interlocking structures configured to engage structures on the distal and/or proximal anchors.
In one embodiment, an implantable sensor module having a substantially cylindrical body is provided, said module having proximal and distal anchor assemblies, wherein the sensor includes raised sections around the circumference of the cylindrical body positioned so as to leave gaps for receiving the neck sections of the fingers, providing a secure and substantially immobile connection between the proximal anchor, the sensor, and the distal anchor. The raised sections are machined into the cylindrical body of the sensor. The raised sections comprise independent segments welded, adhered, or otherwise secured to the cylindrical body of the sensor. The interlocking structures may also be welded together once they are assembled, thereby further securing the connection.
In one embodiment, one or more radiopaque markers are used in conjunction with deployment of the physiological sensor. In one embodiment, radiopaque markers can be applied to the legs of the distal anchor. In one embodiment, radiopaque markers can be applied to the proximal ring of the proximal anchor. In one embodiment, radiopaque markers can be applied to other portions of the proximal or distal anchors, or on the sensor. In one embodiment, radiopaque markers are preferably placed in “low flex zones,” such as the tips of the distal anchor legs and the proximal ring of the proximal anchor. In one embodiment, radiopaque markers are made of noble metals, such as gold, platinum/ iridium, tantalum, etc. In one embodiment, radiopaque markers are attached to the anchor by selective plating or ion beam deposition. In one embodiment, radiopaque markers could be micro rivets and/or rings that are mechanically attached to portions of the system components. In one embodiment, the radiopaque material can be selected to have a galvanic corrosion potential that is substantially similar to a galvanic corrosion potential of the material from which the anchors and/or sensor are made. If the anchors are to be made of nitinol, the radiopaque markers can be made of tantalum. In one embodiment, an electrically insulating coating (conformal coatings) such as parylene or other biocompatible synthetic material can be used to cover the radiopaque markers in order to isolate the marker and anchor section from exposure to the blood or other bodily fluid.
Several embodiments of the present invention provides these advantages, along with others that will be further understood and appreciated by reference to the written disclosure, figures, and claims included herein.
The structure and operation of the invention will be better understood with the following detailed description of embodiments of the invention, along with the accompanying illustrations, in which:
Several embodiments of the present invention relate generally to implantable physiological sensors. Physiological sensors include, but are not limited, to pressure sensors. In one embodiment, a pressure transducer system that is stable following implantation in the medical patient is provided. The sensors and methods described in some of the embodiments are designed for optimal healing and stability of implanted sensors. Several embodiments of the current invention are advantageous because they reduce the risk of thrombus formation. Other embodiments minimize tissue overgrowth that causes pressure sensor drift. Other embodiments of the invention are designed to isolate the sensor diaphragm from stresses in the tissue surrounding the sensor assembly. Other embodiments of the invention are designed to optimize performance. In one embodiment, deployment devices and/or anchoring means are provided integral to or accompanying the sensor. In a further embodiment, the sensor is enclosed in protective packaging. In another embodiment, the sensor is designed to minimize viscoelastic drift. In yet another embodiment, temperature compensation is provided. In a further embodiment, the effects of pressure waveform artifacts due to non-pressure mechanical forces (e.g. “side loading”), are minimized.
Implantable Device Thrombosis and Tissue Overgrowth
Transmural placement of traditional physiologic sensing apparatuses, particularly for the measurement of cardiac chamber or vascular pressures, have a number of limitations that affect long term reliable sensing and may promote serious complications. One area of particular concern is the placement of these devices through the walls of the heart to contact the blood contained in the left atrium or adjacent regions of the left-side of the heart. These devices can activate thrombus formation (blood clots, mural thrombi) on their exposed surfaces or over adjacent injured tissue. Left-sided thrombi have the potential to embolize to arteries of the systemic circulation causing catastrophic complications such as cerebral vascular accidents (stroke) and embolic infarctions of other vital organs.
Several embodiments of the present invention are designed to accommodate for the long-term presence of a device in the left atrium and its attendant risk of thromboembolic events, including stroke. In some embodiments, the surface properties of the device, such as its material constituents and its roughness, the size of the device, and/or the shape of the device are designed to minimize the risk of thromboembolic events. In one embodiment, a pressure transducer system having a relatively small surface area is provided. This embodiment is particularly advantageous because a smaller surface area accelerates healing and decreases the chance of clot formation on the device or adjacent injured wall.
Severe local tissue injury and inflammation promotes thrombus formation. Clots can form as platelets are activated in regions of high blood shear rate or where fibrin is deposited in regions of stasis, classically in the presence of atrial fibrillation. Also, the overall prothrombotic state of the patient is important. Accordingly, in several embodiments, appropriate pharmacologic prophylaxis, including, but not limiting to antiplatelet, antithrombin, and/or antiproliferative drugs, are administered before, during, and/or after implantation of the sensor. In one embodiment, pharmacologic treatments are used to accelerate or facilitate coverage of the device with new tissue growth (overgrowth), which is referred to as a neoendocardium in the case of the heart or a neointima in the case of a blood vessel. As used herein, the terms neoendocardium, neointima, tissue overgrowth, tissue in-growth are used interchangeably. Once tissue overgrowth occurs there often develops a new lining of cells that normally form the blood tissue interface call a neoendothelium. Generally, a functional neoendothelium reduces the risk of an underlying implanted device generating mural thrombus.
In several embodiments of the current invention, one or more of the following factors is addressed in order to decrease the risk of thrombus formation: a rough implant surface, the extent of adjacent tissue injury, interruption of laminar blood flow during deployment, high shear rate of the blood contacting the implant, local blood stasis, and delayed coverage of the device by body tissues.
According to our own studies with stents, we have observed that when a relatively a rough metallic surface (bead blasted nitinol or 316 L stainless) is exposed to rapid blood flow with a high shear rate, exaggerated platelet activation and aggregation are triggered resulting in the formation of platelet-rich thrombi. Accordingly, in several embodiments, at least a portion of the metallic surface of the device is electropolished to reduce the risk of acute thrombosis. In one embodiment, the entire metallic surface is electropolished. In another embodiment, chemical, mechanical, and/or sonic treatments, including, but not limited to passivation and oxygen cleaning, are used to achieve similar effects to electropolishing.
Stent studies have also shown that thrombosis is most likely during the first two to three weeks after implantation until a neoendothelium is present. Further, when tissue overgrowth is delayed or prevented, such as by treatment with intravascular radiation therapy (brachytherapy) at the time of implantation, there is at increased risk for delayed thrombosis (months later). Accordingly, in several embodiments of the present invention, antiplatelet agents are administered to the patient to reduce the risk of thrombosis. In one embodiment, aspirin and/or clopidogrel, are administered to reduce the incidence of thrombosis.
Although not wishing to be bound by the following theory, it is believed that as soon as the device's appropriate surface is covered by an overgrowth of proliferating tissue (neointima), especially when the neointima contains a blood lining barrier of cells call a neoendothelium, the risk of thrombosis is substantially reduced or essentially eliminated. Tissue overgrowth is the natural healing response to local vascular mechanical injury. The sequence of healing events include coverage of the device with plasma proteins such as albumen and fibrin during the initial hours to days, recruitment of blood mononuclear cells over the first week that signal vascular smooth muscle cells in the vessel wall to migrate to the lumen surface, proliferate, and secrete a proteoglycan extracellular matrix. One of the important signals for turning off smooth muscle cell proliferation is in-growth of vascular endothelial cells from adjacent, uninjured tissue. In several embodiments of the current invention, the device is designed to facilitate or accelerate tissue in-growth. In one embodiment, in-growth is enhanced by providing shallow channels on the surface of the device oriented in the direction of blood flow to aid this migration. In some embodiments, complete coverage should take about 2 to 3 weeks, and the rapidity of this overgrowth is desirable because it lowers the risk of thromboembolism and shortens the need for adjunctive antiplatelet medication.
Tissue thickness tends to reach a maximum after about 4 to 6 months, averaging about 300 to 400 microns thick depending on the stent and study. When this thickening encroaches on the vessel lumen causing luminal narrowing of more than 50% of the vessels reference diameter it is called restenosis. After the first 6 months, the extracellular matrix is gradually replaced by collagen and the tissue distribution may change (remodeling) but generally the tissue remains intact and stable for many years thereafter. The tissue remains pliable and only rarely, if ever, becomes atherosclerotic or calcified. The maximal thickness of tissue overgrowth is highly variable but is well known to depend on and a variety of host risk factors, such as diabetes and smaller vessel size. Tissue thickness also depends on mechanical factors including the extent of tissue injury and device design characteristics. In one embodiment of the present invention, the pressure transducer system is designed to have a lower profile or less strut protrusion into the blood stream, thereby promoting a thinner covering of neointima. In other embodiments, the sensor system is designed to develop a thin layer of neointima that provide remodeling benefits to reduce turbulent bloodflow about the sensor system.
Several embodiments of the present invention provide a physiological sensor system that is constructed from a material that is minimally reactive, stable, and that promotes a favorable healing response. Several embodiments of the present invention are particularly advantageous because they minimize thrombotic potential, promote rapid tissue coverage, heal without chronic inflammation, and/or develop a thin neointima with beneficial remodeling features. Other advantages of some embodiments include sensor reliability and accuracy, positioning stability and clinical efficacy for diagnosing and directing therapy in chronic CHF. In one embodiment, the sensor system comprises one or more of the following materials: alloys of stainless steel, nitinol, titanium, cobalt chromium, and tantalum. One skilled in the art will understand that several other biocompatible materials may be used. These materials are typically minimally reactive or non-reactive. Using minimally reactive or non-reactive materials is particularly advantageous because they are hemocompatable and do not promote an inflammatory tissue reaction known to pathologists as a foreign body reaction consisting of granulomas containing macrophages and giant cells. This type of tissue reaction may be associated with higher thrombotic complication rates, more exuberant tissue proliferation and thickening, calcification and possibly even late tissue breakdown and delayed exposure of bare reactive surfaces to blood once again promoting thrombus formation.
In some embodiments, the implantable sensor system will be operable to elute one or more drugs that affect neointimal tissue thickness or thrombosis risk. In some embodiments, a component of the sensor will elute the drug. In an alternative embodiment, a separate device, administered in conjunction with the sensor, will elute the drug. In one embodiment, antiproliferative drugs, such as from biostable or bioerrodable polymeric coatings (including, but not limited to, sirolimus and paclitaxel) are used to control neointimal tissue thickness and virtually eliminate restenosis. In some embodiments, pharmacologic treatment will reduce tissue thickness by more than 50%, to an average of about 120 microns. In certain embodiments of the invention, more precise control of drug delivery is desired because high drug doses may in some cases create toxic reactions or prevent any effective tissue coating and increase the likelihood of late (after three weeks) stent thrombosis. Accordingly, in several embodiments of the present invention, low doses of one or more of these drugs eluted over longer periods are provided. The skilled artisan will understand that while reduced neointimal thickness may be desirable, it is desirable for implant surfaces in contact with blood be covered with at least a thin layer of endothelial cells. One skilled in the art will understand that endothelial cells grow over the surface of an implanted surface from its contact with existing tissue. In one embodiment, one or more pathways or channels are provided to encourage the ingrowth of endothelial cells while reducing neointimal thickness. In one embodiment, anti-thrombotic compounds are eluted from the implanted device. Elution of anti-thrombotic compounds may be used as a bridge to reduce the thrombosis risk until such time the device can develop a neoendocardium covering.
One skilled in the art will understand that an antiproliferative and/or antiplatelet drug regimen can be adjusted to the type of sensor implanted, the location of the implant, and the condition of the patient, and other factors. For example, pharmacologic treatment can be administered in accordance with U.S. Pat. No. 6,152,144 (Lesh) and U.S. Pat. No. 6,485,100 (Roue et al), herein incorporated by reference, which describe permanently implanted devices placed in the left atrium to repair transmural congenital defects of the intra-atrial septum. In one embodiment of the present invention, thromboemboli are prevented with antiplatelet therapy consisting of about six months of aspirin therapy. In one embodiment, aspirin therapy is augmented with a second antiplatelet agent, such as clopidogrel, for approximately the first three months.
In one embodiment of the invention, the sensor system is designed to minimize tissue erosion that may be related to mismatching of the elasticity of the anchoring portions versus the surrounding tissue. It is well known to those skilled in the art that orthopedic prostheses that differ significantly in elasticity from bone produce stress shielding of the bone, resulting in its weakening and producing problems with the prostheses. It is also well known to skilled artisans that soft tissue prostheses such as fabric patches and tubes used in vessel replacement and repair are best tolerated when their elasticity is similar to that of the surrounding tissues to which they are attached. In one embodiment, the elasticity mismatch of the sensor system and the surrounding tissue can be assessed by calculating the difference in the elastic modulus (dyn/cm2) between the sensor system material and the surrounding body tissue at a given pressure. The elastic modulus can be measured by calculating the change in stress over the change in strain of a given material or tissue.
Several embodiments of the current invention are designed to treat CHF. CHF patients have a high incidence of thromboembolic stroke in part because they have a high frequency of known risk factors for left atrial thrombi including: generally enlarged and diseased left atria; mitral valve disease with mitral regurgitation is present in 50%; about 80% of patients are age 65 or older; about one third have atrial fibrillation; atherosclerosis, diabetes and hypertension are also very common. Thromboembolic events typically, but not always, result from the interaction of multiple risk factors. Accordingly, several embodiments of the invention are particularly advantageous for CHF patients because they minimize the incidence of a thromboembolic event by providing an implantable device with reduced thrombogenic effect. Moreover, in accordance with some embodiments of the present invention, a transmurally implanted left atrial pressure transducer device that promotes rapid healing with non-thrombogenic tissue overgrowth is highly desirable for preventing additional thromboembolic complications associated with the implanted devices in patients with CHF.
Several embodiments of the present invention comprise one or more anchors, described below, to affix the sensing device to tissue. To hasten and optimize tissue overgrowth, one embodiment minimizes the path lengths for tissue to in-grow over the distal anchor fixated to the left atrial side of the septum by creating slots or holes in the distal anchor legs. In one embodiment, within several weeks after implantation, the entire device is covered with new tissue, including precursor fibrous tissue and endothelium. A covering of endothelium is desirable because it prevents the formation of blood clots that, if formed, could break loose and cause a blocked artery elsewhere in the body, most dangerously in the brain. A covering of fibrous tissue is also a common component of the body's healing response to injury and/or foreign bodies. In another embodiment, a biocompatible polymeric coating such as parylene is placed on the fixation anchors and diaphragm to minimize platelet adhesions and aggregation, to provide electrical insulation, and to prevent corrosion of underlying metallic constituents. In yet another embodiment, surface grooves or channels are used in at least a portion of the implant to facilitate tissue growth. In one embodiment, at least one groove can be formed on the diaphragm surface or on the anchor legs to serve a similar purpose. The groove's long axes can be linear, circumferential, and serpentine or any other beneficial shape and the groove's cross section can be rectangular, semi-round, or any other beneficial shape. In one embodiment, the grooves, wells, or portions or all of the exposed surfaces are filled with or coated by biostable or bioerrodable polymer or polymers containing agents, including one or more drugs that control the thickness of neointimal tissue overgrowth, or prevent local thrombus formation.
Although tissue overgrowth of the implanted pressure sensor can reduce the thrombosis risk posed by the device, an excessive growth of fibrous tissue on the left atrial surface of the pressure sensor may be undesirable because it may interfere with accurate transmission of fluid pressure in the left atrium to a relatively compliant diaphragm. In addition, uneven contraction of fibrous tissue over time may cause artifactual changes in the pressure waveform, which could confound interpretation of the data. In one embodiment, a coating on the diaphragm surface and or the anchor surfaces inhibits or reduces the formation of undesirable fibrous tissue, while not preventing the beneficial growth of an endothelial covering. Coatings with these properties are well known in the art of implanting medical devices, particularly intravascular stents, into the blood stream. Surface coating materials include, but are not limited to, parylene, polyvinylpyrrolidone (PVP), phosphoryl choline, hydrogels, albumen, polyethylene oxide and pyrolyzed carbon. In another embodiment, parylene is placed on the fixation anchors and diaphragm to minimize platelet adhesion and aggregation, to provide electrical insulation, and to prevent corrosion of underlying metallic constituents.
In one embodiment, at least some areas of the sensor package and diaphragm are electropolished. Electropolished surfaces are known by those skilled in the art to reduce the formation of thrombosis prior to endothelialization, which helps prevent device thrombosis and leads to a reduced burden of fibrotic tissue upon healing. Metallic intracoronary stents currently approved for clinical use are electropolished for this purpose.
Release of antiproliferative substances, including radiation and certain drugs, are also known to be effective in limiting tissue overgrowth after vascular stenting. Such drugs include, but are not limited to, Sirolimus, Everolimus, Tacrolimus and related antirejection compounds, Taxol and other Paclitaxel derivatives, corticosteroids, anti-inflammatory anti-macrophage agents such as 2-chlorodeoxyadenosine (2-CDA), antisense RNA and ribozymes targeted to cell cycle regulating proteins and other targets, and other cell cycle inhibitors, endothelial promoting agents including estradiol, antiplatelet agents such as platelet glycoprotein IIb/IIIa inhibitors (ReoPro), anti-thrombin compounds such as unfractionated heparin, low-molecular weight heparin, hirudin, hirulog etc, thrombolytics such as tissue plasminogen activator (tPA). These drugs may be released from biodegradable or biostable polymeric surface coatings or from chemical linkages to the external metal surface of the device. Alternatively, a plurality of small indentations or holes can be made in the surfaces of the device or its retention anchors that serve as depots for controlled release of the above mentioned antiproliferative substances, as described by Shanley et al. in U.S. Publication No. 2003/0068355, published Apr. 10, 2003, incorporated by reference herein.
Affects of Tissue Growth on Pressure Sensor Calibration
As described above, tissue overgrowth is desirable to reduce the incidence of thrombosis. Although tissue overgrowth has clear benefits, it may also pose some challenges for implanted pressure sensors because the overlying tissue can be a major source of drift, thereby causing the transducer to lose calibration. For example, calibration issues can occur with an implanted pressure transducer that relies on the displacement of an exteriorly exposed mechanical member, such as a membrane or diaphragm, that actuates protected internal components such as piezoresistive strain gauges or other types of transducers that generate a signal related to the pressure change. For transducers that have a linear relationship between the pressure change and the transducer output and to the extent that tissue overgrowth interferes with the displacement of the mechanical member in response to a given pressure change, the sensitivity or “gain” (slope) of the transducer output/input relationship will be reduced or drift. Likewise, if tissue coverage causes displacement of the mechanical member, errors or drift in offset or “zero” (y-intercept) will occur. When these tissue effects cause errors in physiologic pressure measurement that affect diagnosis and treatment decisions, the transducer requires recalibration. Transducers that have non-linear calibration relationships will also be affected by tissue overgrowth and experience drift.
The process of tissue coverage is generally dynamic. As healing takes place the thickness of tissue increases over about 4 to 6 months; thereafter, the thickness may gradually decline or increase (remodel) over the next several years. In addition to tissue thickness effects on drift, the biochemical constituents of the tissue change as the matrix material is replaced with collagen and may have different material properties such as elasticity, that may further contribute to transducer drift.
Recalibration of implanted pressure transducers is typically performed by comparison with a calibrated standard. This most often has meant that the patient is required to undergo periodic invasive catheterization procedures. Thus, in several embodiments of the present invention, a pressure transducer with calibration parameters that are minimally affected by tissue overgrowth, thereby reducing the need for invasive recalibration, is provided. These embodiments are advantageous because they do not subject the patient to the risk, discomfort, and expense of such procedures. In some embodiments, a pressure transducer that promotes reduced but effective tissue overgrowth is provided. This is desirable because it reduces the risk of thromboembolic complications. Typically; if tissue overgrowth causes an essentially linear sensor to drift with respect to both gain and offset, recalibration against a standard at a minimum of two different pressures is required. A pressure sensor that drifts with respect to offset only may be more simply recalibrated against a standard at a single pressure only. Accordingly, several embodiments of the present invention provide pressure transducers that either do not require calibration or can be easily recalibrated using non-invasive methods. Methodology and apparatus to non-invasively assess implanted transducer calibration and automatically recalibrate has been described in U.S. Patent Application Publication No. US 2004/0019285 A1, herein incorporated by reference.
Protective Packaging
Electronic and mechanical devices are frequently placed in environments that may damage the components unless some form of protection is provided. For example, some electronic medical devices implanted into a body may be exposed to body fluids that may cause unprotected semiconductor circuits and non-electronic components to fail. Accordingly, in several embodiments of the current invention, at least a portion of the sensor system is protected against the damaging effects of bodily fluids. In one embodiment, the device is contained in hermetic packaging to limit exposure to these harmful elements.
In some embodiments, a traditional approach to creating protective packaging for implantable medical devices is used. This generally involves the complete encasement of the silicon or semiconductor components of the device in a hermetic package. Such packages typically utilize a metal such as titanium, or a ceramic material like alumina or zirconia. Various glass materials can also be employed. In other embodiments, the sensor is enclosed in a metal packaging and the environmental pressure is coupled to the sensor through a diaphragm bonded to the packaging. Such approaches place an interface between the environment and the sensor for the electronic components to interact with the environment and to protect the integrity of the device. Such a diaphragm can be made from the same or similar materials as the housing to facilitate bonding and hermetic sealing of the diaphragm with the housing or protective barrier of the device. Further methods of hermetic sealing are described below.
Delivery and Deployment of the Pressure Transducer
Additional embodiments that enhance or optimize the transmurally implanted transducer's capabilities are provided. With respect to deployment apparatus and methodology, in one embodiment, the transducer module is delivered to its desired location by a catheter or sheath that transverses the wall of the desired chamber or vessel and can be loaded with the transducer module system with its fixation anchors in a constrained or folded configuration. In another embodiment, the delivery catheter permits simultaneous measurement of fluid pressure from the catheter tip during transducer package transit and deployment. In a further embodiment, the delivery catheter permits injection of radiographic contrast material with the transducer system in its lumen to localize positioning during transducer system deployment. In another embodiment, the transducer module and/or its fixation anchors have radiographic markers to enhance visualization during deployment.
Viscoelastic Drift
In several embodiments of the instant invention, the pressure transducer is optimized for assuring performance and minimizing complications. In one embodiment, the transducer is designed such that viscoelastic drift is minimized. After prolonged exposure to a large change in average ambient pressure, such as the change to lower pressures during travel to high altitude, some pressure transducers undergo viscoelastic drift whereby their components undergo elastic deformation with prolonged time constants lasting hours to days or more before returning to the pre-stressed state. This phenomenon may result in a baseline shift that persists until another large change in average ambient pressure sets into motion another viscoelastic drift to another new baseline. In one embodiment of the present invention, the viscoelastic properties of the pressure transducer are characterized during pre-implant calibration. In one embodiment, the known viscoelastic properties are used in combination with the recorded pressure variations over time to obtain pressure measurements that are corrected for viscoelastic drift.
In one embodiment, the diaphragm has a plurality of resistive strain gauges coupled to the diaphragm's internal surface. In one embodiment, shown in
In another embodiment, a software algorithm is used to automatically correct for viscoelastic drift. In another embodiment, a secondary diaphragm may be located on other portions of the module. In one embodiment, a secondary diaphragm is used to measure pressure at a second site or to measure a differential pressure between the distally located diaphragm and the secondary diaphragm. In one embodiment, the second diaphragm may be used to provide additional calibration information for the first diaphragm, and/or vice versa.
Temperature Compensation
In one embodiment, the pressure sensor includes temperature compensation so that pressure measurements will be minimally affected or unaffected by temperature change. In one embodiment, apparatus to measure the temperature at the site of the sensor is provided. In one embodiment, temperature compensation or modulation is achieved by using multiple resistive strain gauges arranged in a Wheatstone bridge, such that the electrical voltage output of the bridge is proportional to the ratio of two or more resistances, as is well known in the art of electrical measurements. By selecting resistive strain gauges with substantially identical temperature coefficients, the intrinsic output of the bridge is made to be temperature independent. However, in one embodiment, the overall response of the pressure transducer may still be temperature dependent due to other factors, such as the different thermal expansions of the various components and contents of the device. Another embodiment of temperature compensation utilizes an internal thermometer comprising, for example, a resistor whose resistance depends upon temperature in a reproducible way, and which is placed in a location isolated from the transducer diaphragm so that its resistance does not depend on pressure variations. Prior to implanting the device, calibration data is collected consisting of the output of the transducer versus pressure as a function of the reading of the internal thermometer. After implantation, the signal from the internal thermometer is used together with the transducer output and the calibration data to determine the temperature compensated pressure reading. In one embodiment, a band gap voltage reference is used to create a current proportional to absolute temperature that is then compared to the temperature-independent voltage reference. Such methods are well known in the art of CMOS integrated circuit design.
Output Artifacts—Minimizing Effects of Side Loading
Another characteristic of some pressure transducers is that output artifacts can occur when structures adjacent to the mechanical members are stressed. Forces placed on the module casing that distort the mechanical diaphragm are known as side-loads, Side-loads exerted by tissue contact with the transducer module housing and/or its anchors, and/or forces exerted on the module by its lead, may produce non -pressure-signal artifacts in the output signal. Side-loads may develop during the healing process as tissues encroach on the side areas adjacent to the mechanical member supporting the pressure-sensing diaphragm, causing differential loading of said member. Accordingly, in one embodiment of the invention, the pressure transducer is designed to minimize output artifacts.
In one embodiment, the casing adjacent to the diaphragm is made substantially inflexible and non-distortable such that the diaphragm is not distorted by side-loads under physiologic conditions.
Another embodiment, shown in
In a further embodiment, the regions of the transducer module casing where the proximal and distal anchors are affixed are located as far proximal from the distal diaphragm as possible so that differential tension on the anchor legs causes less loading on the module casing near the diaphragm and thereby less distortion of the diaphragm than if the fixation regions were more distal and closer to diaphragm.
The skilled artisan will realize that various combinations of the embodiments described above may be beneficial. Therefore, a further embodiment represents any combination of the above embodiments, including increased casing wall thickness or rigidity, orthogonal placement of outer strain gauges, and/or proximal fixation of anchors utilized to increase pressure transducer insensitivity to side-loads.
Locations and Insertion Routes
In several embodiments, a physiological sensing device comprising implantable, transmurally-placed pressure transducer systems for measuring fluid pressure within a cardiac chamber or a blood vessel is provided. In one embodiment, the transducer system is implantable within any hollow viscous within the body of a medical patient. In one embodiment, the transducer system is optimized for placement in the left atrium of the heart by a percutaneous catheter-based procedure that traverses the intra-atrial septum. In another embodiment, the transducer system is optimized for placement in a pulmonary vein by an open surgical procedure.
As used herein, the terms “proximal” and “distal” are used to describe relative positions, locations and/or orientations of various components. As used herein, the term “distal” is used in its ordinary sense, and generally refers to objects and locations that are further along a trans-vascular path from an operator of a trans-vascular device. Similarly, the term “proximal” is used in its ordinary sense, and refers without limitation, to objects and locations that are closer along a trans-vascular path to an operator of a trans-vascular device. For example, in some embodiments the most proximal end of a catheter is the end that is operated by a clinician performing a procedure within a patient with the catheter. Similarly, in such embodiments the distal-most end of a catheter is the end placed furthest into the body of the patient and furthest from the clinician performing the procedure. The terms “proximal” and “distal” are used herein with reference to certain embodiments of the orientation of certain components during a procedure. The skilled artisan will recognize however, that in alternative embodiments the directions of “proximal” and “distal” as used herein may be reversed with respect to a single component used in a similar procedure.
Several embodiments of the current invention comprise permanently implantable transmurally-placed pressure transducer systems for measuring fluid pressure within a cardiac chamber or a blood vessel, or any other hollow viscous or fluid filled space within the body of a medical patient. The term “permanently implantable” as used herein shall be given its ordinary meaning and shall refers to any and all such devices that are intended for implanted for more than about one week and are therefore potentially or substantially permanent. In one embodiment, the transducer system is optimized for placement in the left atrium of the heart by a percutaneous catheter procedure traversing the intra-atrial septum. In another embodiment, the transducer system is optimized for placement in a pulmonary vein by an open surgical procedure. In yet another embodiment, the transducer system is optimized for placement through the free wall of the left atrium, or through the wall of the left atrial appendage, or across the right atrial free wall or right atrial appendage or transmurally into the main or branch pulmonary arteries by a minimally invasive thorascopic surgical procedure or by a traditional open surgical approach. Intrathoracic pressure may be monitored by placement of the pressure transducer system through the chest wall or diaphragmatic respiratory muscles by local puncturing techniques, under direct or fiberoptic endoscopic vision, or by robotic surgical manipulation. In one embodiment, output from an intrathoracic pressure transducer may be used to compensate for arterial pressure fluctuations caused by a patient's breathing rate and effort. In one embodiment, the intrathoracic pressure transducer can be used to validate and/or error check the operating status of other pressure transducers located in the thoracic cavity by comparing pressure tracings and checking for analogous respiratory fluctuations. In one embodiment, the intrathoracic pressure transducer is used to measure the respiratory efforts to assess respiratory status.
It will be apparent to those skilled in the art that transmural pressure monitoring refers in general to monitoring pressure anywhere in the body with a pressure transducer system that is placed through the wall of or traversing a septum, membrane or any other dividing structure that physically separates or represents a barrier or boundary of the location with the desired pressure to be monitored and other body structures. It will also be apparent that several methods of reaching the desired location can be used in accordance with several embodiments of this invention depending on the suitability of the specific anatomy to a particular method. These methods include, but are not limited to, catheter delivery, endoscopic delivery, minimally invasive surgery, and open surgery. One of skill in the art will understand that any location and transmural routes and methods of positioning implanted pressure transducer systems can be used in accordance with several embodiments of the present invention.
Pressure Sensor Designs
In one embodiment, the internal transducer components including the transducer, power, and communications components are enclosed in a hermetic casing or housing called a transducer module. In one embodiment, the casing comprises metal, ceramic, or glass, alone or in combination, or other constituents known to skilled artisans for constructing hermetic packaging. The transducer module has proximal and distal ends. Referring to
In one embodiment, the enclosed transducer components comprise semiconductors that control power, pressure signal transduction, local signal processing, and data telemetry. In one embodiment, resistive strain gauges 303, 304 are bonded, or otherwise coupled, to the inside surface of the diaphragm 302. In one embodiment, a titanium cylindrical housing 306 comprises an application-specific integrated circuit (ASIC) 307 or “measurement electronics.” Measurement electronics 307 are contained within the housing and electrically connected to the strain gauges by fine gold wires 308 or other means of electrical connection. In one embodiment, the proximal end of the housing is sealed by a zirconia ceramic feed-through 310 that is brazed to a titanium cylinder. In one embodiment, the housing contains a gaseous atmosphere. The gaseous atmosphere may comprise helium, argon, or any other advantageous gas or combination of gases known to skilled artisans. In one embodiment, the housing is evacuated prior to sealing. In another embodiment, an electrical insulating liquid such as an oil or other electrically insulating liquids known to skilled artisans is contained within the housing.
In one embodiment, the implanted module contains an internal power source, such as a battery. In another embodiment, the module is powered transcutaneously by induction of radio frequency current in an implanted wire coil connected directly to the module or connected by a flexible lead containing electrical conductors, to charge an internal power storage device such as a capacitor.
In one embodiment, the pressure transducer is contained within a hermetically sealed sensor package, or module. The sensor package may be provided in a wide range of sizes and shapes. In one embodiment, the sensor package is a cylindrical in shape with a distal end and a proximal end. In one embodiment, the module is between about 1 mm and 5 mm long, and 3 mm in diameter. In another embodiment, the module is between about 5 mm and about 15 mm long. In another embodiment, the package is about 8 mm long, and about 3 mm in diameter. In one embodiment, the package is less than about 1 mm in diameter. In another embodiment, the package is less than about 10 mm long. In one embodiment, the package may be rectangular, square, spherical, oval, elliptical, or any other shape suitable for implantation. In one embodiment, the sensor package is rigid, and in another embodiment, the sensor package is flexible.
In one embodiment, the sensor module includes a cylindrical housing comprising one or more component pieces of titanium CP, titanium 6-4, or other suitable biocompatible metallic alloy or other material suitable for making a hermetic package such as ceramic material like alumina or zirconia. Titanium pieces can be hermetically affixed to each other by laser welding and ceramic materials may be hermetically bonded to metallic components by brazing techniques. In one embodiment, the housing is closed at one end by a membrane called a diaphragm. In one embodiment, comprising a titanium cylindrical housing, the diaphragm comprises a titanium foil that is diffusion bonded or otherwise hermetically affixed to the titanium housing. In another embodiment, the membrane may be machined, lapped, or otherwise manufactured from titanium bar or rod stock so that part of the cylindrical housing and the diaphragm are one piece. One skilled in the art will understand that any construction techniques and material for creating a hermetic package can be used in accordance with several embodiments of the present invention. As used herein, the term hermetic shall be given its ordinary meaning and shall also mean a device enclosure with a helium leak rate from about ×10−11 to about 5×10−13 std. cc/sec
In another embodiment, the pressure sensor is fabricated by micro electro-mechanical systems (MEMS) techniques, as taught by, for example U.S. Pat. No. 6,331,163, herein incorporated by reference. Electronic and mechanical devices are frequently placed in environments that may damage the components unless some form of protection is provided. For example, some electronic medical devices implanted into a body may be exposed to body fluids that may cause unprotected semiconductor circuits and non-electronic components to fail. Such devices may benefit from a hermetic packaging to limit exposure to these harmful elements. Traditional approaches to creating a protective hermetic package for an implantable medical device generally involve the complete encasement of the silicon or semiconductor components of the device in the hermetic package. Such packages typically utilize a metal such as titanium, or a ceramic material like alumina or zirconia. Various glass materials have also been employed. For example, hermetic cavities have been created to form small vacuum chambers for pressure transducers by bonding silicon components to either silicon or glass. The silicon component is usually fixed into a package with epoxy or soldered into the package. The complete encasement of the silicon component with a separate package adds to the size of the device and also increases its cost.
Similarly, other approaches that have been used for pressure transducers by enclosing the sensor in a metal packaging and coupling the environmental pressure to the sensor through a diaphragm bonded to the packaging. Such approaches place an interface between the environment and the sensor for the electronic components to interact with the environment and to protect the integrity of the device. Such a diaphragm may be made from the same or similar materials as the housing which protects the inner components to facilitate bonding and hermetic sealing of the diaphragm with the housing or protective barrier of the device.
In light of the above discussion, there still remains a need in the art for a system to accommodate medical devices that function effectively by having direct contact of the silicon component with the environment (in many cases, the body). The effective operation of some of these devices precludes complete encasement of the sensor in a protective package. Newer semiconductor components, however, such as semiconductor chemical sensors, may require such direct contact of the silicon component, thereby precluding complete encasement of the sensor. Similarly, pressure sensors fabricated by micro electromechanical systems (MEMS) techniques, as described in U.S. Pat. No. 6,331,163, herein incorporated by reference, require either direct contact with the environment or adequate transmission of environmental pressure through a medium to the sensor.
Accordingly, in one embodiment of the present invention, a method for hermetically sealing a silicon device is provided. The silicon device is coupled to a sensor, such as a pressure transducer, which benefits from having direct contact with its environment (the body). Thus, a method is provided to hermetically seal the non-sensing portion of a silicon device while allowing the sensing portion (e.g. the pressure transducer) to have direct contact with the body. In one embodiment, a silicon chip, a gold preform and a metallic housing are each primed for sealing and are assembled. The assembly is then heated to react the gold preform to the silicon chip and to form a molten gold-silicon alloy in-situ to bind said metallic housing to the non-sensing portion of the silicon chip. In this way, the non-sensing portion of the silicon chip is hermetically sealed, while still permitting exposure of the sensing portion of the silicon chip to the environment.
In one embodiment, the physiological sensor system is configured similarly to a cardiac pacemaker, with a hermetically sealed housing implanted under the patient's skin (subcutaneous) and a flexible lead containing signal conductors with a hermetically sealed pressure transducer module at or near its distal end. The signal conductors may be electrical, fiber optic, or any other means of signal conduction known to skilled artisans. The lead may have a stylet lumen to aid with transducer deployment in the body of a medical patient. The lead may have a lumen for connection of the sensor module to a reference pressure. In one embodiment, the housing contains a battery, microprocessor and other electronic components, including transcutaneous telemetry means for transmitting programming information into the device and for transmitting physiological data out to an external programmer/interrogator. In another embodiment, the implanted pressure sensor lead combination is an integral part of a cardiac rhythm management system such as a pacemaker or defibrillator or various other implantable cardiovascular therapeutic systems know to skilled artisans.
In another embodiment, the signal processing, and patient signaling components are located in a device external to the patient's body in communication with the implanted subcutaneous housing via one of various forms of telemetry well known in the art, such as two-way radio frequency telemetry. In this embodiment, the subcutaneous housing can comprise only a tuned electrical coil antenna, or a coil antenna in conjunction with other components. Other designs for antennae are well known to those skilled in the art and are can be used in accordance with several embodiments of the present invention.
In still another embodiment, the sensor module is directly connected to a coil antenna by short lead or lead of zero length such that the entire system resides in the heart. Such a system may have a small internal battery or power could be delivered transcutaneously by magnetic inductance or electromagnetic radiation of a frequency suitable for penetrating the body and inducing a voltage in the implanted coil antenna. In one embodiment, radiofrequency electromagnetic radiation is used with a frequency of about 125 MHz.
In one embodiment, the sensor module comprises one or more sensors in addition to a pressure transducer at its distal end. These sensors may include a plurality of pressure transducers to measure pressures in the transmural space or locations proximal to the transmural space, or to measure differential pressure between the distal diaphragm and another location. Other types of sensors include, but are not limited to, accelerometers, temperature sensors, electrodes for measuring electrical activity such as the intracardiac electrogram (IEGM), oxygen partial pressure or saturation, colorimetric sensors, chemical sensors for glucose or for sensing other biochemical species, pH sensors, and other sensor types that may be advantageous for diagnostic purposes, or for controlling therapy. Pressure sensors with a frequency response of from about 500 to about 2000 Hz are adequate to detect a wide range of cardiac or respiratory sounds such as valvular closure, opening, murmurs due to turbulent blood flow, pulmonary rates due to congestion, etc. A frequency response of less than about 500 Hz and greater than 2000 Hz can also be used in accordance with several embodiments of the instant invention. Alternatively, a separate hydrophone sensor may be placed in the sensor module. In one embodiment, the sensor module may serve dual diagnostic and therapeutic functions. In one embodiment, the sensor module contains at least one electrode for stimulating the organ in which it is placed. For example, such an electrode or electrodes may be used for electrical pacing the left atrium. Other combinations with therapeutic applications will be known to skilled artisans.
Signals
Left Atrial Pressure Signals
In one embodiment, one of the physiological sensors is a pressure transducer that is used to generate a signal indicative of pressure in the left atrial chamber of the patient's heart (the “left atrial pressure,” or LAP). In one embodiment, a LAP versus time signal is processed to obtain one or more medically useful parameters. These parameters include, but are not limited to, mean LAP, temporally filtered LAP (including low-pass, high-pass, or band-pass filtering), heart rate, respiratory variations of LAP, respiration rate, and parameters related to specific features of the LAP waveform such as the so-called a, v, and c waves, and the x, x′, and y descents. All these parameters are well known to those skilled in the art. Examples of parameters derived from specific LAP waveform features include the mechanical A-V delay interval, as defined below (as distinct from the electrical A-V interval derived from the electrocardiogram); the relative peak pressures of the a and v waves, and the pressure values at specific times in the LAP waveform, as are understood by those skilled in the art.
In one embodiment, signals indicative of left atrial pressure are periodic signals that repeat with a period the length of which is equal to the period in between heartbeats. Any portion of the signal or a summary statistic of that periodic signal may be indicative of left atrial pressure and provide diagnostic information about the state of the heart. For example, the a, c, and v waves and the x, x′, and y descents, described above, correlate with mechanical events such as heart valves closing and opening. Any one of these elements can yield useful information about the heart's condition. Each discrete element represents an individual signal indicative of left atrial pressure. A summary statistic such as the arithmetic mean left atrial pressure also represents a signal indicative of left atrial pressure. One skilled in the art will appreciate that there are additional discrete elements and summary statistics that are valuable indicators of left atrial pressure. Advantageously these components of left atrial pressure are relative to each other and therefore do not have to be compensated for atmospheric pressure and are not subject to offset drift inherent in most pressure transducers. Another such index will be the pressure differential between the mean and respiratory minima.
In one embodiment, the relative heights and/or shapes of the left atrial “a,” “c,” and “v” waves are monitored to detect and diagnose changes in severity of cardiovascular disease. This information permits differentiation between worsening symptoms of CHF due to volume overload versus impaired left ventricular pump function (such as decrease left ventricular compliance, or acute mitral regurgitation), allowing medical therapy to be appropriately targeted. For example, pure volume overload is usually manifest with a progressive elevation of the mean left atrial pressure and generally responds to fluid removal by taking a diuretic medication, natriuretic peptide, or an invasive technique known as ultrafiltration of the blood. Decreased left ventricular compliance is the diagnosis when the “a” wave increases without shortening of the atrioventricular (AV) delay or in the presence of mitral stenosis. Acutely decreased compliance may be indicative of left ventricular (LV) ischemia, while chronically decreased compliance may be indicative of LV wall thickening know as hypertrophy. The former may respond to nitrates or coronary artery interventions, while the latter may respond to beta or calcium antagonist drugs, or chemical septal ablation. Increases in the “v” wave amplitude and merging with the “c” wave to produce a “cv” wave is usually indicative of acute mitral valve regurgitation. This may be due to a sudden mechanical failure of the valve or its supporting apparatus or it may be due to acute ischemia of the supporting papillary muscles as part of an acute coronary artery syndrome. Sudden mechanical failure requires surgical repair or replacement, while ischemia may require anti-ischemic medications such as nitroglycerin or coronary artery interventions such as angioplasty or bypass surgery. In another embodiment, atrial fibrillation and atrial flutter are detected by analysis of the LAP waveform. In another embodiment, spectral analysis of the LAP versus time signal is performed.
Measurement of Relative Pressure (Gauge Pressure)
In one embodiment, the system contains components to obtain a signal indicative of pressure relative to atmospheric pressure. An implanted apparatus for measuring absolute pressure at a location within the body is provided as above, which further communicates this information, as either an analog or digital signal, to an external signal analyzer/communications device. The external signal analyzer/communications device further contains a second pressure transducer configured to measure the atmospheric (barometric) pressure. The analyzer/communications device performs a calculation using the absolute pressure from the implanted module and the atmospheric pressure to obtain the internal pressure relative to atmospheric pressure, that is, difference between the absolute pressure at the location within the body and the absolute barometric pressure outside the body. This pressure, also known as the gauge pressure, is known to those skilled in the art to be the most physiologically relevant pressure measure.
In one embodiment, gauge pressure measurements are performed only when the implanted apparatus is queried by the external analyzer/communications device, advantageously assuring that the atmospheric pressure at the time and patient's location is available and correctly matched with the absolute internal pressure reading. It will be clear to those skilled in the art that unmatched internal and barometric pressure readings would render the gauge pressure measurement inaccurate or useless. In this embodiment, internal absolute measurements are made only when the external analyzer/communications device is physically present. In one embodiment, this is accomplished by having the external device supply operating power to the implant module to make the measurement. In another embodiment, this is accomplished by requiring a proximity RF link to be present between the external and implantable modules, immediately before, after and/or during the measurement.
In another embodiment, differential pressure is obtained by the lead containing a lumen that communicates a reference pressure to the sensor module as well known to skilled artisans.
Anchoring/Fixation Apparatus
In several embodiments, the physiological sensor system is coupled to surrounding tissue by one or more anchoring mechanism. In one embodiment, tissue anchoring apparatus is used to affix the transducer module in the desired transmural position, to prevent sensor module migration, to promote rapid tissue overgrowth without thrombus formation, and to be mechanically and biologically compatible with the tissue so as not to induce an inflammatory reaction or cause device erosion. In several embodiments, a pressure measurement device is anchored within an atrial septum wall. However, the skilled artisan will recognize that the methods described for anchoring a pressure transducer to a septal wall can also be applied to affix any suitable sensing module to any wall of an organ or a vessel within a patient.
In one embodiment, the module is associated with proximal and distal anchoring systems that assure localized fixation of the distal end of the module and transducer diaphragm essentially coplanar with the plane of the blood contacting surface of the desired chamber or vessel so as to promote rapid tissue overgrowth. One such a system is described in U.S. patent application Ser. No. 10/672,443, herein incorporated by reference.
In one embodiment, an anchoring device is configured to cross the septum between the right and left atrium and trap itself between the two chambers such that a pressure-sensing member is exposed to the left atrium. The device is configured in a manner that will allow positioning of the pressure-sensing member at a desired location relative to the septal wall while conforming to anatomical variations. In one embodiment, the diaphragm is essentially coplanar with the left atrial side of the intra-atrial septum. In one embodiment, the term “essentially coplanar” is defined as the plane defined by the outer surface of the diaphragm is within about ±0.5 mm distance of the plane tangential to the left atrial side of the intra-atrial septum at the location it is traversed by the pressure-monitoring module. In another embodiment, this distance is defined as about ±1 mm. In yet another embodiment of the present invention, this distance is defined as about ±2 mm.
In one embodiment, the device is designed such that the diaphragm will not be recessed within the septal wall. This embodiment is particularly advantageous because thrombi are more likely to form in regions of blood stasis within the recess. A thicker layer of neointima will tend to form as the tissue remodels, creating an optimal blood flow pattern by eliminating the recess. Likewise, a diaphragm that protrudes into the left atrium may cause microscopic high shear zones where high velocity blood flow interacts with the device. High shear is known to activate platelet thrombus formation. Also, the longer distance for tissue in-growth from the surrounding septum may delay tissue coverage and healing. Nonetheless, one skilled in the art will understand that, in accordance with a few embodiments of the current invention, a portion of the diaphragm may be recessed within the septal wall or may protrude through the left atrium.
According to one embodiment, the sensor system comprises a proximal anchor having one or more helical legs extending between a proximal ring and a distal ring. In one embodiment, the device also comprises a distal anchor having one or more legs. The device further includes a hermetically sealed pressure transducer module configured to be supported by the proximal and distal anchors. The proximal and distal anchors of this embodiment are preferably configured to be movable between a collapsed delivery position and an expanded position in which the proximal and distal anchors secure the module to a wall of an organ within a patient.
In one embodiment of the current invention, a system for diagnosing and/or treating a medical condition in a patient using a device to measure pressure is provided. One embodiment comprises a pressure-sensing module configured to be implanted within a patient, a proximal anchor comprising at least one helical leg configured to expand from a compressed state to a relaxed state, and a distal anchor comprising at least one leg configured to expand from a compressed state to an expanded state. The proximal anchor and the distal anchor of this embodiment are preferably configured to sandwich an atrial septum wall (or the left atrial free wall, the pulmonary vein wall, or any other suitable wall of a heart or a blood vessel) between the proximal anchor leg and the distal anchor leg and to support the module in the septum wall. In one embodiment, the system also comprises a delivery system, such as a catheter, configured to deploy the sensor, the proximal anchor, and the distal anchor in the septum wall. In one embodiment, the system is particularly suited to monitor congestive heart failure in the patient.
Another embodiment provides a system for monitoring a patient for congestive heart failure, comprising an implantable pressure transducer and a means for anchoring the pressure transducer to an organ wall. In one embodiment, the means for anchoring comprises one or more anchoring members adapted to contact a proximal side and a distal side of a wall of an organ to anchor the pressure transducer to the organ wall. The system can further comprise a means for delivering the implantable transducer and means for contacting the organ wall.
In another embodiment, a method of monitoring congestive heart failure in a patient is provided. In one embodiment, the method comprises providing a pressure sensor secured to a proximal anchor and a distal anchor, and delivering the pressure sensor to a hole in an atrial septum of the patient's heart. The method further comprises deploying the pressure sensor with the proximal anchor on a proximal side of the septum, and the distal anchor on a distal side of the septum; monitoring a fluid pressure in the left atrium of the patient's heart.
Another embodiment provides a method of monitoring congestive heart failure within a patient. In one embodiment, the method comprises providing an implantable pressure transducer and coupling said implantable pressure transducer to a means for anchoring said pressure transducer in an organ wall. The method further comprises delivering said pressure transducer and said means for anchoring to said organ wall, and causing said means for anchoring said pressure transducer in said organ wall to expand, thereby capturing said organ wall and anchoring said pressure transducer thereto.
According to still another embodiment, a method of anchoring a device in the heart of a patient is provided. The method includes providing an implantable cardiac anchoring device comprising a proximal anchor having at least one helical leg and a distal anchor having at least one linear leg. The method comprises attaching an implantable pressure-sensing module to the implantable cardiac anchoring device, positioning a tubular delivery catheter in a wall of a patient's heart, and inserting the implantable module and the implantable cardiac anchoring device into the tubular delivery catheter. The method further includes deploying the sensor and the implantable cardiac anchoring device such that the sensor is retained in a transverse orientation relative to the wall.
Turning to the figures, embodiments of cardiovascular anchoring devices for use in anchoring an implantable pressure sensor module to an organ wall (such as an atrial septum wall) will now be described. In some embodiments, the module comprises a sensor, and in one particular embodiment, the module is a pressure sensor, such as a pressure transducer. Several figures included herein illustrate a straight device and deployment apparatus for the purpose of demonstration. However, one skilled in the art will understand that, in use, the delivery catheter and contained components will typically be substantially flexible or may assume other non-straight shapes. For example, a delivery catheter can be configured to include a pre-shaped curve or a pre-shaped stylet in order to facilitate navigation of a patient's tortuous vasculature. As will also be clear to the skilled artisan, the flexibility of certain components will be particularly advantageous for navigation through tortuous anatomy.
In order to allow the proximal and distal anchors 110 and 112 to self-expand from a compressed state to an expanded state, they are preferably made from materials that exhibit superelastic and/or shape memory characteristics. Alternatively, the anchors could be made from other non-superelastic or non-shape memory materials as desired. For example, suitable materials for fabrication of the proximal and distal anchors include, but are not limited to, nickel titanium alloys (NiTi or NITINOL), cobalt-chromium alloys, stainless steel, ELGILOY, MP35N or other biocompatible, superelastic, and/or shape memory materials that are well known to those skilled in the art of clinical medical devices. The anchors can be made by any suitable process appropriate for a particular material. For example, the anchors could be molded, machined, laser cut, etc as desired.
In an expanded shape, as shown in
In the embodiment of
In their fully expanded state, the anchor legs 144 preferably bend outwards and distally until each leg 144 forms a loop 152 with a distal most edge 154 that is positioned substantially distally from the distal edge of the distal ring 142. In some embodiments, the anchor assembly can be configured such that, in free space (i.e. with no tissue or material between the proximal and distal anchors), the distal edge 154 of the proximal anchor leg loops 152 and the proximal tissue-contacting surface of the distal anchor 110 can actually overlap by up to about 0.06″. In some embodiments the overlap can be between about 0.03″ and about 0.05″, and in one embodiment, the distance is about 0.04″. In some non-overlapping embodiments (as shown in
In the embodiment of
The distal anchor of
Radiopaque Markers
In one embodiment, one or more radiopaque markers are used in conjunction with deployment of the physiological sensor.
Radiopaque markers are typically made of noble metals, such as gold, platinum/ iridium, tantalum, etc, and are typically attached to the anchor by selective plating or ion beam deposition. Alternatively, the markers could be micro rivets and/or rings that are mechanically attached to portions of the system components. In order to reduce the risk of galvanic corrosion which can be experienced by dissimilar metals exposed to blood, the radiopaque material can be selected to have a galvanic corrosion potential that is substantially similar to a galvanic corrosion potential of the material from which the anchors and/or sensor are made. For example, if the anchors 110, 112 are to be made of NITINOL, the radiopaque markers 200 can be made of tantalum. Alternatively, an electrically insulating coating (conformal coatings) such as parylene or other biocompatible synthetic material can be used to cover the radiopaque markers in order to isolate the marker and anchor section from exposure to the blood or other bodily fluid.
In one embodiment, the legs 144 of the proximal anchor 112 apply a lower spring force to the septum wall 210 than the legs 124 of the distal anchor 110 so that variations in septum wall thickness are accommodated by variations in the position of the proximal anchor legs 144 as shown in
FIGS. 27A-C, 28 and 29A-B show another embodiment of the proximal anchoring assembly. In this embodiment, the legs 320 of the proximal anchor 322 attach in a similar manner to the embodiment shown in
Diaphragm Mechanics and Material Properties
In one embodiment, the transducer module distal diaphragm is a relatively thick titanium membrane such that its compliance (defined as the change in displacement of the center portion of the diaphragm per change in unit pressure) is substantially lower than the compliance of the overlying tissue encapsulation thus assuring that the motion of the diaphragm in response to changes in fluid pressure is only minimally reduced by tissue overgrowth. In one embodiment, a 2.5 mm diameter diaphragm is between about 0.001 to 0.003 inches (25 to 76 microns) thick. In another embodiment, the diaphragm thickness is between about 0.003 to 0.005 inches (76 to 127 microns). Diaphragms of this type have relatively low compliance, meaning that they exhibit relatively little strain, or displacement, in response to changes in pressure. For example, in one embodiment, a 2.5 mm diameter by 50-micron thick titanium foil diaphragm has a displacement at its center of only about 4 nm per mm Hg pressure change. One advantage of using a low compliance diaphragm is that tissue overgrowth will minimally affect the relatively reduced range of motion, thus minimizing errors in the sensed pressure reading. Generally, the more non-compliant a diaphragm is, the more sensitive or higher gain the internal transducer components may need to be to maintain the output signal amplitude.
In general, the motion of the center of the diaphragm, assuming uniform diaphragm thickness, small deflections, infinitely rigid clamping around the diaphragm periphery, perfectly elastic behavior and negligible stiffening and mass effects due to presence of strain gauges on the diaphragm, is given by the equation
where: Yc=center deflection (mm), P=pressure (Pa), Ro=diaphragm radius (mm), v=Poisson's ratio (dimensionless), t=diaphragm thickness (mm), and E=modulus of elasticity (Pa).
In one embodiment, the pressure transducer diaphragm is constructed of Ti 6-4 with material properties comprising of approximately Ro=1.1 mm, v=0.31, t=0.05 mm, and E=100 GPa. Such a titanium diaphragm will have very small deflections, about 2.4×10−6 mm/mm Hg. Tissue growth over such a diaphragm can be modeled by the material properties of the aorta where v=0.30, t=0.5 mm (10 times the diaphragm thickness), and E=1 MPa or 100,000 times more elasticity than titanium. Such tissue will be displaced approximated 2.6×10−4 mm/mm Hg, or about 100 times more than the titanium diaphragm. Thus, such tissue overgrowth will inhibit the motion of the titanium diaphragm by less than about 1.0%, thus having a clinically negligible effect on sensor gain over the range of physiologic pressures expected in the left atrium. Halving the diaphragm thickness to about 0.025 would cause similar tissue overgrowth to inhibit the motion of the diaphragm by more than about 7% and, if other adjustments are not made, may cause clinically significant errors over the physiologic range of expected left atrial pressures.
In one embodiment, the pressure transducer membrane is designed to have very low compliance. In one embodiment, a low compliance pressure transducer is fabricated using titanium foil as described above. In another embodiment, a low compliance pressure transducer is fabricated from, for example, silicon, using micro electromechanical systems (MEMS) techniques.
While the effect of tissue overgrowth on sensor gain may be minimized by aspects of this invention described above, the skilled artisan will recognize that any force on the sensor produced by contact with tissue will cause a positive offset in the sensed pressure. If such tissue-contact force is constant, then it will be clear to one skilled in the art that the offset produced thereby may be simply subtracted once its magnitude is determined by comparison of the measured pressure with a known pressure. However, if the tissue-contact force is not constant, a time-varying pressure waveform artifact will be produced. Such may be the case if changes in the stretch or wall tension of the intra-atrial septum produce changes in tissue-contact force on the diaphragm. In embodiment of the invention, the sensor assembly is designed to decouple intra-atrial stretching or tension from the tissue in contact with the diaphragm. As shown in
Implantation Apparatus and Techniques
Many of the embodiments of implantable devices shown and described herein are preferably configured to be deployed via a tubular, flexible delivery catheter that can be guided either alone or over a guidewire to a delivery location within a patient. A delivery catheter for use in delivering and deploying an implantable device preferably comprises an internal diameter that is at least as large as the outer diameter of the distal and proximal anchors in their compressed states. In some embodiments, a delivery catheter can be configured to be sufficiently large in diameter to allow the catheter to be filled with a continuous cylindrical column of fluid surrounding the sensor module and its lead. This advantageously allows for simultaneous monitoring of a fluid pressure at the distal end of the catheter through the continuous fluid column surrounding the anchoring system in the catheter. Such an arrangement would also advantageously allow for the injection of a radiographic contrast medium through the delivery catheter in order to determine the precise location of the catheter tip in the cardiovascular system. The proximal portion of the catheter may contain a hemostatic adaptor to prevent back bleeding through the catheter around the pressure transducer system and to prevent the entrainment of air during transducer insertion and advancement. The skilled artisan will recognize that other embodiments of delivery catheters incorporating additional fluid-carrying lumens can also be used to deliver an implantable anchoring device.
As shown in
The introducer sheath containing the anchor and sensor assembly is then inserted into the proximal end of the delivery catheter, and the introducer sheath is retracted and withdrawn. The anchor assembly is then guided through the delivery catheter 220 (which was previously positioned through the septum wall) until the legs of the distal anchor 110 are positioned at the distal end of the delivery catheter 220, which can be visually verified under fluoroscopy by noting the alignment of the distal radiopaque marker 225 on the distal edge of the delivery catheter 220 with the distal end of the sensor assembly 100. The delivery catheter 220 can be withdrawn while holding the anchor and sensor assembly 100 in place with the stylet 224 that extends through the center of the sensor lead 226. The stylet 224 is preferably configured to provide sufficient column strength to allow the anchor and sensor assembly 100 to be held in place relative to the septum 210 while the catheter 220 is retracted to expose and deploy the distal anchor legs 124, as shown in
In one embodiment, after the distal anchor legs 124 expand to assume their expanded state on a distal side of the septum wall 210, contrast material is injected to assure correct positioning in the left atrium. The catheter 220 is further retracted while holding the stylet 224 and sensor assembly 100 in place until the distal edge of the catheter 220 is coincident with the proximal end of the sensor assemble 100. Further contrast is injected while the entire catheter 220, stylpt 224 and sensor assembly 100 are retracted in 1 to 2 mm increments until contrast material exiting the tip of the catheter 220 is observed on fluoroscopy to exit into the right atrium. At this point further retraction of the catheter 220 will expose the proximal anchor 112, allowing it to relax to its expanded state on a proximal side of the septum wall 210 as shown in
In one embodiment, to facilitate tissue overgrowth, the path lengths for tissue to in-grow over the distal anchor fixated to the left atrial side of the septum is minimized by creating one or more perforations, holes, pores, or slots in the distal anchor legs 124. For example,
Exemplary modes of operation for one embodiment of the invention are described as follows. The following Example illustrates various embodiments of the present invention and is not intended in any way to limit the invention.
In Vivo Studies
Several of the discoveries in this patent application results from the inventor's first hand experience percutaneously implanting transmural pressure transducer and anchor systems with catheter delivery systems similar to those depicted in
After opening the left atrial free wall in the pig sacrificed immediately after implantation it was observed that the diaphragm was coplanar, protruding less than 0.5 mm from the surrounding left atrial surface. The distal anchor was flat against the left side of the septum and the proximal anchor was contacting the right side of the septum. Perturbation of the system along any axis was counterbalanced such that when the perturbation force was relieved, the transducer/anchor system restored itself to the original coplanar position.
For the pig euthanized 3 weeks after transducer deployment, the diaphragm and all 3 legs of the distal anchor were again ideally oriented coplanar with the left atrial wall. It was noted that the location of transmural puncture was somewhat posterior of the thinnest portion and probably made from a non-orthogonal approach. Nevertheless, the device was orthogonally oriented related to its internal restorative force configuration. On the left atrial side of the septum, the transducer diaphragm and the distal anchor legs were entirely covered with a thin, translucent layer of neoendocardium. Histologic sections reveal that the covering tissue was comprised of normal granulation tissue, morphologic smooth muscle cells and fibrocytes without a chronic inflammatory reaction. We obtained ambulatory recordings of the left atrial pressure repeatedly during the 3 week survival. After sacrifice, with the transducer in situ covered with tissue, repeat calibration showed that in comparison to the pre-implantation calibration, there was no change in gain and small change in offset of less than about 2 mm Hg
For the pig euthanized 18 weeks after transducer deployment it was noted again that the location of transmural puncture was somewhat posterior of the thinnest portion and probably made from a non-orthogonal approach. Once again, the device was correctly oriented related to its internal restorative force configuration. On the left atrial side of the septum, the transducer diaphragm and the distal anchor legs were now entirely covered with a much thicker, opaque layer of neoendocardium. Histologic sections reveal that the covering tissue was comprised of fibrous tissue staining positively for collagen and there was no inflammatory reaction. We obtained ambulatory recordings of the left atrial pressure repeatedly during the 18 week survival. As shown in
The apparatus and methods of several embodiments of the present invention may be embodied in other specific forms and for other applications without departing from its spirit or essential characteristics. The described embodiments are to be considered in all respects only as illustrative and not restrictive.
Although certain embodiments and examples have been described herein, it will be understood by those skilled in the art that many aspects of the methods and devices shown and described in the present disclosure may be differently combined and/or modified to form still further embodiments. Additionally, it will be recognized that the methods described herein may be practiced using any device suitable for performing the recited steps. Such alternative embodiments and/or uses of the methods and devices described above and obvious modifications and equivalents thereof are intended to be within the scope of the present disclosure. Thus, it is intended that the scope of the present invention should not be limited by the particular embodiments described above, but should be determined only by a fair reading of the claims that follow.
Additionally, the skilled artisan will recognize that the embodiments of anchoring devices and methods described herein may be advantageously applied for implanted pressure transducers transmurally positioned on, in or through a wall of any organ or vessel within a patient. It will also be apparent to one skilled in the art that the field of use of the embodiments of devices and methods described herein extends beyond the specific condition of heart failure to any cardiovascular condition or other condition in a medical patient where a device is implanted through a wall of a chamber or vessel or is affixed to a wall of that chamber of vessel.
The present application is a continuation of co-pending U.S. application Ser. No. 11/______, [Attorney Docket No. SAVCOR.003CP1 titled IMPLANTABLE PRESSURE TRANSDUCER SYSTEM OPTIMIZED FOR REDUCED THROMBOSIS EFFECT] filed Apr. 21, 2005, which 1) claims priority under 35 U.S.C. §119(e) to U.S. Provisional Application No. 60/564,315 filed Apr. 22, 2004, and 2) is also a continuation-in-part of co-pending U.S. application Ser. No. 10/672,443 filed Sep. 26, 2003, which claims priority under 35 U.S.C. § 119(e) to U.S. Provisional Application No. 60/413,758 filed Sep. 26, 2002, the disclosures of which are incorporated by reference herein in their entirety.
| Number | Date | Country | |
|---|---|---|---|
| 60564315 | Apr 2004 | US | |
| 60413758 | Sep 2002 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 11111691 | Apr 2005 | US |
| Child | 11115991 | Apr 2005 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10672443 | Sep 2003 | US |
| Child | 11115991 | Apr 2005 | US |
