Patent Grant
7896915
This invention relates to a medical device for treating a heart valve insufficiency, with an endoprosthesis which can be introduced into a patient's body with minimal invasion and automatically expanded in order to position and secure a heart valve prosthesis in the patient's aorta, which endoprosthesis has at least three positioning arches for automatically positioning the medical device in the patient's aorta and a retaining segment with retaining arches for accommodating a heart valve prosthesis, and the endoprosthesis assumes a first pre-definable mode during the process of introducing it into the patient's body and a second pre-definable mode in the state when the medical device is implanted, and when the medical device is in a collapsed state when the endoprosthesis is in the first mode and in an expanded state when the endoprosthesis is in the second mode.
The operating principle of such a device is known from medical technology. Biological or mechanical valve models are currently available as a means of replacing human heart valves, which are securely stitched in the heart valve base through an opening in the thorax during surgery once the diseased heart valve has been removed. In order to undertake this intervention, the patient's circulation must be supported by a heart and lung machine and the heart is arrested whilst the heart valve prosthesis is being implanted. This is a risky surgical intervention which places the patient at risk accordingly and which involves a long post-operative phase of treatment. In multi-morbid patients in particular, the risk of carrying out such intervention is no longer justifiable.
In more recent times, treatment methods which are minimally invasive have been developed, which are distinctive due to the fact that the intervention can be carried out with a local anaesthetic. This option is based on the use of a self-expanding stent with a collapsible heart valve prosthesis, which is implanted in the human body by means of an appropriate catheter system. A self-expanding heart valve prosthesis of this type can be fed by means of a catheter system through a main artery or vein to the implantation site at the heart. Once the implantation site is reached, the stent, which is made up of several self-expanding stent segments which can be angled relative to one another, is successively unfolded. Once unfolded, the heart valve prosthesis can be anchored in the respective blood vessel at least in the vicinity of the heart with the assistance of anchoring hooks for example. The actual heart valve prosthesis is then disposed directly in the proximal region of the stent or endoprosthesis.
Patent publication DE 100 10 074 A1, for example, discloses a device for securing and anchoring heart valve prostheses, which essentially comprises shaped wire elements connected to one another. In this instance, different arches are used as a means of reliably securing and anchoring the heart valve prosthesis. To this end, the device described in this specification has three identical pairs of arches respectively disposed at a distance of 120° apart. These arches are connected to one another by fixed body joints, and the fixed body joints assume the function of pivot bearings. Arches bent in the opposite direction are also provided, which form lever arms which are of identical length as far as possible, to enable a reliable seating of the arches, even in the event of peristaltic movements of the heart and blood vessel, and afford a reliable seal for an implanted and secured heart valve prosthesis.
With the known solution, however, there is still a risk of heart valves being incorrectly implanted. In particular, this is attributable to the fact that the heart valve prosthesis must be exactly positioned and longitudinally oriented. In particular, it requires enormous skill on the part of the surgeon performing the treatment—if it is possible at all—to position a stent which has a heart valve prosthesis at its proximal end and to do so accurately enough in the vicinity of the patient's diseased heart valve to ensure both correct lateral positioning accuracy and a correct longitudinal position of the heart valve prosthesis as far as possible.
Amongst other things, incorrect implantation of a heart valve prosthesis that is not optimally positioned can lead to inadequate sealing or valve insufficiency, which places considerable stress on the ventricle. If a heart valve prosthesis is implanted too far above the actual heart valve plane, for example, this can cause the outlets of the coronary vessels (coronaries) to close, thus leading to fatal coronary ischaemia due to heart infarction. This being the case, it is absolutely vital that both the lateral positioning accuracy and longitudinal positioning accuracy of a heart valve prosthesis meet requirements.
In the case of conventional implantation techniques whereby self-expandable heart valve prostheses are fed to the implantation site at the heart through a main artery of the patient requiring minimal invasion, for example, the prosthesis is usually introduced by means of a guide wire and with the aid of catheters, in which case it is standard practice to use a balloon catheter for this intervention. Although it is possible to monitor and control the introduction process during such an intervention, for example with the aid of an X-ray system (heart catheter laboratory=HCL) or with the aid of ultrasound (trans-oesophageal echocardiagram=TEE), the heart valve prosthesis is still of relatively large dimensions in spite of being collapsed whilst it is being introduced and it is often not possible to obtain the required positioning accuracy due to restricted ability to manoeuvre, and in particular to ensure correct longitudinal positioning of the heart valve prosthesis to be implanted with the fixing elements attached to it accordingly. Especially if there is a risk that the coronary vessels might close, implanting the heart valve prosthesis in a position angularly offset from the optimum implantation site represents a particular risk for the patient.
When designing a heart valve prosthesis, allowance must specifically be made for the considerable forces which act on the prosthesis, including during the filling phase of the heart cycle (diastole), and reliable anchoring is necessary in order to prevent the implanted heart valve prosthesis from becoming detached.
Accordingly, it must be possible to manoeuvre the heart valve prosthesis in the relevant access vessel as efficiently as possible during the implantation process in order to ensure optimum positioning accuracy on the one hand, and on the other hand, the implanted heart valve prosthesis must be firmly anchored at the implantation site in order effectively to prevent the prosthesis from shifting subsequently.
The underlying problem addressed by this invention is the fact that known devices used for the transvascular implantation of heart valve prostheses are often not suitable for implanting a heart valve prosthesis easily to the required degree of positioning accuracy. Furthermore, until now, it has only been possible to correct an incorrectly positioned heart valve prosthesis that has already been partially implanted with great difficulty—if at all.
Against this background, the objective of the invention is to improve a medical device for treating heart valve insufficiency of the type outlined above so that maneuvering of the device is optimised during the implantation process on the one hand, and whilst achieving optimum positioning accuracy and anchoring of the implanted heart valve prosthesis on the other hand, thereby permitting a routine treatment of heart valve insufficiency without subjecting the patient to excessive stress.
This objective is achieved by means of a medical device of the type outlined above due to the fact that the endoprosthesis of the medical device is of an integral structure cut from a metal tube, and every end portion of the positioning arch at the distal end of the endoprosthesis is joined to the terminal portion of the associated retaining arch.
Accordingly, a medical device is proposed which essentially comprises a self-expandable endoprosthesis (hereafter referred to simply as stent), and this stent has a valve-supporting retaining segment for accommodating a heart valve prosthesis. The stent design is distinctive due to the fact that at least three positioning arches are provided, which project radially outwards and are open when the endoprosthesis assumes the second pre-definable mode, in which the original (old) heart valves of the heart valve to be replaced engage, thereby resulting in an automatic fixing and positioning of the medical device as regards the axial rotation on the one hand and the horizontal position on the other hand.
Since the endoprosthesis (stent) of the medical device has an integral structure cut from a metal tube incorporating the positioning arches on the one hand and the retaining segment with the retaining arches on the other hand, the endoprosthesis and hence also the medical device can be made particularly inexpensively and in large numbers. Specifically, it would be conceivable to cut the stent structure from a metal tube by means of a laser, after which the structure is subjected to an appropriate shaping and heat treatment process so that the endoprosthesis and hence also the medical device can be transferred from the collapsed sate during implantation to the expanded state at the implantation site. This shaping and heat treatment process is advantageously operated in steps in order to prevent damage to the stent structure.
Since the endoprosthesis of the medical device is of an integral structure cut from a metal tube as proposed by the invention and a retaining arch is associated with every positioning arch and every end portion of the positioning arch at the distal end of the endoprosthesis is joined to the terminal portion of the associated retaining arch, there is no need to provide fixed body joints or similar connecting devices. On the other hand, the endoprosthesis of the medical device proposed by the invention is a stent which, on the one hand, offers a positioning function due to the positioning arches with a minimal longitudinal extension and, on the other hand, offers a function of retaining a heart valve prosthesis due to the retaining arches.
As will be seen, when transferring the endoprosthesis from the first pre-definable mode to the second pre-definable mode by widening the cross-section of the entire stent, the retaining arches on the one hand and the positioning arches on the other hand are opened out in the radial direction. The second mode of the endoprosthesis is advantageously selected so that as the retaining and positioning arches open up, they hit against the vessel wall of the aorta and form a positive connection with it, thereby anchoring the medical device firmly at the implantation site.
Due to the fact that the structure of the endoprosthesis imparts a particularly short shape to the medical device, the medical device is particularly easy to manoeuvre in the collapsed state, which is of particular advantage if the implantation route to the heart valve to be replaced leads through the arch of the aorta. The minimum length of the medical device is made possible in particular by the special structure of the endoprosthesis due to the fact that every end portion of the positioning arch at the distal end is joined to the end portion of the associated retaining arch, and both the positioning arch and the retaining arch extend to the proximal retaining region of the medical device or endoprosthesis. The retaining segment for accommodating the heart valve prosthesis therefore lies at the proximal retaining region of the endoprosthesis.
Advantageous embodiments of the medical device are specified in the dependent claims, especially as regards the endoprosthesis (stent).
In one particular embodiment of the endoprosthesis used with the medical device proposed by the invention, every positioning arch and its associated retaining arch is respectively of an essentially U-shaped or V-shaped structure, which is closed towards the proximal end of the endoprosthesis. By particular preference, every positioning arch is cut from the material blank of the metal tube which is accommodated by the essentially U-shaped or V-shaped structure of the associated retaining arch. In this preferred embodiment of the stent structure, therefore, the respective retaining arches of the retaining segment form the proximal retaining region of the endoprosthesis and the respective positioning arches are of a design symmetrical with the retaining arches but lie slightly in front of the distal retaining region of the medical device. The respective distal ends of the positioning arches are joined to the respective distal ends of the co-operating retaining arches in the distal retaining region of the medical device or endoprosthesis. When the medical device is in the expanded state, not only the proximal retaining region with the heart valve prosthesis fitted to it and the positioning arches disposed between the proximal and the distal retaining regions of the medical device open out, but also the joining points between the respective positioning arches and retaining arches at the distal end of the medical device, so that a radially acting force is also applied to the vessel wall via the distal retaining region of the medical device, which further assists anchoring of the medical device at the implantation site.
Since the medical device is in a (an expanded) state in which the distal and proximal retaining region as well as the positioning arches are radially opened out when the endoprosthesis assumes the second mode, the expanded medical device has as shorter length than it does in its collapsed state. To enable the length of the medical device in its expanded state to be set beforehand, it would be conceivable to connect the respective distal end portions of the positioning arches to the distal end portions of the associated retaining arches using a connecting web extending essentially in the longitudinal direction of the endoprosthesis rather than directly. The length of the medical device in the expanded state can therefore be adapted by selecting the length of this connecting web accordingly. However, it is preferable, especially with a view to ensuring good manoeuvrability of the medical device during the implantation process, i.e. when the endoprosthesis is in its first (collapsed) mode, if the connecting web between the respective end portions of the positioning arches and retaining arches is selected so that it is as short as possible.
In one particularly preferred embodiment of the medical device, the endoprosthesis has other fixing means at its distal end, which can be engaged with an introduction catheter system. In a preferred embodiment of the fixing means, it would be conceivable for the latter to have a respective anchoring eye disposed between two adjacent positioning arches, in which case the respective arms of the adjacent positioning arches on the one hand and the respective arms of the retaining arches associated with the adjacent positioning arches on the other hand are connected to the anchoring eye. It would likewise be conceivable for the respective arms of the adjacent positioning arches to be directly and the respective arms of the retaining arches associated with the adjacent positioning arches to be indirectly connected via a connecting web extending essentially in the longitudinal direction of the endoprosthesis. Generally speaking, the purpose of the fixing means provided on the distal end of the endoprosthesis is to accommodate appropriate mechanisms on the introduction catheter system and these mechanisms are of a design complementing that of the fixing means of the endoprosthesis. The engagement between the catheter system on the one hand and the fixing means on the distal end of the endoprosthesis on the other hand can be released by means of an external manipulation in order to release the medical device at the implantation site, thereby ensuring that the medical device expands and is thus reliably anchored. Naturally, however, other fixing means could also be used.
As mentioned above, because of the special structure of the endoprosthesis, it is possible to use a self-expandable medical device which is distinctive due to its short overall length in the collapsed state, thereby ensuring improved manoeuvrability during the implantation process, whilst simultaneously affording a self-positioning function in the pockets of the old heart valve with the aid of the positioning arches so that the endoprosthesis is reliably anchored by the proximal and distal retaining regions of the endoprosthesis pressing radially against the vessel wall in the expanded state.
As an alternative to the preferred embodiment of the medical device outlined above, in which the respective arms of the adjacent positioning arches are joined directly and the respective arms of the retaining arches associated with the adjacent positioning arches are joined indirectly to the fixing eye by means of a connecting web extending essentially in the longitudinal direction of the endoprosthesis, it would however also be conceivable for the respective arms of the adjacent positioning arches to be joined to the fixing eye indirectly via a connecting web extending essentially in the longitudinal direction of the endoprosthesis, in which case the respective arms of the retaining arches associated with the adjacent positioning arches are joined to the fixing eye indirectly via a connecting web extending essentially in the longitudinal direction of the endoprosthesis, and the connecting web of the retaining arches merges into the connecting web of the positioning arches at the end portion of the positioning arches. Providing the respective connecting webs for connecting the arms of the positioning arches to the fixing eye and for connecting the arms of the retaining arches to the end portion of the positioning arches offers a particularly simple but effective way of adapting the length of the endoprosthesis to respective requirements and does so because the respective lengths of the connecting webs can be selected accordingly.
In a preferred embodiment of the solution proposed by the invention, in order to ensure that the distal retaining region of the endoprosthesis can be retained at the implantation site in its expanded state particularly reliably, the endoprosthesis is provided with fixing eyes or similar at its distal retaining region, and these fixing eyes, which are preferably disposed between two adjacent positioning arches, are respectively provided with at least one barb, the tip of which points in the direction of the proximal end of the endoprosthesis. In this preferred embodiment, therefore, the endoprosthesis is secured at the implantation site due to the radial force exerted on the vessel wall by the endoprosthesis and in particular by the distal retaining region of the endoprosthesis, but also due to the barb hooking into the vessel wall. As regards the barb, it would naturally also be possible to use other appropriate design options.
As an alternative to or in addition to the barbs, which are preferably provided on the fixing eyes, another conceivable way of securing the endoprosthesis reliably at the implantation site is for the respective arms of the retaining arches of the endoprosthesis to be respectively provided with an anchoring support in the shape of a bow, which projects out from the relevant arm of the retaining arch when the endoprosthesis is in the expanded state, the tip of which points in the direction of the distal end of the endoprosthesis. This embodiment therefore provides additional fixing means for the endoprosthesis and accordingly additionally secures the medical device to prevent it from becoming dislocated.
In a preferred embodiment of the anchoring support, it would be conceivable for the anchoring support to be of an essentially U-shaped or V-shaped structure which is closed at the distal end of the endoprosthesis or the distal end of the medical device, in which case the distal region of the anchoring support constitutes the tip of the anchoring support and the respective arms of the anchoring support are joined to the respective arms of two adjacent retaining arches at the proximal end of the anchoring support.
Alternatively, in another preferred embodiment, the respective arms of the retaining arches have continuous slots or elongate holes extending in the longitudinal direction of the retaining arches, the purpose of which is to enable and assist the expansion of the endoprosthesis from the collapsed state into the expanded state because these slots or elongate holes are preferably designed to permit a particularly easy cross-sectional expansion of the stent (endoprosthesis) whilst simultaneously reducing the length. Such slots or elongate holes have the additional advantage of saving on material.
In the case of the latter embodiment in which the respective retaining arches incorporate slots extending in the longitudinal direction of the retaining arches designed to influence the shape of the endoprosthesis in the second mode, it would be conceivable for the respective retaining arches to be additionally provided with reinforcing portions which interrupt the slots extending in the longitudinal direction of the retaining arches and which prevent components of the retaining arches from projecting outwards when the endoprosthesis is in the expanded state, which is of particular advantage in preventing explanation of the medical device.
In a preferred embodiment, the endoprosthesis has an external diameter of approximately 5.0 mm and a length of between 33.0 mm and 40.0 mm, preferably between 34.0 and 39.0 mm, and even more preferably between 34.37 mm and 38.37 mm, in its first mode, which means that the medical device can be introduced by means of a 21 F introduction system, for example, and heart valve prostheses with a diameter of 21 mm to 28 mm may be used. The length specifications given above are currently preferred values, on the basis of which the medical device is suitable for the majority of patients to be treated.
In order to obtain a particularly reliable anchoring of the implanted medical device in its expanded state, the endoprosthesis is subjected to a shaping and heat treatment process during its manufacture so that when the endoprosthesis is in the finished state, it has a slightly concave shape tapering in the direction of the proximal retaining region of the endoprosthesis in its second mode.
In other words, this means that the proximal retaining region of the endoprosthesis, i.e. the region to which the heart valve prosthesis is attached, has a slightly narrower diameter than the distal retaining region. It has effectively been found that if the distal retaining region of the endoprosthesis in the second mode has an approximately 10% to 25% bigger diameter than the proximal retaining region of the endoprosthesis, radial forces are generated at the distal retaining region of the endoprosthesis in particular which enable the medical device to be securely retained in the vessel without causing damage to the vessel wall, and due allowance is also made for the peristaltic movements of the heart and vessel wall. The slightly lower radial force expended by the proximal retaining region of the endoprosthesis not only serves as a means of anchoring the medical device in the aorta but in particular also opens out the heart valve prosthesis fitted on the proximal retaining region of the endoprosthesis and imparts to it a reliable seal with respect to the vessel wall. Naturally, however, it would also be conceivable for the concave shape to be more or less pronounced when the endoprosthesis assumes the second mode.
In particular, however, it is preferable if the retaining region of the endoprosthesis has a diameter of between 22 mm and 33 mm, and preferably between 25 mm and 31 mm, in the second mode. This being the case, it would be conceivable for the endoprosthesis to be made in two or more differently dimensioned sizes, in which case an optimum size of endoprosthesis could be selected depending on the patient, and the exact dimensions of the endoprosthesis are adapted to the patient to be treated—starting from a pre-defined stent size—by an appropriate finishing treatment of the endoprosthesis (stent), in particular by tempering.
In one, particularly preferred embodiment of the medical device, not only does it have the endoprosthesis (stent) but also a heart valve prosthesis, preferably a bio-heart valve prosthesis, which is attached to the retaining segment of the endoprosthesis by means of a thread or similar, in which case orifices are provided in the retaining arches of the endoprosthesis through which the thread or similar is inserted. Accordingly, it would also be conceivable for the heart valve prosthesis to be connected to the retaining segment of the endoprosthesis immediately prior to the medical intervention. As a result, the medical device can be made in a modular design, which is of particular advantage in terms of transporting and storing the medical device.
As regards the preferred material used for the endoprosthesis of the medical device, a shape memory material is used, which is designed so that the endoprosthesis is transformed from a temporary shape to a permanent shape by means of an external stimulus, in which case the endoprosthesis assumes the temporary shape in the first mode (when the medical device is in the collapsed state) and the endoprosthesis assumes the permanent shape in the second mode (when the medical device is in the expanded state). Especially if a shape memory material such as Nitinol is used, i.e. an equal atomic alloy of nickel and titanium, the implantation process will be particularly gentle during the operation of implanting the medical device.
During production of an endoprosthesis made from a shape memory material, after the stent structure has been cut from the metal tube, it is deformed and fixed in the desired permanent shape, a process which is known as programming. This operation may be performed on the one hand by heating, deforming and then cooling the stent structure. Alternatively, the stent structure may also be deformed at low temperature by an operation known as cold stretching. As a result, the permanent shape is memorised whilst the temporary shape actually prevails. If the stent structure is then subjected to an external stimulus, the shape memory effect is triggered and the memorised permanent shape is restored.
In a particularly preferred embodiment, the external stimulus is a settable switching temperature. It is therefore conceivable for the endoprosthesis material to be heated to a temperature higher than the switching temperature in order to trigger the shape memory effect and thus restore the memorised permanent shape of the endoprosthesis. By selecting the chemical composition of the shape memory material accordingly, a specific switching temperature can be fixed beforehand.
This being the case, the switching temperature is set so that it falls within the range of room temperature and the body temperature of the patient. This is of particular advantage in applications where the medical device is to be implanted in a patient's body. Accordingly, when implanting the medical device, it is merely necessary to ensure that the instrument is not heated and thus triggers the shape memory effect of the endoprosthesis material until it is in the implanted state on the patient's body (36° C.).
Preferred embodiments of an endoprosthesis of a medical device proposed by the invention will be described in more detail below with reference to the appended drawings.
Of these:
a illustrates a first, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first predefined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d shows a first, preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the first, preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a second, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates a second preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the second preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a third, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates a third preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the third preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a fourth, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates a fourth preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the fourth, preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a fifth preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates a fifth preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the fifth, preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a sixth preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates a sixth preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the sixth, preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a seventh, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates a seventh preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the seventh preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows an eighth, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b shows the endoprosthesis illustrated in
c shows the endoprosthesis illustrated in
d illustrates an eighth preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis of the type illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the eighth preferred, self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a shows a ninth, preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention in its first, pre-determined mode in which the medical device is in its collapsed state;
b is a perspective side view of a connecting web between an end portion of a positioning arch and an end portion of an associated retaining arch of the endoprosthesis illustrated in
c is a perspective side view of a positioning arch and the associated retaining arch of the endoprosthesis illustrated in
d is a perspective plan view of the distal region of the endoprosthesis illustrated in
e is a flat projection of a cutting pattern which can be used for the production of the ninth preferred embodiment of the self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
a is a schematic view intended to illustrate one possible implantation operation of the medical device proposed by this invention; and
b is a schematic view of the medical device proposed by the invention in the implanted state.
A first preferred embodiment of the self-expandable endoprosthesis 1 for the medical device proposed by the invention will be described first of all with reference to
The endoprosthesis 1 based on the first preferred embodiment is distinctive due to the fact that it has a structure which is cut integrally from a metal tube. The cutting pattern used to produce the stent design is illustrated in a flat projection in
The head portions 12 of the positioning arches 10 pointing respectively towards the proximal end 3 of the endoprosthesis 1 are appropriately rounded so that the vessel wall is not damaged when the positioning arches 10 engage in the pockets of the heart valve to be replaced. Extending from the head portion 12 of the positioning arch 10 to the distal end 2 of the endoprosthesis 1 are two positioning webs or arms 11 in total for each positioning arch 10, which merge into an eye-shaped element 30 at the distal end 2 of the endoprosthesis 1. This eye-shaped element 30 serves as a fixing means for attaching the endoprosthesis 1 and hence the medical device to an introduction catheter system.
Specifically, the respective fixing eyes 30 are disposed between the two arms 11 of two mutually adjacent positioning arches 10. Opening into the transition portion 13 between the two arms 11 of two mutually adjacent positioning arches 10 incorporating the fixing eye 30 is a connecting web 15 extending essentially in the longitudinal direction of the endoprosthesis 1. At the proximal end, the connecting web 15 merges into the respective retaining arms 21 of two mutually adjacent retaining arches 20.
As a result of this stent design, an axially symmetrical structure is obtained, whereby a retaining arch 20 is associated with each positioning arch 10. The endoprosthesis 1 in the preferred embodiment illustrated in
When the endoprosthesis 1 is in the state illustrated in
Particular attention should be paid to
As may be seen by comparing
d illustrates a first preferred embodiment of the medical device proposed by the invention in its expanded state, with an endoprosthesis 1 of the type illustrated in
Although the force exerted by the retaining arches 21 in the radial direction onto the vessel wall causes the medical device to be secured at the implantation site to a certain extent, the distal retaining region 2 is expanded by a further 10% to 25% in the radial direction than is the case at the proximal retaining region 3 of the endoprosthesis 1 when the medical device is in the expanded state in order to obtain a permanently stable implantation of the medical device, especially in view of the unavoidable peristaltic movement of the vessel wall and the relatively high fluid pressures which prevail. As a result, a slightly concave shape is imparted to the endoprosthesis 1, which tapers in the direction of the proximal retaining region 3 of the endoprosthesis 1, thereby ensuring that the medical device is firmly anchored in the vessel due to the distal retaining region 2 of the endoprosthesis 1 pressing against the vessel wall.
In the embodiment illustrated, the respective arms 21 of the retaining arches 20 have uninterrupted slots or elongate holes 24, the purpose of which is to enable or assist expansion of the endoprosthesis 1 from the collapsed state into the expanded state, because these slots or elongate holes 24 make it easy to widen the cross-section of the stent 1 whilst simultaneously reducing its length. Naturally, however, it would also be conceivable for these slots or elongate holes 24 to accommodate a thread 41 or similar used to attach the heart valve prosthesis 40 (illustrated in
The solution proposed by the invention is a medical device of a modular design essentially comprising the two separately manufactured components, endoprosthesis 1 and heart valve prosthesis 40, and the endoprosthesis 1 assumes the function of positioning and securing the heart valve prosthesis 40 in the patient's aorta. It may be preferable if the two components (endoprosthesis 1 and heart valve prosthesis 40) are not connected to one another until immediately prior to performing the surgical intervention; this is of advantage in terms of transporting and storing the endoprosthesis 1 as such since the endoprosthesis 1 is a relatively robust component from a mechanical point of view and in particular can be stored for a longer period. This applies in particular if the endoprosthesis 1 is stored in its second mode, i.e. in the expanded state, and is not switched to its first (collapsed) mode until immediately prior to undertaking the surgical intervention.
The state of the endoprosthesis 1 illustrated in
When the medical device is being implanted, it would therefore be conceivable for the medical device to be cooled accordingly during the introduction process. When the medical device has been moved to the desired implantation site, in other words in front of the native heart valve, preferably by means of an appropriate introduction system, cooling can be interrupted so that the endoprosthesis 1 of the medical device is heated to the body temperature (36° C.) of the patient, thereby triggering the shape memory effect of the endoprosthesis material. Having triggered the self-expanding property of the endoprosthesis 1, radial forces are generated which act on the individual components of the endoprosthesis 1 and in particular on the respective positioning arches 10, 11 and retaining arches 20, 21 of the endoprosthesis 1. Since the endoprosthesis 1 of the medical device is still disposed in the introduction catheter system as before, the radial forces which build up once the critical switch temperature is exceeded and act on the individual components of the endoprosthesis 1 are still compensated by the introduction port of the introduction catheter system so that—in spite of the shape memory effect having been triggered—the endoprosthesis 1 of the medical device is forcibly retained in its first (collapsed) mode.
By releasing the endoprosthesis 1 from the introduction catheter system in appropriate steps, it is then possible to release the positioning arches 10, 111 of the endoprosthesis 1 through the introduction port of the introduction catheter system first, as a result of which it opens up due to the radial forces acting in the radial direction. The opened positioning arches 10, 11 can then be positioned in the pockets of the native heart valve.
The remaining components of the endoprosthesis 1 and the medical device can then be released through the introduction port of the introduction catheter system. As this happens, the retaining arches 20, 21 open in the radial direction and the heart valve prosthesis 40 attached to the retaining arches 20, 21 by means of a thread 41, etc., for example, thus unfolds in the manner of an umbrella. The radial forces acting on the retaining arches 20, 21 but also on the distal retaining region 2 of the endoprosthesis 1 cause the endoprosthesis 1 to be pressed in the radial direction against the vessel wall, which guarantees a reliable anchoring of the medical device at the implantation site on the one hand and ensures a reliable seal of the heart valve prosthesis 40 at the proximal retaining region 3 of the endoprosthesis 1 on the other hand.
a to 2c illustrate a second preferred embodiment of a self-expandable endoprosthesis 1 for the medical device proposed by the invention in its first, pre-definable mode (see
d illustrates a second preferred embodiment of the medical device proposed by the invention in its expanded state with an endoprosthesis of the type illustrated in
The endoprosthesis 1 based on the second preferred embodiment essentially corresponds to the first preferred embodiment described above with reference to
The third preferred embodiment of a self-expandable endoprosthesis for the medical device proposed by the invention illustrated in
d illustrates a third preferred embodiment of the medical device proposed by the invention in its expanded state with an endoprosthesis of the type illustrated in
A flat projection of a cutting pattern which may be used for the production of the third preferred embodiment of the self-expandable endoprosthesis 1 is illustrated in
a to
The fourth preferred embodiment of the self-expandable prosthesis 1 corresponds to a combination of the second and third preferred embodiments described above. Specifically, the respective arms 11 of the adjacent positioning arches 10 are indirectly joined via the connecting web 16 extending essentially in the longitudinal direction of the endoprosthesis to the fixing eye 30, whilst barbs 17 are provided on the respective fixing eyes 30, the tips of which point in the direction of the proximal end 3 of the endoprosthesis 1. The advantages which can be achieved as a result of the features provided on the fourth preferred embodiment were described above and will not be reiterated at this stage.
The fifth preferred embodiment of a self-expandable endoprosthesis 1 and a medical device proposed by the invention illustrated in
e illustrates a flat projection of a cutting pattern which may be used for production of the fifth preferred embodiment of the self-expandable endoprosthesis 1 in order to cut the endoprosthesis 1 illustrated in
The sixth preferred embodiment of the self-expandable endoprosthesis and the medical device proposed by the invention illustrated in
The seventh preferred embodiment of the endoprosthesis 1 and the medical device proposed by the invention illustrated in
The eighth preferred embodiment of the self-expandable endoprosthesis and the medical device proposed by the invention illustrated in
The ninth preferred embodiment of the self-expandable endoprosthesis for the medical device proposed by the invention illustrated in
e illustrates a flat projection of a cutting pattern which may be used to produce the ninth preferred embodiment of the self-expandable endoprosthesis in order to cut the endoprosthesis illustrated in
Unlike the first embodiment, the respective head portions 12 of the positioning arches 10 pointing towards the proximal end 3 of the endoprosthesis are of a slightly wider design at the proximal end in the ninth embodiment of the endoprosthesis 1. Although the head portions 12 of the positioning arches 10 have a slightly rectangular in shape compared with the first embodiment, all the respective corners of the head portions 12 are rounded so that the vessel wall is not damaged when the positioning arches 10 engage in the pockets of the heart valve to be replaced. The advantage of the slightly wider design of the head portions 12 of the positioning arches 10 is that the positioning arches 10 can be placed in the pockets of the native heart valve with the smallest possible clearance during the implantation operation, thereby enabling even more accurate positioning of the medical device at the implantation site.
As with the embodiments described above, a total of two positioning webs or arms 11 extend from the head portion 12 of the positioning arches 10 to the distal end 2 of the endoprosthesis 1 for every positioning arch 10 in the ninth embodiment of the endoprosthesis 1, which merge at the distal end 2 of the endoprosthesis 1 into an eye-shaped element 30. This eye-shaped element 30 serves as a fixing means for attaching the endoprosthesis 1 and hence the medical device to an introduction catheter system.
Specifically in the case of the ninth embodiment of the endoprosthesis 1, the respective fixing eyes 30 are disposed between the two arms 11 of two mutually adjacent positioning arches 10. The connecting web 15 extending essentially in the longitudinal direction of the endoprosthesis 1 opens into the transition portion 13 between the two arms 11 of two mutually adjacent positioning arches 10 where the fixing eye 30 is formed. At the proximal end of the connecting web 15, the latter merges into the respective retaining arms 21 of two mutually adjacent retaining arches 20. This design is illustrated particularly clearly in
By contrast with the embodiments described above, the respective retaining arms 21 of the retaining arches 20 on the transition portion 23 between the two arms 21 of two mutually adjacent retaining arches 20 are not provided with slots or elongate holes 24 in the ninth embodiment of the endoprosthesis 1. Due to the fact that only one arm web 21 actually opens into the transition portion 23 between the two arms 21 of two mutually adjacent retaining arches 20 for each retaining arch, there are advantageously no components belonging to the retaining arches 20 which project out from the respective retaining arches 20 in the radial direction when the endoprosthesis 1 is in the expanded state (see
Although the ninth embodiment of the endoprosthesis 1 does not have slots or elongate holes 24 at the respective transition portions 23 between the two arms 21 of two mutually adjacent retaining arches 20, the respective retaining arms 21 of the endoprosthesis 1 have reinforcing portions 26, which are respectively provided on portions of the retaining arms 21 that are not congruent with the transition portions 23 between the two arms 21 of two mutually adjacent retaining arches 20.
The endoprosthesis 1 illustrated in
The endoprosthesis 1 illustrated in
A more detailed description will be given below with reference to
The medical device proposed by the invention, and in particular the endoprosthesis 1 with the heart valve prosthesis 40 contained in it, is designed to be introduced into the patient's body either backwards or transapically, i.e. coming from the heart apex, via a special catheter, positioned percutaneously orthotopically in vivo and assume the function of an insufficient or narrowed heart valve.
In the case of the implantation route illustrated in
Alternatively, a special catheter system can be pushed transapically from the heart apex through the left ventricle to the aortal valve, where a similar implantation of the endoprosthesis 1 with the heart valve prosthesis 40 is possible using a catheter tube modified accordingly.
As the special catheter system is being fed forwards, the medical device is preferably appropriately cooled, for example by rinsing the special catheter system with an appropriate coolant, such as a salt solution. When the medical device has been moved forward to the desired implantation site, cooling is interrupted, as a result of which the endoprosthesis 1 of the medical device is warmed to the body temperature (36° C.) of the patient, thereby triggering the shape memory effect of the endoprosthesis material.
Due to the triggering of the self-expanding property of the endoprosthesis 1, radial forces develop which act on the individual components of the endoprosthesis 1 and in particular on the respective positioning arches 10, 11 and retaining arches 20, 21 of the endoprosthesis 1. Since the endoprosthesis 1 of the medical device is still disposed in the introduction catheter system as before, the radial forces which develop once the critical switching temperature is exceeded and act on the individual components of the endoprosthesis 1 are still compensated by the introduction port of the introduction catheter system so that—in spite of the shape memory effect having been triggered—the endoprosthesis 1 of the medical device is forcibly held in its first (collapsed) shape.
By releasing the endoprosthesis 1 from the introduction catheter system in appropriate steps, the positioning arches 10, 11 of the endoprosthesis 1 are then moved out though the introduction port of the introduction catheter system. The positioning arches 10, 11 open out due to the radial forces acting in the radial direction. The opened positioning arches 10, 11 are then positioned in the pockets 50 of the native heart valve 51.
The other components of the endoprosthesis 1 and the medical device are then released through the introduction port of the introduction catheter system. As illustrated in
When the medical device is in the implanted state illustrated in
As may specifically be seen from
The system is afforded additional mechanical support and reliable anchoring can also be achieved by providing barbs 17 on the fixing eyes 30 disposed at the distal retaining region 2 of the endoprosthesis 1 and/or by appropriate anchoring supports 25. When the endoprosthesis 1 is in the expanded state, the anchoring supports 25 stand proud of the co-operating arm 21 of the retaining arches 20, and their tips point in the direction of the distal end 2 of the endoprosthesis 1.
In principle, the special design of the endoprosthesis 1 offers the possibility of gripping the endoprosthesis 1 subsequently by means of the fixing eyes 30 and collapsing the medical device by the longitudinal extension of the endoprosthesis 1 so that the medical device can be removed from the patient's body again by means of a catheter tube.
Due to the modular integration of retaining elements (fixing eyes) on the self-expandable endoprosthesis 1, it can also be explanted again by means of a special catheter once it has been implanted. To this end, the distal retaining region 2 of the endoprosthesis 1 is pulled into a catheter by several retaining points using guide wires. This being the case, in the reverse of the implantation operation, the endoprosthesis 1 is pulled from its expanded state into the collapsed state and released from the anchoring in the pockets of the actual heart valve.
In summary, it remains to be said that the solution proposed by the invention is based on a metal endoprosthesis 1 with a heart valve prosthesis which can be stitched to it or is stitched to it, designed for use in treating diseases of the heart valve which make replacement of the old heart valve necessary. The heart valve stent 1 (endoprosthesis) may be introduced in the inverted position and thus positioned orthotopically in vivo percutaneously and assume the function of the insufficient or defective native heart valve. The radial forces created due to the self-expanding property of the endoprosthesis 1 guarantee reliable anchoring in the region of the aorta.
Specifically, a medical instrument comprising an endoprosthesis 1 for positioning and securing a heart valve prosthesis in the aorta of the patient is described, and a specially developed endoprosthesis 1 made from a base of Nitinol is provided as a means of accommodating a heart valve prosthesis for implantation in the aorta. The ready-to-use medical device proposed by the invention consists of the components comprising the self-expandable Nitinol stent 1 with the valve-supporting segment 20, valve and system for introducing it to the desired site in the body.
In terms of design, the endoprosthesis 1 has three positioning arches for positioning and fixing the medical device in the vessel of the patient and retaining webs for accommodating/attaching the heart valve prosthesis by means of a thread, for example. From a functional point of view, the endoprosthesis 1 exerts high radial forces in its second mode to ensure that the medical device is anchored in the aorta. Eyes 30 are preferably provided on the distal retaining region of the endoprosthesis 1 or medical device, which can be releasably engaged with corresponding components of an introduction catheter system.
The material used to trigger the shape memory effect of the endoprosthesis has a switching temperature between 20° C. and 36° C. and is preferably 22° C. In the cooled state, therefore, the medical device can be introduced into the patient's body by means of a 21 F introduction system.
As regards the exact dimensions of the endoprosthesis 1, it is designed to accommodate heart valve prostheses with a valve diameter of 21 mm to 25 mm, in which case the distal retaining region 2 of the endoprosthesis 1 in particular has a diameter that is approximately 10% to 15% bigger than this in order to ensure that the medical device is reliably anchored.
The medical device proposed by the invention has an endoprosthesis which is readily visible by X-ray, which can be achieved by applying markers at the proximal and/or distal region of the endoprosthesis if necessary.
The materials used for the endoprosthesis 1 are materials that have been tried and tested for implantation purposes, for example Nitinol and Tantal. As regards the dimensions of the endoprosthesis, two different stent sizes are currently preferred, which are set out in the table below together with the diameter of the proximal retaining region and the distal retaining region.
By applying an appropriate finishing treatment, in particular tempering, other dimensions of the stent can be achieved—starting from the two currently preferred stent sizes.
The invention is not restricted to the features described in connection with the preferred embodiments illustrated in the drawings. All combinations of the features described in the specification would be conceivable.
| Number | Name | Date | Kind |
|---|---|---|---|
| 5002566 | Carpentier et al. | Mar 1991 | A |
| 5061277 | Carpentier et al. | Oct 1991 | A |
| 5094661 | Levy et al. | Mar 1992 | A |
| 5104407 | Lam et al. | Apr 1992 | A |
| 5197979 | Quintero et al. | Mar 1993 | A |
| 5279612 | Eberhardt | Jan 1994 | A |
| 5332402 | Teitelbaum | Jul 1994 | A |
| 5336258 | Quintero et al. | Aug 1994 | A |
| 5352240 | Ross | Oct 1994 | A |
| 5368608 | Levy et al. | Nov 1994 | A |
| 5411552 | Andersen et al. | May 1995 | A |
| 5456713 | Chuter | Oct 1995 | A |
| 5509930 | Love | Apr 1996 | A |
| 5549666 | Hata et al. | Aug 1996 | A |
| 5595571 | Jaffe et al. | Jan 1997 | A |
| 5613982 | Goldstein | Mar 1997 | A |
| 5632778 | Goldstein | May 1997 | A |
| 5674298 | Levy et al. | Oct 1997 | A |
| 5679112 | Levy et al. | Oct 1997 | A |
| 5683451 | Lenker et al. | Nov 1997 | A |
| 5697972 | Kim et al. | Dec 1997 | A |
| 5713953 | Vallana et al. | Feb 1998 | A |
| 5746775 | Levy et al. | May 1998 | A |
| 5755777 | Chuter | May 1998 | A |
| 5824041 | Lenker et al. | Oct 1998 | A |
| 5824080 | Lamuraglia | Oct 1998 | A |
| 5840081 | Andersen et al. | Nov 1998 | A |
| 5841382 | Walden et al. | Nov 1998 | A |
| 5843181 | Jaffe et al. | Dec 1998 | A |
| 5876434 | Flomenblit et al. | Mar 1999 | A |
| 5880242 | Hu et al. | Mar 1999 | A |
| 5899936 | Goldstein | May 1999 | A |
| 5928281 | Huynh et al. | Jul 1999 | A |
| 5935163 | Gabbay | Aug 1999 | A |
| 5104407 | Lam et al. | Sep 1999 | A |
| 6001126 | Nguyen-Thien-Nhon | Dec 1999 | A |
| 5061277 | Carpentier et al. | Feb 2000 | A |
| 6077297 | Robinson et al. | Jun 2000 | A |
| 6093530 | McIlroy et al. | Jul 2000 | A |
| 6102944 | Huynh et al. | Aug 2000 | A |
| 6117169 | Moe | Sep 2000 | A |
| 6126685 | Lenker et al. | Oct 2000 | A |
| 6168614 | Andersen et al. | Jan 2001 | B1 |
| 6177514 | Pathak et al. | Jan 2001 | B1 |
| 6183481 | Lee et al. | Feb 2001 | B1 |
| 6200336 | Pavcnik et al. | Mar 2001 | B1 |
| 6214055 | Simionescu et al. | Apr 2001 | B1 |
| 6231602 | Carpentier et al. | May 2001 | B1 |
| 6254564 | Wilk et al. | Jul 2001 | B1 |
| 6254636 | Peredo | Jul 2001 | B1 |
| 6283995 | Moe et al. | Sep 2001 | B1 |
| 6287338 | Sarnowski et al. | Sep 2001 | B1 |
| 6338740 | Carpentier | Jan 2002 | B1 |
| 6342070 | Nguyen-Thien-Nhon | Jan 2002 | B1 |
| 6344044 | Fulkerson et al. | Feb 2002 | B1 |
| 6350278 | Lenker et al. | Feb 2002 | B1 |
| 6379740 | Rinaldi et al. | Apr 2002 | B1 |
| 6391538 | Vyavahare et al. | May 2002 | B1 |
| 6425916 | Garrison et al. | Jul 2002 | B1 |
| 6454799 | Schreck | Sep 2002 | B1 |
| 6471723 | Ashworth et al. | Oct 2002 | B1 |
| 6478819 | Moe | Nov 2002 | B2 |
| 6508833 | Pavcnik et al. | Jan 2003 | B2 |
| 6509145 | Torrianni | Jan 2003 | B1 |
| 6521179 | Girardot et al. | Feb 2003 | B1 |
| 6540782 | Snyders | Apr 2003 | B1 |
| 6558417 | Peredo | May 2003 | B2 |
| 6558418 | Carpentier et al. | May 2003 | B2 |
| 6572642 | Rinaldi et al. | Jun 2003 | B2 |
| 6582462 | Andersen et al. | Jun 2003 | B1 |
| 6585766 | Huynh et al. | Jul 2003 | B1 |
| 6613086 | Moe et al. | Sep 2003 | B1 |
| 6682559 | Myers et al. | Jan 2004 | B2 |
| 6730118 | Spenser et al. | May 2004 | B2 |
| 6736845 | Marquez et al. | May 2004 | B2 |
| 6767362 | Schreck | Jul 2004 | B2 |
| 6790230 | Beyersdorf et al. | Sep 2004 | B2 |
| 6808529 | Fulkerson | Oct 2004 | B2 |
| 6821211 | Otten et al. | Nov 2004 | B2 |
| 6821297 | Snyders | Nov 2004 | B2 |
| 6824970 | Vyavahare et al. | Nov 2004 | B2 |
| 6830584 | Seguin | Dec 2004 | B1 |
| 6861211 | Levy et al. | Mar 2005 | B2 |
| 6872226 | Cali et al. | Mar 2005 | B2 |
| 6881199 | Wilk et al. | Apr 2005 | B2 |
| 6893460 | Spenser et al. | May 2005 | B2 |
| 6908481 | Cribier | Jun 2005 | B2 |
| 6911043 | Myers et al. | Jun 2005 | B2 |
| 6945997 | Huynh et al. | Sep 2005 | B2 |
| 6974474 | Pavcnik et al. | Dec 2005 | B2 |
| 7014655 | Barbarash et al. | Mar 2006 | B2 |
| 7018406 | Seguin et al. | Mar 2006 | B2 |
| 7037333 | Myers et al. | May 2006 | B2 |
| 7050276 | Nishiyama | May 2006 | B2 |
| 7078163 | Torrianni | Jul 2006 | B2 |
| 7081132 | Cook et al. | Jul 2006 | B2 |
| 7137184 | Schreck | Nov 2006 | B2 |
| 7141064 | Scott et al. | Nov 2006 | B2 |
| 7163556 | Xie et al. | Jan 2007 | B2 |
| 7189259 | Simionescu et al. | Mar 2007 | B2 |
| 7198646 | Figulla et al. | Apr 2007 | B2 |
| 7201772 | Schwammenthal et al. | Apr 2007 | B2 |
| 7238200 | Lee et al. | Jul 2007 | B2 |
| 7252682 | Seguin | Aug 2007 | B2 |
| 7318278 | Zhang et al. | Jan 2008 | B2 |
| 7318998 | Goldstein et al. | Jan 2008 | B2 |
| 7322932 | Xie et al. | Jan 2008 | B2 |
| 7329278 | Seguin et al. | Feb 2008 | B2 |
| 7381218 | Schreck | Jun 2008 | B2 |
| 7393360 | Spenser et al. | Jul 2008 | B2 |
| 7399315 | Iobbi | Jul 2008 | B2 |
| 7452371 | Pavcnik et al. | Nov 2008 | B2 |
| 7473275 | Marquez | Jan 2009 | B2 |
| 20010011187 | Pavcnik et al. | Aug 2001 | A1 |
| 20010039450 | Pavcnik et al. | Nov 2001 | A1 |
| 20010044652 | Moore | Nov 2001 | A1 |
| 20020032481 | Gabbay | Mar 2002 | A1 |
| 20020055775 | Carpentier et al. | May 2002 | A1 |
| 20020123790 | White et al. | Sep 2002 | A1 |
| 20020133226 | Marquez et al. | Sep 2002 | A1 |
| 20020198594 | Schreck | Dec 2002 | A1 |
| 20030027332 | Lafrance et al. | Feb 2003 | A1 |
| 20030036791 | Philipp et al. | Feb 2003 | A1 |
| 20030036795 | Andersen et al. | Feb 2003 | A1 |
| 20030040792 | Gabbay | Feb 2003 | A1 |
| 20030050694 | Yang et al. | Mar 2003 | A1 |
| 20030055495 | Pease et al. | Mar 2003 | A1 |
| 20030065386 | Weadock | Apr 2003 | A1 |
| 20030114913 | Spenser et al. | Jun 2003 | A1 |
| 20030125795 | Pavcnik et al. | Jul 2003 | A1 |
| 20030139796 | Sequin et al. | Jul 2003 | A1 |
| 20030139803 | Sequin et al. | Jul 2003 | A1 |
| 20030149476 | Damm et al. | Aug 2003 | A1 |
| 20030153974 | Spenser et al. | Aug 2003 | A1 |
| 20030195620 | Huynh et al. | Oct 2003 | A1 |
| 20030236570 | Cook et al. | Dec 2003 | A1 |
| 20040006380 | Buck et al. | Jan 2004 | A1 |
| 20040039436 | Spenser et al. | Feb 2004 | A1 |
| 20040049262 | Obermiller et al. | Mar 2004 | A1 |
| 20040073289 | Hartley et al. | Apr 2004 | A1 |
| 20040078950 | Schreck et al. | Apr 2004 | A1 |
| 20040117004 | Osborne et al. | Jun 2004 | A1 |
| 20040117009 | Cali et al. | Jun 2004 | A1 |
| 20040148018 | Carpentier et al. | Jul 2004 | A1 |
| 20040153145 | Simionescu et al. | Aug 2004 | A1 |
| 20040186558 | Pavcnik et al. | Sep 2004 | A1 |
| 20040186563 | Lobbi | Sep 2004 | A1 |
| 20040186565 | Schreck | Sep 2004 | A1 |
| 20040193244 | Hartley et al. | Sep 2004 | A1 |
| 20040210301 | Obermiller et al. | Oct 2004 | A1 |
| 20040210304 | Seguin et al. | Oct 2004 | A1 |
| 20040260389 | Case et al. | Dec 2004 | A1 |
| 20050009000 | Wilhelm et al. | Jan 2005 | A1 |
| 20050033220 | Wilk et al. | Feb 2005 | A1 |
| 20050033398 | Seguin | Feb 2005 | A1 |
| 20050043790 | Seguin | Feb 2005 | A1 |
| 20050049692 | Numamoto et al. | Mar 2005 | A1 |
| 20050075725 | Rowe | Apr 2005 | A1 |
| 20050075726 | Svanidze et al. | Apr 2005 | A1 |
| 20050075776 | Cho | Apr 2005 | A1 |
| 20050096726 | Sequin et al. | May 2005 | A1 |
| 20050096736 | Osse et al. | May 2005 | A1 |
| 20050098547 | Cali et al. | May 2005 | A1 |
| 20050113910 | Paniagua et al. | May 2005 | A1 |
| 20050119728 | Sarac | Jun 2005 | A1 |
| 20050119736 | Zilla et al. | Jun 2005 | A1 |
| 20050137687 | Salahieh et al. | Jun 2005 | A1 |
| 20050137688 | Salahieh et al. | Jun 2005 | A1 |
| 20050137690 | Salahieh et al. | Jun 2005 | A1 |
| 20050137697 | Salahieh et al. | Jun 2005 | A1 |
| 20050137698 | Salahieh et al. | Jun 2005 | A1 |
| 20050137702 | Haug et al. | Jun 2005 | A1 |
| 20050143804 | Haverkost | Jun 2005 | A1 |
| 20050143807 | Pavcnik et al. | Jun 2005 | A1 |
| 20050149166 | Schaeffer et al. | Jul 2005 | A1 |
| 20050150775 | Zhang et al. | Jul 2005 | A1 |
| 20050171597 | Boatman et al. | Aug 2005 | A1 |
| 20050171598 | Schaeffer | Aug 2005 | A1 |
| 20050192665 | Spenser et al. | Sep 2005 | A1 |
| 20050197695 | Stacchino et al. | Sep 2005 | A1 |
| 20050222668 | Schaeffer et al. | Oct 2005 | A1 |
| 20050228496 | Mensah et al. | Oct 2005 | A1 |
| 20050234546 | Nugent et al. | Oct 2005 | A1 |
| 20050267560 | Bates | Dec 2005 | A1 |
| 20060009842 | Huynh et al. | Jan 2006 | A1 |
| 20060025857 | Bergheim et al. | Feb 2006 | A1 |
| 20060047343 | Oviatt et al. | Mar 2006 | A1 |
| 20060058864 | Schaeffer et al. | Mar 2006 | A1 |
| 20060074484 | Huber | Apr 2006 | A1 |
| 20060111770 | Pavcnik et al. | May 2006 | A1 |
| 20060142846 | Pavcnik et al. | Jun 2006 | A1 |
| 20060149360 | Schwammenthal et al. | Jul 2006 | A1 |
| 20060155366 | LaDuca et al. | Jul 2006 | A1 |
| 20060167543 | Bailey et al. | Jul 2006 | A1 |
| 20060193885 | Neethling et al. | Aug 2006 | A1 |
| 20060210597 | Hiles | Sep 2006 | A1 |
| 20060229718 | Marquez | Oct 2006 | A1 |
| 20060229719 | Marquez et al. | Oct 2006 | A1 |
| 20060246584 | Covelli | Nov 2006 | A1 |
| 20060259134 | Schwammenthal et al. | Nov 2006 | A1 |
| 20060259136 | Nguyen et al. | Nov 2006 | A1 |
| 20060265056 | Nguyen et al. | Nov 2006 | A1 |
| 20060287717 | Rowe et al. | Dec 2006 | A1 |
| 20060287719 | Rowe et al. | Dec 2006 | A1 |
| 20060290027 | O'Connor et al. | Dec 2006 | A1 |
| 20060293745 | Carpentier et al. | Dec 2006 | A1 |
| 20070005129 | Damm et al. | Jan 2007 | A1 |
| 20070005131 | Taylor | Jan 2007 | A1 |
| 20070005132 | Simionescu et al. | Jan 2007 | A1 |
| 20070020248 | Everaerts et al. | Jan 2007 | A1 |
| 20070021826 | Case et al. | Jan 2007 | A1 |
| 20070027535 | Purdy, Jr. et al. | Feb 2007 | A1 |
| 20070038291 | Case et al. | Feb 2007 | A1 |
| 20070038295 | Case et al. | Feb 2007 | A1 |
| 20070043435 | Seguin et al. | Feb 2007 | A1 |
| 20070050014 | Johnson | Mar 2007 | A1 |
| 20070088431 | Bourang et al. | Apr 2007 | A1 |
| 20070093887 | Case et al. | Apr 2007 | A1 |
| 20070100435 | Case et al. | May 2007 | A1 |
| 20070100440 | Figulla et al. | May 2007 | A1 |
| 20070112422 | Dehdashtian | May 2007 | A1 |
| 20070123700 | Ueda et al. | May 2007 | A1 |
| 20070123979 | Perier et al. | May 2007 | A1 |
| 20070142906 | Figulla et al. | Jun 2007 | A1 |
| 20070162103 | Case et al. | Jul 2007 | A1 |
| 20070173932 | Cali et al. | Jul 2007 | A1 |
| 20070179592 | Schaeffer | Aug 2007 | A1 |
| 20070185565 | Schwammenthal et al. | Aug 2007 | A1 |
| 20070203576 | Lee et al. | Aug 2007 | A1 |
| 20070213813 | Von Segesser et al. | Sep 2007 | A1 |
| 20070239271 | Nguyen | Oct 2007 | A1 |
| 20070244551 | Stobie | Oct 2007 | A1 |
| 20070260327 | Case et al. | Nov 2007 | A1 |
| 20070288087 | Fearnot et al. | Dec 2007 | A1 |
| 20080004688 | Spenser et al. | Jan 2008 | A1 |
| 20080021546 | Patz et al. | Jan 2008 | A1 |
| 20080033534 | Cook et al. | Feb 2008 | A1 |
| 20080065011 | Marchand et al. | Mar 2008 | A1 |
| 20080071361 | Tuval et al. | Mar 2008 | A1 |
| 20080071362 | Tuval et al. | Mar 2008 | A1 |
| 20080071363 | Tuval et al. | Mar 2008 | A1 |
| 20080071366 | Tuval et al. | Mar 2008 | A1 |
| 20080071368 | Tuval et al. | Mar 2008 | A1 |
| 20080071369 | Tuval et al. | Mar 2008 | A1 |
| 20080077236 | Letac et al. | Mar 2008 | A1 |
| 20080086205 | Gordy et al. | Apr 2008 | A1 |
| 20080097586 | Pavcnik et al. | Apr 2008 | A1 |
| 20080102439 | Tian et al. | May 2008 | A1 |
| 20080133003 | Seguin et al. | Jun 2008 | A1 |
| 20080140189 | Nguyen et al. | Jun 2008 | A1 |
| 20080154355 | Benichou et al. | Jun 2008 | A1 |
| 20080200977 | Paul et al. | Aug 2008 | A1 |
| 20080215143 | Seguin | Sep 2008 | A1 |
| 20080255661 | Straubinger et al. | Oct 2008 | A1 |
| 20080262602 | Wilk et al. | Oct 2008 | A1 |
| 20080269878 | Iobbi | Oct 2008 | A1 |
| 20080275549 | Rowe | Nov 2008 | A1 |
| Number | Date | Country |
|---|---|---|
| 2006308187 | May 2007 | AU |
| 2006310681 | May 2007 | AU |
| 2436258 | Jan 2005 | CA |
| 2595233 | Jul 2006 | CA |
| 2627555 | May 2007 | CA |
| 195 46 692 | Jun 1997 | DE |
| 19546692 | Jun 1997 | DE |
| 20003874 | Jun 2000 | DE |
| 19857887 | Jul 2000 | DE |
| 10010073 | Sep 2001 | DE |
| 10010074 | Oct 2001 | DE |
| 101 21 210 | Nov 2002 | DE |
| 19546692 | Nov 2002 | DE |
| 10010073 | Dec 2002 | DE |
| 10301026 | Feb 2004 | DE |
| 10302447 | Jul 2004 | DE |
| 10335948 | Feb 2005 | DE |
| 10010074 | Apr 2005 | DE |
| 19857887 | May 2005 | DE |
| 10 2005 051 849 | May 2007 | DE |
| 10 2005 052 628 | May 2007 | DE |
| 202007005491 | Jul 2007 | DE |
| 0084395 | Jul 1983 | EP |
| 0458877 | Aug 1990 | EP |
| 0402036 | Dec 1990 | EP |
| 0402176 | Dec 1990 | EP |
| 0458877 | Apr 1991 | EP |
| 0515324 | Nov 1992 | EP |
| 0547135 | Jun 1993 | EP |
| 0871414 | Sep 1995 | EP |
| 0 592 410 | Oct 1995 | EP |
| 0756498 | Oct 1995 | EP |
| 0 592 410 | Nov 1995 | EP |
| 0786970 | May 1996 | EP |
| 0729364 | Sep 1996 | EP |
| 0756498 | May 1997 | EP |
| 0778775 | Jun 1997 | EP |
| 0786970 | Aug 1997 | EP |
| 0888142 | Sep 1997 | EP |
| 0971649 | Oct 1998 | EP |
| 0928615 | Jul 1999 | EP |
| 1051204 | Jul 1999 | EP |
| 1089676 | Dec 1999 | EP |
| 0986348 | Mar 2000 | EP |
| 1117446 | Apr 2000 | EP |
| 1 164 976 | Aug 2000 | EP |
| 1158937 | Sep 2000 | EP |
| 1 251 805 | Oct 2000 | EP |
| 1041942 | Oct 2000 | EP |
| 1041943 | Oct 2000 | EP |
| 1171061 | Oct 2000 | EP |
| 1206179 | Feb 2001 | EP |
| 1 233 731 | May 2001 | EP |
| 1117446 | Jul 2001 | EP |
| 1 255 510 | Aug 2001 | EP |
| 1259193 | Sep 2001 | EP |
| 1 233 731 | May 2002 | EP |
| 1 330 213 | May 2002 | EP |
| 1206179 | May 2002 | EP |
| 1347785 | Aug 2002 | EP |
| 1235537 | Sep 2002 | EP |
| 1248655 | Oct 2002 | EP |
| 1251804 | Oct 2002 | EP |
| 1257305 | Nov 2002 | EP |
| 0 971 649 | Dec 2002 | EP |
| 1395208 | Dec 2002 | EP |
| 1 401 359 | Jan 2003 | EP |
| 1406561 | Jan 2003 | EP |
| 1281357 | Feb 2003 | EP |
| 1281375 | Feb 2003 | EP |
| 1408882 | Feb 2003 | EP |
| 1 435 878 | Apr 2003 | EP |
| 1 435 879 | Apr 2003 | EP |
| 1 017 868 | Sep 2003 | EP |
| 1354569 | Oct 2003 | EP |
| 1494616 | Oct 2003 | EP |
| 1 441 672 | Jan 2004 | EP |
| 1 519 697 | Jan 2004 | EP |
| 1 539 047 | Apr 2004 | EP |
| 1551274 | Apr 2004 | EP |
| 1 560 542 | May 2004 | EP |
| 1414295 | May 2004 | EP |
| 1 603 493 | Sep 2004 | EP |
| 1452153 | Sep 2004 | EP |
| 0987998 | Oct 2004 | EP |
| 1 087 727 | Nov 2004 | EP |
| 1499366 | Jan 2005 | EP |
| 1 663 070 | Mar 2005 | EP |
| 1 253 875 | Apr 2005 | EP |
| 1 667 614 | Apr 2005 | EP |
| 1 251 803 | Jun 2005 | EP |
| 1 702 247 | Jul 2005 | EP |
| 1734902 | Aug 2005 | EP |
| 1469797 | Nov 2005 | EP |
| 1835948 | Jun 2006 | EP |
| 1863545 | Sep 2006 | EP |
| 1893132 | Nov 2006 | EP |
| 1901681 | Nov 2006 | EP |
| 1 255 510 | Mar 2007 | EP |
| 1835948 | Sep 2007 | EP |
| 1112042 | Nov 2007 | EP |
| 1878407 | Jan 2008 | EP |
| 1886649 | Feb 2008 | EP |
| 1 900 343 | Mar 2008 | EP |
| 1259195 | Oct 2008 | EP |
| 1980220 | Oct 2008 | EP |
| 1994913 | Nov 2008 | EP |
| 2 000 115 | Dec 2008 | EP |
| 2828263 | Feb 2003 | FR |
| 2433700 | Jul 2007 | GB |
| 2440809 | Feb 2008 | GB |
| 2003-523262 | Aug 2003 | JP |
| 2003-524504 | Aug 2003 | JP |
| 2005-118585 | May 2005 | JP |
| 2007-296375 | Nov 2007 | JP |
| 2008539305 | Nov 2008 | JP |
| WO-9009102 | Aug 1990 | WO |
| WO 9511055 | Apr 1995 | WO |
| WO 9524873 | Sep 1995 | WO |
| WO-9528183 | Oct 1995 | WO |
| WO-9613227 | May 1996 | WO |
| WO-9732615 | Sep 1997 | WO |
| WO 9843556 | Oct 1998 | WO |
| WO-9846165 | Oct 1998 | WO |
| WO-9937337 | Jul 1999 | WO |
| WO-9966863 | Dec 1999 | WO |
| WO 0015148 | Mar 2000 | WO |
| WO-0018445 | Apr 2000 | WO |
| WO 0025702 | May 2000 | WO |
| WO 0047139 | Aug 2000 | WO |
| WO-0053125 | Sep 2000 | WO |
| WO-0062714 | Oct 2000 | WO |
| WO-0110209 | Feb 2001 | WO |
| WO 0135870 | May 2001 | WO |
| WO-0141679 | Jun 2001 | WO |
| WO-0151104 | Jul 2001 | WO |
| WO 0154625 | Aug 2001 | WO |
| WO 0158503 | Aug 2001 | WO |
| WO 0162189 | Aug 2001 | WO |
| WO 0164137 | Sep 2001 | WO |
| WO 0236048 | May 2002 | WO |
| WO-02058745 | Aug 2002 | WO |
| WO-02100301 | Dec 2002 | WO |
| WO-02102286 | Dec 2002 | WO |
| WO 03003949 | Jan 2003 | WO |
| WO-03007795 | Jan 2003 | WO |
| WO-03009785 | Feb 2003 | WO |
| WO 03011195 | Feb 2003 | WO |
| WO 03013239 | Feb 2003 | WO |
| WO 03028592 | Apr 2003 | WO |
| WO 03047468 | Jun 2003 | WO |
| WO-03079928 | Oct 2003 | WO |
| WO 03096935 | Nov 2003 | WO |
| WO 2004004597 | Jan 2004 | WO |
| WO 2004016200 | Feb 2004 | WO |
| WO 2004016201 | Feb 2004 | WO |
| WO 2004019825 | Mar 2004 | WO |
| WO-2004026117 | Apr 2004 | WO |
| WO 2004026173 | Apr 2004 | WO |
| WO 2004028399 | Apr 2004 | WO |
| WO 2004043301 | May 2004 | WO |
| WO 2004082527 | Sep 2004 | WO |
| WO 2004082528 | Sep 2004 | WO |
| WO 2004096100 | Nov 2004 | WO |
| WO 2005021063 | Mar 2005 | WO |
| WO 2005034812 | Apr 2005 | WO |
| WO 2005062980 | Jul 2005 | WO |
| WO 2005063980 | Jul 2005 | WO |
| WO-2005072654 | Aug 2005 | WO |
| WO 2006066327 | Jun 2006 | WO |
| WO-2006066327 | Jun 2006 | WO |
| WO 2006076890 | Jul 2006 | WO |
| WO-2006102063 | Sep 2006 | WO |
| WO 2006108090 | Oct 2006 | WO |
| WO-2006124649 | Nov 2006 | WO |
| WO 2006124649 | Nov 2006 | WO |
| WO 2006127756 | Nov 2006 | WO |
| WO 2006127765 | Nov 2006 | WO |
| WO-2006132948 | Dec 2006 | WO |
| WO 2007047488 | Apr 2007 | WO |
| WO 2007047945 | Apr 2007 | WO |
| WO 2007051620 | May 2007 | WO |
| WO 2007059252 | May 2007 | WO |
| WO-2007071436 | Jun 2007 | WO |
| WO 2007098232 | Aug 2007 | WO |
| WO 2007120543 | Oct 2007 | WO |
| WO-2008028569 | Mar 2008 | WO |
| WO 2008045949 | Apr 2008 | WO |
| WO 2008070797 | Jun 2008 | WO |
| WO 2006076890 | Jul 2008 | WO |
| WO 2008079962 | Jul 2008 | WO |
| WO 2008101083 | Aug 2008 | WO |
| WO 2008125153 | Oct 2008 | WO |
| WO 2008138584 | Nov 2008 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 20080255660 A1 | Oct 2008 | US |
