Patent Grant
10350066
Field
Certain embodiments disclosed herein relate generally to prostheses for implantation within a lumen or body cavity and delivery systems for a prosthesis. In particular, the prostheses and delivery systems relate in some embodiments to replacement heart valves, such as replacement mitral heart valves.
Background
Human heart valves, which include the aortic, pulmonary, mitral and tricuspid valves, function essentially as one-way valves operating in synchronization with the pumping heart. The valves allow blood to flow downstream, but block blood from flowing upstream. Diseased heart valves exhibit impairments such as narrowing of the valve or regurgitation, which inhibit the valves' ability to control blood flow. Such impairments reduce the heart's blood-pumping efficiency and can be a debilitating and life threatening condition. For example, valve insufficiency can lead to conditions such as heart hypertrophy and dilation of the ventricle. Thus, extensive efforts have been made to develop methods and apparatuses to repair or replace impaired heart valves.
Prostheses exist to correct problems associated with impaired heart valves. For example, mechanical and tissue-based heart valve prostheses can be used to replace impaired native heart valves. More recently, substantial effort has been dedicated to developing replacement heart valves, particularly tissue-based replacement heart valves that can be delivered with less trauma to the patient than through open heart surgery. Replacement valves are being designed to be delivered through minimally invasive procedures and even percutaneous procedures. Such replacement valves often include a tissue-based valve body that is connected to an expandable frame that is then delivered to the native valve's annulus.
Development of prostheses including but not limited to replacement heart valves that can be compacted for delivery and then controllably expanded for controlled placement has proven to be particularly challenging. An additional challenge relates to the ability of such prostheses to be secured relative to intralumenal tissue, e.g., tissue within any body lumen or cavity, in an atraumatic manner.
Delivering a prosthesis to a desired location in the human body, for example delivering a replacement heart valve to the mitral valve, can also be challenging. Obtaining access to perform procedures in the heart or in other anatomical locations may require delivery of devices percutaneously through tortuous vasculature or through open or semi-open surgical procedures. The ability to control the deployment of the prosthesis at the desired location can also be challenging.
Embodiments of the present disclosure are directed to a prosthesis, such as but not limited to a replacement heart valve. Further embodiments are directed to delivery systems, devices and/or methods of use to deliver and/or controllably deploy a prosthesis, such as but not limited to a replacement heart valve, to a desired location within the body. In some embodiments, a replacement heart valve and methods for delivering a replacement heart valve to a native heart valve, such as a mitral valve, are provided.
The present disclosure includes, but is not limited to, the following numbered embodiments.
A delivery system for delivering an expandable implant to a body location, the delivery system comprising an elongate shaft assembly comprising a proximal end and a distal end, wherein the elongate shaft assembly comprises an implant retention area configured to retain the expandable implant in a compressed configuration, wherein the elongate shaft assembly comprises an elongate tubular shaft comprising a proximal end and a distal end and a longitudinal axis extending between the proximal end and the distal end, wherein the elongate tubular shaft comprises a plurality of slots spaced apart longitudinally along a length of the elongate tubular shaft, each of the plurality of slots being oriented substantially perpendicular to the longitudinal axis and comprising a proximal side, a distal side, and two circumferentially spaced apart opposite ends, wherein each slot forms a gap between the proximal and distal sides of the slot that is configured to close upon application of force to the elongate tubular shaft, wherein the opposite ends of the slots are separated from each other by a spine portion extending longitudinally along the length of the elongate tubular shaft, and wherein the position and/or shape of the slots varies along the length of the elongate tubular shaft to provide different bending characteristics to different portions of the elongate tubular shaft.
The delivery system of Embodiment 1, wherein the plurality of slots comprises a proximal slot section that extends parallel to the longitudinal axis of the elongate tubular shaft, a transition slot section that is angled relative to the longitudinal axis to move the transition slot section from a first circumferential location aligned with the proximal slot section to a second circumferential location, and a distal slot section that extends from the second circumferential location and is parallel to the longitudinal axis of the elongate tubular shaft, the distal slot section being circumferentially offset from the proximal slot section.
The delivery system of Embodiment 2, wherein the proximal slot section comprises a plurality of identical slots and the distal slot section comprises a plurality of identical slots.
The delivery system of any one of Embodiments 1-3, wherein the plurality of slots have varying widths over the length of the elongate tubular shaft, the widths of the slots being defined between the two circumferentially spaced apart opposite ends.
The delivery system of Embodiment 4, wherein the plurality of slots comprises a first slot section having a plurality of slots with a first width, a second slot section having a plurality of slots with a second width, and a third slot section having a plurality of slots with a third width, wherein the third width is greater than the second width and the second width is greater than the first width.
The delivery system of Embodiment 5, wherein the plurality of slots comprises a first transition section between the first slot section and the second slot section, and a second transition section between the second slot section and the third slot section, wherein the first transition section comprises a plurality of slots having different widths that are between the first width and the second width, and wherein the second transition section comprises a plurality of slots having different widths that are between the second width and the third width.
The delivery system of any one of Embodiments 1-6, wherein each of the plurality of slots comprises a central tooth and triangular gaps positioned on opposite sides of the triangular gaps.
The delivery system of any one of Embodiments 1-7, further comprising one or more pull wires configured to apply a force that causes bending of the elongate tubular shaft along the plurality of slots.
The delivery system of any one of Embodiments 1-8, further comprising a handle comprising an actuator configured to cause controlled bending of the elongate tubular shaft along the plurality of slots.
The delivery system of Embodiment 9, further comprising one or more pull wires configured to apply a force that causes bending of the elongate tubular shaft along the plurality of slots wherein the one or more pull wires attached to a tear drop shaped connector in communication with the actuator.
The delivery system of any one of Embodiments 1-10, wherein the elongate shaft assembly further comprises a retention ring at the distal end of the elongate tubular shaft configured to radially restrain at least a portion of the expandable implant.
The delivery system of Embodiment 11, wherein one or more pull wires extend within the elongate tubular shaft and attach to a proximal portion of the retention ring, the one or more pull wires configured to apply a force that causes bending of the elongate tubular shaft along the plurality of slots.
The delivery system of any one of Embodiments 1-12, wherein the elongate shaft assembly further comprises an outer shaft assembly slideable over the elongate tubular shaft, the outer shaft assembly configured to radially restrain at least a portion of the expandable implant.
The method of Embodiment 13, further comprising an actuating knob configured to bend the elongate tubular shaft while simultaneously moving the outer shaft assembly distally.
The delivery system of any one of Embodiments 1-14, wherein the elongate shaft assembly further comprises an inner shaft assembly slideable within the elongate shaft assembly configured to engage a proximal end of the expandable implant.
The delivery system of any one of Embodiments 1-15, wherein the plurality of slots of the elongate tubular shaft are configured for positioning between the septum between right and left atria and a native mitral valve of a heart, and wherein the plurality of slots are configured to bend the elongate tubular shaft to direct the implant retention area toward the native mitral valve.
The delivery system of any one of Embodiments 1-16, wherein the plurality of slots are configured to bend the elongate tubular shaft first in two dimensions and then in three dimensions.
The delivery system of any one of Embodiments 1-17, wherein the plurality of slots are configured to bend the elongate tubular shaft in multiple stages.
The delivery system of any one of Embodiments 1-18, wherein the plurality of slots are configured to bend the elongate tubular shaft in three dimensions.
The delivery system of any one of Embodiments 1-19, further comprising a sheath around the elongate tubular shaft configured to prevent bending of the proximal end of the elongate tubular shaft.
A method of steering a delivery system to a native mitral valve for delivery of a replacement mitral valve, the method comprising advancing a delivery system into a heart in a patient, the delivery system retaining a replacement mitral valve in a collapsed configuration, the delivery system being delivered through the septum between the right atrium and the left atrium, steering a delivery component of the delivery system from the septum toward the native mitral valve, the delivery component comprising a plurality of slots that enable bending of the delivery component toward the native mitral valve, and expanding the replacement mitral valve from the delivery system at the native mitral valve.
The method of Embodiment 21, further comprising actuating a pull wire connected to the delivery component to cause bending of the delivery component toward the native mitral valve along the plurality of slots.
The method of Embodiment 22, further comprising releasing the pull wire so that the delivery component translates to an original position prior to bending.
The method of Embodiment 23, wherein the pull wire is never compressed during the actuating and releasing.
The method of any one of Embodiments 21-24, further comprising actuating two pull wires connected to the delivery component to cause bending of the delivery component toward the native mitral valve along the plurality of slots.
The method of any one of Embodiments 21-25, wherein the delivery component first bends in a proximal section along a first plurality of slots and then bends in a distal section along a second plurality of slots, wherein the second plurality of slots are different from the first plurality of slots.
The method of any one of Embodiments 21-26, wherein steering the delivery component causes bending of the delivery component within a single plane.
The method of Embodiment 27, wherein steering the delivery component causes bending of the delivery component in three dimensions.
The method of any one of Embodiments 21-28, wherein the delivery component is steered toward the native mitral valve without the use of a guidewire.
The method of any one of Embodiments 21-29, wherein steering comprises actuating a knob on a handle of the delivery system.
The method of any one of Embodiments 21-30, further comprising a rigid live-on sheath at least partially surrounding a proximal end of the delivery component to prevent substantial bending at a proximal end of the delivery component and allow substantial bending at a distal end of the delivery component.
The method of Embodiment 31, wherein the rigid live-on sheath allows some bending of the proximal end of the delivery system.
A delivery system for delivering an expandable implant to a body location, the delivery system comprising an elongate shaft assembly comprising a proximal end and a distal end, wherein the elongate shaft assembly comprises an implant retention area configured to retain the expandable implant in a compressed configuration, wherein the elongate shaft assembly comprises an elongate tubular shaft comprising a proximal end and a distal end and a longitudinal axis extending between the proximal end and the distal end, wherein the proximal end of the elongate tubular shaft comprises a plurality of slot rings spaced apart longitudinally along a length of the elongate tubular shaft, each of the plurality of slot rings comprising a circumferentially repeating pattern of a first longitudinal slot longitudinally overlapping with a second longitudinal slot, wherein the first longitudinal slot intersects a first circumferential slot and the second longitudinal slot intersects a second circumferential slot, wherein the first and second circumferential slots circumferentially overlap.
The delivery system of Embodiment 33, wherein the distal end of the elongate tubular shaft comprises a plurality of generally H-shaped slots.
A delivery system for delivering an expandable implant to a body location, the delivery system comprising an elongate shaft assembly comprising a proximal end and a distal end and a lumen extending between the proximal end and the distal end, wherein the elongate shaft assembly comprises an implant retention area configured to retain a distal end of the expandable implant in a compressed configuration, a mid shaft assembly located within the lumen of the elongate shaft assembly and comprising a proximal end and a distal end and a lumen extending between the proximal end and the distal end, wherein the distal end of the mid shaft assembly comprises an outer retention ring configured to retain a proximal end of the expandable implant in the compressed configuration, an inner assembly located within the lumen of the mid shaft assembly and comprising a proximal end and a distal end and a lumen extending between the proximal end and the distal end, wherein the distal end of the inner assembly is configured to releasably retain the proximal end of the expandable implant, and a spacer sleeve comprising a proximal end and a distal end and a lumen extending between the proximal end and the distal end, the spacer sleeve located radially between the mid shaft assembly and the inner assembly, wherein the spacer sleeve is located within the lumen of the mid shaft assembly, and the inner assembly is located within the lumen of the spacer sleeve.
The delivery system of Embodiment 35, wherein the spacer sleeve is not connected to the inner assembly or the mid shaft.
The delivery system of any one of Embodiments 35-36, wherein the spacer sleeve is sized to prevent snaking of the inner assembly.
The delivery system of any one of Embodiments 35-37, wherein the spacer sleeve comprises plastic.
A delivery system for delivering a replacement mitral valve prosthesis to a native mitral valve of a patient, the delivery system comprising a handle, the handle comprising a first section, the first section comprising a rotatable outer sheath assembly knob, and a translatable nose cone assembly actuator, threading on an outer surface of the first section, wherein the threading is located between the rotatable outer sheath assembly knob and the translatable nose cone assembly actuator, a second section, the second section configured to translate over the first section and comprising a rotatable deflection knob, a rotatable mid shaft retraction knob, the rotatable mid shaft retraction knob having threading on an internal surface mating with the threading on the outer surface of the first section, a deflection indicator section having at least one deflection indicator, wherein the rotation of the rotatable mid shaft retraction knob translates the second section along the threading on the outer surface of the first section, a nose cone shaft having a proximal end and a distal end, the proximal end of the nose cone shaft being operably connected to the translatable nose cone assembly actuator and the distal end of the nose cone shaft attached to a nose cone, an inner shaft having a proximal end and a distal end and a lumen to pass over the nose cone shaft, the proximal end of the inner shaft being operably connected to the handle and the distal end attached to an inner retention ring, a mid shaft having a proximal end and a distal end and a lumen to pass over the inner shaft, the proximal end of the mid shaft being operably connected to the rotatable mid shaft retraction knob and a distal end of the mid shaft attached to an outer retention ring, the mid shaft having a plurality of slots configured to allow the mid shaft to bend, a pull wire having a proximal end and a distal end, the proximal end of the pull wire being operably connected to the rotatable deflection knob and the distal end of the pull wire attached to the outer retention ring or the mid shaft, a spacer sleeve located between the mid shaft and the inner shaft, an outer sheath assembly having a proximal end and a distal end and a lumen to pass over the mid shaft, the proximal end of the outer sheath assembly being operably connected to the rotatable outer sheath assembly knob and the distal end of the outer sheath assembly comprising a capsule, a replacement mitral valve prosthesis comprising an expandable frame extending between a first end and a second end, a plurality of atrial anchors configured to be positioned on an atrial side of the native mitral valve, and a plurality of ventricular anchors configured to be positioned on a ventricular side of the native mitral valve, wherein the replacement mitral valve prosthesis is configured to expand from a compressed configuration to an expanded configuration, wherein, in the compressed configuration, the first end is releasably held within the inner retention ring and radially compressed within the outer retention ring, and the second end is radially compressed within the capsule, wherein the ventricular anchors extend distally in the compressed configuration, wherein rotation of the deflection knob is configured to pull the pull wire proximally and push the mid shaft distally, thereby causing desired bending of the mid shaft to assist in steering a distal end of the system to the native mitral valve, wherein rotation of the rotatable outer sheath assembly knob is configured to translate the outer sheath assembly proximally to uncover the second end of the replacement mitral valve when the distal end of the system is located at the native mitral valve, thereby allowing the second end to expand and the ventricular anchors to flip so that they extend proximally while located on a ventricular side of an annulus of the native mitral valve, wherein rotation of the rotatable mid shaft knob is configured to translate the mid shaft proximally to uncover the first end of the replacement mitral valve, allowing the first end to expand and release from inner retention ring with the atrial anchors located on an atrial side of the annulus of the native mitral valve, and wherein translation of the translatable nose cone assembly actuator is configured to translate the nose cone shaft proximally through the expanded replacement mitral valve.
The delivery system of Embodiment 39, further comprising a stationary shaft having a proximal end and a distal end and a lumen to pass over the outer sheath assembly, the proximal end of the stationary shaft being operably connected to the handle.
The delivery system of Embodiment 40, further comprising a live-on introducer sheath having a proximal and distal end and a lumen to pass over the stationary shaft, the live-on introducer sheath having a gasket on an inside surface of the lumen in contact with the stationary shaft.
A delivery system for delivering an expandable implant to a body location, the delivery system comprising an elongate deflectable delivery component configured to at least partially retain the expandable implant, the elongate deflectable delivery component configured to bend to assist in steering the delivery system to the body location, and a handle comprising a rotatable deflection actuator configured to cause desired bending of the deflectable delivery component, threading on an outer surface of the handle, and a rotatable retraction actuator configured to mate with the threading, the rotatable retraction actuator being operably connected to the elongate deflectable delivery component, wherein rotation of the rotatable retraction actuator causes the rotatable retraction actuator and the rotatable deflection actuator to translate proximally along the threading, thereby translating the elongate deflectable delivery component proximally to at least partially release the expandable implant.
The delivery system of Embodiment 42, wherein rotation of the rotatable deflection actuator causes desired bending of the deflectable delivery component while simultaneously applying a distal force to the deflectable delivery component.
The delivery system of any one of Embodiments 42-43, further comprising a pull wire operably connected between the rotatable deflection knob and the deflectable delivery component.
The delivery system of any one of Embodiments 42-44, wherein the deflectable delivery component comprises a mid-shaft and an outer retention ring configured to partially retain the expandable implant.
The delivery system of any one of Embodiments 42-45, wherein the deflectable delivery component comprises a plurality of slots configured to allow the mid-shaft to bend.
The delivery system of any one of Embodiments 42-46, further comprising an outer sheath assembly configured to slide over the deflectable delivery component, and wherein the handle comprises an outer sheath actuator configured to move the outer sheath relative to the deflectable delivery component.
The delivery system of any one of Embodiments 42-47, further comprising an inner assembly configured to at least partially engage the expandable implant, wherein rotation of the rotatable retraction actuator causes translation of the elongate deflectable delivery component proximally relative to the inner assembly.
The delivery system of any one of Embodiments 42-48, further comprising a nose cone shaft and a nose cone at a distal end of the nose cone shaft, and wherein the handle comprises a nose cone actuator.
The present specification and drawings provide aspects and features of the disclosure in the context of several embodiments of replacement heart valves, delivery systems and methods that are configured for use in the vasculature of a patient, such as for replacement of natural heart valves in a patient. These embodiments may be discussed in connection with replacing specific valves such as the patient's aortic or mitral valve. However, it is to be understood that the features and concepts discussed herein can be applied to products other than heart valve implants. For example, the controlled positioning, deployment, and securing features described herein can be applied to medical implants, for example other types of expandable prostheses, for use elsewhere in the body, such as within an artery, a vein, or other body cavities or locations. In addition, particular features of a valve, delivery system, etc. should not be taken as limiting, and features of any one embodiment discussed herein can be combined with features of other embodiments as desired and when appropriate. While certain of the embodiments described herein are described in connection with a transfemoral delivery approach, it should be understood that these embodiments can be used for other delivery approaches such as, for example, transapical approaches. Moreover, it should be understood that certain of the features described in connection with some embodiments can be incorporated with other embodiments, including those which are described in connection with different delivery approaches.
Delivery System
With reference to
The delivery system 10 can be used to deploy a prosthesis, such as a replacement heart valve as described elsewhere in this specification, within the body. The delivery system 10 can receive and/or cover portions of the prosthesis such as a first end 301 and second end 303 of the prosthesis 70 illustrated in
The delivery system 10 can be relatively flexible. In some embodiments, the delivery system 10 is particularly suitable for delivering a replacement heart valve to a mitral valve location through a transseptal approach (e.g., between the right atrium and left atrium via a transseptal puncture).
As shown in
As shown in cross-sectional view of
As shown, the outer sheath assembly 22 can form an radially outer covering, or sheath, to surround an implant retention area 16. Moving radially inward, the mid shaft assembly 20 can be composed of a mid shaft 50 with its distal end attached to outer retention member or outer retention ring 40. Moving further inwards, the inner assembly 18 can be composed of an inner retention shaft 42 and an inner retention member 32. Further, the most radially-inward assembly is the nose cone assembly 31 which includes the nose cone shaft 30 having its distal end connected to the nose cone 28.
The elongate shaft assembly 12, and more specifically the nose cone assembly 31, inner assembly 18, mid shaft assembly 20, and outer sheath assembly 22, can be configured to deliver a prosthesis 70 positioned within the implant retention area 16 (shown in
Additional details and example designs for a prosthesis are described in U.S. Pat. Nos. 8,403,983, 8,414,644, 8,652,203 and U.S. Patent Publication Nos. 2011/0313515, 2012/0215303, 2014/0277390, 2014/0277422, 2014/0277427, the entirety of these patents and publications are hereby incorporated by reference and made a part of this specification. Further details and embodiments of a replacement heart valve or prosthesis and its method of implantation are described in U.S. patent application Ser. No. 14/716,507, filed May 19, 2015, and Ser. No. 15/141,684, filed Apr. 28, 2016 the entirety of each of which is hereby incorporated by reference and made a part of this specification.
As will be discussed below, the inner retention member 32, the outer retention ring 40 and the outer sheath assembly 22 can cooperate to hold the prosthesis 70 in a compacted configuration. The inner retention member 32 is shown engaging struts 72 at the proximal end of the prosthesis 70. For example, slots located between radially extending teeth on the inner retention member 32 can receive and engage the struts 72 which may end in mushroom-shaped tabs 74 on the proximal end of the prosthesis 70. The outer retention ring 40 can be positioned over the inner retention member 32 so that the first end 301 of the prosthesis 70 is trapped therebetween, securely attaching it to the delivery system 10.
As shown in
The delivery system 10 may be provided to users with a prosthesis 70 preinstalled. In other embodiments, the prosthesis 70 can be loaded onto the delivery system shortly before use, such as by a physician or nurse.
The outer sheath assembly 22 will now be described, which is shown in
The second segment 58 can be a metal hypotube which in some embodiments may be cut or have slots. The tube 58 can be covered or encapsulated with a layer of ePTFE, PTFE, or other material so that the outer surface of the outer sheath assembly is generally smooth. The covered second segment 58 is shown in
In some embodiments the third segment 60 can include one or more wings or tabs 63, shown in
Through the use of the handle 14, the mid shaft assembly 20 can translate or slide over the inner assembly 18, which thereby causes the outer retention ring 40 to slide over the inner assembly 18 and encircle the inner retention member 32 described below. As shown in
Further, as shown in
As mentioned the inner assembly 18 can be composed of the inner retention shaft 42 with the inner retention member 32 attached to the distal end of the inner retention shaft 42. Similar to the assemblies above, the inner retention shaft 42 can comprise a tube, such as a hypodermic tube or hypotube (not shown). The tube can be made from one of any number of different materials including nitinol, stainless steel, and medical grade plastics. The tube can be a single piece tube or multiple pieces connected together. Using a tube made of multiple pieces can allow the tube to provide different characteristics along different sections of the tube, such as rigidity and flexibility.
In some embodiments a first segment (now shown) of the inner assembly 18 can be made of a hypotube can extend along a majority of the length of the inner assembly 18. For example, metal hypotube extends from within the handle 16 at the proximal end towards the distal end up until a second segment (or inner retention shaft) 42 of the inner assembly 18 before the implant retention area 16. The hypotube can provide column strength (pushability) to the inner assembly. Further, the handle 16 can allow for rotation of the second segment 42, which can allow for rotation of the prosthesis 70. A second segment 42 of the inner assembly 18 can be made of a more flexible material. For example, the second segment 42 can comprise a wire such as a multi-stranded wire, wire rope, or wire coil. The wire can surround a more flexible tube, such as a plastic tube, or it may be formed as a tube without any additional inner materials or core. Thus, in some embodiments, the wire can be a hollow core wire rope. The wire can provide the inner assembly 18 with strength, but it can also provide more flexibility to allow for navigating the curvosities of the vasculature, such as within the heart.
The inner assembly 18 can also include a prosthesis retention mechanism such as an inner retention member 32 at a distal end of the second segment 42 that can be used to engage with the prosthesis, as discussed with respect to
Further, as shown in
The nose cone shaft 30 may include a lumen sized and configured to slidably accommodate a guidewire so that the delivery system 10 can be advanced over the guidewire through the vasculature. However, embodiments of the system 10 discussed herein may not use a guide wire and thus the nose cone shaft 30 can be solid. The nose cone shaft 30 may be connected from the nose cone 28 to the handle, or may be formed of different segments such as the other assemblies. Further, the nose cone shaft 30 can be formed of different materials, such as plastic or metal, similar to those described in detail above.
This view also illustrates that the nose cone shaft 36 can be slidably disposed within the inner assembly 18, thus allowing the nose cone shaft 28 (and thus nose cone 28) and the inner retention member 32 to move separately from one another during deployment and use.
The inner retention member 32 and outer retention ring 40 and the delivery system 10 generally may be similar to those disclosed in U.S. Pat. Nos. 8,414,644 and 8,652,203, the entire contents of both of which are hereby incorporated by reference herein and made a part of this specification. This is inclusive of the entire disclosure, including other apparatuses and methods described therein, and is not in any way limited to the disclosure of the inner and outer retentions and/or the delivery system.
Steerable Mid Shaft Construction
Advantageously, embodiments of the system 10 can be configured to be flexible when located in a patient and can allow for steering of the system 10 in a particular direction as desired by a user. In particular, in a transfemoral approach to the mitral valve, embodiments of the system 10 can provide for controlled steerability to allow a user to better navigate and turn the distal end of the system 10 from the septum between the left and right atrial and into the native mitral valve annulus. In some embodiments, no guidewire is required to steer the system 10. Although particular shaft constructions are described below with respect to the mid shaft assembly 20, it will be appreciated that these constructions may be applied to other components as well.
As mentioned,
The flat pattern 900 can be considered to include a center line 908 extending longitudinally from the proximal end to the distal end, with the slots 902 oriented perpendicular or substantially perpendicular to the center line. In other words, the slots 902 may be oriented perpendicular or substantially perpendicular to a longitudinal axis of the mid shaft 50, and may extend or rotate circumferentially around the mid shaft 50. Slots 902 can rotate circumferentially around the flat pattern 900 in the tubular form almost the entirety of the mid shaft 50, for example over 80, 100, 120, 170, 180, 200, 220, 280, 300, 320, or 340 degrees circumferentially, leaving a small gap between lateral ends of each slot.
Some of the slots 902, for example those closer to the proximal end 904 of the tube (herein referred to as proximal slots 921), may have the same circumferential position over a portion of the length of the tube (here the proximal slot section). As illustrated, there are 16 proximal slots 921 which may be identical to each other, each having a center portion located on the center line 908 and extending transversely from the center line 908 in a symmetrical pattern about the center line 908 (e.g., parallel to the longitudinal axis of the mid shaft 50). Distal to the proximal slots 921 are a plurality of transition slots 923 similar in shape to the proximal slots 921, but having center portions that gradually move transversely further away from the center line 908 so that the transition slots 923 are angled relative to the center line 908. As illustrated, there may be 5 such transition slots 923. Whereas the proximal slots 921 are oriented perpendicular or substantially perpendicular to the longitudinal axis of the shaft 50, the transition slots 923 are slightly angled relative to proximal slots 921.
Distal to the transition slots 923 are a plurality of distal slots 925 in a distal slot section, for example 21 distal slots 925, which may have the same circumferential position over a proximal portion of the tube. The distal slots 925 may be identical to each other. The distal slots 925 may also be identical to the proximal slots 921. The distal slots 925 may each have a center portion that is circumferentially offset from the center portions of the proximal slots 921, and may continue longitudinally along the length of the tube from the proximalmost transition slot. Like the proximal slots 921, the distal slots 925 may be oriented perpendicular or substantially perpendicular to the longitudinal axis of the shaft 50 and the center line 908.
It will therefore be appreciated that the slots 902 can be located at different circumferential positions along the length of the flat pattern 900. For example, the center portions of the distal slots 925 and the center portions of the proximal slots 921 can be about 0-180° apart, preferably from about 45° to about 90°. Other circumferential changes, such as, for example, 10, 20, 30, 40, 45, 50, 60, 70, 80, or 90° could be used as well. A majority of the slots 902 can be the proximal slots 921 and the distal slots 925, with only a small number of transition slots 923 between the two locations. Further, approximately half or more of the slots 902 can be proximal slots, though in other embodiments the number of slots 902 in these positions can change. Further, as shown in
The slots 902 themselves can be generally identical throughout the length of the mid shaft 50, though there may be some minor variations. This can allow the proximal end 904 to generally always be activated (e.g., at least some slight bending) during application of a force at the distal end 906. Each individual slot 902 as illustrated in
The slot patterns described herein advantageously provide for a desired deformation of the slots 902 and therefore the mid shaft 50 as a force is applied to the mid shaft 50. For example, using the pull wire(s) as described below, a proximal force applied to a distal end of the mid shaft 50 will bend or steer the mid shaft 50 in a direction aligned with the slots 902, thereby closing the slots and bending the mid shaft 50 in the direction of the closure. Thus, when a force is applied, the mid shaft 50 can bend in more than one dimension to follow the closure of the slots 902, allowing 3-dimensional bending (and thus 3-dimensional steering) in part due to the transition slots 923. Moreover, the bending in the proximal and distal sections can occur simultaneously or in a two-part manner, depending on the size of the slots 902 and/or the strength of the force applied to the mid shaft 50. Typically, when a pulling force is applied to the distal end of the mid shaft, the proximal section having proximal slots 921 will experience the bending first, following by the transition section having transition slots 923, followed by the distal section having distal slots 925. However, in some embodiments, the above referenced live-on sheath 51 can at least partially surround the proximal section and can stiffen the proximal section during delivery. For example, when crossing a native mitral valve annulus from a transseptal access location, the live-on sheath may at least partially cover the proximal section, providing an outer wall barrier to prevent bending of the proximal section and proximal slots 921, because it can be advantageous for the distal section and distal slots 925 to provide more guiding during implantation than the proximal slots 921. Specifically, the further the distance from the distal end 906, the greater the moment generated by each pound of pull, causing the proximal end 904 to bend first, followed by the distal end 906. Thus, a user can better control the articulation of the mid shaft 50. However, it is advantageous for the proximal slots 921 to be activated by the least force because it can then always be activated during bending, thus providing stability for fine tuning the distal section 925 and providing torque to the entire delivery system 10 for additional positioning.
The flat pattern 1000 can be considered to include a center line 1010 extending longitudinally from the proximal end 1004 to the distal end 1006, with the slots 1002 oriented perpendicular or substantially perpendicular to the center line. In other words, the slots 1002 may be oriented perpendicular or substantially perpendicular to a longitudinal axis of the mid shaft 50, and may extend or rotate circumferentially around the mid shaft 50.
Further, as shown in
Some of the slots 1002, for example those closer to the proximal end of the tube (herein referred to as the proximal slot section or proximal slots 1021), may be smaller over a portion of the length of the tube. As illustrated in
Distal to the middle slots 1023 are a plurality of distal slots 1025 (or a distal slot section), for example 18 distal slots 1025, which have a greater width than the middle slots 1023 and proximal slots 1021. The distal slots 1025 may be identical to each other. The distal slots 1025 may each be centered on center line 1010, and may continue longitudinally along the length of the tube from the distalmost middle slot 1023.
The decrease in slot width from the distal end 1006 to the proximal end 1004 can allow the mid shaft 50 to bend at the distal end 1006 prior to the proximal end 1004. Specifically, typically the higher the moment (e.g., force×distance from the force), the quicker the specific area will bend/deflect. In the mid shaft 50, the force is located at the distal end 1006, and thus the highest moment will be experienced at the proximal end 1004 as it is the farthest distance from the force. However, by having distal slots 1025 be larger than the proximal slots 1021, and thus the spine 1031 around the distal slots 1025 is smaller than around the proximal slots 1021, the distal end 1006 will bend first as there is significantly less material to bend and thus a lower moment is needed to bend, even though the distance from the force is the smallest. Further, having the transition slots 1023 with a width between the width of the distal slots 1025 and the width of the proximal slots 1021, thus creating a generally gradual change in width, can provide stress relief that would otherwise concentrate near the proximal end 1004.
The slots 1002 themselves can be generally identical in shape throughout the length of the mid shaft 50, though the dimensions (e.g., width) of the slots 1002 can vary. Each individual slot 1002 as illustrated in
Further, the flat pattern 1000 shown in
Described next is the construction for enacting a force and thus causing the bending of the above disclosed mid shafts 50 having flat patterns as described above. As shown in
Further, the steering knob 610 can compensate for foreshortening of the delivery system 10 during bending. As the different components of the delivery system 10 bend (for example, the mid shaft bending to close slots 402 or the hypotube 150 of the outer sheath assembly 22 bending to close slots 152 described below), the mid shaft 50 and the outer sheath assembly 22 will reduce in length due to the closure of the slots, which could cause accidental release of prosthesis 70. Thus, the steering knob 610 can be configured to move the outer sheath assembly 22 distally during activation of the steering knob 610, while simultaneously pulling on the pull wire 612. This can prevent unwanted relative motion of the components of the delivery system 10 or unbalanced forces, in particular unwanted release of the prosthesis 70.
The steering knob 610 in the handle 14 can be connected to a pull wire 612 generally at the proximal end of the system 10. The pull wire 612 can extend through the lumen of the mid shaft 50 and on the outside of the inner assembly 18. The pull wire 612 can connect to the outer retention ring connecter 614 which connects the distal portion of the mid shaft 50 to the outer retention ring 40. Specifically, the outer retention ring connecter 614 can act as a weld spot for the pull wire 612 through, for example, a groove in the outer retention ring connector 614. The outer retention ring connector 614 can be connected to the mid shaft 50 by a series of rivets, though the attachment mechanism is not limiting.
The pull wire 612 can be connected to the handle 14 through a proximal wire connector 1200 shown in
The pull wire 612 can then be welded in place in the longitudinal lumen radially inward from the larger end 1208. The tear-drop shaped groove 1206 is advantageous as the amount of heat the pull wire 612 is exposed to during welding decreases from the proximal end 1202 to the distal end 1204 as more mass is present neared the distal end 1204. Thus, the weld can be more consistent and less prone to issues caused by any heat-affected-zone during welding. Further, whereas most welding occurs at a 20% loss, the tear-shaped groove 1206 allows for about 5% loss or less.
A user can thus manipulate the steering knob 610 to provide or relax a proximal force on the pull wire 612. Specifically, the proximal wire connector 1200 can be placed in a channel in handle 14 that narrows at one point distal to the proximal wire connector 1200. The channel can be pulled proximally by the steering knob 610 and once the proximal wire connector 1200 abuts the narrowed portion of the channel on its distal end, the proximal wire connector 1200 (and thus the pull wire 612) will be pulled proximally along with the channel, creating a proximal force on the pull wire 612. As proximal force is enacted onto the pull wire 612, the mid shaft 50 will bend in the direction of the slot openings. The slot pattern on the mid shaft 50 will cause the mid shaft 50 to bend along the direction of the slots 402 with the enactment of the pull wire 612 force. As mentioned above, in the embodiment shown in
As the force on the pull wire 612 is removed, the mid shaft 50 can translate back (e.g., “spring back”) to its original position. This can occur at least partially due to the material (e.g., nitinol) and partially due to the construction of the ends of slots 902, which are generally T-shaped. This can be advantageous because, as discussed below, the pull wire 612 will not be compressed, thus avoiding kinks. In some embodiments, the mid shaft 50 will remain in the bent configuration even upon removal of the force. In some alternate embodiments, a second pull wire can be used, located in a different portion of the mid shaft 50. For example, the second pull wire can located 90° or 180° from the pull wire 612, thus allowing for two-way steering of the mid shaft 50. A user can operate both pull wires independently, or they can operate in tandem with one another to produce the desired bend in the mid shaft 50.
Outer Sheath Assembly Construction
As mentioned above, the outer sheath assembly 22 can be composed of a number of different parts, namely a first segment 56 a second segment 58, and a third segment 60. These different segments can have different features, builds, or constructions allowing for the segments to have properties advantageous to that particular section.
Starting at the proximalmost portion of the outer sheath assembly 22 is first segment 56 which can be in the tube of a form having a lumen throughout its length.
As shown in the figures, the first segment can be formed from a series of transverse and longitudinal slot pairs 710, which are designed to transmit torque (e.g., rotating the delivery system 10 clockwise/counter-clockwise) while being flexible. The delivery system 10 can be rotated anywhere between 0 to 180° to reposition the prosthesis 70. Each slot of the slot pairs 710 can be composed of a shorter longitudinal slot 712 and a longer circumferential slot 714 with its end connected approximately at the middle of the longitudinal slot 712. The circumferential slot 714 can be slightly on angle from the longitudinal slot 712 and thus not perpendicular to the longitudinal axis. Thus each of the slot pairs 710 can form a generally T-shaped pattern. This T-shape will allow the first segment 56 to translate back to its original position as the T-shaped pattern can distribute strain more evenly. As shown in
Further, the slot rings 714 can be repeated along the length of the first segment 56, wherein they can be repeated at a length of about 0.251 inches. The slot rings 716 can extend along approximately 38.251 inches of the first segment 56. In some embodiments, the slot rings 716 are not found in a portion at the beginning and end of the first segment 56. This portion can be about 0.719 inches in length. Any number of slot rings 716 can be used, and the number of slot rings 716 is not limiting.
The longitudinal slots 712 can have a length of about 0.5, 0.6, 0.61, 0.7, or 0.8 inches, though the particular length is not limiting. Further, the longitudinal slots 712 can have a width of about 0.0005, 0.001, 0.0015, or 0.0002 inches. Longitudinal slots 712 of the slot pairs 712 can be spaced about 0.302 inches apart.
On the other hand, the circumferential slots 714 can have a width (as measured circumferentially or transverse to the longitudinal axis of the mid shaft 50) of about 0.2765 inches. In some embodiments, the circumferential slots 714 can have a width that increases in thickness, wherein the thickness portion of the circumferential slots 714 can be located in the middle of the circumferential slots 714, thus forming an extended ovaloid shape. This ovaloid can have a radius of about 1.881 inches. For example, the thickness of the circumferential slots 714 can transition from approximately 0.001 inches at the beginning and end of the circumferential slots 714 to about approximately double in thickness. Circumferential slots 714 of the slot pairs 710 can have an overlap of approximately 0.251 inches. They can be spaced apart by approximately 0.026 inches.
As shown,
Advantageously, embodiments of the disclosed slot configuration can maintain strength and torque-transmission of, for example, stainless steel, while providing new flexibility. The configuration can handle compression, tension, and torque transmission with nearly 1:1 with no stretching. For example, a knob on the handle 14 can translate the outer sheath assembly 22 wherein every inch of turning of the knob results in an inch of translation of the outer sheath assembly 22, hence the 1:1 ratio. This is advantageous over other types of shafts, such as those formed of PEBAX, which would act like a rubber band where a user would see no response for an inch of travel of the knob as the PEBAX would stretch the whole time, and a user would be unsure when the translation would reach the distal end. The distal end would then translate suddenly and with no control, which could cause serious problems in a patient. Further, embodiments of the disclosed outer sheath assembly 22 can have minimal stretching. For example, if a 40 lb weight were attached to the outer sheath assembly, it would only stretch about 0.1 inches over an approximate 40 inches of length. Other types of sheathes, again such as PEBAX, would stretch up to 1.5 inches with the same application of force.
Moving distally, the outer sheath assembly 22 can include a third segment 60 and a second segment 58, the second segment 58 being proximal to the third segment 60. The third segment 60 may be larger in inner diameter and outer diameter than the second segment 58, and may be sized in length and inner diameter to receive a prosthesis 70 as described herein in a collapsed configuration. These two segments can each have a different diameter, thereby forming a stepped configuration.
It should be noted that the second segment 58, relative to the overall length of the delivery system 10, is still generally positioned at a distal portion of the delivery system 10 while the delivery system 10 is being used to deliver the replacement valve towards the in situ implantation site. Moreover, the outer sheath assembly 22 may include other segments positioned proximal of the second segment 58. Such segments may, for example, couple the second segment 58 to a handle of the delivery system 10. The third segment 60 can be positioned radially outward from a replacement valve when the delivery system 10 is in an initial, delivery configuration such that the replacement valve is maintained in the delivery system 10 in an undeployed configuration.
The second segment 58 can be formed from a hypotube 150 (such as a nitinol hypotube) as shown in the embodiment in
As shown, the slots 152 may be formed with a generally H-shaped structure centered on the hypotube 150. The slots 152 may have a generally T-shaped ends 153 spaced circumferentially opposite one another on the flat hypotube 150. These T-shaped ends 153 can be connected by a circumferential slot 155 extending circumferentially between the two slots. The circumferential slot 155 can change in height between the two w-shaped slots. For example, the circumferential slot 155 can have a greater height in the middle than where the circumferential slot 155 connects to the T-shaped ends 153. As shown in
In the embodiment shown in
In some embodiments, smaller slots can be used. For example, slots can be spaced offset from one another to create, for example, a spiral pattern. In some embodiments, adjacent slots can be offset by about 90°, thereby forming a repeating pattern along the longitudinal lengths of the hypotube 150.
The outer sheath assembly 22 can include a lumen running therethrough to allow the sheath assembly 22 to be moveable or slideable relative to components contained therein. The walls forming the third segment 60 and/or the walls forming the second segment 58 can be formed from one or more materials, such as PTFE, ePTFE, PEBAX, ULTEM, PEEK, urethane, nitinol, stainless steel, and/or any other biocompatible material. Preferably, the third segment 60 is formed from one or more materials which allow the third segment 60 to be compliant and flexible while still maintaining a sufficient degree of radial strength to maintain a replacement valve within the third segment 60 without substantial radial deformation which could increase friction between the third segment 60 and a replacement valve contained therein, sufficient column strength to resist buckling of the third segment 60, and sufficient tear resistance to reduce the likelihood that the replacement valve causes the third segment 60 to tear. Flexibility of the third segment 60 can be advantageous, particularly for a transseptal approach. For example, while being retracted along a curved member, the third segment 60 can follow the curved member without applying significant forces upon the curved member which may cause the curved member to decrease in radius. Rather, the third segment 60 can bend and/or kink as it is being retracted along such a curved member such that the radius of the curved member is maintained.
The hypotube 150 can be optimized for maximum flexibility and minimum strain while providing for structural rigidity. Thus, the hypotube 150 can be formed from stainless still instead of nitinol, which can advantageously incase processing/manufacturing, though other materials can be used as well. The hypotube 150 can be about 5.5, 6.0, 6.3, 6.5, 7.0, or 7.5 inches in length, the particular dimensions of the hypotube 150 is not limiting.
Delivery Method
Methods of use of the delivery system in connection with a replacement mitral valve will now be described. In particular, the delivery system 10 can be used in a method for percutaneous delivery of the replacement mitral valve to treat patients with moderate to severe mitral regurgitation. The below methods are just a few examples of the how the delivery system may be used. It will be understood that the delivery systems described herein can be used as part of other methods as well.
As shown in
Accordingly, it can be advantageous for a user to be able to steer the delivery system 10 through the complex areas of the heart in order to place a replacement mitral valve in line with the native mitral valve. This task can be performed with or without the use of a guide wire with the above disclosed system. The distal end of the delivery system can be inserted into the left atrium 1078. A user can then turn the steering knob 610 on the handle 14 in order to cause bending of the mid shaft 50, and thus the distal end of the delivery system 10. A user can then continue to pass the bent delivery system through the transseptal puncture and into the left atrium 1078. A user can then further manipulate the steering knob 610 to create an even greater bend in the mid shaft 50. Further, a user can torque the entire delivery system 10 to further manipulate and control the position of the delivery system 10. In the fully bent configuration, a user can then place the replacement mitral valve in the proper location. This can advantageously allow delivery of a replacement valve to an in situ implantation site, such as a native mitral valve, via a wider variety of approaches, such as a transseptal approach.
As shown in
It should be understood that the bending experienced by the delivery system especially between the right atrium 1076 and the mitral valve are relatively complex and are generally not in a single plane, although single plane flexibility can be used. This part of the delivery system may experience bending between 110-180 degrees and typically between 130-160 degrees, of course this is dependent on the actual anatomy of the patient.
Further descriptions of the delivery methodology, as well of a discussion of a guide wire which can be used in some embodiments, can be found in U.S. Provisional App. No. 62/210,165, filed Aug. 26, 2015.
Reference is now made to
As shown in the situation illustrated in
As illustrated in
During delivery, the distal anchors 80 (along with the frame) can be moved toward the ventricular side of the annulus 106 with the distal anchors 80 extending between at least some of the chordae tendineae 110 to provide tension on the chordae tendineae 110. The degree of tension provided on the chordae tendineae 110 can differ. For example, little to no tension may be present in the chordae tendineae 110 where the leaflet 108 is shorter than or similar in size to the distal anchors 80. A greater degree of tension may be present in the chordae tendineae 110 where the leaflet 108 is longer than the distal anchors 80 and, as such, takes on a compacted form and is pulled proximally. An even greater degree of tension may be present in the chordae tendineae 110 where the leaflets 108 are even longer relative to the distal anchors 80. The leaflet 108 can be sufficiently long such that the distal anchors 80 do not contact the annulus 106.
The proximal anchors 82 can be positioned such that the ends or tips of the proximal anchors 82 are adjacent the atrial side of the annulus 106 and/or tissue of the left atrium 1078 beyond the annulus 106. In some situations, some or all of the proximal anchors 82 may only occasionally contact or engage atrial side of the annulus 106 and/or tissue of the left atrium 1078 beyond the annulus 106. For example, as illustrate in
The annular flap 81 can be positioned such that a proximal portion of the annular flap 81 is positioned along or adjacent an atrial side of the annulus 106. The proximal portion can be positioned between the atrial side of the annulus 106 and the proximal anchors 82. The proximal portion can extend radially outward such that the annular flap 81 is positioned along or adjacent tissue of the left atrium 1078 beyond the annulus 106. The annular flap 81 can create a seal over the atrial side of the annulus 106 when the flap 81 is in the expanded state.
Alternate Valve Prosthesis
The frame 1020 can be made of many different materials, but is preferably made from metal. In some embodiments, the frame 1020 can be made from a shape memory material, such as nitinol. A wire frame or a metal tube can be used to make the frame 1020. The wire frame of a metal tube can be cut or etched to remove all but the desired metal skeleton. In some embodiments a metal tube is laser cut in a repeating pattern to form the frame 1020. As shown, one of the anchors 1022 can include an eyelet, which can help manufacturing with alignment. As the frame 1020 can be generally round and symmetric, the eyelet can serve as a reference position for frame dimensional measurements as well as alignment. However, the eyelet may not be included in all embodiments. Further, more eyelets can be included on the anchors 1022 as well, and the particular number of eyelets is not limiting. The flat pattern can be cut from a metal tube and then the tube can be shaped and/or bent to the expanded shape shown in
As shown, the frame when in an expanded configuration, such as in a fully expanded configuration, has a bulbous or slightly bulbous shape, with a middle portion 1033 being larger than the proximal 1032 and distal 1034 ends. In some embodiments, the inside diameter of the both ends can be the same, or it can be bigger on one end than the other, while still having a middle portion 1033 larger than both the proximal and distal ends 1032/1034. In some embodiments, the effective diameter of the distal frame end 1034 is smaller than the effective diameter of the middle portion 1033. The bulbous shape of the frame 1020 can advantageously allow the frame 1020 to engage a native valve annulus or other body cavity, while spacing the inlet and outlet from the heart or vessel wall. This can help reduce undesired contact between the prosthesis and the heart or vessel, such as the ventricular wall of the heart. In some embodiments, the frame 1020 may not have a bulbous portion, and can have substantially the same outer dimension along its entire length (e.g., cylindrical), or it may have one end larger than the other end. The prosthesis 1010 and frame 1020 may be similar to the replacement heart valves and associated frames disclosed in U.S. Pat. No. 8,403,983, U.S. Publication Nos. 2010/0298931, 2011/0313515, 2012/0078353, 2014/0277390, 2014/0277422, and 2014/0277427, and U.S. patent application Ser. No. 15/141,684, filed Apr. 26, 2016, the entireties of each of which are hereby incorporated by reference and made a part of this specification. This is inclusive of the entire disclosure and is not in any way limited to the disclosure of the replacement heart valves and associated frames.
A number of struts collectively make up the frame 1020.
The proximal struts 1012 and the vertical struts 1015 may be arranged so that they are parallel or generally or substantially parallel to a longitudinal axis of the frame. The proximal struts 1012 and the vertical struts 1015 can further be inclined relative to the longitudinal axis so that the proximal ends of the proximal struts 1012 are closer to the longitudinal axis than distal ends of the proximal struts 1012. The longitudinal axis of the frame 1020 may be defined as the central axis that extends through the center of the frame 1020 between the proximal 1032 and distal 1034 ends.
The illustrated embodiment includes one ring, or row of hexagonal or generally hexagonal cells 1021 shown in proximal portion 1016 of the frame 1020, and two rows of diamond-shaped cells 1023 shown in distal portion 1018. As discussed in more detail below, the proximal portion 1016 includes the portion of the hexagonal cells 1021 extending proximally from the distal end of vertical struts 1015 and may be considered to be or to include a substantially non-foreshortening portion. Foreshortening refers to the ability of the frame to longitudinally shorten as the frame radially expands. The distal portion 1018 includes the diamond-shaped cells 1023 extending distally from the distal ends of the vertical struts 1015 and may be considered a foreshortening portion. In some embodiments, the hexagonal cells 1021 can be irregular hexagons. For example, the hexagonal cells 1021 can be symmetrical about a vertical axis extending from proximal to distal ends of the hexagonal cell 1021. Vertical struts 1015 can form opposite sides, while circumferentially-expansible struts 1014 of two adjacent diamond-shaped cells 1023 in the proximalmost row can form a base of the hexagonal cell 1021 ending at a distalmost corner that is distal to the distal ends of the vertical struts 1015. These circumferentially-expansible struts 1014 can connect to the vertical struts 1015. Further, the proximal row of circumferentially-expansible struts 1017 can form the upper sides of the hexagonal cell 1021 that extend to a proximalmost corner of the hexagonal cell 1021 that is proximal to the proximal ends of vertical struts 1015. These circumferentially-expansible struts 1017 can connect to the proximal ends of the vertical struts 1015. In some embodiments, two of the sides of the hexagonal cells 1021 can be one length, while the other four sides of the hexagonal cells 1021 can be a greater length. In some embodiments, the two sides with the same length can be generally parallel to one another.
As described above, the frame 1020 has a proximal portion 1016 and a distal portion 1018. In
The frame 1020 shown in
Foreshortening of the frame 1020 can be used to engage and secure the prosthesis to intralumenal tissue in a body cavity, for example tissue at or adjacent a native valve, such as a native valve annulus and/or leaflets. Opposing anchors 1022, 1024 can be constructed on the frame 1020 so that portions of the anchors, such as tips or ends 1026, 1028, move closer together as the frame foreshortens. As one example, this can allow the anchors 1022, 1024 to grasp tissue on opposite sides of the native mitral annulus to thereby secure the prosthesis at the mitral valve. In some embodiments, one set of anchors (such as anchors 1024) are secured to or grasp tissue, while the other set of anchors (such as anchors 1022) are used to provide stabilization and help align the prosthesis, and may or may not directly engage tissue, as described further below.
The anchors 1022, 1024 and anchor tips 1026, 1028 are preferably located along the frame 1020 with at least part of the foreshortening portion positioned between the anchors so that a portion of the anchors will move closer together with expansion of the frame. As shown, distal anchors 1024 are connected to the distal portion 1018, and may extend from distalmost corners of the diamond-shaped cells 1023. As illustrated, the distal anchors 1024 extend distally from distalmost corners of the proximal row of diamond-shaped cells 1023, such that the second, distal row of diamond-shaped cells 1023 extend longitudinally alongside a portion of the distal anchors.
Preferably, each of the anchors 1022, 1024 is positioned or extends generally radially outwardly from the frame 1020 so that the anchor tips 1026, 1028 are generally spaced away or radially outward from the rest of the frame 1020 and from where the base of the anchors connect to the frame. For example, the anchor tips may be located radially outward from the middle portion 1033 of the frame, with the tips 1026 and 1028 being axially spaced from one another. The middle portion 1033, which has the largest cross-sectional dimension when the frame is radially expanded, can be defined by the proximalmost row of diamond-shaped cells 1023. The anchors 1022, 1024 can include a base located on the anchor on a side opposite the tip. The base can be for example where the anchor begins to extend from or away from the frame 1020.
Proximal anchors 1022 are shown having a single strut extending into the hexagonal cells 1021 of portion 1016. Thus, the anchor 1022 extends from a proximal intersection of two segments of the hexagonal cell 1021, for example, from the proximalmost corner of the hexagonal cells 1021. As shown, the proximal anchors 1022 extend generally distally into the hexagonal cells 1021 while curving outwards away from the frame 1020. Thus, the anchor 1022 extends radially outwardly from the frame 1020 as it extends generally distally towards the tip 1026. The tips 1026 of the proximal anchors 1022 can end after extending approximately half the length or more of the hexagonal cells 1021. Further, the tips 1026 can extend farther outwards than the main body of the frame 1020.
In some embodiments, the tip 1026 of the anchor 1022 also includes an enlarged or bulbed portion 1026, which can be generally circular in shape, though the particular shape is not limiting. As illustrated, the bulbed portion 1026 is located at the distal end, though the bulbed portion 1026 can be positioned in other locations along the anchor 1022. The bulbed portion 1026 can have a radius greater than the width of the rest of the anchor 1022, making the bulbed portion 1026 larger than the rest of the anchor 1022. As illustrated, the enlarged or bulbed portions can extend in a direction generally or substantially perpendicular to the longitudinal axis, caused for example by gradual bending of the anchor 1022 distally and radially outwardly.
As another example, the distal anchors 1024 are shown having looped ends 1048. The looped ends can be larger near the tip to form a type of elongated teardrop. In some embodiments, the tips 1028 may be substantially flat. The looped end may assist the frame in not getting caught up on structures at or near the treatment location. For example, each loop can be configured so that when the frame is deployed in-situ and expands, the movement of each loop from a delivered position to a deployed position avoids getting caught on the papillary muscles.
Each distal anchor 1024 is connected to the frame at a base 1042. As illustrated in
It will be understood that the anchors can have various other configurations, including the various embodiments that follow. In some embodiments, each of the anchors can extend radially outwardly from the frame at an anchor base and terminate at an anchor tip. The anchors can be connected to the frame at one of many different locations including apices, junctions, other parts of struts, etc. The anchors can comprise first, second, third, or more spaced apart bending stages along the length of each anchor. The anchors can also extend either distally or proximally before and/or after one or more of the bending stages. A portion of the anchor may extend with the frame before or after any bending stages.
The tips or ends 1013 of proximal struts 1012 can be enlarged relative to other portions of the tips 1013. For example, the ends of tips 1013 can have a generally “mushroom” shape. The proximal struts 1012 and enlarged tips 1013 can form locking tabs used to engage a locking mechanism of a delivery system for the prosthesis. In some embodiments, the longitudinal extensions 1012 and the mushroom tips 1013 can be inclined generally radially inward.
Delivery Method
The system 10 can first be positioned to a particular location in a patient's body, such as at the native mitral valve, through the use of the steering mechanisms discussed herein or other techniques. With reference next to the step of
With reference next to the step of
Accordingly, during this step the system 10 may be moved proximally or distally to cause the distal or ventricular anchors 1024 to properly capture the native mitral valve leaflets. In particular, the tips of the ventricular anchors 1024 may be moved proximally to engage a ventricular side of the native annulus, so that the native leaflets are positioned between the anchors 1024 and the body of the prosthesis 1010. When the prosthesis 1010 is in its final position, there may or may not be tension on the chordae, though the distal anchors 1024 can be located between at least some of the chordae.
As shown in
With reference next to the step of
Alternative Systems and Modifications
As shown in
Surrounding the outer sheath assembly 22 can be a stationary sheath (or shaft) 5021. The stationary sheath 5021 can extend partially down the length of the system 5000. The proximal end of the stationary sheath 5021 can be fixed to the handle 5014.
Surrounding the stationary sheath 5021 can be the integrated (or live-on) introducer sheath 5023. The introducer sheath 5023 can be relatively rigid, and approximately a foot in length, though the particular dimensions are not limiting. The introducer sheath 5023 can contain a hemostasis gasket within its lumen that can seal with the stationary sheath 5021. In some embodiments, introducer sheath 5023 can be a braided 72D Pebax shaft with a PTFE internal liner, though other materials can be used as well. Further, the introducer sheath 5023 can include a port assembly 5025 for flushing of the lumen of the introducer sheath 5023.
The stationary sheath 5021 allows the outer sheath assembly 22 to be withdrawn through the introducer sheath 5023 without unwanted movement of the system 5000. For example, if the gasket of the introducer sheath 5023 was sealed onto the outer sheath assembly 22, attempts to retract the outer sheath assembly 22 may move the entire system 5000 forward instead due to the high friction of the gasket on the outer sheath assembly 22.
Moving now to
Accordingly, the spacer sleeve 5020 can float between the two layers (inner assembly 18 running through its lumen and the mid shaft assembly 20 being on the outside) which can take out any of the extra space. Thus, when the prosthesis 70/1010 is released, the inner assembly 18 no longer snakes and is held concentric. This can lead to a 1:1 motion during prosthesis 70/1010 release and a smooth and reliable prosthesis 70/1010 release.
The spacer sleeve 5020 can be mechanically contained by the other lumens and components (e.g., radially by the inner assembly 18 and mid shaft assembly 20 and longitudinally by the outer retention ring 40 and the first segment 43 of the mid shaft assembly 20), and is thus not physically attached to any of the other components, allowing the spacer sleeve 5020 to be “floating” in that area. In some embodiments, the spacer sleeve 5020 may have a shorter length than the mid shaft 50, in some embodiments approximately 1 cm shorter. The floating aspect of the spacer sleeve 5020 allows it to move where needed during deflection and provide a support and/or lubricious bear surface/surfaces. However, in some embodiments, the spacer sleeve 5020 can be connected to other components.
Further,
The deflection knob 5032, indicator section 5036, and mid shaft retraction knob 5035 can be generally connected and translated as one section, or sleigh, 5038 over the rest of the handle 5014 designated as stationary portion 5030.
Specifically, as shown the stationary portion 5030 includes outer threads 5031 that can be threadably attached to the mid shaft retraction knob 5035, such as with inner threads 5041. The proximal end of the mid shaft assembly 20 can be attached to an internal surface of the mid shaft retraction knob 5035. Thus, as the mid shaft retraction knob 5035 is rotated, it translates proximally or distally on the outer threads 5031 of the handle 5014. Thus, as the mid shaft retraction knob 5035 is rotated, the mid shaft assembly 20, deflection knob 5032, and indicator section 5036 translate along the thread as well. Accordingly, the sleigh 5038 can have a distal position (
Indicators section 5036 can include indicators on the outer surface of the handle 5014 in order to provide a user with visual or auditory indications of the locations of certain parts of the system 5000. For example, in some embodiments, the indicators 5036 can provide visual or auditory indications of the deflection of the distal end of the system 5000. The indicator 5036 can contain “speed bumps” on an inside surface of a slot that can provide a clicking sound as the distal end of the system 5000 is deflected. In some embodiments, the indicators 5036 can include a number of a tab running through a slot with a number of markings, each marking being one rotation of the deflection knob 5032 as the tab passes through the slot.
In some embodiments, proximal connections of the mid shaft assembly 20 and the inner assembly 18 can include snap features to secure them (typically as rigid hypotubes on their proximal end) to the internal portions of the handle 5014. These snap features can provide strong connections and can resist both torque and compression/tension. In some embodiments, the snap connections can be supported externally from another component, which further prevents them from disengaging during use. Additionally, in some embodiments an O-ring can be used to seal the snap mechanisms hemostatically.
Operation of Handle
Discussed next is the operation of the distal end of the system 5000, shown in
First, the distal end 5013 of the system 5000 is positioned into the desired location, such as at the mitral valve. The deflection knob 5032 can be rotated to pull the pull wire 612 attached to the outer retention ring 40. Thus, as the deflection knob 5032 is rotated, the mid shaft 50 will bend along the direction of the pull wire 612. Thus, this bending can be used to position the system 5000, in particular the distal end, at the desired patient location, such as at the native mitral valve. In some embodiments, rotation of the deflection knob can help steer the distal end of the delivery system 5000 through the septum and left atrium and into the left ventricle so that the prosthesis 1010 is located at the native mitral valve.
Further, rotation of the deflection knob 5032 can push the mid shaft 50 distally, in some cases simultaneously with the pulling of the pull wire 612, thus preventing unwanted release of the prosthesis 1010. The deflection knob 5032 can perform this action by having two sets of threads 5043/5045 on its internal surface that are in opposite directions. One of the threads is attached to the pull wire 612, and the other is attached to the mid shaft 50. Thus, when the deflection knob 5032 is rotated, one set of threads 5043 pull the pull wire 612 proximally while the other set of threads 5045 push the mid shaft 50 distally.
The system 5000 can be used to place the prosthesis 1010, covered by the outer sheath assembly 22 at this time, so that a central portion of the prosthesis 1010 is along the plane formed by the native mitral annulus. Thus, at this time the atrial anchors 1022 can be located in the left atrium and the ventricular anchors 1024 can be located in the left ventricle.
Next, the outer sheath assembly knob 5033 can be rotated in order to retract the outer sheath assembly 22 proximally relative to the nose cone 28, as shown in
At this time, the prosthesis 1010 can be repositioned as need be in the mitral valve area. For example, the system 5000 can be moved proximally or distally to capture the native valve leaflets by the ventricular anchors 1024, with the ventricular anchors 1024 positioned behind (or radially outward) of the native valve leaflets. In some embodiments, rotation of the outer sheath assembly knob 5033 to release the prosthesis 1010 will cause the ventricular anchors 1024 to hold the native mitral valve leaflets, such as shown in
Once the prosthesis 1010 is in the desired position, such as with the ventricular anchors 1024 secured to tissue on a ventricular side of the native mitral valve annulus, the mid shaft retraction knob 5035 can then be rotated to retract the mid shaft assembly 20 proximally, as shown in
After release of the prosthesis 1010, the nose cone articulator 5037 can be moved proximally in order to withdraw the nose cone 28 through the prosthesis 1010 and into the outer sheath assembly 22 so that the nose cone 28 does not catch on tissue while removing the system 5000. Once the nose cone 28 is in the proper position, the entire system 5000 can be withdrawn from the patient.
From the foregoing description, it will be appreciated that an inventive product and approaches for implant delivery systems are disclosed. While several components, techniques and aspects have been described with a certain degree of particularity, it is manifest that many changes can be made in the specific designs, constructions and methodology herein above described without departing from the spirit and scope of this disclosure.
Certain features that are described in this disclosure in the context of separate implementations can also be implemented in combination in a single implementation. Conversely, various features that are described in the context of a single implementation can also be implemented in multiple implementations separately or in any suitable subcombination. Moreover, although features may be described above as acting in certain combinations, one or more features from a claimed combination can, in some cases, be excised from the combination, and the combination may be claimed as any subcombination or variation of any subcombination.
Moreover, while methods may be depicted in the drawings or described in the specification in a particular order, such methods need not be performed in the particular order shown or in sequential order, and that all methods need not be performed, to achieve desirable results. Other methods that are not depicted or described can be incorporated in the example methods and processes. For example, one or more additional methods can be performed before, after, simultaneously, or between any of the described methods. Further, the methods may be rearranged or reordered in other implementations. Also, the separation of various system components in the implementations described above should not be understood as requiring such separation in all implementations, and it should be understood that the described components and systems can generally be integrated together in a single product or packaged into multiple products. Additionally, other implementations are within the scope of this disclosure.
Conditional language, such as “can,” “could,” “might,” or “may,” unless specifically stated otherwise, or otherwise understood within the context as used, is generally intended to convey that certain embodiments include or do not include, certain features, elements, and/or steps. Thus, such conditional language is not generally intended to imply that features, elements, and/or steps are in any way required for one or more embodiments.
Conjunctive language such as the phrase “at least one of X, Y, and Z,” unless specifically stated otherwise, is otherwise understood with the context as used in general to convey that an item, term, etc. may be either X, Y, or Z. Thus, such conjunctive language is not generally intended to imply that certain embodiments require the presence of at least one of X, at least one of Y, and at least one of Z.
Language of degree used herein, such as the terms “approximately,” “about,” “generally,” and “substantially” as used herein represent a value, amount, or characteristic close to the stated value, amount, or characteristic that still performs a desired function or achieves a desired result. For example, the terms “approximately”, “about”, “generally,” and “substantially” may refer to an amount that is within less than or equal to 10% of, within less than or equal to 5% of, within less than or equal to 1% of, within less than or equal to 0.1% of, and within less than or equal to 0.01% of the stated amount. If the stated amount is 0 (e.g., none, having no), the above recited ranges can be specific ranges, and not within a particular % of the value. For example, within less than or equal to 10 wt./vol. % of, within less than or equal to 5 wt./vol. % of, within less than or equal to 1 wt./vol. % of, within less than or equal to 0.1 wt./vol. % of, and within less than or equal to 0.01 wt./vol. % of the stated amount.
Some embodiments have been described in connection with the accompanying drawings. The figures are drawn to scale, but such scale should not be limiting, since dimensions and proportions other than what are shown are contemplated and are within the scope of the disclosed inventions. Distances, angles, etc. are merely illustrative and do not necessarily bear an exact relationship to actual dimensions and layout of the devices illustrated. Components can be added, removed, and/or rearranged. Further, the disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with various embodiments can be used in all other embodiments set forth herein. Additionally, it will be recognized that any methods described herein may be practiced using any device suitable for performing the recited steps.
While a number of embodiments and variations thereof have been described in detail, other modifications and methods of using the same will be apparent to those of skill in the art. Accordingly, it should be understood that various applications, modifications, materials, and substitutions can be made of equivalents without departing from the unique and inventive disclosure herein or the scope of the claims.
This Application claims the benefit of U.S. Provisional Application No. 62/211,574, filed Aug. 28, 2015, titled “STEERABLE DELIVERY SYSTEM FOR REPLACMENT MITRAL VALVE AND METHODS OF USE,” and U.S. Provisional Application No. 62/349,326, filed Jun. 13, 2016, titled “STEERABLE DELIVERY SYSTEM FOR REPLACMENT MITRAL VALVE AND METHODS OF USE,” the entirety of each of which is incorporated herein by reference.
| Number | Name | Date | Kind |
|---|---|---|---|
| 3657744 | Ersek | Apr 1972 | A |
| 3671979 | Moulopoulos | Jun 1972 | A |
| 3739402 | Cooley et al. | Jun 1973 | A |
| 4056854 | Boretos et al. | Nov 1977 | A |
| 4079468 | Liotta et al. | Mar 1978 | A |
| 4204283 | Bellhouse et al. | May 1980 | A |
| 4222126 | Boretos et al. | Sep 1980 | A |
| 4265694 | Boretos et al. | May 1981 | A |
| 4339831 | Johnson | Jul 1982 | A |
| 4340977 | Brownlee et al. | Jul 1982 | A |
| 4470157 | Love | Sep 1984 | A |
| 4477930 | Totten et al. | Oct 1984 | A |
| 4490859 | Black et al. | Jan 1985 | A |
| 4553545 | Maass et al. | Nov 1985 | A |
| 4777951 | Cribier et al. | Oct 1988 | A |
| 4865600 | Carpentier et al. | Sep 1989 | A |
| 4994077 | Dobben | Feb 1991 | A |
| 5326371 | Love et al. | Jul 1994 | A |
| 5332402 | Teitelbaum | Jul 1994 | A |
| 5370685 | Stevens | Dec 1994 | A |
| 5411552 | Andersen et al. | May 1995 | A |
| 5415667 | Frater | May 1995 | A |
| 5545214 | Stevens | Aug 1996 | A |
| 5554185 | Block et al. | Sep 1996 | A |
| 5697382 | Love et al. | Dec 1997 | A |
| 5840081 | Andersen et al. | Nov 1998 | A |
| 5855601 | Bessler et al. | Jan 1999 | A |
| 5944690 | Falwell et al. | Aug 1999 | A |
| 5957949 | Leonhardt et al. | Sep 1999 | A |
| 6086612 | Jansen | Jul 2000 | A |
| 6113631 | Jansen | Sep 2000 | A |
| 6168614 | Andersen et al. | Jan 2001 | B1 |
| 6251093 | Valley et al. | Jun 2001 | B1 |
| 6312465 | Griffin et al. | Nov 2001 | B1 |
| 6358277 | Duran | Mar 2002 | B1 |
| 6440164 | Di Matteo et al. | Aug 2002 | B1 |
| 6458153 | Bailey et al. | Oct 2002 | B1 |
| 6482228 | Norred | Nov 2002 | B1 |
| 6527800 | McGuckin, Jr. et al. | Mar 2003 | B1 |
| 6582462 | Andersen et al. | Jun 2003 | B1 |
| 6610088 | Gabbay | Aug 2003 | B1 |
| 6629534 | St. Goar et al. | Oct 2003 | B1 |
| 6652578 | Bailey et al. | Nov 2003 | B2 |
| 6676698 | McGuckin, Jr. et al. | Jan 2004 | B2 |
| 6695878 | McGuckin, Jr. et al. | Feb 2004 | B2 |
| 6712836 | Berg et al. | Mar 2004 | B1 |
| 6716207 | Farnholtz | Apr 2004 | B2 |
| 6729356 | Baker et al. | May 2004 | B1 |
| 6730118 | Spenser et al. | May 2004 | B2 |
| 6746422 | Noriega et al. | Jun 2004 | B1 |
| 6749560 | Konstorum et al. | Jun 2004 | B1 |
| 6767362 | Schreck | Jul 2004 | B2 |
| 6780200 | Jansen | Aug 2004 | B2 |
| 6790229 | Berreklouw | Sep 2004 | B1 |
| 6790230 | Beyersdorf et al. | Sep 2004 | B2 |
| 6875231 | Anduiza et al. | Apr 2005 | B2 |
| 6893460 | Spenser et al. | May 2005 | B2 |
| 6908481 | Cribier | Jun 2005 | B2 |
| 7018406 | Seguin et al. | Mar 2006 | B2 |
| 7186265 | Sharkawy et al. | Mar 2007 | B2 |
| 7192440 | Andreas et al. | Mar 2007 | B2 |
| 7198646 | Figulla et al. | Apr 2007 | B2 |
| 7201772 | Schwammenthal et al. | Apr 2007 | B2 |
| 7276078 | Spenser et al. | Oct 2007 | B2 |
| 7329278 | Seguin et al. | Feb 2008 | B2 |
| 7381219 | Salahieh et al. | Jun 2008 | B2 |
| 7393360 | Spenser et al. | Jul 2008 | B2 |
| 7429269 | Schwammenthal et al. | Sep 2008 | B2 |
| 7442204 | Schwammenthal et al. | Oct 2008 | B2 |
| 7445631 | Salahieh et al. | Nov 2008 | B2 |
| 7462191 | Spenser et al. | Dec 2008 | B2 |
| 7510575 | Spenser et al. | Mar 2009 | B2 |
| 7524330 | Berreklouw | Apr 2009 | B2 |
| 7553324 | Andreas et al. | Jun 2009 | B2 |
| 7585321 | Cribier | Sep 2009 | B2 |
| 7618446 | Andersen et al. | Nov 2009 | B2 |
| 7621948 | Herrmann et al. | Nov 2009 | B2 |
| 7628805 | Spenser et al. | Dec 2009 | B2 |
| 7748389 | Salahieh et al. | Jul 2010 | B2 |
| 7753949 | Lamphere et al. | Jul 2010 | B2 |
| 7803185 | Gabbay | Sep 2010 | B2 |
| 7806919 | Bloom et al. | Oct 2010 | B2 |
| 7815673 | Bloom et al. | Oct 2010 | B2 |
| 7824443 | Salahieh et al. | Nov 2010 | B2 |
| 7892281 | Seguin et al. | Feb 2011 | B2 |
| 7914569 | Nguyen et al. | Mar 2011 | B2 |
| 7918880 | Austin | Apr 2011 | B2 |
| 7947075 | Goetz et al. | May 2011 | B2 |
| 7959672 | Salahieh et al. | Jun 2011 | B2 |
| 7972378 | Tabor et al. | Jul 2011 | B2 |
| 7981151 | Rowe | Jul 2011 | B2 |
| 7993392 | Righini et al. | Aug 2011 | B2 |
| 8016877 | Seguin et al. | Sep 2011 | B2 |
| 8048153 | Salahieh et al. | Nov 2011 | B2 |
| 8052750 | Tuval et al. | Nov 2011 | B2 |
| 8070800 | Lock et al. | Dec 2011 | B2 |
| 8070802 | Lamphere et al. | Dec 2011 | B2 |
| 8075615 | Eberhardt et al. | Dec 2011 | B2 |
| 8080054 | Rowe | Dec 2011 | B2 |
| 8092520 | Quadri | Jan 2012 | B2 |
| 8109996 | Stacchino et al. | Feb 2012 | B2 |
| 8118866 | Herrmann et al. | Feb 2012 | B2 |
| 8136218 | Millwee et al. | Mar 2012 | B2 |
| 8137398 | Tuval et al. | Mar 2012 | B2 |
| 8157852 | Bloom et al. | Apr 2012 | B2 |
| 8167934 | Styrc et al. | May 2012 | B2 |
| 8182528 | Salahieh et al. | May 2012 | B2 |
| 8182530 | Huber | May 2012 | B2 |
| 8216301 | Bonhoeffer et al. | Jul 2012 | B2 |
| 8219229 | Cao et al. | Jul 2012 | B2 |
| 8220121 | Hendriksen et al. | Jul 2012 | B2 |
| 8221493 | Boyle et al. | Jul 2012 | B2 |
| 8226710 | Nguyen et al. | Jul 2012 | B2 |
| 8236045 | Benichou et al. | Aug 2012 | B2 |
| 8246675 | Zegdi | Aug 2012 | B2 |
| 8246678 | Salahieh et al. | Aug 2012 | B2 |
| 8252051 | Chau et al. | Aug 2012 | B2 |
| 8252052 | Salahieh et al. | Aug 2012 | B2 |
| 8287584 | Salahieh et al. | Oct 2012 | B2 |
| 8303653 | Bonhoeffer et al. | Nov 2012 | B2 |
| 8313525 | Tuval et al. | Nov 2012 | B2 |
| 8323335 | Rowe et al. | Dec 2012 | B2 |
| 8353953 | Giannetti et al. | Jan 2013 | B2 |
| 8403983 | Quadri et al. | Mar 2013 | B2 |
| 8414644 | Quadri et al. | Apr 2013 | B2 |
| 8414645 | Dwork et al. | Apr 2013 | B2 |
| 8444689 | Zhang | May 2013 | B2 |
| 8449599 | Chau et al. | May 2013 | B2 |
| 8454685 | Hariton et al. | Jun 2013 | B2 |
| 8460368 | Taylor et al. | Jun 2013 | B2 |
| 8470023 | Eidenschink et al. | Jun 2013 | B2 |
| 8475521 | Suri et al. | Jul 2013 | B2 |
| 8475523 | Duffy | Jul 2013 | B2 |
| 8479380 | Malewicz et al. | Jul 2013 | B2 |
| 8486137 | Suri et al. | Jul 2013 | B2 |
| 8491650 | Wiemeyer et al. | Jul 2013 | B2 |
| 8500733 | Watson | Aug 2013 | B2 |
| 8500798 | Rowe et al. | Aug 2013 | B2 |
| 8511244 | Holecek et al. | Aug 2013 | B2 |
| 8512401 | Murray, III et al. | Aug 2013 | B2 |
| 8518096 | Nelson | Aug 2013 | B2 |
| 8518106 | Duffy et al. | Aug 2013 | B2 |
| 8562663 | Mearns et al. | Oct 2013 | B2 |
| 8579963 | Tabor | Nov 2013 | B2 |
| 8579964 | Lane et al. | Nov 2013 | B2 |
| 8579965 | Bonhoeffer et al. | Nov 2013 | B2 |
| 8585755 | Chau et al. | Nov 2013 | B2 |
| 8585756 | Bonhoeffer et al. | Nov 2013 | B2 |
| 8591570 | Revuelta et al. | Nov 2013 | B2 |
| 8597348 | Rowe et al. | Dec 2013 | B2 |
| 8617236 | Paul et al. | Dec 2013 | B2 |
| 8640521 | Righini et al. | Feb 2014 | B2 |
| 8647381 | Essinger et al. | Feb 2014 | B2 |
| 8652145 | Maimon et al. | Feb 2014 | B2 |
| 8652201 | Oberti et al. | Feb 2014 | B2 |
| 8652202 | Alon et al. | Feb 2014 | B2 |
| 8652203 | Quadri et al. | Feb 2014 | B2 |
| 8668733 | Haug et al. | Mar 2014 | B2 |
| 8673000 | Tabor et al. | Mar 2014 | B2 |
| 8679174 | Ottma et al. | Mar 2014 | B2 |
| 8679404 | Liburd et al. | Mar 2014 | B2 |
| 8685086 | Navia et al. | Apr 2014 | B2 |
| 8721708 | Seguin et al. | May 2014 | B2 |
| 8721714 | Kelley | May 2014 | B2 |
| 8728154 | Alkhatib | May 2014 | B2 |
| 8728155 | Montorfano et al. | May 2014 | B2 |
| 8740974 | Lambrecht et al. | Jun 2014 | B2 |
| 8740976 | Tran et al. | Jun 2014 | B2 |
| 8747458 | Tuval et al. | Jun 2014 | B2 |
| 8747459 | Nguyen et al. | Jun 2014 | B2 |
| 8747460 | Tuval et al. | Jun 2014 | B2 |
| 8758432 | Solem | Jun 2014 | B2 |
| 8764818 | Gregg | Jul 2014 | B2 |
| 8771344 | Tran et al. | Jul 2014 | B2 |
| 8771345 | Tuval et al. | Jul 2014 | B2 |
| 8771346 | Tuval et al. | Jul 2014 | B2 |
| 8778020 | Gregg et al. | Jul 2014 | B2 |
| 8784337 | Voeller et al. | Jul 2014 | B2 |
| 8784478 | Tuval et al. | Jul 2014 | B2 |
| 8784481 | Alkhatib et al. | Jul 2014 | B2 |
| 8790387 | Nguyen et al. | Jul 2014 | B2 |
| 8795356 | Quadri et al. | Aug 2014 | B2 |
| 8795357 | Yohanan et al. | Aug 2014 | B2 |
| 8808356 | Braido et al. | Aug 2014 | B2 |
| 8828078 | Salahieh et al. | Sep 2014 | B2 |
| 8828079 | Thielen et al. | Sep 2014 | B2 |
| 8834564 | Tuval et al. | Sep 2014 | B2 |
| 8845718 | Tuval et al. | Sep 2014 | B2 |
| 8858620 | Salahieh et al. | Oct 2014 | B2 |
| 8870948 | Erzberger et al. | Oct 2014 | B1 |
| 8870950 | Hacohen | Oct 2014 | B2 |
| 8876893 | Dwork et al. | Nov 2014 | B2 |
| 8876894 | Tuval et al. | Nov 2014 | B2 |
| 8876895 | Tuval et al. | Nov 2014 | B2 |
| 8911455 | Quadri et al. | Dec 2014 | B2 |
| 8926693 | Duffy et al. | Jan 2015 | B2 |
| 8926694 | Costello | Jan 2015 | B2 |
| 8939960 | Rosenman et al. | Jan 2015 | B2 |
| 8945209 | Bonyuet et al. | Feb 2015 | B2 |
| 8951299 | Paul et al. | Feb 2015 | B2 |
| 8961593 | Bonhoeffer et al. | Feb 2015 | B2 |
| 8961595 | Alkhatib | Feb 2015 | B2 |
| 8974524 | Yeung et al. | Mar 2015 | B2 |
| 8979922 | Jayasinghe et al. | Mar 2015 | B2 |
| 8986372 | Murry, III et al. | Mar 2015 | B2 |
| 8986375 | Garde et al. | Mar 2015 | B2 |
| 8992608 | Haug et al. | Mar 2015 | B2 |
| 8998979 | Seguin et al. | Apr 2015 | B2 |
| 8998980 | Shipley et al. | Apr 2015 | B2 |
| 9005273 | Salahieh et al. | Apr 2015 | B2 |
| 9011521 | Haug et al. | Apr 2015 | B2 |
| 9011523 | Seguin | Apr 2015 | B2 |
| 9011524 | Eberhardt | Apr 2015 | B2 |
| 9028545 | Taylor | May 2015 | B2 |
| 9034032 | McLean et al. | May 2015 | B2 |
| 9034033 | McLean et al. | May 2015 | B2 |
| 9039757 | McLean et al. | May 2015 | B2 |
| 9055937 | Rowe et al. | Jun 2015 | B2 |
| 9066801 | Kovalsky et al. | Jun 2015 | B2 |
| 9078749 | Lutter et al. | Jul 2015 | B2 |
| 9078751 | Naor | Jul 2015 | B2 |
| 9084676 | Chau et al. | Jul 2015 | B2 |
| 9125738 | Figulla et al. | Sep 2015 | B2 |
| 9138312 | Tuval et al. | Sep 2015 | B2 |
| 9155619 | Liu et al. | Oct 2015 | B2 |
| 9161834 | Taylor et al. | Oct 2015 | B2 |
| 9173737 | Hill et al. | Nov 2015 | B2 |
| 9180004 | Alkhatib | Nov 2015 | B2 |
| 9186249 | Rolando et al. | Nov 2015 | B2 |
| 9220594 | Braido et al. | Dec 2015 | B2 |
| 9241790 | Lane et al. | Jan 2016 | B2 |
| 9248014 | Lane et al. | Feb 2016 | B2 |
| 9277990 | Klima et al. | Mar 2016 | B2 |
| 9277993 | Gamarra et al. | Mar 2016 | B2 |
| 9289291 | Gorman, III et al. | Mar 2016 | B2 |
| 9289296 | Braido et al. | Mar 2016 | B2 |
| 9295551 | Straubinger et al. | Mar 2016 | B2 |
| 9326815 | Watson | May 2016 | B2 |
| 9331328 | Eberhardt et al. | May 2016 | B2 |
| 9339382 | Tabor et al. | May 2016 | B2 |
| 9351831 | Braido et al. | May 2016 | B2 |
| 9351832 | Braido et al. | May 2016 | B2 |
| 9364321 | Alkhatib et al. | Jun 2016 | B2 |
| 9445897 | Bishop et al. | Sep 2016 | B2 |
| 9456877 | Weitzner et al. | Oct 2016 | B2 |
| 9586025 | Salahieh et al. | Mar 2017 | B2 |
| 9681968 | Goetz et al. | Jun 2017 | B2 |
| 9700329 | Metzger et al. | Jul 2017 | B2 |
| 9700411 | Klima et al. | Jul 2017 | B2 |
| 9795479 | Lim et al. | Oct 2017 | B2 |
| 9833313 | Board et al. | Dec 2017 | B2 |
| 9861473 | Lafontaine | Jan 2018 | B2 |
| 9861476 | Salahieh et al. | Jan 2018 | B2 |
| 9861477 | Backus et al. | Jan 2018 | B2 |
| 9867698 | Kovalsky et al. | Jan 2018 | B2 |
| 9877830 | Lim et al. | Jan 2018 | B2 |
| 9889029 | Li et al. | Feb 2018 | B2 |
| 9895225 | Rolando et al. | Feb 2018 | B2 |
| 9925045 | Creaven et al. | Mar 2018 | B2 |
| 20010007956 | Letac et al. | Jul 2001 | A1 |
| 20020016623 | Kula et al. | Feb 2002 | A1 |
| 20020032481 | Gabbay | Mar 2002 | A1 |
| 20020045929 | Diaz | Apr 2002 | A1 |
| 20020052644 | Shaolian et al. | May 2002 | A1 |
| 20030105517 | White et al. | Jun 2003 | A1 |
| 20030120333 | Ouriel et al. | Jun 2003 | A1 |
| 20030130729 | Paniagua et al. | Jul 2003 | A1 |
| 20030176914 | Rabkin et al. | Sep 2003 | A1 |
| 20030199971 | Tower et al. | Oct 2003 | A1 |
| 20030220683 | Minasian et al. | Nov 2003 | A1 |
| 20040117009 | Cali et al. | Jun 2004 | A1 |
| 20040133273 | Cox | Jul 2004 | A1 |
| 20040186561 | McGuckin et al. | Sep 2004 | A1 |
| 20040210304 | Seguin et al. | Oct 2004 | A1 |
| 20040210307 | Khairkhahan | Oct 2004 | A1 |
| 20040215325 | Penn et al. | Oct 2004 | A1 |
| 20040225353 | McGuckin et al. | Nov 2004 | A1 |
| 20040236411 | Sarac et al. | Nov 2004 | A1 |
| 20050033398 | Seguin | Feb 2005 | A1 |
| 20050075727 | Wheatley | Apr 2005 | A1 |
| 20050090887 | Pryor | Apr 2005 | A1 |
| 20050096738 | Cali et al. | May 2005 | A1 |
| 20050107872 | Mensah et al. | May 2005 | A1 |
| 20050137682 | Justino | Jun 2005 | A1 |
| 20050137686 | Salahieh et al. | Jun 2005 | A1 |
| 20050137687 | Salahieh et al. | Jun 2005 | A1 |
| 20050137691 | Salahieh et al. | Jun 2005 | A1 |
| 20050137693 | Haug et al. | Jun 2005 | A1 |
| 20050159811 | Lane | Jul 2005 | A1 |
| 20050182486 | Gabbay | Aug 2005 | A1 |
| 20050216079 | MaCoviak | Sep 2005 | A1 |
| 20050234546 | Nugent et al. | Oct 2005 | A1 |
| 20050283231 | Haug et al. | Dec 2005 | A1 |
| 20060020327 | Lashinski et al. | Jan 2006 | A1 |
| 20060052867 | Revuelta et al. | Mar 2006 | A1 |
| 20060058872 | Salahieh et al. | Mar 2006 | A1 |
| 20060095115 | Bladillah et al. | May 2006 | A1 |
| 20060100687 | Fahey et al. | May 2006 | A1 |
| 20060173537 | Yang et al. | Aug 2006 | A1 |
| 20060195183 | Navia et al. | Aug 2006 | A1 |
| 20060212110 | Osborne et al. | Sep 2006 | A1 |
| 20060241745 | Solem | Oct 2006 | A1 |
| 20060259135 | Navia et al. | Nov 2006 | A1 |
| 20060265056 | Nguyen et al. | Nov 2006 | A1 |
| 20060287717 | Rowe et al. | Dec 2006 | A1 |
| 20060293745 | Carpentier et al. | Dec 2006 | A1 |
| 20070010876 | Salahieh et al. | Jan 2007 | A1 |
| 20070043435 | Seguin et al. | Feb 2007 | A1 |
| 20070050021 | Johnson | Mar 2007 | A1 |
| 20070100432 | Case et al. | May 2007 | A1 |
| 20070129794 | Realyvasquez | Jun 2007 | A1 |
| 20070142906 | Figulla et al. | Jun 2007 | A1 |
| 20070213813 | Von Segesser et al. | Sep 2007 | A1 |
| 20070255394 | Ryan | Nov 2007 | A1 |
| 20080021546 | Patz et al. | Jan 2008 | A1 |
| 20080071366 | Tuval et al. | Mar 2008 | A1 |
| 20080082164 | Friedman | Apr 2008 | A1 |
| 20080082165 | Wilson et al. | Apr 2008 | A1 |
| 20080097581 | Shanley | Apr 2008 | A1 |
| 20080147179 | Cai et al. | Jun 2008 | A1 |
| 20080147183 | Styrc | Jun 2008 | A1 |
| 20080161911 | Revuelta et al. | Jul 2008 | A1 |
| 20080177381 | Navia et al. | Jul 2008 | A1 |
| 20080183273 | Mesana et al. | Jul 2008 | A1 |
| 20080208328 | Antocci et al. | Aug 2008 | A1 |
| 20080228254 | Ryan | Sep 2008 | A1 |
| 20090005863 | Goetz et al. | Jan 2009 | A1 |
| 20090138079 | Tuval et al. | May 2009 | A1 |
| 20090171456 | Kveen et al. | Jul 2009 | A1 |
| 20090182413 | Burkart et al. | Jul 2009 | A1 |
| 20090188964 | Orlov | Jul 2009 | A1 |
| 20090270972 | Lane | Oct 2009 | A1 |
| 20090276027 | Glynn | Nov 2009 | A1 |
| 20090276040 | Rowe et al. | Nov 2009 | A1 |
| 20090281618 | Hill et al. | Nov 2009 | A1 |
| 20090287296 | Manasse | Nov 2009 | A1 |
| 20090292350 | Eberhardt et al. | Nov 2009 | A1 |
| 20090306768 | Quadri | Dec 2009 | A1 |
| 20100069882 | Jennings et al. | Mar 2010 | A1 |
| 20100114305 | Kang et al. | May 2010 | A1 |
| 20100191326 | Alkhatib | Jul 2010 | A1 |
| 20100217382 | Chau et al. | Aug 2010 | A1 |
| 20100249894 | Oba et al. | Sep 2010 | A1 |
| 20100249911 | Alkhatib | Sep 2010 | A1 |
| 20100256723 | Murray | Oct 2010 | A1 |
| 20100305685 | Millwee et al. | Dec 2010 | A1 |
| 20110004296 | Lutter et al. | Jan 2011 | A1 |
| 20110029067 | McGuckin, Jr. et al. | Feb 2011 | A1 |
| 20110208297 | Tuval et al. | Aug 2011 | A1 |
| 20110208298 | Tuval et al. | Aug 2011 | A1 |
| 20110224785 | Hacohen | Sep 2011 | A1 |
| 20110264196 | Savage et al. | Oct 2011 | A1 |
| 20110313515 | Quadri et al. | Dec 2011 | A1 |
| 20120022639 | Hacohen et al. | Jan 2012 | A1 |
| 20120041550 | Salahieh et al. | Feb 2012 | A1 |
| 20120059454 | Millwee et al. | Mar 2012 | A1 |
| 20120078360 | Rafiee | Mar 2012 | A1 |
| 20120101571 | Thambar et al. | Apr 2012 | A1 |
| 20120101572 | Kovalsky et al. | Apr 2012 | A1 |
| 20120123529 | Levi et al. | May 2012 | A1 |
| 20120215303 | Quadri et al. | Aug 2012 | A1 |
| 20120271398 | Essinger et al. | Oct 2012 | A1 |
| 20120290062 | McNamara et al. | Nov 2012 | A1 |
| 20120310328 | Olson et al. | Dec 2012 | A1 |
| 20130006294 | Kashkarov et al. | Jan 2013 | A1 |
| 20130030520 | Lee et al. | Jan 2013 | A1 |
| 20130035759 | Gross et al. | Feb 2013 | A1 |
| 20130053950 | Rowe et al. | Feb 2013 | A1 |
| 20130131788 | Quadri et al. | May 2013 | A1 |
| 20130144378 | Quadri et al. | Jun 2013 | A1 |
| 20130211508 | Lane et al. | Aug 2013 | A1 |
| 20130253635 | Straubinger et al. | Sep 2013 | A1 |
| 20130253642 | Brecker | Sep 2013 | A1 |
| 20130310928 | Morriss et al. | Nov 2013 | A1 |
| 20130331929 | Mitra et al. | Dec 2013 | A1 |
| 20130338766 | Hastings et al. | Dec 2013 | A1 |
| 20130345786 | Behan | Dec 2013 | A1 |
| 20140018912 | Delaloye et al. | Jan 2014 | A1 |
| 20140025163 | Padala et al. | Jan 2014 | A1 |
| 20140039611 | Lane et al. | Feb 2014 | A1 |
| 20140052237 | Lane et al. | Feb 2014 | A1 |
| 20140052242 | Revuelta et al. | Feb 2014 | A1 |
| 20140088565 | Vongphakdy et al. | Mar 2014 | A1 |
| 20140100651 | Kheradvar et al. | Apr 2014 | A1 |
| 20140100653 | Savage et al. | Apr 2014 | A1 |
| 20140142694 | Tabor et al. | May 2014 | A1 |
| 20140163668 | Rafiee | Jun 2014 | A1 |
| 20140172077 | Bruchman et al. | Jun 2014 | A1 |
| 20140172083 | Bruchman et al. | Jun 2014 | A1 |
| 20140194981 | Menk et al. | Jul 2014 | A1 |
| 20140207231 | Hacohen et al. | Jul 2014 | A1 |
| 20140214153 | Ottma et al. | Jul 2014 | A1 |
| 20140214154 | Nguyen et al. | Jul 2014 | A1 |
| 20140214155 | Kelley | Jul 2014 | A1 |
| 20140214160 | Naor | Jul 2014 | A1 |
| 20140222136 | Geist et al. | Aug 2014 | A1 |
| 20140222139 | Nguyen et al. | Aug 2014 | A1 |
| 20140222142 | Kovalsky et al. | Aug 2014 | A1 |
| 20140230515 | Tuval et al. | Aug 2014 | A1 |
| 20140236288 | Lambrecht et al. | Aug 2014 | A1 |
| 20140257467 | Lane et al. | Sep 2014 | A1 |
| 20140277390 | Ratz et al. | Sep 2014 | A1 |
| 20140277402 | Essinger et al. | Sep 2014 | A1 |
| 20140277422 | Ratz et al. | Sep 2014 | A1 |
| 20140277427 | Ratz et al. | Sep 2014 | A1 |
| 20140296973 | Bergheim et al. | Oct 2014 | A1 |
| 20140296975 | Tegels et al. | Oct 2014 | A1 |
| 20140303719 | Cox et al. | Oct 2014 | A1 |
| 20140309728 | Dehdashtian et al. | Oct 2014 | A1 |
| 20140309732 | Solem | Oct 2014 | A1 |
| 20140324160 | Benichou et al. | Oct 2014 | A1 |
| 20140324164 | Gross et al. | Oct 2014 | A1 |
| 20140330368 | Gloss et al. | Nov 2014 | A1 |
| 20140330371 | Gloss et al. | Nov 2014 | A1 |
| 20140330372 | Weston et al. | Nov 2014 | A1 |
| 20140336754 | Gurskis et al. | Nov 2014 | A1 |
| 20140343669 | Lane et al. | Nov 2014 | A1 |
| 20140343670 | Bakis et al. | Nov 2014 | A1 |
| 20140343671 | Yohanan et al. | Nov 2014 | A1 |
| 20140350663 | Braido et al. | Nov 2014 | A1 |
| 20140350666 | Righini | Nov 2014 | A1 |
| 20140350668 | Delaloye et al. | Nov 2014 | A1 |
| 20140358223 | Rafiee et al. | Dec 2014 | A1 |
| 20140364939 | Deshmukh et al. | Dec 2014 | A1 |
| 20140364943 | Conklin | Dec 2014 | A1 |
| 20140371842 | Marquez et al. | Dec 2014 | A1 |
| 20140371844 | Dale et al. | Dec 2014 | A1 |
| 20140371845 | Tuval et al. | Dec 2014 | A1 |
| 20140371847 | Madrid et al. | Dec 2014 | A1 |
| 20140371848 | Murray, III et al. | Dec 2014 | A1 |
| 20140379067 | Nguyen et al. | Dec 2014 | A1 |
| 20140379068 | Thielen et al. | Dec 2014 | A1 |
| 20140379077 | Tuval et al. | Dec 2014 | A1 |
| 20150005863 | Para | Jan 2015 | A1 |
| 20150012085 | Salahieh et al. | Jan 2015 | A1 |
| 20150018938 | Von Segesser et al. | Jan 2015 | A1 |
| 20150018944 | O'Connell et al. | Jan 2015 | A1 |
| 20150039083 | Rafiee | Feb 2015 | A1 |
| 20150045880 | Hacohen | Feb 2015 | A1 |
| 20150142103 | Vidlund | May 2015 | A1 |
| 20150148731 | McNamara et al. | May 2015 | A1 |
| 20150157457 | Hacohen | Jun 2015 | A1 |
| 20150157458 | Thambar et al. | Jun 2015 | A1 |
| 20150173897 | Raanani et al. | Jun 2015 | A1 |
| 20150196390 | Ma et al. | Jul 2015 | A1 |
| 20150209141 | Braido et al. | Jul 2015 | A1 |
| 20150272737 | Dale et al. | Oct 2015 | A1 |
| 20150297346 | Duffy et al. | Oct 2015 | A1 |
| 20150327994 | Morriss et al. | Nov 2015 | A1 |
| 20150328001 | McLean et al. | Nov 2015 | A1 |
| 20150335429 | Morriss et al. | Nov 2015 | A1 |
| 20150351903 | Morriss et al. | Dec 2015 | A1 |
| 20150351906 | Hammer et al. | Dec 2015 | A1 |
| 20150359629 | Ganesan et al. | Dec 2015 | A1 |
| 20160000591 | Lei et al. | Jan 2016 | A1 |
| 20160030169 | Shahriari | Feb 2016 | A1 |
| 20160030170 | Alkhatib et al. | Feb 2016 | A1 |
| 20160030171 | Quijano et al. | Feb 2016 | A1 |
| 20160038281 | Delaloye et al. | Feb 2016 | A1 |
| 20160074160 | Christianson et al. | Mar 2016 | A1 |
| 20160106537 | Christianson et al. | Apr 2016 | A1 |
| 20160113765 | Ganesan et al. | Apr 2016 | A1 |
| 20160113766 | Ganesan et al. | Apr 2016 | A1 |
| 20160113768 | Ganesan et al. | Apr 2016 | A1 |
| 20160143732 | Glimsdale | May 2016 | A1 |
| 20160158010 | Lim et al. | Jun 2016 | A1 |
| 20160166383 | Lim et al. | Jun 2016 | A1 |
| 20160184097 | Lim et al. | Jun 2016 | A1 |
| 20160199206 | Lim et al. | Jul 2016 | A1 |
| 20160213473 | Hacohen et al. | Jul 2016 | A1 |
| 20160235529 | Ma et al. | Aug 2016 | A1 |
| 20160279386 | Dale et al. | Sep 2016 | A1 |
| 20170128209 | Morriss et al. | May 2017 | A1 |
| 20170216023 | Lane et al. | Aug 2017 | A1 |
| 20170216575 | Asleson et al. | Aug 2017 | A1 |
| 20170258614 | Griffin | Sep 2017 | A1 |
| 20170325954 | Perszyk | Nov 2017 | A1 |
| 20170348096 | Anderson | Dec 2017 | A1 |
| 20170367823 | Hariton et al. | Dec 2017 | A1 |
| 20180055636 | Valencia et al. | Mar 2018 | A1 |
| 20180085218 | Eidenschink | Mar 2018 | A1 |
| 20180110534 | Gavala et al. | Apr 2018 | A1 |
| Number | Date | Country |
|---|---|---|
| 2304325 | Oct 2000 | CA |
| 2827556 | Jul 2012 | CA |
| 102006052564 | Dec 2007 | DE |
| 1171059 | Jan 2002 | EP |
| 1255510 | Nov 2002 | EP |
| 1259194 | Nov 2002 | EP |
| 1281375 | Feb 2003 | EP |
| 1369098 | Dec 2003 | EP |
| 1472996 | Nov 2004 | EP |
| 1734903 | Dec 2006 | EP |
| 1827558 | Sep 2007 | EP |
| 1239901 | Oct 2007 | EP |
| 2124826 | Dec 2009 | EP |
| 1935377 | Mar 2010 | EP |
| 2237746 | Oct 2010 | EP |
| 2238947 | Oct 2010 | EP |
| 2285317 | Feb 2011 | EP |
| 2308425 | Apr 2011 | EP |
| 2319458 | May 2011 | EP |
| 2398543 | Dec 2011 | EP |
| 2496182 | Sep 2012 | EP |
| 2566416 | Mar 2013 | EP |
| 2745805 | Jun 2014 | EP |
| 2749254 | Jul 2014 | EP |
| 2750630 | Jul 2014 | EP |
| 2777617 | Sep 2014 | EP |
| 2815723 | Dec 2014 | EP |
| 2815725 | Dec 2014 | EP |
| 2898858 | Jul 2015 | EP |
| 2926766 | Oct 2015 | EP |
| 2967858 | Jan 2016 | EP |
| 2985006 | Feb 2016 | EP |
| 2168536 | Apr 2016 | EP |
| 2262451 | May 2017 | EP |
| 3184083 | Jun 2017 | EP |
| 2446915 | Jan 2018 | EP |
| 3057541 | Jan 2018 | EP |
| 3037064 | Mar 2018 | EP |
| 3046511 | Mar 2018 | EP |
| 3142603 | Mar 2018 | EP |
| 3294220 | Mar 2018 | EP |
| 1264471 | Feb 1972 | GB |
| 1315844 | May 1973 | GB |
| 2398245 | Aug 2004 | GB |
| 2002540889 | Dec 2002 | JP |
| 2008541865 | Nov 2008 | JP |
| 1997049355 | Dec 1997 | WO |
| 0061034 | Oct 2000 | WO |
| 03092554 | Nov 2003 | WO |
| 2004030569 | Apr 2004 | WO |
| 2005011534 | Feb 2005 | WO |
| 2006070372 | Jul 2006 | WO |
| 2006085225 | Aug 2006 | WO |
| 2006089236 | Aug 2006 | WO |
| 2006127765 | Nov 2006 | WO |
| 2007025028 | Mar 2007 | WO |
| 2007058857 | May 2007 | WO |
| 2007123658 | Nov 2007 | WO |
| 2008013915 | Jan 2008 | WO |
| 2008070797 | Jun 2008 | WO |
| 2008103722 | Aug 2008 | WO |
| 2008125153 | Oct 2008 | WO |
| 2008150529 | Dec 2008 | WO |
| 2009026563 | Feb 2009 | WO |
| 2009033469 | Mar 2009 | WO |
| 2009045331 | Apr 2009 | WO |
| 2009053497 | Apr 2009 | WO |
| 2009091509 | Jul 2009 | WO |
| 2009094500 | Jul 2009 | WO |
| 2009134701 | Nov 2009 | WO |
| 2010005524 | Jan 2010 | WO |
| 2010008549 | Jan 2010 | WO |
| 2010022138 | Feb 2010 | WO |
| 2010037141 | Apr 2010 | WO |
| 2010040009 | Apr 2010 | WO |
| 2010057262 | May 2010 | WO |
| 2011008538 | Jan 2011 | WO |
| 2011025945 | Mar 2011 | WO |
| 2011035327 | Mar 2011 | WO |
| 2011057087 | May 2011 | WO |
| 2011111047 | Sep 2011 | WO |
| 2011137531 | Nov 2011 | WO |
| 2012023978 | Feb 2012 | WO |
| 2012177942 | Dec 2012 | WO |
| 2013028387 | Feb 2013 | WO |
| 2013075215 | May 2013 | WO |
| 2013120181 | Aug 2013 | WO |
| 2013175468 | Nov 2013 | WO |
| 2013192305 | Dec 2013 | WO |
| 2014018432 | Jan 2014 | WO |
| 2014099655 | Jun 2014 | WO |
| 2014110019 | Jul 2014 | WO |
| 2014110171 | Jul 2014 | WO |
| 2014121042 | Aug 2014 | WO |
| 2014139545 | Sep 2014 | WO |
| 2014145338 | Sep 2014 | WO |
| 2014149865 | Sep 2014 | WO |
| 2014163706 | Oct 2014 | WO |
| 2014164364 | Oct 2014 | WO |
| 2014194178 | Dec 2014 | WO |
| 2014204807 | Dec 2014 | WO |
| 2014205064 | Dec 2014 | WO |
| 2014210124 | Dec 2014 | WO |
| 2015077274 | May 2015 | WO |
| WO-2015095475 | Jun 2015 | WO |
| 2015148241 | Oct 2015 | WO |
| 2016016899 | Feb 2016 | WO |
| 2018035375 | Feb 2018 | WO |
| Entry |
|---|
| Mack, Michael M.D., “Advantages and Limitations of Surgical Mitral Valve Replacement; Lessons for the Transcatheter Approach,” Applicant believes this may have been available as early as Jun. 7, 2010. Applicant believes this may have been presented at the Texas Cardiovascular Innovative Ventures (TCIV) Conference in Dallas, TX on Dec. 8, 2010. |
| Bavaria, Joseph E M.D. et al.: “Transcatheter Mitral Valve Implantation: The Future Gold Standard for MR?,” Applicant requests the Examiner to consider this reference to be prior art as of Dec. of 2010. |
| Int'l. Search Report for PCT/US2016/048957, completed Nov. 30, 2016. |
| Kronemyer, Bob, “CardiAQ Valve Technologies: Percutaneous Mitral Valve Replacement,” Start Up—Windhover Review of Emerging Medical Ventures, vol. 14, Issue No. 6, Jun. 2009, pp. 48-49. |
| Bavaria, Joseph E. M.D.: “CardiAQ Valve Technologies: Transcatheter Mitral Valve Implantation,” Sep. 21, 2009. |
| Ostrovsky, Gene, “Transcatheter Mitral Valve Implantation Technology from CardiAQ,” medGadget, Jan. 15, 2010, available at: http://www.medgadget.com/2010/01/transcatheter_mitral_valve_implantation_technology_from_cardiaq.html. |
| Berreklouw, Eric, PhD, et al., “Sutureless Mitral Valve Replacement With Bioprostheses and Nitinol Attachment Rings: Feasibility in Acute Pig Experiments,” The Journal of Thoracic and Cardiovascular Surgery, vol. 142, No. 2, Aug. 2011 in 7 pages, Applicant believes this may have been available online as early as Feb. 7, 2011. |
| Boudjemline, Younes, et al., “Steps Toward the Percutaneous Replacement of Atrioventricular Valves,” JACC, vol. 46, No. 2, Jul. 19, 2005:360-5. |
| Chiam, Paul T.L., et al., “Percutaneous Transcatheter Aortic Valve Implantation: Assessing Results, Judging Outcomes, and Planning Trials,” JACC: Cardiovascular Interventions, The American College of Cardiology Foundation, vol. 1, No. 4, Aug. 2008:341-50. |
| Condado, Jose Antonio, et al., “Percutaneous Treatment of Heart Valves,” Rev Esp Cardio. 2006;59(12):1225-31, Applicant believes this may have been available as early as Dec. of 2006. |
| Vu, Duc-Thang, et al., “Novel Sutureless Mitral Valve Implantation Method Involving a Bayonet Insertion and Release Mechanism: A Proof of Concept Study in Pigs,” The Journal of Thoracic and Cardiovascular Surgery, vol. 143, No. 4, 985-988, Apr. 2012, Applicant believes this may have been available online as early as Feb. 13, 2012. |
| Fanning, Jonathon P., et al., “Transcatheter Aortic Valve Implantation (TAVI): Valve Design and Evolution,” International Journal of Cardiology 168 (2013) 1822-1831, Applicant believes this may have been available as early as Oct. 3, 2013. |
| Spillner, J. et al., “New Sutureless ‘Atrial- Mitral-Valve Prosthesis’ for Minimally Invasive Mitral Valve Therapy,” Textile Research Journal, 2010, in 7 pages, Applicant believes this may have been available as early as Aug. 9, 2010. |
| Karimi, Houshang, et al., “Percutaneous Valve Therapies,” SIS 2007 Yearbook, Chapter 11, pp. 1-11. |
| Leon, Martin B., et aL, “Transcatheter Aortic Valve Replacement in Patients with Critical Aortic Stenosis: Rationale, Device Descriptions, Early Clinical Experiences, and Perspectives,” Semin. Thorac. Cardiovasc. Surg. 18:165-174, 2006 in 10 pages, Applicant believes this may have been available as early as the Summer of 2006. |
| Lutter, Georg, et al., “Off-Pump Transapical Mitral Valve Replacement,” European Journal of Cardio-thoracic Surgery 36 (2009) 124-128, Applicant believes this may have been available as early as Apr. 25, 2009. |
| Ma, Liang, et al., “'Double-Crowned Valved Stents for Off-Pump Mitral Valve Replacement,” European Journal of Cardio-thoracic Surgery 28 (2005) 194-199, Applicant believes this may have been available as early as Aug. of 2005. |
| Pluth, James R., M.D., et al., “Aortic and Mitral Valve Replacement with Cloth-Covered Braunwald-Cutter Prosthesis, A Three-Year Follow-up,” The Annals of Thoracic Surgery, vol. 20, No. 3, Sep. 1975, pp. 239-248. |
| Seidel, Wolfgang, et al., “A Mitral Valve Prosthesis and a Study of Thrombosis on Heart Valves in Dogs,” JSR—vol. II, No. 3—May 1962, submitted for publication Oct. 9, 1961. |
| Engager System, Precise Valve Positioning, Transcatheter Aortic Valve Implantation System, Transcatheter Aortic Valve Replacement—TAVR I Medtronic Engager, http://www.medtronic-engager.com/home/transcatheter-aortic-valve-repl., 2014 Medtronic, Inc. in 2 pages. Applicant believes this may have been available online as early as Aug. 25, 2013. |
| Webb, John G., et al., “Transcatheter Aortic Valve Implantation: The Evolution of Prostheses, Delivery Systems and Approaches,” Archives of Cardiovascular Disease (2012) 105, 153-159. Applicant believes this may have been available as early as Mar. 16, 2012. |
| Sondergaard, Lars, et al., “Transcatheter Mitral Valve Implantation: CardiAQ™,” Applicant believes this may have been presented at TCT 2013. |
| Sondergaard, Lars, et al., “Transcatheter Mitral Valve Implantation: CardiAQ™,” Applicant believes this may have been presented at EuroPCR 2013. |
| Sondergaard, Lars, “CardiAQ TMVR FIH—Generation 2,” Applicants believe this may have been presented in 2014 at the TVT symposium. |
| CardiAQ Valve Technologies, “Innovations in Heart Valve Therapy,” In3 San Francisco, Jun. 18, 2008, PowerPoint presentation in 19 slides. |
| Ratz, J. Brent, “LSI EMT Spotlight,” May 15, 2009. |
| Ratz, J. Brent, “In3 Company Overview,” Jun. 24, 2009. |
| “Company Overview,” at TVT on Jun. 25, 2009. |
| Ruiz, Carlos E., “Overview of Novel Transcatheter Valve Technologies,” Applicant believes this may have been presented on May 27, 2010 at EuroPCR. |
| “Update,” Applicant believes this may have been presented on Jun. 6, 2010 at TVT. |
| Mack, Michael, M.D., “Antegrade Transcatheter Mitral valve Implantation: A Short-term Experience in Swine Model,” Applicant believes this may have been presented on May of 2011 at TVT. |
| Mack, Michael, M.D., “Antegrade Transcatheter Mitral valve Implantation: On-Going Experience in Swine Model,” Applicant believes this may have been presented on Nov. of 2011 at TCT. |
| Fitzgerald, Peter J. M.D., “Tomorrow's Technology: Percutaneous Mitral Valve Replacement, Chordal Shortening, and Beyond,” Transcatheter Valve Therapies (TVT) Conference. Seattle, WA. Applicant believes this may have been available as early as Jun. 7, 2010. |
| Quadri, Arshad M.D., “Transcatheter Mitral Valve Implantation (TMVI) (An Acute In Vivo Study),” Applicant believes this may have been presented on Sep. 22, 2010 at TCT. |
| Masson, Jean-Bernard, et al., “Percutaneous Treatment of Mitral Regurgitation,” Circulation: Cardiovascular Interventions, 2:140-146, Applicant believes this may have been available as early as Apr. 14, 2009. |
| Horvath et al.: “Transapical Aortic Valve Replacement under Real-time Magnetic Resonance Imaging Guidance: Experimental Results with Balloon- Expandable and Self-Expanding Stents,” http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038190/. Jun. 2011. |
| Treede et al.: “Transapical transcatheter aortic valve implantation using the JenaValve™ system: acute and 30-day results of the multicentre CE-mark study.” http://ejcts.oxfordjournals.org/content/41/6/e131.long. Apr. 16, 2012. |
| Taramasso et al.: “New devices for TAVI: technologies and initial clinical experiences” http://www.nature.com/nrcardio/journal/v11/n3/full/nrcardio.2013.221.html?message-global=remove#access. Jan. 21, 2014. |
| Van Mieghem, et al., “Anatomy of the Mitral Valvular Complez and Its Implications for Transcatheter Interventions for Mitral Regurgitation,” J. Am. Coll. Cardiol., 56:617-626 (Aug. 17, 2010). |
| Wayback Machine, Cleveland Clinic Lerner Research Institute, Transcatheter Mitral Stent/Valve Prosthetic, https://web.archive.org/web/20130831094624/http://mds.clevelandclinic.org/Portfolio.aspx?n=331, indicated as archived on Aug. 31, 2013. |
| Grube, E. et al, “Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis: device success and 30-day clinical outcome.” J Am Coll Cardiol. Jul. 3, 2007;50(1):69-76. Epub Jun. 6, 2007. |
| Piazza, Nicoló, MD, et al., “Anatomy of the Aortic Valvar Complex and Its Implications for Transcatheter Implantation of the Aortic Valve,” Contemporary Reviews in Interventional Cardiology, Circ. Cardiovasc. Intervent., 2008;1:74-81, Applicant believes this may have been available as early as Aug. of 2008. |
| Feldman, Ted, MD. “Prospects for Percutaneous Valve Therapies,” Circulation 2007;116:2866-2877. Applicant believes that this may be available as early as Dec. 11, 2007. |
| Backer, Ole De, MD, et al., “Percutaneous Transcatheter Mitral Valve Replacement—An Overview of Devices in Preclinical and Early Clinical Evaluation,” Contemporary Reviews in Interventional Cardiology, Circ Cardiovasc Interv. 2014;7:400-409, Applicant believes this may have been available as early as Jun. of 2014. |
| Preston-Maher, Georgia L., et al., “A Technical Review of Minimally Invasive Mitral Valve Replacements,” Cardiovascular Engineering and Technology, vol. 6, No. 2, Jun. 2015, pp. 174-184. Applicant believes this may have been available as early as Nov. 25, 2014. |
| BioSpace, “CardiAQ Valve Technologies (CVT) Reports Cardiovascular Medicine Milestone: First-In-Humannonsurgical Percutaneous Implantation of a Bioprosthetic Mitral Heart Valve,” Jun. 14, 2012, p. 1, http://www.biospace.com/News/cardiaq-valve-technologies-cvt-reports/263900. |
| BioSpace, “CardiAQ Valve Technologies (CVT) Reports First-In-Human Percutaneous Transfemoral, Transseptal Implantation With Its Second Generation Transcatheter Bioprosthetic Mitral Heart Valve,” Jun. 23, 2015, p. 1, http://www.biospace.com/News/cardiaq-valve-technologies-cvt-reports-first- in/382370. |
| “CardiAQTM Valve Technologies reports Successful First-in-Human Trans-Apical implantation of its Second Generation Transcatheter Mitral Valve,” CardiAQ Valve Technologies Press Release, May 20, 2014. |
| Dave Fornell, “Transcatheter Mitral Valve replacement Devices in Development,” Diagnostic and Interventional Cardiology, Dec. 30, 2014, p. 3, <http://www.dicardiology.com/article/transcatheter-mitral-valve-replacement-devices-development>. |
| The Journal of the American College of Cardiology, “Transapical Mitral Implantation of the Tiara Bioprosthesis Pre-Clinical Results,” Feb. 2014, <http://interventions.onlinejacc.org/article.aspx?articleid=1831234>. |
| Ratz, J. Brent et al., “Any experiences making an expandable stent frame?” Arch-Pub.com, Architecture Forums: Modeling, Multiple forum postings from Feb. 3, 2009 to Feb. 4, 2009, http://www.arch-pub.com. |
| Neovasc corporate presentation, Oct. 2009, available at http://www.neovasc.com/investors/documents/Neovasc-Corporate-Presentation-October-2009.pdf. |
| NJ350: Vote for Your Favorite New Jersey Innovations, Jun. 27, 2014, http://www.kilmerhouse.com/2014/06/nj350-vote-for-your-favorite-new-jersey-innovations/. |
| Number | Date | Country | |
|---|---|---|---|
| 20170056171 A1 | Mar 2017 | US |
| Number | Date | Country | |
|---|---|---|---|
| 62349326 | Jun 2016 | US | |
| 62211574 | Aug 2015 | US |
