Patent Grant
11839540
Some applications of the present invention generally relate to medical apparatus. Specifically, some applications of the present invention relate to apparatus and methods associated with placing a valve in one or more of a subject's renal veins.
It is common for cardiac dysfunction or congestive heart failure to develop into kidney dysfunction, which in turn, causes congestive heart failure symptoms to develop or worsen. Typically, systolic and/or diastolic cardiac dysfunction causes systemic venous congestion, which gives rise to an increase in renal venous and interstitial pressure. The increase in the pressure causes fluid retention by the body to increase due both to kidney dysfunction and renal neurohormonal activation, both of which typically develop as a result of the increase in renal venous and interstitial pressure. The resulting fluid retention causes congestive heart failure to develop or worsen, by causing a blood volume overload at the heart and/or by increasing systemic resistance. Similarly, it is common for kidney dysfunction and/or renal neurohormonal activation to develop into cardiac dysfunction and/or congestive heart failure. This pathophysiological cycle, in which cardiac dysfunction and/or congestive heart failure leads to kidney dysfunction and/or renal neurohormonal activation, or in which kidney dysfunction and/or renal neurohormonal activation leads to cardiac dysfunction and/or congestive heart failure, each dysfunction leading to deterioration in the other dysfunction, is called the cardio-renal syndrome.
Increased renal venous pressure has been experimentally shown to cause azotemia, and a reduction in glomerular filtration rate, renal blood flow, urine output, and sodium excretion. It has also been shown to increase plasma renin and aldosterone, and protein excretion. Venous congestion may also contribute to anemia via three different pathways: a reduction in the kidney's erythropoietin production, hemodilution by fluid retention, and an inflammatory response leading to a reduced gastro-intestinal iron uptake.
Mechanistically, increased renal venous pressure, may cause intracapsular pressure and, subsequently, interstitial peritubular pressure, to rise. A rise in peritubular pressure may impact tubular function (reduce sodium excretion), as well as diminish glomerular filtration by raising the pressure in the Bowman capsule.
In heart failure patients, increased renal venous pressure may not only result from increased central venous (right atrial) pressure, but also from intraperitoneal fluid accumulations (ascites) exerting direct pressure on the renal veins. Reduction of intraabdominal pressure in heart failure patients by removal of fluid (e.g., via paracentesis, and/or ultrafiltration) has been shown to reduce plasma creatinine levels.
Increased venous return resulting from activation of the “leg muscle pump” during physical activity such as walking may raise systemic venous pressure, particularly in heart failure patients, and may result in reflux into the renal veins.
For some applications of the present invention, a device is placed in at least one of a subject's renal veins, the device being configured to reduce pressure at the subject's kidney relative to the subject's central venous pressure. The device is typically a passive device, i.e., the device is configured to reduce pressure at the subject's kidney without requiring external energy to be supplied to the device (e.g., from a power supply or a battery). When the device is in a deployed state inside the renal vein, any movement of any portion of the device is caused by blood flow and/or pressure that is imparted to the portion of the device rather than being caused by energy that is imparted to the device (e.g., from a power supply and/or a battery).
Typically, the device reduces pressure at the subject's kidney by reducing the back flow of blood toward the kidney via the renal vein, and/or by reducing renal venous pressure relative to central venous pressure, by protecting the renal vein from high central venous pressures. Further typically, the device is placed inside the renal vein in response to identifying the subject as suffering from a condition that causes the subject to have elevated central venous pressure relative to that of a healthy subject. For some applications, the condition includes cardiac dysfunction, congestive heart failure, low renal blood flow, high renal vascular resistance, arterial hypertension, kidney dysfunction, and/or cardio-renal syndrome. For some applications, at least one of the devices is placed in each of the subject's left and right renal veins.
For some applications, the device is placed in the renal vein temporarily in order to provide an acute treatment for one or more of the above-listed conditions. For example, the valve may be placed in a renal vein for a period of more than 12 hours (e.g., more than 24 hours), and/or less than three months (e.g., less than one month), during which the subject is undergoing an acute episode of heart failure, and subsequently, the valve may be retrieved from the renal vein.
Typically a prosthetic valve is placed (e.g., transcatheterally placed) inside the renal vein. The valve reduces pressure at the subject's kidney by reducing the back flow of blood toward the kidney via the renal vein, by the valve closing in response to blood flowing back into the renal vein. Alternatively or additionally, the valve protects the renal vein from pressure increases resulting from high central venous pressures, by the valve closing in response to pressure within the vena cava being greater than a threshold pressure.
Typically, placement of the device inside the renal vein causes an improvement of renal function and/or prevention or a reduction in deterioration of the subject's renal function. The device typically reduces renal venous and interstitial pressure, thereby causing a decrease in parenchymal ischemia and injury, and/or an increase in renal blood flow, glomerular filtration rate, and/or in erythropoetin production. For some applications, the device improves the subject's cardiac function, e.g., by reducing afterload. For some applications, the device improves the subject's cardiac and/or renal function, e.g., by causing improved renal salt and water excretion, by suppressing renin-angiotensin-aldosterone system (RAAS) activation, by suppressing arginine-vasopressin system activation, and/or by suppressing the sympathetic nervous system.
For some applications, placement of the device inside the renal vein causes renal venous pressure to decrease such as to prevent or diminish a rise in renal parenchymal intracapsular pressure as a result of increased pressure and backflow from the inferior vena cava to the renal vein (e.g., backflow from the heart and/or from the veins of the lower body towards the renal vein). For some applications, placement of the device inside the renal vein reduces deterioration, or promotes recovery of renal function in a patient with acute or chronic heart failure. For some applications, placement of the device inside the renal vein blocks or attenuates the activation of neural and endocrine control axes which generate the physiological effects that are responsible for the development and sustainment of the heart failure syndrome.
There is therefore provided, in accordance with some applications of the present invention, apparatus including:
For some applications, the valve is configured to be placed entirely within the subject's renal vein.
For some applications, the valve is configured in the closed state thereof to reduce venous pressure within the renal vein relative to central venous pressure of the subject even in an absence of any device being placed at a location that is within an abdomen of the subject and outside a venous system of the subject.
For some applications, the valve frame is configured to reduce compression of the renal vein resulting from intra-abdominal pressure that is exerted on the renal vein, relative to a level of compression of the renal vein resulting from intra-abdominal pressure that is exerted on the renal vein in an absence of the valve frame.
For some applications, the valve frame defines:
For some applications, the valve is configured to be placed in the renal vein for a period of less than three months, and subsequently, to be retrieved from the subject's renal vein.
For some applications, the valve is configured to be placed in the renal vein for a period of less than one month, and subsequently, to be retrieved from the subject's renal vein.
For some applications, the valve frame defines:
For some applications, the protruding portion is shaped to be disposed outside of radial projections of downstream edges of the valve leaflets, such that even when the valve leaflets are in open states thereof, the valve leaflets do not contact the protruding portion.
For some applications, the valve leaflets are coupled to the frame downstream of the protruding portion, such that an upstream end of each of the valve leaflets is longitudinally spaced from a downstream end of the protruding portion.
For some applications, the cylindrical portion and the protruding portion are reversibly couplable to one another.
For some applications, the protruding portion diverges from the outer surface of the cylindrical portion at an angle of greater than 40 degrees with respect to the outer surface of downstream portion of the cylindrical portion.
For some applications, the protruding portion diverges from the outer surface of the cylindrical portion at an angle of greater than 50 degrees with respect to the outer surface of downstream portion of the cylindrical portion.
There is further provided, in accordance with some applications of the present invention, a method including:
For some applications, placing the device at least partially within the renal vein includes placing the device entirely within the renal vein.
For some applications, reducing pressure within the renal vein includes reducing pressure within the renal vein by placing the device at least partially within the renal vein in an absence of any device being placed at a location that is within an abdomen of the subject and outside a venous system of the subject.
For some applications, identifying the subject as suffering from the condition that causes the subject to have elevated central venous pressure includes identifying the subject as suffering from elevated renal venous pressure that is substantially due to the subject suffering from elevated central venous pressure.
For some applications, identifying the subject as suffering from the condition that causes the subject to have elevated central venous pressure includes identifying the subject as suffering from elevated renal venous pressure even in an absence of a condition that causes renal venous pressure of the subject to be elevated due to pressure being exerted on the subject's renal vein through walls of the subject's renal vein from a location outside the renal vein.
For some applications, identifying the subject as suffering from the condition that causes the subject to have elevated central venous pressure includes identifying the subject as suffering from elevated central venous pressure even in an absence of the subject suffering from tricuspid valve regurgitation.
For some applications, placing the device in the subject's renal vein includes placing a first device in a left renal vein of the subject and placing a second device in a right renal vein of the subject.
For some applications, reducing the blood pressure within the renal vein includes treating anemia of the subject that is related to the subject's condition, by reducing the blood pressure within the renal vein.
For some applications, reducing the blood pressure within the renal vein includes reducing the blood pressure within the subject's renal vein relative to central venous pressure of the subject, even during lower body exercise that is performed by the subject.
For some applications, identifying the subject as suffering from the condition includes identifying the subject as suffering from a condition selected from the group consisting of: cardiac dysfunction, congestive heart failure, and kidney dysfunction.
For some applications, identifying the subject as suffering from the condition includes identifying the subject as suffering from a condition selected from the group consisting of: cardiac dysfunction, and congestive heart failure.
For some applications, placing the device at least partially within the subject's renal vein includes placing the device at least partially within the subject's renal vein for a period of less than three months, and subsequently, retrieving the device from the subject's renal vein.
For some applications, placing the device at least partially within the subject's renal vein includes placing the device at least partially within the subject's renal vein for a period of less than one month, and subsequently, retrieving the device from the subject's renal vein.
For some applications, reducing the blood pressure within the renal vein includes treating the subject's condition, by reducing the blood pressure within the renal vein.
For some applications, treating the subject's condition includes reducing activation of a neurohormonal pathway of the subject, by reducing the blood pressure within the renal vein.
For some applications, placing the device in the subject's renal vein includes placing a valve in the subject's renal vein.
For some applications, placing the valve at least partially within the subject's renal vein, includes placing at least partially within the subject's renal vein a valve that includes valve leaflets, such that in an open state of the valve, the valve leaflets allow generally unimpeded antegrade blood flow therethrough.
For some applications, placing the valve in the subject's renal vein includes reducing compression of the renal vein resulting from intra-abdominal pressure that is exerted on the renal vein, relative to a level of compression of the renal vein resulting from intra-abdominal pressure that is exerted on the renal vein in an absence of the valve.
For some applications, placing the valve at least partially within the renal vein includes forming a bulged portion within the subject's renal vein by placing at least partially within the renal vein a valve that includes:
For some applications, placing the valve at least partially within the renal vein includes forming a bulged portion within the subject's renal vein by placing at least partially within the renal vein a valve that includes:
For some applications, placing the valve at least partially within the renal vein includes placing at least partially within the renal vein a valve, the protruding portion of the valve being shaped to be disposed outside of radial projections of downstream edges of the valve leaflets, such that even when the valve leaflets are in open states thereof, the valve leaflets do not contact the protruding portion.
For some applications, placing the valve at least partially within the renal vein includes placing the valve at least partially within the renal vein, the valve leaflets of the valve being coupled to the frame downstream of the protruding portion, such that an upstream end of each of the valve leaflets is longitudinally spaced from a downstream end of the protruding portion.
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are couplable to one another, and placing the valve at least partially within the renal vein includes:
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are reversibly couplable to one another, and the method further includes:
For some applications, placing the valve at least partially within the renal vein includes placing at least partially within the renal vein a valve, the protruding portion of the valve diverging from the outer surface of the cylindrical portion of the valve at an angle of greater than 40 degrees with respect to the outer surface of downstream portion of the cylindrical portion.
For some applications, placing the valve at least partially within the renal vein includes placing at least partially within the renal vein a valve, the protruding portion of the valve diverging from the outer surface of the cylindrical portion of the valve at an angle of greater than 50 degrees with respect to the outer surface of downstream portion of the cylindrical portion.
For some applications, placing the valve at least partially within the renal vein includes placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the bulged portion.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the bulged portion includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to reduce stagnation of blood in the vicinity of the leaflets.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the bulged portion includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to open in response to antegrade blood flow in the vicinity of the leaflets.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the bulged portion includes placing bases of the leaflets in a vicinity of a region of the bulged portion at which a cross sectional area of the bulged portion is at a maximum value thereof.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the bulged portion includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to close in response to antegrade blood flow in the vicinity of the leaflets.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the bulged portion includes placing bases of the leaflets in a widening region of the bulged portion.
For some applications, placing the valve at least partially within the renal vein includes deforming at least a portion of a junction between the renal vein and a vena cava of the subject, by placing the valve at least partially within the renal vein such that a portion of the valve is disposed in a vicinity of the junction, the portion of the valve being shaped such as to deform the portion of the junction.
For some applications, the valve includes valve leaflets, and placing the valve at least partially within the renal vein includes placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the cavity at the portion of the junction.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the cavity at the portion of the junction includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to open in response to antegrade blood flow in the vicinity of the leaflets.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the cavity at the portion of the junction includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to reduce stagnation of blood in the vicinity of the leaflets.
For some applications, placing the valve at least partially within the renal vein such that the valve leaflets are disposed within the cavity at the portion of the junction includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to close in response to antegrade blood flow in the vicinity of the leaflets.
For some applications,
For some applications, the valve includes a valve, the at least one protruding portion of which diverges radially from the outer surface of the cylindrical portion, such that a separation between the protruding portion and the outer surface of the cylindrical portion is greater at a downstream end of the protruding portion than at an upstream end of the protruding portion, and deforming at least the portion of the junction includes deforming the portion of the junction with the at least one protruding portion.
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are couplable to one another, and placing the valve at least partially within the renal vein includes:
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are reversibly couplable to one another, and the method further includes:
There is further provided, in accordance with some applications of the present invention, a method including:
For some applications,
For some applications, the valve includes valve leaflets, and placing the valve within the first vein includes placing the valve within the first vein such that the valve leaflets are disposed within the cavity at the portion of the junction.
For some applications, placing the valve within the first vein such that the valve leaflets are disposed within the cavity at the portion of the junction includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to open in response to antegrade blood flow in the vicinity of the leaflets.
For some applications, placing the valve within the first vein such that the valve leaflets are disposed within the cavity at the portion of the junction includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to reduce stagnation of blood in the vicinity of the leaflets.
For some applications, placing the valve within the first vein such that the valve leaflets are disposed within the cavity at the portion of the junction includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to close in response to antegrade blood flow in the vicinity of the leaflets.
For some applications,
For some applications, the valve includes a valve, the at least one protruding portion of which diverges radially from the outer surface of the cylindrical portion, such that a separation between the protruding portion and the outer surface of the cylindrical portion is greater at a downstream end of the protruding portion than at an upstream end of the protruding portion, and deforming at least the portion of the junction includes deforming the portion of the junction with the at least one protruding portion.
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are couplable to one another, and placing the valve within the first vein includes:
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are reversibly couplable to one another, and the method further includes:
There is further provided, in accordance with some applications of the present invention, apparatus for use with a blood vessel, including:
For some applications, the cylindrical portion and the protruding portion are reversibly couplable to one another.
There is further provided, in accordance with some applications of the present invention, apparatus for use with a blood vessel, including:
For some applications, the cylindrical portion and the protruding portion are reversibly couplable to one another.
For some applications, the protruding portion diverges from the outer surface of the cylindrical portion at an angle of greater than 50 degrees with respect to the outer surface of downstream portion of the cylindrical portion.
There is further provided, in accordance with some applications of the present invention, a method including:
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are couplable to one another, and placing the valve within the vein includes:
For some applications, the valve includes a valve, the cylindrical portion and the protruding portion of which are reversibly couplable to one another, and the method further includes:
For some applications, placing the valve within the vein includes placing the valve within the vein such that the valve leaflets are disposed within the bulged portion.
For some applications, placing the valve within the vein such that the valve leaflets are disposed within the bulged portion includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to reduce stagnation of blood in the vicinity of the leaflets.
For some applications, placing the valve within the vein such that the valve leaflets are disposed within the bulged portion includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to open in response to antegrade blood flow in the vicinity of the leaflets.
For some applications, placing the valve within the vein such that the valve leaflets are disposed within the bulged portion includes placing bases of the leaflets in a vicinity of a region of the bulged portion at which a cross sectional area of the bulged portion is at a maximum value thereof.
For some applications, placing the valve within the vein such that the valve leaflets are disposed within the bulged portion includes generating fluid flow dynamics in a vicinity of the leaflets that are such as to cause the leaflets to close in response to antegrade blood flow in the vicinity of the leaflets.
For some applications, placing the valve within the vein such that the valve leaflets are disposed within the bulged portion includes placing bases of the leaflets in a widening region of the bulged portion.
There is further provided, in accordance with some applications of the present invention, a method including:
For some applications, identifying the subject as suffering from the condition includes identifying the subject as suffering from a condition selected from the group consisting of: cardiac dysfunction, and congestive heart failure.
There is further provided, in accordance with some applications of the present invention, apparatus for use with a blood vessel, including:
There is further provided, in accordance with some applications of the present invention, a method for use with renal veins and a vena cava of a subject, the method including:
For some applications, placing the nozzle inside the vena cava includes placing the nozzle inside the vena cava at a location that is upstream of junctions of the vena cava with the subject's renal veins, the method further including placing a valve inside the subject's vena cava at a location that is downstream of the junctions of the vena cava with the subject's renal veins.
There is further provided, in accordance with some applications of the present invention, apparatus for use with renal veins and a vena cava of a subject, the apparatus including:
For some applications, the valve frame includes a central portion that is configured to be placed inside the vena cava and side branches that branch from the central portion and that are configured to be placed at least partially inside respective renal veins, and the valve leaflets are coupled to the side branches.
For some applications, the valve leaflets are coupled to the valve frame such that when the valve frame is placed at least partially inside the vena cava, the valve leaflets are disposed inside the vena cava in the vicinities of the ostia of the junctions between the vena cava and the renal veins.
For some applications, the valve leaflets are coupled to the valve frame such that when the valve frame is placed at least partially inside the vena cava, the valve leaflets are disposed inside the renal veins in the vicinities of the ostia of the junctions between the vena cava and the renal veins.
There is further provided, in accordance with some applications of the present invention, a method for use with renal veins and a vena cava of a subject, the method including:
For some applications,
For some applications, placing the valve frame at least partially inside the subject's vena cava includes placing the valve frame at least partially inside the subject's vena cava such that the valve leaflets are disposed inside the vena cava in the vicinities of the ostia of the junctions between the vena cava and the renal veins.
For some applications, placing the valve frame at least partially inside the subject's vena cava includes placing the valve frame at least partially inside the subject's vena cava such that the valve leaflets are disposed inside the renal veins in the vicinities of the ostia of the junctions between the vena cava and the renal veins.
The present invention will be more fully understood from the following detailed description of embodiments thereof, taken together with the drawings, in which:
Reference is now made to
Reference is now made to
Reference is now made to
Reference is now made to
The inventor of the present application hypothesizes that by reducing pressure at the kidneys, placement of a valve inside a renal vein, causes an improvement of renal function and/or prevention or a reduction in deterioration of the subject's renal function. Typically, placement of a valve inside a renal vein reduces renal venous and interstitial pressure, thereby causing a decrease in parenchymal ischemia and injury, and/or an increase in renal blood flow, glomerular filtration rate, and/or in erythropoetin production. For some applications, placement of a valve inside a renal vein improves the subject's cardiac function, e.g., by reducing afterload. For some applications, placement of a valve inside a renal vein improves the subject's renal function and/or cardiac function, e.g., by causing improved renal salt and water excretion, by suppressing renin-angiotensin-aldosterone system (RAAS) activation, by suppressing arginine-vasopressin system activation, and/or by suppressing the sympathetic nervous system. For some applications, placement of a valve inside a renal vein treats anemia of the subject, by improving the subject's renal function.
Valve 34 is typically placed inside one or both of the subject's renal veins in order to provide acute treatment to a subject suffering from cardiac dysfunction, congestive heart failure, low renal blood flow, high renal vascular resistance, arterial hypertension, and/or kidney dysfunction. In accordance with respective applications, valve 34 is permanently implanted in left and/or right renal vein 32 or is temporarily (e.g., retrievably) placed within the renal vein. For example, the valve may be placed in a renal vein for a period of more than 12 hours (e.g., more than 24 hours), and/or less than three months (e.g., less than one month), during which the subject is undergoing an acute episode of heart failure, and subsequently, the valve may be retrieved from the renal vein. Or, valve 34 may be permanently implanted in left and/or right renal vein 32 in order to provide chronic treatment to a subject suffering from cardiac dysfunction, congestive heart failure, low renal blood flow, high renal vascular resistance, arterial hypertension, and/or kidney dysfunction. For some applications, a course of treatment is applied to a subject over several weeks, several months, or several years, in which the valves are intermittently placed inside the subject's left and/or right renal vein, and the subject is intermittently treated in accordance with the techniques described herein. For example, the subject may be intermittently treated at intervals of several days, several weeks, or several months.
Typically, valve 34 is placed inside one or both of the subject's renal veins in order to provide treatment to a subject suffering from elevated central venous pressure relative to central venous pressure of a healthy subject. The valve is configured to reduce the subject's renal venous pressure relative the subject's elevated central venous pressure. For some applications, the valve is placed inside the renal vein of a subject in response to the subject's renal venous pressure being elevated relative to that of a healthy subject, the subject's elevated renal venous pressure being substantially due to the subject suffering from elevated central venous pressure. For some applications, the valve is placed in the subject's renal vein in response to the subject's central venous pressure being elevated relative to that of a healthy subject, even though the subject is not suffering from a condition that causes renal venous pressure to be elevated due to pressure being exerted on the renal vein through the walls of the renal vein from a location outside the renal vein (e.g., as in the case of a subject suffering from nutcracker syndrome). For some applications, the valve is placed inside the renal vein of a subject in response to the subject's central venous pressure being elevated relative to that of a healthy subject and even though the subject is not suffering from tricuspid valve regurgitation. The valve is typically configured to be placed in the subject's renal vein in order to treat the subject, even in the absence of any other device being placed outside the subject's venous system and within the subject's abdomen (e.g., around the outside of the subject's renal vein).
Reference is now made to
It is noted that for some applications, a valve is placed in only one of the left or the right renal veins. For some applications, more than one valve is placed in one or both of the left and right renal veins. For example, a first valve may be placed in the main branch of the renal vein that is a direct tributary of the vena cava, and a second valve may be placed in an upstream branch of the renal vein that is closer to the kidney, and is a tributary of the main renal vein. For some applications, three or more valves are placed in respective renal veins of a subject who has multiple renal veins.
Typically, the valve that is placed in the renal vein includes a frame 31 (e.g., a frame that is made of nitinol, stainless steel, cobalt chromium, platinum iridium (or other non-absorbable metals), magnesium (or other absorbable metals), a polymer, and/or a different material). Further typically, the valve includes prosthetic valve leaflets 33 (e.g., leaflets made from complete or partial venous valves harvested from calves, pigs, sheep, horses, marsupials, or other animals; leaflets made from pericardial tissue, from small intestinal submucosa from pigs or other animals, and/or from a synthetic material, such as polyester, polyurethane, any other polymer, and/or any thin and flexible material (e.g. material generated by electrospinning, or sputter deposition, including thin-film nitinol leaflets)). Still further typically, the valve includes sealing material 35, which is coupled to (e.g., sutured to) the valve frame, and that seals the valve frame with respect to the walls of the renal vein. For some applications, a similar material is used for sealing material 35 as is used for prosthetic valve leaflets 33. The frame supports the prosthetic valve leaflets, e.g., by the prosthetic valve leaflets being sutured to the frame. Typically, the valve frame is a non-branched valve frame. For example, the frame may define a generally cylindrical portion thereof, the frame not defining additional cylindrical portions that branch from the generally cylindrical portion. Thus, typically, the valve frame defines a single longitudinal axis thereof, the longitudinal axis being a generally straight line along a full length of the frame.
Typically, the prosthetic valve is configured such that the valve leaflets close in response to pressure within the vena cava being greater than a threshold pressure, and/or in response to retrograde blood flow through the renal veins exerting pressure on the downstream sides of the prosthetic valve leaflets. In the closed state of the valve, the valve leaflets, in a passive manner (i.e., without requiring external energy to be supplied to the device (e.g., from a power supply or a battery)), reduce venous pressure within the renal vein relative to central venous pressure of the subject.
Typically, the prosthetic valve is configured such that the valve leaflets open in response to antegrade blood flow through the renal vein, from the kidney to the vena cava, exerting pressure on the upstream sides of the prosthetic valve leaflets. Further typically, the valve leaflets are configured to open in response to a pressure of less than 6 mmHg (e.g., less than 3 mmHg) being exerted on the upstream sides of the prosthetic valve leaflets. For some applications, the valve leaflets are configured to open in response to antegrade blood flow through the vena cava, due to the fluid flow dynamics of the antegrade blood flow in the vicinity of the downstream sides of the prosthetic valve leaflets. In the open state of the valve, the valve leaflets typically allow generally unimpeded antegrade blood flow therethrough. For some applications, the prosthetic valve frame is shaped such as to deform a shape of a vessel wall in the vicinity the downstream sides of the prosthetic valve leaflets, such as to enhance the aforementioned fluid flow dynamics, as described in further detail hereinbelow.
It is noted that, when used in the present application to refer to locations within a subject's veins, the term “upstream” is used to denote a location that is further from the subject's right atrium, and the term “downstream” is used to refer to a location that is closer the subject's right atrium. Thus, blood typically flows from upstream locations to downstream locations. When used in the present application to refer to a portion of a device, the term “upstream” is used to denote an end or side of the device (or a portion thereof) which, subsequent to the device being deployed, will typically be at an upstream location within the vein relative to another end or side of the device. When used in the present application to refer to a portion of a device, the term “downstream” is used to denote an end or side of the device (or a portion thereof) which, subsequent to the device being deployed, will typically be at a downstream location within the vein relative to another end or side of the device.
Typically, a valve (e.g., valve 34) is placed inside renal vein 32, such that the valve leaflets are disposed inside the renal vein. Alternatively, a valve is placed within the subject's vena cava such that valve leaflets are disposed in the vicinity of the ostium at the junction of the renal vein with the vena cava. For example, a valve frame may be anchored to the vena cava with the valve leaflets coupled to the valve frame, such that the valve leaflets are disposed in the vicinity of the ostium at the junction of the renal vein with the vena cava, e.g., as described hereinbelow with reference to valves 110 and 120, shown in
For some applications, as an alternative to, or in addition to, placing a valve (e.g. valve 34) in renal vein 32 or placing a valve such as valve 110 or valve 120 in the vena cava, a prosthetic valve is placed in inferior vena cava 28, valve leaflets of the valve being configured such that the valve leaflets (a) open in response to antegrade blood flow through the vena cava from a location within the vena cava that is upstream of the valve leaflets to a location within the vena cava that is downstream of the valve leaflets, and (b) close in response to retrograde blood flow through the vena cava from a location within the vena cava that is downstream of the valve leaflets to a location within the vena cava that is upstream of the valve leaflets. For example, valve 100 described hereinbelow with reference to
It is noted that placing the valve in the inferior vena cava in the above-described manner (e.g., as described with reference to
It is further noted that, by placing the valve in the renal vein, or inside the vena cava, such that the valve leaflets are disposed in the vicinity of the ostium of the junction of the renal vein with the vena cava, retrograde blood flow to the kidney may be reduced by the valve even during exercise, and/or other physical activity of the subject's body, during which there is typically increased flow and pressure in the inferior vena cava that is generated by venous return from veins of the subject's legs. By contrast, a valve placed in the inferior vena cava such that the valve leaflets (a) open in response to antegrade blood flow through the vena cava from a location within the vena cava that is upstream of the valve leaflets to a location within the vena cava that is downstream of the valve leaflets, and (b) close in response to retrograde blood flow through the vena cava from a location within the vena cava that is downstream of the valve leaflets to a location within the vena cava that is upstream of the valve leaflets, may not reduce pressure in the renal vein during exercise, and/or other physical activity of the subject's body, during which there is typically increased flow and pressure in the inferior vena cava that is generated by venous return from veins of the subject's legs. This is because, under such circumstances, a valve that is implanted in the inferior vena cava, and the leaflets of which are configured as described, will typically remain open in response to the increased flow and pressure at the inferior vena cava.
Furthermore, if a valve is placed in the inferior vena cava downstream of the junction that the renal vein makes with the inferior vena cava and such that the valve leaflets (a) open in response to antegrade blood flow through the vena cava from a location within the vena cava that is upstream of the valve leaflets to a location within the vena cava that is downstream of the valve leaflets, and (b) close in response to retrograde blood flow through the vena cava from a location within the vena cava that is downstream of the valve leaflets to a location within the vena cava that is upstream of the valve leaflets (e.g., valve 100 shown in
Reference is now made to
Typically, valve 34A includes a frame 41 (e.g., a frame that is made of nitinol, stainless steel, cobalt chromium, platinum iridium (or other non-absorbable metals), magnesium (or other absorbable metals), a polymer, and/or a different material). Further typically, the valve includes prosthetic valve leaflets 43 (e.g., leaflets made from complete or partial venous valves harvested from calves, pigs, sheep, horses, marsupials, or other animals; leaflets made from pericardial tissue, from small intestinal submucosa from pigs or other animals, and/or from a synthetic material, such as polyester, polyurethane, any other polymer, and/or any thin and flexible material (e.g. material generated by electrospinning, or sputter deposition, including thin-film nitinol leaflets)). Still further typically, the valve includes sealing material 45, which is coupled to (e.g., sutured to) the valve frame, and that seals the valve frame with respect to the walls of the renal vein. For some applications, a similar material is used for sealing material 45 as is used for prosthetic valve leaflets 43. The frame supports the prosthetic valve leaflets, e.g., by the prosthetic valve leaflets being sutured to the frame.
For some applications, valve frame 41 is shaped to define a generally cylindrical portion 44, the prosthetic valve leaflets being coupled to a downstream portion of the generally cylindrical portion. At least one protruding portion 46 protrudes radially from the generally cylindrical portion of the valve frame. Typically the protruding portion diverges radially from the outer surface of the cylindrical portion of the valve frame, such that the separation between the protruding portion and the outer surface of the cylindrical portion of the frame is greater at the downstream end of the protruding portion than at the upstream end of the protruding portion.
For some applications, the prosthetic valve is placed at junction 40, such that protruding portion 46 deforms at least a portion of the junction, such as to form a cavity 42 at the junction. Typically, the prosthetic valve leaflets are coupled to the valve frame such that the valve leaflets are disposed at least partially (and typically, fully) downstream of the downstream end of the protruding portion. Thus, when the valve is placed at junction 40, the valve leaflets are typically disposed within the cavity that is formed at the junction by the protruding portion. Typically, the valve frame is shaped such that, when the valve is placed at junction 40, the protruding portion forms a cavity that generates blood flow at the valve leaflets that is such as to prevent blood from stagnating in the vicinity of the valve leaflets.
For some applications, the valve frame is shaped such that, when the valve is placed at junction 40, the protruding portion forms a cavity that is such as to cause blood flow in the vicinity of the downstream side of the valve leaflets to exert pressure on the valve leaflets, such that the valve leaflets close, or move closer together to facilitate closing. Alternatively, the valve frame is shaped such that, when the valve is placed at junction 40, the protruding portion forms a cavity that is such as to cause antegrade blood flow to accelerate in the vicinity of the downstream side of the valve leaflets, thereby causing (or enhancing) opening of the leaflets.
For some applications, valve frame 41 defines a single protruding portion 46. For some applications, the single protruding portion is disposed around the full circumference of the valve frame. Alternatively, the valve frame defines two or more (e.g., two, three, or four) protruding portions that protrude from generally cylindrical portion 44 of the valve frame. As shown in
For some applications, valve frame 41 defines generally cylindrical portion 44, and at least one protruding portion 46 (e.g., a plurality of protruding portions), the generally cylindrical portion and the protruding portion being reversibly couplable to one another. Typically, the valve leaflets are coupled to the generally cylindrical portion, as described hereinabove. The at least one protruding portion is couplable to the cylindrical portion such that when the protruding portion is coupled to the cylindrical portion, the protruding portion protrudes radially from the cylindrical portion, as described hereinabove. For some applications, the protruding portion is implanted within the renal vein separately from the cylindrical portion. For example, the protruding portion may first be placed in the renal vein, and, subsequently, the cylindrical portion may be placed within the renal vein and coupled to the protruding portion.
For some applications of the invention, the valve leaflets of the prosthetic valve are replaced, subsequent to the valve having been placed in the subject's renal vein (e.g., in the event of fatigue of the valve leaflets). In order to replace the prosthetic valve leaflets, the cylindrical portion of the valve frame is decoupled from the protruding portion of the valve frame. The cylindrical portion is removed from the subject's body, and the protruding portion is left inside the subject's vein. Subsequently, a replacement cylindrical portion (or the same cylindrical portion with new prosthetic leaflets coupled thereto) is placed inside the renal vein and coupled to the protruding portion.
For some applications, valve frame 41 defines generally cylindrical portion 44, and at least one protruding portion 46 (e.g., a plurality of protruding portions), the cylindrical portion and the protruding portion being irreversibly coupled to one another, and/or being formed as a single integrated structure.
As described hereinbelow with reference to valve 34C (shown in
Alternatively, prosthetic valve leaflets 43 of valve 34A may be coupled to valve frame 41 such that an upstream end of each of the prosthetic valve leaflets is upstream of at least a portion of the at least one protruding portion 46. For some applications, protruding portions 46 are shaped and/or sized to be disposed outside of radial projections of downstream edges of the valve leaflets, such that when the prosthetic valve leaflets are fully opened, the leaflets do not impact any rigid or partially rigid portions of the protruding portions. For example, as shown in
Reference is now made to
Typically, frame 11 of valve 34B includes a relatively narrow portion 13 thereof to which valve leaflets 14 are coupled. Further typically, a sealing material 15 is coupled to the narrow portion of the valve frame, the sealing material being configured to seal the valve frame with respect to the walls of the renal vein. The valve leaflets and the sealing material are generally as described hereinabove. Bulging portion 12 of frame 11 of valve 34B is typically disposed downstream with respect to the narrow portion of the valve frame and is bulged with respect to the narrow portion. Bulging portion 12 is configured to form a cavity at the junction such that the valve leaflets are disposed inside the cavity.
Typically, valve frame 11 of valve 34B is shaped such that, when the valve is placed at junction 40, bulging portion 12 of frame 11 forms a cavity 42 that generates blood flow at the valve leaflets that is such as to prevent blood from stagnating in the vicinity of the valve leaflets. For some applications, the valve frame is shaped such that, when the valve is placed at junction 40, the bulging portion forms a cavity that is such as to cause blood flow in the vicinity of the downstream side of the valve leaflets to exert pressure on the valve leaflets, such that the valve leaflets close, or move closer together to facilitate closing. Alternatively, the valve frame is shaped such that, when the valve is placed at junction 40, the bulging portion forms a cavity that is such as to cause antegrade blood flow to accelerate in the vicinity of the downstream side of the valve leaflets, thereby causing (or enhancing) opening of the leaflets.
For some applications, valve 34B is configured to be retrieved from the renal vein, subsequent to being placed inside the renal vein. For some applications, valve 34B is retrieved by pulling the bulging portion 12 of frame 11, such as to cause the bulging portion to radially constrict.
Reference is now made to
Typically, valve 34C includes a frame 50 (e.g., a frame that is made of nitinol, stainless steel, cobalt chromium, platinum iridium (or other non-absorbable metals), magnesium (or other absorbable metals), a polymer, and/or a different material). Further typically, the valve includes prosthetic valve leaflets 54 (e.g., leaflets made from complete or partial venous valves harvested from calves, pigs, sheep, horses, marsupials, or other animals; leaflets made from pericardial tissue, from small intestinal submucosa from pigs or other animals, and/or from a synthetic material, such as polyester, polyurethane, any other polymer, and/or any thin and flexible material (e.g. material generated by electrospinning, or sputter deposition, including thin-film nitinol leaflets)). Still further typically, the valve includes sealing material 55, which is coupled to (e.g., sutured to) the valve frame, and that seals the valve frame with respect to the walls of the renal vein. For some applications, a similar material is used for sealing material 55 as is used for prosthetic valve leaflets 54. The frame supports the prosthetic valve leaflets, e.g., by the prosthetic valve leaflets being sutured to the frame. For some applications, the frame is shaped to define a generally cylindrical portion 56, the prosthetic valve leaflets being coupled to a downstream portion of the generally cylindrical portion. Valve 34C, as shown in
For some applications, the prosthetic valve is placed within a renal vein (e.g. within the main branch of the left renal vein, as shown), such that protruding portion 58 deforms at least a portion of the renal vein, such as to form bulged portion 52 within the renal vein. Typically, the prosthetic valve leaflets are coupled to the valve frame such that the valve leaflets are disposed at least partially (and typically, fully) downstream of the downstream end of the protruding portion. Thus, when the valve is placed within the renal vein, the valve leaflets are typically disposed within the bulged portion of the renal vein that is formed by the protruding portion. Typically, the valve frame is shaped such that, when the valve is placed within the renal vein, the protruding portion forms a bulged portion of the renal vein that generates blood flow at the valve leaflets that is such as to prevent blood from stagnating in the vicinity of the valve leaflets.
For some applications, the valve frame is shaped such that, when the valve is placed within the renal vein, the protruding portion forms a bulged portion of the renal vein that is such as to cause blood flow in the vicinity of the downstream side of the valve leaflets to exert pressure on the valve leaflets, such that the valve leaflets close, or move closer together to facilitate closing. For some applications, valve 34C is configured as shown in
For some applications, the bulged portion of the renal vein is such as to generate blood flow at the valve leaflets that is such as to prevent blood from stagnating in the vicinity of the valve leaflets.
Typically, prosthetic valve leaflets 54 are coupled to valve frame 50 such that an upstream end 60 of each of the prosthetic valve leaflets is longitudinally spaced from a downstream end 62 of the at least one protruding portion 58. This is shown in
Alternatively, prosthetic valve leaflets 54 of valve 34C may be coupled to valve frame 50 such that an upstream end of each of the prosthetic valve leaflets is upstream of at least a portion of the at least one protruding portion 58. For some applications, protruding portions 58 are shaped and/or sized to be disposed outside of radial projections of downstream edges of the valve leaflets, such that when the prosthetic valve leaflets are fully opened, the leaflets do not impact any rigid or partially rigid portions of the protruding portions. For example, as shown in
For some applications, valve frame 50 defines a single protruding portion 58. For some applications, a single protruding portion is disposed around the full circumference of the valve frame. Alternatively, the valve frame defines two or more (e.g., two, three, or four) protruding portions that protrude from generally cylindrical portion 56 of the valve frame. Typically, the valve includes the same number of protruding portions as valve leaflets. For example, valve 34C as shown in
For some applications, valve frame 50 defines generally cylindrical portion 56, and at least one protruding portion 58 (e.g., a plurality of protruding portions), the generally cylindrical portion and the protruding portion being reversibly couplable to one another. Typically, the valve leaflets are coupled to the generally cylindrical portion, as described hereinabove. The at least one protruding portion is couplable to the cylindrical portion such that when the protruding portion is coupled to the cylindrical portion, the protruding portion protrudes radially from the cylindrical portion, as described hereinabove. For some applications, the protruding portion is implanted within the renal vein separately from the cylindrical portion. For example, the protruding portion may first be placed in the renal vein, and, subsequently, the cylindrical portion may be placed within the renal vein and coupled to the protruding portion.
For some applications of the invention, the valve leaflets of the prosthetic valve are replaced, subsequent to the valve having been placed in the subject's renal vein (e.g., in the event of fatigue of the valve leaflets). In order to replace the prosthetic valve leaflets, the cylindrical portion of the valve frame is decoupled from the protruding portion of the valve frame. The cylindrical portion is removed from the subject's body, and the protruding portion is left inside the subject's renal vein. Subsequently, a replacement cylindrical portion (or the same cylindrical portion with new prosthetic leaflets coupled thereto) is placed inside the renal vein and coupled to the protruding portion.
For some applications, valve frame 50 defines generally cylindrical portion 56, and at least one protruding portion 58 (e.g., a plurality of protruding portions), the cylindrical portion and the protruding portion being irreversibly coupled to one another, and/or being formed as a single integrated structure.
Reference is now made to
Typically, frame 64 of valve 34D includes a relatively narrow portion 68 thereof to which valve leaflets 66 are coupled. Further typically, a sealing material 69 is coupled to the narrow portion of the valve frame, the sealing material being configured to seal the valve frame with respect to the walls of the renal vein. The valve leaflets and the sealing material are generally as described hereinabove. Bulging portion 67 of frame 64 of valve 34D is typically disposed downstream with respect to the narrow portion of the valve frame and is bulged with respect to the narrow portion. Bulging portion 67 causes the renal vein to form a bulged portion, such that the valve leaflets are disposed inside the bulged portion. For some applications, the bulged portion is such as to cause vortex flow within the bulged portion, which exerts pressure on the downstream sides of the valve leaflets, such that the valve leaflets close. Alternatively or additionally, the bulged portion of the renal vein that is such as to cause antegrade blood flow to accelerate in the vicinity of the downstream side of the valve leaflets, thereby causing (or enhancing) opening of the leaflets. Further alternatively or additionally, the bulged portion of the renal vein is such as to generate blood flow at the valve leaflets that is such as to prevent blood from stagnating in the vicinity of the valve leaflets.
For some applications, frame 64 of valve 34D ends in the vicinity of the upstream ends of valve leaflets 66, as shown in
For some applications, valve 34D is configured to be retrieved from the renal vein, subsequent to being placed inside the renal vein. For some applications, valve 34D is retrieved by pulling the bulging portion 67 of frame 64, such as to cause the bulging portion to radially constrict.
Reference is now made to
Reference is now made to
As shown, valve 34F is generally similar to valve 34A described hereinabove with reference to
For some applications, prosthetic valve 34F is configured to reduce retrograde blood flow to the subject's kidney via the renal vein and/or to reduce renal venous pressure such that renal venous pressure is lower than the subject's central venous pressure, in a generally similar manner to that described hereinabove. Valve frame 80 of the prosthetic valve is typically rigid or semi-rigid. For applications in which valve 34F is configured to be placed in the subject's left renal vein, the valve frame typically has a length L of more than 20 mm (e.g., more than 25 mm), and/or less than 95 mm (e.g., less than 90 mm). For some applications, a ratio of the length of the valve to a maximum radial span of the valve is greater than 1:1, e.g., greater than 4:1. For applications in which valve 34F is configured to be placed in the subject's right renal vein, the valve frame typically has a length of more than 6 mm (e.g., more than 8 mm), and/or less than 45 mm (e.g., less than 40 mm). In addition to supporting prosthetic valve leaflets 81 of the prosthetic valve, the valve frame is configured to support the renal vein and to reduce (e.g., to prevent) compression of the renal vein that would occur in the absence of the valve frame, due to intra-abdominal pressure of the subject.
In general, the scope of the present invention includes placing a stent or a valve frame inside a subject's renal vein such as to protect the renal vein from compression due to high intra-abdominal pressure, resulting from fluid accumulation within the abdomen. For some applications, a valve that includes valve leaflets and a valve frame is placed inside the renal vein such that (a) the valve leaflets reduce retrograde blood flow to the subject's kidney via the renal vein, and/or reduce renal venous pressure such that renal venous pressure is lower than the subject's central venous pressure, and (b) the valve frame protects the renal vein from compression due to high intra-abdominal pressure, resulting from fluid accumulation within the abdomen.
Reference is now made to
Subsequent to the coupling of the upstream end of valve 34 to the wall of renal vein 32, catheter 90 is retracted, such as to release the downstream end of the prosthetic valve. In response thereto, the downstream end of the valve typically self-expands, such as to contact the wall of the renal vein, e.g., such as to contact the wall of the renal vein at the junction of the renal vein with the vena cava, as shown in
It is noted that although the valve shown in
Reference is now made to
Valve 100 is coupled to the subject's vena cava at a location that is downstream of the junction of the vena cava with the left renal vein (and, typically, downstream of all of the junctions that the vena cava forms with the subject's renal veins). Valve 100 typically includes a valve frame 106, valve leaflets 107, and sealing material 108. The valve leaflets and the sealing material are coupled to the valve frame, and are typically generally similar to the valve leaflets and the sealing materials described hereinabove. The valve leaflets are configured to (a) open in response to antegrade blood flow through the vena cava from a location within the vena cava that is upstream of the valve leaflets to a location within the vena cava that is downstream of the valve leaflets, and (b) close in response to retrograde blood flow through the vena cava from a location within the vena cava that is downstream of the valve leaflets to a location within the vena cava that is upstream of the valve leaflets. Thus valve 100 is configured to prevent the renal veins from backflow and pressure of blood from the portion of the vena cava that is downstream of the renal veins.
Reference is now made to
Reference is now made to
It is noted that, although a prosthetic valve that defines a valve frame and prosthetic valve leaflets has been described as being used to reduce and/or prevent retrograde blood flow to a subject's kidney, and/or to reduce renal venous pressure relative to central venous pressure, for some applications, a different device is used to reduce and/or prevent retrograde blood flow to the subject's kidney, and/or to reduce renal venous pressure relative to central venous pressure. For some applications, an electronically-controlled valve or shutter is used, the valve or shutter being configured to be opened and closed in response to physiological signals of the subject that are detected using a sensor (e.g., an ECG sensor, and/or a blood pressure sensor). For some applications, an active micro-assist device, such as an Archimedes screw, is used to reduce and/or prevent retrograde blood flow to a subject's kidney, to reduce renal venous pressure relative to central venous pressure, and/or to promote antegrade blood flow from the renal vein to the vena cava. For some applications, a stent is placed in the renal vein such as to reduce pressure in the renal vein relative to pressure in the renal vein in the absence of the stent, by reducing compression of the subject's renal vein resulting from intra-abdominal pressure of the subject.
It is further noted that the scope of the present invention includes using a bi-leaflet valve, a tri-leaflet valve, or a valve having any number of leaflets for any of the valves described herein.
It will be appreciated by persons skilled in the art that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof that are not in the prior art, which would occur to persons skilled in the art upon reading the foregoing description.
The present application is a continuation of U.S. Ser. No. 16/273,898 to Tuval (published as US 2019/0175340), filed Feb. 12, 2019, which is a division of U.S. Ser. No. 15/423,368 to Tuval (issued as U.S. Pat. No. 10,299,918), filed Feb. 2, 2017, which is a continuation of U.S. Ser. No. 14/405,144 to Tuval (issued as U.S. Pat. No. 9,597,205), filed Dec. 2, 2014, which is the US national phase application of PCT Application No. PCT/IL/2013/050495 to Tuval (published as WO 13/183060), filed Jun. 6, 2013, which claims priority from U.S. Provisional Patent Application 61/656,244 to Tuval, filed Jun. 6, 2012, which is incorporated herein by reference.
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| Number | Date | Country | |
|---|---|---|---|
| 20220151774 A1 | May 2022 | US |
| Number | Date | Country | |
|---|---|---|---|
| 61656244 | Jun 2012 | US |
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|---|---|---|---|
| Parent | 15423368 | Feb 2017 | US |
| Child | 16273898 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 16273898 | Feb 2019 | US |
| Child | 17487145 | US | |
| Parent | 14405144 | US | |
| Child | 15423368 | US |
