| WO2000021584A1 | 2000-04-20 | |||
| WO2005007219A2 | 2005-01-27 |
| US20040097804A1 | 2004-05-20 | |||
| US6682545B1 | 2004-01-27 |
CLAIMS
1. A balloon for use in valvuloplasty of aortic valve stenosis that consists of the standard valvuloplasty balloon/catheter assemble (Figure 1) (the known configuration of a catheter having 2 lumens (Figure l,a,b) running through its entire shaft and reaching to its external end (Figure l,c) that remains outside of the patient's body: one lumen is used for the inflation of the balloon (Figure l ,d) that is mount to the other end of the catheter (Figure l,e), and the other lumen is used for passing the guide-wire over which the balloon is advanced from the entry site to the application site). The invention lies in that a drug against restenosis, which invariably occurs after valvuloplasty, coats the external surface of this balloon. The antirestenotic drug is delivered from the external surface of the balloon to the aortic valve tissues during the inflation of the balloon in performing valvuloplasty.
2. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 1, whose entire external balloon surface is coated with an antirestenotic drug (Figure 2,a).
3. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 1 , whose external balloon surface is partially coated with an antirestenotic drug at the level of its middle segment that contacts the aortic valve tissues upon inflation. The other balloon surfaces at its both ends remain uncoated (Figure 3,a).
4. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 1 , which takes the shape of an hour-glass shape when inflated with its waist having a smaller diameter than that of its ends. Only the surfaces of the middle segment of this balloon (the level of the hour-glass waist) are coated with an antirestenotic drug.
5. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 4, whose waist has a crease shape (Figure 4,a). Only the surfaces of the middle segment of this balloon (the level of the hour-glass waist) are coated with an antirestenotic drug (Figure 4,b).
6. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 4, whose waist has a concave shape (Figure 5,a). Only the surfaces of the middle segment of this balloon (the level of the hour-glass waist) are coated with an antirestenotic drug (Figure 5,b).
7. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 1, whose distal end surface has a shape that is the relief of the upper surfaces of the aortic valve leaflets (Figure 6,a) and is coated with an antirestenotic drug (Figure 6,b). This balloon is inflated in the aortic root above the aortic valve and then gently pushed against its upper surfaces delivering the drug coating to them.
8. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 7, whose distal end surface that comes in contact with the upper surfaces of the aortic valve has in addition tiny microholes/pores (Figure 7,a). These microholes/pores allow the exit of the inflating solution when the balloon is expanded. The inflation solution contains the antirestenotic drug that soaks the upper surfaces of the aortic leaflets.
9. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 5, whose waist is so short and so deep (Figure 8,a) that when it is inflated it forms an 'envelope' in which the aortic valve leaflets are 'captured' (Figure 8,b). The surfaces of this 'envelope' are coated with the antirestenotis drug (Figure 8,c) that is delivered this way to both upper and lower surfaces of the aortic valve, which are inserted within.
10. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 9, in which the surfaces that form its waist have in addition microscopic holes/pores (Figure 9,a). These microholes/pores allow the exit of the inflating solution when the balloon is expanded. The inflation solution contains the antirestenotic drug that soaks both the upper and lower surfaces of the aortic leaflets.
1 1. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 9, whose waist reaches the central lumen of the system and separates completely the two spaces on its sides (Figure 10). They do not communicate and they are inflated by two separate lumens. Therefore, the total number of lumens in this system are 3 (Figure 10,a): one for the guiding-wire and one for each of the two spaces that in effect are two balloons in a row. The advantage of this system is that the two balloons in the row that form the narrow and deep waist can be inflated separately. The proximal balloon (Figure 10,b) is inflated first and its distal drug-coated surface (Figure 10,b) is pushed against and contacts the upper surfaces of the aortic leaflets. Immediately afterwards the distal balloon (Figure 10,c) is inflated forming the 'envelope' in which the leaflets are captured. The proximal surface (Figure 10,d) of the distal balloon is dug-coated and comes in contact with the lower surfaces of the aortic leaflets delivering the drug.
12. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claim 9, which in addition has a hollow center along its long axis that when the balloon is inflated it is expanded and creates a central cylindrical lumen (Figure 11, a). In the internal surface of this lumen and at the level of the waist of the balloon there are 2 or 3 artificial crests (Figure ll,b) that have the shape of the aortic leaflets. When the balloon is deflated and shrunk these crests are contained within the also shrunk central lumen of the balloon, but as the balloon is inflated the walls of the central cylindrical lumen are apposed and the lumen appears, the 'artificial' leaflets drop within it and function as a temporary 'artificial' aortic valve. As the hour-glass shaped balloon is inflated the aortic valve leaflets are captured within the envelope that is formed in the waist and drug coating from the attendant balloon surfaces (Figure ll,c) is delivered to the leaflet tissues. In addition, with the inflation and expansion of the balloon the central cylindrical lumen running its long axis from end to end opens allowing blood flow with each heart beat from the left ventricle to the aorta through the temporary 'artificial' aortic valve that drops and functions within the lumen. Backflow of the blood to the left ventricle is not possible through this 'artificial' valve. Competent cardiac function and output is preserved with the use of this balloon system allowing its prolonged inflation and contact with the aortic valve tissues and achieving this way release and delivery to the valve of larger quantities of the antirestenotic drug
13. A balloon for use in valvuloplasty of aortic valve stenosis similar to Claims 1 to 12, but it is used for valvuloplasty of other than the aortic heart valves. |
Anti-restenosis drug covered and eluting balloons for valvuloplasty of aortic valve stenosis for the prevention of restenosis
Background. Where aortic valvuloplasty stands today
Although aortic valve surgery is the gold standard, life saving treatment for symptomatic aortic stenosis, some patients do not undergo surgery. According to the 2003 Euro Heart Survey (lung B, et al, Eur Heart J 2003;24: 1231 -43) one third of community patients above the age of 75 with symptomatic severe aortic stenosis do not undergo surgery. The most apparent reason for this is the high mortality of the aortic valve replacement (AVR) in this population. The Medicare data in 2003 found a 8.8% in-hospital mortality of AVR in 145 000 patients aged over 65. There are other data showing average mortality of AVR up to 20% in octogenarians.
The incidence of known and severe aortic stenosis in US population in 2006 was 318,000 cases, of which only 74,000 had undergone AVR (based on Nkomo et al, Lancet 2006). According to other US estimates for 2006, of the 161 ,107 cases of ECHO diagnosed severe aortic stenosis over a 10-year period only 61,658 undergone AVR (based on Loma Linda data). Given the bad prognosis of severe symptomatic aortic stenosis, there has been an unmet need for another supplementary /alternative therapy.
Recently there has been considerable change in the technical approach to balloon aortic valvuloplasty (BAV) owing to the progress of percutaneous aortic valve implantation retrograde from the femoral artery and advances in the interventional hardware. A decrease in the complication rate of BAV over the past 15 years has been reported and has important implications regarding the morbidity associated with percutaneous aortic valve replacement techniques. In a recent series of 104 BAV procedures there were no procedural deaths and the incidence of total
vascular complications was 9%. In-hospital, 1-, 2- and 3-year mortality rates were 6%, 44%, 62% and 71%, respectively. In the 1980's NHLBl Balloon Valvuloplasty Registry the procedural mortality was 3% and the in-hospital mortality 1 1%.
BAV has been well demonstrated to moderately increase aortic valve area by an average of 0.3-0.4 cm 2 and reduce mean valvular gradient by roughly 50%. This is achieved despite the use of balloon diameters of 18-24mm, not far smaller from the diameter of the aortic valve ring. Transient valve leaflet and annular stretch undoubtedly contribute to early recoil. The large majority of patients experience immediate symptomatic improvement.
However, the restenosis rates of 42-83% at 5-9 months and consistently >80% at 1 year remain the Achilles heel of the method and is the reason of the dismal long-term event-free and actuarial survival after balloon aortic valvuloplasty that resembles the natural history of untreated aortic stenosis.
It is now recognized that calcific aortic stenosis is a complex cellular process with features of atherosclerosis and biomineralization similar to osteogenesis, which should have specific pathways for targeted inhibition. Similarly, regulated processes may play a role in restenosis following BAV. Although the mechanisms of restenosis are poorly understood, scar formation and heterotopic ossification are believed to play a central role. If specific targeted inhibition of these processes is completely or even partially successful the long-term results of the BAV procedure will improve and it may become an acceptable treatment of aortic valve stenosis in the elderly.
An increasing number of patients are living into the 80s and beyond. Although many of these patients who may have symptomatic stenosis are acceptable candidates for surgical treatment, many are not. Given the uniform desire on behalf of the elderly for improvement in their quality of life, any advance in the
BAV procedure that will limit restenosis and improve its long-term results would be welcome in this population.
The first effort to prevent restenosis following BAV was with radiation. The results of the RADAR pilot trial were published in Cathet Cardiovasc Intervent 2006;68: 183-92. This was a series of 20 patients over 80 years of age with an estimated operative mortality risk above 15%. They underwent prophylactic external beam radiation therapy (EBRT) starting the day following the BAV procedure and for 3 days. A total dose of 1200 cGy and 1500-1800 cGy was administered in the low and high dose groups of patients. Restenosis was defined as over 50% late loss of acute gain in aortic valve area. By 1 year the restenosis rate in the low dose group was 30% and in the high dose group 1 1%, results impressively better than historical controls.
Description of the invention
The restenosis in coronary arteries and aortic valve following dilatation of a balloon share certain pathophysiological aspects. My hypothesis is that local antiproliferative drug delivery at the stenotic aortic valve with a balloon is a simple and effective way of preventing restenosis. If the restenosis problem is solved or even attenuated the acceptance/usage of this therapy would be completely revived.
I describe the development of drug-coated balloon for BAV, which elutes the loaded drug to the aortic valve tissues upon contact. There are numerous possibilities to drug coatings for this balloon, from drugs inhibiting scar formation to drugs inhibiting heterotopic ossification.
Since the mechanism of valve restenosis following BAV share certain characteristics with the coronary in-stent restenosis, drugs used for prevention of the latter can be tested for efficacy in the former. Paclitaxel for example is known
to inhibit fibroblast migration in vitro and in vivo, and can be the first one to be used for coating a BAV balloon.
Recently, a pilot trial of external beam radiation therapy (EBRT) following BAV in 20 patients demonstrated a sustained significant improvement in the aortic valve area and mean gradient up to 1 year after the procedure (in reality there were only 2 outliers). However, this preventive strategy, even if it is conclusively proved, has certain inherent disadvantages such as the need for liaison with other medical specialties and medical facilities, precision of targeting, and prolonged hospital stay. The effort of restenosis prevention with radiation is reminiscent of the usage of brachytherapy for in-stent restenosis in coronary arteries, before the advent of drug-eluting stents.
In the event that antiproliferative drugs, such as paclitaxel, do not prove to be sufficiently effective, the component of valve restenosis due to heterotopic ossification could be dealt with incorporation in the coating of inhibitors of mineralization/calcification such as MGP, fetuin, osteopontinad and others or oral administration of inhibitors such as phosphate binding drugs (used by all chronic renal failure patients) and NSAA (i.e. the selective cyclooxygenase-2 (COX-2) inhibitor Rofecoxib).
An effective drug-coated balloon for BAV would prevent restenosis with local drug delivery at the aortic valve leaflets at the time of balloon inflation. This method is obviously superior to EBRT, which requires prolonged hospital stay and considerable material and human resources.
If such a balloon proves to prevent restenosis and offers a long-term symptomatic improvement, it will undoubtedly become the treatment of choice in the elderly. The procedure will be much simpler, safer and cheaper compared to the implantation of a percutaneous prosthetic valve. Even partial success with reduction and delay but not elimination of restenosis will be welcome, since repeat BAV can be done in those in need. It is known that
repeat BAV is feasible, safe and offers further relief, but cannot be seen as the solution when the restenosis rate is close to 100% after 1 year. However, if the use of the drug-coated balloon attenuates and cuts down the restenosis to acceptable rates, BAV with drug-coated balloon will become readily acceptable.
DIOR (Eurocor, Germany) is a balloon catheter coated with paclitaxel (3 mcg/mm 2 of balloon surface area) for use in the coronary arteries. It releases 35% of the drug with every 20-second contact with the vessel wall (i.e. 2 such dilatations release almost 70% of the loaded drug). It has been shown to significantly reduce late lumen loss and coronary in-stent restenosis compared with an uncoated balloon.
The aortic valvuloplasty balloon first introduced in the late 70s and today there are plenty plain valvuloplasty balloons manufacturers for use in heart valves. My proposal, which I submit for patenting, is an aortic valvuloplasty balloon that is covered by and elutes an antirestenosis substance (drug) to the aortic valve tissues upon contact with them during its inflation (Claim 1 ). The drug is released to the aortic valve tissues and exerts its antirestenotic action. The same technology used in the aforementioned balloon catheter (DIOR) or any other drug-covering technology (mechanical or chemical bonding of the drug to the balloon surface) is applied in manufacturing of this balloon.
The entire external balloon surfuce or a part of it will be covered the antirestenotic drug [Claim 2: the entire balloon surface is covered by drug (Figure 2). Claim 3: the drug covers the middle-part area of the balloon that is coming into direct contact to the aortic valve and the edges remain uncovered (Figure 3)].
The time of the balloon inflation in BAV cannot exceed 10-15 seconds, but multiple balloon inflations can be applied to reach a total time of balloon-valve contact of almost 1 minute. This allows the almost complete release of the loaded drug to the contacted tissue. If necessary, the quantity of the drug administered at the valve tissues by the balloon may be increased by storing higher dose of the
drug at the balloon surface with appropriate technology (i.e. more and/or deeper and/or larger micropores).
A pilot trial in animals is designed to prove the concept of local drug delivery at the aortic leaflets followed by studies with experimental models of animal aortic valve stenosis and ultimately studies in humans with aortic valve stenosis.
This balloon will achieve contact and drug release at the inferior/external surfaces of the aortic valve, which have considerably larger area compared to the superior/internal surface for geometrical reasons. The safety of drug delivery at other endothelial sites in the vicinity (i.e. aortic root and left ventricular outflow tract-LVOT) will be assessed. If animal or initial human experience raises concerns about possible side effects of paclitaxel or other drugs apposition at the aortic root/LVOT endothelium, a hour-glass shaped balloon is developed with the drug loaded only in the middle slimmer part (waist) of the balloon (Claim 4). With such a design the drug will be administered in a targeted manner at the aortic valve tissue only, and contact with other structures will be avoided. In addition, such a shape will act protectively with regards to any premature release of the drug into the blood flow. Claim 5 describes a balloon that when inflated forms a circular crease at its middle part, the surface of which is covered by the drug (Figure 4). In BAV the pathological aortic valve contacts this balloon at the level of its drug-covered crease. Claim 6 describes a balloon similar to that of Claim 5, the only difference being that instead of forming a crease it forms a circular concave perimeter (Figure 5).
All the previously described balloons achieve the opening of the stenotic aortic valve and contact and deliver their drug coating at the inferior/external surfaces of the aortic valve, which have considerably larger area compared to the superior/internal surface for geometrical reasons. In the event that delivery of the antirestenotic drug at the superior/internal surfaces of the aortic valve is desirable, 2 further BAV balloons have been developed to perform this task. These balloons cannot effectively dilate the stenotic aortic valve on their own, but they have been
exclusively designed for drug delivery to prevent restenosis. BAV with a plain balloon or one of the balloons described in Claims 1 to 6 should precede. Claim 7 describes the first of the aforementioned balloon invents, and is specifically designed to achieve delivery of the antirestenosis drug at the superior/internal surfaces of the aortic valve (Figure 6). This balloon is inflated within the aortic root and its distal surface, which is covered by the drug, has a shape that is the relief of the upper surfaces of the aortic leaflets. Then it is gently pushed against the upper surfaces of the leaflets and fits perfectly to them delivering drug upon contact. Claim 8 describes a balloon that is a modification of that presented in Claim 7. It is identical in shape but in addition it has micro-holes/pores at its distal edge surface that comes in direct contact with the upper aortic leaflet surfaces, allowing the fluid used for its inflation to exit the balloon and sprinkle or soak these surfaces (Figure 8). The inflating fluid is a dilution of the anti-restenosis drug and the size of the micro-holes is such that allows full balloon inflation at low pressures before the drug containing fluid starts exiting through them.
Claim 9 describes the second of the aforementioned balloon invents. This balloon has been developed for the simultaneous delivery of the antirestenosis drug at both upper and lower surfaces of the aortic valve. When inflated it has a hourglass shape with very deep and narrow 'waist' that creates an 'envelope', in which the aortic valve leaflets are 'captured' (Figure 8). The surfaces of the balloon that form this 'envelope' are covered by the antirestenotic drug and its targeted delivery at both the upper and lower surfaces of the aortic leaflets is accomplished. In addition, such a shape acts protectively with regards to any premature release of the drug into the blood flow. The difference of this balloon design compared to that described by Claims 4 to 6 lies to that the waist of the hour-glass is so narrow that when the balloon is inflated its lateral surfaces come into contact and so deep that it almost reaches the central long axis of the balloon. Because of its design this balloon is not indented for the initial opening of the stenotic aortic valve (that can be achieved with a plain balloon or one of the
balloons described in Claims 4 to 6) but it is used after its dilatation with another balloon for accomplishment of targeted drug delivery at both surfaces of the leaflets.
Claim 10 describes a balloon that is a modification of that presented in Claim 9. It is identical in shape but in addition it has micro-holes/pores at its surface that forms the waist of the hour-glass and directly contacts the leaflets of the aortic valve. These micro-holes/pores allow the fluid used for the inflation of the balloon to exit the balloon and sprinkle or soak these surfaces (Figure 9). The inflating fluid is a dilution of the anti-restenosis drug and the size of the micro- holes is such that allows full balloon inflation at low pressures before the drug containing fluid starts exiting through them.
The balloons described in Claims 9 and 10 are in essence two-spaced balloons with the 2 spaces communicating at the 'neck' of the hour-glass they form together and are inflated through a single lumen. Therefore, the simultaneous inflation of the two spaces of these balloons (the single inflation lumen of the catheter ends at the proximal balloon space and as a result this is inflated slightly ahead of the distal space) means that its precise positioning at the level of the aortic valve is of paramount importance if the leaflets of the valve are to be captured within the 'envelope' the two spaces of the balloon shape as it inflates. The surfaces of this envelope are covered with the antirestenotic drug (and/or have microholes/pores) that is delivered to both surfaces of the aortic leaflets. To avoid the need of the precise positioning another balloon has been developed and is described in Claim 1 1. This balloon is similar to that described in Claim 9, but the 2 spaces are in essence 2 different balloons in a row that do not communicate at the neck of the hour-glass and the distal space is inflated separately by an additional lumen (Figure 10). Therefore, the total number of the lumens in this system is 3 (Figure 10,a): one is used for the advance of the system over the guide-wire, one is used for the inflation of the proximal and one for the inflation of the distal space. The advantage of this system is that the 2 in a row balloons that form the deep and narrow neck of the hour-glass can inflate separately allowing the 'dynamic' capture of the aortic valve between them. The
proximal balloon is inflated first (Figure 10,b) and the system is quickly pushed against the upper surfaces of the aortic leaflets delivering the drug coating it carries out at its distal surface (Figure 10,c) to them. The inflation of the distal balloon (Figure 10,d) follows immediately forming the 'envelope' that captures the aortic leaflets within. The proximal surface of the distal balloon is drug-coated (Figure 10,e) and comes into contact with the lower surfaces of the aortic leaflets delivering the antirestenotic drug.
All the previously described balloons for use in BAV have a common disadvantage: they stop blood flow from the heart to the aorta and result in a circulation arrest during their inflation. This can be tolerated for very short time that cannot exceed 15-20 seconds. If a more prolonged contact with the drug covered balloon is required for an efficient delivery of the antirestenotic drug to the valve tissues the same or other drug-eluting balloon can be used for multiple short-lived inflations.
Alternatively, a balloon system has been developed that can stay in contact with the aortic valve tissues for prolonged time allowing an effective cardiac output at the same time without halting the blood circulation from the heart to the aorta. Claim 12 describes this balloon system (Figure 1 1). This is a balloon that is similar to that described in Claim 9, but it has a hollow center along its long axis that when the balloon is inflated it is expanded and creates a central cylindrical lumen (Figure 1 1, a) with an area of approximately 0.5-1.2 cm 2 . In the internal surface of this lumen and at the level of the waist of the balloon there are 2 or 3 artificial crests (Figure 1 l,b) that have the shape of the aortic leaflets. When the balloon is deflated and shrunk these crests are contained within the also shrunk central lumen of the balloon, but as the balloon is inflated the walls of the central cylindrical lumen are apposed and the lumen appears, the 'artificial' leaflets drop within it and function as a temporary 'artificial' aortic valve. As the hour-glass shaped balloon is inflated the aortic valve leaflets are captured within the envelope that is formed in the waist (as described in Claim 9) and drug coating from the attendant balloon surfaces (Figure l l,c) are delivered to the leaflet
tissues. In addition, with the inflation and expansion of the balloon the central cylindrical lumen running its long axis from end to end opens allowing blood flow with each heart beat from the left ventricle to the aorta through the temporary 'artificial' aortic valve that drops and functions within the lumen. Backflow of the blood to the left ventricle is not possible through this 'artificial' valve. Competent cardiac function and output is preserved with the use of this balloon system allowing its prolonged inflation and contact with the aortic valve tissues and achieving this way release and delivery to the valve of larger quantities of the antirestenotic drug.
All previously described balloons can be used for valvuloplasty of other heart valves (Claim 13).
Phosphate binding drugs could be used for inhibition of the valve/vascular calcification component of restenosis in these studies.
Other antirestenotic and anticalcification drugs (alone or in combination) can be tested for local delivery with a coated balloon.