WO2008154534A2 - Methods for pre-stressing and capping bioprosthetic tissue - Google Patents
Methods for pre-stressing and capping bioprosthetic tissue Download PDFInfo
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- WO2008154534A2 WO2008154534A2 PCT/US2008/066411 US2008066411W WO2008154534A2 WO 2008154534 A2 WO2008154534 A2 WO 2008154534A2 US 2008066411 W US2008066411 W US 2008066411W WO 2008154534 A2 WO2008154534 A2 WO 2008154534A2
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- calcification
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
- A61L27/36—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
- A61L27/3604—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix characterised by the human or animal origin of the biological material, e.g. hair, fascia, fish scales, silk, shellac, pericardium, pleura, renal tissue, amniotic membrane, parenchymal tissue, fetal tissue, muscle tissue, fat tissue, enamel
- A61L27/3625—Vascular tissue, e.g. heart valves
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
- A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
- A61F2/02—Prostheses implantable into the body
- A61F2/24—Heart valves ; Vascular valves, e.g. venous valves; Heart implants, e.g. passive devices for improving the function of the native valve or the heart muscle; Transmyocardial revascularisation [TMR] devices; Valves implantable in the body
- A61F2/2412—Heart valves ; Vascular valves, e.g. venous valves; Heart implants, e.g. passive devices for improving the function of the native valve or the heart muscle; Transmyocardial revascularisation [TMR] devices; Valves implantable in the body with soft flexible valve members, e.g. tissue valves shaped like natural valves
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
- A61L27/36—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
- A61L27/3683—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
- A61L27/36—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
- A61L27/3683—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment
- A61L27/3687—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment characterised by the use of chemical agents in the treatment, e.g. specific enzymes, detergents, capping agents, crosslinkers, anticalcification agents
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
- A61L27/36—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix
- A61L27/3683—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment
- A61L27/3691—Materials for grafts or prostheses or for coating grafts or prostheses containing ingredients of undetermined constitution or reaction products thereof, e.g. transplant tissue, natural bone, extracellular matrix subjected to a specific treatment prior to implantation, e.g. decellularising, demineralising, grinding, cellular disruption/non-collagenous protein removal, anti-calcification, crosslinking, supercritical fluid extraction, enzyme treatment characterised by physical conditions of the treatment, e.g. applying a compressive force to the composition, pressure cycles, ultrasonic/sonication or microwave treatment, lyophilisation
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L27/00—Materials for grafts or prostheses or for coating grafts or prostheses
- A61L27/50—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials
- A61L27/507—Materials characterised by their function or physical properties, e.g. injectable or lubricating compositions, shape-memory materials, surface modified materials for artificial blood vessels
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
- A61F2210/00—Particular material properties of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
- A61F2210/0004—Particular material properties of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof bioabsorbable
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
- A61F2210/00—Particular material properties of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof
- A61F2210/0076—Particular material properties of prostheses classified in groups A61F2/00 - A61F2/26 or A61F2/82 or A61F9/00 or A61F11/00 or subgroups thereof multilayered, e.g. laminated structures
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L2400/00—Materials characterised by their function or physical properties
- A61L2400/02—Treatment of implants to prevent calcification or mineralisation in vivo
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L2430/00—Materials or treatment for tissue regeneration
- A61L2430/20—Materials or treatment for tissue regeneration for reconstruction of the heart, e.g. heart valves
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61L—METHODS OR APPARATUS FOR STERILISING MATERIALS OR OBJECTS IN GENERAL; DISINFECTION, STERILISATION OR DEODORISATION OF AIR; CHEMICAL ASPECTS OF BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES; MATERIALS FOR BANDAGES, DRESSINGS, ABSORBENT PADS OR SURGICAL ARTICLES
- A61L2430/00—Materials or treatment for tissue regeneration
- A61L2430/40—Preparation and treatment of biological tissue for implantation, e.g. decellularisation, cross-linking
Definitions
- Heart valve replacement may be indicated when there is a narrowing of the native heart valve, commonly referred to as stenosis, or when the native valve leaks or regurgitates, such as when the leaflets are calcified.
- the native valve may be excised and replaced with either a biologic or a mechanical valve.
- Tissue-type or "bioprosthetic" valves have flexible leaflets supported by a base structure that project into the flow stream and function much like those of a natural human heart valve by coapting against each other to ensure one-way blood flow.
- tissue-type valves a whole xenograft valve (e.g., porcine) or a plurality of xenograft leaflets (e.g., bovine pericardium) typically provide fluid occluding surfaces. Synthetic leaflets have also been proposed. Two or more flexible leaflets mount within a peripheral support structure, for example as seen in the CARPENTIER-EDWARDS Porcine Heart Valve and PERIMOUNT Pericardial Heart Valve available from Edwards Lifesciences of Irvine, California. [0004] Implantable biological tissues can be formed of human tissues preserved by freezing (i.e., cryopreserving) the homograft tissues, or of animal tissues preserved by chemically fixing (i.e., tanning) the xenograft tissues.
- the type of biological tissues used as bioprostheses include cardiac valves, blood vessels, skin, dura mater, pericardium, small intestinal submucosa ("SIS tissue”), ligaments and tendons. These biological tissues typically contain connective tissue proteins (i.e., collagen and eJastin) that act as the supportive framework of the tissue.
- connective tissue proteins i.e., collagen and eJastin
- the pliability or rigidity of each biological tissue is largely determined by the relative amounts of collagen and elastin present within the tissue and/or by the physical structure and configuration of its connective tissue framework.
- Collagen is the roost abundant connective tissue protein present in most tissues.
- Each collagen molecule is made up of three (3) polypeptide chains intertwined in a coiled helical configuration.
- the techniques used for chemical fixation of biological tissues typically involve the exposure of the biological tissue to one or more chemical fixatives (i.e., tanning agents) that form cross-linkages between the polypeptide chains within a given collagen molecule (i.e., intramolecular crosslinkages), or between adjacent collagen molecules (i.e., intermoiecular crosslinkages).
- chemical fixative agents i.e., tanning agents
- Examples of chemical fixative agents that have been utilized to cross-link collagenous biological tissues include: formaldehyde, glutaraldehyde, dialdehyde starch, hexamethylene diisocyanate and certain polyepoxy compounds.
- connective tissue proteins i.e., collagen and elastin
- calcification can result in undesirable stiffening or degradation of the bioprosthesis.
- glutaraldehyde (also referred to as simply "glut") has been the most widely used since the discovery of its anti immunological and antidegenerative effects by Dr. Alain Carpentier in 1968. See Carpentier, A., J. Thorac. Cardiovascular Surgery, 58: 467-69 (1969).
- glutaraldehyde is one of the most efficient sterilization agents.
- Glutaraldehyde is therefore used as the fixative and the sterilant for many commercially available bioprosthetic products, such as in the bioprosthetic heart valve available from Edwards Lifesciences of Irvine, California.
- the present invention accounts for certain detrimental changes within the tissue that can occur as a result of the service (implant) environment. Namely, when the tissue is cyclically stressed during normal service, certain potential binding sites for calcification, immune system attack, etc. are created. The present invention involves pre-stressing the tissue to expose such binding sites, and then capping or otherwise neutralizing such sites.
- a method of treating bioprosthetic implant tissue to reduce in vivo calcification of the present invention comprises at least partially cross- linking bioprosthetic implant tissue, then stressing the cross-linked tissue; and applying a calcification mitigant to the stressed, cross- linked tissue.
- the calcification mitigant may be a capping agent solution having at least one constituent that can bind to calcium, phosphate, or immunogenic factor binding sites.
- the calcification mitigant is a linking agent solution including a long elastic molecule.
- the calcification mitigant comprises a capping agent, it is desirably selected from the group consisting of: an amine, an amino acid, an amino sulfonate, a hydrophilic multifunctional polymer, a hydrophobic multifunctional polymer, ⁇ dicarbonyl, a hydraz ⁇ des, a N s N-disuccinimidyl carbonate, a carbodiimide, 2-chloro-l-methylpyridinium iodide (CMPI), an antibiotic, a cell recruiting agent, a hemocompat ⁇ bility agent, an antiinflamatory agent, an antiproliferative agent, an immunogenic suppressing agent, a reducing agent, and a mono-, di- or polyepoxy alkane.
- a capping agent it is desirably selected from the group consisting of: an amine, an amino acid, an amino sulfonate, a hydrophilic multifunctional polymer, a hydrophobic multifunctional polymer, ⁇ d
- the calcification mitigant is desirably delivered in one or a combination of the following solutions: an aqueous solution such as an aqueous buffered solution,, water, alcohols, glycerol, or plasticizers, an organic solvent, and an organic buffered solution.
- an aqueous solution such as an aqueous buffered solution, water, alcohols, glycerol, or plasticizers, an organic solvent, and an organic buffered solution.
- the tissue is preferably fully cross-linked prior to stressing.
- the tissue comprises precut heart valve leaflets mounted and flexed in a suitable flow apparatus.
- the tissue may be bulk sheets of tissue flexed in a suitable apparatus.
- the bioprosthetic implant tissue may be a bioprosthetic heart valve, and the step of stressing comprises subjecting the heart valve to pulsed fluid flow therethrough.
- the heart valve is subjected to pulsed fluid flow for at least 100 cycles.
- the step of stressing comprises subjecting the bioprosthetic implant tissue to a simulated post-implant physiological environment. Additionally, the step of stressing comprises subjecting the bioprosthetic implant tissue to at least one stress-accelerating environmental parameter.
- the stress-accelerating environmental parameter may comprise a rapid pulsed fluid flow in a range of 4 - 1500Hz, an elevated temperature range of 26 - 65 0 C, an acidic solution of pH of 4-7, an alkaline solution of pH 8-10, an oxidizing solution, or at least two of the preceding.
- the step of stressing is done until the newly exposed sites to be capped on the bioprosthetic tissue increase by at least 10%.
- Another measure is to stress the tissue until the level of damage in the bioprosthetic implant tissue increases by about 10%.
- the stressing is done at least until the rate of acid production in the bioprosthetic implant tissue decreases by about 10%.
- the steps of first stressing the tissue and then applying a calcification mitigant thereto may be done multiple times. In addition, the steps of first stressing the tissue and then applying a calcification mitigant thereto may be done at least twice with different calcification mit ⁇ gants.
- Another aspect of the invention is a method of treating bioprosthetic implant tissue to reduce in vivo calcification, comprising cyclically stressing the bioprosthetic implant tissue until the rate of acid production in the bioprosthetic implant tissue decreases by about 10%, and then applying a calcification mitigant to the stressed tissue.
- the bioprosthetic implant tissue comprises a bioprosthetic heart valve
- the step of stressing comprises subjecting the heart valve to pulsed fluid flow therethrough.
- the step of stressing may be done until the rate of increase of the acid level of the bioprosthetic implant tissue levels off.
- the calcification mitigant may be a capping agent solution having at least one constituent that can bind to calcium or phosphate, and/or immunogenic binding sites.
- the calcification mitigant comprises a linking agent solution including a long elastic molecule.
- Another aspect of the invention is method of treating a bioprosthetic heart valve to reduce in vivo calcification, comprising mounting a bioprosthetic heart valve in a simulated fluid flow system, subjecting the bioprosthetic heart valve to pulsed fluid flow for at least 100 cycles, then applying a calcification mitigant to the bioprosthetic heart valve.
- the bioprosthetic heart valve is subjected to pulsed fluid flow for at least 100,000 cycles.
- the steps of first subjecting the bioprosthetic heart valve to pulsed fluid flow and then applying a calcification mitigant thereto may be done multiple times.
- the steps of first subjecting the bioprosthetic heart valve to pulsed fluid flow and then applying a calcification mitigant thereto may be done at least twice with different calcification mitigants.
- the step of subjecting is done until the rate of increase of the acid level of the bioprosthetic implant tissue levels off.
- the calcification mitigant may be a capping agent solution having at least one constituent that can bind to calcium or phosphate, and/or immunogenic binding sites.
- the calcification mitigant comprises a linking agent solution including a long elastic molecule.
- Figure 1 is a graph showing the aldehyde and acid content in bovine pericardial tissue after several different chemical treatments
- FIG. 2 is a graph correlating the calcium content of in vivo tissue with the corresponding acid and aldehyde content for tissue treated three different ways;
- Figure 3 is a graph illustrating the acid content of glutaraldehyde treated tissue prior to and after being damaged (minced);
- Figure 4 is a graph showing the acid content of tissue treated in one particular way and subjected to increasing amounts of flexion cycles
- Figure 5 is a graph showing the acid content of tissue treated in the same way as the tissue in the graph of Figure 4 and subjected to increasing amounts of flexion cycles, and then after having been treated with a calcification mitigant, in this case a capping agent;
- Figure 6 is a graph showing the level of acid generation with increasing cycles from a whole prosthetic heart valve in an accelerated wear tester (AWT); and
- Figure 7 is a graph showing how the present calcification mitigation process greatly reduces the acid levels in a tissue strip subjected to flexion cycles.
- Bioprosthetic tissue in this sense means at least bovine pericardium and whole porcine valves which are commonly used in bioprosthetic heart valves that must endure years and even decades without calcifying.
- Other tissues that may be improved by the treatment include blood vessels, skin, dura mater, pericardium, small intestinal submucosa ("SIS tissue”), ligaments and tendons.
- SIS tissue small intestinal submucosa
- transplants in the present application refers not only to heart valves but also to vascular prostheses and grafts, tissue grafts, bone grafts, and orbital implant wraps, among others.
- a “bioprosthetic heart valve” in the present application refers to a fully assembled prosthetic valve made at least partly from bioprosthetic tissue. Some whole porcine valves are used in so-called “stentless” bioprosthetic valves in which there is very little if any synthetic material added for support or anchoring purposes.
- a “stented” bioprosthetic valve typically has some form of synthetic (e.g., polymer or metallic) support for the leaflets, which, as stated, may be the leaflets of a whole porcine xenograft or separate bovine pericardial leaflets.
- Prior tissue treatment processes address crosslinking s microbes, and other aspects of the tissue in a "static" setting, and typically involve immersion of the tissue in glutaraldehyde, Tween (polyoxyethylene 20 sorbitan monooleate), ethanol, formaldehyde, and other agents in order to mitigate post- implant calcification.
- Some prior art processes include the addition of various chemicals either in a static or dynamic (agitation) setting to reduce the toxicity of the crosslinked tissue or mitigate calcification via the use of meta! ions (i.e. Al 3+ or Fe 3+ - see U.S. Pat. No. 5,746,775 Levy) or bulk blocking agents (i.e. 2- amino oleic acid - see U.S. Pat.
- this invention describes an additional process whereby acids and other potential binding sites formed from the fixation processes as well as the "binding sites” and “potential binding sites” that are generated from flexion of fixed tissue and other in vivo service-related, stress- induced damage are "capped”.
- Tissue typically treated with glutaraldehyde, Tween (polyoxyethylene 20 sorbitan monooleate), ethanol, formaldehyde, and other agents can provide useful fixation of the tissue.
- fixation of the tissue will also generate "binding sites” capable of interacting with or attracting calcium, phosphate, immunogenic factors, or other precursors to calcification.
- carboxylic acid groups formed after glutaraldehyde fixation of the tissue and these groups are capable of attracting calcium ions (due to their negative charge and electrostatic interactions with positively charged ions) leading to calcification of the tissue or adverse cellular interactions.
- Carboxylic acid groups like that found in glutamic acid or gamma carboxy glutamic acid are known to bind calcium atoms (Hauschka et al. PNAS 1975 72:3925).
- Calcium binding proteins such as bone sialoprotein contain carboxylic acid rich domains designed to attract and bind calcium, leading to hydroxyapatite formation (calcification).
- the overall level and location of acid groups in these proteins determines the ability of the protein to efficiently bind calcium and form hydroxyapatite (calcification).
- the term "acid potential" of the tissue refers to the level of these chemical functional groups within the fixed tissue that can or may eventually form acid groups or "binding sites” through any means such as oxidation, dehydration, hydration, or similar processes.
- the present invention exploits the fact that subjecting already treated tissue to stress or flexion (micro-fibril damage of the fixed tissue) will generate additional acid binding sites. This is demonstrated by intentionally damaging such tissue, where such damage increases the binding sites dramatically as shown in Figure 3. Cyclic flexion of glutaraldehyde crosslinked tissue will also increase the level of acids in the tissue compared to static or unflexed tissue ( Figure 4). The flexed or stressed tissue now has a higher "acid potential” and increased propensity for calcification or stimulation of immunogenic responses. The "capping" of both statically formed and stress- induced sites will decrease the overall "acid potential" of the tissue and reduce the risk of calcification and immunogenic response, and is the basic premise of this invention.
- bioprosthetic materials especially tissues used for heart valve leaflets
- experience significant post- implant damage which tends to undo some of the beneficial effects of any tissue fixation treatment process.
- repeated stress flexion of the tissue leaflets in its in vivo "service"-type environment can create micro-damage to the collagen Fibrils and other areas of the leaflets, depending on the severity of the flexion.
- This progressive leaflet damage process can create new binding sites or potential binding sites that are precursors to calcification and immunogenic related pathways.
- the present invention describes a method to cap such stress-induced binding sites prior to implantation into the body.
- An objective of the invention is the permanent "capping" of the acid groups which would dramatically reduce their ability to attract calcium, phosphate, immunogenic factors, or other groups. This can be accomplished by, for example, capping of acid groups once they are formed or as they are formed through repeated flexion or stress.
- the term “capping” refers to the blocking, removal, or alteration of some group that would have previously had an adverse effect on the bioprosthesis function. For example, the addition of 1- ethyl-3-[3-dimethylaminopropyl]carbodiimide hydrochloride (EDC), N- hydroxysulfosuccinimide (sulfo-NHS), and ethanolamine will effectively cap the acid groups with a non-reactive alcohol group.
- EDC 1- ethyl-3-[3-dimethylaminopropyl]carbodiimide hydrochloride
- sulfo-NHS N- hydroxysulfosuccinimide
- ethanolamine will effectively cap the
- tissue treated with glutaraldehyde or other aldehyde containing agents also yields a tissue with many free aldehyde groups, which cause increased toxicity, higher calcification, and creation of immunogenic responses.
- These aldehyde groups can easily oxidize into carboxy ⁇ c acid groups (described above) via air oxidation, in vivo blood oxidation, macrophage oxidation, and other similar oxidation pathways.
- additional aldehydes can be generated which create more binding sites or acid groups through increased and repeated flexion or stress of the fixed tissue.
- an additional target of the invention includes the permanent capping of aldehyde groups which are potential binding sites in a way that would prevent their ability to transform into acids or other groups and thus further mitigate the potential for calcification in the body (in vivo).
- aldehyde groups which are potential binding sites in a way that would prevent their ability to transform into acids or other groups and thus further mitigate the potential for calcification in the body (in vivo).
- acids and aldehydes there are other possible binding sites such as immunogenic and antigenic factors that are included within the scope of this invention.
- the invention's capping process includes the chemical reduction of the tissue which, when applied to the tissue in the presence of a capping agent either prior to, during, or after flexion, will permanently connect the capping agent to the target group.
- a capping agent sodium cyanoborohydride
- the aldehyde group is ultimately replaced with a sulfonate group which may be beneficial for tissue hydration, flexibility, and cell interactions.
- Another preferred strategy is to cap the acid groups and includes the addition of EDC, sulfo-NHS and ethanolamine.
- capping agents can be used instead of ethanolamine and other reducing agents other than sodium cyanoborohydride are known by those skilled in the art and which are included in the scope of this patent.
- This new "capped" group will drastically reduce the attraction of calcium, phosphate, immunogenic factors, or other similar agents.
- Exemplary capping agents may be selected from the following list: amines, including alkyl amines, amino alcohols, ethanolamine; amino acids, including, lysine, hydroxylysine; amino sulfonates, including, taurine, amino sulfates, dextran sulfate, chondroitin sulfate; hydrophilic multifunctional polymers, including polyvinyl alcohol, polyethyleneimine; hydrophobic multifunctional polymers, ⁇ -dicarbonyls including methylglyoxal, 3- deoxyglucosone; glyoxal; hydrazides, including adipic; hydrazide, N,N- disuccinimidyl carbonate; carbodiimides, including, l-ethyl-3-[3 ⁇ dimethylaminopropyljcarbodiimide hydrochloride (EDC), N-cyclohexyl ⁇ N'-(2- morpholinoethyl)carbodiimide
- the binding sites By "linking" the binding sites with a long elastic molecule containing at least two or more complimentary reactive functional groups specific for either the newly formed functional groups produced by a stress damage (capping function), or other available nearby functional group, creates a long molecule cross-link that will act as an elastic reinforcement or shock- absorbing spring element in the tissue structure at the site of damage. This will then prevent the cascade failure described above.
- the initial damage (functional group i.e. acid) sites of potential calcification may benefit from being capped in the manner as described for the "capping" of the acid groups, and may be “linked” in concurrent or subsequent treatments.
- the terms “capping” or “linking” agents all refer to agents for treating pre-stressed tissue to mitigate future potential calcification (i.e., calcification mitigants).
- CMPI 2-chloro-l-methylpyridinium iodide
- the effect of preferred capping agents is to not only block functional groups that will attract calcium, phosphate, immunogenic factors, or other similar agents, but to replace those groups with a superior "biological functionality".
- Biological functionality is defined as the effect of tissue components on the local biology of the implanted material. Improved biological functionality of a tissue treatment may include reduction in overall charge of the tissue, better hemocompatibility, increased tissue hydration, better cell interactions, better flexibility, etc.
- capping aldehyde functions with taurine would block the aldehyde group from oxidizing into an acid and replace it with a sulfonate group which may be beneficial for tissue hydration, flexibility, and cell interactions.
- the desired biological functionality of the capped tissue will determine the type of capping compounds employed.
- the capping strategy is also designed to block the biological functionality of components of the tissue that may contribute to adverse cellular reactions.
- Some of these targets include, but are not limited to ⁇ -gal, MHC-I associated proteins, HLA antigens and the like.
- the invention is also directed to the capping or blocking of proteins, carbohydrates, lipids, and other components of the tissue that may contribute to cellular reactions.
- the ⁇ -gal carbohydrate may be blocked by treatment with 2-chloro-l- methylpyridinium iodide (CMPI) and other agents that neutralize the hydroxyl groups which are known by those skilled in the art.
- CMPI 2-chloro-l- methylpyridinium iodide
- Another example includes MHC-I associated proteins that may be capped or effectively neutralized by treatment with EDC and taurine.
- capping process is the targeting of proteins, carbohydrates or lipids associated with cell and vessel remnants.
- proteins may be capped or blocked by the addition of methylglyoxal to the tissue. This dicarbonyl is known to bind critical argin ⁇ ne functions within proteins and impairs the biological functionality of these proteins.
- the invention provides for automatic capping upon sterilization.
- specific capping agents e.g. glucose and taurine
- the capping agents added to the tissue would effectively cap targets within the tissue immediately, but sterilization (i.e. with ethylene oxide or gamma irradiation) would generate new binding sites that would then be capped by the residual capping agents within the tissue.
- sterilization i.e. with ethylene oxide or gamma irradiation
- Gamma irradiation of collagen is known to cleave peptide bonds within the backbone and produce new functional groups that may have adverse effects on the tissue. These new functional groups are targets or binding sites described in this invention and may be capped or blocked by the capping agents listed herein.
- tissue for use in valves and assembled valves of the prior art is is not subjected to the amount of stress or damage that occurs after implantation. Indeed, after fixation and valve assembly, the tissues are typically statically immersed in the treatment solutions.
- "fully fixed bioprosthetic tissue” means tissue that has been subjected to at least some cross-linking and/or other treatments to render it stable and durable, essentially ready for implant. Different tissues and different cross-linking treatments require varying time periods to fully fix bioprosthetic tissue, and the duration of the fixation process is therefore, relative.
- Fixation of bioprosthetic tissue desirably involves treatment with a cross-Unking agent, typically glutaraldehyde; or in the case of EDC/SNHS chemistry, hexane diamine and/or suberic acid; or for Denacol (epoxy) chemistry, butanediol diglycidyl ether.
- a cross-Unking agent typically glutaraldehyde
- EDC/SNHS chemistry hexane diamine and/or suberic acid
- Denacol (epoxy) chemistry butanediol diglycidyl ether
- One aspect of the present invention is a process in which fixed bioprosthetic tissue or an assembled valve is preconditioned, pre-stressed, or pre-damaged (where "pre-" refers to pre-implant) and then subjected to a capping agent.
- pre- refers to pre-implant
- Such pre-implant stressing is in addition to the stresses caused by any agitation or pressurization required for fixation.
- the methods disclosed herein preempt post-implant damage and subsequent propensity for calcification by pre- stressing the bioprosthetic tissue and then "capping" any new calcification sites.
- one embodiment of the invention involves damaging (“preconditioning") or stressing a partially fixed bioprosthetic tissue heart valve leaflets and other tissue components (similar to that imposed on the valve post- implantation) prior to implantation, and then suppressing or capping any freshly exposed binding sites that might otherwise initiate calcification.
- the heart valve leaflets may be repeatedly stressed (e.g., flexed) while immersed in a solution of capping agents that can cap new, freshly exposed calcium or phosphate binding sites (acids, aldehydes, etc.), or sites that can attract antigens and various adverse cell and protein constituents that can initiate an immunologic response (i.e. cell remnants, blood vessel cells, etc.).
- capping agents that can cap new, freshly exposed calcium or phosphate binding sites (acids, aldehydes, etc.), or sites that can attract antigens and various adverse cell and protein constituents that can initiate an immunologic response (i.e. cell remnants, blood vessel cells, etc.).
- the heart valve leaflets may be pre-stressed, such as by repeated flexion, and then immersed in the capping agent solution, or some combination of these.
- Immunogenic factors are defined as anything causing or involved in stimulating an immunogenic response. This includes any chemical or biological agent capable of inducing an immune type response. For example, vessel and cell membrane components left in the tissue may cause some type of immunogenic or antigenic response from the body's natural immune system.
- the invention includes capping agents capable of masking, replacing, or blocking these immunogenic elements in the tissue either statically or dynamically. For example, a whole valve could be flexed after fixation and then capped with a non-immunogen ⁇ c or more hemocompatible capping agent such as heparin. This is different from prior art processes that add heparin to fixed tissue without any flexion of the valve or any consideration of the post-process service conditions.
- the invention process can be supplemented with a decellularization process to reduce immunologic or antigenic binding sites and potential binding sites and is also within the scope of this invention.
- the invention generally comprises treating stressed or damaged (flexed) tissue so that calcium or phosphate binding sites, or other such sites which could trigger calcification, are capped.
- the correlation between acid binding sites and tissue calcification is compelling ( Figure 2 and Hauschka et al. PNAS 1975 72:3925) and it is a well known fact that acid templating directs mineralization in a variety of species.
- an increasing amount of free acids and/or aldehydes in the tissue at the time of implant correlates with the number of such binding sites, and therefore increases the potential for calcification.
- the amount of free acids and aldehydes present in tissue can be measured by known methods, in particular a standard spectrophotomelric assay.
- Figure 1 is a graph showing both the free aldehyde and free acid content in bovine pericardial tissue as measured by the aforementioned technique. It should be understood that all of the tests referred to herein involve gJutaraldehyde fixed bovine pericardia] tissue. The tissues studied have all been chemically treated, one with glutaraldehyde only, and two others with tissue treatments that have been used by Edwards Lifesciences to prepare commercial bioprosthetic tissue for implant. However, other cross-linking and tissue processing methods can be used and are within the scope of this invention.
- the aldehyde and acid content of the tissues is measured subsequent to the chemical treatments, and without any damage or stress imparted to the tissue.
- the tissue samples On the right side of the graph of Figure 1, the tissue samples have been treated in glutaraldehyde only, in particular in a solution of 0.625% glutaraldehyde for a period of 14 days. A total of 10 samples were treated and subsequently tested. The measurements showed an average level of about 40 nanomoles of aldehydes and about 17 nanomoles of acids per milligram of dry weight of the tissue.
- the middle of the graph of Figure 1 shows the results from testing a total of 10 tissue samples subjected to Treatment A, which is commercially known as the XenoLogiXTM tissue treatment process from Edwards Lifesciences of Irvine, CA.
- Treatment A involves first fixing with glutaraldehyde then treating twice with a ste ⁇ lant including a cross-linking agent such as formaldehyde, a surfactant such as Tween-80 (polyoxyethylene sorbitan monooleate), and a denaturant such as ethyl alcohol.
- a cross-linking agent such as formaldehyde
- a surfactant such as Tween-80 (polyoxyethylene sorbitan monooleate)
- denaturant such as ethyl alcohol
- Treatment B which is commercially known as the Carpentier-Edwards ThermaFixTM tissue treatment process from Edwards Lifesciences.
- Treatment B is essentially the same as Treatment A, with the addition of a heat treating step after fixing and prior to sterilizing.
- Both the aldehyde and acid content of the tissue subjected to Treatment B were less than glutaraldehyde alone, with the aldehyde content decreasing by about 33% and the acid content by more than 50%.
- Treatment B reduces both the aldehyde and acid content relative to Treatment A by between 10-20%.
- Figure 2 is a graph that repeats the results of aldehyde/acid content measurements for the three tissue treatments shown in Figure 1, and also superimposes measurements of calcium uptake from like tissue samples implanted subcutaneously in rabbits from a separate study. These acid levels are measured in the tissue prior to implant and are likely to increase in vivo.
- Figure 2 reveals that the amount of calcium found in the implanted tissues essentially correlates with the levels of aldehydes/acids from the three tissue treatments. That is, as the level of free aldehydes and free acids in the various tissue samples decreases, the amount of calcium absorbed upon implant also decreases.
- Figure 4 shows, as expected, that increased amount of flexion (micro collagen fibril damage) increases the level of acid binding sites.
- the acid levels increase fairly rapidly, initially, and then gradually level off. Thus after an initial “wear in” period, the rate of micro damage and associated production of acid binding sites decreased. This effect is analogous to the initial "wear in” period of a car engine.
- FIG. 5 is a graph showing another representation of the level of charged acid production in tissue as it is cycliciy damaged. Also shown in Figure 5 is an example of "capping" pre-flexed ("pre-conditioned") tissue after a given amount of flexion cycles (1 million in this case). Importantly, when this pre-conditioned and capped tissue is then flexed further in a similar manner, the production of further acid binding sites is significantly mitigated even after an additional million flex cycles.
- the acid capping treatment used in this experiment involved a 60 minute incubation of the flexed tissue in 9OmM EDC, 5mM sulfo-NHS, and 5OmM ethanolamine.
- FIG. 6 is a graph showing the level of acid generation with increasing cycles in a heart valve in an accelerated wear tester (AWT).
- AAT accelerated wear tester
- the particular valve tested was the Carpentier-Edwards® Perimount MagnaTM Aortic Heart Valve, and the AWT was a standard accelerated wear tester used to validate durability of current products.
- a modified wear tester would be used to simulate the cyclic flexion of the implant environment that is simpler than the AWT' s presently used for validation. The results indicate the increased amount of flexion (micro collagen fibril damage) increases the level of acid binding sites.
- FIG. 7 is a graph showing how the present calcification mitigation process greatly reduces the acid levels in a tissue strip subjected to millions of flexion cycles.
- Bovine pericardium tissue strips were subjected to simple flexion. At one million cycles, some samples were treated in accordance with the present invention to mitigate the stress damage ("cap" the acid binding sites).
- the tissue was treated with an aldehyde capping agent comprising 5OmM taurine and 5OmM borohydride.
- the difference in subsequently measured acid content between the capped samples and the samples not treated at one million cycles is about 20 nmoles/ ⁇ g tissue.
- the inventors believe that this difference in acid levels will greatly reduce the level and speed of post-implant calcification in the capped samples.
- a whole heart valve subjected to the pre-stress and calcification mitigant process described herein will also exhibit a reduction in calcification, and thus an improvement in durability and life.
- the present invention involves preconditioning, pre-damaging, or pre-stressing tissue and mitigating by linking or capping the resulting increased calcification initiation sites.
- the preferred embodiments include, but are not limited to, a whole valve which is placed in an accelerated heart valve simulated service tester or other device to simulate the repeated leaf motion characteristic of that seen by the valve after implantation into the patient (service condition), such as in the following processes:
- the fixed tissue valve is cycled in a simulated service environment until the rate of acid binding sites begins to decrease (i.e. about 0.5 to 2 million cycles), and then capped. 2.
- the fixed tissue valve is cycled in a simulated service environment until the rate of acid binding sites begins to decrease and while in a solution containing a capping agent.
- Embodiments 1 and 2 but where the processing is accelerated to reduce overall processing time.
- the aldehyde capping solution may contain an amine (5OmM taurine) and a reducing agent (5OmM sodium borohydride) in 10OmM 3-(N-morpholino)propanesulfonic acid (MOPS) buffer at pH 7.4.
- an amine (5OmM taurine) and a reducing agent
- 5OmM sodium borohydride 5OmM sodium borohydride
- MOPS 3-(N-morpholino)propanesulfonic acid
- the acid capping solution may contain about 50-20OmM EDC, about 1-1OmM sulfo-NHS, and 10-10OmM ethanolamine.
Abstract
Description
Claims
Priority Applications (4)
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AT08770578T ATE554802T1 (en) | 2007-06-11 | 2008-06-10 | METHOD FOR TENSIONING AND COVERING BIOPROSTHETIC TISSUE |
CN2008800198922A CN101678152B (en) | 2007-06-11 | 2008-06-10 | Methods for pre-stressing and capping bioprosthetic tissue |
CA2688404A CA2688404C (en) | 2007-06-11 | 2008-06-10 | Methods for pre-stressing and capping bioprosthetic tissue |
EP08770578A EP2152330B1 (en) | 2007-06-11 | 2008-06-10 | Methods for pre-stressing and capping bioprosthetic tissue |
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US12/135,507 US9101691B2 (en) | 2007-06-11 | 2008-06-09 | Methods for pre-stressing and capping bioprosthetic tissue |
US12/135,507 | 2008-06-09 |
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US20080302372A1 (en) | 2008-12-11 |
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US9101691B2 (en) | 2015-08-11 |
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