Local regional perfusion of the nonarrested beating heart

Abstract

A method of treating cardiac disease by perfusing a drug through a patient's non-arrested beating heart is disclosed. A closed circuit through the patient's coronary arterial and venous system may be formed from a first drug delivery catheter (1822) placed in the right coronary artery, a second drug delivery catheter (1824) placed in the left coronary artery, a drug withdrawal catheter (1826) placed in the coronary sinus, and an external membrane oxygenation system (1820) fluidly coupled to the various catheters. Drugs for treating cardiac disease may be perfused through the closed circuit.

Description

[Technical field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims the benefit of priority to U.S. Provisional Patent Application No. 63 / 312,029, filed February 20, 2022, and U.S. Provisional Patent Application No. 63 / 151,938, filed February 22, 2021, the disclosures of which are incorporated by reference in their entireties herein.

[0002] The present invention relates to the treatment of cardiac disease, and in particular to the localized delivery of therapeutic agents to the heart of a patient. [Background technology]

[0003] Despite pharmacological advances in the treatment of various cardiac diseases such as heart failure, mortality and morbidity remain unacceptably high. Moreover, certain therapeutic approaches are not suitable for many patients (e.g., patients with advanced heart failure conditions associated with other comorbidities). Alternative approaches such as gene therapy and cell therapy have attracted increasing attention because they may be uniquely tailored and effective in addressing the pathogenic mechanisms of the underlying causes of many cardiac diseases.

[0004] Nevertheless, issues remain regarding delivery, including vector efficiency, dosage, specificity, and safety. Therefore, further research is needed to address how to achieve more targeted delivery of drugs suitable for the treatment of various cardiac diseases that is effective, well tolerated, and minimally invasive. Summary of the Invention

[0005] It is an object of the present invention to provide a minimally invasive method for perfusing drugs into a patient's non-arrested, beating heart.

[0006] It is an object of the present invention to provide a method for circulating perfusion fluid (which may contain one or more of blood or drugs) through a patient's non-arrested, beating heart such that the perfusion fluid is isolated from the patient's systemic circulation.

[0007] It is an object of the present invention to provide locoregional delivery of pharmacological gene therapy.

[0008] It is an object of the present invention to reduce the total dose of medication delivered to a patient to treat a cardiac condition.It is an object of the present invention to reduce the total dose of medication delivered to a patient to treat a cardiac condition.

[0009] It is an object of the present invention to reduce the risk and / or adverse immune reactions to the administration of drugs suitable for the treatment of cardiac disease.

[0010] It is an object of the present invention to enable re-dosing and / or dosing of pharmacogenetic therapeutic agents to patients who would otherwise be poor candidates for receiving pharmacogenetic therapeutic agents, for example, patients with neutralizing antibodies to a gene therapy vector.

[0011] The objective of the present invention is to circulate perfusate through a non-arrested, beating heart to oxygenate the heart and isolate the coronary circulation from the patient's systemic circulation in a manner that prevents or reduces exposure of the drug to the heart while allowing potentially cardiotoxic drugs to be introduced into the systemic circulation.

[0012] The above objects and others are met by the present invention, which in certain embodiments is directed to a method of perfusing a drug into a non-arrested beating heart of a patient. In some embodiments, the method includes placing a first drug delivery catheter in the right coronary artery of the heart. The method further includes placing a second drug delivery catheter in the left main coronary artery of the heart. The method further includes placing a drug retrieval catheter in the coronary sinus of the heart. In some embodiments, the first drug delivery catheter, the second drug delivery catheter, and the drug retrieval catheter form a closed circuit with the coronary arteries of the heart, the coronary venous system of the heart, and a membrane oxygenator. The method further includes perfusing the drug through the closed circuit that isolates the patient's coronary circulation from the patient's systemic circulation. In some embodiments, at least about 50% of the perfused drug remains in the closed circuit for at least 45 minutes. In some embodiments, the drug is delivered to at least 30% of the heart tissue during perfusion.

[0013] In some embodiments, the method further comprises applying a negative pressure to the drug retrieval catheter, hi some embodiments, the negative pressure is in the range of about -100 mmHg to 0 mmHg.

[0014] In some embodiments, the closed circuit may further include one or more suction mechanisms that allow for the application of negative suction pressure to the drug retrieval catheter to prevent and / or minimize leakage of blood / drug circulated through the closed circuit through the Thebesian vein.

[0015] In some embodiments, one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug retrieval catheter are introduced percutaneously. In some embodiments, the first drug delivery catheter and / or the second drug delivery catheter are placed via antegrade cannulation. In some embodiments, the first drug delivery catheter and / or the second drug delivery catheter are placed via the patient's aorta by accessing the femoral artery and / or the radial artery. In some embodiments, the drug retrieval catheter is placed into the coronary sinus via the patient's vena cava. In some embodiments, the drug retrieval catheter is placed via the patient's jugular or femoral vein. In some embodiments, the membrane oxygenator is placed between the retrieval catheter and one or more of the first drug delivery catheter and the second drug delivery catheter. In some embodiments, one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug retrieval catheter are sealed by a balloon to reduce or prevent leakage.

[0016] In some embodiments, the method further comprises circulating blood through the closed circuit. In some embodiments, the blood comprises autologous blood, matched blood from a donor, or a combination thereof. In some embodiments, the blood component, such as serum or plasma, is selected according to one or more parameters. In some embodiments, the one or more parameters comprise the presence or absence of a selected antibody. In some embodiments, about 1000 mL, about 800 mL, about 600 mL, about 400 mL, about 200 mL, about 100 mL, or about 50 mL of blood is circulated through the closed circuit.

[0017] In some embodiments, the perfusing occurs for a duration of about 5 minutes to about 5 hours, about 15 minutes to about 4 hours, about 30 minutes to about 3 hours, or about 1 hour to about 2 hours. In some embodiments, the perfusing occurs for at least 60 minutes. In some embodiments, the perfusing occurs at a flow rate of about 75 mL / min to about 750 mL / min, about 150 mL / min to about 500 mL / min, or about 200 mL / min to about 300 mL / min.

[0018] In some embodiments, the drug is suitable for treating a cardiac condition. In some embodiments, the cardiac condition is heart failure. In some embodiments, the cardiac condition is a genetically determined cardiac disease. In some embodiments, the genetically determined cardiac disease is a genetically determined cardiomyopathy.

[0019] In some embodiments, the drug comprises a therapeutic polynucleotide sequence. In some embodiments, the therapeutic polynucleotide sequence is present in one or more viral vectors. In some embodiments, the one or more viral vectors are selected from the group consisting of adeno-associated virus, adenovirus, retrovirus, herpes simplex virus, bovine papilloma virus, lentiviral vector, vaccinia virus, polyoma virus, Sendai virus, orthomyxovirus, paramyxovirus, papovavirus, picornavirus, poxvirus, alphavirus, mutants thereof, and combinations thereof.

[0020] In some embodiments, the viral vector is an adeno-associated virus (AAV). In some embodiments, the AAV is one or more of AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, mutants thereof, and combinations thereof.

[0021] In some embodiments, the therapeutic polynucleotide sequence comprises a nucleic acid sequence that encodes a protein, antisense RNA, ncRNA, or miRNA for the treatment of cardiac disease. In some embodiments, the protein corresponds to a gene that is expressed in human heart. In some embodiments, the protein is one or more of SERCA2, MyBPC3, MYH7, PKP2, dystrophin, FKRP, or combinations or variants thereof. In some embodiments, the therapeutic polynucleotide sequence comprises a promoter.

[0022] In some embodiments, less than about 20% v / v, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially none (0% v / v) of the blood circulating through the closed circuit leaks outside the closed circuit. In some embodiments, less than about 20% v / v, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially none (0% v / v) of the drug perfused through the closed circuit leaks outside the closed circuit.

[0023] In some embodiments, one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug retrieval catheter is a balloon catheter.

[0024] The above objects and others are met by the present invention, which in certain embodiments is directed to a method of maintaining perfusion of perfusate through a closed circuit within a patient's non-arrested, beating heart during perfusion. In some embodiments, the method includes placing a first catheter in the right coronary artery of the heart. In some embodiments, the method further includes placing a second catheter in the left main coronary artery of the heart. In some embodiments, the method further includes placing a collection catheter in the coronary sinus of the heart. In some embodiments, the first catheter, the second catheter, and the collection catheter form a closed circuit through the heart with the coronary artery, the coronary venous system, and the membrane oxygenator. In some embodiments, the method further includes flowing the perfusate through the closed circuit by introducing perfusate into the heart via the first catheter and the second catheter and collecting the perfusate via the collection catheter. In some embodiments, the closed circuit isolates the patient's coronary circulation from the patient's systemic circulation.

[0025] In some embodiments, perfusion is maintained for at least 60 minutes, hi some embodiments, perfusion is maintained for at least 120 minutes.

[0026] In some embodiments, the method further comprises applying a negative pressure to the recovery catheter, such that the negative pressure is in the range of about -100 mmHg to 0 mmHg.

[0027] In some embodiments, one or more of the first catheter, the second catheter, or the recovery catheter are introduced percutaneously.

[0028] In some embodiments, the membrane oxygenator is positioned between the collection catheter and one or more of the first drug delivery catheter and the second drug delivery catheter.

[0029] In some embodiments, the method further comprises circulating the blood through a closed circuit such that the blood comprises autologous blood, matched blood from a donor, or a combination thereof. In some embodiments, about 1000 mL, about 800 mL, about 600 mL, about 400 mL, about 200 mL, about 100 mL, or about 50 mL of blood is circulated through the closed circuit.

[0030] In some embodiments, the perfusion occurs at a flow rate of about 75 mL / min to about 750 mL / min, about 150 mL / min to about 500 mL / min, or about 200 mL / min to about 300 mL / min. In some embodiments, less than about 20% v / v, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially none (0% v / v) of the blood circulating through the closed circuit leaks outside the closed circuit.

[0031] In some embodiments, one or more of the first catheter, the second catheter, or the recovery catheter is a balloon catheter.

[0032] The above objects and others are further met by the present invention, which in certain embodiments is directed to a system for performing locoregional perfusion within a patient's heart when fluidly coupled to the patient's heart. In some embodiments, the system includes a first catheter adapted for insertion into the right coronary artery of the heart, a second catheter adapted for insertion into the left main coronary artery of the heart, a collection catheter adapted for insertion into the coronary sinus of the heart, a membrane oxygenator fluidly coupled to the first catheter, the second catheter, the collection catheter, and an oxygen source, and a pump configured to drive fluid flow through the first catheter and the second catheter. In some embodiments, the first catheter, the second catheter, the collection catheter, and the membrane oxygenator together form a closed circuit through the heart that is isolated from the patient's systemic circulation when the first catheter is inserted into the right coronary artery, the second catheter is inserted into the left main coronary artery, and the collection catheter is inserted into the coronary sinus. In some embodiments, at least about 50% of the perfused drug remains in the closed circuit for at least 45 minutes.

[0033] The above objects and others are further met by the present invention, which in certain embodiments is directed to a local-regional perfusion including a first catheter inserted into the right coronary artery of a patient's heart, a second catheter inserted into the left main coronary artery of the heart, a collection catheter inserted into the coronary sinus of the heart, a membrane oxygenator fluidly coupled to the first catheter, the second catheter, the collection catheter, and an oxygen source, and a pump configured to drive the flow of fluid into the heart through the first catheter and the second catheter, and out of the heart through the collection catheter. In some embodiments, the first catheter, the second catheter, the collection catheter, and the membrane oxygenator form a closed circuit through the heart, isolated from the patient's systemic circulation, together with the coronary arterial and venous systems of the heart. In some embodiments, at least about 50% of the perfused drug remains in the closed circuit for at least 45 minutes.

[0034] In some embodiments, the membrane oxygenator includes a reservoir configured for infusing a drug into the closed circuit during perfusion.

[0035] In some embodiments, the pump is configured to generate a negative pressure range of approximately -100 mmHg to 0 mmHg.

[0036] In some embodiments, one or more of the first catheter, the second catheter, or the recovery catheter are introduced percutaneously. In some embodiments, the first catheter and / or the second catheter are placed via antegrade cannulation. In some embodiments, the recovery catheter is placed into the coronary sinus via the patient's vena cava.

[0037] The above objects and others are further met by the present invention, which in certain embodiments is directed to a method of isolating a patient's heart from the patient's systemic circulation, the method comprising: placing a first catheter in the right coronary artery of the heart; placing a second catheter in the left main coronary artery of the heart; placing a withdrawal catheter in the coronary sinus of the heart such that the first catheter, the second catheter, and the withdrawal catheter form a closed circuit with the coronary arteries of the heart, the coronary venous system of the heart, and a membrane oxygenator; causing oxygenated blood to flow through the closed circuit; and introducing a drug into the patient's systemic circulation. In some embodiments, the closed circuit isolates the patient's coronary circulation from the patient's systemic circulation. In some embodiments, the drug is a cardiotoxic drug, and exposure of the cardiotoxic drug to the heart is prevented or reduced compared to administering the cardiotoxic drug without the presence of the closed circuit.

[0038] The above objects and others are further met by the present invention which, in certain embodiments, is directed to a locoregional perfusion system configured to carry out any of the above methods.

[0039] The above and other features of the present disclosure, its nature and various advantages will become apparent from a consideration of the following detailed description taken in conjunction with the accompanying drawings. [Brief description of the drawings]

[0040] [Figure 1] FIG. 1 shows a schematic diagram of a first exemplary retrieval catheter having a single balloon structure in accordance with at least one embodiment. [Diagram 2] 1 is a photograph of a retrieval catheter manufactured in accordance with a first exemplary retrieval catheter embodiment. [Diagram 3] 1 illustrates the deployment of a first exemplary retrieval catheter in accordance with at least one embodiment. [Figure 4] 13 illustrates the deployment of a second exemplary retrieval catheter having a single balloon structure in accordance with at least one embodiment. [Diagram 5] 13 illustrates the deployment of a third exemplary retrieval catheter and a fourth exemplary retrieval catheter, each having a single balloon structure in accordance with at least one embodiment. [Figure 6] 13 illustrates the deployment of a fifth exemplary retrieval catheter having a single balloon structure and a sixth exemplary retrieval catheter without a balloon structure, in accordance with at least one embodiment. [Figure 7] 13 illustrates the deployment of a seventh exemplary retrieval catheter having a multiple balloon structure according to at least one embodiment. [Figure 8] 13 illustrates the deployment of an eighth exemplary retrieval catheter having a partially covered, recaptureable stent structure in accordance with at least one embodiment. [Figure 9] 13 illustrates the deployment of a ninth exemplary retrieval catheter having a deployable and retractable stent structure and a balloon structure in accordance with at least one embodiment. [Figure 10] 13 illustrates the deployment of a tenth exemplary retrieval catheter having a covered disc-shaped stent structure in accordance with at least one embodiment. [Figure 11A] FIG. 1 shows a schematic diagram of a first exemplary perfusion catheter having a single balloon structure in accordance with at least one embodiment. [Figure 11B]FIG. 2 is a schematic diagram of a balloon structure of a first exemplary perfusion catheter in an inflated state in accordance with at least one embodiment. [Figure 11C] FIG. 2 is a schematic diagram of a balloon configuration of a first exemplary perfusion catheter in a retracted state in accordance with at least one embodiment. [Figure 11D] 1 illustrates the deployment of a first exemplary perfusion catheter within an aorta in accordance with at least one embodiment. [Figure 12A] FIG. 13 is a schematic diagram of a second exemplary perfusion catheter having a distal plug in accordance with at least one embodiment. [Figure 12B] FIG. 13 is a schematic diagram of a plug of a second exemplary perfusion catheter in accordance with at least one embodiment. [Figure 12C] FIG. 13 is a schematic diagram of a plug of a second exemplary perfusion catheter in an expanded state in accordance with at least one embodiment. [Figure 12D] 1 illustrates the deployment of a second exemplary perfusion catheter within the aorta in accordance with at least one embodiment. [Figure 13A] FIG. 13 is a schematic diagram of a third exemplary perfusion catheter having a distal wedge in accordance with at least one embodiment. [Figure 13B] FIG. 13 is a schematic diagram of a third exemplary perfusion catheter wedge in accordance with at least one embodiment. [Figure 13C] FIG. 13 is a further schematic diagram of a distal end of a third exemplary perfusion catheter in an expanded state in accordance with at least one embodiment. [Figure 13D] 1 illustrates the deployment of a third exemplary perfusion catheter within the aorta in accordance with at least one embodiment. [Figure 14A] 13 illustrates the deployment of a fourth exemplary perfusion catheter having a partially covered, recaptureable stent structure in accordance with at least one embodiment. [Figure 14B] 13 illustrates a fourth exemplary perfusion catheter stent structure in a stored state in accordance with at least one embodiment. [Figure 14C] 1 illustrates a fourth exemplary perfusion catheter stent structure in a deployed state in accordance with at least one embodiment. [Figure 15A] 13 illustrates the deployment of a fifth exemplary perfusion catheter having a releasable covered braided disc in accordance with at least one embodiment. [Figure 15B] 13 illustrates a braided disc of a fifth exemplary perfusion catheter in a deployed state in accordance with at least one embodiment. [Figure 16A] FIG. 13 is a schematic diagram of a sixth exemplary perfusion catheter having a tapered lumen shaft in accordance with at least one embodiment. [Figure 16B] 13 illustrates the deployment of a sixth exemplary perfusion catheter in accordance with at least one embodiment. [Figure 16C] 13 illustrates the deployment of a sixth exemplary perfusion catheter within the aorta in accordance with at least one embodiment. [Figure 16D] 13 illustrates a pre-shaped lumen shaft of a sixth exemplary perfusion catheter in accordance with at least one embodiment. [Figure 17] 1 illustrates an exemplary pre-shaped lumen shaft for an exemplary catheter according to various embodiments. [Figure 18A] 1 illustrates an exemplary local-regional perfusion system in accordance with an embodiment of the present disclosure. [Figure 18B] 1 is a schematic diagram of an exemplary local-regional perfusion device according to an embodiment of the present disclosure. [Figure 19] FIG. 1 is an x-ray taken during locoregional perfusion of a non-arrested porcine heart showing the location of the left main coronary artery catheter, the right coronary artery catheter, and the coronary sinus balloon. [Figure 20] 1 is a plot of pump speed, flow rate, and pressure measured during local regional perfusion.

[0041] definition As used herein, the singular forms "a," "an," and "the" include plural references unless the context clearly dictates otherwise. Thus, for example, reference to a "drug" includes not only a single drug but also a mixture of two or more different drugs, reference to a "viral vector" includes not only a single viral vector but also a mixture of two or more different viral vectors, and so forth.

[0042] Also, as used herein, "about," when used in reference to a measured quantity, refers to normal variations in that measured quantity that would be expected by one of ordinary skill in the art when making the measurement and using a level of care commensurate with the purpose of the measurement and the precision of the measuring device. In certain embodiments, the term "about" includes the recited number ±10%, so that "about 10" would include 9-11.

[0043] Also, as used herein, "polynucleotide" has its normal and accustomed meaning in the art and includes any polymeric nucleic acid, such as a DNA molecule or an RNA molecule, as well as chemical derivatives known to those of skill in the art. Polynucleotides include those that encode therapeutic proteins, but also include sequences that can be used to decrease the expression of a target nucleic acid sequence using techniques known in the art (e.g., antisense, interfering, or small interfering nucleic acids). Polynucleotides can also be used to initiate or increase the expression of a target nucleic acid sequence or the production of a target protein in cells of the cardiovascular system. Target nucleic acids and proteins include, but are not limited to, nucleic acids and proteins that are normally found in the target tissue, derivatives of such naturally occurring nucleic acids or proteins, naturally occurring nucleic acids or proteins that are not normally found in the target tissue, or synthetic nucleic acids or proteins. One or more polynucleotides can be used in combination and administered simultaneously and / or sequentially to increase and / or decrease one or more target nucleic acid sequences or proteins.

[0044] Also, as used herein, "perfusion," "perfused," and "perfusing" have their normal and accustomed meaning in the art and refer to administration over a period of time (usually one minute or longer) that is substantially longer than the art-recognized terms "injection" or "bolus administration" (usually less than one minute). The rate of perfusion depends at least in part on the amount administered.

[0045] Also, as used herein, an "exogenous" nucleic acid or gene is one that is not naturally present in the vector utilized for nucleic acid transfer, e.g., is not naturally found in a viral vector, although the term is not intended to exclude nucleic acids that encode proteins or polypeptides that are naturally present in the patient or host.

[0046] As used herein, "cardiac cells" also includes any cell of the heart involved in maintaining the structure or providing the function of the heart, such as cardiomyocytes, cells of the cardiovascular system, or cells present within the cardiac valves. Cardiac cells include cardiomyocytes (which have both normal and abnormal electrical properties), epithelial cells, endothelial cells, fibroblasts, cells of the conducting tissue, cardiac pacemaker cells, and neurons.

[0047] Also, as used herein, "isolated," "substantially isolated," "largely isolated," and variations thereof are terms that do not require complete or absolute isolation of the coronary venous circulation, cardiac circulation, systemic venous circulation, or systemic circulation. Rather, they are intended to mean that a majority, preferably a majority or substantially all, of the designated circulation is isolated. Also, as used herein, "partially isolated" refers to any significant portion of the designated circulation being isolated.

[0048] Also, as used herein, "non-naturally restricted" includes any method of restricting fluid flow through a blood vessel, e.g., balloon catheters, sutures, etc., but does not include naturally occurring restrictions, e.g., plaque buildup (stenosis). Non-natural restrictions include, for example, substantial or complete isolation of the coronary circulation.

[0049] Also, as used herein, "minimally invasive" is intended to include any procedure that does not require surgical open access to the heart or blood vessels closely associated with the heart. Such procedures include the use of endoscopic means to access the heart, as well as catheter-based means that rely on access via the aorta and vena cava.

[0050] Also, as used herein, the term "adeno-associated virus" or "AAV" encompasses all subtypes, serotypes, and pseudotypes, as well as naturally occurring and recombinant forms. Various AAV serotypes and strains are known in the art and are publicly available from sources such as ATCC and academic or commercial sources. Alternatively, sequences from AAV serotypes and strains that are publicly available and / or available from various databases can be synthesized using known techniques.

[0051] Also, as used herein, "serotype" refers to an AAV that is identified by and distinguished from other AAVs based on the reactivity of the capsid protein with a defined antiserum. There are at least 12 known serotypes of human AAV, including AAV1 to AAV12, although additional serotypes continue to be discovered, and the use of newly discovered serotypes is contemplated.

[0052] Also, as used herein, "pseudotyped" AAV refers to an AAV that contains capsid proteins of one serotype and a viral genome that contains 5' and 3' inverted terminal repeats (ITRs) of a different or heterologous serotype. A pseudotyped recombinant AAV (rAAV) would be expected to have the cell surface binding properties of the capsid serotype and genetic properties that match the ITR serotype. A pseudotyped rAAV can contain AAV capsid proteins, including VP1, VP2, and VP3 capsid proteins, and ITRs from any serotype of AAV, including any primate AAV serotype from AAV1 to AAV12, so long as the capsid proteins are of a heterologous serotype to the serotype(s) of the ITRs. In a pseudotyped rAAV, the 5' and 3' ITRs can be the same or heterologous. A pseudotyped rAAV is generated using standard techniques described in the art.

[0053] Also, as used herein, a "chimeric" rAAV vector includes AAV vectors that contain heterologous capsid proteins. That is, a rAAV vector may be chimeric with respect to its capsid proteins VP1, VP2, and VP3, such that VP1, VP2, and VP3 are not all of the same serotype of AAV. As used herein, a chimeric AAV includes AAVs in which the capsid proteins VP1, VP2, and VP3, including but not limited to capsid proteins from AAV1 and AAV2, are different in serotype, are a mixture of capsid proteins of other parvoviruses, or contain other viral proteins, or other proteins, such as proteins that target the delivery of AAV to a desired cell or tissue. As used herein, a chimeric rAAV also includes rAAVs that contain chimeric 5' and 3' ITRs.

[0054] Also, as used herein, "a pharma- ceutically acceptable excipient or carrier" refers to any inactive ingredient in a composition that is combined with an active agent in a formulation. Pharmaceutically acceptable excipients may include, but are not limited to, carbohydrates (such as glucose, sucrose, or dextran), antioxidants (such as ascorbic acid or glutathione), chelating agents, low molecular weight proteins, high molecular weight polymers, gel-forming agents, or other stabilizers and additives. Other examples of pharma- ceutically acceptable carriers include wetting agents, emulsifying agents, dispersing agents, or preservatives that are particularly useful for preventing the growth or action of microorganisms. Various preservatives are well known and include, for example, phenol and ascorbic acid. Examples of carriers, stabilizers, or adjuvants are described in Remington's Pharmaceutical Sciences, Mack Publishing Company, Philadelphia, Pa, 17th ed. (1985).

[0055] Also, as used herein, "patient" refers to a subject, particularly humans (but will include non-humans), who is exhibiting clinical signs of a particular condition or symptoms indicating the need for treatment, is being prophylactically treated for a condition, or has been diagnosed with a condition to be treated.

[0056] Also, as used herein, "subject" encompasses the definition of the term "patient" and does not exclude individuals who are otherwise healthy.

[0057] Also, as used herein, "treatment of" and "treating" include the administration of a drug for the purpose of reducing the severity of or preventing a condition, e.g., heart disease.

[0058] As used herein, "prevention of" and "prevent" also include avoiding the onset of a condition, such as, for example, heart disease.

[0059] Also, as used herein, "condition" or "conditions" refers to those medical conditions, such as heart disease, that can be treated, alleviated, or prevented by administration of an effective amount of a drug to a subject.

[0060] Also, as used herein, "effective amount" refers to an amount of drug sufficient to produce a beneficial or desired effect at a level that is easily detectable by a method commonly used for detecting such an effect. In some embodiments, such an effect produces at least a 10% change from the basal level value when the drug is not administered. In other embodiments, the change is at least 20%, 50%, 80%, or even higher from the basal level. As explained below, the effective amount of a drug may vary from subject to subject depending on the subject's age, general condition, the severity of the disease being treated, the particular drug being administered, and the like. The appropriate "effective" amount in any individual case may be determined by one of ordinary skill in the art by reference to the relevant texts or literature and / or by routine experimentation.

[0061] Also, as used herein, "active drug" refers to any substance intended to produce a therapeutic, prophylactic, or other intended effect, regardless of whether it has been approved by a government agency for that purpose.

[0062] The recitation of ranges of values ​​herein is intended to serve merely as a shorthand method of individually referring to each separate value falling within the range, unless otherwise indicated herein, and each separate value is incorporated herein as if it were individually recited herein. All methods described herein may be performed in any suitable order, unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples or exemplary language (e.g., "such as") provided herein is intended merely to facilitate understanding of certain materials and methods, and does not limit the scope of the claims. No language in the specification should be construed as indicating any non-claimed element as essential to the practice of the disclosed materials and methods. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0063] The present invention is directed to a method of treating cardiac disease in a minimally invasive manner. The method may include isolating the patient's coronary circulation from the patient's systemic circulation and perfusing the patient's isolated or substantially isolated coronary circulation with a fluid, such as a fluid containing a drug. The perfusion may be performed in a non-arrested beating heart of the patient. The method may also be used to isolate the patient's cardiac circulation to allow administration of, for example, a cardiotoxic drug (or any composition that may be harmful to the patient's heart) to the patient's systemic circulation in order to protect the patient's heart from harmful effects. Isolation of the patient's coronary circulation is described in more detail below with reference to Figures 1A and 1B.

[0064] The coronary circulation provides the blood supply to the cardiac tissue. There are several coronary arteries. Usually, four major coronary arteries, namely the left main and right coronary arteries, the left anterior descending artery, and the left circumflex artery, provide oxygenated blood to the heart for distribution throughout the cardiac tissue. Oxygen-depleted blood flows through the coronary sinus.

[0065] The embodiments disclosed herein contemplate isolating or substantially isolating the patient's coronary circulation from the patient's systemic circulation by forming a closed circuit including (consisting of, or consisting essentially of) a first drug delivery catheter, a second drug delivery catheter, a drug retrieval catheter, a coronary artery, a coronary venous system, and an external membrane oxygenator. The present disclosure further contemplates, in certain embodiments, perfusing the myocardium with a drug suitable for treating a cardiac condition while substantially isolating the patient's coronary circulation from the patient's systemic circulation using said closed circuit. In some embodiments, the methods disclosed herein deliver the drug to the entire myocardium, as opposed to an isolated site within the heart. The drug delivered to the myocardium by the methods disclosed herein can be distributed uniformly throughout the heart.

[0066] There are several advantages to isolating a patient's coronary circulation from the patient's systemic circulation when treating cardiac disease, including, but not limited to, (1) local-regional delivery of drugs, minimal leakage of drugs into other organs, and reduced total drug dose, (2) increased targeted drug dose, (3) reduced risks and side effects, and (4) the possibility to re-medicate selected patients or to dose patient populations that were not suitable candidates for a particular therapy (such as gene therapy using viral vectors for patients who had antibodies to the viral vector).

[0067] Exemplary Catheter Embodiments Exemplary retrieval and perfusion catheters are described herein. The catheters can be configured for the anatomy of any target organ (e.g., the heart) in which LRP must be performed, as would be understood by one of skill in the art. Additionally, it should be understood that any of the catheters described as "retrieval catheters" can also be used as "perfusion catheters" and vice versa. The embodiments described herein are not limited to LRP of the heart, but can be used to isolate the cardiac circulation from the systemic circulation, for example, to reduce or prevent exposure of the heart to drugs or other substances introduced into the systemic circulation that may have deleterious effects on the heart. Those skilled in the art will appreciate other uses for the catheter embodiments described herein, such as in applications in which sealing of blood vessels is desired.

[0068] Exemplary catheter embodiments for use as a recovery catheter in an LRP system are described herein. In at least one embodiment, the recovery catheter is designed to support a liquid aspiration flow rate of about 400 mL / min or more (e.g., about 700 mL / min or more). For example, in certain embodiments, an exemplary catheter can support an in vitro aspiration flow rate of about 800 mL / min at about -80 mmHg.

[0069] Certain embodiments of retrieval catheters are advantageous for use in the return tubing of an LRP system that is used to form a closed circuit in a non-arrested beating heart when inserted into the coronary sinus. The catheters described herein can be designed to meet the following criteria: ability to access the coronary sinus via the right internal jugular vein, compatibility with introducer sheaths having an inner diameter of 24 Fr or less, compatibility with guidewires of 0.035 inches or less, ability to access, seal, and occlude coronary sinuses having vessel inner diameters of 6-20 mm in human subjects or up to 30 mm in porcine animal models, ability to avoid occlusion of significant side veins (e.g., central cardiac veins), as well as ability to maintain a stable position for at least 60 minutes during the LRP procedure.

[0070] 1-10 show various catheter embodiments suitable for fluid collection within an LRP system. Any of the catheters shown in FIGS. 1-10 may be configured to support a fluid flow rate (aspiration or irrigation) of at least about 400 mL / min, at least about 450 mL / min, at least about 500 mL / min, at least about 550 mL / min, at least about 600 mL / min, at least about 650 mL / min, at least about 700 mL / min, at least about 750 mL / min, at least about 800 mL / min, at least about 850 mL / min, at least about 900 mL / min, at least about 950 mL / min, or at least about 1000 mL / min. Each catheter may be compatible with a steerable introducer sheath that provides stability and guides the distal end of the catheter and allows the catheter to create a guided pushing force. Each catheter may also have a pull wire integrated into its shaft assembly, allowing the portion proximal to the occluding structure to bend at an angle of up to 120° to achieve better tracking and centering of the occluding structure.

[0071] In certain embodiments, one or more of the catheters may be a multi-lumen catheter, such as a double lumen catheter. In certain embodiments, the multi-lumen catheter allows for the flow of fluid (e.g., perfusion fluid) and allows for the inflation of one or more balloons. In certain embodiments, one or more of the catheters may be a multi-balloon catheter having two or more balloons. In certain embodiments, one or more of the balloons may be independently deployed or deflated.

[0072] FIG. 1 illustrates an exemplary catheter 100 having a lumen shaft 104 / 106 having a proximal end 101 and a distal end 102. The lumen shaft 104 / 106 can be formed from an outer lumen shaft 104 that at least partially surrounds the inner lumen shaft 106 and exposes a distal portion of the inner lumen shaft 106 near the distal end 102. The proximal end 101 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the outer lumen shaft 104 or the inner lumen shaft 106 can be formed from a durable polymeric material, such as a polyether block amide (PEBA) material (e.g., commercially available as PEBAX®). In at least one embodiment, the innermost diameter ("inner diameter") of the inner lumen shaft 106 is at least about 4 mm to provide a liquid flow path. In at least one embodiment, the catheter 100 can be designed to include additional lumen shafts.

[0073] The catheter 100 includes a tip section 108 at the distal end 102 and an inflatable balloon structure 110 disposed along a section 112 of the inner lumen shaft 106. In at least one embodiment, the tip section 108 includes an elongate shaft extending from the balloon structure 110 to the distal end 102. In at least one embodiment, the length of the elongate shaft of the tip section is between about 2 mm and about 35 mm, about 5 mm and about 30 mm, about 10 mm and about 25 mm, about 15 mm and about 25 mm, or any subrange defined therebetween (e.g., about 2 mm and about 5 mm). In at least one embodiment, the tip section 108 includes an opening at the distal end 102 and one or more perforations along the elongate shaft. In at least one embodiment, the tip section is formed from a pliable material that is more flexible than the material of the inner lumen shaft 106.

[0074] In at least one embodiment, the inner lumen shaft 106 includes a concentric inner flow passage surrounding the liquid flow passage. The concentric inner flow passage provides a path for gas flow from the balloon structure 110 to a port 114, which can be used to inflate or deflate the balloon depending on pressure applied at the port 114. In at least one embodiment, the outermost surface of the inner lumen shaft 106 at section 112 is removed such that section 112 is sealed by the balloon structure 110, isolating gas flow from the concentric inner flow passage to the balloon structure 110. In at least one embodiment, the inflated diameter of the balloon structure is about 15 mm to about 30 mm, about 15 mm to about 20 mm, about 20 mm to about 25 mm, about 24 mm to about 28 mm, or about 25 mm to about 30 mm.

[0075] FIG. 2 is an image of a catheter with a similar structure to catheter 100 with the balloon in a deployed state. The catheter dimensions include a cross profile of 19 Fr (6.3 mm), a maximum inner diameter of 12 Fr (4.0 mm), a usable length of 80 cm, a balloon diameter (deployed) of 25 mm, and a tip length of 20 mm. The lumen shaft may be formed from a polymeric material such as PEBAX® 63 supported by a strong stainless steel braid. The balloon may be formed from a flexible thermoplastic / elastomeric material such as ChronoPrene™ 25A. The tip section may be formed from a polymeric material such as PEBAX® 35 and may be filled with a radiopaque filler composition such as a radiomarker or BaSO4.

[0076] 3 illustrates the insertion of an exemplary catheter 300 into the coronary sinus 352 via the right atrium 350, according to at least one embodiment. The catheter 300 may be the same as or similar to the catheter 100, and has a proximal end 301, a distal end 302, an inner lumen shaft 304, an outer lumen shaft 306, a tip portion 308, and a balloon structure 310 disposed at a portion 312 of the inner lumen shaft 304. The balloon structure 310, upon deployment, is flexible enough to conform to the anatomy of the coronary sinus 352 and occlude blood flow through the coronary sinus 352 into the right atrium 350 without creating excessive force on the tissue. As shown in FIG. 3, the catheter 300 is inserted beyond the central vein (MCV) 354 to avoid occluding flow from the MCV 354 into the atrium 350.

[0077] Figures 4-10 illustrate other occlusion techniques according to various embodiments of the present disclosure. The catheters illustrated in Figures 4-10 may, in certain aspects, be similar to the catheters illustrated in Figures 1-3 in terms of, for example, dimensions, materials, or construction.

[0078] 4 shows a catheter 400 according to at least one embodiment only partially inserted into the coronary sinus 352 such that it abuts the ostium of the coronary sinus 352. The catheter 400 includes a proximal end 401, a distal end 402, an inner lumen shaft 404, an outer lumen shaft 406, a tip section 408, and a balloon structure 410 disposed on a section 412 of the inner lumen shaft 404. In at least one embodiment, the diameter of the balloon structure 410 when deployed is greater than about 15 mm, greater than about 20 mm, greater than about 25 mm, or greater than about 30 mm. The tip section 408 may include one or more perforations in addition to the openings at the distal end 402 to facilitate blood flow from the coronary sinus 352 and the MCV 354 into the catheter 400.

[0079] In at least one embodiment, during deployment, the outer lumen shaft 406 can move distally to abut the deployed balloon structure 410, resulting in additional pressure by the balloon structure 410 against the ostium of the coronary sinus 352, further stabilizing the position of the catheter 400. In at least another embodiment, a wire structure may be utilized to apply pressure to the balloon structure 410. The wire structure may have, for example, a sinusoidal shape that is deployable into an expanded flower-like structure that radiates from the outer lumen shaft 406 or the inner lumen shaft 404. When the wire structure contacts the balloon structure 410, it may generate a more uniform pressure profile across the surface of the balloon structure 410. Before deployment, the wire structure may be covered by the outer lumen shaft 406 or may be covered by an additional lumen outside the outer lumen shaft 406.

[0080] 5 illustrates the use of a first catheter 500 and a second catheter 550 to separately occlude and drain the coronary sinus 352 and the MCV 354, respectively, in accordance with at least one embodiment. The first catheter 500 includes a proximal end 501, a distal end 502, a lumen shaft 504, a tip portion 508, and a balloon structure 510 disposed on a portion 512 of the lumen shaft 504. Similarly, the second catheter 550 includes a proximal end 551, a distal end 552, a lumen shaft 554, a tip portion 558, and a balloon structure 560 disposed on a portion 562 of the lumen shaft 554. In this configuration, the first catheter 500 is inserted into the coronary sinus 352, while the second catheter 550 is inserted directly into the MCV 354, such that the balloon structure 510 does not occlude the MCV 354. The dimensions of the first catheter 500 and the second catheter 550 may be selected to provide safe and effective occlusion of the coronary sinus 352 and the MCV 354, respectively.

[0081] FIG. 6 illustrates a variation of FIG. 5 using two catheters, only one of which has a balloon structure according to at least one embodiment. A first catheter 600 includes a proximal end 601, a distal end 602, a lumen shaft 604, a tip portion 608, and a balloon structure 610 disposed on a portion 612 of the lumen shaft 604. A second catheter 650 includes a proximal end 651, a distal end 652, a lumen shaft 654, a tip portion 658, and does not include a balloon structure. The first catheter 600 is inserted into the coronary sinus 352 such that a portion of the balloon 610 occludes the MCV 354 and is partially within the atrium 350 and the coronary sinus 352. The second catheter 650 is inserted directly into the MCV 354 and is disposed between the vessel wall and the balloon 610, thereby at least partially occluding the MCV 354.

[0082] 7 illustrates the use of a single catheter 700 including multiple balloons according to at least one embodiment. The catheter 700 includes a proximal end 701, a distal end 702, a lumen shaft 704, a tip portion 708, a first balloon structure 710 disposed on a first portion 712 of the lumen shaft 704, and a second balloon structure 720 disposed on a second portion 722 of the lumen shaft 704. In at least one embodiment, the catheter 700 is designed for insertion into the coronary sinus 352 such that the first balloon structure 710 occludes the coronary sinus 352 and the second balloon structure 720 abuts the ostium of the coronary sinus 352 to occlude the MCV 354 (and further occlude the coronary sinus 352). An intermediate portion 724 of the lumen shaft 704 between the first balloon structure 710 and the second balloon structure 720 includes one or more perforations to allow drainage of the MCV 354. In at least one embodiment, the inflated diameter of the second balloon structure 720 is greater than the inflated diameter of the first balloon structure 710. In at least one embodiment, the catheter 700 is a multi-lumen catheter designed to allow each balloon to be deployed and deflated independently of each other.

[0083] 8 illustrates a catheter 800 including a partially covered, recaptureable stent structure 810 according to at least one embodiment. The catheter 800 includes a proximal end 801 and a distal end 802, an inner lumen shaft 804 coupled to the stent structure 810, and an outer lumen shaft 806. A portion of the outer lumen shaft 806 is depicted as a cutaway to show the inner lumen shaft 804 within. The stent structure 810 is shown in a deployed state, but may be contained within the outer lumen shaft 806 prior to deployment. The stent structure 810 is further depicted as having a proximal covered portion 810A, which may be formed from a flexible and durable polymeric material, and a distal uncovered portion 810B. When inserted into the coronary sinus 352, the covered portion 810A, as shown, occludes blood flow out of the coronary sinus 352, while the uncovered portion 810B provides structural support within the coronary sinus 352 while allowing blood flow into the catheter 800 directly from both the coronary sinus 352 and the MCV 354. In at least one embodiment, the catheter 800 can be used as a perfusion catheter connected to a supply line.

[0084] 9 illustrates a catheter 900 including a deployable and retractable stent structure 920 according to at least one embodiment. The catheter 900 further includes a proximal end 901, a distal end 902, a lumen shaft 906, a tip section 908, and a balloon structure 910 disposed at section 912 of the lumen shaft 906. The catheter 900 may further include an outer lumen shaft (not shown) that substantially encapsulates the stent structure 920 and the balloon structure 910 prior to deployment. Deployment of the stent structure 920 may be performed by moving the outer lumen shaft in a proximal direction, and retraction of the stent structure 920 may be performed by moving the outer lumen shaft in a distal direction. The stent structure 920 may be formed, for example, from stainless steel, and is disposed between the balloon structure 910 and the tip section 908. In at least one embodiment, the lumen shaft 906 includes at least one perforation along a portion 922 between the balloon structure 910 and the stent structure 920 to allow drainage of the MCV 354 into the catheter 900. When inserted into the coronary sinus 352, the balloon structure 910 abuts the ostium of the coronary sinus 352.

[0085] FIG. 10 illustrates a catheter 1000 including a disk-shaped covered stent structure 1010 according to at least one embodiment. The catheter 1000 further includes a proximal end 1001, a distal end 1002, an outer lumen shaft 1006, an inner lumen shaft 1004, and a tip section 1008. The stent structure 1010 may be formed, for example, from a stainless steel stent with a durable polymeric coating. The outer lumen shaft 1006 may cover the stent structure 1010 prior to deployment. Once the catheter 1000 is properly positioned, the outer lumen shaft 1006 may be moved proximally to allow for deployment of the stent structure 1010. In at least one embodiment, the stent structure 1010 may be partially contained within the inner lumen shaft 1004 and coupled to a tip section 1008 that is actuable (using a wire) to deploy the stent structure 1010 when moved proximally and to retract the stent structure 1010 when moved distally. In at least one embodiment, the stent structure 1010 is large enough that, when deployed, it will occlude the coronary sinus 352 and the MCV 354 when abutting the ostium of the coronary sinus 352. In at least one embodiment, the diameter of the stent structure 1010 is between about 10 mm and about 30 mm.

[0086] Exemplary catheter embodiments for use as perfusion catheters in an LRP system are described herein. In at least one embodiment, the perfusion catheter is designed to support a liquid perfusion flow rate of about 400 mL / min or more (e.g., about 700 mL / min or more). Embodiments utilizing multiple perfusion catheters (e.g., a first catheter inserted into the right coronary artery and a second catheter inserted into the left coronary artery) can support a combined flow capacity of 700 mL / min or more.

[0087] Certain embodiments of retrieval catheters are advantageous for use in the supply tubing of an LRP system that is used to form a closed circuit in a non-arrested beating heart when inserted into a coronary artery. The catheters described herein can be designed to meet the following criteria: ability to femorally access the coronary arteries, outer diameter for coronary entry of 8Fr or less, outer diameter for occlusion of about 6mm to about 8mm, compatibility with 0.018 inch guidewires and 0.014 inch pressure wires, and ability to maintain a stable position for at least 60 minutes during an LRP procedure.

[0088] 11-16 show various catheter embodiments suitable for fluid perfusion within an LRP system. Any of the catheters shown in FIGS. 11-16 can be configured to support a fluid flow rate (aspiration or perfusion) of at least about 400 mL / min, at least about 450 mL / min, at least about 500 mL / min, at least about 550 mL / min, at least about 600 mL / min, at least about 650 mL / min, at least about 700 mL / min, at least about 750 mL / min, at least about 800 mL / min, at least about 850 mL / min, at least about 900 mL / min, at least about 950 mL / min, or at least about 1000 mL / min. Each catheter can be designed to have a smooth profile from the proximal catheter body to a low distal profile, for example, using one or more concentric lumen shafts.

[0089] In certain embodiments, one or more of the catheters may be a multi-lumen catheter, such as a double lumen catheter. In certain embodiments, the multi-lumen catheter allows for the flow of fluid (e.g., perfusion fluid) and allows for the inflation of one or more balloons. In certain embodiments, one or more of the catheters may be a multi-balloon catheter having two or more balloons. In certain embodiments, one or more of the balloons may be independently deployed or deflated.

[0090] 11A-11C show an exemplary catheter 1100 having a lumen shaft 1104 / 1106 having a proximal end 1101 and a distal end 1102 with an opening through which perfusion fluid can flow. The lumen shaft 1104 / 1106 can be formed from an outer lumen shaft 1104 that at least partially surrounds the inner lumen shaft 1106 and exposes a distal portion of the inner lumen shaft 1106 near the distal end 1102. The proximal end 1101 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the outer lumen shaft 1104 or inner lumen shaft 1106 can be formed from a durable polymeric material, such as a polyether block amide (PEBA) material (e.g., commercially available as PEBAX®). In at least one embodiment, the innermost diameter of the inner lumen shaft 1106 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path.

[0091] The catheter 1100 includes an inflatable balloon structure 1110 disposed along a portion 1112 corresponding to the inner lumen shaft 1106, and a tip portion formed by an additional lumen. In at least one embodiment, the inner lumen shaft 1106 includes a concentric inner flow passage surrounding a liquid flow passage. The concentric inner flow passage provides a path for gas flow from the balloon structure 1110 to a port 1114, which can be used to inflate or deflate the balloon structure 1110 depending on pressure applied at the port 1114. In at least one embodiment, the outermost surface of the inner lumen shaft 1106 at the portion 1112 is removed such that the portion 1112 is sealed by the balloon structure 1110, isolating gas flow from the concentric inner flow passage to the balloon structure 1110. In at least one embodiment, the inflated diameter of the balloon structure 1110 is about 15 mm to about 30 mm, about 15 mm to about 20 mm, about 20 mm to about 25 mm, about 24 mm to about 28 mm, or about 25 mm to about 30 mm, or any subrange defined therebetween (e.g., about 20 mm and about 28 mm). Figures 11B and 11C show the balloon structure 1110 in its deployed and deflated states.

[0092] 11D illustrates the deployment of catheter 1100 within aorta 1150 in accordance with at least one embodiment. As shown, catheter 1100 is pre-shaped for insertion into aorta 1150 for ease of navigation. Additionally, the shape can utilize backup forces from the aortic wall to further enhance stability during coronary occlusion and perfusion.

[0093] 12 and 13 show catheters including plug and wedge occlusion structures, respectively, which advantageously conform their shape to a blood vessel or ostium, are formed from highly compressible and atraumatic materials for safe introduction and deployment, are short in length compared to balloon structures, and do not require an additional lumen for expansion as balloon structures require.

[0094] 12A-12C show an exemplary catheter 1200 having a lumen shaft 1204 / 1206 having a proximal end 1201 and a distal end 1202 with an opening through which perfusion fluid can flow. The lumen shaft 1204 / 1206 can be formed from an outer lumen shaft 1204 that at least partially surrounds the inner lumen shaft 1206 and exposes a distal portion of the inner lumen shaft 1206 near the distal end 1202. The proximal end 1201 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the outer lumen shaft 1204 or inner lumen shaft 1206 can be formed from a durable polymeric material, such as a polyether block amide (PEBA) material (e.g., commercially available as PEBAX®). In at least one embodiment, the innermost diameter of the inner lumen shaft 1206 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path.

[0095] The catheter 1200 further includes a plug 1210 near the distal end 1202. In at least one embodiment, the plug 1210 is formed from a flexible material such as silicone or a foam material. In at least one embodiment, the plug 1210 includes an inner portion 1210A that fits over the inner lumen shaft 1206 and a flexible outer portion 1210B that is shaped to be configurable between a stored state (FIG. 12A) and an expanded state (FIG. 12C) in which the outer portion 1210B extends distally from the distal end 1202. The plug 1210 in FIG. 12A is shown as tapering distally. In at least one embodiment, the plug 1210 can be inverted so that it tapers proximally. In at least one embodiment, the outer lumen shaft 1204 can be configured to cover the plug 1210 prior to deployment.

[0096] 12D illustrates deployment of the catheter 1200 within the aorta 1150 according to at least one embodiment. The pressure of the arterial blood flow into the hollow space between the inner portion 1210A and the outer portion 1210B of the plug 1210 may help improve sealing of the catheter 1200 within the coronary artery. As shown, the catheter 1200 is pre-shaped for insertion into the aorta 1150 for ease of navigation. Additionally, the shape can utilize backup forces from the aortic wall to further enhance stability during occlusion and perfusion of the coronary artery.

[0097] 13A-13C show an exemplary catheter 1300 having a lumen shaft 1304 / 1306 having a proximal end 1301 and a distal end 1302 with an opening through which perfusion fluid can flow. The lumen shaft 1304 / 1306 can be formed from an outer lumen shaft 1304 that at least partially surrounds the inner lumen shaft 1306 and exposes a distal portion of the inner lumen shaft 1306 near the distal end 1302. The proximal end 1301 includes an outlet structure that can be fluidly coupled to an LRP system. One or more of the outer lumen shaft 1304 or inner lumen shaft 1306 can be formed from a durable polymeric material, such as a polyether block amide (PEBA) material (e.g., commercially available as PEBAX®). In at least one embodiment, the innermost diameter of the inner lumen shaft 1306 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path.

[0098] The catheter 1300 further includes a wedge 1310 near the distal end 1302, which may be shaped to fit a blood vessel or ostium. In at least one embodiment, the wedge 1310 is formed from a flexible material, such as a silicone or foam material. In at least one embodiment, the outer lumen shaft 1304 may be configured to cover the wedge 1310 prior to deployment.

[0099] 13D illustrates the deployment of catheter 1300 within aorta 1150 in accordance with at least one embodiment. As shown, catheter 1300 is pre-shaped for insertion into aorta 1150 for ease of navigation. Additionally, the shape can utilize backup forces from the aortic wall to further enhance stability during coronary occlusion and perfusion.

[0100] 14A-14C illustrate an exemplary catheter 1400 including a partially covered, recaptureable stent structure 1406 according to at least one embodiment, similar to the catheter 800 described with respect to FIG. 8. The catheter 1400 is shown inserted into a coronary artery 1452 via an aorta 1450. The catheter 1400 includes an outer lumen shaft 1402 and an inner lumen shaft 1404 that, in certain embodiments, is coupled to the stent structure 1406. The stent structure 1406 is further depicted as having a proximal covered portion and a distal uncovered portion, which may be formed from a flexible and durable polymeric material. FIGS. 14B and 14C illustrate the placement and deployment, respectively, of the stent structure 1406 when inserted into the coronary artery 1452. The deployment of the stent structure 1406 is performed by moving the outer lumen shaft 1402 in a proximal direction.

[0101] 15A and 15B show an exemplary catheter 1500 including a releasable covered braided disc 1510, according to at least one embodiment. The catheter 1500 includes an outer lumen shaft 1506 and an inner lumen shaft 1504. The braided disc 1510 is contained within the outer lumen shaft 1506 during placement of the catheter 1500 and can be deployed by moving the outer lumen shaft 1506 in a proximal direction. In certain embodiments, upon deployment, the braided disc 1510 does not extend beyond the distal end 1502 and is used to stabilize the catheter 1500 against the ostium of the coronary artery 1452 to reduce the risk of stenosis during occlusion of the coronary artery 1452 while allowing the distal end 1502 to extend into the coronary artery 1452.

[0102] 16A-16D show an exemplary catheter 1600 having a lumen shaft 1606 with a proximal end 1601 and a distal end 1602 with an opening through which perfusion fluid can flow. The proximal end 1601 includes an outlet structure that can be fluidly coupled to an LRP system. The lumen shaft 1604 can be formed from a durable polymeric material, such as a polyether block amide (PEBA) material (e.g., commercially available as PEBAX®). In at least one embodiment, the innermost diameter of the lumen shaft 1606 is at least about 2 mm, at least about 2.5 mm, at least about 3 mm, at least about 3.5 mm, at least about 4 mm, at least about 4.5 mm, or at least about 5 mm to provide a liquid flow path. In at least one embodiment, the proximal portion 1606A of the lumen shaft 1606 can have a larger diameter than the distal portion 1606B of the lumen shaft 1606 and may gradually taper over the length of the lumen shaft 1606.

[0103] FIG. 16C illustrates the deployment of catheter 1600 within aorta 1150 according to at least one embodiment. As shown, catheter 1600 is pre-shaped for insertion into aorta 1150 to facilitate navigation. Additionally, the shape can utilize backup forces from the aortic wall to further enhance stability during occlusion and perfusion of the coronary arteries. In addition to catheter 1600, other catheters described herein can be designed with pre-shaped lumen shafts depending on the anatomy where the LRP procedure is to be performed, which may improve overall safety during use. An example of a pre-shaped catheter lumen is shown in FIG. 17.

[0104] Exemplary LRP System Embodiments 18A illustrates an exemplary local-regional perfusion (LRP) system 1800 according to an embodiment of the present disclosure. The LRP system 1800 is shown in a closed circuit configuration with a heart 1810 (both anterior 1810A and posterior 1810B views are shown for clarity). The LRP system 1800 includes a membrane oxygenator 1820, a blood gas analysis (BGA) monitor 1830, and a pressure monitor 1840. The LRP system 1800 may be assembled by placing a first catheter 1822 in the right coronary artery 1812 of the heart 1810, a second catheter 1824 in the left main coronary artery 1814 of the heart 1810, and a recovery catheter 1826 in the coronary sinus 1816 of the heart. The first catheter 1822, the second catheter 1824, and the recovery catheter 1826 form a closed circuit with the coronary arteries, the coronary venous system, the membrane oxygenator 1820, and one or more optional additional components. This closed circuit may isolate, or substantially isolate, the patient's coronary circulation from the patient's systemic circulation.

[0105] The first catheter 1822, the second catheter 1824, and the recovery catheter 1826 may be introduced percutaneously and in a minimally invasive manner. In some embodiments, the first catheter 1822 and / or the second catheter 1824 may be introduced via antegrade intubation. In other embodiments, the first catheter 1822 and / or the second catheter 1824 may be introduced via retrograde intubation. The first catheter 1822 and the second catheter 1824 may be referred to herein as "drug delivery catheters," and the recovery catheter 1826 may be referred to as a "drug collection catheter" or a "drug recovery catheter" when the catheter is used for drug delivery to the heart.

[0106] The first catheter 1822 and / or the second catheter 1824 may be standard infusion catheters that may optionally include a standard guidewire and infusion pump. Each catheter may deliver a perfusion fluid to the heart 1810, which may include, for example, drugs to be delivered to the heart 1810 during local-regional perfusion. In certain embodiments, the first catheter 1822 and the second catheter 1824 may each correspond to an exemplary perfusion catheter embodiment described in the examples below.

[0107] The first catheter 1822 and / or the second catheter 1824 may be positioned through the patient's aorta by, for example, accessing the femoral artery and / or the radial artery. In one embodiment, the first catheter 1822 may be positioned through the patient's aorta by accessing the femoral artery. In another embodiment, the first catheter 1822 may be positioned through the patient's aorta by accessing the radial artery. In one embodiment, the second catheter 1824 may be positioned through the patient's aorta by accessing the femoral artery. In another embodiment, the second catheter 1824 may be positioned through the patient's aorta by accessing the radial artery.

[0108] The recovery catheter 1826 may be a balloon catheter such that a balloon may be inflated within the coronary sinus 1816 to ensure that all blood circulating through the closed circuit flows through the recovery catheter 1826. The balloon catheter may be a Fogarty® catheter, or any other catheter described herein and suitable for its intended purpose, as will be understood by those skilled in the art. In certain embodiments, the recovery catheter 1826 corresponds to the exemplary recovery catheter embodiment described below in the examples. In some embodiments, the recovery catheter 1826 may be placed via the patient's vena cava. In one embodiment, the recovery catheter 1826 may be placed via the patient's jugular vein. In another embodiment, the recovery catheter 1826 may be placed via the patient's femoral vein. In some embodiments, the first catheter 1822, the second catheter 1824, the recovery catheter 1826, or a combination thereof may each be a balloon catheter that serves to reduce leakage. In some embodiments, any of the catheters may be selected from one or more of the catheters described with respect to FIGS. 1-17.

[0109] The LRP system 1800 may further include one or more additional components, such as, without limitation, one or more pumps, one or more suction mechanisms, one or more perfusion fluids, and combinations thereof. For example, the LRP system 1800 is depicted in some embodiments as including a pressure monitor 1840 that is operatively coupled to or is part of the membrane oxygenator 1820. The pressure monitor 1840 may be used to control the perfusion rate (i.e., flow rate) by continuously monitoring the coronary pressure to ensure safety. A first pressure sensor 1842 and a second pressure sensor 1844 may be co-inserted with, for example, the first catheter 1822 and the second catheter 1824, respectively, to measure pressure in the right and left main coronary arteries, respectively. LRP system 1800 is further depicted as including a BGA monitor operably coupled to membrane oxygenator 1820 to measure gas concentrations in the perfusate (e.g., when the perfusate comprises blood), e.g., prior to perfusion via first catheter 1822 and second catheter 1824 and / or after the perfusate has been collected by return catheter 1826. Membrane oxygenator 1820, and one or more additional components, may be disposed between return catheter 1826 and one or more of first catheter 1822 or second catheter 1824.

[0110] In some embodiments, one or more drugs may be perfused through the patient's systemic circulation while the closed circuit is established. For example, if a drug is cardiotoxic or potentially toxic to the heart, but systemic delivery is desired, establishing a closed circuit to isolate the coronary perfusion from the systemic circulation is advantageous in preventing or reducing exposure of the drug to the heart. In such embodiments, a membrane oxygenator 1820 may be used to perfuse the coronary circulation with physiological oxygenation levels while it is isolated from the systemic circulation. For example, anthracycline (e.g., doxorubicin) chemotherapy formulations for treating breast cancer cause irreversible damage to the cardiac microcirculation, leading to anthracycline cardiomyopathy.

[0111] 18B is a schematic diagram of a membrane oxygenator 1820 that may be used to oxygenate the perfusate, mix the perfusate with other components (e.g., drugs), remove carbon dioxide from the perfusate, and / or push the perfusate into one or more of a first catheter 1822 (in the right coronary artery 1812) and / or a second catheter 1824 (in the left main coronary artery 1814). The membrane oxygenator 1820 may be any commercially available extracorporeal membrane oxygenation (ECMO) device for exchanging oxygen contained in the blood for carbon dioxide.

[0112] As shown in FIG. 18B, the membrane oxygenator 1820 includes various components including a heat exchanger 1856 (through which the perfusate leaves the outlet 1852 before entering the first catheter 1822 and the second catheter 1824), a delivery pump 1858, a reservoir 1860 (for adding components such as blood and / or drugs to the perfusate returning through the return catheter 1826 via the inlet 1854), sensors 1862 and 1864 at various stages of the closed circuit (e.g., for measuring pressure and / or blood gas content), and a membrane oxygenator 1866. In some embodiments, deoxygenated blood enters the membrane oxygenator 1866 and is mixed with oxygen-rich gas. The oxygen-rich gas may be provided from a gas blender 1868 that may mix oxygen with carbon dioxide and nitrogen gases in various ratios and is regulated by a gas flow regulator 1870.

[0113] The perfusion fluid may include one or more of blood (or components thereof, such as plasma or serum) and / or drugs suitable for treating cardiac disease, and / or excipients, such as saline or dextrose solution. A delivery pump 1858 may deliver the perfusion fluid into the first catheter 1822 and / or the second catheter 1824. In some embodiments, the perfusion fluid may be contained in an IV bag or syringe and administered directly to the first catheter 1822 and / or the second catheter 1824 with or without the use of a delivery pump 1858.

[0114] The suction mechanism may be used to apply a negative suction pressure to the recovery catheter 1826 to minimize leakage of blood and / or drug through the Thebesian venous system. The negative suction pressure may be about -150 mmHg, about -100 mmHg, about -50 mmHg, about -20 mmHg, about -15 mmHg, about -10 mmHg, about -5 mmHg, about 0 mmHg, or within a subrange defined by any of these points.

[0115] The blood circulating through the closed circuit may be autologous blood, matched blood from a donor, or a combination thereof. In some embodiments, blood components such as serum or plasma are selected according to one or more parameters. One of the parameters may be the presence or absence of a selected antibody. For example, when the drug is one or more viral vectors containing a therapeutic nucleic acid sequence, the patient's autologous blood may be tested to determine whether antibodies against the one or more viral vectors are present. The presence of antibodies in the patient's autologous blood may reduce and / or completely negate the effectiveness of the treatment and / or may result in an undesirable immune response. Therefore, it may be possible to dilute or replace the patient's autologous blood with seronegative matched blood from a donor, thereby reducing the patient's immune response to the drug and increasing the effectiveness of the drug.

[0116] Although the various components shown in FIG. 18B depict components that are part of membrane oxygenator 1820 or that are separate from membrane oxygenator 1820, it should be understood that this schematic diagram is merely illustrative, as one or more of the components may be included in membrane oxygenator 1820 or may be separate (external) from membrane oxygenator 1820.

[0117] The LRP system 1800 may be set up and operated as follows. That is, (1) a recovery catheter 1826 is carefully placed and tightly sealed within the coronary sinus 1816 to allow collection of only cardiac venous (deoxygenated) blood, (2) a first catheter 1822 and a second catheter 1824 are placed in a sealed manner within the right and left main coronary arteries (RCA), (3) the catheters are then connected to the arterial and venous lines of the membrane oxygenator 1820 using standard tubing, (4) operation of the LRP system 1800 is initiated and the coronary arteries are proactively perfused with oxygenated blood while returning deoxygenated blood is collected from the venous heart system via the recovery catheter 1826 using gentle negative pressure, and (5) the blood is then directed to a reservoir 1860 where it is oxygenated by the membrane oxygenator 1866 and proactively reinfused back into the heart via the first catheter 1822 and second catheter 1824 (driven by a delivery pump 1858). If a drug (e.g., a vector) is to be administered, it can be added to the perfusion fluid via reservoir 1860 after priming with blood or plasma and a blood sample can be taken, or the drug can be applied via reservoir 1860 during the entire perfusion process.

[0118] In some embodiments, diluting or replacing a patient's antibody-containing autologous blood with matched seronegative blood from a donor may reduce adverse immune responses and / or enhance drug efficacy. For example, when autologous blood is diluted or replaced with matched seronegative blood from a donor, the adverse immune response of the patient may be reduced by about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, or may be completely alleviated when compared to the immune response of the patient without dilution or replacement of the autologous blood. When autologous blood is diluted or replaced with compatible seronegative blood from a donor, the efficacy of the administered drug may be increased by about 10%, about 20%, about 30%, about 40%, about 50%, about 60%, about 70%, about 80%, about 90%, about 100%, about 150%, about 200%, about 300%, about 400%, or about 500% compared to the efficacy of the drug in a patient without dilution or replacement of the autologous blood.

[0119] In some embodiments, the blood portion of the perfusate may be in the range of about 5 mL to about 5000 mL, about 50 mL to about 2500 mL, about 100 mL to about 1000 mL, about 150 mL to about 500 mL, about 50 mL, about 75 mL, about 100 mL, about 125 mL, about 150 mL, about 175 mL, about 200 mL, about 225 mL, about 250 mL, about 275 mL, about 300 mL, about 325 mL, about 350 mL, about 375 mL, about 400 mL, about 425 mL, about 450 mL, about 475 mL, about 500 mL, about 550 mL, about 600 mL, about 650 mL, about 700 mL, about 750 mL, about 800 mL, about 850 mL, about 900 mL, about 950 mL, or about 1000 mL.

[0120] The ratio of autologous blood to compatible blood from the donor in the blood circulating through the closed circuit may be adjusted as necessary to obtain a blood mixture that is most acceptable to the drug and will produce the least immune response upon drug introduction. In some embodiments, the ratio may be in the range of about 1:100 to about 100:1, about 1:80 to about 80:1, about 1:50 to about 50:1, about 1:30 to about 30:1, about 1:20 to about 20:1, about 1:10 to about 10:1, about 1:8 to about 8:1, about 1:5 to about 5:1, about 1:3 to about 3:1, or about 1:2 to about 2:1 (volume of autologous blood):(volume of compatible blood from the donor).

[0121] The flow rate of the perfusate through the closed circuit can be adjusted to match the patient's blood flow rate. As will be appreciated by those skilled in the art, blood flow rate varies from patient to patient and for any given patient throughout the day. Thus, the flow rate of the perfusate circulating through the closed circuit can be adjusted in situ. The flow rate can be measured across the closed circuit. In certain embodiments, the flow rate can be measured with a trans-sound probe (such as a clamp on the tubing). In some embodiments, the flow rate of the perfusate at a given time during perfusion can be within about 20%, within about 15%, within about 10%, within about 8%, within about 5%, within about 3%, within about 2%, within about 1%, or within about 0.5% of the patient's blood flow rate, based on mL / min. To avoid ischemia and / or underperfusion, it is important that the flow rate of the perfusate circulating through the closed circuit does not deviate significantly from the patient's own blood flow rate.

[0122] Exemplary flow rates of the perfusion fluid circulating through the closed circuit may be in the range of, without limitation, about 75 mL / min to about 750 mL / min, about 100 mL / min to about 650 mL / min, about 125 mL / min to about 600 mL / min, about 150 mL / min to about 500 mL / min, about 175 mL / min to about 400 mL / min, about 200 mL / min to about 300 mL / min, about 150 mL / min, about 175 mL / min, about 200 mL / min, about 225 mL / min, about 250 mL / min, about 275 mL / min, about 300 mL / min, about 325 mL / min, or about 350 mL / min.

[0123] The perfusion solution may be circulated through the closed circuit for a duration ranging from, but not limited to, about 5 minutes to about 5 hours, about 15 minutes to about 4 hours, about 30 minutes to about 3 hours, or about 1 hour to about 2 hours. In some embodiments, the treatment duration may occur over a number of days, for example, 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, etc.

[0124] According to the systems disclosed herein, in some embodiments, a larger dose of drug may be administered directly and only to the heart than could otherwise be safely administered by systemic delivery, and in some embodiments, a smaller total dose of drug may be required to achieve the same therapeutic effect (as achieved with a larger dose to the systemic circulation or only partial isolation of the coronary circulation) since there may be substantially no leakage of perfusate outside the heart and / or into the Thebesian venous system.

[0125] In some embodiments, less than about 50% v / v, less than about 40% v / v, less than about 30% v / v, less than about 20%, less than about 15% v / v, less than about 10% v / v, less than about 5% v / v, less than about 4% v / v, less than about 3% v / v, less than about 2% v / v, less than about 1% v / v, less than about 0.5% v / v, or substantially none (0% v / v) of the perfusion fluid (e.g., blood and / or drug) circulating through the closed circuit leaks outside the closed circuit during the perfusion process.

[0126] The reduction in perfusion fluid leakage outside the closed circuit (compared to other methods disclosed in the art) may be due to the seals formed within the closed circuit and each individual component utilized within the closed circuit.

[0127] In certain embodiments, some perfusate leakage from the closed circuit may remain. For example, up to about 0.5% v / v, about 1% v / v, about 2% v / v, about 3% v / v, about 4% v / v, about 5% v / v, about 10% v / v, about 15% v / v, about 20% v / v, about 30% v / v, about 40% v / v, or about 50% v / v of the perfusate circulating through the closed circuit may leak outside the closed circuit. Any drug amount lost due to perfusate leakage may be replaced in the perfusate to keep the drug exposure to the heart constant over the calculated exposure time. The calculated exposure time may be, in certain embodiments, about 5 minutes to about 5 hours, about 15 minutes to about 4 hours, about 30 minutes to about 3 hours, about 1 hour to about 2 hours, or any subrange therebetween.

[0128] therapeutic composition A drug suitable for treating cardiac disease (i.e., a drug contained in the perfusion solution) may comprise a therapeutic polynucleotide sequence. In some embodiments, the therapeutic polynucleotide sequence may encode a protein for treating cardiac disease. The protein for treating cardiac disease may be of human origin or may be from a different species (e.g., without limitation, murine, feline, porcine, or simian). In some embodiments, the protein encoded by the therapeutic polynucleotide sequence may correspond to a gene expressed in the human heart.

[0129] Exemplary proteins may include, without limitation, one or more of SERCA2, MYBPC3, MYH7, PKP2, MYL3, MYL2, ACTC1, TPM1, TNNT2, TNNI3, TTN, FHL1, ALPK3, dystrophin, FKRP, mutants thereof, or combinations thereof. The one or more proteins used may also be functional mutants of the proteins mentioned herein and may show significant amino acid sequence identity compared to the original protein. For example, the amino acid identity may reach at least about 30%, at least about 35%, at least about 40%, at least about 45%, at least about 50%, at least about 55%, at least about 60%, at least about 65%, at least about 70%, at least about 75%, at least about 80%, at least about 85%, at least about 90%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, at least about 99%. In this context, the term "functional variant" means that a variant of a protein is capable of partially or completely exerting the function of the corresponding naturally occurring protein. A functional variant of a protein may include a protein that differs from its naturally occurring counterpart by, for example, the substitution, deletion, or addition of one or more amino acids.

[0130] Amino acid substitutions may be conservative or non-conservative. It is preferred that the substitution is a conservative substitution, i.e., a replacement of an amino acid residue with an amino acid of similar polarity that acts as a functional equivalent. Preferably, the amino acid residue used as a replacement is selected from the same amino acid group as the amino acid residue to be replaced. For example, a hydrophobic residue may be replaced with another hydrophobic residue, or a polar residue may be replaced with another polar residue with the same charge. Functionally homologous amino acids that may be used for conservative substitutions include non-polar amino acids such as, for example, glycine, valine, alanine, isoleucine, leucine, methionine, proline, phenylalanine, and tryptophan. Examples of uncharged polar amino acids include serine, threonine, glutamine, asparagine, tyrosine, and cysteine. Examples of charged polar (basic) amino acids include histidine, arginine, and lysine. Examples of charged polar (acidic) amino acids include aspartic acid and glutamic acid.

[0131] Also considered as variants are proteins that differ from their naturally occurring counterparts by one or more (e.g., 2, 3, 4, 5, 10, or 15) additional amino acids. These additional amino acids may be present within the amino acid sequence of the original protein (i.e., as an insertion) or may be added to one or both termini of the protein. Essentially, insertions can be made at any position, provided that the addition of the amino acids does not inhibit the function of the polypeptide to perform the function of the naturally occurring protein in the subject to be treated. Furthermore, variants of proteins also include proteins that lack one or more amino acids when compared to the original polypeptide. Such deletions may affect any amino acid position, provided that they do not impair the ability of the protein to perform its normal function.

[0132] Finally, a variant of cardiac sarcomere protein also refers to a protein that differs from the naturally occurring protein by structural modifications, such as modified amino acids. Modified amino acids are amino acids that have been modified either by natural processes, such as post-processing or post-translational modifications, or by chemical modification processes known in the art. Exemplary amino acid modifications include phosphorylation, glycosylation, acetylation, O-linked N-acetylglucosamination, glutathionylation, acylation, branching, ADP-ribosylation, cross-linking, disulfide bridge formation, formylation, hydroxylation, carboxylation, methylation, demethylation, amidation, cyclization, and / or covalent or non-covalent binding with phosphatidylinositol, flavin derivatives, lipoteichoic acid, fatty acids, or lipids.

[0133] Therapeutic polynucleotide sequences encoding a target protein may be administered to the subject to be treated in the form of a gene therapy vector, i.e., a nucleic acid construct that contains a coding sequence including translation and termination codons, next to other sequences required to provide expression of the exogenous nucleic acid, such as a promoter, a Kozak sequence, a polyA signal, etc.

[0134] For example, gene therapy vectors can be part of a mammalian expression system. Useful mammalian expression systems and expression constructs are commercially available. Also, several mammalian expression systems, such as plasmid or viral vector-based systems, e.g., LENTI-Smart™ (InvivoGen), GenScript™ Expression vector, pAdVAntage™ (Promega), ViraPower™ Lentiviral, Adenoviral Expression Systems (Invitrogen), and adeno-associated virus expression system (Cell Biolabs), are sold by different manufacturers and can be used in the present invention.

[0135] The gene therapy vector for expressing the exogenous therapeutic polynucleotide sequence of the present invention may be a viral or non-viral expression vector suitable for introducing the exogenous therapeutic polynucleotide sequence into cells, for example, for the subsequent expression of the protein encoded by the nucleic acid. The expression vector may be an episomal vector, i.e., a vector capable of autonomously replicating itself in a host cell, or an integrative vector, i.e., a vector that is stably integrated into the genome of a cell. Expression in a host cell may be constitutive or regulated (e.g., inducible).

[0136] In certain embodiments, the gene therapy vector is a viral expression vector. The viral vector for use in the present invention may comprise a viral genome with a deletion of a portion of the native sequence in order to introduce a heterologous polynucleotide without destroying the infectivity of the virus. Due to the specific interaction between the viral components and the host cell receptor, the viral vector is highly suitable for efficient introduction of genes into target cells. The viral vector suitable for facilitating gene transfer into mammalian cells can be derived from different types of viruses, such as, for example, from AAV, adenovirus, retrovirus, herpes simplex virus, bovine papilloma virus, lentivirus, vaccinia virus, polyoma virus, Sendai virus, orthomyxovirus, paramyxovirus, papovavirus, picornavirus, poxvirus, alphavirus, or any other viral shuttle suitable for gene therapy, their mutants, and their combinations.

[0137] "Adenoviral expression vector" or "adenovirus" is intended to include those constructs that contain sufficient adenoviral sequences to (a) support packaging of a therapeutic polynucleotide sequence construct and / or (b) ultimately express a tissue- and / or cell-specific construct that has been cloned therein. In one embodiment of the present invention, the expression vector comprises a genetically engineered form of adenovirus. Knowledge of the genetic organization of adenovirus, a 36 kilobase (kb) linear double-stranded DNA virus, allows for the replacement of large pieces of adenoviral DNA with foreign sequences up to 7 kb.

[0138] Adenovirus growth and manipulation is known to those of skill in the art and exhibits a broad host range in vitro and in vivo. This group of viruses can be produced in high titers, e.g., 10 per mL. 9 ~10 11 Adenoviruses can be acquired in plaque-forming units of 10 ...

[0139] Retroviruses (also called "retroviral vectors") may be chosen as gene delivery vectors due to their ability to integrate genes into the host genome, introduce large amounts of foreign genetic material, infect a wide range of species and cell types, and be packaged in specialized cell lines.

[0140] The retroviral genome contains three genes, gag, pol, and env, which code for capsid proteins, polymerase enzyme, and envelope components, respectively. Sequences upstream from the gag gene contain signals for packaging of the genome into virions. Two long terminal repeat (LTR) sequences are present at the 5' and 3' ends of the viral genes. These contain strong promoter and enhancer sequences and are also required for integration into the host cell genome.

[0141] To construct a retroviral vector, a nucleic acid encoding a gene of interest is inserted into the viral genome in place of a specific viral sequence to generate a replication-defective virus. To produce virions, a packaging cell line is constructed that contains the gag, pol, and / or env genes, but does not contain the LTR and / or packaging components. When a recombinant plasmid containing a cDNA is introduced into this cell line (e.g., by calcium phosphate acid precipitation) along with retroviral LTRs and packaging sequences, the packaging sequences allow packaging of the RNA transcripts of the recombinant plasmid into viral particles that are then secreted into the medium. The medium containing the recombinant retrovirus is then collected, optionally condensed, and used for gene transfer. Retroviral vectors are capable of infecting a wide variety of cell types. However, integration and stable expression require the division of the host cell.

[0142] Retroviruses can be derived from any of the subfamilies. For example, vectors from murine sarcoma virus, bovine leukemia virus, Rous sarcoma virus, murine leukemia virus, mink cell focus-inducing virus, reticuloendotheliosis virus, or avian leukemia virus can be used. Those skilled in the art can combine parts from different retroviruses, such as LTR, tRNA binding site, and packaging signal, to provide recombinant retroviruses. These retroviruses are then usually used to produce transduction-competent retroviral vector particles. For this purpose, the vector is introduced into a suitable packaging cell line. Retroviruses can also be constructed for site-specific integration into the DNA of host cells by incorporating a chimeric integrase enzyme into the retroviral particle.

[0143] Herpes simplex virus (HSV) is of great interest for the treatment of nervous system diseases because of its neurotropism. Furthermore, the ability of HSV to establish latent infection in non-dividing neuronal cells without integrating into the host cell chromosome or otherwise altering the host cell metabolism, as well as the presence of promoters that are active during latency, make HSV an attractive vector. And although much attention has been focused on the neurotropic applications of HSV, the vector has a broad host range and can therefore be used in other tissues.

[0144] Another factor that makes HSV an attractive vector is the size and organization of its genome. Because HSV is large, the integration of multiple genes or expression cassettes is less problematic than with other smaller viral systems. In addition, the ability to use different viral regulatory sequences with different performance (time, strength, etc.) allows for greater control of expression than with other systems. Another advantage is that the virus has relatively few spliced ​​messages, making genetic manipulation easier.

[0145] HSV is also relatively easy to manipulate and can be grown to high titers. Thus, delivery is less of a problem, both in terms of the amount needed to achieve a sufficient multiplicity of infection (MOI) and in terms of reducing the need for repeated dosing. Non-virulent mutants of HSV have been developed and are readily available for use in the context of gene therapy.

[0146] Lentiviruses are complex retroviruses that contain, in addition to the common retroviral genes gag, pol, and env, other genes with regulatory or structural functions. The increased complexity allows the virus to regulate its life cycle, such as during latent infection. Examples of lentiviruses include human immunodeficiency viruses (HIV-1, HIV-2) or simian immunodeficiency viruses (SIV). Lentiviral vectors have been generated by multiple attenuation of HIV toxic genes, e.g., genes env, vif, vpr, vpu, and nef are deleted, making the vector biologically safe.

[0147] Lentiviral vectors are plasmid-based or virus-based, and are constructed to carry the necessary sequences for the selection and introduction of nucleic acid into host cells in order to incorporate foreign nucleic acid. The gag, pol and env genes of interest are also known in the art. Thus, the relevant genes are cloned into the selected vector and then used to transform the target cells of interest.

[0148] Vaccinia virus vectors have been widely used because they are easy to construct, can produce relatively high levels of expression, have a wide host range, and have a large DNA carrying capacity. Vaccinia contains a linear double-stranded DNA genome of approximately 186 kb that shows a pronounced "AT" preference. Approximately 10.5 kb of inverted terminal repeats flank the genome. The majority of essential genes appear to map within a central region that is most highly conserved among poxviruses. There are an estimated 150-200 open reading frames in vaccinia virus. Although both strands are encoded, extensive overlap of the reading frames is not common.

[0149] At least 25 kb can be inserted into the vaccinia virus genome. Prototypical vaccinia vectors contain a transgene inserted into the viral thymidine kinase gene via homologous recombination. Vectors are selected on the basis of the tk phenotype. Inclusion of the non-translated leader sequence from encephalomyocarditis virus results in expression levels higher than those of conventional vectors, with the transgene accumulating to more than 10% of the protein in infected cells at 24 hours.

[0150] Empty capsids of papovaviruses, such as mouse polyomavirus, have attracted attention as potential vectors for gene transfer. The use of empty polyoma was first reported when polyoma DNA and purified empty capsids were incubated in a cell-free system. The DNA of the new particles was protected from the action of pancreatic DNase. The reconstituted particles were used to introduce transforming polyoma DNA fragments into rat FIII cells. The empty capsids and reconstituted particles consist of all three of the polyoma capsid antigens VP1, VP2, and VP3.

[0151] AAV is a parvovirus belonging to the Dependovirus genus. They are small, non-enveloped, single-stranded DNA viruses that require a helper virus to replicate. Superinfection with a helper virus (such as adenovirus, herpesvirus, or vaccinia virus) is required to form a functionally complete AAV virion. In vitro, in the absence of superinfection with a helper virus, AAV establishes a latent state in which the viral genome exists in episomal form, but no infectious virions are produced. Subsequent infection with a helper virus "rescues" the genome, allowing it to replicate and be packaged into viral capsids, thereby reconstituting infectious virions. Recent data indicate that in vivo, both wild-type and recombinant AAV exist primarily as large episomal concatemers. In one embodiment, the gene therapy vector used herein is an AAV vector. The AAV vector may be a purified, replication-incompetent, pseudotyped rAAV particle.

[0152] AAV is not associated with any known human disease, is generally not considered pathogenic, and does not appear to alter the physiological properties of host cells upon integration. AAV can infect a wide range of host cells, including non-dividing cells, and can infect cells of different species. In contrast to some vectors that are rapidly cleared or inactivated by both cellular and humoral responses, AAV vectors have been shown to induce sustained transgene expression in various tissues in vivo. The persistence of recombinant AAV-mediated transgenes in non-dividing cells in vivo may be due to the lack of native AAV viral genes and the vector's ability to form ITR-associated episomal concatemers.

[0153] AAV is an attractive vector system for use in cell transduction according to the invention because it has a high frequency of persistence as episomal concatemers, is capable of infecting non-dividing cells, including cardiomyocytes, and is therefore useful, for example, for delivery of genes to mammalian cells in tissue culture and in vivo.

[0154] Typically, rAAV is produced by co-transfecting a plasmid containing the gene of interest flanked by two AAV terminal repeats, such as pIM45, and / or an expression plasmid containing a wild-type AAV coding sequence without the terminal repeats. Cells are also infected and / or transfected with adenovirus and / or a plasmid carrying the adenovirus genes required for AAV helper function. Stocks of rAAV produced in such a way are contaminated with adenovirus and must be physically separated from the rAAV particles (e.g., by cesium chloride density centrifugation or column chromatography). Alternatively, adenovirus containing the AAV coding region and / or a cell line containing some or all of the AAV coding region and / or adenovirus helper genes could be used. Cell lines with rAAV DNA as an integrated provirus can also be used.

[0155] Multiple serotypes of AAV exist in nature, with at least 12 serotypes (AAV1-AAV12). Despite high homology, different serotypes have tropism for different tissues. Upon transfection, AAV induces only minor (if any) immune responses in the host. Therefore, AAV is well suited for gene therapy approaches.

[0156] The present disclosure may be directed to a drug comprising an AAV vector, which in some embodiments is one or more of AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, ANC AAV, their chimeric AAV derivatives, their mutants, and combinations thereof, which are more suitable for high efficiency transduction in the tissue of interest. In certain embodiments, the gene therapy vector is an AAV serotype 1 vector. In certain embodiments, the gene therapy vector is an AAV serotype 2 vector. In certain embodiments, the gene therapy vector is an AAV serotype 3 vector. In certain embodiments, the gene therapy vector is an AAV serotype 4 vector. In certain embodiments, the gene therapy vector is an AAV serotype 5 vector. In certain embodiments, the gene therapy vector is an AAV serotype 6 vector. In certain embodiments, the gene therapy vector is an AAV serotype 7 vector. In certain embodiments, the gene therapy vector is an AAV serotype 8 vector. In certain embodiments, the gene therapy vector is an AAV serotype 9 vector. In certain embodiments, the gene therapy vector is an AAV serotype 10 vector. In certain embodiments, the gene therapy vector is an AAV serotype 11 vector. In certain embodiments, the gene therapy vector is an AAV serotype 12 vector.

[0157] The appropriate dose of AAV for humans is approximately 1 × 10 per kilogram of body weight. 8 Vector genome (vg / kg) ~ approx. 3 × 10 14 vg / kg, approximately 1×10 8 vg / kg, approximately 1×10 9 vg / kg, approximately 1×10 10 vg / kg, approximately 1×10 11 vg / kg, approximately 1×10 12 vg / kg, approximately 1×10 13 vg / kg, or approximately 1 × 10 14 The total viral load, or DRP, can be in the range of about 5×10 15 vg / kg, 4 × 10 15 vg / kg, 3 × 10 15vg / kg、2×10 15 vg / kg、1×10 15 vg / kg、9×10 14 vg / kg、8×10 14 vg / kg、7×10 14 vg / kg、6×10 14 vg / kg、5×10 14 vg / kg、4×10 14 vg / kg、3×10 14 vg / kg、2×10 14 vg / kg、1×10 14 vg / kg、9×10 13 vg / kg、8×10 13 vg / kg、7×10 13 vg / kg、6×10 13 vg / kg、5×10 13 vg / kg、4×10 13 vg / kg、3×10 13 vg / kg、2×10 13 vg / kg、1×10 13 vg / kg、9×10 12 vg / kg、8×10 12 vg / kg、7×10 12 vg / kg、6×10 12 vg / kg、5×10 12 vg / kg、4×10 12 vg / kg、3×10 12 vg / kg、2×10 12 vg / kg、1×10 12 vg / kg、9×10 11 vg / kg、8×10 11 vg / kg、7×10 11 vg / kg、6×10 11 vg / kg、5×10 11 vg / kg、4×10 11 vg / kg、3×10 11 vg / kg、2×10 11 vg / kg、1×10 11 vg / kg、9×10 10 vg / kg、8×10 10 vg / kg、7×10 10 vg / kg、6×10 10 vg / kg、5×10 10 vg / kg、4×1010 vg / kg, 3 × 10 10 vg / kg, 2×10 10 vg / kg, 1×10 10 vg / kg, 9×10 9 vg / kg, 8×10 9 vg / kg, 7×10 9 vg / kg, 6×10 9 vg / kg, 5×10 9 vg / kg, 4 × 10 9 vg / kg, 3 × 10 9 vg / kg, 2×10 9 vg / kg, 1×10 9 vg / kg, 9×10 8 vg / kg, 8×10 8 vg / kg, 7×10 8 vg / kg, 6×10 8 vg / kg, 5×10 8 vg / kg, 4 × 10 8 vg / kg, 3 × 10 8 vg / kg, 2×10 8 vg / kg, or 1 × 10 8 vg / kg, about these, at least these, at least about these, less than these, or less than these, or within a range defined by any two of these values. The above indicated doses as being in vg / kg cardiac tissue units.

[0158] According to the systems and methods disclosed herein, in some embodiments, there may be substantially no leakage of perfusate outside the heart and / or into the Thebesian venous system, so that a higher dose of drug may be administered directly and exclusively to the heart than would otherwise be safely administered by systemic delivery. Although not intended to be limiting, it is believed that AAV toxicity may be due to systemic effects such as hepatotoxicity, platelet activation and loss, and complement activation and loss. These toxicities and others may be reduced, minimized, or avoided entirely by the application of locoregional perfusate as described in the methods and systems disclosed herein. Thus, up to about 5×10 15Doses of vg / kg of cardiac tissue may be well tolerated, and in certain embodiments, the AAV dose to the heart, expressed in vg / kg of cardiac tissue, may exceed the highest systemically administered dose by about 2 to about 200 times, about 5 to about 150 times, about 10 to about 100 times, or any subrange therein.

[0159] Apart from viral vectors, non-viral expression constructs can also be used to introduce the gene encoding the target protein or its functional variant or fragment into the cells of a patient.The non-viral expression vectors that allow the in vivo expression of protein in target cells include, for example, plasmids, modified RNA, mRNA, cDNA, antisense oligomers, DNA lipid complexes, nanoparticles, exosomes, any other non-viral shuttle suitable for gene therapy, their variants, and their combinations.

[0160] Apart from viral and non-viral vectors, nuclease systems may be used in conjunction with vectors and / or electroporation systems to enter and introduce into the patient's cells a gene encoding a target protein or a functional variant or fragment thereof. Exemplary nuclease systems may include, but are not limited to, clustered regularly interspaced short palindromic repeats (CRISPR), DNA cleavage enzymes (e.g., Cas9), meganucleases, TALENs, zinc finger nucleases, any other nuclease system suitable for gene therapy, their variants, and their combinations. For example, in one embodiment, one viral vector (e.g., AAV) may be used for a nuclease (e.g., CRISPR), and another viral vector (e.g., AAV) may be used for a DNA cleavage enzyme (e.g., Cas9) to introduce both (nuclease and DNA cleavage enzyme) into the target cell.

[0161] Other vector delivery systems that can be used to deliver therapeutic polynucleotide sequences encoding therapeutic genes into cells are receptor-mediated delivery vehicles. These take advantage of the selective uptake of macromolecules by receptor-mediated endocytosis in almost all eukaryotic cells. Due to the cell type-specific distribution of various receptors, delivery can be highly specific. Receptor-mediated gene targeting vehicles can contain two components: a ligand specific for a cell receptor, and a DNA-binding agent.

[0162] Suitable methods for the introduction of non-viral vectors into target cells include, for example, lipofection, calcium phosphate coprecipitation, DEAE-dextran, and direct DNA introduction using microglass tubes, ultrasound, electroporation, etc. Prior to the introduction of the vector, cardiomyocytes can be treated with permeabilizing agents such as phosphatidylcholine, streptolysin, sodium caprate, decanoylcarnitine, tartaric acid, lysolecithin, Triton X-100, etc. Exosomes can also be used to introduce naked DNA or DNA wrapped in the capsid of AAV.

[0163] The gene therapy vector of the present invention may include a promoter operably linked to a nucleic acid sequence encoding a target protein. The promoter sequence should be compact and ensure strong expression. Preferably, the promoter provides expression of the target protein in the myocardium of a patient who has been treated with the gene therapy vector. In some embodiments, the gene therapy vector includes a cardiac-specific promoter operably linked to a nucleic acid sequence encoding a target protein. As used herein, "cardiac-specific promoter" refers to a promoter whose activity in cardiac cells is at least two-fold higher than in any other non-cardiac cell type. Preferably, cardiac-specific promoters suitable for use in the vectors of the present invention have at least 5-fold, at least 10-fold, at least 15-fold, at least 20-fold, at least 25-fold, or at least 50-fold higher activity in cardiac cells compared to activity in non-cardiac cell types.

[0164] A cardiac-specific promoter may be a selected human promoter or a promoter comprising a functionally equivalent sequence having at least about 80%, at least about 90%, at least about 95%, at least about 96%, at least about 97%, at least about 98%, or at least about 99% sequence identity to a selected human promoter. An exemplary non-limiting promoter that may be used is the cardiac troponin T promoter (TNNT2). Other non-limiting examples of promoters include α-myosin heavy chain promoter, myosin light chain 2v promoter, α-myosin heavy chain promoter, α-cardiac actin promoter, α-tropomyosin promoter, cardiac troponin C promoter, cardiac troponin I promoter, cardiac myosin binding protein C promoter, and sarco / endoplasmic reticulum Ca promoter. 2+ -ATPase (SERCA) promoter (e.g., isoform 2 of this promoter (SERCA2)).

[0165] Vectors useful in the present invention may have various transduction efficiencies. As a result, viral or non-viral vectors transduce, equal to, or at least about, about 10%, about 20%, about 30%, about 40%, about 50%, about 55%, about 60%, about 65%, about 70%, about 75%, about 80%, about 85%, about 90%, about 95%, about 99%, or about 100% or more of the cells in the target vascular area. Multiple vectors (viral or non-viral, or combinations thereof) can be used simultaneously or sequentially. This can be used to introduce multiple polynucleotides and / or target multiple cell types. When multiple vectors or multiple drugs are used, multiple transduction / transfection efficiencies can occur.

[0166] The pharmaceutical composition containing the gene therapy vector can be prepared as either a liquid solution or a suspension. The pharmaceutical composition of the present invention may contain commonly used pharma- ceutical acceptable excipients, such as diluents and carriers. In particular, the composition contains a pharma- ceutical acceptable carrier, such as water, saline, Ringer's solution, or dextrose solution. In addition to carriers, the pharmaceutical composition may also contain emulsifiers, pH buffers, stabilizers, dyes, and the like.

[0167] In certain embodiments, the pharmaceutical composition comprises a therapeutic gene dose, which is a dose that is not toxic to the subject and can prevent or treat the subject's cardiomyopathy.Prevention or treatment of cardiomyopathy may be evaluated as a change in phenotypic characteristics associated with cardiomyopathy, and such change is effective for preventing or treating cardiomyopathy.Thus, a therapeutic gene dose is usually a dose that is sufficient to improve or prevent the pathogenic cardiac phenotype of the treated subject when administered in a physiologically acceptable composition.

[0168] Cardiac diseases that may be treated by the methods disclosed herein include, but are not limited to, genetically determined cardiac disease (e.g., genetically determined cardiomyopathies), arrhythmic heart disease, heart failure, ischemia, arrhythmias, myocardial infarction, congestive heart failure, transplant rejection, abnormal cardiac contractility, non-ischemic cardiomyopathy, mitral regurgitation, aortic stenosis or regurgitation, abnormal Ca 2+ These may include one or more of metabolism, congenital heart disease, primary or secondary cardiac tumors, and combinations thereof.

[0169] Real-life examples The following examples are provided to aid in the understanding of the present disclosure and should not be construed as specifically limiting the embodiments described and claimed herein. Such variations of the embodiments, including the substitution of all currently known or later developed equivalents that would be within the skill of a person skilled in the art, and changes in formulations or minor changes in experimental design, should be construed as being included within the scope of the embodiments incorporated herein.

[0170] Example 1: Feasibility study of locoregional perfusion in three pigs The feasibility of the LRP system was demonstrated by successfully performing the 60-minute procedure in three pigs (sus scrofa domestica). In two pigs, a thoracotomy was performed for monitoring purposes, but all catheters were introduced percutaneously. In the third pig, no thoracotomy was performed and the entire LRP procedure was performed percutaneously.

[0171] LRP was performed on three animals utilizing the LRP system 1800 shown and described with respect to Figures 18A and 18B. In all three animals, the LRP procedure could be maintained while the heart was beating spontaneously for 60 minutes without any technical problems. During the LRP, all animals (n=3) were hemodynamically stable without the need for circulatory working drugs. Cardiac function after LRP was unremarkable and comparable to baseline in all animals. Overall occlusion of the coronary arteries was acceptable. In animal 1, the left coronary artery (LCA) could not be completely occluded (leakage was considered mild). In animal 2, the right coronary artery (RCA) could not be completely occluded (leakage was considered trace). In animal 3, both coronary arteries could be occluded.

[0172] Tight occlusion of the coronary sinus (CS) was technically more challenging due to variable anatomy in pigs, in contrast to humans, where the azygos vein attaches directly into the coronary sinus and needs to be occluded to simulate the human situation. Complete occlusion was achieved in animal 3 (using the Reliant balloon) and partial occlusion was achieved in animals 1 and 2 (ProPledge catheter). Flow rates ranging from 166 mL / min to a maximum of 244 mL / min were achieved during the 60 minute LRP procedure. The accessory devices used in this example are listed in Table 1, including their intended use and use in the LRP system according to embodiments of the present disclosure.

[0173] FIG. 19 is an x-ray of a typical LRP in situ setup, with the coronary artery catheter indicated by the arrow and the coronary sinus balloon (retrieval catheter) indicated by the triangle.

[0174] The mean LRP parameters (pump speed, flow rate, and pressure) for the three animals are summarized in FIG. 20 (bars indicate standard deviation). [Table 1] [Table 2-1] [Table 2-2]

[0175] Example 2: Safety study of the locoregional perfusion system in two pigs The safety of the LRP system was demonstrated by performing a 60-minute LRP procedure using a percutaneous approach in two pigs (sus scrofa domestica) and following the animals for 24 hours after the procedure while they were under anesthesia. After 24 hours, the animals were sacrificed and macroscopic and microscopic examination of the animals' hearts was performed. In addition, blood biomarkers were obtained to assess cardiac tissue damage.

[0176] In both experiments, the LRP was performed without incident and without serious adverse effects. A technical problem occurred in animal 5, where the pump head tubing connection failed after 10 minutes. The LRP was immediately stopped and all catheters were disconnected and deflated. The pump head was immediately replaced and the LRP system was reconnected, deflated, and restarted. During this procedure, the animals were hemodynamically stable and no serious adverse effects were observed. The LRP procedure was then maintained for 60 minutes, thus demonstrating safety and efficacy even with minor device failure.

[0177] Animals remained hemodynamically stable throughout the procedure, including initiation, resumption, and up to 24 hours after LRP, without the need for circulatory agonists.

[0178] For both animals, a mean LRP flow rate of 173 mL / min could be achieved while the left main and right coronary arteries were completely occluded and the coronary sinus was partially occluded (leakage was moderate). Postoperative and 24-hour cardiac function was unremarkable and comparable to baseline. Cardiac biomarkers (myoglobin and troponin) were slightly elevated during and immediately after the LRP procedure, but then quickly declined toward baseline values ​​during the 24-hour follow-up. Given the continued hemodynamic stability of the animals throughout the procedure, the absence of serious adverse effects, and the minor and transient increases in cardiac biomarkers, as well as only transient electrocardiographic changes that promptly normalized within 24 hours, the LRP procedure was demonstrated to be safe. Table 3 compiles flow and pressure characteristics over 60 minutes of LRP procedure in animals 4 and 5 used in the safety study. [Table 3]

[0179] The hearts of Animal 4 and Animal 5 were examined macroscopically after sacrifice.

[0180] The heart of Animal 4 weighed 312 grams. No gross pathology was observed, specifically no signs of myocardial ischemia or infarction. A localized hematoma was observed on the posterior side of the heart of Animal 4, in the region of the right coronary artery, likely due to wire damage during the procedure.

[0181] The heart of Animal 5 weighed 293 grams. No gross pathology was observed, specifically no signs of myocardial ischemia or infarction. Localized hematomas were observed on the posterior side of the heart of Animal 5 in the region of the distal right coronary artery and the distal left circumflex artery, likely due to wire damage during the procedure.

[0182] To ascertain the biochemical integrity of the cardiac tissue, serum (seric) cardiac biomarkers were obtained and summarized in Table 4. Creatine kinase (CK) levels remained stable during the LRP procedure but showed a continued elevation after LRP, likely due to the animals lying in a supine position. Myoglobin levels remained stable during the LRP procedure and showed only minimal increases thereafter, still within baseline levels for animal 4 and only very slightly above baseline levels for animal 5. Troponin T was minimally elevated during the LRP procedure, peaking at 60 minutes and then declining to baseline values ​​during follow-up. [Table 4]

[0183] Example 3: Vector biodistribution studies Biodistribution studies were performed in three pigs undergoing the LRP procedure described above using a similar protocol and equipment. The first pig ("Pig 1") and the second pig ("Pig 2") underwent LRP for 60 minutes, and their coronary circulation was delivered a total dose of 10 per kilogram of heart weight of AAV9 containing a construct encoding green fluorescent protein (GFP) under the cytomegalovirus (CMV) promoter (AAV9 CMV-GFP). 14 The third pig ("Pig 3") received the same dose of AAV9 CMV-GFP via intracoronary (IC) infusion. None of the various pigs considered for the study were identified as AAV9 antibody negative. Thus, the pigs exhibiting the lowest antibody titers were selected for the study (Pig 1: anti-AAV9 1:20, Pig 2: anti-AAV9>1:100, Pig 3: anti-AAV9>1:100).

[0184] Vector release from the closed circuit remained low throughout the LRP procedure (see Tables 5 and 6 below). For pig 1 and pig 2, 98.7% and 81.8% of vector was detected in plasma samples at 5 minutes and 60.1% and 52.9% at 30 minutes, respectively, of the LRP procedure, demonstrating that vector was maintained in the closed circuit for at least 45 minutes early in the LRP procedure. The lower limit of quantification was 5.33 x 10 3 vg / mL. [Table 5] [Table 6]

[0185] Vector biodistribution was assessed by determining vg / g using quantitative polymerase chain reaction (qPCR) analysis and by visually detecting expression in 26 pre-determined cardiac sections per pig using immunofluorescence. Using qPCR analysis (as summarized in Table 7), the overall detection level was low, but vector was detected in 22 of 26 cardiac sections in pig 1, indicating broad vector distribution. In pig 2 (which had higher anti-AAV Ab titers), vector was detected in 8 of 26 sections. In contrast, in pig 3, vector was only detected in 3 of 26 cardiac sections after intracoronary injection. The lower limit of quantification is <0.004 vector genomes per diploid genome (vg / dg). [Table 7-1] [Table 7-2]

[0186] Immunofluorescence (IF) analysis was performed using GFP detection as a method of quantification. Tissue samples were prepared using frozen tissue sections to obtain 10 mm thick samples. A primary monoclonal antibody was used for GFP detection, and an Alexa-555-conjugated secondary antibody was used for mouse antibody detection. Wheat germ agglutinin (WGA) was used for connective tissue detection. Counterstaining was performed with 4',6-diamidino-2-phenylindole (DAPI).

[0187] Automated immunofluorescence quantification was performed on tissue sections (whole section scanning using a ZEISS Axio Scan microscope). GFP-positive cardiomyocytes were detected in 8 of 25 sections in pig 1 (only 25 sections were examined), 4 of 26 sections in pig 2, and 0 sections in pig 3. The total number of transduced cardiomyocytes was less than 1%.

[0188] In the above description, many specific details are set forth, such as specific materials, dimensions, process parameters, etc., to provide a thorough understanding of the invention. Particular features, structures, materials, or characteristics may be combined in any suitable manner in one or more embodiments. The word "example" or "exemplary" is used herein to mean serving as an example, instance, or illustration. Any aspect or design described herein as "example" or "exemplary" should not necessarily be construed as preferred or advantageous over other aspects or designs. Rather, the use of the word "example" or "exemplary" is merely intended to present a concept in a concrete manner. As used in this application, "or" is intended to mean an inclusive "or" rather than an exclusive "or." That is, unless otherwise specified or clear from the context, "X includes A or B" is intended to mean all natural inclusive permutations. That is, if X includes A, if X includes B, or if X includes both A and B, then "X includes A or B" is satisfied under any of the above illustrative examples. References throughout this specification to "an embodiment," "a particular embodiment," or "one embodiment" mean that a particular feature, structure, or characteristic described in connection with that embodiment is included in at least one embodiment. Thus, the appearances of the phrases "one embodiment," "a particular embodiment," or "one embodiment" in various places throughout this specification are not necessarily all referring to the same embodiment.

[0189] The invention has been described with reference to specific exemplary embodiments thereof. The specification and drawings are accordingly to be regarded in an illustrative rather than a restrictive sense. Various modifications of the invention in addition to those shown and described herein will become apparent to those skilled in the art and are intended to fall within the scope of the appended claims.

Claims

1. 1. A system for performing local-regional perfusion within a patient's heart when fluidly coupled to the heart, comprising: a first catheter adapted for insertion into a right coronary artery of the heart; a second catheter adapted for insertion into the left main coronary artery of the heart; a retrieval catheter adapted for insertion into the coronary sinus of the heart; a membrane oxygenator fluidly coupled to the first catheter, the second catheter, the recovery catheter, and an oxygen source, wherein the first catheter, the second catheter, the recovery catheter, and the membrane oxygenator together form a closed circuit through the coronary circulation of the heart that is isolated from the patient's systemic circulation when the first catheter is inserted into the right coronary artery, the second catheter is inserted into the left main coronary artery, and the recovery catheter is inserted into the coronary sinus; a reservoir configured for infusing a drug into said closed circuit during perfusion, wherein said drug comprises a therapeutic polynucleotide sequence for the treatment of a cardiac disease present in one or more viral vectors, said cardiac disease being a genetically determined cardiomyopathy. a pump configured to drive fluid flow through the first catheter and the second catheter, wherein when the closed circuit is established and the drug is perfused through the closed circuit, the system is adapted to maintain at least 50% of the drug within the closed circuit for at least 45 minutes; The system comprising:

2. The system of claim 1 , wherein the pump is configured to generate a negative pressure range of −100 mmHg to 0 mmHg.

3. The system described in claim 1 or 2, wherein the one or more viral vectors are selected from the group consisting of adeno-associated virus, adenovirus, retrovirus, herpes simplex virus, bovine papilloma virus, lentiviral vector, vaccinia virus, polyoma virus, Sendai virus, orthomyxovirus, paramyxovirus, papovavirus, picornavirus, poxvirus, alphavirus, mutants thereof, and combinations thereof.

4. The system described in claim 3, wherein the viral vector is an adeno-associated virus (AAV).

5. The system described in claim 4, wherein the AAV is one or more of AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, mutants thereof, and combinations thereof.

6. A system described in any one of claims 1 to 5, wherein the therapeutic polynucleotide sequence includes a promoter.

7. A system described in any one of claims 1 to 6, wherein the therapeutic polynucleotide sequence corresponds to a gene expressed in the human heart.

8. The system of claim 1, wherein the retrieval catheter comprises a double balloon catheter.

9. The system configured to perform a method of perfusing a patient's non-arrested, beating heart, the method comprising: placing a first catheter in a right coronary artery of the heart; placing a second catheter in the left main coronary artery of the heart; placing a recovery catheter in the coronary sinus of the heart, the first catheter, the second catheter, and the recovery catheter forming a closed perfusion circuit through the heart with at least one membrane oxygenator; causing a perfusion fluid to flow through said closed circuit, said closed circuit isolating perfusion through the heart from the patient's systemic circulation, and wherein at least 50% of said perfused drug remains in said closed circuit for at least 45 minutes. The system according to any one of claims 1 to 8, comprising:

10. The system of claim 9, wherein the first catheter and / or the second catheter are positioned through the patient's aorta by accessing the femoral artery and / or the radial artery.

11. A system as described in claim 9 or 10, wherein the retrieval catheter is positioned within the coronary sinus via the patient's vena cava.

12. The system of claim 9 or 10, wherein the retrieval catheter is placed via the patient's jugular or femoral vein.

13. A system described in any one of claims 9 to 12, wherein 1000 mL, 800 mL, 600 mL, 400 mL, 200 mL, 100 mL, or 50 mL of blood circulates through the closed circuit.

14. A system described in any one of claims 9 to 13, wherein one or more of the first catheter, the second catheter, or the recovery catheter are introduced percutaneously.

15. A system described in any one of claims 9 to 14, wherein the perfusion occurs for a duration of 5 minutes to 5 hours, 15 minutes to 4 hours, 30 minutes to 3 hours, or 1 hour to 2 hours.

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