System for loco-regional perfusion of an unarrested beating heart

Abstract

This invention discloses a method for treating cardiac conditions by perfusing drugs through a patient's beating heart. A closed loop is formed through the patient's coronary arteries and coronary veins using a first drug delivery catheter positioned in the right coronary artery, a second drug delivery catheter positioned in the left coronary artery, a drug recovery catheter positioned in the coronary sinus, and an extracorporeal membrane oxygenation system fluidly coupled to the catheters. Drugs for treating cardiac conditions can be perfused through this closed loop.

Description

[Technical Field]

[0001] This invention relates to the treatment of heart disease, and more specifically, to the local delivery of a therapeutic agent to the heart of a patient. [Previous Technology]

[0002] Despite advances in pharmacology for treating various cardiac conditions such as heart failure, mortality and morbidity remain unacceptably high. Furthermore, some treatments are unsuitable for many patients (e.g., those with advanced heart failure associated with other comorbidities). Alternative approaches, such as gene therapy and cell therapy, are attracting significant attention due to their ability to uniquely and effectively address the underlying pathogenic mechanisms of many heart diseases.

[0003] Nevertheless, delivery-related issues remain, including carrier efficiency, dosage, specificity, and safety. Therefore, further research is needed to achieve highly targeted and uniform delivery methods suitable for treating various cardiac conditions, which are also effective, well-tolerated, and minimally invasive. [Summary of the Invention]

[0004] One object of the present invention is to provide a method for perfusing a drug into a patient’s non-stop beating heart in a minimally invasive manner.

[0005] One object of the present invention is to provide a method for circulating an perfusion fluid (which may contain one or more of blood or drugs) through the patient’s non-stop beating heart so as to separate the perfusion fluid from the patient’s systemic circulation.

[0006] One objective of the present invention is to provide localized delivery of pharmaco-gene therapy.

[0007] One objective of the present invention is to reduce the overall dose of medicine delivered to patients to treat heart conditions.

[0008] One objective of the present invention is to reduce the risk and / or adverse immune response of administering a drug suitable for treating heart conditions.

[0009] One object of the present invention is to allow the re-administration and / or administration of pharmaceutical-gene therapy drugs to patients who have, for example, neutralizing antibodies against gene therapy vectors, otherwise they would not be suitable candidates to receive such drugs.

[0010] One objective of the present invention is to circulate the perfusion fluid through a non-stop beating heart to oxygenate the heart and separate the coronary circulation from the patient’s systemic circulation, so as to allow the introduction of potentially cardiotoxic drugs into the systemic circulation while preventing or reducing the exposure of the drugs to the heart.

[0011] The above and other objectives are achieved by means of the present invention, which in some embodiments relates to a method of perfusing a drug into a patient's non-stop beating heart. In some embodiments, the method includes positioning a first drug delivery catheter in the right coronary artery of the heart. The method further includes positioning a second drug delivery catheter in the left main coronary artery of the heart. The method further includes positioning 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, together with the coronary arteries of the heart, the coronary venous system of the heart, and a membrane oxygenation device, form a closed loop. The method further includes perfusing the drug through the closed loop, the closed loop separating 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 loop for at least 45 minutes. In some embodiments, during the perfusing, the drug is delivered to at least 30% of the heart tissue.

[0012] In some embodiments, the method further includes applying negative pressure at the drug recovery catheter. In some embodiments, the negative pressure is in the range of about -100 mmHg to 0 mmHg.

[0013] In some embodiments, the closed loop may further include one or more suction mechanisms that allow for further negative suction pressure to be applied to the drug recovery catheter to prevent and / or minimize leakage of blood and / or drugs circulating through the Thebesian vein via the closed loop.

[0014] In some embodiments, one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug retrieval catheter are inserted percutaneously. In some embodiments, the first drug delivery catheter and / or the second drug delivery catheter are positioned via antegrade cannulation. In some embodiments, the first drug delivery catheter and / or the second drug delivery catheter are positioned via the patient's aorta, by entering the femoral aorta and / or radial aorta. In some embodiments, the drug retrieval catheter is positioned in the coronary sinus via the patient's vena cava. In some embodiments, the drug retrieval catheter is positioned via the patient's jugular or femoral vein. In some embodiments, the membrane oxygenation device is positioned between the retrieval catheter and one or more of the first and second drug delivery catheters. In some embodiments, one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug retrieval catheter are sealed with a balloon to reduce or prevent leakage.

[0015] In some embodiments, the method further includes circulating blood through the closed loop. In some embodiments, the blood comprises 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. In some embodiments, the one or more parameters include the presence or absence of selected antibodies. 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 are circulated through the closed loop.

[0016] In some embodiments, the perfusion occurs over 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 perfusion occurs for at least 60 minutes. 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.

[0017] 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 heart disease. In some embodiments, the genetically determined heart disease is a genetically determined cardiomyopathy.

[0018] In some embodiments, the medicament 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 papillomavirus, lentiviral vector, vaccinia virus, polyomavirus, Sendai virus, orthomyxovirus, paramyxovirus, polyvesicular virus, microRNA virus, poxvirus, alpha virus, variants thereof, and combinations thereof.

[0019] In some embodiments, the viral vector is adeno-associated virus (AAV). In some embodiments, the AAV is one or more of the following: AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, variants thereof, and combinations thereof.

[0020] In some embodiments, the therapeutic polynucleotide sequence comprises a nucleic acid sequence encoding a protein, antisense RNA, ncRNA, or miRNA for treating a cardiac condition. In some embodiments, the protein corresponds to a gene expressed in the human heart. In some embodiments, the protein is one or more of the following: SERCA2, MyBPC3, MYH7, PKP2, myoglobin, FKRP, or combinations or variants thereof. In some embodiments, the therapeutic polynucleotide sequence comprises a promoter.

[0021] 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 no (0% v / v) leakage out of the closed loop in the blood circulated through the closed loop. 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 no (0% v / v) leakage out of the closed loop in the drug perfused through the closed loop.

[0022] In some embodiments, one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug recovery catheter are balloon catheters.

[0023] The above and other objectives are further satisfied by the present invention. In some embodiments, the present invention relates to a method for maintaining perfusion fluid in a patient's heart via a closed loop, during which the heart does not stop beating. In some embodiments, the method includes positioning a first catheter in the right coronary artery of the heart. In some embodiments, the method further includes positioning a second catheter in the left main coronary artery of the heart. In some embodiments, the method further includes positioning a retrieval catheter in the coronary sinus of the heart. In some embodiments, the first catheter, the second catheter, and the retrieval catheter, together with the coronary arteries, the coronary venous system, and the membrane oxygenation device, form a closed loop through the heart. In some embodiments, the method further includes introducing perfusion fluid into the heart via the first and second catheters and collecting the perfusion fluid via the retrieval catheter, thereby allowing the perfusion fluid to flow through the closed loop. In some embodiments, the closed loop separates the patient's coronary circulation from the patient's systemic circulation.

[0024] In some embodiments, the perfusion is maintained for at least 60 minutes. In some embodiments, the perfusion is maintained for at least 120 minutes.

[0025] In some embodiments, the method further includes applying a negative pressure at the recovery catheter such that the negative pressure is in the range of about -100 mmHg to 0 mmHg.

[0026] In some embodiments, one or more of the first catheter, the second catheter, or the recovery catheter are introduced percutaneously.

[0027] In some embodiments, the membrane oxygenation device is positioned between the recovery catheter and one or more of the first drug delivery catheter and the second drug delivery catheter.

[0028] In some embodiments, the method further includes circulating blood through the closed loop, 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 are circulated through the closed loop.

[0029] 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 no (0% v / v) leakage outside the closed loop in the blood circulating through the closed loop.

[0030] In some embodiments, one or more of the first catheter, the second catheter, or the retrieved catheter are balloon catheters.

[0031] The above and other objectives are further satisfied by the present invention. In some embodiments, the present invention relates to a system for performing localized perfusion within a patient's heart when fluidly coupled to the 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 retrieval catheter adapted for insertion into the coronary sinus of the heart; a membrane oxygenation device fluidly coupled to the first catheter, the second catheter, the retrieval catheter, and an oxygen source; and a pump configured to drive fluid flow through the first and second catheters. In some embodiments, when the first catheter is inserted into the right coronary artery, the second catheter is inserted into the left main coronary artery, and the retrieval catheter is inserted into the coronary sinus, the first catheter, the second catheter, the retrieval catheter, and the membrane oxygenation device together form a closed loop through the heart, separating the heart from the patient's systemic circulation. In some embodiments, at least about 50% of the perfused drug remains in the closed loop for at least 45 minutes.

[0032] The above and other objectives are further satisfied by the present invention. In some embodiments, the present invention relates to a localized perfusion system comprising: 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 retrieval catheter inserted into the coronary sinus of the heart; a membrane oxygenation device fluidly coupled to the first catheter, the second catheter, the retrieval catheter, and an oxygen source; and a pump configured to drive fluid flow through the first and second catheters into the heart and out of the heart via the retrieval catheter. In some embodiments, the first catheter, the second catheter, the retrieval catheter, and the membrane oxygenation device, together with the coronary artery and coronary venous system of the heart, form a closed loop through the heart, thereby separating the heart from the patient's systemic circulation. In some embodiments, at least about 50% of the perfused drug remains in the closed loop for at least 45 minutes.

[0033] In some embodiments, the membrane oxygenation device includes a reservoir configured to inject drugs into the closed loop during perfusion.

[0034] In some embodiments, the pump is configured to generate a negative pressure in the range of about -100 mmHg to 0 mmHg.

[0035] In some embodiments, one or more of the first catheter, the second catheter, or the retrieved catheter are inserted percutaneously. In some embodiments, the first catheter and / or the second catheter are positioned via antegrade cannulation. In some embodiments, the retrieved catheter is positioned in the coronary sinus via the patient's vena cava.

[0036] The above and other objectives are further satisfied by the present invention. In some embodiments, the present invention relates to a method for separating a patient's heart from the patient's systemic circulation, the method comprising: positioning a first catheter in the right coronary artery of the heart; positioning a second catheter in the left main coronary artery of the heart; positioning a retrieval catheter in the coronary sinus of the heart, thereby forming a closed loop together with the coronary arteries, the coronary venous system, and the membrane oxygenation device of the heart; allowing oxygenated blood to flow through the closed loop; and introducing a drug into the patient's systemic circulation. In some embodiments, the closed loop separates the patient's coronary circulation from the patient's systemic circulation. In some embodiments, the drug is a cardiotoxic drug, and the exposure of the heart to the cardiotoxic drug is prevented or reduced compared to administration of the cardiotoxic drug in the absence of the closed loop.

[0037] The above and other objectives are further satisfied by the present invention, and in some embodiments, the present invention relates to a localized irrigation system configured to perform any of the foregoing methods.

Implementation Method

[0075] Cross-reference to related applications

[0076] This application claims 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 hereby incorporated herein by reference in their entirety. Definitions

[0077] Unless the context clearly indicates otherwise, as used herein, the singular forms “a / an” and “the” include a plural reference. Thus, for example, reference to “drug” includes a single drug and a mixture of two or more different drugs; and reference to “viral vector” includes a single viral vector and a mixture of two or more different viral vectors, and so on.

[0078] Furthermore, as used herein, when used in conjunction with the quantity being measured, "about" means the normal variation in the quantity being measured that would be expected by one of ordinary skill in the art to make the measurement and operation commensurate with the target of the measurement and the accuracy of the measuring device at the level of interest. In some embodiments, the term "about" includes the value ±10%, whereby "about 10" would include 9 to 11.

[0079] Furthermore, as used herein, "polynucleotide" has its common and conventional meaning in this art and includes any polymeric nucleic acid, such as DNA or RNA molecules, and chemical derivatives known to those skilled in the art. Polynucleotides include not only polynucleotides encoding therapeutic proteins, but also sequences (e.g., antisense, interfering, or small interfering nucleic acids) that can be used to reduce the expression of target nucleic acid sequences using techniques known in this art. Polynucleotides can also be used to initiate or increase the expression of target nucleic acid sequences or the production of target proteins within the cells of the cardiovascular system. Target nucleic acids and proteins include, but are not limited to, nucleic acids and proteins commonly found in target tissues, derivatives of such naturally occurring nucleic acids or proteins, naturally occurring nucleic acids or proteins not commonly found in target tissues, or synthetic nucleic acids or proteins. One or more polynucleotides may be used in combination, simultaneously and / or sequentially, to increase and / or decrease one or more target nucleic acid sequences or proteins.

[0080] Furthermore, as used herein, "perfusion / perfused / perfusing" has its common and conventional meaning in this art and refers to an administration of a duration substantially longer than the technically accepted terms "injection" or "pump injection" (usually less than one minute) (usually one minute or longer). The flow rate of the perfusion will depend at least in part on the volume administered.

[0081] Also, as used herein, “exogenous” nucleic acid or nucleic acid whose gene lineage is not naturally present in the vector used for nucleic acid transfer; for example, nucleic acid that is not naturally present in viral vectors, but the term is not intended to exclude nucleic acids encoding proteins or polypeptides that are naturally present in patients or hosts.

[0082] Furthermore, as used herein, "cardiac cell" includes any cardiac cell involved in maintaining structure or providing cardiac function, such as cardiomyocytes, cells of the cardiac vascular structure, or cells present in the heart valves. Cardiac cells include cardiomyocytes (with both normal and abnormal electrical properties), epithelial cells, endothelial cells, fibroblasts, cells of conduction tissue, cardiac pacemakers, and neurons.

[0083] Furthermore, as used herein, “separation,” “substantially separated,” “largely separated,” and variations thereof are terms that do not require complete or absolute separation of the coronary veins, heart, systemic meridians, or systemic circulation; in fact, they are intended to mean that most, preferably the main, or even substantially all of the specified circulation has been separated. Also, as used herein, “partially separated” means that any significant portion of the specified circulation has been separated.

[0084] Furthermore, as used herein, "non-natural limitation" includes any method that restricts fluid flow through a blood vessel, such as balloon catheters, sutures, etc., but does not include naturally occurring limitations, such as plaque buildup (stenosis). Non-natural limitation includes, for example, substantial or complete separation of the coronary circulation.

[0085] Furthermore, as used herein, "minimally invasive" is intended to include any procedure that does not require opening the heart or surgical access to blood vessels closely connected to the heart. Such procedures include those using endoscopic access to the heart and those using catheter-based methods that rely on access via large arteries and veins.

[0086] Furthermore, as used herein, "adeno-associated virus" or "AAV" encompasses all subtypes, serotypes, and pseudotypes, as well as naturally occurring and recombinant forms. Various AAV serotypes and viral strains are known in this art and are publicly available from various sources, such as the ATCC, and academic or commercial sources. Alternatively, sequences from AAV serotypes and viral strains publicly available and / or obtained from various databases can be synthesized using known techniques.

[0087] Furthermore, as used herein, "serotype" refers to an AAV that is identified and distinguished from other AAVs based on capsid proteins that are reactive to a known antiserum. There are at least twelve known serotypes of human AAVs, including AAV1 to AAV12, but other serotypes are constantly being discovered and the use of newly discovered serotypes is being considered.

[0088] Furthermore, as used herein, "pseudotyped" AAV refers to an AAV containing a capsid protein and viral genome derived from a serotype, the viral genome including 5' and 3' inverted terminal repeats (ITRs) of different or heterologous serotypes. It is anticipated that pseudotyped recombinant AAV (rAAV) will possess the cell surface binding characteristics of the capsid serotype and genetic characteristics consistent with the ITR serotype. Pseudotyped rAAV may contain AAV capsid proteins, including VP1, VP2, and VP3 capsid proteins; and ITRs derived from any serotype AAV, including ITRs from any primate AAV serotype from AAV1 to AAV12, provided that the capsid protein is heterologous to the ITR serotype. In pseudotyped rAAV, the 5' and 3' ITRs may be identical or heterologous. Pseudotyped rAAV is produced using the standard techniques described herein.

[0089] Furthermore, as used herein, "chimeric" rAAV vectors encompass AAV vectors containing heterologous capsid proteins; that is, rAAV vectors may be chimeric with respect to their capsid proteins VP1, VP2, and VP3, such that VP1, VP2, and VP3 are not all of the same serotype of AAV. As used herein, chimeric AAV encompasses AAVs in which the capsid proteins VP1, VP2, and VP3 differ in serotype, including, for example, but not limited to, capsid proteins derived from AAV1 and AAV2; mixtures of other parvovirus capsid proteins; or containing other viral proteins or other proteins, such as proteins that target AAV delivery to desired cells or tissues. As used herein, chimeric rAAV also encompasses rAAVs containing chimeric 5' and 3' ITRs.

[0090] Furthermore, as used herein, "pharmaceutical-acceptable excipients or carriers" means any inert component in a composition combined with an active agent in a formulation. Pharmaceutical-acceptable excipients may include, but are not limited to, carbohydrates (such as glucose, sucrose, or polydextrose), antioxidants (such as ascorbic acid or glutathione), chelating agents, low molecular weight proteins, high molecular weight polymers, gelling agents, or other stabilizers and additives. Examples of other pharmaceutically acceptable carriers include wetting agents, emulsifiers, dispersants, or preservatives particularly suitable for preventing microbial growth or action. Various preservatives are well known and include, for example, phenol and ascorbic acid. Examples of carriers, stabilizers, or adjuvants can be found in Remington's Pharmaceutical Sciences, Mack Publishing Company, Philadelphia, Pa., 17th edition (1985).

[0091] Furthermore, as used herein, “patient” means an individual who presents with one or more specific symptoms that suggest a need for treatment, who is undergoing preventative treatment for a condition, or who has been diagnosed with a condition requiring treatment, particularly a human being (but may also include non-humans).

[0092] Furthermore, as used herein, “individual” encompasses the definition of the term “patient” and does not exclude individuals who are otherwise healthy.

[0093] Furthermore, as used herein, “treatment of / treating” includes administering medication in an effort to reduce the severity of a condition, such as heart disease, or to prevent a condition, such as heart disease.

[0094] Furthermore, as used herein, "prevention of / preventing" includes avoiding conditions such as heart disease.

[0095] Furthermore, as used herein, "condition" refers to a medical condition that can be treated, alleviated, or prevented by administering an effective dose of medication to an individual, such as heart disease.

[0096] Furthermore, as used herein, "effective amount" means an amount of drug sufficient to produce an effect that can be easily detected by methods commonly used to detect beneficial or desired effects. In some embodiments, such an effect causes a change of at least 10% relative to a baseline level without drug administration. In other embodiments, this change is at least 20%, 50%, 80%, or even higher percentages relative to the baseline level. As will be described below, the effective amount of drug can vary from person to person depending on the individual's age, general condition, severity of the condition being treated, the specific drug administered, and similar factors. In any individual case, the appropriate "effective" amount can be determined by a person generally skilled in the art by referring to relevant texts and literature and / or by using conventional experiments.

[0097] Furthermore, as used herein, "active agent" means any substance that is expected to produce a therapeutic, preventive or other expected effect, whether or not it has been approved by a government agency for such purpose.

[0098] Unless otherwise indicated herein, the description of ranges of values ​​herein is intended only as a shorthand for individually referring to each individual value within that range, and each individual value is incorporated into this specification as if individually described herein. Unless otherwise indicated herein or clearly contradicted by the context, all methods described herein may be performed in any suitable order. The use of any and all examples or illustrative language (such as "such as") provided herein is intended only to describe certain substances and methods and does not limit the scope. The language of this specification should not be construed as indicating that any non-claimed element is essential to the practice of the disclosed substances and methods.

[0099] This invention relates to a method for treating a cardiac condition in a minimally invasive manner. The method may include separating a patient's coronary circulation from the patient's systemic circulation and perfusing fluid, such as a drug-containing fluid, into the separated or substantially separated coronary circulation. Perfusing may be performed in the patient's beating heart. These methods may also be used to separate a patient's cardiac circulation to allow the administration of, for example, a drug (or any composition potentially harmful to the patient's heart) to the patient's systemic circulation in order to protect the heart from adverse effects. The separation of a patient's coronary circulation will be described in more detail below with reference to Figures 1A and 1B.

[0100] The coronary circulation supplies blood to the heart tissue. There are multiple coronary arteries. Normally, four main coronary arteries deliver oxygenated blood to the heart for distribution throughout the heart tissue: the left main coronary artery and right coronary artery, the left anterior descending artery and the left circumflex artery. Deoxygenated blood flows through the coronary sinuses.

[0101] The embodiments disclosed herein cover the separation or substantial separation of a patient's coronary circulation from the patient's systemic circulation by forming a closed loop comprising (consisting of or substantially comprising of): a first drug delivery catheter, a second drug delivery catheter, a drug recovery catheter, coronary arteries, a coronary venous system, and an extracorporeal membrane oxygenator. In some embodiments, this disclosure further covers the perfusion of a drug suitable for treating a cardiac condition into the myocardium using the closed loop described above, while substantially separating the patient's coronary circulation from the patient's systemic circulation. In some embodiments, the method disclosed herein delivers the drug to the entire myocardium, in contrast to delivery to a separated area within the heart. Drugs delivered to the myocardium using the method disclosed herein can be uniformly distributed throughout the heart.

[0102] When treating cardiac conditions, separating a patient's coronary circulation from their systemic circulation has many advantages. These advantages include, but are not limited to: (1) localized drug delivery, minimal drug leakage to other organs, and a reduced overall drug dose; (2) increased target drug dose; (3) reduced risks and side effects; and (4) the possibility of re-administering to selected patients or to patient populations that are not suitable candidates for certain therapies (such as gene therapy using viral vectors for patients with antibodies against such viral vectors). Illustrative Catheter Examples

[0103] Exemplary retrieval catheters and perfusion catheters are now described. Those skilled in the art will understand that these catheters can be configured for the anatomy of any target organ (e.g., the heart) to which LRP is to be performed. Furthermore, 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 also be used to separate cardiac circulation from systemic circulation, for example, to reduce or prevent cardiac exposure to drugs or other agents introduced into the systemic circulation that may have harmful effects on the heart. Those skilled in the art will understand other uses of the catheter embodiments described herein, such as in applications where it is desirable to seal blood vessels.

[0104] Embodiments of exemplary catheters used as retrieval catheters in LRP systems are now described. In at least one embodiment, the retrieval catheter is designed to support fluid aspiration flow rates of about 400 mL / min or higher (e.g., about 700 mL / min or higher). For example, in some embodiments, the exemplary catheter can support an in vitro aspiration flow rate of about 800 mL / min at about -80 mmHg.

[0105] Certain embodiments of the retrieval catheter are advantageous for use in the return line of an LRP system, which, when inserted into the coronary sinus, forms a closed loop within a beating heart. The catheter described herein may be designed to meet the following criteria: capable of accessing the coronary sinus via the right internal jugular vein; compatible with guide sheaths of 24 Fr or less; compatible with guidewires of 0.035 inches or less; capable of accessing, sealing, and occluding coronary sinuses of 6 to 20 mm in diameter in human individuals or up to 30 mm in diameter in porcine animal models; capable of avoiding occlusion of important lateral veins (e.g., the central cardiac vein); and capable of maintaining stable positioning for at least 60 minutes during the LRP procedure.

[0106] Figures 1 through 10 depict various catheter embodiments suitable for fluid recovery in an LRP system. Any of the catheters depicted in Figures 1 through 10 can be configured to support fluid flow rates (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 is compatible with a controllable guide sheath that provides stability and guides the distal end of the catheter and allows the catheter to generate directional thrust. Each catheter may also have a traction line integrated into its shaft assembly to allow bending at an angle of up to 120° in the proximal segment of the occlusion structure and to achieve better tracking and centering of the occlusion structure.

[0107] In some embodiments, one or more catheters may be multi-lumen catheters, such as dual-lumen catheters. In some embodiments, such multi-lumen catheters allow fluid flow (e.g., perfusion fluid) and are capable of inflating one or more balloons. In some embodiments, one or more catheters may be multi-balloon catheters having two or more balloons. In some embodiments, one or more balloons may deploy or depress independently.

[0108] Figure 1 illustrates an exemplary catheter 100 having lumen shafts 104 / 106, the catheter having a proximal end 101 and a distal end 102. Lumen shafts 104 / 106 may be formed from an outer lumen shaft 104 that at least partially surrounds an inner lumen shaft 106, exposing the 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 may be formed from a durable polymeric material, such as a polyether block amide (PEBA) material (e.g., commercially available from 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 fluid flow path. In at least one embodiment, the catheter 100 may be designed to include an additional lumen shaft.

[0109] The catheter 100 includes a tip portion 108 at a distal end 102 and an expandable balloon structure 110 disposed along a portion 112 of an internal lumen axis 106. In at least one embodiment, the tip portion 108 includes an elongated axis extending from the balloon structure 110 to the distal end 102. In at least one embodiment, the length of the elongated axis of the tip portion is about 2 mm to about 35 mm, about 5 mm to about 30 mm, about 10 mm to about 25 mm, about 15 mm to 25 mm, or any subrange defined therebetween (e.g., about 2 mm to about 5 mm). In at least one embodiment, the tip portion 108 includes an opening at the distal end 102 and one or more perforations along the elongated axis. In at least one embodiment, the tip portion is formed of a flexible material that is more flexible than the material of the internal lumen axis 106.

[0110] In at least one embodiment, the internal lumen shaft 106 includes a concentric internal flow path around the liquid flow path. This concentric internal flow path provides a path for gas to flow from the balloon structure 110 to the orifice 114, which can be used to inflate or deflate the balloon depending on the pressure applied at the orifice 114. In at least one embodiment, the outermost surface of the internal lumen shaft 106 at a portion 112 is removed such that the portion 112 is sealed by the balloon structure 110 to isolate gas flow from the concentric internal flow path to the balloon structure 110. In at least one embodiment, the expansion 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.

[0111] Figure 2 is an image of a catheter with a balloon in an deployed state, similar in structure to catheter 100. The catheter dimensions include: a cross-sectional diameter of 19 Fr (6.3 mm); an innermost diameter of 12 Fr (4.0 mm); a usable length of 80 cm; a balloon diameter of 25 mm (when deployed); and a tip length of 20 mm. The lumen axis may be formed from a polymer material such as PEBAX® 63, supported by a strong stainless steel braid. The balloon may be formed from a flexible thermoplastic / elastic material such as ChronoPrene™ 25A. The tip may be formed from a polymer material such as PEBAX® 35 and may be loaded with a radiolabeled material or a radiopaque filler composition such as BaSO4.

[0112] Figure 3 illustrates, according to at least one embodiment, the insertion of an exemplary catheter 300 into the coronary sinus 352 via the right atrium 350. The catheter 300 may be identical or similar to catheter 100, having a proximal end 301, a distal end 302, an internal lumen axis 304, an external lumen axis 306, a tip portion 308, and a balloon structure 310 positioned on a portion 312 of the internal lumen axis 304. When deployed, the balloon structure 310 is sufficiently flexible 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 exerting excessive force on the tissue. As shown in Figure 3, the catheter 300 is inserted across the central cardiac vein (mollusc virus) 354 to prevent flow occlusion from the MCV 354 into the atrium 350.

[0113] Figures 4 to 10 illustrate other occlusion techniques according to various embodiments of the present invention. The catheters depicted in Figures 4 to 10 may be similar to the catheters depicted in Figures 1 to 3 in some aspects, such as size, material or structure.

[0114] Figure 4 illustrates a catheter 400 according to at least one embodiment, which is partially inserted into the coronary sinus 352 such that it is adjacent to the foramen of the coronary sinus 352. The catheter 400 includes a proximal end 401, a distal end 402, an internal lumen axis 404, an external lumen axis 406, a tip portion 408, and a balloon structure 410 disposed on a portion 412 of the internal lumen axis 404. In at least one embodiment, when deployed, the diameter of the balloon structure 410 is greater than about 15 mm, greater than about 20 mm, greater than about 25 mm, or greater than about 30 mm. The tip portion 408 may include one or more perforations in addition to the opening at the distal end 402 to allow blood to flow from the coronary sinus 352 and the MCV 354 into the catheter 400.

[0115] In at least one embodiment, during deployment, the outer lumen axis 406 may be moved distally to abut the deployed balloon structure 410, such that the balloon structure 410 exerts additional pressure on the orifice of the coronary sinus 352 to further stabilize the position of the catheter 400. In at least another embodiment, pressure may be applied to the balloon structure 410 using a linear structure. The linear structure may, for example, have a sinusoidal shape and may be arranged as an expanding flower-like structure extending radially from the outer lumen axis 406 or the inner lumen axis 404. When in contact with the balloon structure 410, the linear structure may generate a more uniform pressure distribution across the entire surface of the balloon structure 410. Prior to deployment, the linear structure may be covered by the outer lumen axis 406 or by an additional lumen beyond the outer lumen axis 406.

[0116] Figure 5 illustrates, according to at least one embodiment, the use of a first catheter 500 and a second catheter 550 to individually occlude and empty the coronary sinus 352 and the MCV 354, respectively. The first catheter 500 includes a proximal end 501, a distal end 502, a luminal axis 504, a tip portion 508, and a balloon structure 510 positioned on a portion 512 of the luminal axis 504. Similarly, the second catheter 550 includes a proximal end 551, a distal end 552, a luminal axis 554, a tip portion 558, and a balloon structure 560 positioned on a portion 562 of the luminal axis 554. In this configuration, the first catheter 500 is inserted into the coronary sinus 352 such that the balloon structure 510 does not occlude the MCV 354, while the second catheter 550 is directly inserted into the MCV 354. The selected sizes of the first catheter 500 and the second catheter 550 provide safe and effective occlusion of the coronary sinus 352 and the MCV 354, respectively.

[0117] Figure 6 shows a variation of Figure 5, which uses two catheters, only one of which has a balloon structure according to at least one embodiment. The first catheter 600 includes a proximal end 601, a distal end 602, a luminal axis 604, a tip portion 608, and a balloon structure 610 positioned on a portion 612 of the luminal axis 604. The second catheter 650 includes a proximal end 651, a distal end 652, a luminal axis 654, and a tip portion 658, but does not include the balloon structure. The first catheter 600 is inserted into the coronary sinus 352 such that a portion of the balloon 610 partially occludes the MCV 354 and partially within the atrium 350 and the coronary sinus 352. The second catheter 650 is inserted directly into the MCV 354 and positioned between the vessel wall and the balloon 610, at least partially occluding the MCV 354.

[0118] Figure 7 illustrates the use of a single catheter 700 according to at least one embodiment, the catheter including multiple balloons. The catheter 700 includes a proximal end 701, a distal end 702, a lumen axis 704, a tip portion 708, a first balloon structure 710 disposed on a first portion 712 of the lumen axis 704, and a second balloon structure 720 disposed on a second portion 722 of the lumen axis 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 orifice of the coronary sinus 352 to occlude the MCV 354 (and further occlude the coronary sinus 352). The intermediate portion 724 of the lumen axis 704 between the first balloon structure 710 and the second balloon structure 720 includes one or more perforations allowing the MCV 354 to drain. In at least one embodiment, the expansion diameter of the second balloon structure 720 is larger than the expansion diameter of the first balloon structure 710. In at least one embodiment, the catheter 700 is designed as a multi-lumen catheter that allows each balloon to expand and contract independently of the others.

[0119] FIG8 illustrates a catheter 800 according to at least one embodiment, the catheter including a partially covered and retractable stent structure 810. 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 in cross-section to show the inner lumen shaft 804 therein. The stent structure 810 is depicted in its deployed state, but may be contained within the outer lumen shaft 806 before deployment. The stent structure 810 is further depicted having a proximal covered portion 810A and a distal uncovered portion 810B that can be formed of a flexible and durable polymer material. When inserted into the coronary sinus 352, as shown, the covered portion 810A blocks the 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 from the coronary sinus 352 and MCV 354 to flow directly into the catheter 800. In at least one embodiment, the catheter 800 can be used as an irrigation catheter connected to a supply line.

[0120] Figure 9 illustrates a catheter 900 according to at least one embodiment, which includes a deployable and retractable stent structure 920. The catheter 900 further includes a proximal end 901, a distal end 902, a lumen shaft 906, a tip portion 908, and a balloon structure 910 disposed on a portion 912 of the lumen shaft 906. The catheter 900 may further include an external lumen shaft (not shown) that substantially encloses the stent structure 920 and the balloon structure 910 before deployment. Deployment of the stent structure 920 may be performed by moving the external lumen shaft in a proximal direction, and retraction of the stent structure 920 may be performed by moving the external lumen shaft in a distal direction. The stent structure 920 may be formed of, for example, stainless steel and disposed between the balloon structure 910 and the tip portion 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 MCV 354 to drain into the catheter 900. When inserted into the coronary sinus 352, the balloon structure 910 is adjacent to the opening of the coronary sinus 352.

[0121] FIG10 illustrates a catheter 1000 according to at least one embodiment, which includes a covered disc-shaped stent structure 1010. The catheter 1000 further includes a proximal end 1001, a distal end 1002, an external lumen shaft 1006, an internal lumen shaft 1004, and a tip portion 1008. The stent structure 1010 may be formed of, for example, a stainless steel stent with a durable polymer cover. The external lumen shaft 1006 may cover the stent structure before the stent structure 1010 is deployed. After the catheter 1000 is properly positioned, the external lumen shaft 1006 can be moved in the proximal direction to deploy the stent structure 1010. In at least one embodiment, the stent structure 1010 is coupled to the tip portion 1008, which may be partially contained within the internal lumen shaft 1004, and may be actuable (using a wire) to deploy the stent structure 1010 when moved in the proximal direction and to retract the stent structure 1010 when moved in the distal direction. In at least one embodiment, the stent structure 1010 is large enough when deployed to occlude the coronary sinus 352 and the MCV 354 when adjacent to the orifice of the coronary sinus 352. In at least one embodiment, the diameter of the stent structure 1010 is from about 10 mm to about 30 mm.

[0122] Examples of exemplary catheters used as perfusion catheters in LRP systems are now described. In at least one embodiment, the perfusion catheter is designed to support a fluid perfusion flow rate of about 400 mL / min or higher (e.g., about 700 mL / min or higher). In 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), it can support a combined flow capacity of 700 mL / min or higher.

[0123] Certain embodiments of the retrieval catheter are advantageous for use in the supply line of an LRP system, which, when inserted into the coronary artery, forms a closed circuit within the beating heart. The catheter described herein may be designed to meet the following criteria: capability to access the coronary artery via the femoral artery; coronary artery inlet diameter of 8 Fr or less; occlusion diameter of approximately 6 mm to approximately 8 mm; compatibility with a 0.018-inch guidewire and a 0.014-inch pressure wire; and the ability to maintain stable positioning for at least 60 minutes during an LRP procedure.

[0124] Figures 11 to 16 depict various catheter embodiments suitable for fluid perfusion in an LRP system. Any of the catheters depicted in Figures 11 to 16 can be configured to support fluid flow rates (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 with a smooth profile from the proximal catheter body to the lower distal end, for example, by using one or more concentric lumen axes.

[0125] In some embodiments, one or more catheters may be multi-lumen catheters, such as dual-lumen catheters. In some embodiments, such multi-lumen catheters allow fluid flow (e.g., perfusion fluid) and are capable of inflating one or more balloons. In some embodiments, one or more catheters may be multi-balloon catheters having two or more balloons. In some embodiments, one or more balloons may deploy or depress independently.

[0126] Figures 11A to 11C illustrate an exemplary catheter 1100 having a lumen shaft 1104 / 1106, the catheter having a proximal end 1101 and a distal end 1102, the distal end having an opening from which irrigation fluid can flow out. The lumen shaft 1104 / 1106 may be formed of an external lumen shaft 1104 that at least partially surrounds an internal lumen shaft 1106, exposing the distal portion of the internal 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 external lumen shaft 1104 or the internal lumen shaft 1106 may be formed of a durable polymer material, such as a polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the inner cavity 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.

[0127] The catheter 1100 includes an expandable balloon structure 1110 disposed along a portion 1112 corresponding to an internal lumen axis 1106 and a tip portion formed by an additional lumen. In at least one embodiment, the internal lumen axis 1106 includes a concentric internal flow path around a liquid flow path. This concentric internal flow path provides a path for gas to flow from the balloon structure 1110 to an orifice 1114, which can be used to inflate or deflate the balloon structure 1110 depending on the pressure applied at the orifice 1114. In at least one embodiment, the outermost surface of the internal lumen axis 1106 at the portion 1112 is removed such that the portion 1112 is sealed by the balloon structure 1110 to isolate gas flow from the concentric internal flow path to the balloon structure 1110. In at least one embodiment, the expansion 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, about 25 mm to about 30 mm, or any sub-range defined therebetween (e.g., about 20 mm to about 28 mm). Figures 11B and 11C illustrate the balloon structure 1110 in its expanded and contracted states.

[0128] Figure 11D illustrates the arrangement of a catheter 1100 in an aorta 1150 according to at least one embodiment. As shown, the catheter 1100 is pre-formed for insertion into the aorta 1150 for navigation. Additionally, this shape can utilize the backflow force from the aortic wall to further enhance stability during coronary artery occlusion and perfusion.

[0129] Figures 12 and 13 respectively show catheters including plug and wedge occlusion structures, which are advantageously shaped to fit blood vessels or orifices, formed of highly compressible and non-invasive materials for safe insertion and placement, have a shorter length than balloon structures, and do not require additional lumen expansion as balloon structures typically do.

[0130] Figures 12A to 12C illustrate an exemplary catheter 1200 having a lumen shaft 1204 / 1206, the catheter having a proximal end 1201 and a distal end 1202, the distal end having an opening from which irrigation fluid can flow out. The lumen shaft 1204 / 1206 may be formed of an outer lumen shaft 1204 that at least partially surrounds an inner lumen shaft 1206, exposing the 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 the inner lumen shaft 1206 may be formed of a durable polymer material, such as a polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the inner cavity 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.

[0131] The catheter 1200 further includes a plug 1210 proximate to the distal end 1202. In at least one embodiment, the plug 1210 is formed of a flexible material, such as polysiloxane or foam. In at least one embodiment, the plug 1210 includes an inner portion 1210A that fits onto an inner lumen shaft 1206 and a flexible outer portion 1210B shaped to be configured between a retracted state (FIG. 12A) and an extended state (FIG. 12C), in which the extended state, the outer portion 1210B extends distally from the distal end 1202. The plug 1210 in FIG. 12A is shown tapering in the distal direction. In at least one embodiment, the plug 1210 may be reversed to tapering in the proximal direction. In at least one embodiment, the outer lumen shaft 1204 may be configured to cover the plug before the plug 1210 is deployed.

[0132] Figure 12D illustrates the arrangement of a catheter 1200 in an aorta 1150 according to at least one embodiment. The pressure of arterial blood flow flowing into the hollow space between the inner portion 1210A and the outer portion 1210B of the plug 1210 helps improve the seal of the coronary catheter 1200. As shown, the catheter 1200 is pre-formed for insertion into the aorta 1150 for navigation. In addition, this shape can utilize the backflow force from the aortic wall to further enhance stability during coronary artery occlusion and perfusion.

[0133] Figures 13A to 13C illustrate an exemplary catheter 1300 having a lumen shaft 1304 / 1306, the catheter having a proximal end 1301 and a distal end 1302, the distal end having an opening from which irrigation fluid can flow out. The lumen shaft 1304 / 1306 may be formed of an outer lumen shaft 1304 that at least partially surrounds an inner lumen shaft 1306, exposing the 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 the inner lumen shaft 1306 may be formed of a durable polymer material, such as a polyether block amide (PEBA) material (e.g., commercially available PEBAX®). In at least one embodiment, the innermost diameter of the inner cavity 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.

[0134] The catheter 1300 further includes a wedge 1310 proximal to the distal end 1302, which can be shaped to fit a blood vessel or orifice. In at least one embodiment, the wedge 1310 is formed of a flexible material, such as polysiloxane or foam. In at least one embodiment, an external lumen shaft 1304 can be configured to cover the wedge before the wedge 1310 unfolds.

[0135] Figure 13D illustrates the arrangement of a catheter 1300 in an aorta 1150 according to at least one embodiment. As shown, the catheter 1300 is pre-formed for insertion into the aorta 1150 for navigation. Additionally, this shape can utilize the backflow force from the aortic wall to further enhance stability during coronary artery occlusion and perfusion.

[0136] Figures 14A to 14C illustrate an exemplary catheter 1400 according to at least one embodiment, similar to the catheter 800 described with respect to Figure 8, which includes a partially covered and retractable stent structure 1406. The catheter 1400 is shown inserted into a coronary artery 1452 via the aorta 1450. In some embodiments, the catheter 1400 includes an external lumen shaft 1402 and an internal lumen shaft 1404 coupled to the stent structure 1406. The stent structure 1406 is further depicted having a proximal covered portion and a distal uncovered portion that can be formed of a flexible and durable polymer material. Figures 14B and 14C illustrate the placement and deployment of the stent structure 1406 when inserted into the coronary artery 1452, respectively. Deployment of the stent structure 1406 is performed by moving the external lumen shaft 1402 in the proximal direction.

[0137] Figures 15A and 15B illustrate an exemplary catheter 1500 according to at least one embodiment, which includes a detachable covered braided disc 1510. 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 catheter 1500 placement and can be deployed by moving the outer lumen shaft 1506 in a proximal direction. In some embodiments, when deployed, the braided disc 1510 does not expand beyond the distal end 1502 and serves to stabilize the catheter 1500 against the orifice of the coronary artery 1452 to reduce the risk of stenosis during coronary artery 1452 occlusion, while extending the distal end 1502 into the coronary artery 1452.

[0138] Figures 16A to 16D illustrate an exemplary catheter 1600 having a lumen shaft 1606, the catheter having a proximal end 1601 and a distal end 1602, the distal end having an opening from which irrigation fluid can flow out. The proximal end 1601 includes an outlet structure that can be fluidly coupled to an LRP system. The lumen shaft 1606 may be formed of a durable polymer material, such as a polyether block amide (PEBA) material (e.g., commercially available from 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 fluid flow path. In at least one embodiment, the proximal portion 1606A of the lumen shaft 1606 may have a larger diameter than the distal portion 1606B of the lumen shaft 1606, and may taper gradually along the length of the lumen shaft 1606.

[0139] Figure 16C illustrates the arrangement of a catheter 1600 in an aorta 1150 according to at least one embodiment. As shown, the catheter 1600 is pre-formed for insertion into the aorta 1150 for navigation. Additionally, this shape can utilize the backflow force from the aortic wall to further enhance stability during coronary artery occlusion and perfusion. Besides the catheter 1600, other catheters described herein can be designed with a lumen axis pre-formed according to the anatomy of the LRP procedure to be performed, which improves overall stability during use. An example of a pre-formed catheter lumen is shown in Figure 17. Illustrative LRP System Embodiment

[0140] FIG18A depicts an exemplary localized regional perfusion (LRP) system 1800 according to an embodiment of the present invention. The LRP system 1800 is shown in a closed-loop configuration with the heart 1810 (both front view 1810A and rear view 1810B are shown for clarity). The LRP system 1800 includes a membrane oxygenation device 1820, a blood gas analyzer (BGA) monitor 1830, and a pressure monitor 1840. The LRP system 1800 can be assembled by positioning a first catheter 1822 in the right coronary artery 1812 of the heart 1810, positioning a second catheter 1824 in the left main coronary artery 1814 of the heart 1810, and positioning a retrieval catheter 1826 in the coronary sinus 1816 of the heart. The first catheter 1822, the second catheter 1824, and the retrieval catheter 1826, together with the coronary arteries, the coronary venous system, the membrane oxygenation device 1820, and one or more additional components as needed, form a closed circuit. This closed circuit can separate or substantially separate the patient's coronary circulation from the patient's systemic circulation.

[0141] The first catheter 1822, the second catheter 1824, and the retrieval catheter 1826 can be introduced percutaneously in a minimally invasive manner. In some embodiments, the first catheter 1822 and / or the second catheter 1824 can be introduced via antegrade cannulation. In other embodiments, the first catheter 1822 and / or the second catheter 1824 can be introduced via retrograde cannulation. When using catheters to deliver drugs to the heart, the first catheter 1822 and the second catheter 1824 may be referred to herein as "drug delivery catheters" and the retrieval catheter 1826 may be referred to herein as "drug collection catheters" or "drug retrieval catheters".

[0142] The first catheter 1822 and / or the second catheter 1824 may be standard infusion catheters, which may include a standard guidewire and infusion pump, if applicable. Each catheter is capable of delivering perfusion fluid to the heart 1810, which may contain, for example, a drug to be delivered to the heart 1810 during localized perfusion. In some embodiments, the first catheter 1822 and the second catheter 1824 may each correspond to an exemplary perfusion catheter embodiment described in the following illustrative examples.

[0143] The first catheter 1822 and / or the second catheter 1824 may be located via the patient's aorta, for example, by entering the femoral aorta and / or the radial aorta. In one embodiment, the first catheter 1822 may be located via the patient's aorta by entering the femoral aorta. In another embodiment, the first catheter 1822 may be located via the patient's aorta by entering the radial aorta. In one embodiment, the second catheter 1824 may be located via the patient's aorta by entering the femoral aorta. In another embodiment, the second catheter 1824 may be located via the patient's aorta by entering the radial aorta.

[0144] The retrieval catheter 1826 may be a balloon catheter, such that the balloon can inflate within the coronary sinus 1816 to ensure that all blood circulating through the closed loop flows through the retrieval catheter 1826. Those skilled in the art will understand that the balloon catheter may be a Fogarty® catheter, or any other catheter suitable for the intended purposes discussed herein. In some embodiments, the retrieval catheter 1826 corresponds to an exemplary retrieval catheter embodiment described in the following illustrative examples. In some embodiments, the retrieval catheter 1826 may be located via the patient's vena cava. In one embodiment, the retrieval catheter 1826 may be located via the patient's jugular vein. In another embodiment, the retrieval catheter 1826 may be located via the patient's femoral vein. In some embodiments, the first catheter 1822, the second catheter 1824, the retrieval catheter 1826, or a combination thereof may each be a balloon catheter to help reduce leakage. In some embodiments, any of these catheters may be selected from one or more of the catheters discussed with respect to Figures 1 through 17.

[0145] The LRP system 1800 may further include one or more additional components, such as, but not limited to, one or more pumps, one or more aspiration mechanisms, one or more perfusion fluids, and combinations thereof. For example, the LRP system 1800 is depicted as including a pressure monitor 1840, which in some embodiments is operatively coupled to or is part of a membrane oxygenation device 1820. The pressure monitor 1840 can be used to control the perfusion rate (i.e., flow rate) and ensure safety by continuously monitoring coronary artery pressure. A first pressure sensor 1842 and a second pressure sensor 1844 may, for example, be co-inserted with a first catheter 1822 and a second catheter 1824, respectively, to measure the pressure in the right coronary artery and the left main coronary artery, respectively. The LRP system 1800 is further described as including a BGA monitor operatively coupled to the membrane oxygenation device 1820 to measure, for example, the gas concentration in the perfusion fluid (e.g., when the perfusion fluid contains blood) before perfusion via the first catheter 1822 and the second catheter 1824 and / or after collection of the perfusion fluid via the recovery catheter 1826. The membrane oxygenation device 1820 and one or more additional components may be disposed between the recovery catheter 1826 and one or more of the first catheter 1822 or the second catheter 1824.

[0146] In some embodiments, one or more drugs may be perfused via the patient's systemic circulation during the establishment of a closed loop. For example, if a drug is cardiotoxic or potentially harmful to the heart but requires systemic delivery, establishing a closed loop to separate coronary perfusion from systemic perfusion can help prevent or reduce drug exposure to the heart. In such embodiments, a membrane oxygenation device 1820 can be used to perfuse the coronary circulation at physiological oxygenation levels while simultaneously separating it from systemic circulation. For example, anthracycline chemotherapy formulations (e.g., doxorubicin) used to treat breast cancer can cause irreversible damage to the cardiac microcirculation, leading to anthracycline-cardiomyopathy.

[0147] Figure 18B is a schematic diagram of a membrane oxygenation device 1820, which can be used to oxygenate perfusion fluid, mix the perfusion fluid with other components (e.g., drugs), remove carbon dioxide from the perfusion fluid, and / or push the perfusion fluid 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 oxygenation device 1820 can be any commercially available extracorporeal membrane oxygenation (ECMO) device that exchanges carbon dioxide contained in the blood with oxygen.

[0148] As shown in FIG18B, the membrane oxygenation device 1820 includes various components, including a heat exchanger 1856 (through which the perfusion fluid passes before exiting the outlet 1852 and entering the first conduit 1822 and the second conduit 1824), a delivery pump 1858, a reservoir 1860 (for adding components such as blood and / or drugs to the perfusion fluid returned via the inlet 1854 and the recovery conduit 1826), sensors 1862 and 1864 at various stages of the closed loop (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-enriched gas. The oxygen-enriched gas may be supplied by a gas mixer 1868, which can mix oxygen with carbon dioxide and nitrogen in various ratios and is regulated by a gas regulator 1870.

[0149] The perfusion fluid may contain one or more types of blood (or components thereof, such as plasma or serum) and / or medications suitable for treating cardiac conditions and / or mediators such as saline or dextran solution. The 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 may be directly administered into the first catheter 1822 and / or the second catheter 1824 with or without the delivery pump 1858.

[0150] A negative suction pressure may be applied to the retrieval catheter 1826 using a suction mechanism to minimize leakage of blood and / or medications through the Deutsche Meridian system. The negative suction pressure may be approximately -150 mmHg, approximately -100 mmHg, approximately -50 mmHg, approximately -20 mmHg, approximately -15 mmHg, approximately -10 mmHg, approximately -5 mmHg, 0 mmHg, or a sub-range defined by any of these points.

[0151] The blood circulating via a closed loop can be autologous blood, matched blood from a donor, or a combination thereof. In some embodiments, blood components, such as serum or plasma, are selected based on one or more parameters. One parameter may be the presence or absence of selected antibodies. For example, when the drug is one or more viral vectors containing therapeutic nucleic acid sequences, the patient's autologous blood may be screened to determine the presence of antibodies against the one or more viral vectors. The presence of antibodies in the patient's autologous blood can reduce and / or completely negate the therapeutic effect and / or cause an unwanted immune response. Therefore, the patient's autologous blood can be diluted or replaced with serologically negative matched blood from a donor, thereby reducing the patient's immune response to the drug and enhancing the drug's efficacy.

[0152] Although the various components shown in FIG18B are shown as components that are part of or separate from the membrane oxygenation device 1820, it should be understood that this schematic diagram is merely exemplary, as one or more components may be included in or separate from the membrane oxygenation device 1820 (outside of it).

[0153] The LRP system 1800 can be set up and operated as follows: (1) Carefully place and tightly seal the recovery catheter 1826 in the coronary sinus 1816 so that only cardiac venous (deoxygenated) blood can be collected; (2) Place the first catheter 1822 and the second catheter 1824 in a sealed manner in the right coronary artery (RCA) and the left main coronary artery (RCA); (3) Then, connect the catheters to the membrane oxygenation device 1820 using a standard tube. (4) Initiate operation of the LRP system 1800 and perfuse oxygenated blood into the coronary arteries in an anterograde manner, while using a gentle negative pressure to collect deoxygenated blood returned from the cardiac veins via the recovery catheter 1826; (5) Next, guide the blood into the reservoir 1860 and then oxygenate it by the membrane oxygenation device 1866, and then re-infuse it anterogradely (driven by the delivery pump 1858) into the heart via the first catheter 1822 and the second catheter 1824. If a drug (e.g., a carrier) is administered, it can be added to the perfusion fluid via the reservoir 1860 after filling with blood or plasma, and a blood sample can be obtained, or the drug can be administered via the reservoir 1860 throughout the perfusion procedure.

[0154] In some embodiments, diluting or replacing a patient's antibody-containing autologous blood with seroreactive matched blood from a donor can reduce adverse immune responses and / or improve drug efficacy. For example, compared to patients who have not undergone autologous blood dilution or replacement, diluting or replacing autologous blood with seroreactive matched blood from a donor can reduce the severity of the immune response by approximately 10%, approximately 20%, approximately 30%, approximately 40%, approximately 50%, approximately 60%, approximately 70%, approximately 80%, approximately 90%, or completely alleviate it. Compared to the efficacy of a drug in a patient who has not undergone autologous blood dilution or replacement, the efficacy of a drug administered after dilution or replacement with matching blood from a donor that is serologically negative can be increased by approximately 10%, 20%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, 100%, 150%, 200%, 300%, 400%, or 500%.

[0155] In some embodiments, the blood portion of the perfusion fluid may be in the following ranges: 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.

[0156] The ratio of autologous blood to matched blood from the donor in the blood circulating via a closed loop can be adjusted as needed to obtain a blood mixture that is most readily accepted by the drug and produces the least immune response after drug introduction. In some embodiments, this ratio may be in the following ranges: 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 matched blood from the donor).

[0157] The flow rate of the perfusion fluid circulating through the closed loop can be adjusted to match the patient's blood flow rate. Those skilled in the art will understand that blood flow rate varies from patient to patient and, for any given patient, varies throughout the day. Therefore, the flow rate of the perfusion fluid circulating through the closed loop can be adjusted in situ. The flow rate can be measured within the closed loop. In some embodiments, the flow rate can be measured using a transsonic probe (such as a clamp on the tubing). In some embodiments, at any given time during perfusion, the flow rate of the perfusion fluid, in mL / min, can be within approximately 20%, 15%, 10%, 8%, 5%, 3%, 2%, 1%, or 0.5% of the patient's blood flow rate. Importantly, the flow rate of the perfusion fluid circulating through the closed loop should not deviate significantly from the patient's own blood flow rate to avoid local ischemia and / or inadequate perfusion.

[0158] An exemplary flow rate of the perfusion fluid circulated via a closed loop may be, but is not limited to, the following ranges: 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.

[0159] The perfusion fluid may be circulated via a closed loop for a duration 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 duration of treatment may occur over several days, such as 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, etc.

[0160] Using the systems disclosed herein, in some embodiments, a higher dose of drug than that which could be safely delivered otherwise via systemic delivery can be administered directly and exclusively to the heart. In some embodiments, because the perfusion fluid does not substantially leak outside the heart and / or into the Descemet's vein system, a lower overall drug dose may be required to achieve the same therapeutic effect (the same therapeutic effect achieved by a larger dose that travels through systemic circulation or only through a partial separation of coronary circulation).

[0161] 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% 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 no (0% v / v) leaks out of the closed loop during the perfusion procedure in the perfusion fluid (e.g., blood and / or medicine) circulated through the closed loop.

[0162] The reduction in perfusion fluid leakage outside the closed loop (compared to other methods disclosed in this art) can be attributed to the tight seal formed within the closed loop and each individual component utilized in the closed loop.

[0163] In some embodiments, some perfusion fluid may still leak out of the closed loop. 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 perfusion fluid circulating through the closed loop may leak out of the closed loop. Any amount of drug lost due to leakage through the perfusion fluid can be replaced by the perfusion fluid to maintain continuous cardiac exposure for the calculated exposure time. In some embodiments, the calculated exposure time range may be 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. Therapeutic Composition

[0164] Medications suitable for treating cardiac conditions (i.e., drugs included in perfusion fluid) may include therapeutic polynucleotide sequences. In some embodiments, the therapeutic polynucleotide sequence may encode a protein for treating cardiac conditions. The protein for treating cardiac conditions may be of human origin or may be derived from different species (e.g., not limited to mice, cats, pigs, or monkeys). In some embodiments, the protein encoded by the therapeutic polynucleotide sequence may correspond to a gene expressed in the human heart.

[0165] Exemplary proteins may include, but are not limited to, one or more of the following: SERCA2, MYBPC3, MYH7, PKP2, MYL3, MYL2, ACTC1, TPM1, TNNT2, TNNI3, TTN, FHL1, ALPK3, myoglobin, FKRP, variants thereof, or combinations thereof. One or more proteins may also be functional variants of the proteins mentioned herein and may exhibit substantial amino acid sequence similarity to the original protein. For example, the amino acid similarity may aggregate to 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%, or at least about 99%. In this context, the term "functional variant" means that the variant of the protein can partially or completely realize the function of the corresponding naturally occurring protein. Protein functional variants may include proteins that differ from their naturally occurring counterparts, for example, due to the substitution, deletion, or addition of one or more amino acids.

[0166] Amino acid substitution can be conservative or non-conservative. Preferably, the substitution is conservative, that is, the amino acid residue is substituted by an amino acid of similar polarity that serves as a functional equivalent. Preferably, the amino acid residue used as the substitute is selected from the same group of amino acids as the amino acid residue to be substituted. For example, a hydrophobic residue can be substituted by another hydrophobic residue, or a polar residue can be substituted by another polar residue having the same charge. Functionally homologous amino acids that can be used for conservative substitution include, for example, nonpolar amino acids such as glycine, valine, alanine, isoleucine, leucine, methionine, proline, phenylalanine, and tryptophan. Examples of non-polar amino acids include serine, threonine, glutamic acid, aspartic acid, tyrosine, and cysteine. Examples of polar (basic) amino acids include histidine, arginine, and lysine. Examples of electrically charged (acidic) amino acids include aspartic acid and glutamic acid.

[0167] Proteins that differ from their naturally occurring counterparts due to one or more (e.g., 2, 3, 4, 5, 10, or 15) additional amino acids are also considered variants. 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 ends of the protein. Essentially, an insertion can occur at any location as long as the addition of an amino acid does not impair the ability of the polypeptide to perform the function of the naturally occurring protein in the treated individual. Furthermore, protein variants also include proteins lacking one or more amino acids compared to the original polypeptide. Such deletions can affect any amino acid position, limited by the condition that they do not impair the ability of the protein to perform its normal function.

[0168] Finally, variants of cardiac sarcoproteins also refer to proteins that differ from naturally occurring proteins due to structural modifications, such as modified amino acids. Modified amino acids are those modified by natural methods, such as treatment or post-translational modifications, or by chemical modification methods known in this art. Typical amino acid modifications include phosphorylation; glycosylation; acetylation; O-linked N-acetylglucosamineization; glutathioneization; acetylation; branching; ADP ribosylation; cross-linking; disulfide bridge formation; methionization; hydroxylation; carboxylation; methylation; demethylation; acetylation; cyclization; and / or covalent or non-covalent bonding with phosphatidylinositol, flavin derivatives, lipoteiic acid, fatty acids, or lipids.

[0169] The therapeutic polynucleotide sequence encoding the target protein can be delivered to the individual to be treated in the form of a gene therapy vector, i.e., a nucleic acid construct, which contains other sequences adjacent to the sequences required to provide the expression of the exogenous nucleic acid, such as the coding sequences of promoters, kozak sequences, polyadenylate signals and similar sequences, including translation and stop codons.

[0170] For example, a gene therapy vector may be part of a mammalian expression system. Useful mammalian expression systems and expression constructs are commercially available. Additionally, several mammalian expression systems are distributed by different manufacturers and can be used in this invention, such as plasmid- or viral vector-based systems, for example, LENTI-Smart™ (InvivoGen), GenScript™ expression vectors, pAdVAntage™ (Promega), ViraPower™ lentivirus, adenovirus expression system (Invitrogen), and adeno-associated virus expression system (Cell Biolabs).

[0171] The gene therapy vector used to express the exogenous therapeutic polynucleotide sequence of the present invention can be, for example, a viral or non-viral expression vector, suitable for introducing the exogenous therapeutic polynucleotide sequence into cells for subsequent expression of the protein encoded by the nucleic acid. The expression vector can be a free vector, i.e., a vector capable of autonomously replicating itself within the host cell; or an integrated vector, i.e., a vector stably incorporated into the cellular genome. The expression in the host cell can be constitutive or regulatory (e.g., inducible).

[0172] In one embodiment, the gene therapy vector is a viral expression vector. The viral vector used in this invention may contain a viral genome, wherein a portion of the natural sequence has been deleted to introduce heterologous polynucleotides without compromising viral infectivity. Due to the specific interaction between the viral component and the host cell receptor, the viral vector is particularly suitable for efficiently transferring genes into target cells. Viral vectors suitable for facilitating gene transfer into mammalian cells may be derived from various types of viruses, such as AAV, adenovirus, retrovirus, herpes simplex virus, bovine papillomavirus, lentivirus, vaccinia virus, polyomavirus, Sendai virus, orthomyxovirus, paramyxovirus, polyvesicular virus, microRNA virus, poxvirus, alpha virus, or any other viral shuttle, variants thereof, or combination thereof suitable for gene therapy.

[0173] The term "adenovirus expression vector" or "adenovirus" is intended to include constructs containing adenovirus sequences sufficient to (a) support the packaging of therapeutic polynucleotide sequence constructs and / or (b) ultimately express tissue- and / or cell-specific constructs selected therein. In one embodiment of the invention, the expression vector comprises a genetically engineered form of adenovirus. Understanding the genetic organization of adenovirus (a 36 kb linear double-stranded DNA virus) allows for the replacement of large fragments of adenovirus DNA with foreign sequences of up to 7 kb.

[0174] Adenovirus growth and manipulation are known to those skilled in the art and exhibit a broad host range both in vitro and in vivo. This group of viruses can be obtained at high titers, e.g., 10⁹ to 10¹¹ plaque-forming units / mL, and is highly infectious. The adenovirus life cycle does not require integration into the host cell genome. Derivative genes delivered via adenovirus vectors are free-type and therefore exhibit low genotoxicity to host cells. No side effects have been reported in studies of vaccination with wild-type adenovirus, demonstrating its safety and / or therapeutic potential as an in vivo gene transfer vector.

[0175] Retroviruses (also known as "retroviral vectors") are selected as gene delivery vectors because they can integrate their genes into the host genome, transfer large amounts of foreign genetic material, infect a wide range of species and cell types, and be packaged in special cell lines.

[0176] The retroviral genome contains three genes: gag, pol, and env, which encode the capsid protein, polymerase, and envelope components, respectively. A sequence upstream of the gag gene contains a signal for packaging the genome into viral particles. Two long terminal repeat (LTR) sequences are present at the 5' and 3' ends of the viral genome. These sequences contain strong promoter and enhancer sequences and are also required for integration into the host cell genome.

[0177] To construct retroviral vectors, nucleic acids encoding genes of interest are inserted into the viral genome instead of certain viral sequences to generate replication-defective viruses. To generate viral particles, packaging cell lines containing the gag, pol, and / or env genes but lacking LTRs and / or packaging components are constructed. When recombinant plasmids containing cDNA, retroviral LTRs, and packaging sequences are introduced into these cell lines (e.g., by calcium phosphate precipitation), the packaging sequences allow the RNA transcripts of the recombinant plasmids to be packaged into viral particles, which are then secreted into the culture medium. The culture medium containing the recombinant retrovirus is then collected, concentrated, and used for gene transfer, as needed. Retroviral vectors can infect a wide variety of cell types. However, integration and stable expression require host cell division.

[0178] Retroviruses can originate from any subfamily. For example, vectors derived from murine sarcoma virus, bovine leukemia virus, Rous Sarcoma Virus, murine leukemia virus, mink cell focus-inducing virus, reticuloendothelial cell hyperplasia virus, or avian leukosis virus can be used. Those skilled in this technique will be able to combine components from different retroviruses, such as LTR, tRNA binding sites, and packaging signals, to provide recombinant retroviruses. These retroviruses are then typically used to generate transduction-competent retroviral vector particles. For this purpose, the vector is introduced into a suitable packaging cell line. Alternatively, retroviruses can be constructed by incorporating chimeric integrase into the retroviral particles to enable site-specific integration into the host cell's DNA.

[0179] Because herpes simplex virus (HSV) is neurotropic, it has attracted considerable attention in the treatment of neurological disorders. Furthermore, HSV's ability to induce latent infection in non-dividing neurons without integrating into the host cell chromosome or otherwise altering host cell metabolism, and the presence of an active promoter during the latent period, make HSV an attractive vector. In addition, although much attention has focused on the neurotropic applications of HSV, given its broad host range, this vector can also be used in other tissues.

[0180] Another factor that makes HSV an attractive vector is the size and organization of its genome. Because HSV is large, incorporating multiple genes or expression cartridges is less of a problem compared to other smaller viral systems. Furthermore, the availability of different viral control sequences with varying efficacies (time, intensity, etc.) compared to other systems makes it possible to control expression to a greater extent. It also has the advantage of having relatively little splicing information, further facilitating genetic manipulation.

[0181] HSV is also relatively easy to handle and can grow to a high titer. Therefore, delivery is not a problem in terms of both obtaining the volume required for a sufficient infection rate (MOI) and reducing the need for repeated dosing. Non-toxic variants of HSV have been developed and these variants can be easily used in gene therapy applications.

[0182] Lentivirals are complex retroviruses. In addition to containing the common retroviral genes gag, pol, and env, lentiviruses also contain other genes with regulatory or structural functions. This higher complexity allows viruses to regulate their life cycle, such as during latent infection. Some examples of lentiviruses include human immunodeficiency virus (HIV-1, HIV-2) and simian immunodeficiency virus (SIV). Lentiviral vectors have been produced by repeatedly attenuating HIV pathogenicity genes, such as deleting genes env, vif, vpr, vpu, and nef, to make the vectors biologically safe.

[0183] Lentiviral vector systems are plastid- or virus-based and configured to carry essential sequences for incorporating foreign nucleic acids, for selection, and for transferring nucleic acids into host cells. The gag, pol, and env genes of the vector of interest are also known in this art. Therefore, the relevant genes are selected and colonized into the chosen vector and then used to transform the target cells of interest.

[0184] Vaccinia virus vectors are widely used due to their ease of construction, relatively high expression levels, wide host range, and large capacity for carrying DNA. Vaccinia contains a linear double-stranded DNA genome of approximately 186 kb, exhibiting a pronounced "AT" preference. Approximately 10.5 kb of inverted terminal repeats are flanked by this genome. Most essential genes appear to be located in the central region, which is highly conserved among poxviruses. The number of open reading frames in vaccinia virus is estimated to be between 150 and 200. Despite encoding two strands, significant overlap of reading frames is not common.

[0185] At least 25 kb can be inserted into the vaccinia virus genome. The prototype vaccinia vector contains a transgenic gene inserted into the viral thymidine kinase gene via homologous recombination. The vector system is based on TK phenotypic selection. Non-translational leader sequences of encephalocardiitis virus produce higher expression levels than conventional vectors, wherein the transgenic gene accumulates 10% or more of the protein in infected cells within 24 hours.

[0186] Empty capsids of polyomaviruses (such as mouse polyomavirus) have attracted attention as potential vectors for gene transfer. The use of empty polyomaviruses was first described in the cultivation of polyomavirus DNA in a cell-free system and the purification of empty capsids. The DNA of the new particles is protected from pancreatic deoxyribonuclease. Transformed polyomavirus DNA fragments were transferred into rat FIII cells using reconstructed particles. The empty capsids and reconstructed particles consist of all three polyomavirus capsid antigens VP1, VP2, and VP3.

[0187] AAV belongs to the Dependovirus genus of small viruses. It is a small, single-stranded DNA virus without an envelope, requiring a helper virus for replication. Co-infection with a helper virus (e.g., adenovirus, herpesvirus, or vaccinia virus) is required to form a fully functional AAV viral particle. In vitro, without co-infection with a helper virus, AAV produces a viral genome in a free form, but does not exist in a latent state producing infectious viral particles. Subsequently, infection with a helper virus "rescues" the genome, allowing it to replicate and be packaged in a viral capsid, thereby reconstructing an infectious viral particle. Recent data indicate that both wild-type AAV and recombinant AAV exist primarily in the form of larger, free tandem cells in vivo. In one embodiment, the gene therapy vector used herein is an AAV vector. The AAV vector may be purified replication-incompetent pseudotyped rAAV particles.

[0188] AAV is not associated with any known human diseases, is generally not considered pathogenic, and appears not to alter the physiological characteristics of host cells after integration. AAV can infect a wide range of host cells, including non-dividing cells, and can infect cells from different species. Compared to some vectors that are rapidly cleared or inactivated by both cellular and humoral responses, AAV vectors have been shown to induce persistent transgenic expression in vivo in various tissues. The persistence of recombinant AAV-mediated transgenes in non-dividing cells in vivo can be attributed to the lack of the ability of native AAV viral genes and vectors to form free tandem variants associated with the ITR.

[0189] AAV is an attractive vector system for cell transduction in this invention because it has high-frequency persistence as a free tandem and can infect non-dividing cells, including cardiomyocytes, thereby making it suitable for delivering genes into mammalian cells, such as in tissue cultures and in vivo.

[0190] Typically, rAAV is produced by co-transfection with plastids containing the gene of interest flanked by two AAV terminal repeat sequences and / or phenoplastids (e.g., pIM45) containing the wild-type AAV coding sequence without terminal repeat sequences. Cells are also infected and / or transfected with adenovirus and / or plastids carrying adenovirus genes required for AAV helper function. Stock solutions of rAAV produced in this manner are contaminated with adenovirus, which must be physically separated from the rAAV particles (e.g., by cesium chloride density centrifugation or column chromatography). Alternatively, an adenovirus vector containing the AAV coding region and / or cell lines containing the AAV coding region and / or some or all of the adenovirus helper genes can be used. Cell lines carrying rAAV DNA as an integrated provirus can also be used.

[0191] Multiple AAV serotypes exist in nature, with at least twelve serotypes (AAV1-AAV12). Despite high homology, different serotypes exhibit tissue tropism. After transfection, AAV only elicits a secondary immune response in the host (if present). Therefore, AAV is particularly well-suited for gene therapy approaches.

[0192] In some embodiments, the present invention may be directed to a drug comprising an AAV vector, the AAV vector being one or more of the following: AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, ANC AAV, chimeric AAVs derived therefrom, variants thereof, and combinations thereof, which will be even more preferably suitable for efficient transduction in the tissue of interest. In some embodiments, the gene therapy vector is an AAV serotype 1 vector. In some embodiments, the gene therapy vector is an AAV serotype 2 vector. In some embodiments, the gene therapy vector is an AAV serotype 3 vector. In some embodiments, the gene therapy vector is an AAV serotype 4 vector. In some embodiments, the gene therapy vector is an AAV serotype 5 vector. In some embodiments, the gene therapy vector is an AAV serotype 6 vector. In some embodiments, the gene therapy vector is an AAV serotype 7 vector. In some embodiments, the gene therapy vector is an AAV serotype 8 vector. In some embodiments, the gene therapy vector system is AAV serotype 9. In some embodiments, the gene therapy vector system is AAV serotype 10. In some embodiments, the gene therapy vector system is AAV serotype 11. In some embodiments, the gene therapy vector system is AAV serotype 12.

[0193] The dosage of AAV suitable for human use may be in the following range: about 1×108 vg / kg to about 3×1014 vg / kg, about 1×108 vg / kg, about 1×109 vg / kg, about 1×1010 vg / kg, about 1×1011 vg / kg, about 1×1012 vg / kg, about 1×1013 vg / kg or about 1×1014 vg / kg. The total amount of viral particles or DRP is: approximately, at least, at least approximately, not exceeding or not exceeding approximately 5×10¹⁵ vg / kg, 4×10¹⁵ vg / kg, 3×10¹⁵ vg / kg, 2×10¹⁵ vg / kg, 1×10¹⁵ vg / kg, 9×10¹⁴ vg / kg, 8×10¹⁴ vg / kg, 7×10¹⁴ vg / kg, 6×10¹⁴ vg / kg, 5×10¹⁴ vg / kg, 4×10¹⁴ vg / kg, 3×10¹⁴ vg / kg, 2×10¹⁴ vg / kg, 1×10¹⁴ vg / kg, 9×10¹³ vg / kg , 8×1013vg / kg, 7×1013vg / kg, 6×1013vg / kg, 5×1013vg / kg, 4×1013vg / kg, 3×1013vg / kg, 2×1013vg / kg, 1×1013vg / kg, 9×1012vg / kg, 8×1012vg / kg, 7×1012vg / kg, 6×1012vg / kg, 5×1012vg / kg, 4×1012vg / kg, 3×1012vg / kg, 2×1012vg / kg, 1×1012vg / kg, 9×1011vg / kg, 8×1011vg / kg, 7×1011vg / kg, 6×1011vg / kg, 5×1011vg / kg, 4×1011vg / kg, 3×1011vg / kg, 2×1011vg / kg, 1×1011vg / kg, 9×1010 vg / kg, 8×1010vg / kg, 7×1010vg / kg, 6×1010vg / kg, 5×1010vg / kg, 4×1010vg / kg, 3×1010vg / kg, 2×1010vg / kg, 1×1010vg / kg, 9×10 9 vg / kg, 8×10⁹ vg / kg, 7×10⁹ vg / kg, 6×10⁹ vg / kg, 5×10⁹ vg / kg, 4×10⁹ vg / kg, 3×10⁹ vg / kg, 2×10⁹ vg / kg, 1×10⁹ vg / kg, 9×10⁸ vg / kg, 8×10⁸ vg / kg, 7×10⁸ vg / kg, 6×10⁸ vg / kg, 5×10⁸ vg / kg, 4×10⁸ vg / kg, 3×10⁸ vg / kg, 2×10⁸ vg / kg or 1×10⁸ vg / kg, or within the range of any two of these equivalent values.The dosages listed above are in units of vg / kg heart tissue.

[0194] Using the systems and methods disclosed herein, in some embodiments, because the perfusion fluid substantially does not leak outside the heart and / or into the Descemet's venous system, a higher dose of the drug than that which could be safely administered via other means through systemic delivery can be administered directly and only to the heart. Without being construed as limiting, it is believed that AAV toxicity can be attributed to systemic effects, such as hepatotoxicity, platelet activation and loss, and complement activation and loss. All such toxicities and other effects can be reduced, minimized, or completely avoided by the application of localized perfusion fluid as described in the methods and systems disclosed herein. Therefore, a dose of up to about 5 × 10¹⁵ vg / kg of heart tissue can be well tolerated. In some embodiments, the dose administered to the heart, expressed as vg / kg of heart tissue, can be about 2 to about 200 times, about 5 to about 150 times, about 10 to about 100 times, or any subrange thereof, higher than the highest systemic dose.

[0195] In addition to viral vectors, non-viral expression constructs may also be used to introduce genes encoding target proteins or their functional variants or fragments into patient cells. Non-viral expression vectors that allow in vivo expression of proteins in target cells include, for example, plastids, modified RNA, mRNA, cDNA, antisense oligomers, DNA-lipid complexes, nanoparticles, extracellular bodies, any other non-viral shuttles suitable for gene therapy, their variants, and combinations thereof.

[0196] In addition to viral vectors and non-viral expression vectors, nuclease systems may also be used in conjunction with vectors and / or electroporation systems to enter patient cells and introduce genes encoding target proteins or functional variants or fragments thereof. Exemplary nuclease systems may include, but are not limited to, clustered regularly spaced short palindromic repeats (CRISPR), DNA-cutting enzymes (e.g., Cas9), large-scale nucleases, TALENs, zinc finger nucleases, any other nuclease systems suitable for gene therapy, their variants, and combinations thereof. For example, in one embodiment, a viral vector (e.g., AAV) may be used with a nuclease (e.g., CRISPR) and another viral vector (e.g., AAV) may be used with a DNA-cutting enzyme (e.g., Cas9) to introduce both (nuclease and DNA-cutting enzyme) into target cells.

[0197] Other vector delivery systems that can be used to deliver therapeutic polynucleotide sequences encoding therapeutic genes into cells are receptor-mediated delivery mediators. These utilize the selective uptake of macromolecules in almost all eukaryotic cells via receptor-mediated endoplasmosis. Due to the cell-type-specific distribution of various receptors, delivery can be highly specific. Receptor-mediated gene-targeting mediators may include two components: cell receptor-specific ligands and DNA binders.

[0198] Applicable methods for transferring non-viral vectors into target cells include, for example, lipid transfection, calcium phosphate co-precipitation, DEAE-polydextrose, and direct DNA introduction using microtubes, ultrasound, electroporation, and similar methods. Prior to vector introduction, cardiomyocytes may be treated with permeabilizing agents such as phosphatidylcholine, streptolysin, sodium decanoate, decylcarnitine, tartaric acid, lysophosphatidylcholine, Triton X-100, and analogues. Exosome transfer of naked DNA or AAV-captured DNA may also be used.

[0199] The gene therapy vector of the present invention may include a promoter functionally linked to a nucleic acid sequence encoding a target protein. The promoter sequence should be tight and ensure strong expression. Preferably, the promoter provides expression of the target protein in the myocardium of a patient treated with the gene therapy vector. In some embodiments, the gene therapy vector includes a heart-specific promoter operatively linked to a nucleic acid sequence encoding a target protein. As used herein, a "heart-specific promoter" means a promoter whose activity in cardiac cells is at least twice as high as its activity in any other non-cardiac cell type. Preferably, the heart-specific promoter suitable for use in the vector of the present invention has an activity in cardiac cells that is at least 5, at least 10, at least 15, at least 20, at least 25, or at least 50 times higher than its activity in non-cardiac cell types.

[0200] The heart-specific promoter may be a selected human promoter, or a promoter containing 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 with the selected human promoter. An exemplary non-limiting promoter that may be used is the troponin T promoter (TNNT2). Other non-limiting examples of promoters include the α-myosin heavy chain promoter, the myosin light chain 2v promoter, the α-myosin heavy chain promoter, the α-cardiac actin promoter, the α-myosin promoter, the troponin C promoter, the troponin I promoter, the cardiac myosin-binding protein C promoter, and the sarcoplasmic reticulum / endoplasmic reticulum Ca2+-ATPase (SERCA) promoter (e.g., isoform 2 of this promoter (SERCA2)).

[0201] The vectors used in this invention can have different transduction efficiencies. Therefore, viral or non-viral vectors can transduce more than, equal to, or at least 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 100% of cells in the target vascular site. More than one vector (viral or non-viral vector, or a combination thereof) can be used simultaneously or sequentially. This can be used to transfer more than one polynucleotide and / or target more than one cell type. When multiple vectors or multiple reagents are used, more than one transduction / transfection efficiency can be achieved.

[0202] Pharmaceutical compositions containing gene therapy vectors can be prepared as liquid solutions or suspensions. The pharmaceutical compositions of the present invention may include commonly used pharmaceutically acceptable excipients, such as diluents and carriers. Specifically, the composition contains pharmaceutically acceptable carriers, such as water, saline, Ringer's solution, or dextran solution. In addition to carriers, the pharmaceutical compositions may also contain emulsifiers, pH buffers, stabilizers, dyes, and the like.

[0203] In some embodiments, the pharmaceutical composition will contain a therapeutically effective gene dose that is capable of preventing or treating cardiomyopathy in an individual without being toxic to the individual. Prevention or treatment of cardiomyopathy can be assessed by changes in phenotypic traits associated with cardiomyopathy, wherein such changes are effective in preventing or treating cardiomyopathy. Therefore, a therapeutically effective gene dose is generally a gene dose that, when administered in a physiologically tolerable composition form, is sufficient to improve or prevent the pathogenic cardiac phenotype of the treated individual.

[0204] Cardiac conditions treatable by the methods disclosed herein may include, but are not limited to, one or more of the following: genetically determined heart disease (e.g., genetically determined cardiomyopathy), arrhythmic heart disease, heart failure, ischemia, arrhythmia, myocardial infarction, congestive heart failure, transplant rejection, abnormal cardiac contractions, non-ischemic cardiomyopathy, mitral regurgitation, aortic stenosis or regurgitation, abnormal Ca2+ metabolism, congenital heart disease, primary or secondary cardiac tumors, and combinations thereof. Exemplary Examples

[0205] The following embodiments are described to aid in understanding the invention, and should not be construed as specifically limiting the embodiments described and claimed herein. Such variations in the embodiments, including substitutions for all currently known or subsequently developed equivalents within the capabilities of those skilled in the art, and minor variations in formulations or experimental designs, will be considered within the scope of the embodiments incorporated herein. Example 1: Feasibility study of localized perfusion in three pigs

[0206] The feasibility of the LRP system was determined by successfully performing the procedure for 60 minutes in three pigs (domestic pigs). For monitoring purposes, open-chest surgery was performed on two pigs, but all catheters were introduced percutaneously. Open-chest surgery was not performed on the third pig, and the entire LRP procedure was performed percutaneously.

[0207] Using the LRP system 1800 shown and described with respect to Figures 18A and 18B, LRP was performed on three animals. In all three animals, the LRP procedure could be maintained for 60 minutes while the heart was spontaneously beating, without any technical difficulties. During LRP, all animals (n=3) were hemodynamically stable without the need for any systolic inhibitors. For all animals, cardiac function was normal and comparable to baseline after LRP. Overall coronary artery occlusion was acceptable: in animal 1, the left coronary artery (LCA) was partially occluded (leakage considered minor); in animal 2, the right coronary artery (RCA) was partially occluded (leakage considered minor); and in animal 3, both coronary arteries were occluded.

[0208] Due to the anatomical differences in pigs, where the azygos vein directly inserts into the coronary sinus and requires occlusion to simulate the human condition, achieving complete occlusion of the coronary sinus (CS) is technically more challenging. Complete occlusion was achieved in animal 3 (using a Reliant balloon), and partial occlusion was achieved in animals 1 and 2 (using a ProPledge catheter). Flow rates ranging from 166 mL / min to 244 mL / min were achieved during a 60-minute LRP procedure. The accessory devices used in this example are listed in Table 1, including their intended use and application in the LRP system according to embodiments of the present invention.

[0209] Figure 18 is a radiographic image of a representative LRP in situ installation, in which the coronary artery catheter is indicated by an arrow and the coronary sinus balloon (retrieval catheter) is indicated by a triangle.

[0210] The average values ​​of LRP parameters (pump speed, flow rate, and pressure) for the three animals are summarized in Figure 20 (where the bars represent the standard deviation). Table 1: Devices used in the LRP program project CE intended use LRP applications trademark Research FlowGate 2 Neurology Thrombectomy Coronary artery perfusion Stryker Animal 1 Animal 2 Animal 3 ProPledge Retrograde cardiac arrest Coronary sinus blood return Edwards Animal 1 Animal 2 Animal 3 EndoVent Pulmonary artery blood degassing (aspiration) Coronary sinus blood return and azygos vein occlusion Edwards Animal 1 Animal 2 Animal 3 D100 Oxygenator Kit Pediatric cardiopulmonary bypass (CPB) kit Blood oxygenation and tubing Dideco-Livanova Animal 1 Animal 2 Animal 3 Revolution 5 Centrifugal blood pump Centrifugal blood pump Sorin-Livanova Rotaflow RF-32 Centrifugal blood pump Centrifugal blood pump Getinge Animal 1 Animal 2 Animal 3 BPX-80 Centrifugal blood pump Centrifugal blood pump Medtronic Security research Bio-Medicus 550 BioControl Console ECMO pump control console ECMO pump control console Medtronic Animal 1 Animal 2 Animal 3 PressureWire X Coronary pressure line Coronary pressure line Saint Jude Medical / Abbott Animal 1 Animal 2 Animal 3 Fractional Flow Reserve (FFR) console FFR console Coronary pressure control console Saint Jude Medical / Abbott Animal 1 Animal 2 Animal 3 Reliant aortic clip Coronary sinus occlusion Medtronic Animal 3 Fogarty catheter Thrombectomy Coronary sinus occlusion Fogarty Table 2: Flow and pressure characteristics during the 60-minute LRP program Animal 1 time 0 minutes 5 minutes 10 minutes 15 minutes 30 minutes 45 minutes 60 minutes Flow rate (mL / min) 140 200 190 200 180 220 190 Pressure (mm / Hg) -90 -90 -90 -90 -90 -60 -60 RPM 2650 3020 3020 3020 890 3060 2930 Coronary pressure 48 / 28 44 / 24 44 / 25 48 / 28 44 / 25 47 / 28 48 / 20 Mean coronary pressure 37 32 32 36 32 37 34 Full body pressure 77 / 51 70 / 47 69 / 47 76 / 52 69 / 48 77 / 53 70 / 48 Average body pressure 62 57 56 62 57 60 58 Animal 2 time 0 minutes 5 minutes 10 minutes 15 minutes 30 minutes 45 minutes 60 minutes Flow rate (mL / min) 180 - 140 150 170 180 180 Pressure (mm / Hg) -90 - -90 -90 -90 -90 -90 RPM 3020 - 2940 2980 3050 3050 3010 Coronary pressure 65 / 33 - 61 / 46 63 / 47 73 / 52 70 / 48 66 / 41 Mean coronary pressure 41 - 51 52 60 58 51 Full body pressure 70 / 50 - 60 / 43 60 / 43 68 / 55 67 / 46 59 / 42 Average body pressure 61 - 50 49 62 56 51 Heart rate 71 - 74 75 78 80 81 Animal 3 time 0 minutes 5 minutes 10 minutes 15 minutes 30 minutes 45 minutes 60 minutes Flow rate (mL / min) 260 240 250 250 240 230 240 pressure -60 -80 -70 -70 -70 -70 -70 RPM 3330 3350 3350 3350 3350 3350 3610 Coronary pressure 54 / 44 58 / 44 53 / 4 52 / 41 50 / 40 50 / 40 86 / 56 Mean coronary pressure 49 49 47 46 45 42 70 Full body pressure 71 / 47 66 / 43 67 / 45 67 / 45 67 / 39 54 / 40 57 / 7 Average body pressure 57 54 54 54 47 47 30 Heart rate 73 74 73 72 77 97 88 Example 2: Safety Study of Localized Irrigation System in Two Pigs

[0211] The safety of the LRP system was determined by performing a percutaneous LRP procedure for 60 minutes in two pigs (domestic pigs) while keeping the animals under anesthesia and by tracking the animals for 24 hours after the procedure. After the 24-hour period, the animals were euthanized and their hearts were examined visually and microscopically. In addition, biomarkers were obtained to assess the extent of tissue damage to the heart.

[0212] In both trials, LRP was successfully performed without any serious adverse effects. A technical problem occurred in animal 5, where the pump head tubing connection failed after 10 minutes. LRP was immediately stopped, and all tubing was loosened and tightened. The pump head was immediately replaced, and the LRP system was reconnected, degassed, and restarted. During this procedure, the animal lines were hemodynamically stable, and no serious adverse effects were observed. The LRP program was then maintained for 60 minutes, thus demonstrating safety and efficacy even in the event of minor equipment failure.

[0213] Throughout the entire procedure, including initiation, LRP restart and up to 24 hours thereafter, the animal lineage was hemodynamically stable and required no contractile-influencing agents.

[0214] In two animals, an average LRP flow rate of 173 mL / min was achieved with complete occlusion of the left main coronary artery and right coronary artery and partial occlusion of the coronary sinus (moderate leakage). Postoperative and 24-hour cardiac function was normal and comparable to baseline. Cardiac biomarkers (myoglobin and troponin) increased only slightly during and shortly after the LRP procedure, but immediately decreased toward baseline values ​​during the 24-hour follow-up. Given the continuous hemodynamic stability of the animals throughout the procedure, the absence of serious adverse effects, the minimal and transient increase in cardiac biomarkers, and the only transient ECG changes that immediately returned to normal during the 24-hour period, the LRP procedure is demonstrated to be safe. Table 3 summarizes the flow and pressure characteristics in animals 4 and 5 used in the intrinsic safety study of the 60-minute LRP procedure. Table 3: Parameters of the safety study Animal 4 time 0 15 minutes 30 minutes 45 minutes 60 minutes Flow rate (mL / min) 180-190 200 180 180 190 suction pressure -70 -70 -70 -70 RPM 3400 3400 3320 3350 Coronary pressure 93 / 52 90 / 63 88 / 37 82 / 43 average value 74 77 62 65 Full body pressure 104 / 65 100 / 64 94 / 61 94 / 56 average value 80 78 77 65 Animal 5 time 5 minutes 15 minutes 30 minutes 45 minutes 60 minutes Flow rate (mL / min) 150 150 160 150 170 Suction pressure (mmHg) -80 -80 -80 -80 -80 RPM 2390 2400 2440 2400 2410 Coronary pressure 76 / 44 80 / 40 81 / 40 90 / 45 72 / 24 average value 61 59 58 62 43 Full body pressure 86 / 52 86 / 53 80 / 46 100 / 62 84 / 47 average value 66 66 60 77 63

[0215] After euthanasia, the hearts of animals 4 and 5 were examined visually.

[0216] The heart of animal 4 weighed 312 grams. No gross pathology was observed, and specifically, there were no signs of myocardial ischemia or myocardial infarction. A localized hematoma was observed on the posterior aspect of the heart of animal 4 in the region of the right coronary artery, which is likely attributable to suture injury during the procedure.

[0217] The heart of animal 5 weighed 293 grams. No gross pathology was observed, and specifically, there were no signs of myocardial ischemia or myocardial infarction. A localized hematoma was observed on the posterolateral aspect of the heart of animal 5, in the region of the distal right coronary artery and the distal left circumflex branch, which is likely attributable to suture injury during the procedure.

[0218] To determine the biochemical integrity of cardiac tissue, serum cardiac biomarkers were obtained and are summarized in Table 4. Creatine kinase (CK) levels remained stable during the LRP program but showed a continuous increase after LRP, which is likely attributed to the animal being in a supine position. Myoglobin levels remained stable during the LRP program and showed only a minimal increase thereafter; animal 4 remained within the reference level and animal 5 was only slightly above the reference level. Troponin T showed a minimal increase during the LRP program, peaking at 60 minutes and then decreasing to baseline during follow-up. Table 4: Serum biomarker (creatine kinase (CK), myoglobin (Myo), and troponin T (Trop)) values ​​obtained at baseline, 30 and 60 minutes during LRP, and at various time intervals after LRP. Animal 4 Reference value Baseline LRP 30 minutes LRP 60 minutes 4 hours 8 hours 12 hours 16 hours 20 hours 24 hours CK <190U / L 871 865 883 937 1293 1285 1270 2068 2640 Myo. 25-72µg / L <21 <21 <21 <21 <21 <21 twenty four 35 58 Trop. <14ng / L 53 85 106 56 45 34 28 32 53 Animal 5 Reference value Baseline LRP 30 minutes LRP 60 minutes 4 hours 8 hours 12 hours 16 hours 20 hours 24 hours CK <190U / L 988 899 931 1946 2943 4064 4929 5496 7655 Myo. 25-72µg / L <21 <21 <21 <21 26 35 37 43 83 Trop. <14ng / L 37 44 66 138 120 93 72 61 58 Example 3: Study on the distribution of vector organisms

[0219] Using a similar protocol and equipment, a biodistribution study was performed on three pigs that underwent the LRP procedure described above. The first pig ("Pig 1") and the second pig ("Pig 2") underwent LRP for 60 minutes, and their coronary circulation was perfused with a total dose of AAV9 containing a construct encoding green fluorescent protein (GFP) under the cellular giant virus (CMV) promoter (AAV9 CMV-GFP). The third pig ("Pig 3") received the same dose of AAV9 CMV-GFP via intracoronary (IC) infusion. No AAV9 antibody-negative pigs were identified among the various pigs considered in the study. Therefore, 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: AAV9 >1:100).

[0220] Vectors detached from the closed loop remained at low levels throughout the duration of the LRP procedure (see Tables 5 and 6 below). For pigs 1 and 2, 98.7% and 81.8% of the vectors were detected in plasma samples at 5 minutes of the LRP procedure, respectively, and 60.1% and 52.9% were detected at 30 minutes, respectively, demonstrating that the vectors were mainly maintained within the closed loop in the early stages of the LRP procedure, remaining there for at least 45 minutes. The lower limit of quantitation was 5.33 × 10³ vg / mL. Table 5: Vectors detected in plasma samples obtained from the closed loop and the systemic circulation (peripheral) at various time points during the LRP procedure (in units of vector gene count per milliliter of plasma, vg / mL). plasma samples Pig 1 (LRP) Pig 2 (LRP) Pig 3 (IC) LRP system, +5 minutes 2.11 × 10 11 7.05 × 10 10 N / A LRP system, +15 minutes 2.14 × 10 11 3.81 × 10 10 N / A LRP system, +30 minutes 4.26 × 10 10 1.52 × 10 10 N / A LRP system, +45 minutes 3.33 × 10 10 1.18 × 10 10 N / A LRP system, +60 minutes 2.73 × 10 10 8.61 × 10 9 N / A Surrounding area, before injection < 5.33 × 10 3 < 5.33 × 10 3 < 5.33 × 10 3 Surrounding area, +5 minutes 2.70 × 10 9 1.57 × 10 10 5.26 × 10 9 Surrounding area, +15 minutes 1.68 × 10 10 1.81 × 10 10 6.22 × 10 9 Surrounding area, +30 minutes 2.83 × 10 10 1.36 × 10 10 5.84 × 10 9 Surrounding area, +45 minutes 2.69 × 10 10 1.05 × 10 10 9.07 × 10 9 Surrounding area, +60 minutes 2.27 × 10 10 1.18 × 10 10 9.62 × 10 9 Table 6: Ratio between the amount of carrier detected in the LRP closed loop and the amount detected in the periphery. plasma sample time Pig 1 (LRP) Pig 2 (LRP) LRP system, +5 minutes 98.7% / 1.3% 81.8% / 18.2% LRP system, +15 minutes 93.0% / 7.0% 67.7% / 32.3% LRP system, +30 minutes 60.1% / 39.9% 52.9% / 47.1% LRP system, +45 minutes 55.4% / 44.6% 52.9% / 47.1% LRP system, +60 minutes 54.6% / 45.4% 42.2% / 57.8%

[0221] Vector biodistribution was assessed by determining vg / g using quantitative polymerase chain reaction (qPCR) analysis and by visually detecting its presence in 26 predetermined heart sections from each pig using immunofluorescence. Using qPCR analysis (as outlined in Table 7), although the overall detection rate was low, the vector was detected in 22 of the 26 heart sections from pig 1, indicating widespread vector distribution. In pig 2 (with higher anti-AAV Ab titers), the vector was detected in 8 of the 26 segments. In contrast, in pig 3, the vector was detected in only 3 of the 26 heart sections after intracoronary injection. The lower limit of quantification was <0.004 vector genotypes per diploid genotype (vg / dg). Table 7: Vectors detected in tissue samples by qPCR analysis tissue samples Pig 1 (LRP) Pig 2 (LRP) Pig 3 (IC) Heart, left ventricle, anterior wall of the basement 0.09 < 0.004 < 0.004 Heart, left ventricle, anterior basal septum 0.01 < 0.004 < 0.004 Heart, left ventricle, subbasal septum 0.02 < 0.004 0.11 Heart, left ventricle, inferior wall of the basement 0.01 < 0.004 0.21 Heart, left ventricle, inferior basal wall 0.02 < 0.004 < 0.004 Heart, left ventricle, anterior wall of the basement 0.01 < 0.004 < 0.004 Heart, left ventricle, anterior wall of the middle part 0.01 0.01 < 0.004 Heart, left ventricle, anterior septum 0.02 < 0.004 < 0.004 Heart, left ventricle, middle lower septum < 0.004 < 0.004 < 0.004 Heart, left ventricle, inferior wall of the middle part 0.03 < 0.004 < 0.004 Heart, left ventricle, middle inferior wall 0.01 0.02 < 0.004 Heart, left ventricle, middle anterior wall 0.03 0.01 < 0.004 Heart, left ventricle, anterior wall of the apex 0.01 < 0.004 < 0.004 Heart, left ventricle, apical septal wall 0.01 0.03 < 0.004 Heart, left ventricle, mid-aspect inferior wall of the heart 0.01 < 0.004 < 0.004 Heart, left ventricle, middle apical lateral wall 0.02 < 0.004 0.14 Heart, left ventricle, anterior wall of the apex < 0.004 0.02 < 0.004 Heart, left ventricle, apical septum 0.03 0.01 < 0.004 Heart, left ventricle, inferior wall of the apex 0.01 < 0.004 < 0.004 Heart, left ventricle, apical lateral wall < 0.004 0.01 < 0.004 Heart, left ventricle, apex of the heart 0.03 < 0.004 < 0.004 Heart, right ventricle, basement 0.02 < 0.004 < 0.004 Heart, right ventricle, middle < 0.004 < 0.004 < 0.004 Heart, right ventricle, apex of the heart 0.02 0.01 < 0.004 Heart, left atrial appendage 0.07 < 0.004 < 0.004 Heart, right auricle 0.01 < 0.004 < 0.004 Liver, left lobe 0.64 0.05 < 0.004 Liver, right lobe 0.91 0.09 < 0.004 spleen 0.18 0.06 2.10

[0222] Immunofluorescence (IF) was performed using GFP detection as the quantitative method. Tissue samples were prepared using frozen tissue sections to obtain 10 mm thick samples. Detection was performed using a single monoclonal antibody, and mouse antibody detection was performed using a second Alexa-555-conjugated antibody. Connective tissue was detected using wheat germ agglutinin (WGA). Contrast staining was performed using 4',6-dimethylamidine-2-phenylindole (DAPI).

[0223] Automated immunofluorescence quantification was performed on tissue sections (whole section scanning was performed using a ZEISS Axio scanning microscope). GFP-positive cardiomyocytes were detected in 8 out of 25 sections from pig 1 (only 25 sections were studied), in 4 out of 26 sections from pig 2, and were not detected in pig 3. The total number of transduced cardiomyocytes was less than 1%.

[0224] In the foregoing description, numerous specific details such as particular materials, dimensions, and process parameters are set forth to provide a thorough understanding of the invention. In one or more embodiments, particular features, structures, materials, or properties may be combined in any suitable manner. The terms "example" or "illustrative" are used herein to mean serving as an example, illustration, or description. Any form or design described herein as "example" or "illustrative" should not be construed as being better or more advantageous than other forms or designs. In fact, the use of the terms "example" or "illustrative" is intended only to present the concept in a concrete manner. As used in this application, the term "or" is intended to mean an inclusive "or," not an exclusive "or." That is, unless otherwise stated or apparent from the context, "X includes A or B" is intended to mean either of the naturally inclusive substitutions. That is, if X includes A; X includes B; or X includes both A and B, then "X includes A or B" is satisfied in any of the foregoing cases. Throughout this specification, references to "an embodiment," "some embodiments," or "one embodiment" mean that a particular feature, structure, or characteristic described in connection with an embodiment is included in at least one embodiment. Therefore, the phrases "an embodiment," "some embodiments," or "one embodiment" appearing throughout this specification do not necessarily refer to the same embodiment.

[0225] The invention has been described with reference to specific exemplary embodiments thereof. Therefore, the specification and drawings should be viewed in an illustrative rather than restrictive sense. Various modifications to the invention, other than 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. [Simplified Explanation of the Diagram]

[0038] The above and other features, properties and various advantages of the present invention will become more apparent when the following embodiments are considered in conjunction with the accompanying drawings, wherein:

[0039] Figure 1 shows a schematic diagram of a first exemplary retrieval catheter having a single balloon structure according to at least one embodiment;

[0040] Figure 2 is an image of a retrieval catheter manufactured according to one embodiment of the first exemplary retrieval catheter;

[0041] Figure 3 shows the arrangement of a first exemplary recovery conduit according to at least one embodiment;

[0042] Figure 4 shows the arrangement of a second exemplary retrieval catheter having a single balloon structure according to at least one embodiment;

[0043] Figure 5 shows the arrangement of a third exemplary retrieval catheter and a fourth exemplary retrieval catheter, each having a single balloon structure according to at least one embodiment;

[0044] Figure 6 shows the arrangement of a fifth exemplary retrieval catheter having a single balloon structure and a sixth exemplary retrieval catheter not having a balloon structure according to at least one embodiment;

[0045] Figure 7 shows the arrangement of a seventh exemplary recovery catheter having multiple balloon structures according to at least one embodiment;

[0046] FIG8 shows an arrangement of an eighth exemplary recovery catheter having a partially covered and retractable stent structure according to at least one embodiment;

[0047] Figure 9 shows an arrangement of a ninth exemplary retrieval catheter having an expandable and retractable stent structure and a balloon structure according to at least one embodiment;

[0048] Figure 10 shows the arrangement of a tenth exemplary recovery catheter having a covered disc-shaped support structure according to at least one embodiment;

[0049] FIG11A is a schematic diagram of a first exemplary perfusion catheter having a single balloon structure according to at least one embodiment;

[0050] Figure 11B is a schematic diagram of the balloon structure of a first exemplary perfusion catheter in an expanded state according to at least one embodiment;

[0051] Figure 11C is a schematic diagram of the balloon structure of a first example of an incision catheter in a retracted state according to at least one embodiment;

[0052] Figure 11D shows the arrangement of a first exemplary perfusion catheter in the aorta according to at least one embodiment;

[0053] FIG12A is a schematic diagram of a second exemplary irrigation catheter having a distal plug according to at least one embodiment;

[0054] FIG12B is a schematic diagram of the plug of a second exemplary irrigation catheter according to at least one embodiment;

[0055] Figure 12C is a schematic diagram of the plug of a second exemplary irrigation catheter in an extended state according to at least one embodiment;

[0056] Figure 12D shows the arrangement of a second exemplary perfusion catheter in the aorta according to at least one embodiment;

[0057] FIG13A is a schematic diagram of a third exemplary irrigation catheter having a distal wedge according to at least one embodiment;

[0058] FIG13B is a schematic diagram of a wedge-shaped member of a third exemplary irrigation conduit according to at least one embodiment;

[0059] FIG13C is another schematic diagram of the distal end of a third exemplary irrigation catheter in an extended state according to at least one embodiment;

[0060] Figure 13D shows the arrangement of a third exemplary perfusion catheter in the aorta according to at least one embodiment;

[0061] FIG14A shows an arrangement of a fourth exemplary irrigation catheter having a partially covered and retractable support structure according to at least one embodiment;

[0062] FIG14B shows a fourth exemplary perfusion catheter stent structure in a retracted state according to at least one embodiment;

[0063] FIG14C shows a fourth exemplary perfusion catheter in an unfolded state according to at least one embodiment;

[0064] FIG15A shows an arrangement of a fifth exemplary irrigation catheter having a detachable covered braided disc according to at least one embodiment;

[0065] FIG15B shows a braided disc of a fifth exemplary irrigation catheter in an unfolded state according to at least one embodiment;

[0066] FIG16A is a schematic diagram of a sixth exemplary irrigation catheter having a gradually tapering lumen axis according to at least one embodiment;

[0067] Figure 16B shows the arrangement of a sixth exemplary perfusion conduit according to at least one embodiment;

[0068] Figure 16C shows the arrangement of a sixth exemplary perfusion catheter in the aorta according to at least one embodiment;

[0069] FIG16D shows a preformed lumen shaft of a sixth exemplary irrigation catheter according to at least one embodiment;

[0070] Figure 17 shows an exemplary preformed lumen axis of an exemplary catheter according to various embodiments;

[0071] FIG18A depicts an exemplary localized irrigation system according to an embodiment of the present invention;

[0072] FIG18B is a schematic diagram of an exemplary local area irrigation device according to an embodiment of the present invention;

[0073] Figure 19 is a radiographic image captured during localized perfusion of a pig heart that has not been stopped, showing the positions of the left main coronary ductus arteriosus, the right coronary ductus arteriosus, and the coronary sinus balloon; and

[0074] Figure 20 is a graph showing the pump speed, flow rate and pressure measured during localized irrigation.

Claims

1. A system for performing localized perfusion of a patient's heart when fluidly coupled to the heart, the system comprising: a first drug delivery catheter adapted for insertion into the right coronary artery of the heart; a second drug delivery catheter adapted for insertion into the left main coronary artery of the heart; a drug retrieval catheter adapted for insertion into the coronary sinus of the heart; and a membrane oxygenation device fluidly coupled to the first drug delivery catheter, the second drug delivery catheter, the drug retrieval catheter, and an oxygen source, wherein when the first drug delivery catheter is inserted into the right coronary artery, the second drug delivery catheter is inserted into the left main coronary artery, and the drug retrieval catheter is inserted into the coronary sinus, the first drug delivery catheter, the second drug delivery catheter, the drug retrieval catheter, and the membrane oxygenation device together form a closed loop through the heart, dissociating the heart from the patient's systemic circulation; A pump configured to drive fluid flow through the first drug delivery catheter and the second drug delivery catheter, wherein when the closed loop is established and the drug is perfused through it, the system is adapted to maintain at least about 50% of the drug in the closed loop for at least 45 minutes; and one or more aspiration mechanisms to apply negative aspiration pressure to the drug recovery catheter.

2. A localized perfusion system comprising: a first drug delivery catheter inserted into the right coronary artery of a patient's heart; a second drug delivery catheter inserted into the left main coronary artery of the heart; a drug recovery catheter inserted into the coronary sinus of the heart; and a membrane oxygenation device fluidly coupled to the first drug delivery catheter, the second drug delivery catheter, the drug recovery catheter, and an oxygen source, wherein the first drug delivery catheter, the second drug delivery catheter, the drug recovery catheter, and the membrane oxygenation device, together with the coronary arteries and coronary venous system of the heart, form a closed loop through the heart, thereby isolating the heart from the patient's systemic circulation; a pump configured to drive fluid flow through the first drug delivery catheter and the second drug delivery catheter into the heart and out of the heart through the drug recovery catheter, wherein the system is adapted to maintain at least about 50% of the drug in the closed loop for at least 45 minutes; and one or more suction mechanisms to apply negative suction pressure to the drug recovery catheter.

3. A localized perfusion system as claimed in claim 1 or claim 2, wherein the membrane oxygenation device includes a reservoir configured to inject drugs into the closed loop during perfusion.

4. A localized irrigation system as claimed in claim 1 or 2, wherein the one or more suction mechanisms are configured to generate a negative pressure in the range of approximately -100 mmHg to -5 mmHg.

5. A localized perfusion system as claimed in claim 1 or 2, wherein one or more of the first drug delivery catheter, the second drug delivery catheter, or the drug recovery catheter are introduced percutaneously.

6. The localized perfusion system of claim 1 or 2, wherein the first drug delivery catheter and / or the second drug delivery catheter are positioned via anterograde cannulation.

7. A localized perfusion system as requested in item 1 or 2, wherein the drug recovery catheter is positioned in the coronary sinus via the patient's vena cava.

8. A system for localized perfusion as claimed in claim 1 or 2, wherein the membrane oxygenation device includes a reservoir containing a drug that contains a therapeutic polynucleotide sequence for treating a cardiac condition present in one or more viral vectors.

9. A system for localized perfusion as described in claim 8, wherein the one or more viral vectors are selected from the group consisting of: adeno-associated virus, adenovirus, retrovirus, herpes simplex virus, bovine papillomavirus, lentiviral vector, vaccinia virus, polyomavirus, Sendai virus, orthomyxovirus, paramyxovirus, papillomavirus, microRNA virus, poxvirus, alpha virus, variants thereof, and combinations thereof.

10. A localized perfusion system as described in claim 8, wherein the viral vector is adeno-associated virus (AAV).

11. The localized irrigation system of claim 10, wherein the AAV is one or more of the following: AAV1, AAV2, AAV3, AAV4, AAV5, AAV6, AAV7, AAV8, AAV9, AAV10, AAV11, AAV12, variants thereof, and combinations thereof.

12. A system for localized perfusion as claimed in claim 8, wherein the therapeutic polynucleotide sequence contains a promoter.

13. A system for localized perfusion as claimed in claim 8, wherein the therapeutic polynucleotide sequence corresponds to a gene expressed in the human heart.

14. A localized perfusion system as claimed in claim 1 or 2, wherein the drug recovery catheter comprises a double balloon catheter.

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