A Flow Regulating Device In The Heart

Abstract

A blood flow regulator for creating a shunt in the heart, comprising; a proximal element having a general disc-shape, defined by a braid of one or more wires extending about a central aperture of the proximal element; a distal element having a general disc-shape, defined by a braid of one or more wires extending about a central aperture of the distal element; and a third element defining a neck section intermediate the proximal and distal elements and forming a cavity having a diameter no greater than a diameter of each of the distal and proximal elements, wherein said distal element comprises at least one loop of a wire extending radially outwardly from a center of the distal element and returning towards said center of said distal element.

Claims

1. A blood flow regulator (100) for creating a shunt in the heart, comprising; a proximal element (101) having a general disc-shape, defined by a braid of one or more wires extending about a central aperture (103) of the proximal element; a distal element (102) having a general disc-shape, defined by a braid of one or more wires extending about a central aperture (104) of the distal element; and a third element (105) defining a neck section intermediate the proximal and distal elements and forming a cavity (106) having a diameter no greater than a diameter of each of the distal and proximal elements, wherein said distal element comprises at least one loop (107) of a wire extending radially outwardly from a center (108) of the distal element and returning towards said center of said distal element.

2. Blood flow regulator according to claim 1, wherein said proximal element, said distal element, and said third element are formed of the same braiding of one or more wires.

3. Blood flow regulator according to claim 2, wherein said proximal element comprises a connecting element (109) for a delivery device, wherein ends of said one or more wires are fixed to said connecting element, and wherein said distal element comprises returning loops (107) of said one or more wires whereby opposite ends of said one or more wires forming said distal element are fixed to said connecting element.

4. Blood flow regulator according to any of claims 1-3, wherein the braiding at a perimeter (110) of said distal element is folded radially inwards to form a double layer (111) braid around said perimeter of the distal element.

5. Blood flow regulator according to any of claims 1-4, further comprising a membrane (112) arranged around said cavity.

6. Blood flow regulator according to any of claims 1-5, wherein said distal element further comprises a membrane (113) that promotes endothelialization, and/or wherein said proximal element further comprises a membrane (114) that promotes endothelialization.

7. Blood flow regulator according to any of claims 1-6, wherein said distal element comprises non-braided filaments (115) forming petal-shaped loops (116).

8. Blood flow regulator according to any of claims 1 -7, wherein said third element is resilient such that it is deformable to a non-circular shape in a septum of the heart, such as to an at least partly oval shape, and/or wherein said third element has an at least partly oval cross-section.

9. Blood flow regulator according to claim 3, wherein said connecting element is joined to said proximal portion via a flexing element (117) formed from said one or more wires being fixated to said connecting element.

10. Blood flow regulator according to claim 3, wherein said connecting element is formed by a weld having an at least partly spherical shape.

11. Blood flow regulator according to any of claims 1-10, wherein said distal element comprises an at least partly concave shape (118) being concave in a direction towards said proximal element.

12. Blood flow regulator according to any of claims 1-11, wherein said central apertures are arranged concentrically in said distal and proximal elements.

13. Blood flow regulator according to any of claims 1-12, wherein said proximal element has an oval shape, and/or wherein said distal element has an oval shape.

14. Blood flow regulator according to claim 6, wherein said membrane (113, 114) comprises at least one of; a partially biodegradable material; a filament; an elastic polymeric material; or one or more natural fabrics.

15. Blood flow regulator according to claim 14, wherein said membrane comprises an elastic polymeric material selected from a group including nylon, polyester, polypropylene, polytetrafluoroethylene, and expanded polytetrafluoroethylene.

16. The blood flow regulator according to claim 1, wherein said proximal and distal elements are expandable, and said proximal element has a lower expansion strength than the distal element.

17. A method (200) of manufacturing a blood flow regulator (100) comprising; braiding (201) a tubular braid of wires, where opposite ends of each wire are arranged at a proximal portion of said tubular braid, and loops of said wires are arranged at a distal end of said tubular braiding, forming (202) a distal disc of said distal end of the tubular braiding, forming (203) a proximal disk of said proximal end of the tubular braiding, forming (204) a central aperture in each of said distal and proximal discs such that said apertures are joined by a central channel (106) of the tubular braiding, extending between said discs, fixating (205) said opposite ends of wire in a connecting element located at the proximal disk with an off-set distance (119) from a central axis (108) extending through said channel.

18. Method according to claim 17, comprising folding (206) the braiding at a perimeter of said distal element radially inwards to form a double layered braid around said perimeter of the distal element.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

[0020] These and other aspects, features and advantages of which embodiments of the disclosure are capable of will be apparent and elucidated from the following description of embodiments of the present disclosure, reference being made to the accompanying drawings, in which;

[0021] FIGS. 1a-b illustrate a blood flow regulator according to embodiments of the invention in a cross-sectional side view and in a perspective view of the distal disc, respectively;

[0022] FIGS. 2a-b illustrate a blood flow regulator according to embodiments of the invention in a top-down view of the distal disc and in side view, respectively;

[0023] FIGS. 3a-b illustrate a blood flow regulator according to embodiments of the invention in a top-down view of the proximal disc and distal disc, respectively;

[0024] FIGS. 4a-b illustrate a blood flow regulator according to embodiments of the invention in a cross-sectional side view and in a perspective view of the proximal disc, respectively;

[0025] FIG. 4c illustrates a blood flow regulator according to an embodiment of the invention in a schematic cross-sectional side view of the outline of the braiding;

[0026] FIGS. 4d-e illustrate a blood flow regulator according to an embodiment of the invention in further perspective views, where FIG. 4d is a cross-sectional view;

[0027] FIGS. 5a-c illustrate a blood flow regulator according to embodiments of the invention in a top-down plan view, a cross-sectional side view, and in a perspective side view, respectively;

[0028] FIGS. 6a-c illustrate a blood flow regulator according to embodiments of the invention in a top-down plan view, a cross-sectional side view, and in a perspective side view, respectively;

[0029] FIGS. 7a-c illustrate a blood flow regulator according to embodiments of the invention in a top-down plan view, a cross-sectional side view, and in a perspective side view, respectively;

[0030] FIGS. 8a-c illustrate a blood flow regulator according to embodiments of the invention in a top-down plan view, a cross-sectional side view, and in a perspective side view, respectively;

[0031] FIG. 9 illustrate a catheter used for implantation of a blood flow regulator according to embodiments of the invention; and

[0032] FIG. 10 is a flow-chart of a method of manufacturing a blood flow regulator according to embodiments of the invention.

DESCRIPTION OF EMBODIMENTS

[0033] Specific embodiments of the disclosure now will be described with reference to the accompanying drawings. This disclosure may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein; rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey the scope of the disclosure to those skilled in the art. The terminology used in the detailed description of the embodiments illustrated in the accompanying drawings is not intended to be limiting of the disclosure. In the drawings, like numbers refer to like elements.

[0034] The following description focuses on embodiments of the present disclosure applicable to blood regulating devices for septal defects. However, it will be appreciated that the disclosure is not limited to this application but may be applied to many other medical implants including for example stents, vascular devices, and various other devices that can be provided with a well-defined shunt such as a Patent foramen ovale (PFO) device, a PDA device, or a ventricular septal defect (VSD) device.

[0035] FIG. 1a is a blood flow regulator 100 for creating a shunt in the heart, comprising a proximal element 101 having a general disc-shape, defined by a braid of one or more wires extending about a central aperture 103 of the proximal element. The blood flow regulator further comprise a distal element 102 having a general disc-shape, defined by a braid of one or more wires extending about a central aperture 104 of the distal element, and a third element 105 defining a neck section intermediate the proximal and distal elements and forming a cavity 106, i.e. a trough hole or channel extending through the proximal element, the distal element and the third element. The proximal and distal elements are placed on either side of the septum, with the third element 105 situated within the septum. The diameter of the cavity 106 is not greater than the diameter of each of the distal and proximal elements 101, 102. The distal element 102 comprises at least one loop 107 of a wire extending radially outwardly from a center 108 of the distal element 102 and returning towards said center 108 of the distal element 102. I.e. the braiding of the distal element 102 comprises wires that extend radially outward, i.e. radiates out to a perimeter, from the center axis 108, and then returning towards the center axis 108, thereby forming a loop wire 107. FIG. 1b illustrates only schematically an example of such loop wire 107. FIG. 1a illustrates the blood flow regulator device in a cross-sectional side view. This advantageously removes the need of having to collect wire ends at the distal element of the blood flow regulator 100. A problem with prior art devices is that any element at the distal end collecting the wire ends, such as a connector, weld, or hub, presents a discontinuity in the braiding which will create less than optimal conditions for the endothelialization process, and even result in formation of embolies. Distal connectors will in some instances even protrude from the distal element and thereby further disrupt the endothelialization process. Thus, the wire loops 107 of the braiding at the distal element 102 will provide for a smooth, even, and continuous distal surface that allows for optimal conditions for formation of endothelia. In some embodiments of the invention, all of the wires forming the distal element 102 are loop wires 107, thus the distal element 102 is free from wire ends, that will provide for the smooth, even, and continuous distal surface with the advantages described previously. FIG. 2a shows a top-down view of the distal element or disc 102 of blood flow regulator device 100, showing the loop wires 107 having their apex at the peripheral region of the distal disc 102. In this embodiment, also all of the wires forming the braiding of the distal element are loop wires 107, whereby the distal element is free from wire ends.

[0036] The proximal element 101, the distal element 102, and the third element 105 may be formed of the same braiding of one or more wires. Thus the blood flow regulator device 100 may be formed from the same single piece of braiding, which is illustrated in e.g. FIGS. 2a-b, and 3a-b. This provides for a flexible device that adapts well to the anatomy, after expanding out of the delivery catheter, while at the same time providing good fixation at the implanted site and the necessary support for keeping an open channel, and further, less manufacturing steps. The device 100 can flatten, fold, or collapse inside of delivery catheter and the respective elements of the device recover their original shape after removal from catheter.

[0037] The device 100 may comprise one or more radiopaque markers (not shown) in order to identify the device 100 during the procedure. The radiopaque marker can be applied to any part of the device. The marker may be applied at the periphery of the aperture 103 or 104, so that the channel 106 can be clearly localized. It may be desired to access the opening 106 with a catheter.

[0038] The proximal element may comprise a connecting element 109 for a delivery device, wherein ends of the one or more wires are fixed to the connecting element. The distal element 102 comprises returning loops 107 of the one or more wires whereby opposite ends of the one or more wires forming the distal element 102 are fixed to the connecting element 109. Thus, the ends of the wires forming the distal element 102 are fixated to the connecting element 109 at the proximal end 101. FIGS. 2b, which is a side-view, and FIG. 3a, which is a view of the proximal end 101, illustrates how the ends of the wires are fixated to the connecting element 109, and there is no other connecting element present, or wire end that is not terminating in the proximal connecting element 109. The distal element 102 can therefore be formed of the wire loops 107 and present a flat and smooth surface with the advantages discussed above. Having a smooth, continuous distal surface, which requires fixation of all wire ends to a single proximal connecting element 109, while simultaneously having the connecting element 109 arranged with an off-set distance 119, allowing for the a through channel 106 across the device 100, is advantageously provided and possible due to having the wires at the proximal end 101 looped around the central aperture 103 as illustrated in FIG. 3a.

[0039] The braiding at a perimeter 110 of the distal element 102 may be folded radially inwards to form a double layer 111 braid around the perimeter 110 of the distal element 102, which is illustrated schematically in FIG. 4c. Like the proximal element 101, the distal element 102 may thus have a double layer of braiding around a peripheral portion thereof. The fold 111 may extend with a length radially inwards towards the center axis 108 as desired. The perimeter 110 of the distal disc can thus be provided with a more even circular shape, e.g. comparing FIG. 2a which is not folded with FIG. 3b which has the folded braiding, which can be advantageous with respect to the handling of the device and also the behavior of the device when implanted, as the fold 111 an further increase the structural integrity of the device 100.

[0040] The blood flow regulator 100 may further comprise a membrane 112 arranged around the cavity or channel 106, which is illustrated in FIG. 4a. The membrane 112 can prevent ingrowth of tissue in the cavity 106, thus providing for maintaining the desired flow for long-term use. The membrane can be provided on the outside or the inside of the third element 105. The membrane can be applied by coating a polymer fiber on the third element 105. The polymer fiber can be applied by a spin coating process, where the device 100 can be rotated while spraying the polymer fiber onto the device 100.

[0041] The distal element 102 may further comprise of a membrane 113 that promotes endothelialization. In addition, or alternatively, the proximal element 101 may further comprises of membrane 114 that promotes endothelialization.

[0042] FIG. 4a illustrates how the membranes, 112, 113, 114, may be arranged on the blood flow regulator 100, but the membrane coverage in the device 100 may be varied as desired for the application. FIGS. 6b and 8a also illustrate a membrane arranged at the proximal element, but may also be positioned at the distal element.

[0043] The distal element 102 may comprise non-braided filaments 115 forming petal-shaped loops 116, which is illustrated in FIGS. 6a-c.

[0044] The flow control device illustrated in FIGS. 6a-cis thus partly braided and has comparatively less amount of metallic structure than the previously described examples in FIGS. 1-4. Having less metal may facilitate the incorporation the device in the body since the tissue overgrowth can be faster. The non-braided filaments may have a different rigidity or flexibility which may be advantageous in some applications. The strength of disc-shaped region of distal element 102 does not affect the strength of the proximal element 101.

[0045] The device 100 in FIGS. 6a-c is designed to create a shunt between vessels and heart chambers while minimizing metallic structure and facilitating calibration of a diagnostic system. The filament body structure 115 of the distal element 101 may be formed of one or more nitinol filaments, or any other metal alloy that is biocompatible, and being able to heat set in the desired shape. It may be advantageous to have at least three filaments 115, which can be equally spaced apart to achieve the desired stability of the device 100.

[0046] The retention force of the distal element 102 can be adjusted by selecting the number of filaments 115.

[0047] The distal element 102 may be formed from a single filament wire or it can be formed from a plurality of filament wires.

[0048] A desired filament body structure may employ, for example, 3, 4, 5, 12 6, 7, 8, 9, 10, or 12 pieces of filaments as desired depending on the use of the device. All these filaments may have a regular or irregular filament body structure, e.g. forming forming a petal shape as mentioned, where each filament 115 extend from the axial center 108 of a geometric plane, and each filaments joining each other in a radially inward location, e.g. by welding. The filament body structure may be obtained using techniques such as pinching sutures or wires together or hooking sutures or wires together.

[0049] The filaments 115 may be of equal gauge or of different gauge (wire size).

[0050] The distal element 102 and the proximal element 101 may be formed separately and combined prior to implantation. The third element 105, may also be formed separately.

[0051] It is possible to manufacture the proximal and distal elements with completely different properties independently.

[0052] It is also possible that the proximal element 101 is formed from non-braided filament wires 115, which can assume a petal-shaped proximal portion.

[0053] In a method, the different parts can be joined using techniques such as welding, pinching, clamping or hooking a plurality of wires together.

[0054] It is also possible that a braided device 100, having a braided proximal 101 and distal 102 element and a third neck portion 105 is combined with non-braided filament wires 115.

[0055] Further, the proximal and distal elements 101, 102, may be braided with different wire thicknesses, which would allow e.g. different expansion forces of the proximal and distal elements 101, 102, such as when having a non-braided distal element 102.

[0056] The proximal and distal elements 101, 102, are expandable, and the proximal element may thus have a lower expansion strength than the distal element.

[0057] The third element 105 may be resilient such that it is deformable to a non-circular shape in a septum of the heart, such as to an at least partly oval shape or any irregular shape. In general the device 100 has elastic properties making it suitable both systolic and diastolic motion of the septum, in particular the atrial septum. The third element 105 may be flexible to allow movement of the proximal and distal elements 101, 102, relative to each other, in the plane of the disc-shaped elements, i.e. a parallel sliding motion. This is advantageous in some irregular-shaped anatomies. Further the third element 105 may movement in the axial direction, along the centre axis 108, which allows for a certain adaptation to the geometry of the anatomy also in this direction.

[0058] The third element 105 may have an at least partly oval cross-section in the relaxed, unstrained, heat-set shape. This may be advantageous in some anatomies, and the device can more easily adapt to the anatomy without producing unnecessary strain or dislocation. The cavity 106 may thus also be formed as desired, e.g. having the oval cross-section. The proximal and distal elements 101, 102, may also have varying shapes, such as oval or other irregular shapes as may be advantageous for varying anatomies, and not only disc-shaped. The oval or irregular shapes of the mentioned elements are formed in the heat-setting procedure with respectively shaped molds, such that the shapes can be maintained.

[0059] The connecting element 109 may be joined to the proximal portion 101 via a flexing element 117 formed from the one or more wires being fixated to the connecting element, as illustrated in e.g. FIGS. 2b and 4c. This allows for a flexibility between the connecting element 109 and the proximal and distal portions 101, 102 of the device 100, which can be advantageous during the implantation procedure, e.g. in narrow anatomies where the angle between the delivery device and the blood flow regulating device 100 needs to be increased at the implantation stage, and the pivoting motion provided by the connecting element itself may not be sufficient.

[0060] The connecting element 109 may be formed by a weld having an at least partly spherical shape, as illustrated in e.g. FIG. 2b. This allows for the mentioned pivoting motion by grasping the connecting element with a delivery device having a holder with the corresponding spherical surface.

[0061] The distal element 102 may comprise an at least partly concave shape 118 being concave in a direction towards the proximal element 101, which is illustrated in e.g. FIGS. 1a and 2b. This facilitates a flush apposition of the distal element 102 against the tissue, and also improved fixation, since the concave surface forms an angled rim at the periphery of the distal disc that may flex against the tissue, thereby creating a bias force against the tissue in the axial direction 108. The proximal element may also have a concave shape towards the distal element 102, as illustrated in FIG. 1a. FIG. 4a illustrates the case where the distal element 102 and the proximal element 101 are generally parallel to each other. It may however be possible to have varying angles between these elements.

[0062] The central apertures 103, 104, may be arranged concentrically in the proximal and distal elements 101, 102, respectively, as illustrated in e.g. FIG. 3b. Such symmetry may be advantageous with respect to structural stability of the device 100 and may provide for a more secure anchoring of the device 100 at the implanted site since the disc portions of the proximal and distal ends has a uniform overlap with the tissue.

[0063] The membrane 113 of the distal element, and/or the membrane 114 of the proximal element may be formed of a thin, flexible material and comprise at least one of; a partially biodegradable material; a filament; an elastic polymeric material; or one or more natural fabrics such as silk or wool can be used.

[0064] In one embodiment, the membrane 113, 114, is formed of a woven polyester. The membrane 113, 114, may be made of a dense material. Membranes 113, 114, can also be made, at least partly, by a biodegradable material, which also facilitate thrombosis.

[0065] The membrane 113, 114, may comprise an elastic polymeric material selected from a group including nylon, polyester, polypropylene, polytetrafluoroethylene, and expanded polytetrafluoroethylene.

[0066] In one embodiment, at least one of the distal element 102 or the proximal element 101 includes a coating, preferably a cell proliferation coating. The use of a cell proliferation coating enhances the adhesion and proliferation of endothelial cells onto surfaces. The use of similar coatings may further provide faster endothelization.

[0067] Table 1 and FIG. 4a show possible dimensions of the outer diameter D2 of the distal and/or proximal elements, as well as the diameter D1 of the cavity 106, and the closest distance (h) between the proximal and distal elements 101, 102. The dimensions are given for respective puncture size. In FIGS. 4a, 4d, 4e, the proximal and distal discs have similar or same diameter, but the diameters of these discs may be different and varied as desired for the application. E.g. FIG. 4b illustrates a larger proximal disc. Alternatively, the distal disc may be larger than the proximal disc.

TABLE-US-00001 TABLE 1 Introducing Puncture D1 D2 h System Size Size [mm] [mm] [mm] ODS* D ≦ 4 4 17 2  8F   5 < D ≦ 6 6 19 2 10F 6.5 < D ≦ 8 8 22 2 12F 7.5 < D ≦ 10 10 24 2 14F D ≦ 4 4 17 5  8F   5 < D ≦ 6 6 19 5 10F 6.5 < D ≦ 8 8 22 5 12F 7.5 < D ≦ 10 10 24 5 14F D ≦ 4 4 17 10  8F   5 < D ≦ 6 6 19 10 10F 6.5 < D ≦ 8 8 22 10 12F 7.5 < D ≦ 10 10 24 10 14F

[0068] FIGS. 5a-c, 6a-c, 7a-c, and 8a-c are other illustrations of the blood flow regulating device 100 described above. Diameters D1 and D2 are indicated in FIG. 5a. D1 may be varied to provide the desired flow in the shunt, while D2 is varied to provide sufficient anchoring of the device at the septum. Further dimensions of the device 100 are discussed with reference to FIGS. 6a-c, 7a-c, and 8a-c. For example, with reference to FIG. 6a, dimension D9 is an angular distance between crests of two adjacent nitinol filaments (loops) 115, which are formed to create the distal unit 102 of the flow control device 100. Dimension D10 is intended as a reference to nitinol wire diameter, which may vary according to device size. Turning to FIG. 5b, dimension D4 is the diameter of a connecting element 109 used to connect the flow control device to a pusher cable of a catheter used for device implantation. Dimension D5 is a distance between a proximal element surface 101′ of the proximal element 101 and the connecting element 109. As illustrated in FIG. 6b, for example, dimension D6 is the thickness of the membrane 114 on the proximal element 101 of the flow control device 100. The thickness of the membrane 113 on the distal element 102 is not indicated, but the thickness of the both membranes can be equal. Turning to FIG. 7b, dimension D8 is the thickness of the frame between the cavity diameter D1 and the waist diameter of the third element 105. As illustrated in FIG. 5a, dimension D3 is the distance between the outer tangent of the flow control device diameter and the center of the connecting element 109. FIGS. 7a-c illustrate a flow control device 100 having a cavity 106 with a larger diameter than e.g. the device 100 illustrated in FIGS. 5a-c and 6a-c, thus used for providing a larger opening. FIGS. 8a-c illustrate a flow control device 100, which is used to create a hole in a body with a longer connecting neck, i.e. having a longer dimension (h), for different applications such as posterior descending artery (PDA) stenting. Generally, the two discs on the two sides of the device provide maximum support with a clamping force and with a very limited distance between the disc, providing for improved anchoring and stabilization of the device after implantation, and maintaining the calibrated size of the channel.

[0069] FIG. 10 illustrates a method 200 of manufacturing a blood flow regulator 100. The method comprises braiding 201 a tubular braid of wires, where opposite ends of each wire are arranged at a proximal portion of the tubular braid, and loops of the wires are arranged at a distal end of the tubular braiding. The method comprises forming 202 a distal disc 102 of the distal end of the tubular braiding, forming 203 a proximal disk 101 of the proximal end of the tubular braiding. The method 200 further comprises forming 204 a central aperture 103, 104, in each of the distal and proximal discs such that the apertures are joined by a central channel 106 of the tubular braiding, extending between the discs, and fixating 205 the opposite ends of wire in a connecting element 109 located at the proximal disk with an off-set distance 119 from a central axis 108 extending through the channel. The off-set distance 119 is illustrated in FIG. 4a, and may be varied as desired for providing the optimal location of the connecting element 109.

[0070] The method 200 may further comprise folding 206 the braiding at a perimeter 110 of the distal element 102 radially inwards to form a double layered braid 111 around the perimeter 110 of the distal element 102.

[0071] The various flow control device 100 of the present disclosure are used in medical procedures to provide a shunt in the body, such as in an atrial septum. The medical procedure in question may also comprises of following steps. Positioning the flow control device with a restraining catheter. Positioning a pushing cable into the restraining catheter adjacent to the device. Inserting the restraining catheter, the pushing cable, and the device into the body at a transdermal site. Positioning the distal end of the restraining catheter at the target site and the device inside the body opening created by a previous interventional method such as septostomy. Pushing the device through the restraining catheter with the pushing cable until the device has been released, so that distal element of the device is positioned on an inside of a rupture. Removing the pushing cable and the retraining catheter, so that distal part of the distal unit of the device is positioned on an inside of a rupture to be shaped by the device. FIG. 9 shows a lateral view of a catheter suitable for use in the above described medical procedure for closure of a hole in a body. The catheter is used to deliver the flow control device, also referred to as the blood flow regulating device 100, to the desired location and perform a precise implantation. In one exemplary use, a delivery sheath is placed in the punctured hole in the arterial septum with the aid of a guide wire. The pusher cable with a plastic torque control is used to advance the flow control device to the desired location and to deploy the flow control device when it is advanced to the right location.

[0072] The present disclosure has been described above with reference to specific embodiments. However, other embodiments than the above described are equally possible within the scope of the disclosure. Different method steps than those described above, may be provided within the scope of the disclosure. The different features and steps of the disclosure may be combined in other combinations than those described. The scope of the disclosure is only limited by the appended patent claims. More generally, those skilled in the art will readily appreciate that all parameters, dimensions, materials, and configurations described herein are meant to be exemplary and that the actual parameters, dimensions, materials, and/or configurations will depend upon the specific application or applications for which the teachings of the present disclosure is/are used.