Abstract:
The present invention provides modular transcatheter valve replacement devices and methods of using the same to treat valvular heart diseases. Disclosed is a bottom module that contains a heart valve replacement, and a top module connected to the bottom module. The top module may be bio-absorbable, or may contain one or more severable joints that allow the top module to be removed after implantation. The removable or absorbable top portion serves to add additional length the structure to add in orientation during implantation, but is removed or absorbed to minimize the metal and other foreign material in a patient&#39;s body that could cause thrombosis or other reactions.

Description:
FIELD OF INVENTION 
       [0001]    Provided herein are modular transcatheter valve replacement devices and methods of using the same to optimize valve replacement of a diseased heart valve. 
       BACKGROUND OF THE INVENTION 
       [0002]    All publications cited herein are incorporated by reference in their entirety to the same extent as if each individual publication or patent application was specifically and individually indicated to be incorporated by reference. The following description includes information that may be useful in understanding the present invention. It is not an admission that any of the information provided herein is prior art or relevant to the presently claimed invention, or that any publication specifically or implicitly referenced is prior art. 
         [0003]    Valvular heart disease is characterized by damage to or a defect in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary. The mitral and tricuspid valves control the flow of blood between the atria and the ventricles (the upper and lower chambers of the heart). The pulmonary valve controls the blood flow from the heart to the lungs, and the aortic valve governs blood flow between the heart and the aorta, and thereby to the blood vessels in the rest of the body. The mitral and aortic valves are most frequently affected by valvular heart disease. Transcatheter valve therapies are one treatment option for patients. For example, transcatheter aortic valve replacement (TAVR—also known as TAVI or transcatheter aortic valve implantation) is a procedure for select patients with severe symptomatic aortic stenosis (narrowing of the aortic valve opening) who are not candidates for traditional open chest surgery or are high-risk operable candidates. This procedure wedges a replacement valve into the aortic valve&#39;s place without removing the old or damaged valve. A replacement valve is inserted percutaneously using a catheter and implanted in the orifice of the native aortic valve. Replacement valves may be artificial (prosthetic valves) or made from animal tissue (bioprosthetic valves). The type of replacement valve selected depends on the patient&#39;s age, condition, and the specific valve affected. 
         [0004]    Certain minimum height or length (the longitudinal length along the flow axis of the valve) of the TAVR device is required to optimally orient the device in the aortic canal during deployment of a TAVR device. The longer the TAVR device, the easier it is to position in the canal of the aortic valve. However, the longer the TAVR device, the more metal that remains within the body, which may cause additional complications and reactions including thrombus formation. To solve these technical issues pertaining to the TAVR procedure, the inventors developed modular transcatheter valve replacement devices. In some embodiments, the modular transcatheter valve comprises a top (aortic aspect) module and a bottom (ventricular aspect) module. The bottom module is a small replacement valve (prosthetic or bioprosthetic) that sits in a patient&#39;s heart permanently to replace a diseased valve. The top module is a temporary component that increases the length of the bottom module for easy handling and optimal positioning. The top module may be mechanically detachable, electrically detachable, or bio-absorbable. The modular design maximizes ease of device positioning and minimizes the hardware left behind in the body of the subject. 
       SUMMARY OF THE INVENTION 
       [0005]    The following embodiments and aspects thereof are described and illustrated in conjunction with systems, compositions and methods which are meant to be exemplary and illustrative, not limiting in scope. 
         [0006]    In various embodiments, described herein is a device for transcatheter valve replacement. The device comprises a top module and a bottom module. The bottom module comprises a replacement heart valve. The top module is attached to the bottom module prior to deployment of the device, and then is detached from the bottom module after deployment of the device in some embodiments, or may be bio-absorbable. In some embodiments, the top module may be resemble or be configured as a stent, or may be a simple structure with a few structural wires or ribs to orient the device. 
         [0007]    In various embodiments, provided herein is a method for transcatheter valve replacement. The method comprise the following steps: (1) providing a device, comprising a top module and a bottom module, wherein the bottom module comprises a replacement heart valve, the top module is attached to the bottom module prior to deployment of the device; (2) deploying the device in a patient&#39;s heart to replace a diseased heart valve; (3) detaching the top module from the bottom module; and (4) retrieving the top module out of the patient&#39;s heart. In some embodiments where the top module is bio-absorbable, steps (3) and (4) do not need to be performed. 
         [0008]    In various embodiments, described herein is a device for transcatheter valve replacement. The device comprises a top module and a bottom module. The bottom module comprises a replacement heart valve. The top module is made of bio-absorbable material and is attached to the bottom module prior to deployment of the device. 
         [0009]    In various embodiments, provided herein is a method for transcatheter valve replacement. The method comprise the following steps: (1) providing a device, comprising a top module and a bottom module, wherein the bottom module comprises a replacement heart valve, the top module is attached to the bottom module prior to deployment of the device, and the top module is made of bio-absorbable material; and (2) deploying the device in a patient&#39;s heart to replace a diseased heart valve. 
         [0010]    In various embodiments, disclosed herein is a method of manufacturing a transcatheter valve replacement system including a top module, a bottom module, where the top module is absorbable. This method may include separate manufacturing the bottom module that incorporates a prosthetic valve, but with either a detachable joint portion to the bottom module, or some other connection that may be permanent. Further described is a method of manufacturing a top module that may include manufacturing an absorbable top module, with a detachable joint for attaching to the bottom module. In some embodiments the joint attachment may be permanent, in the case of the absorbable top module. These devices may be manufacturing according to known methods for manufacturing metal allows, shape memory metal and plastic biocompatible plastics and other materials suitable for manufacturing the devices herein. 
     
    
     
       BRIEF DESCRIPTION OF FIGURES 
         [0011]    Exemplary embodiments are illustrated in the referenced figures. It is intended that the embodiments and figures disclosed herein are to be considered illustrative rather than restrictive. 
           [0012]      FIG. 1A  depicts, in accordance with various embodiments of the present invention, a cross sectional view of a modular transcatheter valve replacement device used in TAVR including a top module and a bottom module as implanted into aortic root. 
           [0013]      FIG. 1B  depicts, in accordance with various embodiments of the present invention, a cross sectional view of a modular transcatheter valve replacement device used in TAVR, wherein a bio-absorbable or removable top module has been absorbed or removed. 
           [0014]      FIG. 2A  depicts, in accordance with various embodiments of the present invention, a cross sectional view of a transcatheter valve replacement device with a top module and a bottom module, with retrieval cords attached to the top module. 
           [0015]      FIG. 2B  depicts, in accordance with various embodiments of the present invention, a cross sectional view of a modular transcatheter valve replacement device, wherein the top module has been detached and retrieved after valve deployment, with the bottom module remaining permanently in a patient&#39;s heart. 
           [0016]      FIG. 2C  depicts, in accordance with various embodiments of the present invention, a cross sectional view of a module transcatheter replacement device, wherein the top module has been detached and retrieved after valve deployment through a delivery catheter, which the bottom module remaining permanently in a patient&#39;s heart. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0017]    All references cited herein are incorporated by reference in their entirety as though fully set forth. Unless defined otherwise, technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. Singleton et al., Dictionary of Microbiology and Molecular Biology 3rd ed., J. Wiley &amp; Sons (New York, N.Y. 2001); March, Advanced Organic Chemistry Reactions, Mechanisms and Structure 5th ed., J. Wiley &amp; Sons (New York, N.Y. 2001); and Sambrook and Russell, Molecular Cloning: A Laboratory Manual 3rd ed., Cold Spring Harbor Laboratory Press (Cold Spring Harbor, N. Y. 2001), provide one skilled in the art with a general guide to many of the terms used in the present application. 
         [0018]    One skilled in the art will recognize many methods and materials similar or equivalent to those described herein, which could be used in the practice of the present invention. Indeed, the present invention is in no way limited to the methods and materials described. For purposes of the present invention, the following terms are defined below. 
         [0019]      FIG. 1A  illustrates an embodiment of the valve replacement system that includes a top module  101 , a bottom module  103 , where the bottom module  103  includes a replacement valve. In some embodiments, the replacement valve may include leaflets  102  or valve mechanisms.  FIG. 1A  illustrates the device initially implanted and deployed in the aortic canal, with the ascending aorta  104  above the device, while the device is situated in the native aortic root  105 , and with the left ventricle  106  below the device. After the device is implanted, the top module  101  may either be absorbed or removed. 
         [0020]      FIG. 1B  illustrates the bottom module  103  which contains the valve and leaflets  102  implanted in the native aortic root  105  with the top module  101  already removed or absorbed. This illustrates the reduction in metal and surface area potential for reaction with the implant that removal of the top module  101  allows. Additionally, as can be appreciated from the illustrations that positioning the bottom module  103  without the increased distance of the top module  101 , would allow additional play and rotation of the bottom module, making it difficult to orient during implantation. 
         [0000]    Devices with Mechanically, Electromechanically, or Electrolytically Detachable Top Modules 
         [0021]    In various embodiments, and as illustrated in  FIG. 2A , provided herein is a device for transcatheter valve replacement. The device comprises a top module  101  and a bottom module  103 . The bottom module  103  comprises a replacement heart valve including, in some embodiments, leaflets  102  or other valve structures. The leaflets  102  or other valve structures may be prosthetic or bio-prosthetic. The top module  101  is attached to the bottom module  103  prior to deployment of the device. In some embodiments, and as illustrated in  FIG. 2B , the top module  101  may be detached from the bottom module  103  after deployment of the device. In this embodiment and as illustrated in  FIG. 2A , the top module  101  includes retrieval cords  201  that may be connected to a guide wire, catheter or other structure that may be refracted, thereby removing the top module  101 . In an exemplary embodiment, the retrieval cord  201  is made of nitinol or other suitable materials. In some embodiments, the cords  201  may be attached to the top module  101  in any convenient matter, in this embodiment, they are attached so that connection point is in a center of a cross-section of the top module  101 , so that retraction force will not cause the top module to rotate sideways or put uneven pressure on cardiac or body structures during removal. In some embodiments, top module  101  may be collapsible upon removal, and/or electrolytic disintegration of the detachable joint  203 . Additionally, the device may contain detachable joint  203 , that removably connects the top module  10  to the bottom module  103 , and may be comprised of the various materials and devices disclosed herein. Accordingly, as illustrated in  FIG. 2B , after the detachable joint  203  is detached, and the retrieval cords utilized to retract the top module  101 , only the bottom module  103  remains implanted in the aortic canal. 
         [0022]      FIG. 2C  illustrates an embodiment of the top module  101  being retrieved. In this embodiment, once the top module is detached, it must collapse to fit inside a catheter or other device.  FIG. 2C  shows the top module  101  and cords  201  collapsed inside of and being retrieved through a catheter. In some embodiments, disconnecting the detachable joint  203  may cause the top module  101  to collapse. In other embodiments, the top module  101  may collapse as it is forced into the opening of a catheter. In some embodiments, the catheter used for delivery and retrieving the device may have a small funnel to assist in collapsing the top module  101 . 
         [0023]    In various embodiments, the top module  101  is about 10-30 mm, 5-10 mm, 25-35 mm, or other suitable lengths. In various embodiments, the bottom module  103  is about 10-20 mm, 5-15 mm, or 15-25 mm, or other suitable lengths. 
         [0024]    In various embodiments, the top module  101 , and/or bottom module  103  is self-expandable or balloon expandable. Examples of self-expandable valves include, but are not limited to, MEDTRONIC COREVALVE, which is constructed with a nitinol self-expanding valve stent frame and porcine pericardial leaflets. Examples of balloon-expandable valves include, but are not limited to, EDWARDS SAPIEN XT valve, which is constructed with a cobalt-chromium balloon-expandable valve stent frame and bovine pericardial leaflets. 
         [0025]    In some embodiments, the device can comprise a nitinol frame or other suitable materials. Many other examples of such materials are described in U.S. Publication No. US2011/0319989, incorporated by reference herein in their entirety. The top module  101  may be a stent, or a structure that is comprised of various combinations of supporting ribs or wires that aid in orientation of the device to replace a patient&#39;s valve. In various embodiments, the top module  101  and/or the bottom module  103  comprises a nitinol frame, or other suitable materials as described herein. The bottom module  103  may be a replacement valve that includes a stent or other structure for fixing the bottom module  103  to the aortic canal. 
         [0026]    In various embodiments, the bottom module  103  is configured to replace either an aortic valve, a mitral valve, a pulmonary valve, or a tricuspid valve. In various embodiments, the orientation of the top  101  and bottom  103  modules may switch depending on the access approach employed for device delivery (for instance, transfemoral or transapical). In various embodiments, the replacement heart valve contained in the bottom module  103  is a prosthetic valve or a bio-prosthetic valve. In some embodiments, a prosthetic valve is made of purely artificial or non-biological materials and a bioprosthetic valve is made of animal tissues alone or in combination with artificial or non-biological materials. 
         [0027]    In various embodiments, the top module  101  is mechanically attached to the bottom module  103  prior to deployment of the device. In various embodiments, the top module  101  is mechanically detached from the bottom module  103  after deployment of the device by unlocking a detachable joint  203 . Examples of mechanical detachment mechanisms are shown in U.S. Pat. No. 5,250,071 and U.S. Pat. No. 5,354,295, each of which is incorporated herein by reference in its entirety. For instance, detachable joint  203  may be interlocking clasps that attach the top and bottom modules and are connected to control wires  201  within the catheter. Retraction of the control wire  201  uncouples the detachable joint  203  and therefore separates the top  101  and bottom modules  103  allowing them to separate and the top module  101  to be retrieved. Other mechanical joints  203  that detach may be utilized, including clasp and ring, with a clasp on one module and a ring on the other module, and others. 
         [0028]    In various embodiments, the top module  101  may be electrolytically detached from the bottom module  103  after deployment of the device. In various embodiments, the top module  101  is attached to the bottom module  103  through an electrolytically severable joint  203  prior to deployment of the device. The electrolytically severable joint  203  may be severed after deployment of the device. Examples of electrolytically severable joints  203  include but are not limited to those use in electrically detachable coils (Zubillaga et al., Endovascular occlusion of intracranial aneurysms with electrically detachable coils: correlation of aneurysm neck size and treatment results; AJNR  Am J Neuroradiol.  1994 May; 15(5):815-20). Electrolytically severable joints are a type of sacrificial link between a therapeutic device which is delivered into a patient&#39;s body and is intended to remain at the desired location (e.g., the bottom module  103 ) and another delivery device which is used to deliver the therapeutic device (e.g., the top module  101 ). An electrical current is applied to this type of joints  203  to electrolytically separate the two devices linked together by these joints  203 . For example, in some embodiments, a portion of the link or joint  203  will be stainless steel and will be exposed to the bloodstream. Once the device has been implanted and is in place, positive current may be applied to the exposed portion to corrode away the stainless steel and separating the top module  101  from the bottom module  103 . In some embodiments, this will be after applying current for a few minutes. In this embodiment, certain portions of the joint  203  or surrounding material that are not to be degraded are coated with an insulation coating, for example polyethylene, to prevent their degradation while allowing the exposed portion to degrade and the top module  103  to detach. To apply current, a wire connected to an external power source may be fed into the patient and connected to the exposed stainless steel portion. In other embodiments, a catheter or guide wire may include a battery or other power source embedded within it. In still other embodiments, a series or parallel combination of wires and conductors may carry the electric current to the exposed portion for corrosion. Construction of effective electrolytic joints  203  and mechanisms for applying power to the joints  203  will be apparent for a person of skill in the art, for examples as described in U.S. Pat. No. 5,122,136, U.S. Pat. No. 5,354,295, U.S. Pat. No. 5,423,829, U.S. Pat. No. 5,964,797, U.S. Pat. No. 6,589,230, U.S. Pat. No. 6,953,473 and U.S. Pat. No. 8,377,112, which are herein incorporated by reference in their entirety. 
         [0029]    In various embodiments, provided herein are methods for transcatheter valve replacement. The method comprise the following steps: (1) providing a device, comprising a top module  101  and a bottom module  103 , wherein the bottom module  103  comprises a replacement heart valve, the top module  101  is attached to the bottom module  103  prior to deployment of the device; (2) deploying the device in a patient&#39;s heart to replace a diseased heart valve; (3) detaching the top module  101  from the bottom module  103 ; and (4) retrieving the top module  101  out of the patient&#39;s heart. In some embodiments, the top module  101  is electrolytically or mechanically, or by other electronic means, detached from the bottom module  103  after deployment of the device. 
         [0030]    Also in accordance with the present invention, as TAVR is a known surgical procedure, one of ordinary skill in the art would readily recognize that the method could involve other additional steps, which are not described in details here. These additional steps include, but are not limited to, anesthesia, sterilization, heparinization, accessing the patient&#39;s heart via various routes such as femoral, transaortic, transapical, transaxillary, subclavian, transseptal and transcaval approaches, ventricular pacing, stitching of the access site or percutaneous femoral closure. 
         [0000]    Devices with Bio-Absorbable Top Modules 
         [0031]    In various embodiments, provided herein is a device for transcatheter valve replacement. The device comprises a top module  101  and a bottom module  103 . The bottom module  103  includes a replacement heart valve. The top module  101  is made of bio-absorbable material and is attached to the bottom module  103  prior to deployment of the device. Examples of bio-absorbable materials include, but are not limited to, magnesium alloy, poly-L-lactic acid (PLLA), PLLA coated with poly-D, L-lactide, salicylate molecules, or absorbable tyrosine-derived polycarbonate polymer, or a combination thereof. Additional details may be found in Ormiston et al., (Bioabsorbable Coronary Stents, Circ Cardiovasc Interv. 2009; 2:255-2600), herein incorporated by reference in its entirety. 
         [0032]    In various embodiments, the top module  101  is about 10-30 mm in length. In various embodiments, the bottom module  103  is about 10-20 mm in length. 
         [0033]    In various embodiments, the device is self-expandable or balloon expandable. Examples of self-expandable valves include, but are not limited to, MEDTRONIC COREVALVE, which is constructed with a nitinol self-expanding valve stent frame and porcine pericardial leaflets. Examples of balloon-expandable valves include, but are not limited to, EDWARDS SAPIEN XT valve, which is constructed with a cobalt-chromium balloon-expandable valve stent frame and bovine pericardial leaflets. 
         [0034]    The device can comprise a nitinol or alternative metallic alloy frame. In various embodiments, the top module  101  comprises a nitinol, stainless steel, platinum-iridium, magnesium or cobalt-chromium frame. In various embodiments, the bottom module  103  comprises a nitinol, stainless steel, platinum-iridium, magnesium or cobalt-chromium frame, or other materials as disclosed herein or known in the art. 
         [0035]    In various embodiments, wherein the bottom module  103  is configured to replace aortic valve, mitral valve, pulmonary valve, or tricuspid valve. In various embodiments, the replacement heart valve is a prosthetic valve or a bio-prosthetic valve. In some embodiments, a prosthetic valve is made of purely artificial or non-biological materials, and a bioprosthetic valve is made of animal tissues alone or in combination with artificial or non-biological materials. 
         [0036]    In various embodiments, the top module  101  comprises magnesium alloy, poly-L-lactic acid (PLLA), PLLA coated with poly-D, L-lactide, salicylate molecules, or absorbable tyrosine-derived polycarbonate polymer, or a combination thereof. In various embodiments, the top module  101  is absorbed about 6-12 months or 1-2 years after deployment of the device. For example, the top module  101  can be absorbed 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, or 30 months after deployment of the device. 
         [0037]    In various embodiments, the device further comprises radio-opaque markers. In some embodiments, the radio-opaque markers are made of gold or platinum. In other embodiments, the radio-opaque markers are iodine impregnated in bio-absorbable materials. 
         [0038]    In various embodiments, the present invention provides for a method for transcatheter valve replacement. The method comprise the following steps: (1) providing a device, comprising a top module  101  and a bottom module  103 , wherein the bottom module  103  comprises a replacement heart valve, the top module  101  is attached to the bottom module  103  prior to deployment of the device including leaflets  102 , and the top module  101  is made of bio-absorbable material; and (2) deploying the device in a patient&#39;s heart to replace a diseased heart valve. In various embodiments the method for deploying the device in a patient&#39;s heart may incorporate portions of standard methods and devices for a TAVR or transapical aortic valve implantation. This may include standard guide wire and catheter delivery procedures for delivering the device. In some embodiments, the catheter delivery system may include mechanical actuators that unlock the detachable joint  203  by triggering of an electrical or mechanical switch or action, that is translated or carried down to the detachable joint  203 , releasing the detachable joint. In some embodiments, a catheter/guide wire delivery system will include a retraction mechanism or guide wire that may attached to the retraction cords  201 . 
         [0039]    Also in accordance with the present invention, as TAVR is a known surgical procedure, one of ordinary skill in the art would readily recognize that the method could involve other additional steps, which are not described in details here. These additional steps include, but are not limited to, anesthesia, sterilization, heparinization, accessing the patient&#39;s heart via various routes such as femoral, transaortic and transapical approaches, ventricular pacing, and stitching of the access site or percutaneous femoral closure. 
         [0040]    Currently, replacement valves must be a certain minimum length/height in order for them to be properly positioned during deployment. However, this length makes for a device with a surface area that is considered too large and therefore may provide too much risk of reactions, including thrombus formation. The top module  101  allows optimal positioning of the device, and is detachable or absorbable. The bottom module  103  sits in the aortic root and is short in height. The modular approach described herein allows for the valve to be of optimal length, thus leaving virtually no excess material behind after the valve replacement surgery or only temporarily leaving some excess material behind after the valve replacement surgery. This is optimal, as the extended length is only required for positioning, and is not essential once the valve is anchored in place. 
         [0041]    In various embodiments as described in the present invention, a top module  101  first helps delivery of the replacement heart valve (e.g., the bottom module  103 ), and then is either detached or absorbed over time once the replacement heart valve is deployed in the subject. In the bio-absorbable version of the transcatheter valve, the top module  101  is absorbed in about 6-12 months or 1-2 years after valve deployment. In the detachable version of the transcatheter valve, the top module  101  is detached immediately or shortly after deployment of the valve, and in some embodiments, detached after a few minutes of application of positive current. This modular design is suitable for replacement of diseased aortic valves, mitral (bicuspid) valves, pulmonary valves or tricuspid valves. 
         [0042]    The various methods and techniques described above provide a number of ways to carry out the application. Of course, it is to be understood that not necessarily all objectives or advantages described can be achieved in accordance with any particular embodiment described herein. Thus, for example, those skilled in the art will recognize that the methods can be performed in a manner that achieves or optimizes one advantage or group of advantages as taught herein without necessarily achieving other objectives or advantages as taught or suggested herein. A variety of alternatives are mentioned herein. It is to be understood that some preferred embodiments specifically include one, another, or several features, while others specifically exclude one, another, or several features, while still others mitigate a particular feature by inclusion of one, another, or several advantageous features. 
         [0043]    Furthermore, the skilled artisan will recognize the applicability of various features from different embodiments. Similarly, the various elements, features and steps discussed above, as well as other known equivalents for each such element, feature or step, can be employed in various combinations by one of ordinary skill in this art to perform methods in accordance with the principles described herein. Among the various elements, features, and steps some will be specifically included and others specifically excluded in diverse embodiments. 
         [0044]    Although the application has been disclosed in the context of certain embodiments and examples, it will be understood by those skilled in the art that the embodiments of the application extend beyond the specifically disclosed embodiments to other alternative embodiments and/or uses and modifications and equivalents thereof. 
         [0045]    In some embodiments, the terms “a” and “an” and “the” and similar references used in the context of describing a particular embodiment of the application (especially in the context of certain of the following claims) can be construed to cover both the singular and the plural. The recitation of ranges of values herein is merely intended to serve as a shorthand method of referring individually to each separate value falling within the range. Unless otherwise indicated herein, each individual value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (for example, “such as”) provided with respect to certain embodiments herein is intended merely to better illuminate the application and does not pose a limitation on the scope of the application otherwise claimed. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the application. 
         [0046]    Preferred embodiments of this application are described herein, including the best mode known to the inventors for carrying out the application. Variations on those preferred embodiments will become apparent to those of ordinary skill in the art upon reading the foregoing description. It is contemplated that skilled artisans can employ such variations as appropriate, and the application can be practiced otherwise than specifically described herein. Accordingly, many embodiments of this application include all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above-described elements in all possible variations thereof is encompassed by the application unless otherwise indicated herein or otherwise clearly contradicted by context. 
         [0047]    All patents, patent applications, publications of patent applications, and other material, such as articles, books, specifications, publications, documents, things, and/or the like, referenced herein are hereby incorporated herein by this reference in their entirety for all purposes, excepting any prosecution file history associated with same, any of same that is inconsistent with or in conflict with the present document, or any of same that may have a limiting affect as to the broadest scope of the claims now or later associated with the present document. By way of example, should there be any inconsistency or conflict between the description, definition, and/or the use of a term associated with any of the incorporated material and that associated with the present document, the description, definition, and/or the use of the term in the present document shall prevail. 
         [0048]    It is to be understood that the embodiments of the application disclosed herein are illustrative of the principles of the embodiments of the application. Other modifications that can be employed can be within the scope of the application. Thus, by way of example, but not of limitation, alternative configurations of the embodiments of the application can be utilized in accordance with the teachings herein. Accordingly, embodiments of the present application are not limited to that precisely as shown and described.