WO2002030292A1 - Methods and devices for improving mitral valve function - Google Patents
Methods and devices for improving mitral valve function Download PDFInfo
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- WO2002030292A1 WO2002030292A1 PCT/US2001/030882 US0130882W WO0230292A1 WO 2002030292 A1 WO2002030292 A1 WO 2002030292A1 US 0130882 W US0130882 W US 0130882W WO 0230292 A1 WO0230292 A1 WO 0230292A1
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- splint
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
- A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
- A61F2/02—Prostheses implantable into the body
- A61F2/24—Heart valves ; Vascular valves, e.g. venous valves; Heart implants, e.g. passive devices for improving the function of the native valve or the heart muscle; Transmyocardial revascularisation [TMR] devices; Valves implantable in the body
- A61F2/2478—Passive devices for improving the function of the heart muscle, i.e. devices for reshaping the external surface of the heart, e.g. bags, strips or bands
- A61F2/2487—Devices within the heart chamber, e.g. splints
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/12—Surgical instruments, devices or methods, e.g. tourniquets for ligaturing or otherwise compressing tubular parts of the body, e.g. blood vessels, umbilical cord
- A61B17/122—Clamps or clips, e.g. for the umbilical cord
- A61B17/1227—Spring clips
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
- A61B2017/00238—Type of minimally invasive operation
- A61B2017/00243—Type of minimally invasive operation cardiac
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0401—Suture anchors, buttons or pledgets, i.e. means for attaching sutures to bone, cartilage or soft tissue; Instruments for applying or removing suture anchors
- A61B2017/0404—Buttons
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B17/0469—Suturing instruments for use in minimally invasive surgery, e.g. endoscopic surgery
- A61B2017/048—Suturing instruments for use in minimally invasive surgery, e.g. endoscopic surgery for reducing heart wall tension, e.g. sutures with a pad on each extremity
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/04—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials
- A61B2017/0496—Surgical instruments, devices or methods, e.g. tourniquets for suturing wounds; Holders or packages for needles or suture materials for tensioning sutures
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61F—FILTERS IMPLANTABLE INTO BLOOD VESSELS; PROSTHESES; DEVICES PROVIDING PATENCY TO, OR PREVENTING COLLAPSING OF, TUBULAR STRUCTURES OF THE BODY, e.g. STENTS; ORTHOPAEDIC, NURSING OR CONTRACEPTIVE DEVICES; FOMENTATION; TREATMENT OR PROTECTION OF EYES OR EARS; BANDAGES, DRESSINGS OR ABSORBENT PADS; FIRST-AID KITS
- A61F2/00—Filters implantable into blood vessels; Prostheses, i.e. artificial substitutes or replacements for parts of the body; Appliances for connecting them with the body; Devices providing patency to, or preventing collapsing of, tubular structures of the body, e.g. stents
- A61F2/02—Prostheses implantable into the body
- A61F2/24—Heart valves ; Vascular valves, e.g. venous valves; Heart implants, e.g. passive devices for improving the function of the native valve or the heart muscle; Transmyocardial revascularisation [TMR] devices; Valves implantable in the body
- A61F2/2478—Passive devices for improving the function of the heart muscle, i.e. devices for reshaping the external surface of the heart, e.g. bags, strips or bands
- A61F2/2481—Devices outside the heart wall, e.g. bags, strips or bands
Definitions
- the present invention relates to devices and related methods for improving the function of heart valves, and more particularly to devices and related methods that passively assist in the apposition of heart valve leaflets to improve valve function of poorly functioning valves.
- Heart failure is a condition whereby the left ventricle becomes enlarged and dilated as a result of numerous etiologies.
- Initial causes of heart failure include chronic hypertension, myocardial infarction, mitral valve incompetency, and other dilated cardiomyopathies. With each of these conditions, the heart is forced to overexert itself in order to provide the cardiac output demanded from the body during its various demand states. The result is an enlarged left ventricle.
- a dilated heart and particularly a dilated left ventricle, can significantly increase the tension and/or stress in the heart wall both during diastolic filling and systolic contraction, which contributes to ongoing dilatation of the chamber.
- Prior treatments for heart failure include pharmacological treatments, assist devices such as pumps, and surgical treatments such as heart transplant, dynamic cardiomyoplasty, and the Batista partial left ventriculectomy. These prior treatments are described briefly in U.S. Patent No. 5,961,440 to Schweich, Jr. et al., issued October 5, 1999 and entitled "Heart Wall Tension Reduction Apparatus and Method," the complete disclosure of which is incorporated by reference herein.
- a more recent concept for treating heart failure applies one or more splints onto the heart, and particulary the left ventricle, to reduce the myocardial muscular stresses encountered during pumping.
- Many examples of such approaches are disclosed in the incorporated U.S. Patent No. 5,961,440.
- One example includes one or more transventricular splints placed across the left ventricle.
- Each splint may include a tension member extending across the ventricle and anchors disposed on opposite ends of the tension member and placed on the external surface of the heart.
- Mitral valve incompetency or mitral valve regurgitation is a common comorbidity of congestive heart failure.
- valve function may worsen.
- the resultant volume overload condition in turn, increases ventricular wall stress thereby advancing the dilation process, which may further worsen valve dysfunction.
- the size of the valve armulus increases while the area of the leaflets of the valve remains constant. This may lead to an area of less coaptation of the valve leaflets, and, as a result, eventually to valve leakage.
- the annular size contracts during systole, aiding in valve coaptation.
- the papillary muscles to which the leaflets are connected via the chordae tendonae
- chordae lengths remain substantially constant, which limits the full closure ability of the leaflets by exerting tension prematurely on the leaflets. This condition is commonly referred to as “chordal tethering.”
- chordal tethering The combination of annular changes and papillary changes results in a poorly functioning valve.
- a pre-existing mitral valve incompetency can be exacerbated by the presence and impact of the tightened splints.
- the splints and the local deformation they impart may further alter the positions of the papillary muscles in such a way that the chordae do not allow as complete of a closure of the mitral valve, or that rotation of portions of the ventricular wall (to which additional chordae may be attached) may "tighten” one valve leaflet and "loosen” the other. In this manner, the leaflets may not close at the same level relative to the annulus, causing increased retrograde leakage through the valve.
- a heart with even a small amount of regurgitation may benefit from not only the stress reducing functions of the ventricular splints as described above, but also from the elimination of the regurgitation, which will further off-load the pumping requirements of the myocardium.
- one aspect of the invention comprises a method for improving the function of a valve of a heart.
- the method includes the steps of placing an elongate member transverse a heart chamber so that each end of the elongate member extends through a wall of the heart, and placing first and second anchoring members external to the chamber.
- the first and second anchoring members are attached to first and second ends of the elongate member to fix the elongate member in a position across the chamber so as to reposition papillary muscles within the chamber.
- the invention comprises a method for improving the function of a valve of a heart.
- the method includes the steps of placing an elongate member transverse a heart chamber so that a first end of the elongate member extends through a wall of the heart between two papillary muscles, and a second end of the elongate member extends through a septum of the heart; placing a first anchoring member external the heart; and placing a second anchoring member inside the heart adjacent the septum.
- the first and second anchoring members are attached to the first and second ends of the elongate member respectively to fix the elongate member in a position across the heart chamber.
- the invention comprises a method for improving the function of a valve of a heart.
- the method includes the steps of placing an elongate member transverse a heart chamber so that each end of the elongate member extends through a wall of the heart; and placing first and second anchoring members external the chamber.
- the first and second anchoring members are attached to the ends of the elongate member to fix the elongate member in a position across the chamber. The position is superior to the papillary muscles and proximate and substantially across the valve.
- the invention comprises a splint for improving the function of a valve of a heart.
- the splint includes an elongate member configured to be positioned transverse a heart chamber so that each end of the elongate member extends through a wall of the heart, and first and second anchoring members configured to be positioned external the chamber and attached to the ends of the elongate member to fix the elongate member in a position across the chamber.
- the first anchoring member includes a first portion configured to contact a first region of the heart proximate the valve to change a shape of the valve.
- the first portion will contact a first region of the heart proximate the valve annulus to change the shape of the valve annulus.
- the invention comprises a splint for improving the function of a valve of a heart.
- the splint includes an elongate member configured to be positioned transverse a heart chamber so that each end of the elongate member extends through a wall of the heart, first and second anchoring members configured to be positioned external the chamber and attached to the ends of the elongate member to fix the elongate member in a position across the chamber, a third anchoring member connected to at least one of the first and second anchoring members by a connection member.
- the third anchoring member is configured to contact a region of the heart proximate the valve to change a shape of the valve.
- the invention comprises a device for improving the function of a valve of a heart.
- the device includes a first splint having a first elongate member configured to be positioned transverse a heart chamber so that each end of the elongate member extends through a wall of the heart, and a first anchoring member configured to be positioned external the chamber and attached to a first end of the first elongate member.
- the device further includes a second splint having a second elongate member configured to be positioned transverse a heart chamber so that each end of the second elongate member extends through a wall of the heart, and a second anchoring member configured to be positioned external the chamber and attached to a first end of the second elongate member.
- the device also includes a connecting mechanism configured to be connected to the second ends of each of the first and second elongate members external the chamber and press the wall of the heart chamber to change a shape of the valve.
- Yet a further aspect of the invention includes a method for improving cardiac function, comprising placing a first member relative to a heart chamber to alter the cross-sectional shape of the chamber and placing a second member relative to a valve of the heart chamber to assist in apposition of leaflets of the valve.
- the invention includes a method of improving the function of a valve of a heart comprising applying a force to an exterior surface of a wall surrounding a chamber of the heart substantially at a location of the valve to alter a shape of the valve.
- Yet a further aspect of the invention includes a method for improving the function of a valve of a heart comprising placing a device relative to the heart to alter a shape of the valve and adjusting the device relative to the heart based on data obtained during the adjusting from real-time monitoring of valve function.
- Fig. 1 is a transverse cross section of the left and right ventricles of a human heart showing the placement of splints according to an orientation for lessening myocardial muscular stresses;
- Fig. 2a is a transverse cross section of the left and right ventricles of a human heart showing the orientation of splints according to an embodiment of the present invention for lessening myocardial muscular stresses and assisting in apposition of valve leaflets;
- Fig. 2b is a vertical cross section of the left and right ventricles of a human heart showing another orientation of ventricular shape change splints according to an embodiment of the present invention for lessening myocardial muscular stresses and assisting in apposition of valve leaflets;
- Fig. 3 a is a transverse cross section of the left and right ventricles of a human heart showing an orientation of a mitral valve splint used in combination with a series of transventricular splints according to an embodiment of the present invention for lessening myocardial muscular stresses and assisting in apposition of valve leaflets;
- Fig. 3b is an external view of a human heart showing the orientation of the mitral valve splint and series of transventricular splints of Fig. 3 a;
- Fig. 3 c is a transverse cross section of the left and right ventricle of a human heart showing a various orientations for a mitral valve splint used in combination with a series of transventricular splints according to an embodiment of the present invention
- Fig. 4a is an external view of a human heart showing a series of transventricular splints, with the superior-most splint having an anchor structure according to an embodiment of the present invention that assists in apposition of valve leaflets;
- Fig. 4b is an external view of a human heart showing a series of transventricular splints, with the superior most splint having an anchor structure and a connection mechanism between the superior most and middle anchors according to yet another embodiment of the present invention that assists in apposition of valve leaflets;
- Fig. 4c is a perspective view of an anchor assembly for a transventricular splint according to yet another embodiment of the present invention that assists in apposition of valve leaflets and repositioning of papillary muscles;
- Fig. 5a is a transverse cross section of the left and right ventricles of a human heart showing the placement of splints according to an orientation for lessening myocardial muscular stresses with an accessory anchor assembly according to an embodiment of the present invention to assist in apposition of valve leaflets
- Fig. 5b is a transverse cross section of the left and right ventricles of a human heart showing the placement of splints according to an orientation for lessening myocardial muscular stresses with an accessory anchor assembly according to another embodiment of the present invention to assist in apposition of valve leaflets;
- Fig. 6 is a transverse cross section of the left and right ventricles of a human heart showing an orientation of a mitral valve splint used in combination with a series of transventricular splints, with an interconnecting mechanism according to an embodiment of the present invention for lessening myocardial muscular stresses and assisting in apposition of valve leaflets; and
- Fig. 7 is a perspective view of a heart with an external splint device and mitral valve anchor assembly and connecting mechanism disposed relative to the left ventricle to alter the shape of the left ventricle and to assist in apposition of valve leaflets according to an embodiment of the present invention.
- Each device of the present invention preferably operates passively in that, once placed in the heart, it does not require an active stimulus, either mechanical, electrical, or otherwise, to function.
- Implanting one or more of the devices of the present invention operates to assist in the apposition of heart valve leaflets to improve valve function.
- these devices may either be placed in conjunction with other devices that, or may themselves function to, alter the shape or geometry of the heart, locally and/or globally, and thereby further increase the heart's efficiency.
- the heart experiences an increased pumping efficiency through an alteration in its shape or geometry and concomitant reduction in stress on the heart walls, and through an improvement in valve function.
- inventive devices and related methods offer numerous advantages over the existing treatments for various heart conditions, including valve incompetencies.
- the devices are relatively easy to manufacture and use, and the surgical techniques and tools for implanting the devices of the present invention do not require the invasive procedures of current surgical techniques.
- the surgical technique does not require removing portions of the heart tissue, nor does it necessarily require opening the heart chamber or stopping the heart during operation.
- the surgical techniques for implanting the devices of the present invention also are less risky to the patient than other techniques.
- the less invasive nature of the surgical techmques and tools of the present invention may also allow for earlier intervention in patients with heart failure and/or valve incompetencies.
- the disclosed inventive devices and related methods involve geometric reshaping of the heart and treating valve incompetencies.
- substantially the entire chamber geometry is altered to return the heart to a more normal state of stress.
- Models of this geometric reshaping which includes a reduction in radius of curvature of the chamber walls, can be found in U.S. Patent No. 5,961,440 incorporated above.
- the heart walls Prior to reshaping the chamber geometry, the heart walls experience high stress due to a combination of both the relatively large increased diameter of the chamber and the thinning of the chamber wall. Filling pressures and systolic pressures are typically high as well, further increasing wall stress.
- Geometric reshaping according to the present invention reduces the stress in the walls of the heart chamber to increase the heart's pumping efficiency, as well as to stop further dilatation of the heart.
- the left ventricle and the mitral valve have been selected for illustrative purposes because a large number of the disorders that the present invention treats occur in the left ventricle and in connection with the mitral valve.
- the devices disclosed herein for improving valve function can be "standalone" devices, that is, they do not necessarily have to be used in conjunction with devices for changing the shape of a heart chamber or otherwise reducing heart wall stress. It also is contemplated that a device for improving valve function may be placed relative to the heart without altering the shape of the chamber, and only altering the shape of the valve itself.
- transventricular splints for lessening myocardial muscular stresses is shown in Figure 1, which shows the short-axis left ventricular cross-section from an anterior perspective.
- transventricular splints that are especially suitable for this application include those shown and described in copending U.S. Patent Application Serial No. 09/532,049 to Vidlund et al., filed March 21, 2000, entitled "A Splint Assembly for Improving Cardiac Function in Hearts, and Method for Implanting the Splint Assembly," and commonly assigned to the assignee of the present invention.
- the complete discosure of that application is incorporated by reference herein. That application will be referred to as "the '049 application” in the remainder of this disclosure.
- Figure 1 is a cross-section (short axis) view looking from the superior side of the heart.
- the superior-most splint 14 is placed at approximately the level of the heads of the papillary muscles PM and below the level of leaflet coaptation, and the additional two splints (not shown in Figure 1) are placed inferiorly toward the apex.
- the preferred orientation shown in Figure 1 both bisects the left ventricle LN and avoids key structures such as coronary vessels and the like.
- the splints according to this orientation also extend through the septum S near its edge and enter a small portion of the right ventricle RN.
- Each splint includes a tension member 16 and an anchor assembly 18 at each end of the tension member 16.
- tension member 16 extends through the the heart wall HW, across the left ventricle LN, and through the septum S and a portion of the right ventricle RN.
- Anchor assemblies 18 are placed adjacent the external surface of the heart wall HW.
- FIG. 1 shows an orientation of splints 14 according to an embodiment of the present invention which may assist in both offloading myocardial wall stress and in aiding the apposition of valve leaflets.
- each tension member 16 of splint 14 extends through the heart wall HW at a position approximately midway between the antero lateral papillary muscle PM and the posterio medial papillary muscle PM, extends transverse the left ventricle LN, and extends through the septum S at approximately its midpoint.
- a first anchor assembly 18 is placed external the heart 10 adjacent the heart wall HW and a second anchor assembly is placed inside the right ventricle RN adjacent septum S.
- Figure 2a shows the superior-most splint 14 of preferably three splints, with the other two splints placed inferiorly towards the apex. More or less than three splints may be used.
- the splints in this orientation are generally parallel to one another and substantially perpendicular to the long axis of the left ventricle.
- the orientation of splints 14 shown in Figure 2a helps to "pull" both of the papillary muscles PM toward the center of the left ventricle LN and reposition those muscles closer to their normal physiological position relative to the mitral valve annulus during the complete cardiac cycle.
- the papillary muscles PM are moved laterally away from their normal position, which causes the chordae connected to both valve leaflets to become excessively taut. This in turn inhibits the leaflets from fully closing against each other.
- the chordae are slackened enough to allow the leaflets to appose, thereby improving on mitral valve function.
- the splints 14 in this approach are preferably positioned at and below the level of the tops of the papillary muscles PM, the shape change deformation at the superior-most splint 14 would extend in a region further superior, and potentially include the annulus itself. To the extent that the annulus in the region of the posterior leaflet is deformed, this would further benefit the valve function by reducing the cross-sectional area of the annulus and positioning the posterior leaflet and its attachment zone closer to the anterior annulus. This, in turn, will cause the leaflets to more fully appose, minimizing MNR.
- Splints 14 also may be positioned in the orientation shown in Figure 2a by other surgical techniques, such as those described in the '049 application incorporated by reference above. For example, to gain access to the ventricular septum S, a small incision can be placed within the right ventricular wall to allow for positioning tension member 16 and the anchor assembly 18 within the right ventricle RV.
- the methods of implantation shown and described in the applications referred to above may be used in connection with any of the embodiments shown and described herein.
- Figure 2b shows another orientation of splints 14 according to an embodiment of the present invention which may assist in the offloading of myocardial wall stress and in the apposition of valve leaflets.
- at least one splint 14 is angled with respect to the long axis of the left ventricle LN, in contrast to orienting the at least one splint 14 perpendicular to the axis of the left ventricle LN.
- the lower two splints 14 are angled relative to the ventricular axis and relative to the superior-most splint 14, which is approximately perpendicular to the ventricular axis.
- all three splints 14 are coplanar, as is preferred for optimizing the ventricular shape change.
- Fig. 2b illustrates the ventricular splints having an anchor pad disposed on the septum, it is contemplated that the benefits of angling one or more splints relative to the long axis of the ventricle could be achieved at other cross-sectional orientations including, for example, the orientation shown in Fig. 1, in which an anchor pad is located on an exterior wall of the heart as opposed to the septum wall.
- the lower two splints 14 are positioned at an angle, they tend to "lift" one or both papillary muscles PM as they impart shape change to the left ventricle LN. By lifting the papillary muscle(s) PM, some slack may be provided to the chordae connected to the valve leaflets to permit improved apposition of the leaflets of mitral valve MN. It is contemplated that more or less splints than the lower two splints may be angled (other than perpendicularly) relative to the ventricular axis to achieve the benefits to MNR, and that each splint may have a different angle relative to that axis.
- ventricular splints 14 shown in Figure 2b may be oriented in any suitable cross sectional position, including the positions shown in Figures 1 or 2a.
- the benefits to MNR of angularly positioning one or more of the ventricular splints 14 relative to the ventricular axis, as shown in Figure 2b, may be achieved independent of the particular cross sectional position of the splints 14.
- a method of improving mitral valve function, while maintaining the positions and orientations of the ventricular splints shown in Figure 1, includes the use of an additional splint.
- This additional splint referred to herein as a mitral valve splint or MN splint, preferably has the same construction as the other splints and may be implanted using the similar delivery techniques.
- the primary function of the MN splint is to impart a shape change to the mitral valve annulus, adjacent the left ventricular wall, as well as reposition the papillary muscles PM.
- Figures 3 a and 3b show an MN splint according to an embodiment of the present invention.
- Figures 3 a and 3b show the three ventricular splints 14 in the positions and orientations shown and described in connection with Figure 1 (the dashed lines in Figures 3a, 3b) and show an exemplary orientation of an MN splint 20.
- MN splint 20 is positioned superior to the papillary muscles PM and oriented primarily across the mitral valve MN and on or below the mitral valve annulus while avoiding key vascular structures.
- MN splint 20 is "out of plane" with the other ventricular splints 14, as the overall function of MN splint 20 is to improve and optimize the mitral valve function.
- the MV splint extends through the heart wall between the papillary muscles of the left ventricle LN, and extends transverse the left ventricle LN, through the septum S, tlirough the right ventricle RN, and once again through the heart wall.
- the MN splint 20 improves mitral valve function through a combination of effects.
- the shape of the annulus is directly altered, preferably during the entire cardiac cycle, thereby reducing the annular cross sectional area and bringing the posterior leaflet in closer apposition to the anterior leaflet.
- the position and rotational configuration of the papillary muscles PM and surrounding areas of the left ventricle LN are further altered by the tightening of the MN splint 20. This places the chordae in a more favorable state of tension, allowing the leaflets to more fully appose each other.
- the position of the MN splint 20 shown in Figures 3 a and 3b is exemplary.
- the ventricular splints 14 preferably are positioned prior to positioning MN splint 20, through the use of, for example, both angiographic and ultrasonic visualization tools.
- This positioning technique described in the '049 application incorporated above, achieves optimal positioning of splints 14 to bisect the left ventricle LV and avoid key anatomic structures.
- a device such as the probe/marking device shown and described in the '049 application may be used to . repeatedly probe and deform possible areas near the mitral valve to find the optimal position for the MV splint 20.
- the direct impact of the probing on MVR can be assessed, and pre-existing MNR or MNR exacerbated by placement of the ventricular splints 14 can be corrected.
- the MN splint 20 is implanted and positioned by any of the delivery techniques referred to above, including the endovascular delivery technique or the more direct surgical approaches.
- the use of the MV splint 20 allows for the optimal placement of the ventricular splints 14, which reduce heart wall stress, independent from the optimal subsequent positioning of the MV splint 20, which improves mitral valve function.
- the splint can be adjusted (either in position or in tightness or both) to optimize improvement to valve function, as determined by observation of the valve using real-time imaging techniques.
- the optimal position of the MV splint 20 could be at virtually any orientation relative to the valve leaflets, depending on the heart failure and mitral valve regurgitation associated with the particular heart at issue.
- the position shown and described in connection with Figures 3 a and 3b may yield the most improvement of MVR, whereas in other hearts, alternative positions such as shown in Fig. 3c may yield the most improved results.
- the transventricular splint is shown positioned between the papillary muscles, which may be another preferred orientation for certain hearts.
- Alternative “A” places MV splint to cause shape change between the papillary muscles
- Alternative “B” for MV splint positioning would be in a line more parallel to the valve leaflet edges, as shown in Figure 3d.
- Other placements of the MV splint, as well as the position of the transventricular splints, relative to the heart also are contemplated and could be selected based on the condition of the heart and the mitral valve.
- an alternative anchor assembly for the ventricular splints 14 may be provided to aid in mitral valve function.
- the superior-most splint 14 includes an anchor assembly 28 configured for connection to the "free wall" end of that splint 14, i.e., at the exterior wall of the left ventricle.
- Anchor assembly 28 includes a lower portion in the form of, for example, a lower pad portion 30 which contacts the external surface of the left ventricle wall somewhat below the level of the tension member 16.
- the lower pad portion 30 resembles the shape, size, and construction of the anchor pads described in the '049 application incorporated above.
- Anchor assembly 28 further includes an upper portion in the form of, for example, an upper pad portion 34 which contacts a superior region of the left ventricle wall near the mitral valve annulus.
- Tension member 16 connects to a spanning structure 32 that, in one embodiment, is preferably integrally fabricated with the lower and upper pad portions 30 and 34, and connects portions 30 and 34.
- Suitable materials for anchor assembly may include, but are not limited to, those described in the '049 application.
- At least the lower and upper pad portions 30 and 34 preferably include a covering or a coating of a material, such as, for example, a woven polyester fabric, to encourage tissue in-growth.
- the spanning structure 32 also may be made of, or include a covering or coating made of, a material to encourage tissue in-growth
- the lower pad portion 30 has a circular shape and the upper pad portion 34 has an oblong shape.
- the oblong shape of the upper pad portion 34 has the advantage of inducing relatively extensive shape change along the periphery of the valve annulus, preferably during the entire cardiac cycle. Therefore, in an embodiment, the length and shape of the upper pad portion may extend a significant distance around the valve annulus.
- the upper pad portion 34 may extend from about 1 cm in length to about 10 cm in length, depending on the desired shape change of the valve annulus.
- the width of the upper pad portion 34 is preferably relatively narrow, so as to concentrate its shape change impact to the region near the valve annulus.
- the upper pad portion 34 may be positioned near, but below, the valve annulus. In other embodiments of the present invention, the upper pad portion may be positioned directly on the exterior surface of the annulus or somewhat above the annulus to contact the left atrium wall. The position of the upper pad portion preferably avoids direct compressive contact with important vascular structure near or on the exterior surface of the heart. Significant coronary vasculature often lies on or near the atrio-ventricular groove 36, which corresponds with the posterior annular region of the mitral valve. For this reason, it may be desirable to position the upper pad portion onto the left atrial surface.
- Anchor assembly 28 permits selection of a position that causes valve annulus shape change relatively independent from the positioning of the ventricular splints that cause ventricular shape change.
- the incorporation of an anchor assembly 28 is most suitable for instances where the desired shape change for the mitral valve is relatively co-planar with the main ventricular shape change splints, hi addition, anchor assembly 28 provides for annulus shape change without the need for an additional MN splint, such as that shown in Figures 3 a and 3b.
- FIG. 4b An alternative embodiment of a splint with a mitral valve anchor assembly according to the invention is illustrated in Figure 4b.
- the tension member 16 was connected to the spanning structure 32 approximately in the middle of the spanning structure 3, yielding a relatively stable structure that remains substantially parallel to the exterior surface of the heart.
- the embodiment of the anchor assembly 28' shown in Figure 4b places the ventricular shape change caused by the lower pad portion 30' below the end of the tension member 16'.
- the anchor assembly 28' illustrated in Figure 4b is similar to the anchor assembly 28 of Figure 4a, except that the tension member 16' is anchored within the lower pad portion 30'.
- a second spanning structure 33 is provided to mechanically connect the anchor assembly 28' to an anchor pad 14 of the splint disposed below the superior-most splint.
- This second spanning structure 33 also may be integrally formed with the anchor assembly 28' and, in turn, with the anchor pad 14.
- the second spanning structure 33 can be a separate component connecting anchor assembly 28' and anchor pad 14' once they are positioned with respect to the heart. This could be done, for example, by mechanical fastening, such as with screws or the like.
- FIG. 4c A further alternative anchor assembly 28" is shown in Figure 4c.
- This anchor assembly 28" is similar to the anchor assembly 28 shown in Figure 4a, except that anchor assembly 28" also includes one or more additional papillary pad portions 35 connected to lower pad portion 30" at a location substantially opposite to spanning structure 32"
- the papillary pad portion or portions 35 serve to provide one or more additional sites of deformation of the ventricular wall, preferably to further reposition one or both papillary muscles to aid in appoistion of the valve leaflets.
- the papillary pad portions 35 may be formed integrally with the anchor assembly 28" or may be separate and connected thereto via suitable connection mechanisms.
- the optimal orientation of shape change for improving the mitral valve function may be significantly offset from the position and orientation of transventricular splints 14. It is therefore desirable to have an approach to cause mitral valve shape change at positions away from the transventricular splints 14, and even more desirably, without the addition of another splint structure traversing the ventricle.
- Figure 5 a shows such an approach according to an embodiment of the present invention.
- Figure 5a shows an accessory anchor pad structure 40 attached to a connection member, shown as a runner 42.
- Runner 42 connects at its ends to both anchor pads 18 of preferably the superior-most splint assembly 14.
- runner 42 may connect to one anchor pad 18 and extend between that anchor pad 18 and structure 40.
- the accessory pad structure 40 is positioned at the location on the heart wall that yields the greatest improvement in MNR, as determined with repeated probing and deforming at the exterior of the heart proximate the mitral valve annulus, as described above in connection with positioning the MN splint 20 in Figures 3 a and 3b.
- accessory anchor pad structure 40 may be of the same shape and material as the anchor pads 18. While this embodiment may result in significantly improved MNR in some instances, in another embodiment, accessory pad 40 may take a form, including shape and material, similar to the anchor assemblies 28, 28', 28" shown in Figures 4a-4c. This latter configuration permits positioning accessory pad 40 at a position higher than the level of the anchor pads 18 of the superior-most transventricular splint, resulting in even greater shape change to the mitral valve annulus.
- accessory pad 40 would include, in addition to characteristics of anchor assembly 28, 28', 28", shown in Figures 4a-4c, a connecting mechanism 41 which would allow for adjustable positioning and securing of the accessory pad 41 to runner 42.
- a connecting mechanism 41 which would allow for adjustable positioning and securing of the accessory pad 41 to runner 42.
- a locking screw 43 may be used to secure runner 42 to pad 41.
- Other mechanisms suitable for securing the pad 41 to the runner 42 and permitting adjustment of the pad position along the runner are within the scope of the present invention.
- Runner 42 preferably includes a wire-like, or braid-like, structure which secures to each of the splint anchor pads 18 also through any suitable means, such as, for example, a locking screw mechanism 44, a pinning connection for a braid-like runner, or the like.
- Figure 5b shows an alternative embodiment for connecting an accessory anchor pad assembly 50 to a runner 52 and for connecting runner 52 to anchor pads 18.
- Each end of runner 52 connects to a connection mechanism in the form of a cap 54.
- Each cap 54 locks in place over a pad 18.
- At least one of the caps 54 includes an adjustable locking mechanism for adjusting the length of the runner 52 between the caps 54, and also thereby adjusting the position of the accessory pad 50 on the heart wall, and locking the runner 52 to cap 54.
- runner 52 is a braid formed of a high strength polymer, such as that used in the tension members described in the '049 application incorporated above.
- a suitable connection mechanism includes the use of one or more pins 56 placed through the braided runner 52 and connected to cap 54 through a flange 58, for example, situated on the cap 54.
- This pinning connection mechanism may be similar to the connection used for the braided tension members and anchor pads shown and described in the '049 application. The same connection mechanism may be used to connect accessory pad 50 to braided runner 52.
- the braided runner 52 may more directly connect to anchor pads 18, without the use of caps 54, by, for example, a pinning securement mechanism incorporated into the superior splint pads themselves.
- the external anchor pad assembly 50 including the runner 52 and anchor pads 18, can be used without the transventricular splint to improve valve function by causing a shape change to the valve annulus without an overall shape change to the left ventricle.
- a mechanism that may exacerbate MNR is the relative rotation of the papillary muscles PM and the adjacent left ventricular wall as the transventricular splints 14 are tightened into position. This relative rotation results in slack in some chordae and tightening in other chordae, which may "pull” one valve leaflet (or portion of the leaflet) while “loosening” the other valve leaflet (or portion of the leaflet).
- Figure 6 shows an embodiment of a device according to the present invention that would alleviate this rotation phenomenon.
- Figure 6 shows an accessory splint 70 connected to the superior-most ventricular splint 14 by a connecting bar 60.
- Accessory splint 70 and connecting bar 60 preferably are placed at approximately the same level along the ventricular wall as splint 14.
- Splint 14 preferably is positioned near to, and in this case medial to, the anterior papillary muscle PM.
- Accessory splint 70 then is positioned through the septum S, across the left ventricle LN, and through the ventricular free wall between the papillary muscles PM, similar to MV splint 20 described in connection with Figures 3a and 3b but at about the same level as the superior splint 14.
- Connecting bar 60 attaches to the ends of tension members 16 and 72 at their left ventricular "free wall” ends. Both tension members 16 and 72 are tensioned, pressing connecting bar 60 into the left ventricle and effecting shape change to the ventricle and the mitral valve annulus. Connecting bar 60 prevents rotation of the left ventricle LV in the region of the anterior papillary muscle PM and causes uniform tensioning of the chordae associated with that papillary muscle PM and any associated ventricular wall. This is believed to lessen any degradation in MVR, and potentially improve the MVR, because the papillary muscles PM are brought to a more desired position, with less rotation, particularly as to the anterior papillary muscle.
- an external splint 199 having a generally U-shaped configuration and including an anterior arm 199a and a posterior arm 199b, is positioned with respect to the left ventricle to create a substantially bi-lobed shape.
- the U-shaped external splint is made from a material that permits the splint to elastically deform under operationalloads and also from a material that is biocompatible. Examples of preferred materials include e-PTFE, or a polyester such as Dacron, for example.
- a splint, as well as other suitable external splints is described in more detail in the '486 application incorporated above. As shown in Fig.
- An accessory anchor pad 299 also similar to the accessory anchor assembly discussed with reference to Figs. 5a and 5b, attaches to the connecting runner 298.
- the runner 298 and accesory anchor pad 299 are positioned with respect to the heart so as to alter the shape of the mitral valve annuls to assist in coaptation of the valve leaflets.
- the runner and accessory anchor pad could be positioned so as to provide a repositioning of the papillary muscles, also to assist in coaptation of the valve leaflets.
- an accessory splint such as MV splint 20 shown in Figures 3 a and 3b may include an anchor assembly 28 as shown in Figure 4 and/or an accesory anchor pad structure 40 or 50 shown in Figures 5a and 5b.
- an accessory splint such as MV splint 20 shown in Figures 3 a and 3b may include an anchor assembly 28 as shown in Figure 4 and/or an accesory anchor pad structure 40 or 50 shown in Figures 5a and 5b.
- Other embodiments of the invention will be apparent to those skilled in the art from consideration of the specification and practice of the invention disclosed herein. The specification and examples are exemplary only, with a true scope and spirit of the invention being indicated by the following claims.
Abstract
Description
Claims
Priority Applications (1)
Application Number | Priority Date | Filing Date | Title |
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AU2001296512A AU2001296512A1 (en) | 2000-10-06 | 2001-10-03 | Methods and devices for improving mitral valve function |
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US09/680,435 | 2000-10-06 | ||
US09/680,435 US6723038B1 (en) | 2000-10-06 | 2000-10-06 | Methods and devices for improving mitral valve function |
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WO2002030292A1 true WO2002030292A1 (en) | 2002-04-18 |
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PCT/US2001/030882 WO2002030292A1 (en) | 2000-10-06 | 2001-10-03 | Methods and devices for improving mitral valve function |
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US (5) | US6723038B1 (en) |
AU (1) | AU2001296512A1 (en) |
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Also Published As
Publication number | Publication date |
---|---|
US20060241340A1 (en) | 2006-10-26 |
US6723038B1 (en) | 2004-04-20 |
US20090270980A1 (en) | 2009-10-29 |
US20050075723A1 (en) | 2005-04-07 |
US7766812B2 (en) | 2010-08-03 |
US9198757B2 (en) | 2015-12-01 |
US20040152947A1 (en) | 2004-08-05 |
AU2001296512A1 (en) | 2002-04-22 |
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