WO2015028986A1

WO2015028986A1 - Rvot wire capturing (rwc) system in mitral valve cerclage annuloplasty

Info

Publication number: WO2015028986A1
Application number: PCT/IB2014/064156
Authority: WO
Inventors: June-Hong Kim
Original assignee: June-Hong Kim
Priority date: 2013-08-29
Filing date: 2014-08-29
Publication date: 2015-03-05

Abstract

A mitral cerclage annuloplasty apparatus comprising of a catheter with a blocking member and a capturing member. The blocking member is in the shape of a pigtail or a balloon, and is configured on the distal portion of the catheter preventing the catheter from traversing through an unsafe zone thereby enabling the catheter to pass through the safe zone. This prevents damage to critical cardiac tissues. The capturing member is adapted for pulling out a RVOT cerclage wire into the IVC, and comprises of an expandable and collapsible mesh so that the RVOT cerclage wire is captured and directed into the IVC through the safe zone. Thus the RVOT cerclage wire is passed through the RV without damaging the heart tissue forming a complete circle around the mitral valvular annulus.

Description

RVOT WIRE CAPTURING (RWC) SYSTEM IN MITRAL VALVE CERCLAGE

ANNULOPLASTY

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] The present application claims the benefit of U.S. Provisional Application No. 61/871 ,353 filed on August 29, 2013; Korean Patent Application No.

10-2014-0052674 filed on April 30, 2014; and Korean Patent Application No.

10-2014-0092817 filed on July 22, 2014, which are incorporated herein by reference in its entirety.

FIELD OF INVENTION

[0002] The present invention generally relates to techniques and devices for cardiovascular valve repair, particularly annuloplasty techniques and devices in which tensioning elements are positioned to treat regurgitation of the mitral valve in which mitral valve cerclage wire is captured and passed through the "safe zone" within the heart without damaging critical cardiac structures.

BACKGROUND

[0003] The heart is at the center of human circulatory system that pumps blood through our body unidirectionally. In order for the heart to effectively keep this unidirectional flow of blood, it must have properly functioning valves that prevent back flow through its system, or regurgitation. The heart is divided into four chambers, right and left atria, and right and left ventricles. The mitral valve (MV) separates the left atrium from the left ventricle while the tricuspid valve (TV) separates the right atrium (RA) from the right ventricle (RV).

[0004] Generally, valves should open and close completely with every heartbeat or contraction. Incomplete opening and closing of the valves cause improper flow of blood. Valvular diseases are divided into two categories, regurgitation and stenosis. Regurgitation is a failure of valve to close completely and stenosis is a failure of valve to open completely.

[0005] Mitral regurgitation (MR) is a common cardiac valve disorder where leakage of blood flow occurs due to an incomplete closure of the MV. Over time, MR burdens the heart and worsens its ability to pump blood properly eventually leading to a heart failure.

[0006] Traditional treatment of a worsening MR requires an open heart surgery with thoracotomy, cardiac arrest and cardiopulmonary bypass. Once the chest is open and access to the heart is gained, the MV is either repaired or replaced using an artificial or porcine valve.

[0007] Although very effective, this open-heart procedure is a high-risk surgery accompanied by substantial morbidity, mortality and prolonged recovery. The mortality due to the surgery itself can be as high as 5%. Hence, the procedure is reserved only for those with severe symptomatic MR and often not offered to patients who are too weak or vulnerable or have significant co-morbidity.

[0008] This high morbidity and mortality rates of an open-heart surgery have motivated further research to develop safer and less risky alternatives. Much of the research involves percutaneous approaches with the use of cardiac catheterization. Recently, this inventor filed a PCT International Application number PCT/

US2007/023836 and PCT International publication number WO2008/060553 on a percutaneous approach to repairing a MR, "The MV cerclage coronary sinus

annuloplasty (MVA)," which are incorporated herein in its entirety.

[0009] Briefly explained, a catheter is placed at the coronary sinus after accessing the RV through the jugular vein, and then a cerclage wire is passed through the proximal septal vein and then through the right ventricular outflow tract ("RVOT"). Then the cerclage wire is pulled into the RV thus placing the cerclage wire circumferentially around the mitral annulus. Once the cerclage wire is positioned, tension is applied tightening the MV and bringing together the two leaflets of the MV.

[0010] Further, in the published U.S. Patent Application Nos. 2005/0216039 and 2010/0049314, tensioning material is introduced around the MV annulus using a secondary catheter, such as a steerable guide wire or canalization catheter. The MV annulus is accessed by a number of different percutaneous approaches, including access from and through the coronary sinus. Cerclage wire is placed around the mitral annulus then tension is applied re-opposing the leaflets of the MV and reducing the defect.

[0011] While percutaneous cerclage annuloplasty is promising in valve repair, the procedure is technically demanding especially in proper positioning of the tension material around the valvular annulus to provide the proper plane of cerclage.

Particularly, as the tensioning material traverses through the heart in its intramyocardial trajectory, there is a significant risk of tissue entrapment that limits the procedure and can result in serious adverse outcomes.

[0012] For example, in mitral cerclage annuloplasty, as the cerclage wire leaves the coronary sinus and enters the RVOT of the RV, if the cerclage wire must be grabbed and pulled through the RV then through the superior vena cava (SVC) or inferior vena cava (IVC). As the suture material enters the RVOT, if it is not grabbed right away and pulled into the RV, then it can undermine the ventricular structures such as chordae tendonae of the tricuspid valve (TV), the papillary muscles, the moderator band and other valvular trabeculae resulting in tissue entrapment.

[0013] If tissue entrapment is not averted, entrapped tissues can be transected and irreversibly damaged resulting not only in failure of the procedure but also in other serious complications. [0014] For this purpose, a special space between RV and RA can be defined as the "safe zone." The safe zone is defined as an imaginary space in which the cerclage wire can safely deliver therapeutic tension without damaging the TV or the moderator band. It should be an enclosed circular space bordered by (1 ) the TV leaflet and its subvalvular structures such as the chordae of TV and the papillary muscle, and (2) the moderator band. The remaining spaces between the RV and the RA other than the "safe zone" is defined here as the "unsafe zone." Therefore, a need exists for a procedure and a device that facilitates proper positioning of the cerclage wire while preventing entrapment of the ventricular tissues.

SUMMARY OF THE DISCLOSURE

[0015] The present invention includes methods, apparatus and devices for valve repair for minimally invasive, percutaneous cerclage annuloplasty. In particular, methods, apparatus and devices of the present invention facilitate MV cerclage annuloplasty. Specifically, as the cerclage wire traverses through the RV via the RVOT exit, methods and devices of the present invention are provided for properly guiding and capturing the cerclage wire through the "safe zone" averting entrapment of the critical cardiac structures.

[0016] For this purpose, a special space between RV and RA can be defined as the "safe zone." The safe zone is defined as an imaginary space in which the cerclage wire can safely deliver therapeutic tension without damaging the TV or the moderator band of the RV. It should be an enclosed circular space bordered by (1 ) the TV leaflet and its subvalvular structures such as the chordae of TV and the papillary muscle, and (2) the moderator band. The remaining spaces between the RV and the RA other than the "safe zone" is defined here as the "unsafe zone."

[0017] In an exemplary embodiment, there is featured a method for performing a MV cerclage annuloplasty by introducing a cerclage capture device into the vasculature of a patient, traversing the capture device through the safe zone, methods of testing or ensuring that the capturing device traversed through the safe zone, positioning the capturing device at an ideal location of a cerclage trajectory, capturing the cerclage wire, and guiding the cerclage wire back through the safe zone preventing capture, entrapment or damage to critical cardiac structures.

[0018] In accordance with the present invention, the ideal cerclage trajectory comprises the coronary sinus, the basal interventricular septum, the RVOT exit, the RV and the IVC. An exemplary embodiment comprises a catheter with a blocking member and a capturing member. The blocking member is configured on the distal portion of the catheter. The blocking member prevents the catheter from traversing through an unsafe zone and enables the catheter to pass through a safe zone thereby

circumventing damage to the tricuspid valvular structures and the moderator band of the right ventricle. The capturing member is configured proximal to the blocking member, wherein the capturing member is adapted for pulling out a RVOT wire through the IVC. The RVOT wire is positioned in the RV through the SVC and the CS prior to being captured by the capturing member. The blocking member is generally configured in the shape of a pigtail or in the shape of a balloon that is inflatable and deflatable using a control located outside of the patient's body. The capturing member further comprises a mesh which is collapsible and expandable using a control located outside of the patient's body. When the mesh is expanded, the RVOT wire passes through the mesh, and when the mesh is collapsed, the RVOT wire is securely grabbed by the mesh enabling the catheter to pull out the RVOT wire into the IVC. In another embodiment, the capturing member further comprises a magnet adapted for magnetically capturing the RVOT wire.

[0019] Further, the catheter comprises of a lumen adapted for passing a guide wire through the catheter. The surface of the capturing member can also be formed of a radio-opaque material adapted for visualizing the capturing catheter to confirm its location radiographically. Yet, in another embodiment, the capturing member comprises of a central lumen catheter, an outer catheter and a mesh. The central lumen catheter holds the guide wire, wherein the outer catheter holds the central lumen catheter enabling the central lumen catheter to move in and out. The distal portion of the mesh is gathered and secured to the central lumen catheter and the proximal portion of the mesh is gathered and secured to the outer catheter. Additionally, the capturing member comprises of at least one connector(s) which attaches the mesh to the central lumen catheter allowing the connector(s) to move back and forth causing the mesh to expand and collapse thereby forming a D-shape when the mesh is expanded.

[0020] In another exemplary embodiment of the present invention, there is another method for directing a RVOT wire into the IVC in cerclage annuloplasty. This method comprises of inserting a safe-zone catheter through the IVC, passing through a safe zone of the RV, preventing passage through an unsafe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the RV, and positioning the distal end of the safe-zone catheter at the RV and the Pulmonary Artery (PA), while positioning the RVOT wire in the RV through the SVC and the CS. Then a guide wired is inserted through a lumen of the safe-zone catheter, the safe-zone catheter is removed while keeping the guide wire in its place, a capturing catheter is inserted along the guide wire to the RV to capture the RVOT wire, and the RVOT wire is directed so that the capturing catheter steers the captured RVOT wire into the IVC.

[0021] The safe zone is further defined as an imaginary space in which the cerclage material can safely traverse through the right ventricle and deliver therapeutic tension without damaging the TV and the moderator band of the RV, wherein the safe zone is an enclosed circular space bordered by (1 ) the subvalvular structures such as the TV leaflet, chordae of TV, and the papillary muscle, and (2) the moderator band, and wherein the remaining space between the RV and the RA other than the safe zone is defined here as the unsafe zone.

[0022] In this exemplary body, a blocking member is further comprised on the distal portion of the safe-zone catheter, wherein the blocking member prevents the safe- zone catheter from traversing through the unsafe zone and enables the safe-zone catheter to pass through the safe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the RV. The blocking member is generally configured in the shape of a pigtail, or in the shape of a balloon that is inflatable and deflatable using a control located outside of the patient's body. The capturing catheter further comprises a mesh which is collapsible and expandable also using a control located outside of the patient's body. When the mesh is expanded, the RVOT wire passes through the mesh, and when the mesh is collapsed, the RVOT wire is firmly grabbed by the mesh enabling the capturing catheter to pull out the RVOT wire through the IVC. The capturing catheter further comprises a magnet adapted for magnetically capturing the RVOT wire. Each of the safe-zone catheter and the capturing catheter further comprises a lumen adapted for passing a guide wire through.

[0023] Furthermore, the outer surface of the capturing catheter is formed of a radio-opaque material adapted for visualizing the capturing catheter to confirm its location radiographically. The capturing catheter further comprises a central lumen catheter, an outer catheter and a mesh wherein the central lumen catheter which holds a wire. The outer catheter holds the central lumen catheter enabling the central lumen catheter to move back and forth within the outer catheter. The distal portion of the mesh is gathered and secured to the central lumen catheter, and the proximal portion of the mesh is gathered and secured to the outer catheter. The capturing catheter further comprises at least one connector(s) which attaches the mesh to the central lumen catheter allowing the connector(s) to move back and forth along the central lumen catheter causing the mesh to expand and collapse thereby forming a D-shape when the mesh is expanded.

BRIEF DESCRIPTION OF THE DRAWINGS

[0024] Figure 1 shows anatomical structures and the safe trajectory for the MV cerclage annuloplasty wire exiting the RVOT into the RV and then exiting through the IVC. Also shown are the potentially vulnerable cardiac structures that can be entrapped and damaged.

[0025] Figure 2 shows a close up anatomical view of a wire passing through the safe zone and a wire passing through the unsafe zone. [0026] Figure 3 shows another close up anatomical view of the wires in the safe zone and the unsafe zone.

[0027] Figure 4 is a schematic drawing of the MV cerclage annuloplasty RWC catheter device comprising the wire, the wire catheter, the mesh and the mesh catheter.

[0028] Figure 5 and 6 show a schematic view of the RWC catheter device in operation. First, the RWC catheter device is traversed through the safe zone and placed in the PA near the RVOT exit. Second, the mesh is expanded. Third, the RVOT cerclage wire entering the RV through the RVOT exit passes through the mesh. Fourth, the mesh is collapsed capturing the RVOT cerclage wire. Finally, the RWC wire capturing catheter is directed into IVC bringing the captured RVOT cerclage wire with it through the safe zone.

[0029] Figure 7 is another embodiment of MV cerclage annuloplasty

RWC device comprising a safe-zone catheter having a balloon-shaped blocking member. Balloon is inflated to prevent the catheter from passing through the unsafe zone. Due to the size of the inflated balloon, the catheter can only pass through the safe zone.

[0030] Figure 8 is a drawing of another embodiment of MV cerclage annuloplasty RWC device comprising a safe-zone catheter having a pigtail-shaped blocking member on the distal end of the catheter and having a mesh proximal to the pigtail-shaped blocking member.

[0031] Figure 9a shows a wall stent currently used as a self expanding stent in an angioplasty procedure requiring modifications to be used as the mesh in the RWC catheter device. [0032] Figure 9b is a schematic drawing of the self expanding mesh with closed upper part and a sheath or a catheter covering the mesh. The mesh sheath or the catheter can be used to control the expansion size of the mesh.

[0033] Figure 10 is an anatomical view of the RVOT cerclage wire traversing through the SVC and the CS. Then the RVOT cerclage wire exits the CS through the RVOT into the RV.

[0034] Figure 11 shows a drawing of the MV cerclage annuloplasty RWC device comprising a safe-zone catheter having a pigtail-shaped blocking member on the distal end of the catheter, and a guide wire passing through the lumen of the catheter.

[0035] Figure 12 shows a drawing of another embodiment of the MV cerclage annuloplasty RWC device comprising a capturing catheter with a mesh on the distal end of the catheter.

[0036] Figure 13 shows a drawing of another embodiment of MV cerclage annuloplasty RWC device comprising a safe-zone catheter having a balloon-shaped blocking member on the distal end of the catheter, and a mesh proximal to the balloon- shaped blocking member.

[0037] Figure 14 shows a drawing of another embodiment of MV cerclage annuloplasty RWC device comprising a capturing catheter with a D-shaped mesh wherein figure 14(a) shows the D-shaped mesh in its collapsed state, and figure 14(b) shows the D-shaped mesh in its expanded state.

[0038] Figure 15 shows a drawing of the capturing catheter with the D-shaped mesh in a heart, wherein figure 15(a) shows the D-shaped mesh in its collapsed state, and figure 15(b) shows the D-shaped mesh in its expanded state. DETAILED DESCRIPTION

[0039] The present invention feature methods and devices for repairing a cardiac valve in a patient. In particular, methods and devices are for treatment of valvular regurgitation in a cerclage annuloplasty procedure. It is noted, while the methods and devices described in particular is in connection with the MV regurgitation repair, such methods and devices can also be utilized for repairs of other valves. The detailed disclosure of the RVOT Wire Capturing (RWC) system methods and devices will be disclosed.

[0040] Methods of the current invention generally include ensuring the RVOT wire, which has entered the RV through the SVC, the CS and the RVOT, safely passes through the safe zone into the IVC without damaging the TV structures and the moderator band.

[0041] Methods of the invention generally include the RWC catheter device comprising a safe-zone catheter, a guide wire that passes through the catheter lumen, and a RVOT wire capturing catheter will be discussed in detail. Additionally, an embodiment where the safe-zone catheter and the RVOT wire capturing catheter functioning as unibody will be discussed in detail as well.

[0042] In MV cerclage annuloplasty procedure, a wire is inserted into a tube that has passed through the SVC and the CS. Then a catheter is inserted over the wire through the SVC and the CS. At that point, a contrast media is injected into the catheter to visualize and confirm the location of catheter within the CS. Then the wire is removed and the RVOT wire is introduced through the catheter. Subsequently, the RVOT wire passes through the basal interventricular septum exiting through the RVOT into the RV, and thus, the RVOT wire is named as the RVOT cerclage wire. In another words, in MV cerclage annuloplasty, the RVOT cerclage wire is defined as a cerclage wire that passes through the ideal trajectory of the coronary sinus, the interventricular septum and the RVOT into the RV thus encircling the MV. [0043] In Figure 10 is a schematic drawing of the heart showing fthe RVOT cerclage wire 104 as it traverses through the SVC 101 , the CS and the RVOT 105 into the RV.

[0044] In MV cerclage annuloplasty procedure, a RVOT cerclage wire 104 traverses through the SVC 101 , the CS and the RV then back through the SVC 101 thus forming a circle around the MV.

[0045] In order to steer the RVOT cerclage wire back into the SVC, the current invention comprises devices and methods to direct the RVOT cerclage wire 104 first into the IVC 102.

[0046] In order to direct the RVOT cerclage wire into the IVC, first, the safe-zone catheter is inserted through the IVC into the RV passing through the safe zone. Then a guide wire is passed through the safe-zone catheter, thus ideally positioning at the PA. Then, the safe-zone catheter is removed and the RVOT cerclage wire capturing catheter is inserted over the guide wire into the RV positioning at the PA. Then RVOT cerclage wire is captured by the capturing catheter and the catheter is directed to the IVC steering the captured RVOT cerclage wire into the IVC. Then a snare is introduced through the SVC which can grab the RVOT cerclage wire from the IVC into the SVC, thus completing the circle around the MV.

[0047] The current invention includes devices and methods for traversing through the safe zone of the RV in a MV cerclage annuloplasty procedure comprising a safe- zone catheter, a guide wire that passes through the IVC into the RV, a RVOT cerclage wire capturing catheter, and methods for using the said devices for directing the ROVT wire into the IVC. [0048] The capturing catheter refers to the catheter used to capture the RVOT cerclage wire and since the capturing catheter directs the RVOT cerclage wire into the IVC, the catheter may be called RVOT cerclage wire steering device.

[0049] In accordance with the current MV cerclage annuloplasty invention, prior to capturing the RVOT cerclage wire, a guide wire enters into the RV and ends at the PA via the safe-zone catheter which traverses through the femoral vein, the IVC, the RV and the PA. Here, the guide wire is named since the purpose of the guide wire is to guide the capturing catheter into the RV. Thus the guide wire 103 must traverse through the safe zone of the RV.

[0050] Figure 1 shows an anatomical structures and the safe trajectory for the MV cerclage annuloplasty wire exiting the RVOT into the RV and the unsafe trajectory where the potentially vulnerable cardiac structures that can be entrapped and damaged. Figure 2 and Figure 3 show an anatomical view of a wire passing through the safe zone 120 and a wire passing through the unsafe zone.

[0051] Figures 1 -3 show the critical cardiac structures in the RV such as the TV leaflets, the chordae of TV 150, papillary muscles 160 and the moderator band 170. These valvular structures and the moderator band are critical to the proper functioning of the RV, therefore, such structures should not be damaged by cerclage wire or catheters. Accordingly, in MV cerclage annuloplasty procedure the safe-zone catheter should traverse through the safe zone wherein the safe zone is an enclosed circular space bordered by (1 ) the subvalvular structures such as the TV leaflet, chordae of TV, and the papillary muscle 160, and (2) the moderator band 170. The remaining space between the RV and the RA other than the safe zone is defined here as the unsafe zone. Hence the unsafe zone is the space in the RV where the subvalvular structures such as the TV leaflet, chordae of TV and the papillary muscle, and the moderator band can be damaged by the cerclage wire. [0052] Figure 2 clearly shows the difference of the safe zone 220 and the unsafe zone. As shown in Figure 2 and Figure 3, if the catheter passes through the unsafe zone and tension is applied in this pathway, critical heart tissues can be seriously and irreversibly damaged. Therefore, a cerclage wire or a catheter must pass through the safe zone 220 and whether a cerclage wire or a catheter passed through the safe zone must be confirmed.

[0053] Thus, safe-zone catheter refers to a catheter that passes through the safe zone and can be confirmed that it indeed has traversed through the safe zone.

[0054] In the current invention, the safe-zone catheter comprises a balloon- shaped blocking member or pigtail-shaped blocking member. Additionally, the safe- zone catheter is inserted through the IVC instead of the SVC then is directed through the RV and into PA.

[0055] Figures 7, 8 and 11 disclose methods for verifying whether or not the catheter or the cerclage wire passed through the safe zone, and methods for preventing the passage of the catheter or the cerclage wire through the unsafe zone.

[0056] Figure 7 shows one embodiment of the safe-zone catheter of the current invention with a balloon-shaped blocking member, and the Figure 8 shows another embodiment of the safe-zone catheter with a pigtail-shaped blocking member 810 and a mesh 830 located proximal to the pigtail-shaped blocking member. Figure 11 shows the safe-zone catheter with the pigtail-shaped blocking member 113 and a guide wire 111 passing through the lumen of the safe-zone catheter.

[0057] First, according to the Figure 7, a balloon-shaped blocking member is on the distal end of the safe-zone catheter preventing the passage of the safe-zone catheter through the unsafe zone. [0058] The blocking member of the safe-zone catheter provides a method of freely passing through the safe zone of the TV and the RV while preventing the passage through the unsafe zone. Namely, the blocking member prevents the safe-zone catheter from passing through the unsafe zone and assists the blocking member to traverse only through the safe zone.

[0059] The safe-zone catheter with the balloon-shaped blocking member first enters through the IVC, then air is injected into the balloon using the outside control thus assisting the safe-zone catheter to traverse only through the safe zone. In other words, once the balloon enters into the unsafe zone, further advancement into the heart is prevented. Hence, when the inflated balloon no longer advances, the safe-zone catheter can be repeatedly withdrawn and re-entered until the catheter enters through the safe zone freely. Also, the reason why the safe-zone catheter is semi-rigid and the PA is approached from the IVC is to prevent the catheter from entering into a portion of the unsafe zone between the moderator band and the RV wall.

[0060] Figure 8 shows the pigtail-shaped blocking member positioned at the distal end of the safe-zone catheter. Upper left picture 800 in Figure 8 shows the pigtail- shaped blocking member positioned at the distal end of the safe-zone catheter, and central picture in Figure 8 shows the pigtail-shaped blocking member 810 positioned at the distal end 820 of the safe-zone catheter and a mesh situated proximal to the pigtail- shaped blocking member. In other words, the central picture in Figure 8 shows the combined safe-zone catheter 820 and the cerclage wired capturing catheter 830.

[0061] As shown in Figure 8, since the catheter has a pigtail-shaped distal end 810, the catheter is able to pass through the safe zone of the RV to the PA. The enlarged size of the pigtail-shaped end acts as the blocking agent thereby assisting the safe passage of the safe-zone catheter. If pig-tail shaped safe-zone catheter enters into the unsafe zone, it can no longer advance through the heart. When the safe-zone catheter does not advance, it can be withdrawn and re-advanced repeatedly until it advances further through the safe zone into the PA. [0062] Meanwhile, Figure 11 shows a drawing of the MV cerclage annuloplasty RWC device comprising a safe-zone catheter having a pigtail-shaped blocking member 113 on the distal end of the catheter 112, and a guide wire 111 passing through the lumen of the safe-zone catheter. The distal end 113 of the safe-zone catheter is shaped in a pigtail-shape so that the safe-zone catheter can pass through the safe zone, and the safe-zone catheter comprises a lumen that allows the passage of a guide wire 111. Also, the reason why the safe-zone catheter is semi-rigid and the PA is approached from the IVC is to prevent the catheter from entering into a portion of the unsafe zone between the moderator band and the RV wall.

[0063] In an experiment using a 40-50kg pig, this inventor selectively used a pigtail and a balloon that was 1 cm in diameter to pass through the safe zone. The inventor verified that Pigtail or balloon greater than 1 cm in diameter was not able to pass into the unsafe zone. Therefore, in order to pass through the safe zone, the pigtail or the balloon needs be greater than 1 cm in diameter approximately.

[0064] Once safe-zone catheter passes through the safe zone and is positioned in the PA , a guide wire is inserted through the safe-zone catheter. Preferable, the guide wire should be passed into the PA and positioned at the entry of the PA. Then the safe- zone catheter is removed keeping the guide wire positioned at the PA. Then the capture catheter is threaded over the guide wire through the safe zone into the PA to capture the RVOT cerclage wire.

[0065] Figure 4 is a schematic drawing of the capture catheter of the MV cerclage annuloplasty comprising the wire 400, the wire catheter 410, the mesh 420 and the mesh catheter 430. In other words, the RVOT cerclage wire which passed through the SVC or the IVC then through the interventricular septum exiting through RVOT into the RV is captured by the capture catheter 520 and directed from the PA into the IVC. The capture catheter 520 is named to indicate that it functions to capture the RVOT cerclage wire 540, and thus can also be called RVOT wire capture catheter. [0066] Figure 4 also shows the mesh of the capture catheter device. The mesh 510 remains collapsed until the capture catheter reaches the RV and is expanded once it is the RV near the PA to facilitate easy passage of the RVOT cerclage wire 540 through the mesh 420. Once the RVOT cerclage wire passes through the mesh, the mesh is collapsed capturing the RVOT cerclage. In other words, the mesh is collapsed or expanded from a control located outside the patient's body and when it is expanded, the mesh is configured so that the RVOT cerclage wire easily passes through the mesh, and when it is collapsed, it can firmly grab the RVOT cerclage wire.

[0067] To summarize the capture catheter, the mesh is passed through the IVC into the RV near the PA. Since the capture catheter passes over the guide wire which has already traversed through the safe zone, the capture catheter and the mesh placed on the distal portion of the capture catheter can only pass through the safe zone of the RV. Radiographic imaging can be utilized to confirm the position of the mesh and the RVOT cerclage wire. The mesh composes of radio-opaque marker so that it is adapted for visualizing to confirm its location radiographically. Then the mesh is expanded to allow easy passage of the RVOT cerclage wire. Once the RVOT cerclage wire passes through the mesh, the mesh is collapsed using the control located outside the patient's body capturing the RVOT cerclage wire.

[0068] Figures 5 and 6 show how the capture catheter captures the RVOT cerclage wire. Figure 5(a) shows the capture catheter 520 positioned inside the RV, Figure 5(b) shows the capture catheter with the expanded mesh, Figure 5(c) and Figure 6(d) show the RVOT cerclage wire 630 passing through the expanded mesh 610, Figure 6(e) shows collapsed mesh with captured RVOT cerclage wire, and Figure 6(f) shows the capture catheter being directed into the IVC thus steering with it the captured RVOT cerclage wire.

[0069] Though it is not shown in the Figures, instead of the mesh, the capture member of the capture catheter can be formed of a magnetic material to capture the RVOT cerclage wire magnetically. The RVOT cerclage wire or the distal end of the RVOT cerclage wire must be also formed of a magnetic material.

[0070] Figure 9(a) shows a wall stent 900 currently used as a self expanding stent in an angioplasty procedure requiring modifications to be used as the mesh in the RWC catheter device. Figure 9(b) is a schematic drawing of the self expanding mesh with closed upper part 910 and a sheath or a catheter covering the mesh. The mesh sheath or the catheter can be used to control the expansion size of the mesh.

[0071] Figure 12 shows a drawing of another embodiment of the MV cerclage annuloplasty RWC device comprising a capturing catheter 121 with a mesh 124

positioned on the distal end 123 of the capture catheter. Since the capture catheter is inserted over the guide wire into the RV, the capture catheter has a lumen to allow the passage of the guide wire. The proximal or the distal portion of the mesh can be formed of radio-opaque marker 123 so that it can be visualized radiographically from the outside to confirm the location of the mesh and the capture catheter.

[0072] Although, the safe-zone catheter and the capture catheter are described above separately, the two catheters can be combined into one unit 131 so that it has can have both functions and is included within the scope of this invention. This is shown and briefly described in Figure 8 and also in Figure 13.

[0073] Figure 13 shows a drawing of another embodiment of MV cerclage annuloplasty RWC device comprising a safe-zone catheter 131 having a balloon- shaped blocking member 136 on the distal end of the catheter, and a mesh 135

proximal to the balloon-shaped blocking member 136. Figure 8 and Figure 13 both contain the safe-zone catheter's blocking member 136, 810 as well as the capture catheter's capturing member in one body.

[0074] RVOT cerclage wire is captured by the capturing catheter and the catheter is directed to the IVC steering the captured RVOT cerclage wire into the IVC. Then a snare is introduced through the SVC to grab the RVOT cerclage wire from the IVC into the SVC, thus completing the circle around the MV annulus.

[0075] As describe above, during the MV cerclage annuloplasty procedure, the method for steering the RVOT cerclage wire into the IVC comprises of positioning the RVOT cerclage wire in the RV through either the SVC, the CS and the inter ventricular septum, and positioning the safe-zone catheter at the PA through the IVC and the safe zone of the RV. Then a guide wire can be inserted through the safe-zone catheter which traverses through the safe zone. Once the guide wire is positioned at the PA, the safe-zone catheter is removed and the capture catheter is advanced over the guide wire through the safe zone to the PA. Once the capture catheter is positioned in the PA, the RVOT wire can be captured and steered out towards the IVC by directing the capture catheter out toward the IVC.

[0076] If the safe-zone catheter and the capture catheter is combined into one device, the method for steering the RVOT cerclage wire into the IVC comprises of first, positioning the RVOT cerclage wire at the RV after it passes through the SVC, the CS and the inter ventricular septum. Meanwhile the combined MV cerclage annuloplasty catheter is positioned at the PA after traversing through the IVC and the safe zone of the RV. Then, using the capture member of the combined MV cerclage annuloplasty catheter, the RVOT cerclage wire is captured and steered out towards the IVC by directing the combined MV cerclage annuloplasty catheter with the capture member out toward the IVC.

[0077] Once the RVOT cerclage wire is steered into the IVC, then a snare is introduced through the SVC to grab the RVOT cerclage wire from the IVC into the SVC, thus completing the circle around the MV annulus.

[0078] Figure 14 shows a drawing of another embodiment of MV cerclage annuloplasty RWC device comprising a capturing catheter with a D-shaped mesh 143,147 and Figure 15 shows a drawing of the capturing catheter with the D-shaped mesh 155 in a heart.

[0079] Figure 14(a) and Figure 15(a) both show the D-shaped mesh 143, 153 in its collapsed state, and Figure 14(b) and the Figure 15(b) both show the D-shaped mesh 147,156 in its expanded state. Figure 15(a) shows the mesh 153 before it has completely entered the RV.

[0080] Referring to Figure 14 and Figure 15, the capturing catheter of the MV cerclage annuloplasty RWC device comprises of the outer catheter 144,146,155,158, the central lumen catheter 142,156,154 and the D-shaped mesh 143,147,153,156. The distal portion of the D-shaped mesh is gathered and fixed to the central lumen catheter 142,156,154 and the proximal portion of the D-shaped mesh 143,147,153,156 is gathered and fixed to the outer catheter 144,146,155,158.

[0081] The central lumen catheter 142,156,154 has an open internal lumen which holds a guide wire so that the capture catheter can be inserted over the guide wire to the RV.

[0082] The central lumen catheter is placed inside lumen of the outer catheter so that it can move back and forth within the lumen of the outer catheter.

[0083] The capture catheter is inserted over the guide wire passing through the safe zone into the RV. When the outer catheter is pushing inwardly from the outside of the body, then the outer catheter will move inwardly and distally over the central lumen catheter thus expanding the mesh.

[0084] Preferably, when the mesh is expanded, it forms the shape of the capital letter "D" conforming to the shape of the RV so that the RVOT cerclage wire which has entered the RV through the interventricular septum can more easily pass through the expanded mesh. Further, when the mesh is the shape of a capital letter "D," thus it is able to expand the most due to the anatomical shape of the RV such that the RVOT cerclage wire will naturally fall through the expanded mesh enabling precision in the ability to steer the RVOT wire into the IVC.

[0085] Referring to the Figure 14, in the current invention, in order for the mesh 143,147 to be in D-shape when it is expanded, the capturing catheter comprises at least one connector(s) 145 which attaches but does not fix the mesh to the central lumen catheter 142 allowing the connector(s) 145 to move freely back and forth along the central lumen catheter 142, 147 so that the the mesh 143, 147 can expand and collapse forming a D-shape when the mesh is expanded 147. Since the connector(s) 145 is always attached to one side of the central lumen catheter 142, when the mesh expands, it can fully expand towards the opposite, unattached side of the RV in the shape of letter "D."

[0086] Although not illustrated in the Figures, within one outer catheter, the safe- zone catheter and the capture catheter can be inserted. As discussed previously, the combined MV cerclage annuloplasty catheter with the safe-zone catheter and the capture catheter comprises of blocking member positioned proximal to the distal end of the catheter and the capture member positioned on proximal to the blocking member. Alternatively, a separate safe-zone catheter and a separate capture catheter can be positioned inside one single outer catheter.

[0087] Having illustrated and described the principles of the invention by several embodiments, it should be apparent that those embodiments can be modified in arrangement and detail without departing from the principles of the invention. Thus the invention includes all such embodiments and variations thereof, and their equivalents.

Claims

1 . A device for MV cerclage annuloplasty comprising:

a safe-zone catheter having a blocking member configured on the distal portion of the catheter wherein the blocking member prevents the catheter from traversing through an unsafe zone, and enables the catheter to pass through a safe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the right ventricle.

2. The device of claim 1 , wherein the safe zone is further defined as an imaginary space in which the cerclage material safely traverse through the right ventricle and deliver therapeutic tension without damaging the TV or the moderator band of the RV, wherein the safe zone is an enclosed circular space bordered by (1 ) the subvalvular structures such as the TV leaflet, chordae of TV, and the papillary muscle, and (2) the moderator band wherein the remaining space between the RV and the RA other than the safe zone is defined as the unsafe zone.

3. The device of claim 1 , wherein the blocking member is generally configured in the shape of a pigtail.

4. The device of claim 1 , wherein the blocking member is configured in a shape of a balloon that is inflatable and deflatable using a control located outside of the patient's body.

5. The device of claim 1 , wherein the safe-zone catheter further comprises a lumen adapted for passing a guide wire through the catheter lumen.

6. A device for MV cerclage annuloplasty comprising:

a capturing catheter adapted for pulling out a RVOT wire through the IVC wherein the RVOT wire is positioned in the RV through SVC and CS, wherein the capturing catheter is inserted through the IVC to the RV traversing through a safe zone for capturing the RVOT wire.

7. The device of claim 6, wherein the capturing catheter further comprises a mesh which is collapsable and expandable using a control located outside of the patient's body.

8. The device of claim 6, wherein when the mesh is expanded, the RVOT wire passes through the mesh, and when the mesh is collapsed, the RVOT wire is securely grabbed by the mesh enabling the capturing catheter to pull out the RVOT wire through the IVC.

9. The device of claim 6, wherein the capturing catheter further comprises a magnet adapted for magnetically capturing the RVOT wire.

10. The device of claim 6, wherein the safe zone is further defined as an imaginary space in which the cerclage material safely traverse through the right ventricle and deliver therapeutic tension without damaging the TV or the moderator band of the RV, wherein the safe zone is an enclosed circular space bordered by (1 ) the subvalvular structures such as the TV leaflet, chordae of TV, and the papillary muscle, and (2) the moderator band, and wherein the remaining space between the RV and the RA other than the safe zone is defined here as the unsafe zone.

11 . The device of claim 6, wherein the capturing catheter further comprises a lumen adapted for passing a guide wire through the catheter lumen.

12. The device of claim 6, wherein the capturing catheter further comprises a radio-opaque material adapted for visualizing the capturing catheter to confirm its location radiographically.

13. The device of claim 6, wherein the capturing catheter further comprises a central lumen catheter, an outer catheter and a mesh wherein the central lumen catheter holds a wire, wherein the outer catheter holds the central lumen catheter enabling the central lumen catheter to move in and out, and wherein a distal portion of the mesh is gathered and secured to the central lumen catheter and the proximal portion of the mesh is gathered and secured to the outer catheter.

14. The device of claim 6, wherein the capturing catheter further comprises at least one connector which attaches the mesh to the central lumen catheter allowing the connector to move back and forth causing the mesh to expand and collapse thereby forming a D-shape when the mesh is expanded.

15. A device for MV cerclage annuloplasty comprising:

a catheter with a blocking member and a capturing member wherein the blocking member is configured on the distal portion of the catheter wherein the blocking member prevents the catheter from traversing through an unsafe zone and enables the catheter to pass through a safe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the right ventricle, wherein the capturing member is configured on the proximal to the blocking member, wherein the capturing member is adapted for pulling out a RVOT wire through the IVC, and wherein the RVOT wire was positioned in the RV through SVC and CS.

16. The device of claim 15, wherein the blocking member is generally configured in the shape of a pigtail.

17. The device of claim 15, wherein the blocking member is generally configured in the shape of a balloon that is inflatable and deflatable using a control located outside of the patient's body.

18. The device of claim 15, wherein the capturing member further comprises a mesh which is collapsible and expandable using a control located outside of the patient's body.

19. The device of claim 15, wherein when the mesh is expanded, the RVOT wire passes through the mesh, and when the mesh is collapsed, the RVOT wire is securely grabbed by the mesh enabling the catheter to pull out the RVOT wire through the IVC.

20. The device of claim 15, wherein the capturing member further comprises a magnet adapted for magnetically capturing the RVOT wire.

21 . The device of claim 15, wherein the safe zone is further defined as an imaginary space in which the cerclage material can safely traverse through the right ventricle and deliver therapeutic tension without damaging the TV or the moderator band of the RV, wherein the safe zone is an enclosed circular space bordered by (1 ) the subvalvular structures such as the TV leaflet, chordae of TV, and the papillary muscle, and (2) the moderator band, and wherein the remaining space between the RV and the RA other than the safe zone is defined here as the unsafe zone.

22. The device of claim 15, wherein the catheter further comprises a lumen adapted for passing a guide wire through the catheter lumen.

23. The device of claim 15, wherein the surface of capturing member is formed of a radio-opaque material adapted for visualizing the capturing catheter to confirm its location radiographically.

24. The device of claim 15, wherein the capturing member further comprises a central lumen catheter, an outer catheter and a mesh wherein the central lumen catheter holds a wire, wherein the outer catheter holds the central lumen catheter enabling the central lumen catheter to move in and out, and wherein a distal portion of the mesh is gathered and secured to the central lumen catheter and the proximal portion of the mesh is gathered and secured to the outer catheter.

25. The device of claim 15, wherein the capturing member further comprises at least one connector which attaches the mesh to the central lumen catheter allowing the connector to move back and forth causing the mesh to expand and collapse thereby forming a D-shape when the mesh is expanded.

26. A method for directing a RVOT wire into the IVC in cerclage annuloplasty procedure, the method comprising: inserting a safe-zone catheter through the IVC, passing through a safe zone of the RV, preventing passage through an unsafe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the RV, and positioning the distal end of the safe-zone catheter at the RV and the Pulmonary Artery, while positioning the RVOT wire in the RV through the SVC and the CS; inserting a guide wire through a lumen of the safe-zone catheter;

removing the safe-zone catheter while keeping the guide wire in place;

inserting a capturing catheter along the guide wire to the RV to capture the RVOT wire; and

directing the RVOT wire by steering the capturing catheter which has captured the RVOT wire into the IVC.

27. The method of claim 26, wherein the safe zone is further defined as an imaginary space in which the cerclage material safely traverse through the right ventricle and deliver therapeutic tension without damaging the TV and the moderator band of the RV, wherein the safe zone is an enclosed circular space bordered by (1 ) the subvalvular structures such as the TV leaflet, chordae of TV, and the papillary muscle, and (2) the moderator band, and wherein the remaining space between the RV and the RA other than the safe zone is defined here as the unsafe zone.

28. The method of claim 26, wherein a blocking member is further comprised on the distal portion of the safe-zone catheter, wherein the blocking member prevents the safe-zone catheter from traversing through the unsafe zone and enables the safe-zone catheter to pass through the safe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the right ventricle.

29. The method of claim 28, wherein the blocking member is generally configured in the shape of a pigtail.

30. The method of claim 28, wherein the blocking member is generally configured in the shape of a balloon that is inflatable and deflatable using a control located outside of the patient's body.

31 . The method of claim 26, wherein the capturing catheter further comprises a mesh which is collapsible and expandable using a control located outside of the patient's body.

32. The method of claim 31 , wherein when the mesh is expanded, the RVOT wire passes through the mesh, and when the mesh is collapsed, the RVOT wire is firmly grabbed by the mesh enabling the capturing catheter to pull out the RVOT wire through the IVC.

33. The method of claim 31 , wherein the capturing catheter further comprises a magnet adapted for magnetically capturing the RVOT wire.

34. The method of claim 26, wherein the safe-zone catheter and the capturing catheter each further comprises a lumen adapted for passing a guide wire through the catheter lumen.

35. The method of claim 26, wherein on the outer surface of the capturing catheter is formed of a radio-opaque material adapted for visualizing the capturing catheter to confirm its location radiographically.

36. The method of claim 26, wherein the capturing catheter further comprises a central lumen catheter, an outer catheter and a mesh wherein the central lumen catheter holds a wire, wherein the outer catheter holds the central lumen catheter enabling the central lumen catheter to move in and out, and wherein a distal portion of the mesh is gathered and secured to the central lumen catheter and the proximal portion of the mesh is gathered and secured to the outer catheter.

37. The method of claim 26, wherein the capturing catheter further comprises at least one connector which attaches the mesh to the central lumen catheter allowing the connector to move back and forth causing the mesh to expand and collapse thereby forming a D-shape when the mesh is expanded.

38. A method for directing a RVOT wire into the IVC in cerclage annuloplasty procedure, the method comprising:

inserting a safe-zone catheter into the IVC, traversing through a safe zone of the RV, thus preventing passage through an unsafe zone thereby circumventing damage to the tricuspid valvular structures and the moderator band of the RV and positioning the distal end of the safe-zone catheter at the RV and the Pulmonary Artery, while positioning a RVOT wire in the RV through the SVC and the CS;

inserting a capturing catheter adapted for capturing the RVOT wire; and directing the RVOT wire into the IVC by steering the capturing catheter which has captured the RVOT wire into the IVC.

39. The method of claim 38, wherein the capturing catheter further comprises a central lumen catheter, an outer catheter and a mesh wherein the central lumen catheter holds a wire, wherein the outer catheter holds the central lumen catheter enabling the central lumen catheter to move in and out, and wherein a distal portion of the mesh is gathered and secured to the central lumen catheter and the proximal portion of the mesh is gathered and secured to the outer catheter.

40. The method of claim 39, wherein the capturing catheter further comprises at least one connector which attaches the mesh to the central lumen catheter allowing the connector to move back and forth causing the mesh to expand and collapse thereby forming a D-shape when the mesh is expanded.