Patent Application
20100069844
The present invention is related generally to medical devices and methods. More specifically, the present invention relates to methods and devices for injecting medical and biological agents into tissue. The present invention includes elongate devices having injection heads for driving injection needles into tissue that find one, non-limiting use in a minimally invasive procedure for epicardially injecting cells into an infarct zone to repair myocardial tissue.
The human heart wall consists of an inner layer of simple squamous epithelium, referred to as the endocardium, overlying a variably thick heart muscle or myocardium and is enveloped within a multi-layer tissue structure referred to as the pericardium. The innermost layer of the pericardium, referred to as the visceral pericardium or epicardium, clothes the myocardium. The epicardium reflects outward at the origin of the aortic arch to form an outer tissue layer, referred to as the parietal pericardium, which is spaced from and forms an enclosed sac extending around the visceral pericardium of the ventricles and atria. An outermost layer of the pericardium, referred to as the fibrous pericardium, attaches the parietal pericardium to the sternum, the great vessels and the diaphragm so that the heart is confined within the middle mediastinum. Normally, the visceral pericardium and parietal pericardium lie in close contact with each other and are separated only by a thin layer of a serous pericardial fluid that enables friction free movement of the heart within the sac. The space (really more of a potential space) between the visceral and parietal pericardia is referred to as the pericardial space. In common parlance, the visceral pericardium is usually referred to as the epicardium, and epicardium will be used hereafter. Similarly, the parietal pericardium is usually referred to as the pericardium, and pericardium will be used hereafter in reference to parietal pericardium.
It is frequently medically necessary to access the pericardial space to treat an injury, infection, disease or defect of the heart, e.g., an occluded coronary artery, an infarct zone, a defective heart valve, aberrant electrical pathways causing tachyarrhythmias, bacterial infections, to provide cardiac resynchronization therapy, or to place epicardial pacing or cardioversion/defibrillation electrodes against the epicardium or into the myocardium at selected sites. It is necessary in these procedures to surgically expose and cut through the pericardium to obtain access to the pericardial space.
Highly invasive surgical techniques, referred to as a median stemotomy (open-chest surgical exposure) or a thoracotomy, have been typically employed to provide the surgeon access to the pericardial space and the heart. A median sternotomy incision begins just below the sternal notch and extends slightly below the xyphoid process. A sternal retractor is used to separate the sternal edges for optimal exposure of the heart. Hemostasis of the sternal edges is typically obtained using electrocautery with a ball-tip electrode and a thin layer of bone wax.
The open chest procedure involves making a 20 to 25 cm incision in the chest of the patient, severing the sternum and cutting and peeling back various layers of tissue in order to give access to the heart and arterial sources. As a result, these operations typically require large numbers of sutures or staples to close the incision and 5 to 10 wire hooks to keep the severed sternum together. Such surgery often carries additional complications such as instability of the sternum, post-operative bleeding, and mediastinal infection. The thoracic muscle and ribs are also severely traumatized, and the healing process results in an unattractive scar. Post-operatively, most patients endure significant pain and must forego work or strenuous activity for a long recovery period.
Many minimally invasive surgical techniques and devices have been introduced In order to reduce the risk of morbidity, expense, trauma, patient mortality, infection, and other complications associated with open-chest cardiac surgery. Less traumatic limited open chest techniques using an abdominal (sub-xyphoid) approach or, alternatively, a “Chamberlain” incision (an approximately 8 cm incision at the sternocostal junction), have been developed to lessen the operating area and the associated complications. In recent years, a growing number of surgeons have begun performing coronary artery bypass graft (CABG) procedures using minimally invasive direct coronary artery bypass grafting (MIDCAB) surgical techniques and devices. Using the MIDCAB method, the heart typically is accessed through a mini-thoracotomy (i.e., a 6 to 8 cm incision in the patient's chest) that avoids the sternal splitting incision of conventional cardiac surgery. A MIDCAB technique for performing a CABG procedure is described in U.S. Pat. No. 5,875,782, for example.
Other minimally invasive, percutaneous, coronary surgical procedures have been advanced that employ multiple small trans-thoracic incisions to and through the pericardium, instruments advanced through ports inserted in the incisions, and a thoracoscope to view the accessed cardiac site while the procedure is performed as shown, for example, in U.S. Pat. Nos. 6,332,468, 5,464,447, and 5,716,392. Surgical trocars having a diameter of about 3 mm to 15 mm are fitted into lumens of tubular trocar sleeves, cannulae or ports, and the assemblies are inserted into skin incisions. The trocar tip is advanced to puncture the abdomen or chest to reach the pericardium, and the trocar is then withdrawn leaving the sleeve or port in place. Surgical instruments and other devices such as fiber optic thoracoscopes can be inserted into the body cavity through the sleeve or port lumens. As stated in the '468 patent, instruments advanced through trocars can include electrosurgical tools, graspers, forceps, scalpels, electrocauteries, clip appliers, scissors, etc.
In such procedures, the surgeon can stop the heart by utilizing a series of internal catheters to stop blood flow through the aorta and to administer cardioplegia solution. The endoscopic approach utilizes groin cannulation to establish cardio-pulmonary bypass (CPB) and an intraaortic balloon catheter that functions as an internal aortic clamp by means of an expandable balloon at its distal end used to occlude blood flow in the ascending aorta. A full description of an example of one preferred endoscopic technique is found in U.S. Pat. No. 5,452,733, for example.
Problems may develop during CPB due to the reaction blood has to non-endothelially lined surfaces, i.e. surfaces unlike those of a blood vessel. In particular, exposure of blood to foreign surfaces results in the activation of virtually all the humoral and cellular components of the inflammatory response, as well as some of the slower reacting specific immune responses. Other complications from CPB include loss of red blood cells and platelets due to shear stress damage. In addition, cardiopulmonary bypass requires the use of an anticoagulant, such as heparin. This may, in turn, increase the risk of hemorrhage. Finally cardiopulmonary bypass sometimes necessitates giving additional blood to the patient. The additional blood, if from a source other than the patient, may expose the patient to blood born diseases.
Due to the risks incurred during CPB, some surgeons have attempted to perform cardiac-related medical procedures without cardiac arrest and CPB. For example, Trapp and Bisarya in “Placement of Coronary Artery Bypass Graft Without Pump Oxygenator”, Annals Thorac. Surg. Vol. 19, No. 1, (January 1975) pgs. 1-9, immobilized the area of a bypass graft by encircling sutures deep enough to incorporate enough muscle to suspend an area of the heart and prevent damage to the coronary artery. More recently Fanning et al. in “Reoperative Coronary Artery Bypass Grafting Without Cardiopulmonary Bypass”, Annals Thorac. Surg. Vol. 55, (February 1993) pgs. 486-489 also reported immobilizing the area of a bypass graft with stabilization sutures.
Suction stabilization systems, such as the Medtronic Octopus® Tissue Stabilizer and the Medtronic Starfish® and Urchin® Heart Positioners (available from Medtronic, Inc., Minneapolis, Minn. USA) use suction to grip and immobilize the surface of the heart. Additionally, the system allows the surgeon to manipulate the surgical site into better view by rotating and supporting the heart. See, also, e.g., U.S. Pat. Nos. 5,836,311; 5,927,284 and 6,015,378, and co-assigned U.S. patent applications Ser. No. 09/396,047, filed Sep. 15, 1999, Ser. No. 09/559,785, filed Apr. 27, 2000, and Ser. No. 09/678,203, filed Oct. 2, 2000; and European Patent Publication No. EP 0 993 806. The Octopus® stabilizer and Starfish® and Urchin positioners facilitate moving or repositioning the heart to achieve better access to areas which would otherwise be difficult to access, such as the posterior or backside of the heart.
The recently developed, beating heart procedures also disclosed in U.S. Pat. No. 6,394,948, for example, eliminate the need for any form of CPB, the extensive surgical procedures necessary to connect the patient to a CPB machine, and to stop the heart. These beating heart procedures can be performed on a heart exposed in a full or limited thoracotomy or accessed percutaneously.
In some percutaneous procedures, the epicardium of the beating or stopped heart is exposed to view typically by use of grasping and cutting instruments inserted through one port to cut through the pericardium surrounding the heart while the area is viewed through the thoracoscope or endoscope inserted through another port. The thoracoscopic approach typically requires the placement of a chest tube and admission to the hospital for the initial 1-2 post-operative days.
Therefore, much effort has been expended to develop medical devices and techniques to access the pericardial space employing such minimally invasive percutaneous procedures. One difficulty has been that normally the pericardial space is so small or thin that it is difficult to penetrate the pericardium using miniaturized instruments capable of being introduced through a port to the site without also puncturing the underling epicardium and thereby, damaging the myocardium or a coronary vessel. Proliferative adhesions occur between the pericardium and the epicardium in diseased hearts and hamper access to the pericardial space employing such minimally invasive percutaneous procedures. The simple percutaneous approach can be used to penetrate the pericardium to drain a large pericardial effusion, i.e., an accumulation of too much fluid in the pericardial space that widens the pericardial space. A spinal needle (18-20 gauge) and stylet occluding the needle lumen are advanced incrementally in a superior/posterior fashion through a small (2-4 mm) cutaneous incision between the xyphoid and costal cartilage. Periodically, the stylet is removed, and fluid aspiration is attempted through the needle lumen. The advancement is halted when fluid is successfully aspirated, and the pericardial effusion is then relieved.
Methods and apparatus for accessing the pericardial space for the insertion of implantable defibrillation leads are disclosed in U.S. Pat. Nos. 5,071,428 and 6,156,009, wherein a forceps device is used to grip the pericardium and pull it outward to form a “tent”. In the '428 patent, a scissors or scalpel is introduced to cut the pericardium (pericardiotomy) under direct vision through a sub-xyphoid surgical incision. The forceps device disclosed in the '009 patent incorporates a mechanism for introducing electrical leads or guide wires through the outwardly displaced pericardium. It is difficult to introduce and use the forceps through the narrow lumen of a port or sleeve, particularly if the pericardial fluid is under pressure that makes the pericardium taut like an inflated balloon.
Further methods and apparatus for accessing the pericardial space for the insertion of devices or drugs are disclosed in U.S. Pat. No. 6,423,051, wherein an access tube having a device access lumen is provided with a plurality of hooks in the tube distal end that can be used to hook into the pericardium to enable the lifting and “tenting” of the pericardium. A cutting instrument or sharpened tip guide wire or the like can be advanced through the device access lumen to perforate the pericardium.
Other methods and apparatus that are introduced through percutaneously placed ports or directly through small trans-thoracic incisions for accessing the pericardial space employ suction devices to grip the pericardium or epicardium as disclosed, for example, in U.S. Pat. Nos. 4,991,578, 5,336,252, 5,827,216, 5,868,770, 5,972,013, 6,080,175, and 6,231,518 and the above-referenced '948 patent. The suction devices are configured like a catheter or tube having a single suction tool lumen and typically having a further instrument delivery lumen. The suction tool lumen terminates in a single suction tool lumen end opening through the device distal end in the '578, '252, '175, '770, and '013 patents and through the device sidewall in the '216 and '518 patents. Certain of these patents recite that the applied suction draws a “bleb,” i.e., a locally expanded region of the pericardium, into the suction tool lumen or a suction chamber at the device distal end. A needle can then be advanced into the bleb and used to draw off fluids or deliver drugs into the pericardial space, or the like. In addition, it is suggested in these patents that treatment devices including catheters, guide wires, and electrodes, e.g., defibrillation electrodes, can be advanced into the pericardial space through a device introduction lumen for a variety of reasons. Although theoretically plausible, the ability to reliably maintain a vacuum seal against the pericardium when such treatment devices are advanced can be problematic.
For these reasons, it would be desirable to provide additional and improved methods and apparatus for the minimally invasive access to a patient's pericardial space. The methods and devices should be suitable for a wide variety of minimally invasive approaches to the pericardium, including at least intercostal/transthoracic and subxiphoid approaches, and the like. The methods and devices should further provide for secure and stable capture of the pericardium and permit the opening of a large space or volume between the pericardium and epicardium. Such access methods and apparatus should be useful for a wide variety of procedures to be performed in the pericardial space, including fluid withdrawal, drug delivery, cell delivery, diagnostic and therapeutic electrophysiology procedures, pacemaker lead implantation, defibrillator lead placement, transmyocardial revascularization, transmyocardial revascularization with drug delivery, placement of the left ventricular assist devices, placement of the arterial bypass graphs, in situ bypass, i.e., coronary artery-venous fistulae, placement of drug delivery depots, closure of the left arterial appendage, and the like. At least some of these objectives will be met by the invention described herein.
Heart disease, including myocardial infarction, is a leading cause of death and impaired activity in human beings, particularly in the western world, most particularly among males. Heart disease can in turn degrade other physiological systems.
A stenosed or blocked coronary artery is one example of heart disease. A totally blocked, or substantially blocked coronary artery can cause immediate, intermediate term, and long-term problems. In the immediate term, myocardial cells can be starved of oxygen resulting in cell death. In the intermediate term, the cell death can “cascade”, leading to cell death in adjacent cells. In the long term, the myocardial cell death, which creates weakened, non-contracting infarct regions of the heart, can lead to heart failure.
The immediate effects of a blocked coronary artery can be addressed through percutaneous coronary transluminal angioplasty (PCTA). PCTA can be used to dilate an occluded coronary artery, often in conjunction with stenting, to provide perfusing blood flow to cardiac cells downstream of the blockage. More intermediate term damage can be addressed through the systemic or local delivery of agents to reduce or treat the cells affected by the initial injury. The longer-term problems, for example, heart failure resulting from infarct cardiac tissue, can be addressed by the systemic or local delivery of medical agents to the cardiac tissue.
The direct delivery of agents to cardiac tissue is often preferred over the systemic delivery of such agents for several reasons. One reason is the substantial expense and small amount of the medical agents available, for example, agents used for gene therapy. Another reason is the substantially greater concentration of such agents that can be delivered directly into cardiac tissue, compared with the dilute concentrations possible through systemic delivery. Yet another reason is the undesirability or impossibility of systemically delivering agents to the heart tissue requiring treatment.
One mode of delivery for medical agents to myocardial tissue has been an epicardial, direct injection into myocardial tissue during an open chest procedure. Open chest procedures are inherently traumatic procedures with associated risks. The risks are often justified when the alternatives are a substantially high probability of death. In many cases, however, an open chest procedure is not believed justifiable only for the injection of medical agents into the myocardium.
Another approach taken to deliver medical agents into the myocardium has been an intravascular approach. Catheters may be advanced through the vasculature and into the heart to inject materials into myocardial tissue from within the heart. This approach may not allow all areas of the heart to be easily reached however. The size and type of instruments that can be advanced, for example, from a femoral artery approach, are also limited.
One relatively new therapy for treating infarcted cardiac tissue includes the injection of cells that are capable of maturing into actively contracting cardiac muscle cells. Examples of such cells include myocytes, mesenchymal stem cells, and pluripotent cells. Delivery of such cells into the myocardium is believed to be beneficial, particularly to prevent heart failure. Current intravascular delivery devices are less than optimal, being limited in the cardiac regions they can reach and the amount and types of materials they can deliver. Open chest procedures allow access to a larger range of cardiac tissue and also allow the delivery of greater varieties and amounts of agents, for example, cells. An open chest procedure may not be justifiable, however, only for the injection of such cells. In particular, patients having suffered a recent heart attack may be very poor candidates for such a procedure.
What would be desirable are improved devices that can be used to inject medical or biological agents, for example, cells, into myocardial tissue. In particular, devices enabling a minimally invasive cell delivery into myocardial tissue would be most advantageous.
It would further be desirable to have an organ positioning system and method which is capable of positioning, manipulating, stabilizing and/or holding an organ and/or tissue while controllably providing fluid during a medical procedure.
The present invention provides a device for injecting medical agents into tissue, with a preferred medical agent being cells, for example, that can form contracting cardiac muscle cells. The device can be used to inject bone marrow cells, stem cells, pluripotent cells, and other cardiocyte precursor cells. The device can be used to inject these cells into infarct zones of cardiac tissue to prevent or postpone heart failure in heart disease patients. The devices and methods according to the present invention can be used to inject medical agents or substances into any soft tissue, including, but not limited to, heart, kidney, liver, tumor, and muscle tissue.
One device includes an elongate shaft having a distal region coupled to a plurality of hollow needles having sharp distal ends, with the needles operably coupled to the elongate shaft distal region such that the elongate shaft distal region is substantially perpendicular to the needle axes. The device can further include means for driving the needles along the needle axes in the direction of the needle sharp distal ends and means for discharging the fluid from the needle discharge ports. The device can further include a needle trigger operably coupled to the needle driving means for initiating the needle driving means and a discharge trigger operably coupled to the fluid discharge means for initiating fluid discharge from the needles. In one device, the means for driving the needles along the needle axes includes a first body having the needles fixedly attached thereto and a second body having the needles slidably disposed therethrough. In some devices, the first and second bodies each include a substantially planar portion substantially perpendicular to the needle axes. The means for driving the needles can include means for driving the first body toward the second body.
Some devices include a first body inclined portion disposed at an angle to the elongate shaft distal region longitudinal axis. The device can further include a third body longitudinally slidably coupled to the second body and being inclinably slidably coupled to the first body along the first body inclined portion. Longitudinally translating the third body relative to the second body can thus move the first body relative to the second body.
One device includes an elongate shaft having a distal region and an injection head coupled to the shaft distal region. The head can have a plurality of needles for injecting the substance into the tissue, where the needles are oriented substantially perpendicular to the elongate shaft distal region longitudinal axis. The device can include a needle driver for driving the plurality of needles past the injection head tissue-contacting surface and into the tissue. The device preferably includes means for transferring a longitudinal force directed along the shaft to a transverse force at the injection head. The means for transferring force can include two substantially planar members, where the first planar member has the plurality of needles fixedly and transversely attached thereto, and where the second planar member has the plurality of needles transversely and slidably disposed therethrough.
In some devices, the means for transferring force includes the first planar member being transversely slidably coupled to the second planar member, where the first planar member has at least one inclined portion disposed at an angle to the plane of the first planar member. A drive member can be slidably coupled to the second planar member to bear against the first planar member inclined portion. An elongate drive shaft can be slidably disposed along the elongate shaft and coupled to the drive member, such that moving the drive shaft longitudinally urges the drive member to bear against the inclined portion, urging the first planar member toward the second planar member and the plurality of needles away from the second planar member.
Another device includes a first and a second body coupled to each other through a pantograph mechanism having two opposing sides, where the pantograph includes a proximal arm pair and a distal arm pair on each side. The arm pairs can include a first member pivotally joined at one end to the first body, and a second member pivotally joined at one end to the second body. The first and second members each have second ends pivotally coupled to each other at a central joint, in a preferred embodiment. Moving the proximal and distal arm pair central joints closer together urges the first and second bodies apart, and moving the proximal and distal arm pair central joints closer together urges the first and second bodies together. In some devices, the central joint of each proximal and distal arm pair are joined to the corresponding joint on the opposite side, through a rod or other mechanism.
In still another device, the first body has a plurality of hollow needles attached thereto and a first plurality of magnets secured thereto. The second body has a plurality of needles slidably received therethrough. A third body can be slidably disposed on the second body and have a second plurality of magnets thereon, where the first and second plurality of magnets are disposed and have polarities oriented such that the slidable third body has a first position in which the first and third body are magnetically attracted to each other and a second position in which the first and third body are magnetically repulsed from each other. In this way, sliding the third member can pull the first body toward the second body and also push the first body away from the second body, depending on the degree of sliding. In one device, the third body has longitudinally adjacent magnetic pairs having opposite polarities, such that sliding the third member into the first position brings magnets having opposite facing polarities opposite each other, and sliding the third member into a second position brings magnets having the same facing polarities opposite each other.
In yet another device, the first body has a plurality of hollow needles attached thereto and a second body has the needles slidably received therethrough. The device can include a rack fixedly coupled to the second body and a pinion rotatably coupled to the first body and having teeth engaging the rack. Rotating the pinion in a first direction thus urges the first and second bodies closer together, and rotating the pinion in a second direction urges the first and second bodies further apart.
In yet another device, the first body has a plurality of hollow needles attached thereto and the second body has the plurality of needles slidably received therethrough. The first and second bodies can have a first expandable member disposed therebetween, such that expanding the first expandable member urges the first and second bodies apart and retracts the needles toward the second body. The expandable member can be a fluid inflatable member. In some devices, the first inflatable member is coupled to the first and second bodies and is deflatable, such that withdrawing fluid from the first inflatable member urges the first and second bodies closer together. Some devices further include a second expandable member disposed on the first body away from the second body and on a major surface facing away from the second body, such that disposing the second body against the tissue and disposing the second expandable member against a body part urges the first body toward the tissue.
In some devices, the plurality of needles attached to the first body may have a substantially different length as among the needles, to form a phased depth array of needles. The phased array of needles can distribute the initially higher force required to puncture the outer tissue temporally over the needle insertion process. In addition, the phased array of needles can allow the delivery one or more medical agents or substances at different depths within the tissue simultaneously.
One device includes an elongate shaft having a distal region coupled to a plurality of hollow needles having sharp distal ends, with the needles operably coupled to the elongate shaft distal region such that the elongate shaft distal region is substantially parallel to the needle axes. The device can further include means for driving the needles along the needle axes in the direction of the needle sharp distal ends and means for discharging the fluid from the needle discharge ports. The device can further include a needle trigger operably coupled to the needle driving means for initiating the needle driving means and a discharge trigger operably coupled to the fluid discharge means for initiating fluid discharge from the needles. In one device, the means for driving the needles along the needle axes includes a first body having the needles fixedly attached thereto and a second body having the needles slidably disposed therethrough. In some devices, the first and second bodies each include a substantially planar portion substantially perpendicular to the needle axes. The means for driving the needles can include means for driving the first body toward the second body.
One device includes an elongate shaft having a distal region and an injection head coupled to the shaft distal region. The head can have a plurality of needles for injecting the substance into the tissue, where the needles are oriented substantially parallel to the elongate shaft distal region longitudinal axis. The device can include a needle driver for driving the plurality of needles past the injection head tissue-contacting surface and into the tissue.
One device includes an injection head having a suction member for grasping tissue to be injected by one or more needles.
One device includes a suction member for grasping tissue and a lumen sized and shaped to accommodate a needle and syringe barrel.
These and other advantages and features of the present invention will be more readily understood from the following detailed description of the preferred embodiments thereof, when considered in conjunction with the drawings, in which like reference numerals indicate identical structures throughout the several views, and wherein:
The drawing Figures are not necessarily to scale.
The following detailed description should be read with reference to the drawings, in which like elements in different drawings are numbered identically. The drawings, which are not necessarily to scale, depict selected embodiments and are not intended to limit the scope of the invention. Several forms of invention have been shown and described, and other forms will now be apparent to those skilled in art. It will be understood that embodiments shown in drawings and described below are merely for illustrative purposes, and are not intended to limit the scope of the invention as defined in the claims that follow.
As used herein, with respect to the injection devices, the term “transversely” refers to a direction substantially orthogonal to a plane that includes the longitudinal axis of the elongate shaft distal portion. In one embodiment of the present application, a plane of injection may be defined as being orthogonal to the needles that are to extend into the tissue. Many embodiments of the invention include a needle driver that translates force parallel to the injection plane into a needle driving force. Thus, in many of the embodiments illustrated, the second body distal portion or vacuum plate extends substantially along or parallel to the injection plane. Similarly, as used in the present application, a surface may be defined as “inclined” with respect to the injection plane and may often be found to be inclined with respect to a plane extending through the second body distal portion or second body vacuum plate.
The elongate shaft provided can vary from embodiment to embodiment, with one ball-and-socket embodiment being illustrated in
Second body 64 includes a distal portion 70, an intermediate portion 76, and a proximal portion 80. Proximal portion 80 includes a proximal end 82 that can include a cavity for receiving part of the elongate shaft. Second body proximal portion 80 may also be referred to as a clevis. In some embodiments, second body 64 distal portion 70, intermediate portion 76, and proximal portion 80 are all rigidly joined together to move as a single piece. Injection head 60 further includes a drive yoke 81 longitudinally slidably disposed within second body proximal portion 80. Drive yoke 81 can include an internal blind cavity 83 to assist in coupling drive yoke 81 to a drive cable slidably disposed within an elongate shaft coupled to proximal end 82. Second body proximal portion 80 can be coupled to a rigid, outer sheath portion of the elongate shaft while drive yoke 81 is coupled to an elongate drive shaft or cable slidably disposed within the elongate shaft.
First body proximal portion 77 may be seen to include a proximal inclined drive slot 85, a distal inclined drive slot 87, and an intermediate guide slot 89 that is disposed transversely to the longitudinal axis of the elongate shaft coupled to first body proximal portion 80. Drive yoke 81 may be seen to include a proximal drive pin 84 slidably disposed within proximal inclined drive slot 85, an intermediate guide pin 88 extending through transverse guide slot 89, and a distal drive pin 86 extending through distal inclined drive slot 87. Inclined drive slots 85 and 87 may also be referred to as angled slots, having inclined or angled cam surfaces 71 and 73, respectively. Distal injection head 60 is shown in the open position, having drive yoke 81 in the proximal position and first body proximal portion 77 in the upward most position. Forcing a drive cable through the elongate shaft can force drive yoke 81 distally, causing pins 84 and 86 to bear against inclined surfaces 71 and 73 in inclined slots 85 and 87. This distal movement of pins 84 and 86 over inclined surfaces 71 and 73 urges first body proximal portion 77 downward, with slot 89 moving transversely downward over guide pin 88. As first body distal portion 63 is rigidly secured to first body proximal portion 77, first body distal portion 63 is urged toward second body distal portion 74, driving needles 68 through holes 66 and into the target tissue.
With the needles inserted into the tissue, agents can be injected into the tissue by the application of pressure through injection lumens (not shown in
Distal injection head second body 104 includes a distal portion or vacuum plate 91 secured to an intermediate portion 92, which is in turn secured to a proximal portion 93. Second body vacuum plate 91, intermediate portion 92 and proximal portion 93, are all preferably rigidly secured to each other. Intermediate portion 92 preferably includes matching opposite portions on either side of first body proximal portion 95. Intermediate portion 92 includes a tongue 101 extending inwardly from each side of intermediate portion 92 into groove guides 102 in first body proximal portion 95. Tongue 101 is thus slidably and transversely received within groove 102. Intermediate portion 92 can form side-by-side jaws opposed to an inner jaw formed by first body proximal portion 95.
Drive yoke 96 may be seen slidably disposed within second body proximal portion 93. Drive yoke 96 includes drive pins 99 and 100 secured to drive yoke 96 and extending through inclined slots 97 and 98 of first body proximal portion 95, respectively. Drive yoke 96 is shown in the far, distal position, having forced drive pins 99 and 100 distally through inclined slots 97 and 98 to force first body proximal portion 95 downward to force needle plate 94 against vacuum plate 91. Second body intermediate portion 92 has had groove guide 102 of first body intermediate portion 95 slid downward over tongue 101 of second body intermediate portion 92. Proximally retracting drive yoke 96 relative to second body proximal portion 93 can force drive pins 99 and 100 to the far proximal ends of inclined slots 97 and 98, to force needle plate 94 away from vacuum plate 91.
Distal injection head 154 includes a first body 156 mounted in a spaced-apart relation to a second body 158. As previously described with respect to other embodiments, first body 156 can have several injecting needles fixedly attached to first body 156 and slidably received through holes in second body 158. Second body 158 may be seen to have vacuum pods 61 and a vacuum lumen 65, as previously described with respect to
A first side 110 of distal injection head 154 is visible in
Inspection of
In some embodiments, drive rod or cable 136 is externally helically threaded and is received through corresponding, receiving threads near distal joint 118 and/or proximal joint 128. In this embodiment, rotating drive cable or rod 136 can act to bring joints 128 and 118 either closer together or further apart, acting to advance needles into tissue or retract the needles from tissue, as previously described.
Distal injection head 160 further includes a rotable shaft 178 coupled to a proximal gear 185 including a tooth bearing portion 173 and a more distal bushing portion 180. Intermediate sleeve or bushing 176 has rotable shaft 178 rotatably disposed within. Shaft 178 continues distally to couple to a distal gear 187 including a proximal, bushing portion 174 and a tooth bearing portion 172. Teeth portions 173 and 172 engage teeth 170 on guideposts 166 and 168.
Inspection of
Inflatable envelopes 214 and 218, and other inflatable envelopes in the present application can be cylindrical, round, or pancake shaped. The envelopes can be made of many polymeric materials, including polyurethane, latex, PVC, silicone, and polyamide. Distal inflation head 200 includes a proximal, mounting stub 222, including a proximal aperture 224. Distal injection head 200 further includes an aperture or port 206 that can be used for supplying vacuum to the vacuum pods, previously described. Inflation and deflation tubes 216 and 220 can continue along the length of the elongate shaft or be carried within the elongate shaft for much of its length, either as separate tubes or integral lumens, depending on the embodiment. Similarly, vacuum aperture or port 206 can be coupled along the length of the shaft through a separate vacuum tube or have the vacuum carried within a lumen within the elongate shaft itself. Second body 204 has four guideposts 226 fixedly attached to second body 204. Guideposts 226 are slidably received within receiving apertures 228 formed in first body 202.
In use, distal injection head 200 can be advanced to the tissue site of interest, and disposed against the tissue. In some embodiments, a vacuum is applied through vacuum pods, as previously described. A vacuum can then be applied to envelopes 214 and 226, acting to pull first body 202 toward second body 204, and drive needles 68 through second body 204 and into the tissue.
Inflation pressure can be supplied through tubes 216 and 220 to envelopes 214 and 226, urging first body 202 away from second body 204, thereby retracting needles 68 from the tissue. In some embodiments, a gas, for example, carbon dioxide or nitrogen or air is injected through tubes 216 and 220 to inflate inflatable envelopes 214. In other embodiments, liquid, for example, saline, is supplied to tubes 216 and 220 to operate distal injection head 200. In some embodiments, the depth of needle penetration can be controllably and variably set by adjusting the inflation pressure.
First body 262 may be seen to include three magnets 280, 281, and 282. Second body distal portion 270 also includes three magnets 283, 284, and 285. The magnets may be oriented such that each of the opposing pairs of magnets repel each other. Thus, magnet 280 may have the positive pole oriented downward and corresponding second body magnet 283 may have the positive pole oriented upward, and so forth. The pairs formed by magnets 280 and 283, 281 and 284, and 282 and 285 can act to magnetically bias first body 262 away from second body 264. This magnetic repulsive force may be used in conjunction with other embodiments described elsewhere in the present application.
Distal injection head 260 may also be seen to include a first drawstring or wire 290 extending outward from slot 274, extending through a receiving hole 291 in first body 262, and terminating at a hole or junction point 292 in second body distal portion 264. Similarly, a second pullstring, wire, or tether 294 may be seen also extending from slot 274, extending through a distal receiving hole 295 in first body 264 and terminating in a receiving hole or connection point 296 in second body distal portion 264. A proximal collar 298 may be seen disposed about longitudinal slot 274, limiting the transverse travel of tethers 294 and 290 from longitudinal slot 274.
In use, tethers 290 and 294 may be proximally retracted through longitudinal slot 274 and collar 298. As tethers 290 and 294 are slidably received through holes 291 and 295, respectively, retracting the tethers acts to force first body 262 toward second body distal portion 264. This acts to drive needles 68 through receiving holes 66 and into the target tissue. When the tethers are relaxed, the biasing force of the magnet pairs acts to retract the needles from the target tissue. In some embodiments, electromagnets are used in place of some or all of the magnets, with the wires or electrodes extending the length of the elongate shaft to provide energy to the electromagnets. In the electromagnetic embodiments, the polarity of the magnets can be reversed electronically, to both extend the needles and retract the needles.
First body 322 may be seen to include three magnets, 346, 347, and 348 disposed therein. In the example illustrated, each of the three magnets is oriented to have the positive pole facing downward, toward second body 324. Distal injection head 320 also includes a longitudinally slideable third member 338 secured to a shaft 336 that is slidably received through lumen 334. In
Inspection of
First body 452 has inclined cam surfaces 455 that lie at an angle relative to the longitudinal plane of first body 452. First body 452 also includes substantially level, planar high portions 456 that are not substantially inclined with respect to the plane of first body 452 or the plane of second body 454.
First body 452 may also be seen to have a second set of lower non-inclined regions 458 that are not inclined with respect to the injection plane. Thus, extending from distal to proximal, the underside of first body 452 includes a non-inclined portion 456, an inclined portion 455 extending downward, followed by a non-inclined portion 458. Spring-loaded needles 460 may also be seen in
Needle holder 506 can be made by taking a #4 screw having 40 threads per inch, forming bore 514 with electron discharge machining (EDM) or laser welding, then inserting hollow needle 504 into the bore. Needle 504 can be secured to needle holder 506 using epoxy, sliver solder, or a laser weld.
A syringe mechanism 560 may be seen to include a plunger 562 disposed within a bore or barrel 564. Plunger 562 is in fluid communication with a fluid tube 566. One syringe may be used to provide injectable material, for example biologic agents to be injected into the tissue. Some embodiments include a second syringe or other pressurized fluid mechanism for providing pressure and vacuum to inflate and deflate the envelopes, balloons, and bellows described previously in the present application.
The one or more sensors may comprise one or more sensing electrodes. The one or more sensing electrodes may be used to control the delivery of one or more medical agents. The one or more sensors may be used to determine when the distal injection head contacts tissue. For example, a pair of electrodes located on the tissue-contacting surface of the second body may be used to sense when the second body has made contact with tissue. An indicator may then be used to alert the physician that the distal injection head has made contact with tissue thereby allowing the physician to activate suction and/or inject the needles into the tissue. A variety of indicators, e.g., visual or audible, may be used to indicate to the physician that tissue contact has been made.
In one embodiment of the present invention, controller 710 may be used to control one or more functions, elements or components of system 700. For example, controller 710 may control a vacuum source 720, distal injection head 32, e.g., injection of needles into tissue, and/or pressure source 560, e.g., injection of one or more medical agents into tissue. For example, controller 710 may accept a trigger signal from sensor 630 and in-turn will control a vacuum source, control delivery or injection of needles into the tissue and/or control delivery or injection of one or more medical agents into the tissue.
Controller 710 may incorporate any suitable processor. Controller 710 may be used to gather and process information from one or more sensors of the system. For example, controller 710 may be used to gather and process information from sensor 630. Controller 710 may incorporate one or more switches to facilitate regulation of the various components by the operator. The switches may be, for example, hand switches, foot switches, and/or voice-activated switches comprising voice-recognition technologies. Controller 710 may have different modes, e.g., a standby mode, an automatic mode and/or a manual mode. Indicator lights may be used to indicate the mode of operation selected and if the system has malfunctioned. In one embodiment of the present invention, a system malfunction may trigger a flashing light and/or an audible alarm.
On power up, the controller 710 may perform one or more tests. For example, controller 710 may perform a self-test on its self and/or the sensors, switches, valves and/or devices connected to it. If controller 710 detects a malfunction, visual and/or audible alarms may be activated. Controller 710 may be designed to detect failures during operation and set off visual, and/or audible alarms if so desired.
Controller 710 may be powered by AC power, e.g., 90 to 264 VAC, 50 or 60 Hz, or by a primary cell or rechargeable battery pack. It may be equipped with one or more fuses. Controller 710 may supply regulated voltage to one or more sensors, indicator lights, and/or audible alarms. Controller 710 may be designed to detect under/over voltage and shut off power to devices and sound an alarm.
Controller 710 may include an electronics enclosure that encloses one or more circuit boards and/or processors. The enclosure may have a front panel for one or more mounted switches, gauges, displays, and/or indicator lights, e.g., a power switch with indicator light. The enclosure may also include audio feedback system for sounding one or more alarms. The enclosure may include one or more entry points for a power cord and/or connectors for cables, e.g., cables from one or more sensors. The enclosure may be mountable onto a pole or be free standing. The enclosure may contain part or all of the power supply, e.g., a battery pack.
Controller 710 may be designed such that it will tolerate or disable itself in a safe mode if a sensor, electronic, and/or mechanical failure occurs. In addition, controller 710 may be designed to remain functional if, for example, the hospital electrical power or the hospital vacuum system fails. There are several modes in which the electrical power can fail, from a local failure in an individual operating room to a total hospital failure that disables the vacuum system.
In one embodiment of the present invention, the front panel or user interface of controller 710 may provide a place for the user to turn the power on and/or off, to provide the user the ability to select the operating mode, to provide the user the ability to control suction, to provide the user the ability to control needle insertion, and/or to provide the user the ability to mute any audible alarms. Controller 710 may accept inputs from a keypad located on the front panel and/or a reset button on a back panel. In addition, the user interface may provide a place for displaying one or more visual alarms. The circuitry of controller 710 may contain, for example, all of the necessary electronic components for processing signals from the system's sensors, e.g., contact sensors 620, controlling suction and/or power to the distal injection head, driving visual displays, visual alarms and/or audible alarms on the user interface, and/or handling the power supply and/or battery backup.
In one embodiment of the present invention, distinct visual and/or audible alerts inform the user, for example, that suction is on or off, the needles are deployed or retracted, that one or more medical agents are being delivered or have been delivered, and/or that the instrument is no longer operable.
In one embodiment of the present invention, the user interface may include one or more LCDs for displaying messages as well as one or more LEDs for visual warnings and/or alarms. Preferably, display information is visible, under normal indoor lighting conditions, from at least 10 feet away and audible alarms have a 2-minute mute capability with visual alert uninterrupted. Preferably, depending on the operating status, indicator lights will be off or flash. A flashing yellow light may be used to indicate a warning condition is occurring. A flashing red light may be used to indicate an alarm condition is occurring. The audible alarms may be monotone or varying frequency.
In one embodiment one or more tissue activated switches and/or sensors may be coupled to vacuum source 720 for turning on or modulating suction to the distal injection head. For example, when one or more sensors and/or switches determine distal injection head contacts tissue suction may be activated. The one or more sensors may be one or more electrical sensors, fiber optic sensors, chemical sensors, mechanical sensors and/or proximity sensors that measure conductance. The one or more switches may be one or more electrical, chemical and/or mechanical switches. For example, sensors 630 may be replaced with one or more small mechanically activated switches. When the mechanical switches are pushed against tissue they become activated thereby turning on suction to the distal injection head. In addition, sensors that can identify different tissue types may be used. For example, fatty tissue has different impedance than vessel wall tissue, therefore impedance sensors may be used to identify fatty tissue from vessel wall tissue. Sensors designed to sense difference in impedance may be used to change the amount of energy supplied to the distal injection head.
In one embodiment of the present invention, the delivery of medical agents from the distal injection head may be enhanced via iontophoresis. In general, the delivery of ionized drugs may be enhanced via a small current applied across two electrodes. Positive ions may be introduced into the tissues from the positive pole, or negative ions from the negative pole. The use of ion tophoresis may markedly facilitate the transport of certain ionized drug molecules through tissue. For example, lidocaine hydrochloride may be applied to the heart via the distal injection head. Sensors 630 located on the tissue-contacting surface of second body 600 may comprise a positive electrode and a negative electrode. These electrodes may be used for iontophoresis. Current may be applied between the two electrodes, e.g., between the positive electrode and the negative electrode.
In one embodiment of the present invention, one or more electrodes located on the tissue-contacting surface of second body 600 may be used as stimulation electrodes, e.g., to pace the heart during delivery of one or more medical agents. For example, controller 710 may supply stimulation energy to the one or more electrodes for pacing cardiac tissue. One or more sensors 630 may be used to sense contractions of the heart, thereby allowing the delivery of medical agents to be timed with cardiac contractions. For example, it may be desirable to deliver one or more medical agents between contractions of the heart.
Cardiac contraction sensors may be any suitable sensor, e.g., an electrical sensor, a chemical sensor or a biosensor, for detecting one or more signals indicative of a cardiac contraction or heartbeat. In one embodiment, the cardiac contraction sensor may be coupled to controller 710.
In one embodiment, sensor 630 may be used to monitor the electrical activity of the heart by picking up and amplifying electrical signals from the heart and displaying a visual output and/or providing an audio output. For example, the output may be displayed on a display interface of controller 710. The surgeon may check this output to determine the optimal time to inject the needles and/or medical agents into the tissue.
A cardiac contraction sensor may be a sensor that detects cardiac depolarizations. The electrical signal generated by the sinus node of the heart causes the atria to contract to force blood into the ventricles. After a brief delay, the ventricles contract to force blood out through the body. The contraction of the ventricles is reflected by the passage of a depolarization wavefront through the heart muscle. If a depolarization is sensed, a beat is likely to occur. One such depolarization sensor is disclosed in U.S. Pat. No. 5,156,149 entitled “Sensor for Detecting Cardiac Depolarizations Particularly Adapted for use in a Cardiac Pacemaker”, Oct. 2, 1992, to inventor Hudrlik. This patent is assigned to Medtronic, Inc. and is incorporated herein by reference.
A cardiac contraction sensor may be coupled to a cardiac stimulator or controller 710 which may act as a cardiac stimulator. A cardiac contraction sensor may be an apparatus that senses power levels of depolarizations in heart tissue. Such a sensor may be used to distinguish between normally conducted and ectopic heart beats while the heart is beating or may be used to sense an imminent heart beat while the heart is slowed or substantially stilled during a medical procedure. One apparatus that may serve as such a sensor is disclosed in U.S. Pat. No. 5,411,529 entitled “Waveform Discriminator for Cardiac Stimulation Devices”, May 2, 1995, to inventor Hurdlik. This patent is assigned to Medtronic, Inc. and is incorporated herein by reference. Other suitable sensors may also serve as cardiac contraction sensor.
The devices according to the present invention can be used in several methods to deliver material to tissue. In one, mini-thoracotomy method, a patient is intubated with a double-lumen endobronchial tube that allows selective ventilation or deflation of the right and left lungs. The left lung is deflated, thereby helping to provide access to the surface of the heart. A left anterior thoracotomy or incision is created over an intercostal space, preferably the 4th intercostal space. An alternative intercostal space may be used depending on the patient's physiology, e.g., the 5th intercostal space. The thoracotomy should be as anterior and medial as possible without removing cartilage. A two-inch incision is preferable, however, the size of the incision may vary depending on the patient. The ribs, adjacent the incision, may be spread, referably two-inches or less, using a small rib retractor or spreader to allow adequate access into the chest. If desired, a retractor may be used to spread the ribs both horizontally and vertically. Next, the pericardium is opened directly under the incision. Dissection through fat may be required to reach the pericardium. The pericardium may be opened by a number of different techniques. In one embodiment of the present invention, the pericardium may be opened by tenting it with graspers and then cutting it with scissors. In an alternative embodiment of the present invention, a device as disclosed in either U.S. Pat. No. 5,931,810 or U.S. Pat. No. 6,156,009 both to Grabeck may be used to access the pericardial space. In addition, devices as disclosed in U.S. Pat. No. 5,972.013 to Schmidt, U.S. Pat. No. 5,827,216 to Igo, et al., U.S. Pat. No. 6,162,195 to Igo, et al., U.S. Pat. No. 4,991,578 to Cohen and U.S. Pat. No. 5,336,252 to Cohen may be used, for example, to access the pericardial space. These patents are incorporated herein by reference.
In one embodiment of the present invention, one or more devices may be used within the pericardial space for creating space and visualizing the surface of the heart. For example, a device comprising a rigid rod with a light may be used to push on the interior of the pericardium and to move the lung laterally if desired. Another device comprising a flat malleable spatula may be used to rotate the heart and expose the posterior lateral portion of the heart if desired. The spatula device may be bent or formed into whatever shape is required to move and rotate the heart.
In one embodiment of the present invention, a suction positioning device as described in U.S. Pat. No. 6,447,443 to Keogh et al., incorporated herein by reference, may be used to move the heart around and/or hold the pericardium out of the way. The positioning device may be used to engage the heart and to position the heart into a non-physiological orientation.
Upon gaining access to the epicardial surface of the heart, the injection head and shaft are inserted through the mini-thoracotomy. The distal injection head is then placed against the surface of the heart. Suction may be applied prior to the injection of needles into the tissue. Following delivery of one or more biologic agents or medical agents, the needles are retracted and suction, if used, may be turned off. The heart may be repositioned is desired, for example, with a suction positioning device. The distal injection head may then be repositioned for additional delivery of one or more medical agents or the head and shaft may be removed from the patient. All incision may then be closed using standard techniques. If the pleura is closed, a small tube for drainage may be left in place and removed the same day as surgery. If the pleura is open, a larger tube may be left in place for 24 hours.
In one, thoroscopic method, a patient is intubated with a double-lumen endobronchial tube that allows selective ventilation or deflation of the right and left lungs. The left lung is deflated, thereby helping to provide access to the surface of the heart. The patient is rotated approximately 30° with the left side up. The left arm is placed below and behind the patient so as not to interfere with tool manipulation during the delivery of one or more medical agents. While port positions depend to a large extent on heart size and position, in general a 7th and 5th space mid (to posterior) axillary port for tools and a 3rd space anterior axillary port for the scope is preferable. A variety of endoscopes or thoracoscopes may be used including a 30 degree offset viewing scope or a straight ahead viewing scope. In general, short 10 to 12 mm ports are sufficient. A soft 20 mm port with an oval cross section sometimes allows for two tools in the port without compromising patient morbidity.
The pericardium may be opened by a number of different techniques. In one embodiment of the present invention, the pericardium may be opened by tenting it with graspers and then cutting it with scissors. In an alternative embodiment of the present invention, a device as disclosed in either U.S. Pat. No. 5,931,810 or U.S. Pat. No. 6,156,009 both to Grabeck may be used to access the pericardial space. In addition, devices as disclosed in U.S. Pat. No. 5,972,013 to Schmidt, U.S. Pat. No. 5,827,216 to Igo, et al., U.S. Pat. No. 6,162,195 to Igo, et al., U.S. Pat. No. 4,991,578 to Cohen and U.S. Pat. No. 5,336,252 to Cohen may be used, for example, to access the pericardial space. Upon gaining access to the epicardial surface of the heart, the injection head and shaft are inserted through an appropriate port. The distal injection head is then placed against the surface of the heart. Suction may be applied prior to the injection of needles into the tissue. Following delivery of one or more medical agents, the needles are retracted and suction, if used, is turned off. The distal injection head may then be repositioned for additional delivery of one or more medical agents or the head and shaft may be removed from the patient. All incisions may then be closed using standard techniques. Some methods may utilize insufflation, in which the incision or port is sealed about the device shaft and the interior of the thorax pressurized.
In one, sternotomy method, the device may be inserted through an incision made through the sternum. In yet another method, a xiphoid incision method, an incision is made below the sternum and the injection head is then inserted through the incision. The term “xiphoid incision” refers to a surgical incision proximate to, but not necessarily directly above, the xiphoid appendage. The xiphoid incision of the invention provides a surgical field and access site to the heart that extends through an opening beneath the sternum and preferably immediately beneath the lowest rib.
A vertical skin incision is made above the xiphoid process and the center of the xiphoid appendage is transected. Because the xiphoid appendage is cartilaginous, the appendage does not have to be removed and the sternum does not have to be transected. The total length of the xiphoid incision depends on length of xiphoid appendage, i.e., longer xiphoids are less likely to require any cutting into the sternum. The maximum incision is preferably approximately 6-7 cm from below the tip of the xiphoid appendage upwards towards the patient's head. The incision may be extended downward below the xiphoid appendage to the extent necessary to provide an adequate surgical field, but as noted above, the maximum length should not greatly exceed 6-7 cm. The incision may be strictly vertical or may be slightly curved, following the outline of the butt of either the right or left rib cage. In most cases, a curved incision will follow the lower left rib. An approximately 1 cm incision may be made in the pericardium to accommodate insertion of a surgical scope. The scope preferably has a flexible housing and at least a 16× magnification. Insertion of the scope through the pericardial incision allows the surgeon to inspect the epicardial surface of the heart thereby allowing the physician to plan the procedure depending on the clinical status of the individual patient. At this point, the surgeon can confirm that a xiphoid access is appropriate for the particular procedure to be performed.
A vertically offsetting retractor or access platform may be used to engage a portion of the rib cage capable of lifting at least one rib and preferably more than one rib and the sternum, see U.S. Pat. No. 6,199,556 to Benetti et al. This patent is incorporated herein by reference. The term “offsetting” herein is used to describe a manipulation of at least one rib that provides access to the thoracic cavity via the xiphoid incision, generally described herein as “xiphoid access.” Typically, the vertical offsetting procedure comprises engaging the lowermost rib with an offsetting retractor or access platform and lifting at least a portion of the lowermost ribs. This may be accomplished by simultaneously applying force at one or more points about the chest and pelvis, and preferably includes at least a mechanical force applied vertically to orient at least a portion of the lower region of the sternum and rib cage relative to the remainder of the body below the rib cage. As noted, this orientation is most readily achieved by lifting one half of the lower edge of the rib cage, adjacent to he xiphoid appendage using a specially designed surgical retractor. Although retraction devices such as those described in U.S. Pat. No. 5,730,757 are preferred, other more conventional devices could be adapted, see for example U.S. Pat. Nos. 5,026,779, 4,726,358 and 4,852,552. These patents are incorporated herein by reference. Collectively, these devices can provide access to a beating heart via a xiphoid incision and comprise means for offset retraction of the lower rib cage.
Since the size of the incision is preferably minimized in a xiphoid procedure, an organ or tissue positioner may advantageously be used to retract or reposition tissue or internal organs at the site of the incision or inside the thoracic cavity near the site of the surgery. The positioner or retractor may be of any conventional mechanical design, or expandable by inflation on manipulation, and is preferably suitable for minimally invasive procedures. Moreover, a tissue or organ positioner may be affixed to the offsetting retractor during the procedure to maintain access to the surgical field.
Upon gaining access to the epicardial surface of the heart, the injection head and shaft are inserted through the xiphoid incision. The distal injection head is then placed against the surface of the heart. Suction may be applied prior to the injection of needles into the tissue. Following delivery of one or more medical agents, the needles are retracted and suction, if used, may be turned off. The distal injection head may then be repositioned for additional delivery of one or more medical agents or the head and shaft may be removed from the patient. All incisions may then be closed using standard techniques. A small incision may be made below the xiphoid appendage and a drainage tube may be inserted into the pericardium, if the pleura has not been opened, and into the pluera itself if it has been opened. Before finally closing the xyphoid incision, a scope may be used to check the position of the drainage tube, and to check the integrity of the pleura.
The elongate device shaft can be used to position the injection head over the epicardium as desired. In some methods, the device elongate shaft is flexible, and is introduced through a small incision, port or cannula. In some devices, the distal injection head has a thickness of no greater than about 15 millimeters, to allow for insertion between the ribs in an incision having a height of no greater than about 15 millimeters.
Cells suitable for implantation according to the present invention include a wide variety of cells, e.g., undifferentiated contractile cells. Typically, undifferentiated contractile cells differentiate to form muscle cells, however, they can be fibroblasts that have been converted to myoblasts ex vivo, or any of a wide variety of immunologically neutral cells that have been programmed to function as undifferentiated contractile cells. Cells of mesodermal origin that form contractile cells can be injected, and include skeletal muscle cells, heart muscle cells, and smooth muscle cells, as well precursor cells to the cells, such as pluripotent stem cells, embryonic stem cells, mesodermal stem cells, myoblast, fibroblasts, and cardiomyocytes. Suitable cells for use in the present invention can include umbilical cells, and skeletal muscle satellite cells. Suitable cells for implantation also include differentiated cardiac,or skeletal cells, such as cardiomyocytes, myotubes and muscle fiber cells, and the like, whether they are autologous, allogeneic or xenogenic, genetically engineered or non-engineered. Mixtures of such cells can also be used. Autologous cells are particularly desirable. The cells are capable of repopulating the infarct zone of the myocardium or capable of establishing health tissue in damaged or diseased myocardial areas or aiding in the angiogenesis process.
Skeletal muscle satellite cells are particularly suitable for use in the present invention because they can differentiate to muscle cells that are capable of contracting in response to electrical stimulation. They are also particularly suitable for use in the present invention because they can be obtained from cell cultures derived from the biopsy samples of the same patient. Biopsy samples contain mature skeletal fibers along with reserve cells surrounding the mature fibers. Once placed in culture, reserve cells proliferate and their numbers quickly increase. These newly cultured cells can be injected back into the heart in and/or near the infarct zone. Once in the heart muscle, the skeletal myoblasts fuse to form multinucleated myotubes having contractile characteristics.
The undifferentiated and/or differentiated contractile cells can be delivered in combination with a delivery vehicle, such as liposomes or a polymeric matrix. Once the undifferentiated and/or differentiated cells form contractile tissue, their function can be further enhanced by metabolically altering them, for example, by inhibiting the formation of myostatin. This increases the number of muscle fibers.
In some methods, the cells are suspended in a liquid, and supplied to the distal injection head through a lumen in a tube. In other methods, the cells or other material is loaded into the needles in plug form, advanced to the target site, and ejected from the needles through the application of pressure to the needles. In one such method, cell material too viscous to flow through an elongate tube is loaded into the needles and discharged through the application of saline to the needles. In one method, a biopsy type sample is contained in the needles and injected under pressure to the target tissue.
Other therapeutic agents can be injected using devices and methods according to the present invention. Specific examples of therapeutic agents used in conjunction with the present invention include proteins, oligonucleotides, ribozymes, anti-sense genes, DNA compacting agents, gene/vector systems, nucleic acids (including recombinant nucleic acids; naked DNA, cDNA, RNA; genomic DNA, cDNA or RNA in a non-infectious vector or in a viral vector which may have attached peptide targeting sequences; antisense nucleic acid (RNA or DNA); and DNA chimeras which include gene sequences and encoding for ferry proteins such as membrane translocating sequences (“MTS”) and herpes simplex virus-1 (“VP22”)), and viral, liposomes and cationic polymers. Other pharmaceutically active materials include anti-thrombogenic agents such as heparin, heparin derivatives, urokinase, and PPACK (dextrophenylalanine proline arginine chloromethylketone); antioxidants such as probucol and retinoic acid; angiogenic and anti-angiogenic agents; agents blocking smooth muscle cell proliferation such as rapamycin, angiopeptin, and monoclonal antibodies capable of blocking smooth muscle cell proliferation; anti-inflammatory agents such as dexamethasone, prednisolone, corticosterone, budesonide, estrogen, sulfasalazine, acetyl salicylic acid, and mesalamine; calcium entry blockers such as verapamil, diltiazem and nifedipine; antineoplastic/antiproliferative/anti-mitotic agents such as paclitaxel, 5-fluorouracil, methotrexate, doxorubicin, daunorubicin, cyclosporine, cisplatin, vinblastine, vincristine, epothilones, endostatin, angiostatin and thymidine kinase inhibitors; antimicrobials such as triclosan, cephalosporins, aminoglycosides, and nitorfurantoin; anesthetic agents such as lidocaine, bupivacaine, and ropivacaine; nitric oxide (NO) donors such as lisidomine, molsidominc, L-arginine, NO-protein adducts, NO-carbohydrate adducts, polymeric or oligomeric NO adducts; anti-coagulants such as D-Phe-Pro-Arg chloromethyl ketone, an RGD peptide-containing compound, heparin, antithrombin compounds, platelet receptor antagonists, anti-thrombin antibodies, anti-platelet receptor antibodies, enoxaparin, hirudin, Warafin sodium, Dicumarol, aspirin, prostaglandin inhibitors, platelet inhibitors and tick antiplatelet factors; vascular cell growth promotors such as growth factors, growth factor receptor antagonists, transcriptional activators, and translational promotors; vascular cell growth inhibitors such as growth factor inhibitors, growth factor receptor antagonists, transcriptional repressors, translational repressors, replication inhibitors, inhibitory antibodies, antibodies directed against growth factors, bifunctional molecules consisting of a growth factor and a cytotoxin, bifunctional molecules consisting of an antibody and a cytotoxin; cholesterol-lowering agents; vasodilating agents; agents which interfere with endogeneus vascoactive mechanisms; survival genes which protect against cell death, such as anti-apoptotic Bc 1-2 family factors and Akt kinase; and combinations thereof.
Examples of polynucleotide sequences useful in practice of the invention include DNA or RNA sequences having a therapeutic effect after being taken up by a cell. Examples of therapeutic polynucleotides include anti-sense DNA and RNA; DNA coding for an anti-sense RNA; or DNA coding for tRNA or rRNA to replace defective or deficient endogenous molecules. The polynucleotides of the invention can also code for therapeutic proteins or polypeptides. A polypeptide is understood to be any translation product of a polynucleotide regardless of size, and whether glycosylated or not. Therapeutic proteins and polypeptides include as a primary example, those proteins or polypeptides that can compensate for defective or deficient species in an animal, or those that act through toxic effects to limit or remove harmful cells from the body. In addition, the polypeptides or proteins useful in the present invention include, without limitation, angiogenic factors and other molecules competent to induce angiogenesis, including acidic and basic fibroblast growth factors, vascular endothelial growth factor, hif-1, epidermal growth factor, transforming growth factor .alpha. and .beta., platelet-derived endothelial growth factor, platelet-derived growth factor, tumor necrosis factor .alpha., hepatocyte growth factor and insulin like growth factor; growth factors; cell cycle inhibitors including CDK inhibitors; anti-restenosis agents, including p15, p16, p18, p19, p21, p27, p53, p57, Rb, nFkB and E2F decoys, thymidine kinase (“TK”) and combinations thereof and other agents useful for interfering with cell proliferation, including agents for treating malignancies; and combinations thereof. Still other useful factors, which can be provided as polypeptides or as DNA encoding these polypeptides, include monocyte chemoattractant protein (“MCP-1”), and d the family of bone morphogenic proteins (“BMP's”). The known proteins include BMP-2, BMP-3, BMP-4, BMP-5, BMP-6 (Vgr-1), BMP-7 (OP-1), BMP-8, BMP-9, BMP-10, BMP-11, BMP-12, BMP-13, BMP-14, BMP-15, and BMP-16. Currently preferred BMP's are any of BMP-2, BMP-3, BMP-4, BMP-5, BMP-6 and BMP-7. These dimeric proteins can be provided as homodimers, heterodimers, or combinations thereof, alone or together with other molecules. Alternatively or, in addition, molecules capable of inducing an upstream or downstream effect of a BMP can be provided. Such molecules include any of the “hedgehog” proteins, or the DNA's encoding them.
In one embodiment of the present invention, first and second passages 1108 and 1118 are made through the skin 1102 into the thoracic cavity. The passages 1108 and 1118 may be formed employing one-piece rods or trocars of prescribed diameters and lengths that are advanced through body tissue to form the passage and then removed so that other instruments can be advanced through the passage. The passage may also be formed employing two piece trocars that comprise a tubular outer sleeve, sometimes referred to as a port or cannula or at times as the tubular access sleeve itself, having a sleeve access lumen extending between lumen end openings at the sleeve proximal end and sleeve distal end, and an inner puncture core or rod that fits within the sleeve access lumen. The inner puncture rod typically has a tissue penetrating distal end that extends distally from the sleeve distal end when the inner puncture rod is fitted into the sleeve access lumen for use. The two-piece trocar can be assembled and advanced as a unit through body tissue, and the inner puncture rod then removed leaving the tubular access sleeve in place to maintain a fixed diameter passage through the tissue for use by other instruments.
In one of these ways, a tubular access sleeve 1110 is placed through first passage 1108 that is made as described above in the chest wall of patient 1100 between the patient's 2nd rib and 6th rib, for example. The selection of the exact location of the first passage 1108 is dependent upon a patient's particular anatomy. A further conventional tubular access sleeve 1112 is shown left in place in a second passage 1118 that is made as described above in the chest wall of patient 1100.
In one embodiment of the present invention, the patient's left lung is deflated to allow unobstructed observation of the pericardium 1106 employing a thoracoscope 1120 or other imaging device inserted through a sleeve lumen of tubular access sleeve 1112. The thoracoscope or other imaging device may have its own light source for illuminating the surgical field. Deflation of the patient's lung may be accomplished by use of a double lumen endotracheal tube that is inserted into the trachea, and independent ventilation of the right, left or both lungs can be selected. The left lung will collapse for visualization of the structures of the left hemi-sternum when ventilation of the left lung is halted and the left thoracic negative pressure is relieved through a lumen of the tubular access sleeve 1112 or a further access sleeve to atmospheric pressure. After deflation, the thoracic cavity may be suffused with a gas, e.g., carbon dioxide, introduced through a lumen of the tubular access sleeve 1112 or the further access sleeve to pressurize the cavity to keep it open and sterile. The pressurized gas keeps the deflated lung away from the left heart so that the left heart can be viewed and accessed and provides a working space for the manipulation of the tools of the present invention. It will be understood that the access sleeve lumens must be sealed with seals about instruments introduced through the lumens if pressurization is to be maintained.
A thoracoscope 1120 can then inserted into the lumen of the tubular access sleeve 1112 to permit wide angle observation of the thoracic cavity by a surgeon directly through an eyepiece 1122 or indirectly through incorporation of a miniaturized image capture device, e.g., a digital camera, at the distal end of the thoracoscope 1120 or optically coupled to the eyepiece 1122 that is in turn coupled to an external video monitor (not shown). The thoracoscope 1120 also incorporates a light source for illuminating the cavity with visible light so that the epicardial surface can be seen directly or indirectly. The depicted thoracoscope 1120 is used to directly visualize the thoracic cavity and obtain a left lateral view of the pericardial sac or pericardium 1106 over the heart 1104.
The elongated access sleeve 1110 provides an access sleeve lumen 1116 enabling introduction of suction tool 1010 to dispose the suction member or pad 1030 within the thoracic cavity. The tubular access sleeve 1110 and tool 1010 of the present invention are employed to access the pericardium 1106 and to grip its surface to tension it so that an incision can be made through the pericardium 1106. The accessed pericardial space 1124 and epicardium 1106 surrounding the heart 1104 are shown more specifically in the cross-section view of
The suction pad or member 1030, which includes a number of vacuum suction pods, is advanced through the incision formed through the pericardium and against the epicardium. In one use of the suction tool of the present invention, a myocardial bleb is formed by the applied suction so that one or more fluid and/or cell delivery needles may be advanced into the myocardium. An exemplary cell delivery tool 1090 having one or more distal cell delivery needles 1092 is depicted in
The suction tool 1010 may comprise a suction tool body 1012 extending between a proximal suction tool port assembly 1014 and a suction member 1030 depicted in greater detail in
In one embodiment of the present invention, the suction tool proximal assembly 1014 may comprise the proximal end opening of the suction tool working lumen 1020, an optical or electrical illumination connector 1022, a vacuum side port 1024, and an optical or electrical imaging connector 1026.
The vacuum side port 1024 may be adapted to be attached to a vacuum source at the surgical site to draw suction through one or more vacuum lumen extending through the suction tool proximal end assembly 1014, the suction tool body 1012 and then through a plurality of suction ports 1042 of suction port array 1040 depicted in
In accordance with one aspect of the present invention, the tissue sites, i.e., the pericardium, pericardial space and myocardium in this instance, adjacent to the suction pad are optionally illuminated and imaged through the suction tool 1010. The illumination of the sites can be accomplished by one or more miniaturized light emitters incorporated into the suction pad 1030 coupled to conductors extending through the tool body 1012 to an electrical illumination connector 1022 that is coupled to an external battery pack or the like. However, for safety, economic, and space reasons, it is preferred that light be conducted from an external light source to the suction pad 1030. As shown, suction tool 1010 may incorporate an optical illumination connector 1022 including one or more fiber-optic light pipes extending to one or more light emitting lens elements and/or light pipe ends, e.g., light pipe ends 1052 and 1054 depicted in
The illuminated tissue site could be imaged by incorporating a miniaturized video camera digital imaging array and lens in the suction pad 1030 and powering the array and conducing image pixel data through conductors extending to an electrical imaging connector 1026 to be coupled to external video imaging and display apparatus. However, for safety, economic, and space reasons, it is preferred that an image of the illuminated site be optically conveyed from an external light source to the suction pad 1030. Again, it will be understood that the suction tool 1010 incorporates an optical imaging connector 1026 coupled with a fiber-optic light pipe extending to an imaging lens element or pipe end 1038 depicted in
One preferred configuration of the non-conductive suction pad 1030 is depicted in
The working lumen 1020 extends through the tool body 1012 and a proximal portion of the suction pad 1030 to a working lumen port 1046 in the proximal cavity wall 1038 defining the suction cavity 1050. Therefore, the various instruments such as cutting instrument 1080 and cell delivery needles 1092 referred to herein can be advanced tangentially into the tissue bleb.
It should be noted that the working lumen 1020 may also be the suction lumen 1044 in suction tools specifically designed to introduce medical instruments and devices, rather than fluids or materials, through the combined lumen. Suction would then be applied to the tissue bleb through the working lumen port 1046 as well as the array of suction ports.
Optionally, an illumination light pipe 1048 extends from the optical illumination connector 1022 through the length of the tool body 1012 and branches within the proximal portion of the suction pad 1030 to a pair of illumination light pipe ends 1052 and 1054 in proximal suction pad wall 1038. Similarly, optionally, an imaging light pipe 1056 extends from the optical imaging connector 1026 through the length of the tool body 1012 and the proximal portion of the suction pad 1030 to an imaging light pipe end 1058 in proximal cavity wall 1038. Therefore, the area within the concave suction wall 1036 and distal to the suction pad distal end 1062 can be illuminated and imaged remotely. It should be noted that the light pipes 1048 and 1056 can be extended past the suction cavity 1050 to terminate with the light pipe ends 1052, 1054 and 1058 arrayed near the suction pad distal end 1060. Or, the light pipes can extend simply to the more proximal suction pad wall 1062 and terminate with the light pipe ends 1052, 1054 and 1058 arrayed in the more proximal suction pad wall 1062.
In use, the suction pad 1030 is laterally extended out of the suction tool lumen 1020 so that a tangential approach can be made to the tissue, such as the pericardium 1106 as shown in
In
Advantageously, there is no suction applied through the suction tool working lumen 1020 that is necessary to maintain the attachment of the pericardium 1106 while it is being cut to form the pericardial incision 1114 to reach the pericardial space 1138. Due to their redundancy, the plurality of suction ports 1042 of the suction pads 1030 provide more robust fixation to the pericardium 1106 (or other outer tissue layer) than a single large area suction port. At least some of the suction ports 1042 readily engage the pericardial surface under low suction force to maintain the pericardial bleb 1136 and enable lifting of the pericardium 1106 or tracking movement of the pericardium 1106. Engagement of the surface of the pericardium 1106 by all of the suction ports 1042 is not necessary. Similarly, the loss of engagement of some of suction ports 1042 with the surface areas of the pericardium 1106 does not result in complete loss of engagement as is the case when an edge of a single large suction port releases from a tissue surface of an outer tissue layer or the pericardium.
Furthermore, the suction tool 1010 is versatile in that it can be used to simply access the pericardial space 1138. Various instruments, medical devices, drugs or materials can be advanced through the working lumen 1020, out of the working lumen port 1046, through the pericardial incision 1114, and into the pericardial space 1138 for temporary treatment of the heart 1104 or pericardial space 1138 or to complete a surgical procedure or for permanent implantation of medical devices against the epicardium 1140 or within the pericardial space or within the myocardium 1142 or within a coronary vein or artery.
In one embodiment of the current invention, suction tool 1010 may be used to delivery one or more biological agents such as fluids and/or cells to the heart as illustrated in
The cell delivery tool 1090 is then advanced through the working lumen 1020 to dispose the one or more needles 1092 at the working lumen port into the suction cavity 1050. The one or more needles 1092 are then into and through the epicardium 1140 and into the myocardial bleb 1146. One or more biological agents may then be delivered into the myocardium. Following delivery, the suction tool 1010 may be withdrawn and the process of
In accordance with a still further aspect of the invention, the suction tool 1010 is equipped with a steering mechanism that the surgeon can manipulate at the suction tool proximal end assembly 1014 to steer the suction pad 1030 to a desired tissue site, e.g., a site of the pericardium or the epicardium illustrated in
The deflection mechanism can take any of the forms known in the medical device art. A commonly employed approach to providing controllable deflection of the distal end segments of catheters, guide wires, and stylets employs a generally straight outer sheath or tube and a pull or push or push-pull wire extending through a lumen of the outer sheath to an attachment point at the sheath distal end. The wire is pushed or pulled on at its proximal end typically through a handle that is permanently or removably attached to the catheter or guidewire proximal end. The proximal retraction or distal advancement of the pull or push wire, respectively, causes at least a distal segment of the outer sheath to bend or deflect. Examples of such deflection mechanisms in catheters can be found in U.S. Pat. Nos. 4,815,478, 4,898,577, 4,940,062, 5,545,200 and 6,251,092. U.S. Pat. Nos. 4,815,478 and 4,940,062 disclose the use of push-pull wires extending through guidewire lumens for deflecting a guidewire distal end by manipulating a handle at the guidewire proximal end.
Thus, deflection mechanism 1070 can comprise a proximal handle at the suction tool proximal end assembly 1014 coupled to a pair of pull wires extending from handle controls to opposite sides of the suction pad 1030 to selectively induce bends in distal segment 1072 to move the suction pad between positions “A” and “B” and intermediate positions therebetween.
In accordance with a further aspect of the invention, the suction pad distal end 1060 is shaped to facilitate advancement of the suction pad through the tissue incision to facilitate advancement of the suction pad 1030 through and widening of the pericardial incision 1114 as depicted in
Returning to the cutting instrument, cutting blade 1084 of
The cutting blade 1084′ of
The cutting blade 1084″ of
The cutting blade 1084′″ of
The suction tool 1010 as described above can be further modified to facilitate making and increasing the length of such tissue incisions, e.g. pericardial incision 1114, and to facilitate implantation of cardiac leads into or through the myocardial bleb 1146. In particular, an elongated, tapered, suction pad distal end 1060″″ is depicted in the suction pad 1030″″ of
The suction tool 1010 can be further modified to incorporate a pair of elongated electrodes attached to the suction pad lower wall extending alongside the suction cavity 1050. In use, suction is applied to form the pericardial bleb 1136, and ablation current can be applied to the electrodes that would create the peridardial incision 1114. The electrodes can also be used when the suction pad 1030 is applied to the epicardium 1140 to conduct a mapping and threshold determination to locate infarct sites for implantation of cells.
The tubular access sleeve 1010 can be circular or oval or have any other desirable cross-section shape. The tubular access sleeve 1010 can be straight, curved or formed with a bend or formed of a bendable material to be shaped by the user.
The access to the pericardial space in accordance with the present invention facilitates the performance of a number of ancillary procedures. For example, the procedures include introducing and locating the distal end of a catheter or guidewire or an electrode of a cardiac ablation catheter or a pacing lead or a cardioversion/defibrillation lead within the pericardial space and attached to the epicardium or myocardium. Other possible procedures include performing a coronary artery anastomosis in a thoracoscopic CABG procedure, replacing a defective heart valve, ablating aberrant electrical pathways in the atria to alleviate atrial tachyarrhythmias, introducing cells, drugs or anti-bacterial agents into the pericardial space, relieving pericardial fluid pressure or providing cardiac resynchronization therapy. Other procedures that can be performed in the pericardial space, include fluid withdrawal, drug delivery, cell delivery, diagnostic and therapeutic electrophysiology procedures, transmyocardial revascularization, transmyocardial revascularization with drug delivery, placement of the left ventricular assist devices, placement of the arterial bypass graphs, in situ bypass, i.e., coronary artery-venous fistulae, placement of drug delivery depots, closure of the left arterial appendage, and the like.
Referring to
Referring to
The deflection mechanism 1270 can take any of the forms known in the medical device art. A commonly employed approach to providing controllable deflection of the distal end segments of catheters, guide wires, and stylets employs a generally straight outer sheath or tube and a pull or push or push-pull wire extending through a lumen of the outer sheath to an attachment point at the sheath distal end. The wire is pushed or pulled on at its proximal end typically through a handle that is permanently or removably attached to the catheter or guidewire proximal end. The proximal retraction or distal advancement of the pull or push wire, respectively, causes at least a distal segment of the outer sheath to bend or deflect. Examples of such deflection mechanisms in catheters can be found in U.S. Pat. Nos. 4,815,478, 4,898,577, 4,940,062, 5,545,200 and 6,251,092. U.S. Pat. Nos. 4,815,478 and 4,940,062 disclose the use of push-pull wires extending through guidewire lumens for deflecting a guidewire distal end by manipulating a handle at the guidewire proximal end. Thus, deflection mechanism 1270 can comprise a proximal handle at the suction tool proximal end assembly 14 coupled to a pair of pull wires extending from handle controls to suction pad 1030 to selectively move suction pad 1030 relative to working lumen 1020 of suction tool body 1012 between angle positions 0 degrees and 90 degrees and positions therebetween, e.g., “X” and “Y”.
Deflection mechanism 1270 can allow suction tool 1010 to accommodate a variety of approach procedures including sternotomy, thoracotomy, and thoracoscopy procedures. For example, depending on the angle of approach the surgeon is taking relative to a targeted tissue site and depending on the particular procedure, e.g., lead delivery, ablation and/or cell delivery, the more or less angle the surgeon may want suction pad 1030 to be relative to working lumen 1020. It may be desirable to have a lead implanted tangentially to the surface of heart to reduce the strain at the surface of the heart on the lead. In the case of a cell delivery procedure, it may be more desirable to implant the cells more perpendicular to the surface of the tissue or organ thereby placing the cells more deeply into the targeted tissue.
An alternative embodiment of the present invention is to fix the angle between suction pad 1030 and working lumen 1020. In one embodiment, this angle is fixed at approximately 1030 degrees. In cases where the angle needs to be approximately 0 degrees, suction pad 1030 may be made to include a channel, slot or groove within the suction pad 1030 thereby allowing one or more needles to be directed out of suction pad 1030 at an angle greater than 0 degrees, for example 30 degrees relative to the surface of the heart.
In one embodiment of the present invention, the device for injecting agents into tissue may incorporate one or more sensors for sensing or monitoring. For example, referring to
Alternatively, the one or more sensors of suction tool 1010 may be any suitable blood gas sensor for measuring the concentration or saturation of a gas in the blood stream. For example, a sensor for measuring the concentration or saturation of oxygen or carbon dioxide in the blood and/or tissues may be employed.
Alternatively, the one or more sensors of suction tool 1010 may be any suitable sensor for measuring blood pressure or flow, for example a Doppler ultrasound sensor system, or a sensor for measuring hematocrit (HCT) levels.
Alternatively, the one or more sensors of suction tool 1010 may be a biosensor, for example, comprising an immobilized biocatalyst, enzyme, immunoglobulin, bacterial, mammalian or plant tissue, cell and/or subcellular fraction of a cell. For example, the tip of a biosensor may comprise a mitochondrial fraction of a cell, thereby providing the sensor with a specific biocatalytic activity.
Alternatively, the one or more sensors of suction tool 1010 may be based on potentiometric technology or fiber optic technology. For example, the sensor may comprise a potentiometric or fiber optic transducer. An optical sensor may be based on either an absorbance or fluorescence measurement and may include an UV, a visible or an IR light source.
The one or more sensors of suction tool 1010 may be used to detect naturally detectable properties representative of one or more characteristics, e.g., chemical, physical or physiological, of a patient's bodily tissues or fluids. For example, naturally detectable properties of patient's bodily tissues or fluids may include pH, fluid flow, electrical current, impedance, temperature, pressure, components of metabolic processes, chemical concentrations, for example, the absence or presence of specific peptides, proteins, enzymes, gases, ions, etc.
The one or more sensors of suction tool 1010 may include one or more imaging systems, camera systems operating in UV, visible, or IR range; electrical sensors; voltage sensors; current sensors; piezoelectric sensors; electromagnetic interference (EMI) sensors; photographic plates, polymer-metal sensors; charge-coupled devices (CCDs); photo diode arrays; chemical sensors, electrochemical sensors; pressure sensors, vibration sensors, sound wave sensors; magnetic sensors; UV light sensors; visible light sensors; IR light sensors; radiation sensors; flow sensors; temperature sensors; or any other appropriate or suitable sensor. The one or more sensors of suction tool 1010 may be powered by any suitable power source. In addition, the one or more sensors of suction tool 1010 may be coupled to any appropriate output device, for example, a LCD or CRT monitor which receives and displays information regarding the one or more sensors.
A temperature sensor may incorporate one or more temperature-sensing elements such as, for example, thermocouples, thermisters, temperature-sensing liquid crystals, or temperature-sensing chemicals. A temperature sensor could be used, for example, to monitor tissue temperature generated by an ablation apparatus.
Ablation may be performed by heating the tissue to a suitable temperature. Alternatively, ablation may be performed by freezing the tissue to a suitable temperature. The change in tissue temperature may be sensed and/or monitored by one or more temperature sensors of suction tool 10. In one embodiment, the change in tissue temperature may be displayed on an output device. By software control, the user may choose to display the information in a number of ways. The output device may show the current temperature of each sensor. The output device may also lock and display the maximum temperature achieved at each sensor. The output device may also indicate when each sensor has reached an appropriate combination of temperature and time to ensure cell/tissue death.
The signals from one or more sensor may preferably be amplified by a suitable amplifier before reaching an output device. The amplifier may also be incorporated into an output device. Alternatively, the amplifier may be a separate device. The output device may incorporate one or more processors.
In one embodiment, a plurality of temperature sensors may be positioned around the perimeter of suction pad 1030. When sensed tissue reaches a certain temperature, the corresponding temperature sensor may send a signal. Preferably, the temperature sensor may send constant signals. For example, thermocouples may send a constant signal based on their voltage. As the temperature changes, the voltage of the thermocouples may change proportionately and the signal sent by the thermocouples may change proportionately.
In one embodiment of the present invention, the device for injecting agents into tissue may comprise one or more energy transfer elements. For example, suction tool 1010 may comprise one or more energy transfer elements 1400 positioned on, along, within or adjacent a tissue contact surface of suction tool 1010 (see
Energy transfer elements or conductive elements may comprise one or more conductive materials or blends including titanium, titanium alloys, TiNi alloys, shape memory alloys, super elastic alloys, aluminum oxide, platinum, platinum alloys, stainless steels, stainless steel alloys, MP35N, elgiloy, haynes 25, stellite, pyrolytic carbon, silver carbon, conductive polymers or plastics, or conductive ceramics. Energy transfer elements or conductive elements may not be conductive but may serve as a conduit to deliver a conductive material such as a conductive fluid. Energy transfer elements or conductive elements may be porous. For example, energy transfer elements or conductive elements may comprise porous polymers, metals, or ceramics. Energy transfer elements or conductive elements may be coated with non-stick coatings such as PTFE or other types of coatings as discussed herein. Energy transfer elements or conductive elements may be flexible thereby allowing them to conform to the surface of target tissue. Energy transfer elements or conductive elements may be malleable thereby allowing a surgeon to shape them to conform to the surface of target tissue.
Energy transfer elements or conductive elements may comprise one or more metal conductors such as windings inside a polymer or a conductive mesh material. The energy transfer elements or conductive elements may comprise tubes for delivering fluids. The tubes may comprise holes or slots. A polymer tube may be placed inside a metal tube to control fluid deliver through energy transfer elements or conductive elements. One or more of the energy transfer elements or conductive elements may be used as stimulation electrodes, for example, nerve stimulation electrodes or cardiac stimulation electrodes.
Energy transfer elements or conductive elements may comprise needles designed to penetrate tissues such as fat and muscle. For example, energy transfer elements or conductive elements may be designed to penetrate fat on the heart thereby allowing the energy transfer elements or conductive elements to reach cardiac tissue. The needles may allow fluids such as conductive fluids, tissue ablation chemicals, drugs, and/or cells to pass through.
In one embodiment of the present invention, the device for injecting agents into tissue may comprise one or more surgeon-controlled switches and/or valves. For example, a switch or valve may be incorporated in or on suction tool 1010 or any other location easily and quickly accessed by the surgeon for regulation of suction device 1010 by the surgeon. The switch or valve may be, for example, a hand switch or valve, a foot switch or valve, or a voice-activated switch or valve comprising voice-recognition technologies. For example, a vacuum valve may be incorporated into a proximal handle 1390 at the suction tool proximal end assembly 1014 for controlling the application of suction to suction pad 1030 (see
During a tissue ablation procedure, it is sometimes desirable to irrigate the ablation site with irrigation fluid, which may be, for example, any suitable fluid such as saline or another conductive fluid. The irrigating fluid may cool one or more energy transfer elements of suction tool 1010 and may allow for greater lesion depth. Furthermore, continuous fluid flow may keep the temperature below the threshold for blood coagulation, which may clog suction tool 1010 or an ablation device placed within suction tool 1010. Use of irrigating fluid may therefore reduce the need to remove a clogged ablation device for cleaning or replacement. The presence of an ionic fluid layer between an energy transfer element and the tissue to be ablated may also ensure that an ionic fluid layer conforming to the tissue contours is created. In one preferred embodiment, saline solution is used. Alternatively, other energy-conducting liquids, such as Ringer's solution, ionic contrast, or even blood, may be used. Diagnostic or therapeutic agents, such as lidocaine, CA++ blockers, ionic contrast, or gene therapy agents may also be delivered before, with or after the delivery of the irrigating fluid. A standard fluid pump, for example, may be used to deliver fluids. The pump may be connected to central power source or may have its own source of power. Suction tool 1010 may include a means for delivering fluid to an ablation site from a fluid source. Such means may be, for example, fluid openings coupled to one or more fluid conduits or lumens.
A fluid source may be any suitable source of fluid. An fluid source may include a manual or electric pump, an infusion pump, a syringe pump, a syringe, a pressurized reservoir or bag, a squeeze bulb or other fluid moving means, device or system. For example, a pump may be connected to power source or it may have its own source of power. A fluid source may be powered by AC current, DC current, or it may be battery powered either by a disposable or re-chargeable battery. A fluid source may comprise one or more fluid regulators, e.g., to control fluid flow rate, valves, fluid reservoirs, conduits, lines, tubes and/or hoses. The conduits, lines, tubes, or hoses may be flexible or rigid. For example, a flexible line may be used to communicate fluid to suction tool 1010, thereby allowing suction tool 1010 to be easily manipulated by a surgeon. Fluid reservoirs, for example, may be an IV bag or bottle. It may be preferred that the fluid be sterile.
A fluid source may be incorporated into the device for injecting agents into tissue. For example, suction tool 1010 may include a fluid source thereby allowing the delivery of fluid or agents at a targeted site. A fluid source may be slaved to suction tool 1010, for example, to one or more sensors of suction tool 1010. A fluid source may be designed to automatically stop or start the delivery of fluid during a medical procedure. A fluid source and/or suction tool 1010 may be slaved to a robotic system or a robotic system may be slaved to a fluid source and/or suction tool 1010.
Fluid from a fluid source may include saline, e.g., normal, hypotonic or hypertonic saline, Ringer's solution, ionic contrast, blood, or other energy-conducting liquids. An ionic fluid may be used electrically couple one or more electrodes of a suction tool 1010 to the tissue to be ablated thereby lowering the impedance at the ablation site. An ionic fluid may create a larger effective electrode surface. A fluid may be used to cool the surface of the tissue thereby preventing the over heating or cooking of tissue which can cause popping, desiccation, and charring of tissue. A hypotonic fluid may be used to electrically insulate a region of tissue thereby preventing ablation of tissue by an electrical means.
Tissue and/or bodily fluids contacting components of suction tool 1010 are preferably made of one or more biocompatible materials. Biocompatible materials or biomaterials are usually designed and constructed to be placed in or onto tissue of a patient's body or to contact fluid of a patient's body. Ideally, a biomaterial will not induce undesirable reactions in the body such as blood clotting, tumor formation, allergic reaction, foreign body reaction (rejection) or inflammatory reaction; will have the physical properties such as strength, elasticity, permeability and flexibility required to function for the intended purpose; may be purified, fabricated and sterilized easily; will substantially maintain its physical properties and function during the time that it remains in contact with tissues or fluids of the body.
Materials that are either biocompatible or may be modified to be biocompatible and may be used to make the delivery device of the present invention and/or one or more of its components may include metals such as titanium, titanium alloys, TiNi alloys, shape memory alloys, super elastic alloys, aluminum oxide, platinum, platinum alloys, stainless steels, stainless steel alloys, MP35N, elgiloy, haynes 25, stellite, pyrolytic carbon, silver carbon, glassy carbon, polymers or plastics such as polyamides, polycarbonates, polyethers, polyesters, polyolefins including polyethylenes or polypropylenes, polystyrenes, polyurethanes, polyvinylchlorides, polyvinylpyrrolidones, silicone elastomers, fluoropolymers, polyacrylates, polyisoprenes, polytetrafluoroethylenes, rubber, minerals or ceramics such as hydroxapatite, epoxies, human or animal protein or tissue such as bone, skin, teeth, collagen, laminin, elastin or fibrin, organic materials such as wood, cellulose, or compressed carbon, and other materials such as glass, and the like. Materials that are not considered biocompatible may be modified to become biocompatible by a number of methods well known in the art. For example, coating a material with a biocompatible coating may enhance the biocompatibility of that material.
One or more surfaces of the delivery device of the present invention and/or one or more of its components may be coated with one or more radioactive materials and/or biological agents such as, for example, an anticoagulant agent, an antithrombotic agent, a clotting agent, a platelet agent, an anti-inflammatory agent, an antibody, an antigen, an immunoglobulin, a defense agent, an enzyme, a hormone, a growth factor, a neurotransmitter, a cytokine, a blood agent, a regulatory agent, a transport agent, a fibrous agent, a protein, a peptide, a proteoglycan, a toxin, an antibiotic agent, an antibacterial agent, an antimicrobial agent, a bacterial agent or component, hyaluronic acid, a polysaccharide, a carbohydrate, a fatty acid, a catalyst, a drug, a vitamin, a DNA segment, a RNA segment, a nucleic acid, a lectin, an antiviral agent, a viral agent or component, a genetic agent, a ligand and a dye (which acts as a biological ligand). Biological agents may be found in nature (naturally occurring) or may be chemically synthesized by a variety of methods well known in the art.
Suction may be provided by the standard suction available in the operating room. The suction source may be coupled to the delivery device of the present invention with a buffer flask. Alternatively, suction may be provided via a manual or electric pump, a syringe, a suction or squeeze bulb or other suction or vacuum producing means, device or system. The suction source may comprise one or more vacuum regulators, valves, e.g., vacuum releasing valves, conduits, lines, tubes and/or hoses. The conduits, lines, tubes, or hoses may be flexible or rigid. For example, a flexible suction line may be used to communicate suction to suction tool 1010, thereby allowing suction tool 1010 to be easily manipulated by a surgeon. Another method that would allow the surgeon to easily manipulate suction tool 1010 includes incorporation of a suction source into suction tool 1010. For example, a small battery operated vacuum pump may be incorporated into suction tool 10. A suction source may include a visual and/or audible signal used to alert a surgeon to any change in suction. For example, a beeping tone or flashing light may be used to alert the surgeon when suction is present.
One or more portions of the delivery device of the present invention may be malleable, flexible, bendable and/or moveable. For example, suction tool 1010 may comprise one or more hinges or joints (not shown) for maneuvering and placing suction pad 1030 against tissue. The hinges or joints of suction tool 1010 may be actuated, for example, from handle located at the proximal suction tool port assembly 1014. Suction tool body 1012 may be malleable or shapeable. One or more hinges or joints may be used to move suction pad 30 relative to suction tool body 1012 and/or working lumen 1020.
An output device (not shown) coupled to the delivery device of the present invention may be used to control, for example, a suction source, a power source or generator, a cell delivery source, and/or a fluid delivery source. For example, a signal of a first intensity from a sensor of suction tool 1010 may indicate that the power level from a power source should be lowered; a signal of a different intensity may indicate that the power source should be turned off. Preferably, an output device may be configured so that it may automatically raise or lower the power from a power source appropriately. Alternatively, the control of a power source, for example, based on output from output device may be manual.
An output device coupled to the delivery device of the present invention may also be a visual display that indicates to the user the status of a medical procedure. Such a display may be, for example, an indicator on a LCD or CRT monitor. By software control, the surgeon may choose to display the information in a number of ways. The monitor may show the current reading of each sensor, for example. The monitor may also lock and display the maximum reading achieved at each sensor. For example, a monitor may indicate when an appropriate combination of temperature and time has been reached to ensure cell death during an ablation procedure. One such appropriate combination may be 60° C. for 5 seconds. Another combination may be 55° C. for 20 seconds. Information may be displayed to the user in any other suitable manner, such as for example, displaying a virtual representation of an ablation lesion on the monitor.
Alternatively, the monitor may display the voltage corresponding to the signal emitted from a sensor. This signal corresponds in turn to the intensity of the temperature at the tissue site. Therefore a voltage level of 2 would indicate that the tissue was hotter than when the voltage level was 1. In this example, a user may monitor the voltage level and, if it exceeded a certain value, may turn off or adjust a power source.
An indicator, such as an LED light, may be permanently or removably incorporated into suction tool 1010. The indicator may receive a signal from one or more sensors indicating that the tissue had reached an appropriate temperature, for example. In response, the indicator may turn on, change color, grow brighter or change in any suitable manner to indicate that the flow of power from a power source should be modified or halted. The indicator may be located anywhere that would be visible to the user.
Alternatively, an output device may be an audio device that indicates to the user the status of a medical procedure. Such an audio device may be, for example, a speaker that broadcasts a sound (for example, a beep) that increases in intensity, frequency or tone as a characteristic of the procedure has changed, for example, the temperature measured by a sensor. The user may adjust, for example, turn down or turn off a power source when the sound emitted reaches a given volume or level. In another embodiment, the audio device may also give an audible signal (such as the message “turn off power source”) when the temperature, for example, sensed by one or more sensors reaches a certain level. Such an audio device may be incorporated in suction tool 10 or the audio device may be a separate device coupled to suction tool 10.
The delivery device of the present invention may be permanently or removably attached to a source of energy such as electrical, radiofrequency (RF), laser, thermal, microwave or ultrasound or any other appropriate type of energy that may be used during a medical procedure including the use of suction tool 1010. The energy source may be powered by AC current, DC current or it may be battery powered either by a disposable or re-chargeable battery. The energy source may incorporate a controller or any suitable processor. For example, the processor may gather and/or process sensed information from one or more sensors. The controller may store and/or process such information before, during and/or after a medical procedure. For example, the patient's tissue temperature may be sensed, stored and processed prior to and during an ablation procedure.
The information stored and/or processed may be used to adjust power levels and delivery times. For example, an energy source may incorporate one or more switches or be coupled to one or more switches of suction tool 1010 to facilitate regulation of the various system components by the surgeon. An energy source may be coupled to an output device or an output device may be incorporated into the energy source. The energy source may incorporate a cardiac stimulator and/or cardiac monitor. For example, electrodes used to stimulate or monitor the heart may be incorporated into suction tool 1010. An energy source coupled to suction tool 10 may comprise a surgeon-controlled switch for cardiac stimulation or monitoring. A visual and/or audible signal used to alert a surgeon to the completion or resumption of ablation, suction, sensing, monitoring, stimulation and/or delivery of irrigation fluid, drugs and/or cells may be incorporated into an energy source and/or suction tool 1010. For example, a beeping tone or flashing light that increases in frequency as the ablation period ends or begins may be used.
Delivery of suction, energy, cells, and/or fluids may be slaved to one or more sensors of suction tool 1010, for example. In addition, the delivery of energy may be designed to automatically stop if a sensor measures a predetermined sensor value, e.g., a particular temperature value. In one embodiment of the invention, if a sensor of the present invention indicates that tissue has reached a particular temperature, the delivery of energy is stopped automatically, thereby preventing charring of the tissue.
One or more of a variety of diagnostic agents, therapeutic agents, pharmacological agents and/or drugs may be delivered or administered to the patient during a medical procedure performed according to the present invention, prior to a medical procedure performed according to the present invention, intermittently during a medical procedure performed according to the present invention, continuously during a medical procedure performed according to the present invention and/or following a medical procedure performed according to the present invention. For example, one or more of a variety of pharmacological agents or drugs, as discussed below, may be delivered before, during or after an ablation procedure, as discussed earlier.
Drugs, drug formulations or compositions suitable for administration to a patient may include a pharmaceutically acceptable carrier or solution in an appropriate dosage. There are a number of pharmaceutically acceptable carriers that may be used for delivery of various drugs, for example, via direct injection, oral delivery, suppository delivery, transdermal delivery, epicardial delivery and/or inhalation delivery. Pharmaceutically acceptable carriers include a number of solutions, preferably sterile, for example, water, saline, Ringer's solution and/or sugar solutions such as dextrose in water or saline. Other possible carriers that may be used include sodium citrate, citric acid, amino acids, lactate, mannitol, maltose, glycerol, sucrose, ammonium chloride, sodium chloride, potassium chloride, calcium chloride, sodium lactate, and/or sodium bicarbonate. Carrier solutions may or may not be buffered.
Drug formulations or compositions may include antioxidants or preservatives such as ascorbic acid. They may also be in a pharmaceutically acceptable form for parenteral administration, for example to the cardiovascular system, or directly to the heart, such as intracoronary infusion or injection. Drug formulations or compositions may comprise agents that provide a synergistic effect when administered together. A synergistic effect between two or more drugs or agents may reduce the amount that normally is required for therapeutic delivery of an individual drug or agent. Two or more drugs may be administered, for example, sequentially or simultaneously. Drugs may be administered via one or more bolus injections and/or infusions or combinations thereof. The injections and/or infusions may be continuous or intermittent. Drugs may be administered, for example, systemically or locally, for example, to the heart, to a coronary artery and/or vein, to a pulmonary artery and/or vein, to the right atrium and/or ventricle, to the left atrium and/or ventricle, to the aorta, to the AV node, to the SA node, to a nerve and/or to the coronary sinus. Drugs may be administered or delivered via intravenous, intracoronary and/or intraventricular administration in a suitable carrier. Examples of arteries that may be used to deliver drugs to the AV node include the AV node artery, the right coronary artery, the right descending coronary artery, the left coronary artery, the left anterior descending coronary artery and Kugel's artery. Drugs may be delivered systemically, for example, via oral, transdermal, intranasal, suppository or inhalation methods. Drugs also may be delivered via a pill, a spray, a cream, an ointment or a medicament formulation.
In one embodiment of the present invention, suction tool 1010 may incorporate a delivery device for delivering one or more diagnostic agents, therapeutic agents, pharmacological agents and/or drugs. Alternatively, a delivery device may be advanced through working lumen 1020 and out port 1046 of suction tool 1010. For example, a delivery device such as a needle or catheter may be inserted into working lumen 1020. A delivery catheter may include an expandable member, e.g., a low-pressure balloon, and a shaft having a distal portion, wherein the expandable member is disposed along the distal portion. A delivery catheter may comprise one or more lumens. A delivery catheter or needle may be advanced through working lumen 1020 and out port 1046 and into tissue and/or a blood vessel, e.g., an artery such as a femoral, radial, subclavian or coronary artery. Suction tool 1010 can be guided into a desired position using various guidance techniques, e.g., flouroscopic guidance and/or a guiding catheter or guide wire placed through working lumen 1020 or a guide lumen (not shown). Drugs may be delivered with suction tool 1010 via iontophoresis. In general, the delivery of ionized drugs may be enhanced via a small current applied across two electrodes, for example, one or more electrodes located on suction pad 1030. Positive ions may be introduced into the tissues from the positive pole, or negative ions from the negative pole. The use of iontophoresis may markedly facilitate the transport of certain ionized drug molecules. For example, lidocaine hydrochloride may be applied to the heart using iontophoresis. A positive electrode could be located on suction pad 30 while the negative electrode could contact the heart or other body part at some desired distance point to complete the circuit. One or more of the iontophoresis electrodes may also be used as nerve stimulation electrodes or as cardiac stimulation electrodes.
Diagnostic or therapeutic agents, such as one or more radioactive materials and/or biological agents such as, for example, an anticoagulant agent, an antithrombotic agent, a clotting agent, a platelet agent, an anti-inflammatory agent, an antibody, an antigen, an immunoglobulin, a defense agent, an enzyme, a hormone, a growth factor, a neurotransmitter, a cytokine, a blood agent, a regulatory agent, a transport agent, a fibrous agent, a protein, a peptide, a proteoglycan, a toxin, an antibiotic agent, an antibacterial agent, an antimicrobial agent, a bacterial agent or component, hyaluronic acid, a polysaccharide, a carbohydrate, a fatty acid, a catalyst, a drug, a vitamin, a DNA segment, a RNA segment, a nucleic acid, a lectin, an antiviral agent, a viral agent or component, a genetic agent, a ligand and a dye (which acts as a biological ligand) may be delivered. Biological agents may be found in nature (naturally occurring) or may be chemically synthesized. Cells and/or cell components, e.g., mammalian cells, may be delivered. Blood and/or blood components, e.g., platelet rich plasma or autologous platelet gel, may be delivered. One or more tissue sealants, glues or adhesives may be delivered.
A delivery device may be incorporated into suction tool 1010, thereby delivering biological agents at or adjacent the suction tool site, or the delivery device may be placed or used at a location differing from the location of suction tool 1010. For example, a delivery device may be placed in contact with the inside surface of a patient's heart while suction tool 1010 is placed or used on the outside surface of the patient's heart.
The delivery device may be slaved to an output device. For example, a delivery device may be designed to automatically stop or start the delivery of drugs or agents during the placement of a lead. The delivery device may be slaved to a robotic system or a robotic system may be slaved to the delivery device.
The delivery device may comprise a surgeon-controlled switch. For example, a switch may be incorporated in or on the delivery device, suction tool 1010, or any other location easily and quickly accessed by the surgeon. The switch may be, for example, a hand switch, a foot switch, or a voice-activated switch comprising voice-recognition technologies.
The delivery device may include a visual and/or audible signal used to alert a surgeon to any change in the delivery of agents. For example, a beeping tone or flashing light that increases in frequency as the rate of drug delivery increases may be used to alert the surgeon.
The two divisions of the autonomic nervous system that regulate the heart have opposite functions. First, the adrenergic or sympathetic nervous system increases heart rate by releasing epinephrine and norepinephrine. Second, the parasympathetic system also known as the cholinergic nervous system or the vagal nervous system decreases heart rate by releasing acetylcholine. Catecholamines such as norepinephrine (also called noradrenaline) and epinephrine (also called adrenaline) are agonists for beta-adrenergic receptors. An agonist is a stimulant biomolecule or agent that binds to a receptor.
Beta-adrenergic receptor blocking agents compete with beta-adrenergic receptor stimulating agents for available beta-receptor sites. When access to beta-receptor sites are blocked by receptor blocking agents, also known as beta-adrenergic blockade, the chronotropic or heart rate, inotropic or contractility, and vasodilator responses to receptor stimulating agents are decreased proportionately. Therefore, beta-adrenergic receptor blocking agents are agents that are capable of blocking beta-adrenergic receptor sites. Since beta-adrenergic receptors are concerned with contractility and heart rate, stimulation of beta-adrenergic receptors, in general, increases heart rate, the contractility of the heart and the rate of conduction of electrical impulses through the AV node and the conduction system.
Drugs, drug formulations and/or drug compositions that may be used according to this invention may include any naturally occurring or chemically synthesized (synthetic analogues) beta-adrenergic receptor blocking agents. Beta-adrenergic receptor blocking agents or □-adrenergic blocking agents are also known as beta-blockers or □-blockers and as class II antiarrhythmics.
The term “beta-blocker” appearing herein may refer to one or more agents that antagonize the effects of beta-stimulating catecholamines by blocking the catecholamines from binding to the beta-receptors. Examples of beta-blockers include, but are not limited to, acebutolol, alprenolol, atenolol, betantolol, betaxolol, bevantolol, bisoprolol, carterolol, celiprolol, chlorthalidone, esmolol, labetalol, metoprolol, nadolol, penbutolol, pindolol, propranolol, oxprenolol, sotalol, teratolo, timolol and combinations, mixtures and/or salts thereof. The effects of administered beta-blockers may be reversed by administration of beta-receptor agonists, e.g., dobutamine or isoproterenol.
The parasympathetic or cholinergic system participates in control of heart rate via the sinoatrial (SA) node, where it reduces heart rate. Other cholinergic effects include inhibition of the AV node and an inhibitory effect on contractile force. The cholinergic system acts through the vagal nerve to release acetylcholine, which, in turn, stimulates cholinergic receptors. Cholinergic receptors are also known as muscarinic receptors. Stimulation of the cholinergic receptors decreases the formation of cAMP. Stimulation of cholinergic receptors generally has an opposite effect on heart rate compared to stimulation of beta-adrenergic receptors. For example, beta-adrenergic stimulation increases heart rate, whereas cholinergic stimulation decreases it. When vagal tone is high and adrenergic tone is low, there is a marked slowing of the heart (sinus bradycardia). Acetylcholine effectively reduces the amplitude, rate of increase and duration of the SA node action potential. During vagal nerve stimulation, the SA node does not arrest. Rather, pacemaker function may shift to cells that fire at a slower rate. In addition, acetylcholine may help open certain potassium channels thereby creating an outward flow of potassium ions and hyperpolarization. Acetylcholine also slows conduction through the AV node.
Drugs, drug formulations and/or drug compositions that may be used according to this invention may include any naturally occurring or chemically synthesized (synthetic analogues) cholinergic agent. The term “cholinergic agent” appearing herein may refer to one or more cholinergic receptor modulators or agonists. Examples of cholinergic agents include, but are not limited to, acetylcholine, carbachol (carbamyl choline chloride), bethanechol, methacholine, arecoline, norarecoline and combinations, mixtures and/or salts thereof.
Drugs, drug formulations and/or drug compositions that may be used according to this invention may include any naturally occurring or chemically synthesized cholinesterase inhibitor. The term “cholinesterase inhibitor” appearing herein may refer to one or more agents that prolong the action of acetylcholine by inhibiting its destruction or hydrolysis by cholinesterase. Cholinesterase inhibitors are also known as acetylcholinesterase inhibitors. Examples of cholinesterase inhibitors include, but are not limited to, edrophonium, neostigmine, neostigmine methylsulfate, pyridostigmine, tacrine and combinations, mixtures and/or salts thereof.
There are ion-selective channels within certain cell membranes. These ion selective channels include calcium channels, sodium channels and/or potassium channels. Therefore, other drugs, drug formulations and/or drug compositions that may be used according to this invention may include any naturally occurring or chemically synthesized calcium channel blocker. Calcium channel blockers inhibit the inward flux of calcium ions across cell membranes of arterial smooth muscle cells and myocardial cells. Therefore, the term “calcium channel blocker” appearing herein may refer to one or more agents that inhibit or block the flow of calcium ions across a cell membrane. The calcium channel is generally concerned with the triggering of the contractile cycle. Calcium channel blockers are also known as calcium ion influx inhibitors, slow channel blockers, calcium ion antagonists, calcium channel antagonist drugs and as class IV antiarrhythmics. A commonly used calcium channel blocker is verapamil.
Administration of a calcium channel blocker, e.g., verapamil, generally prolongs the effective refractory period within the AV node and slows AV conduction in a rate-related manner, since the electrical activity through the AV node depends significantly upon the influx of calcium ions through the slow channel. A calcium channel blocker has the ability to slow a patient's heart rate, as well as produce AV block. Examples of calcium channel blockers include, but are not limited to, amiloride, amlodipine, bepridil, diltiazem, felodipine, isradipine, mibefradil, nicardipine, nifedipine (dihydropyridines), nickel, nimodinpine, nisoldipine, nitric oxide (NO), norverapamil and verapamil and combinations, mixtures and/or salts thereof. Verapamil and diltiazem are very effective at inhibiting the AV node, whereas drugs of the nifedipine family have a lesser inhibitory effect on the AV node. Nitric oxide (NO) indirectly promotes calcium channel closure. NO may be used to inhibit contraction. NO may also be used to inhibit sympathetic outflow, lessen the release of norepinephrine, cause vasodilation, decrease heart rate and decrease contractility. In the SA node, cholinergic stimulation leads to formation of NO.
Other drugs, drug formulations and/or drug compositions that may be used according to this invention may include any naturally occurring or chemically synthesized sodium channel blocker. Sodium channel blockers are also known as sodium channel inhibitors, sodium channel blocking agents, rapid channel blockers or rapid channel inhibitors. Antiarrhythmic agents that inhibit or block the sodium channel are known as class I antiarrhythmics, examples include, but are not limited to, quinidine and quinidine-like agents, lidocaine and lidocaine-like agents, tetrodotoxin, encainide, flecainide and combinations, mixtures and/or salts thereof. Therefore, the term “sodium channel blocker” appearing herein may refer to one or more agents that inhibit or block the flow of sodium ions across a cell membrane or remove the potential difference across a cell membrane. For example, the sodium channel may also be totally inhibited by increasing the extracellular potassium levels to depolarizing hyperkalemic values, which remove the potential difference across the cell membrane. The result is inhibition of cardiac contraction with cardiac arrest (cardioplegia). The opening of the sodium channel (influx of sodium) is for swift conduction of the electrical impulse throughout the heart.
Other drugs, drug formulations and/or drug compositions that may be used according to this invention may include any naturally occurring or chemically synthesized potassium channel agent. The term “potassium channel agent” appearing herein may refer to one or more agents that impact the flow of potassium ions across the cell membrane. There are two major types of potassium channels. The first type of channel is voltage-gated and the second type is ligand-gated. Acetylcholine-activated potassium channels, which are ligand-gated channels, open in response to vagal stimulation and the release of acetylcholine. Opening of the potassium channel causes hyperpolarization, which decreases the rate at which the activation threshold is reached. Adenosine is one example of a potassium channel opener. Adenosine slows conduction through the AV node. Adenosine, a breakdown product of adenosine triphosphate, inhibits the AV node and atria. In atrial tissue, adenosine causes the shortening of the action potential duration and causes hyperpolarization. In the AV node, adenosine has similar effects and also decreases the action potential amplitude and the rate of increase of the action potential. Adenosine is also a direct vasodilator by its actions on the adenosine receptor on vascular smooth muscle cells. In addition, adenosine acts as a negative neuromodulator, thereby inhibiting release of norepinephrine. Class III antiarrhythmic agents also known as potassium channel inhibitors lengthen the action potential duration and refractoriness by blocking the outward potassium channel to prolong the action potential. Amiodarone and d-sotalol are both examples of class III antiarrhythmic agents.
Potassium is the most common component in cardioplegic solutions. High extracellular potassium levels reduce the membrane resting potential. Opening of the sodium channel, which normally allows rapid sodium influx during the upstroke of the action potential, is therefore inactivated because of a reduction in the membrane resting potential.
Drugs, drug formulations and/or drug compositions that may be used according to this invention may comprise one or more of any naturally occurring or chemically synthesized beta-blocker, cholinergic agent, cholinesterase inhibitor, calcium channel blocker, sodium channel blocker, potassium channel agent, adenosine, adenosine receptor agonist, adenosine deaminase inhibitor, dipyridamole, monoamine oxidase inhibitor, digoxin, digitalis, lignocaine, bradykinin agents, serotoninergic agonist, antiarrythmic agents, cardiac glycosides, local anesthetics and combinations or mixtures thereof. Digitalis and digoxin both inhibit the sodium pump. Digitalis is a natural inotrope derived from plant material, while digoxin is a synthesized inotrope. Dipyridamole inhibits adenosine deaminase, which breaks down adenosine. Drugs, drug formulations and/or drug compositions capable of reversibly suppressing autonomous electrical conduction at the SA and/or AV node, while still allowing the heart to be electrically paced to maintain cardiac output may be used according to this invention.
Beta-adrenergic stimulation or administration of calcium solutions may be used to reverse the effects of a calcium channel blocker such as verapamil. Agents that promote heart rate and/or contraction may be used in the present invention. For example, dopamine, a natural catecholamine, is known to increase contractility. Positive inotropes are agents that specifically increase the force of contraction of the heart. Glucagon, a naturally occurring hormone, is known to increase heart rate and contractility. Glucagon may be used to reverse the effects of a beta-blocker since its effects bypass the beta receptor. Forskolin is known to increase heart rate and contractility. As mentioned earlier, epinephrine and norepinephrine naturally increase heart rate and contractility. Thyroid hormone, phosphodiesterase inhibitors and prostacyclin, a prostaglandin, are also known to increase heart rate and contractility. In addition, methylxanthines are known to prevent adenosine from interacting with its cell receptors. Suction tool 10 can be modified to incorporate one or more fluid lumens and/or conduits for providing one or more fluids, e.g., irrigation fluid to an ablation site.
Tissues and organs of a patient, such as the heart, lung, liver, stomach, intestine, spleen, brain, spine, bone, muscle, and tumor, may be treated using the present invention.
An alternative embodiment of injection device 30 is shown in
In one embodiment of the present invention, a tissue-engaging device 20 may be fixed in position relative to a patient. For example, the maneuvering or support apparatus of device 20 may be designed to attach to or lock onto one or more stable objects such as an operating table, a retractor, an endoscopic port and/or a support arm of another tissue-engaging apparatus. A retractor may be, for example, a sternal retractor or a rib retractor. An endoscopic port may be, for example, a cannula, such as a trocar cannula placed in a patient's chest. A portion of a patient's skeletal system may also be considered a stable object.
As described above, the elongate shaft provided can vary from embodiment to embodiment, with a rigid embodiment being illustrated in
The first position of needle trigger mechanism 39 causes the release of a needle injection locking mechanism, which comprises a needle injection locking element 137 and a needle injection locking spring 139. Needle trigger mechanism 39 is movably coupled to needle injection locking element 137 via element 141 (as shown in
The second position of needle trigger mechanism 39 causes the release of a needle retraction locking mechanism, which comprises a needle retraction locking element 143 and a needle retraction locking spring 147. Movement of needle trigger mechanism 39 into a second position causes the release of the needle retraction locking mechanism thereby allowing retraction spring element 143 to exert a force that moves push rod 31 in a proximal direction. Movement of needle trigger mechanism 39 into a second position also releases needle loading element 131, thus allowing element 131 to move back into a preloading position wherein a surgeon may again move needle loading element 131 back into a loaded position if desired.
In one embodiment of the present invention, discharge trigger mechanism 38 is movably coupled to a discharge mechanism for controlling the injection of one or more medical or biologic agents. The discharge mechanism may comprise multiple ratcheting elements such as plunger push element 563. Movement of plunger push element 563 in a distal direction pushes or moves plunger 562 further into barrel 564. Pushing or moving plunger 562 into barrel 564 causes the discharge of the contents of syringe mechanism 560 through fluid tube 566 and out through injecting needles 44. Plunger push element 563 has a plurality of notches 565 along one edge (as shown in
In one embodiment of the present invention, interstitial injection device 30 may comprise a distal injection head 32 having suction capabilities, see
In one embodiment of the present invention, suction tool 1010 may comprise a suction pad 1030 having a plurality of suction ports 1042 coupled to a suction lumen 1044. Needle 1092 of syringe mechanism 560 may be advanced through working lumen port 1046 as shown in
In one embodiment of the present invention, suction tool 1010 may comprise a suction pad 1030 having a plurality of suction ports 1042 coupled to a suction lumen 1044 and a suction port 1024, see
In one embodiment of the present invention, a nerve stimulator may be used to electrically manipulate cardiac rhythm by stimulating the vagus nerve. This vagal stimulation may produce asystole (slowing or stopping of the heart's beating.) Once this induced asystole is stopped, i.e. once the vagal stimulation is stopped, the heart may be allowed to return to its usual cardiac rhythm. Alternatively, the heart may be paced, thereby maintaining a normal cardiac output. Vagal stimulation, alone or in combination with electrical pacing, may be used selectively and intermittently to allow a surgeon to perform injection of one or more agents into a temporarily stopped heart. For example, stimulation of the vagus nerve in order to temporarily and intermittently slow or stop the heart is described in U.S. Pat. No. 6,006,134 entitled “Method and Device for Electronically Controlling the Beating of a Heart Using Venous Electrical Stimulation of Nerve Fibers”, Dec. 21, 1999, to Hill and Junkman and in U.S. patent application Ser. No. 09/670,441 filed Sep. 26, 2000, Ser. No. 09/669,960 filed Sep. 26, 2000, Ser. No. 09/670,370 filed Sep. 26, 2000, Ser. No. 09/669,961 filed Sep. 26, 2000, Ser. No. 09/669,355 filed Sep. 26, 2000 and Ser. No. 09/670,369 filed Sep. 26, 2000. These patents and patent applications are assigned to Medtronic, Inc. and are incorporated herein by reference.
Typically, vagal nerve stimulation prevents the heart from contracting. This non-contraction must then be followed by periods without vagal nerve stimulation during which the heart is allowed to contract, and blood flow is restored throughout the body. Following initial slowing or stopping of the heart, a medical procedure comprising the delivery of one or more biologic or medical agents, such as cells, may be delivered via a delivery device of the present invention to the stopped or slowed heart (Block 710). Following a brief interval of nerve stimulation while the medical procedure is performed, nerve stimulation is ceased (Block 713) and the heart is allowed to contract. A cardiac stimulator or pacemaker may be used to cause the heart to contract or the heart may be free to beat on its own (Blocks 722 and 724). In one embodiment of the present invention, tissue-engaging device 20 includes one or more electrodes, which may be used for pacing, coupled to an energy source. A processor may control both cardiac and nerve stimulation. For example, a processor may automatically proceed to block 713 to cease nerve stimulation. In addition, processor 70 may automatically begin cardiac stimulation. If the medical procedure needs to continue or a new medical procedure is to be performed, the heart may be repositioned if necessary or desired at Block 748.
It is known that infarcted tissue does not regenerate naturally in humans. Therefore, if a person has a heart attack the resultant infracted tissue won't regenerate and the heart generally becomes weaker as a result. If the weaker heart, in turn, cannot keep up with the necessary cardiac output, heart failure will often ensue. Currently, methods for treating heart failure include administration of various pharmacological agents, use of left ventricular assist devices, and use of cardiac wraps or reinforcement devices. A promising technique for cardiac regeneration is cell transplantation.
One method for improving cell retention and cell survival in a cell transplantation technique is the use of a platelet gel, e.g., an autologous platelet gel, to provide a better “growth” medium for the cells. In addition, autologous platelet gel can “hold” the cells in place by forming a clot. Other methods for improving cell retention in a cell transplantation technique is to use a thermo-sensitive gel that firms up at body temperature or a viscous medium such as polyethylene glycol that could hold the cells in place at the injection or transplantation site.
There are potentially a number of reasons why injected cells in cardiac tissue may not survive long after injection. One reason may be that the beating heart is constantly being perfused and an injectate may be washed out of the extracellular space. Another reason may be that cells injected into ischemic tissue will not have the proper nutrients to survive. A third reason why fewer cells may be found chronically after cell injection, is that the cells may not be distributed well enough around the injection site. For example, the distribution of cells around an injection needle may be fairly discreet. Therefore, there is a need for methods that aid in more broadly distributing cells around an injection site.
The use of a fibrin or platelet gel, e.g., an autologous platelet gel (APG), may provide for improved cell retention, dispersion and/or survival. For example, APG can provide a very rich growth medium for the cells. In fact, APG has been shown to enhance cell survival in vitro. Therefore, cells injected with APG may find themselves in a richer milieu then if injected simply into infarcted tissue. APG can also help hold the cells in place until they have had a chance to integrate into the existing extracellular matrix. Just as a natural blood clot degrades with time, the platelet gel will also degrade with time, serving as an ideal biodegradable matrix. APG may prevent injected cells from being “washed out” soon after injection.
In general, platelet gel is formed by activating plasma that contains platelets, e.g., platelet rich plasma (PRP) or platelet poor plasma (PPP), with a clot promoting activator or agent, e.g., thrombin. For example, platelet gel may be formed by mixing platelet rich plasma with thrombin. The thrombin initiates the clotting cascade and creates a platelet gel. The addition of thrombin to platelet rich plasma and platelet poor plasma is further disclosed in U.S. Pat. No. 6,444,228, the disclosure of which is incorporated herein by reference. Since it would be difficult to pass a clot through a needle, it is preferable to inject the platelet gel with the cells before it forms a clot. Therefore, methods for causing the plasma and platelets to clot within the tissue are desirable. Mixing a clotting agent or activator, e.g., thrombin, with the plasma and platelets immediately prior to administration can be desirable. For example, thrombin and PRP may be mixed at the very tips of two separate injection needles lying adjacent each other wherein thrombin is delivered via one needle and PRP is delivered via the second needle. In this case, the PRP may permeate tissue at the injection site prior to clotting. Alternatively, thrombin may be injected into tissue through one or more needles and the PRP injected through a different needle or needles. In one embodiment, the needles may be interlaced so that the thrombin and the plasma and platelets are injected simultaneously in close proximity. For example, a device may be designed to comprise alternating PRP and thrombin needles spaced 2 mm apart such that mixing occurs will occur within the tissue around the injection site. In one embodiment, delivery devices of the present invention may include two or more syringes 560 for the delivery of multiple agents such as cells, PRP and thrombin to an injection site. For example, a first syringe 560 may be used to deliver PRP and cells to a first set of needles 44 while a second syringe 560 may be used to deliver thrombin to a second set of needles 44. In one embodiment, the first and second sets of needles are interlaced with each other in a needle array. In one embodiment, the first and second sets of needles alternate with each other along a row. In an alternative embodiment, two or more syringes 560 with needles 1092 may be used sequentially. For example, cells and PRP may be delivered with a first syringe to an injection site followed by a second syringe used to deliver thrombin to the same injection site.
In one embodiment, plasma, e.g. PRP, may be injected into tissue without the addition of any exogenous clotting agent or agents, since there are initiators within the extracellular matrix to cause the plasma to clot. Therefore, cells may be injected in combination with plasma into target tissue with or without the addition of an activating agent, for example, via a cell delivery device of the present invention. In an alternative embodiment, a clotting protein, e.g. fibrinogen, may be injected into tissue in combination with cells. The fibrinogen and cells may be injected into tissue with or without the addition of a clotting agent, for example, thrombin.
It can be desirable in a cell transplantation therapy to distribute the cells as widely as possible around the injection site. It can also be desirable to have the cells be uniformly distributed around the injection site. One method for enhancing distribution of an injectate around an injection site is to use needles having holes in the side vs. using needles having holes in the end. Multiple side holes can provide a wider distribution of injectate around the injection site. Side holes also provide access to the tissue from a multitude of places rather than just from the end of the needle, therefore requiring less travel of the injectate for wider distribution. A potential benefit of side holes in the needles is that if the needle tip accidentally penetrates through the heart wall and into a cardiac chamber, the cells may still be injected into cardiac tissue as opposed to being all injected into the blood stream within the cardiac chamber. Another method for enhancing distribution of an injectate around an injection site is to increase the number of needles used at the injection site. If desired, the multi-needle injection device of the present invention, allows for multiple needles to be placed close to each other in order to provide a uniform distribution over a larger area as compared to the use of a single needle device. The combination of side holes on the needles of a multi-needle device may provide may provide a broad distribution of cells around an injection site.
In one embodiment of the present invention, suction may be used to improve the distribution of cells around the injection site. The use of suction can create a negative pressure in the interstitial space. This negative pressure within the interstitial space can help the injectate to travel farther and more freely, since the injectate is traveling into a negative pressure gradient. The applicants have discovered that an injectate such as cells will distribute more broadly around a needle injection site when suction has been provided than when no suction has been provided. Cells have been seen to distribute throughout an area under suction even when only one end hole needle is used at the center of the area under suction. For this reason, the combination suction and side holes on the needles of a multi-needle device may provide may provide a very thorough and broad distribution of cells around an injection site. Furthermore, the combination of suction with side holes on the needles as well as the injection of platelet rich plasma and thrombin may provide a broad distribution of cells with a nutritious milieu and an enhanced retention of the cells at the injection site. For example, device 1010 as shown in
To avoid injecting a needle to deeply into an area of tissue, the needle may be aligned essentially parallel to the tissue to be injected. For example, certain areas of the myocardium are relatively thin. Therefore, to avoid having the needle(s) penetrate through the myocardium and into a cardiac chamber where the injectate can be washed away by the blood stream, the needle(s) may be delivered relatively parallel to the surface of the heart. As shown earlier, an injection device could be designed so that a suction member pulls up a certain depth of myocardium and then allows the needle to be injected into this bleb of myocardium at a fixed depth, thereby allowing good distribution of cells due to use of suction yet the needle would not penetrate the cardiac chamber and the cells or injectate would not be lost to the bloodstream.
In one embodiment, following the injection of cells within cardiac tissue a pacemaker lead, e.g., an epicardial pacing lead, may be placed or implanted at the injection site as disclosed earlier. For example suction tool 1010 may be used to deliver cells to an infarct area of tissue of the heart. Following cell delivery, suction tool 1010 may then be used to deliver and implant an epicardial pacing lead at the injection site or adjacent the area of tissue implanted with cells. The pacing lead may then be coupled to a pacing device to provide electrical stimulation to the area of the newly implanted cells.
It will be appreciated by those skilled in the art that while the invention has been described above in connection with particular embodiments and examples, the invention is not necessarily so limited, and that numerous other embodiments, examples, uses, modifications and departures from the embodiments, examples and uses are intended to be encompassed by the claims attached hereto. The entire disclosure of each patent and publication cited herein is incorporated by reference, as if each such patent or publication were individually incorporated by reference herein.
This application is a divisional application of co-pending U.S. patent application Ser. No. 11/000,798, filed Nov. 30, 2004, which in turn is a continuation-in-part of U.S. patent application Ser. No. 10/341,743, filed Jan. 14, 2003, the disclosures of which are incorporated herein by reference. This application is also a continuation-in-part of U.S. patent application Ser. No. 10/622,147, filed Jul. 17, 2003, now U.S. Pat. No. 6,918,908, which is a continuation-in-part of U.S. patent application Ser. No. 10/342,932, filed Jan. 15, 2003, now U.S. Pat. No. 6,837,848, which is related to commonly assigned U.S. patent application Ser. No. 10/283,794, filed Oct. 30, 2002, now U.S. Pat. No. 7,146,225, U.S. patent application Ser. No. 10/342,960 filed Jan. 15, 2003, now U.S. Pat. No. 6,786,898 and U.S. patent application Ser. No. 10/284,771 filed Oct. 31, 2002, now U.S. Pat. No. 6,890,295, the disclosures of which are incorporated herein by reference. This application is also a continuation-in-part of U.S. patent application Ser. No. 10/156,315, filed May 28, 2002, now U.S. Pat. No. 7,507,235, which in turn is a continuation application of U.S. patent application Ser. No. 09/879,294, filed Jun. 12, 2001, now U.S. Pat. No. 6,447,443, which claims the benefit to co-owned U.S. Provisional Patent application Ser. Nos. 60/261,343 filed Jan. 13, 2001, Ser. No. 60/263,739 filed Jan. 24, 2001, Ser. No. 60/282,029 filed Apr. 6, 2001 and Ser. No. 60/286,952 filed Apr. 26, 2001, the disclosures of which are incorporated herein by reference.
| Number | Date | Country | |
|---|---|---|---|
| 60261343 | Jan 2001 | US | |
| 60263739 | Jan 2001 | US | |
| 60282029 | Apr 2001 | US | |
| 60286952 | Apr 2001 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 11000798 | Nov 2004 | US |
| Child | 12609225 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 09879294 | Jun 2001 | US |
| Child | 10156315 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 10341743 | Jan 2003 | US |
| Child | 11000798 | US | |
| Parent | 10622147 | Jul 2003 | US |
| Child | 10341743 | US | |
| Parent | 10342932 | Jan 2003 | US |
| Child | 10622147 | US | |
| Parent | 10283794 | Oct 2002 | US |
| Child | 10342932 | US | |
| Parent | 10342960 | Jan 2003 | US |
| Child | 10283794 | US | |
| Parent | 10284771 | Oct 2002 | US |
| Child | 10342960 | US | |
| Parent | 10156315 | May 2002 | US |
| Child | 10284771 | US |
