Patent Application
20230414357
The present disclosure relates to novel and advantageous transcatheter devices and methods to facilitate valvular repair and/or replacement. More specifically, the devices and methods herein relate to the removal of therapies which interact with heart valve leaflets.
Heart valve conditions can occur when the leaflets of a patient's valve are unable to fully close, which allows blood to regurgitate or abnormally flow backward. Referring to
A common treatment for valvular regurgitation is the use of treatment devices that appose or permanently connect the leaflets together. This heart valve therapy hardware may have been placed using surgical, transcatheter, or minimally-invasive means. For example, the hardware or therapy targeted for removal may be the MitraClip (Abbott Structural, Santa Clara, CA), the PASCAL device (Edwards Lifesciences, Irvine, CA), a suture placed surgically (e.g., Alfieri stitch), or similar heart valve therapy. Other heart valve therapy may be the result of techniques that have involved the leaflets as part of a therapeutic target, and the part or whole leaflet involvement requires removal. Other examples include chordal replacement technologies placed with either transcatheter methods or surgery to compensate for improper length, disruption, or mispositioning of existing chords. For purposes of the present application, the phrase “heart valve therapy” shall be defined as any devices and/or methods used for therapeutic treatment of a heart valve, such as leaflet clips, sutures, artificial chords, or any other devices or methods associated with the treatment of heart valves and associated leaflets.
In some instances, these structures need to be removed in order to facilitate other valvular therapy, such as when there is recurrent or residual regurgitation that needs to be addressed. For example, the valve may require placement of other leaflet technologies, annuloplasty or rings, chordae or cords, positioning devices, or a replacement valve, many of which may not be usable with heart valve therapy previously performed.
In some instances, these therapies need to be removed from one or more attachment points on the leaflets, but not completely in order to facilitate other valvular therapy, leaving the structure in the heart but able to move it from the area of interest and apply desired therapy.
However, these heart valve therapies are typically removed via open heart surgery, which can be particularly traumatic for patients and presents a relatively high risk of complications. Therefore, what is needed is a less traumatic approach to removing heart valve therapy that presents a lower risk of complications.
The present disclosure relates to systems and methods for removing heart valve therapies that have been used to position valve leaflets. This removal may be necessary when additional therapies for the treatment of valve disease are needed (e.g., different repair method, valve replacement), when the heart valve therapies have caused harm or the potential for harm to a patient (e.g., stenosis, infection), when the heart valve therapies have been deemed to not be of clinical benefit, or when there is a general desire to not have the therapy in place.
The present disclosure relates to systems and methods for removing heart valve therapies used to position leaflets, and this heart valve therapy may have been placed using surgical, transcatheter, or minimally-invasive means. In at least one embodiment, the hardware or therapy targeted for removal may be the MitraClip (Abbott Structural, Santa Clara, CA), the PASCAL device (Edwards Lifesciences, Irvine, CA), a suture placed surgically (e.g., Alfieri stitch), or similar positioning devices and techniques. In at least one embodiment, such positioning devices that need to be removed may be the result of techniques that have involved the leaflets as part of a therapeutic target, and the part or whole leaflet involvement requires removal. Examples of such devices are chordal replacement technologies placed with either transcatheter methods or surgery. In some instances, the cord or chords are not effective due to improper length, disruption, mispositioning, or defective prosthetic material.
A present method comprises a tool for cutting native valve tissue that has been attached to heart valve therapy with or without a capturing tool to hold the hardware to be removed while it is exteriorized from the human body. In at least one embodiment, the cutting method consists of an adjustable snare that envelops the heart valve therapy and can either cut the native tissue from the heart valve therapy mechanically, or by using a RF electrosurgical device that will heat tissue such that the electrosurgical cutting device's intracellular temperature rapidly reaches 100 degrees C., the intracellular contents undergo a liquid to gas conversion, massive volumetric expansion, and resulting vaporization. In at least one embodiment, the capturing tool is an adjustable basket, bag, or bin. This capturing tool can be used to cut, release, compress, modify, or fully retrieve the heart valve therapy from the human body.
In some embodiments, a method for removing previously placed heart valve therapy consists of a steerable catheter, which has been inserted into the patient using a transseptal, transatrial, or transventricular approach. The steerable catheter contains a delivery catheter that enables placement of the tools for cutting and for capturing the heart valve therapy.
In some embodiments, capture of the heart valve therapy is performed by insertion and embedding of a tool directly into, onto, and/or around the heart valve therapy. In this approach, the native tissue is cut from the heart valve therapy by the use of an electrosurgical cutting device (RF electrical or a similar device) or similar energy or force delivered from within the embedded tool. A basket or bag to capture the heart valve therapy may not be necessary for removal of the targeted material. Thus, in at least one embodiment, a cutting tool is used alone without the need for a capturing basket.
In at least one embodiment, a loop structure is pushed onto the tissue bridge, chordal implants, or method of fixation created by the heart valve therapy. The loop structure can be used to cut with either electrification or mechanical means. The loop structure may be circular, oval, or multi-segmented, and may completely or incompletely encapsulate the area for cutting and removal. The loop structure can be used to encircle the heart valve therapy and tissue for removal, followed by exteriorization.
In at least one embodiment, a tool is used to expand the heart valve therapy for removal. This expansion can be mechanical, electrical, pneumatic, hydraulic, or similar means in order to unfold or change the shape of heart valve therapy for its removal.
Elements of the tool can be fixated to the heart valve therapy to reduce the risk of embolization. This fixation can be accomplished by anchors that are straight, helical, barbed, or a combination of these approaches.
In at least one embodiment, a catheter, spacer, balloon, or other device could be used in conjunction with the removal device to manage the blood flow or regurgitation of the valve post removal of the heart valve therapy. This could be performed quickly if the removed heart valve therapy and basket could be retracted through the steerable catheter—then this sealing device could be delivered through the same delivery catheter.
A further embodiment of the present invention is directed to a removal system for a valve clip or similar heart valve therapy that may include a cutting and capture catheter and a snare catheter, both of which can be deployed from the same or separate delivery catheters. The snare catheter can be used to initially grasp and pull the valve clip distally (e.g., further into the left ventricle) to create tension or force on the leaflets. Next, the cutting loop and basket of the cutting and capture catheter can be placed over the valve clip so that the cutting loop is positioned on the proximal or atrial side of the heart valve therapy. Finally, the cutting loop can be activated to cut off the heart valve therapy device, and finally the clip can be captured by the basket and removed from the patient. This design enables cutting and capture of the heart valve therapy simultaneously as the cutting loop is pulled through the tissue and the capture basket is closed around the heart valve therapy device.
The snare catheter may include a snare loop having a circular shape or an oval saddle shape that creates an arc shape along each of its sides. The snare loop may have a plurality of teeth, a frictional coating, or can be composed of a coiled wire. The snare catheter may also include a distal tip with an opening in its sidewall and features to create friction with a snared valve clip, such as abrupt edges, ridges, grooves, or hooks.
The snare catheter may also include a handle configured to retract the snare loop into the snare catheter. The handle may include a mechanism to ensure tension is always applied to the clip, as well as limit the amount of force the user can apply to the tightened snare. The handle may include a locking mechanism to lock the snare in a desired retracted position.
The removal system may also include a guidewire passage through one or both of the cutting and capture catheter and a snare catheter. In a specific example, a guidewire passage may extend through the snare catheter and the basket of the cutting and capture catheter. The guidewire could traverse the length of the capture basket or pass through only the tip and then alongside the exterior surface of the basket.
The removal system may also include a chord dilator configured to at least partially block a distal opening of the delivery catheter and provide a relatively smooth transition which may provide less abrupt surfaces to “catch” on a chord or other feature of the valve.
The cutting and capture catheter may also include a stretchable capture basket that stretches from a longitudinally compressed configuration to a longitudinally stretched configuration once a valve clip is captured.
The removal system may also include a catheter that is configured to push on a valve clip from the atrial side of the valve to provide counter force. Hence, the cutting loop of the cutting and capture catheter may be better able to be positioned between the atrial side of the valve clip and the valve leaflets. The catheter may be configured solely for contact or may be configured to affirmatively engage or attach the valve clip.
The removal system may also include a snare catheter that includes a cutting element that allows it to engage tissue surrounding a valve clip or other heart valve therapy to facilitate capture and removal.
While multiple embodiments are disclosed, still other embodiments of the present disclosure will become apparent to those skilled in the art from the following detailed description, which shows and describes illustrative embodiments of the invention. As will be realized, the various embodiments of the present disclosure are capable of modifications in various obvious aspects, all without departing from the spirit and scope of the present disclosure. Accordingly, the drawings and detailed description are to be regarded as illustrative in nature and not restrictive.
These and other aspects, features and advantages of which embodiments of the invention are capable of will be apparent and elucidated from the following description of embodiments of the present invention, reference being made to the accompanying drawings, in which
Specific embodiments of the invention will now be described with reference to the accompanying drawings. This invention may, however, be embodied in many different forms and should not be construed as limited to the embodiments set forth herein; rather, these embodiments are provided so that this disclosure will be thorough and complete, and will fully convey the scope of the invention to those skilled in the art. The terminology used in the detailed description of the embodiments illustrated in the accompanying drawings is not intended to be limiting of the invention. In the drawings, like numbers refer to like elements.
The present invention is generally directed to devices and methods for removing heart valve therapy devices via a transcatheter procedure. While current methods for removal of heart valve therapy devices require open heart surgery, the techniques and devices of the present invention utilize transcatheter devices and procedures which are less invasive and can provide better patient outcomes.
For purposes of the present application, the phrase “heart valve therapy” shall be defined as any devices and/or methods used for therapeutic treatment of a heart valve, such as leaflet clips, sutures, artificial chords, or any other devices or methods associated with the treatment of heart valves and associated leaflets. While specific embodiments may discuss or illustrate specific heart valve therapy devices or methods, such as heart valve leaflet clips, it should be understood that use with any heart valve therapy is specifically contemplated. Hence, none of the embodiments discussed in this specification should be limited solely to use with heart valve leaflet clips.
As best seen in
Referring to
The cutting loop 104 can similarly be formed in a general loop shape (e.g., circular, oval, saddle shape, etc.) and can include an elongated straight portion 104E that can also be connected to the control member 108 via the connecting sleeve 112. In this respect, both of the elongated straight portions 106A and 104E are located within the connective sleeve 112, as seen in the cross-sectional view of
In one embodiment, the cutting loop 104 cuts tissue when radio frequency energy is supplied to it. In one example, the RF power source is connected to a proximal end of the control member 108 which is composed of a conductive metal and therefore communicates the RF energy to its distal end and then into the attached cutting loop 104. To complete the RF energy circuit with the cutting loop 104, a second RF electrode can be connected to the RF power source and can be attached elsewhere to the patient via an electrode pad (a monopolar RF system), a second electrode can be included elsewhere on the removal catheter 100 (a bipolar RF system), or a second insulated wire can be included on the control member 108 (a bipolar RF system).
It may be desirable to isolate the RF energy circuit of the cutting loop 104 from both the cinching loop 106 and the basket 102 to prevent other tissue in the heart from being damaged. This can be achieved with the use of electrical insulation as specific locations on the device. For example, electrical wire insulation 114 can be placed over the elongated straight portion 106A (or optionally the entire cinching loop 106) to electrically isolate the cinching loop 106 from the RF current of the control member 108, as seen in the cross sectional view of
In other examples seen in
The uninsulated portion 104B may include only a single area in which the underlying wire 104C is exposed (e.g., between about 1 and 5 mm) as seen in
In all cutting loop embodiments, the majority of the surface of the cutting loop 104 is insulated. To create the uninsulated portion 104B, the cutting loop insulation 104A can be selectively removed (for wires with existing insulation) to expose the cutting loop conduction wire 104C in a manner that will allow it to contact and deliver the RF cutting energy to the leaflet tissue bridge when it is in contact with tissue in proximity to the heart valve therapy. Alternately, the insulation 104A can be added (e.g., by dipping, spraying, or similar techniques) and the uninsulated portions 104B can be created by masking the intended areas prior to insulation application.
It will be understood that the uninsulated portion 104B can be oriented any number of ways, e.g., on the inner/outer surface of the cutting loop 104 as well as on the bottom (i.e., atrial) side of the loop 104.
The underlying wire 104C of the cutting loop 104 may be composed of a shape memory metal (e.g., Nitinol) or a similar conductive metal (e.g., stainless steel or copper). As seen in the cross-sectional views of
The cutting loop 104 may also be composed of one or more wires, such as a first wire 104C and a second wire 104D. Both wires can be composed of similar material (e.g., Nitinol, stainless steel, copper, silver, or similar materials), or each wire can be composed of a different material. For example, one wire 104C can be composed of a metal that better conducts current (e.g., stainless steel, silver, or copper) and the other wires 104D can be composed of a material that retains its shape between a compressed and expanded configuration (e.g., shape memory metal such as Nitinol). The multiple wires may be electrically isolated or insulated from each other or independently. Different cross sectional shapes can be further used with the same or different materials, as seen in
In another example, the cutting loop 104 may be composed of a single wire containing a plurality of strands of different wire materials. For example,
The cutting loop may have a variety of different shapes, structures, and electrical insulation patterns to facilitate tissue removal around the clip 104 that can, for example, provide additional length and/or a predetermined path or geometry.
Many different tissue engagement methods can be facilitated by to the cutting loop 316, such as end portions 312 and 313 can be electrically activated first in unison while the cutting loop 316 applies axial tension onto the tissue structure, effectively cutting the tissue in contact with those portions 312, 313 and partially freeing the leaflet clip 40. Next, the free end portion 311 can be activated to excise the tissue adjunct to it and completing the excision of the leaflet clip 40 from the leaflets. Alternately, all three portions 311, 312, and 313 can be activated at the same time. Axial tension on the loop 316 can be applied before, during, or intermittently to control the engagement of the loop 316. This embodiment illustrates three uninsulated cutting areas or portions 311, 312, and 313, however there may be any number of cutting elements (e.g., from 1-100), including the entire loop 316 as being one continuous, uninsulated cutting member.
Including additional length along the side portions 314 and 315 can accommodate other tissue structures present around the leaflet clip 40. The extra length of the side portions 314 and 315 can also be deformable such that when tension is applied by the elongated straight portions 317, the side portions 314 and 315 will straighten and cause the loop 316 to elongated to an approximate axial configuration. During this tension and elongation, the axial distance between the free end portion 311 and the proximal end portions 312, 313 is increased, accommodating a greater variation in both diameter and approach angle to the clip. Any such nonlinear path could also accomplish this and are hence considered in this disclosure, but for sake of brevity are not shown herein.
Another example embodiment of a cutting loop 350 can be seen in
In the present example, the first cutting loop 104 has a somewhat larger diameter (e.g., similar to the opening of the basket 104) and the second cutting loop 316 has a diameter that is smaller than the first cutting loop 104 and that is positioned further away from the basket 104. Hence, the second loop 316 may be placed against the valve leaflets and/or chords (e.g., cut 370A through the antero-lateral chords and cut 370B through the postero-medial chords in
While specific embodiments of the cutting loops 104 and 316 are shown in
If the cinching loop 106 has an insulation coating entirely along its length, the cutting loop 104 may be located directly on top of the cinching loop 106, contacting the loop. The cutting loop 104 may also be longitudinally spaced apart from the cinching loop 106, such as between about 0 mm and about 15 mm.
Preferably, the inner control member 108 (seen best in
In a preferred embodiment the inner control member 108 consists of an inner control stylet that is joined or welded to a more flexible inner control cable, which is then joined to the cutting loop conduction wire tails using a distal coupler. in a preferred embodiment the inner control stylet, inner control cable, cutting loop conduction wire, and distal coupler are the same material (e.g., steel alloy) to enable a strong weld joint and efficient current delivery throughout. The inner control cable could be a laser cut tube, a stranded cable, a stranded cable tube, a coil, or a combination of these. In another embodiment, the inner control cable may extend from the proximal handle to the cutting loop 104, and eliminate the need for the inner control stylet.
In an alternate embodiment, the inner control member 108 can be two separate wires; one of which connects to the cinching loop 106 and the other that connects to the cutting loop 104. In the case of both inner control members being disposed in the same single lumen of the outer tubular sheath 110, the basket 102 may be deployed first by advancing the inner basket control member distally until the basket cinching loop 106 is fully exposed. Then, the inner cutting loop control member can be advanced distally to deploy the cutting loop 104. Each of the loops can be rotated, advanced, or retracted by their respective control members. This provides the operator with more degrees of freedom. The heart valve therapy may be first captured or encircled by the cutting loop 104, and then the basket cinching loop 106 and basket 102 can follow. The cutting loop 104 can then be closed onto the leaflet tissue bridge by retracting the inner cutting loop control member. Once the cutting loop is closed on the tissue bridge, one of two steps can be taken: 1) the basket cinching wire 104 and basket 102 can then be closed by retracting the inner basket control member proximally or 2) if the cutting loop 104 is unable to get to the base of the heart valve therapy, RF cutting energy can be applied to cut down one side of the device to get to the base of the clip 40; then the basket 102 can be closed. Once both loops are properly closed on the tissue on the atrial side of the heart valve therapy, the inner cutting loop control member is energized with RF power as it is retracted proximally into the outer delivery sheath 110. The inner cutting loop control member delivers the cutting energy to only the cutting element through the cutting loop 104.
The aforementioned inner control members can alternately be disposed in separate outer tubular sheaths or separate lumens in the same sheath 110. It is possible for this system to be designed such that each sheath can be placed in separate orifices (i.e., on opposite sides of the heart valve therapy). Once both loops have captured the heart valve therapy, the same steps as described above would follow.
The control member insulation that covers the outer surface of the inner control stylet and inner control member is preferred to be flexible enough to not impact the navigation of the delivery catheter through a valve orifice. It is also desirable be as lubricious as possible, such that the friction between the inner control member and the delivery catheter is minimized as the inner control member is pushed distally to deploy the basket and cutting loop in the left ventricle. For example, this insulation may include a hydrophilic coating, a silicone coating, a Teflon like coating, a polyolefin coating, a thermoform or thermoset coating, or fluoropolymers.
Returning to the basket 102, the length and diameter of the basket 102 may depend on the size of the heart valve therapy device or clip 40. For example, the basket 102 may have a length within a range of about 20 mm to about 50 mm, and a diameter within a range of about 10 mm and 20 mm. Depending on the size of the leaflet clip 40 and the angle that the basket 102 is expected to capture the clip 40, the diameter of the basket 102 can be adjusted accordingly. For example, the greater the angle of interception relative to a top plane across the opening of the basket 102, the larger the diameter of the basket 102 should be. Put another way, unless it is expected that the basket 102 is to be substantially directly underneath the clip 40, the basket 102 should expand to a diameter much greater than that of the clip 40.
In one embodiment seen in
The wire size is preferably small enough to allow for it to be easily collapsed into and deployed from the delivery catheter during the procedure, but large enough to give the basket some rigidity such that it can adequately open in the presence of valve chordae or other structures. The basket pore size can vary on a woven basket, depending on the design intent. In general, the pore size should be smaller than either the length, width, or height of the heart valve therapy to avoid it embolizing through the basket after it has been cut free. Weaving a basket with very small pores could help with filtering and capturing any debris generated during the tissue cutting process.
One benefit of coating a metal basket is to ensure the electrical energy is concentrated in the cutting element and not being distributed across the entire metal structure of the basket and into the blood pool. The second benefit of coating is that it can also reduce friction and therefore can facilitate easier capture of the heart valve therapy inside the basket. If the basket is too rough or there are too many edges inside the basket, the heart valve therapy may not want to fully seat within the basket. Adding a lubricious coating or a smooth layer to the inner surface of the capture basket may enable easier capture of the heart valve therapy.
In an alternate embodiment seen in
Construction of the polymer basket 152 can be completed using a braid, mesh, weave, knit, or via injection molding. Potential basket shape and material combinations are infinite, and only a few are described here. Choosing a polymer material that has high heat resistance, low moisture absorption, and is durable enough to be collapsed into the outer sheath multiple times is important. Silicone tends to meet all of these performance requirements the best. In the event the basket is made of a silicone, it could be molded into the basket shape as a standalone component, or molded directly onto a loop structure. If creating the basket from a flat sheet of silicone, it could be cut to a designed pattern, and stitched onto a loop, into the desired shape.
The size and spacing of the pores 152A can be adjusted, depending on the material selected. In general, the pore size may be smaller than either the length, width, or height of the heart valve therapy to avoid it embolizing through the basket after it has been cut free. Using a basket with very small pores may help with filtering and capturing any debris generated during the tissue cutting process. Designing a basket with pores also allows some blood to flow through it; this helps improve the operators control of the basket by minimizing the force applied to it from pumping blood (i.e., it minimizes the ‘parachute effect’). A polymer basket could be constructed with eyelets or not; if there are eyelets as shown, it will be slidably mounted to the basket cinching loop. If there are no eyelets, it will be securely affixed to the basket cinching loop.
Since the polymer basket 152 does not conduct current, other embodiments are possible in which the cutting loop 104 of a removal catheter 160 also acts as a cinching loop, as seen in
Similar “single loop” embodiments are also possible with other shapes and materials. For example,
In other embodiments, the basket can be partially or fully composed of a laser cut basket. For example,
The benefits of a laser cut basket are that its behavior/performance can be altered by changing the tube dimensions and/or cut pattern/density (i.e., basket pore size) while keeping the diameter and length of the basket fixed. The basket diameter and length design are primarily driven by the size of the intended heart valve therapy to be removed. The size, spacing, and number of laser-cut eyelets could also be adjusted and optimized. The material used preferably has shape memory properties, like Nitinol, to allow for the laser cut portion of the tube to be expanded and shaped. Using a material with shape memory is what enables the basket to collapse and open back up to the same shape, repeatedly. The wire size is preferably small enough to allow for it to be easily collapsed into and deployed from the delivery catheter during the procedure, but large enough to give the basket some rigidity such that it can adequately open in the presence of valve chordae or other structures.
Basket pore size can be varied in a laser cut design by changing the cut pattern to achieve the desired result. For example, pore sizes may vary within a range of about 100 microns to about 4 mm. In general, the pore size should be smaller than either the length, width, or height of the heart valve therapy to avoid it embolizing through the basket after it has been cut free. One unique benefit of a laser cut basket is that the pore size and spacing could vary throughout the basket length. For example, the proximal opening side of the basket could have large pores with a certain pattern density. The pore size and pattern density could get smaller and denser towards the distal end of the basket.
Any of the basket embodiments described in this specification can further include an outer covering to help collect any debris or embolic material freed during the procedure. Such an outer covering may include a solid or perforated polymer sheet, a woven fabric, a tubular shape formed from relatively small, finely braided metal wires, or similar materials. In one specific embodiment, the interior of the basket can have a nonconductive liner, film, or coating (e.g., silicone) on its inner surface to help prevent conduction with the cutting element 104.
In one embodiment, the removal catheter 100 can include a proximal handle portion 170, as seen in
Optionally, the handle 170 may also include a fluid connection port 176 (e.g., a luer port) that is in communication with an interior of the interior passage of the outer tubular sheath 110 so that an electrically neutral solution (e.g., a dextrose solution) can be delivered to the area near the cutting loop, amplifying the tissue cutting effects and minimizing energy loss around the area to the blood pool. The amount and timing of this fluid can be determined by a physician (e.g., via a syringe) or via an electrically actuated pump mechanism based on a position of the cutting loop 106 (i.e., when the cutting loop is outside of the outer tubular sheath and in good contact with desired tissue 110).
As seen in
Alternately, a wire 113 can be attached to the inner control member 108 to ensure the current pathway always involves the blood pool, even after the cut has been completed. The wire 113 is preferably designed to be long enough to always protrude from the distal end of the outer tubular sheath 110, even with the basket 102 fully collapsed inside the outer tubular sheath 110. It would also preferably have a very small region of exposed metal at the very distal tip, and the rest would be insulated. In this way, when the cut is completed the current will choose to flow through the lower resistance wire and to the blood as opposed through the higher resistance basket 102 (e.g., silicone).
In
To assist in determining when to manually turn off the RF energy, a radiopaque marker can be placed at the distal end of the outer tubular sheath 110. As the physician performs the tissue bridge cut, they will have their eyes on the fluoroscopy screen. Since tissue is typically not visible on fluoroscopy, providing the operator with a visual indicator on the catheter 100 indicating that the tissue bridge has been cut may be useful. The inner control member 108 and cutting loop 104 are retracted into the sheath 110 during the cutting process and the radiopaque marker is located such that when the operator sees on fluoroscopy the entire cutting loop 104 on the proximal side of the radiopaque marker, the tissue bridge has been cut. Not only is this a useful visual indicator for the operator, but it also makes the procedure safer. Once the cutting loop 104 has passed the radiopaque marker, the RF cutting energy can be terminated immediately by the operator to prevent any unintended heating by applying power longer than necessary.
Finally, the opening of the basket 102 is nearly completely cinched closed and the positioned of the inner control member 108 may optionally be locked in place (e.g., with locking mechanism 173 on the handle 170). The basket 102 may be maintained outside of the outer tubular sheath 110 and pulled into a larger guide catheter used during the procedure.
The present invention includes different methods or approaches of removing a heart valve therapy such as a valve clip 40. For example,
The mitral valve access procedure of
Turning first to
The guidewire can be removed and the inner steerable guide catheter 180 can then be advanced through the outer transseptal guide catheter 182 so that its distal end is located within the left atrium 12. The distal end of the inner steerable guide catheter 180 can be “steered” or deflected so that its distal opening is directed toward a desired location of the mitral valve 20. Since the guide catheter is independent of the outer transseptal guide catheter 182, the physician has the ability to direct the inner steerable guide catheter 180 to any location along the mitral valve 20, such that it can be rotated, advanced/retracted, or have the degrees of deflection altered while keeping the outer transseptal guide catheter 182 in the same location.
In the example of a mitral valve 20 having a leaflet clip 40, the inner steerable guide catheter 180 is preferably pointed towards either of the two valve openings on each side of the center clip 40 (see top view of
As seen in
Once the capture basket 102, cinching loop 106, and the cutting loop 104 are deployed, the inner control member 108 (or alternately the outer tubular sheath 110) can be proximally withdrawn so that the leaflet clip 40 is positioned inside of the basket 102, as seen in
Turning to
As seen in
It is further contemplated that, after removal of the leaflet clip 40, an artificial valve may be installed at the location of the mitral valve 20. If a guidewire is used during the removal procedure, it can also be used to advance and orient a valve delivery catheter to delivery and implant the artificial valve. One example of such an artificial valve replacement can be found in U.S. Pat. No. 8,579,964, entitled Transcatheter Mitral Valve Prosthesis, the content of which is hereby incorporated by reference.
It is further contemplated that, after removal of the leaflet clip a blood flow management apparatus such as a spacer, catheter, balloon, or other device is in and could be expanded in the location of the valve to manage the flow across the valve until such time as additional therapy could be delivered such as a replacement valve.
Turning to
As seen in
Preferably the capture basket 102, cinching loop 106, and the cutting loop 104 are connected to the inner control member 108 so that they expand to an orientation in which the opening of the basket 102 and the opening of the cutting loop 104 are directed or point towards the leaflet clip 40. For example, the plane 103A of the opening of the basket 102 and the opening of the cutting loop 104 may be an angle 103C between 25 degrees and 135 degrees relative to an axis 103B of the inner control member 108 (e.g., 90 degrees).
If the transapical sheath 184 has a large enough diameter, the outer tubular sheath 110 can be proximally retracted and the basket 102 containing the leaflet clip is withdrawn into the passage of the transapical sheath 184 for removal. If the basket 102 and leaflet clip 40 are too large for the transapical sheath 184, both the sheath 184 and the removal catheter 100 can be pulled out together simultaneously.
Next, the removal catheter 100 is advanced through the aortic guide catheter 186 so that a distal end of the outer tubular sheath 110 extends from the distal end of the catheter 186 and into the left ventricle 14. The inner control member 108 is further distally advanced relative to the outer tubular sheath 110 so that the basket 102 and cutting loop 104 are deployed, expanded, and positioned in the left ventricle 14. The opening of the basket 102 and the opening of the cutting loop 104 are both or oriented so that they face the leaflet clip 40. For example, the face of the opening of the basket 102 and the opening of the cutting loop 104 may be within a range of about 300 degrees and 45 degrees relative to an axis of the inner control member 108 (e.g., about 320 degrees).
Referring to
The present invention also contemplates using the removal catheter 100 (or any of the variations described in this specification) on the tricuspid valve 15, as seen in
Next, the removal catheter 100 is advanced through the inner intermediate catheter 189 so that it passes out of the distal end of the inner intermediate catheter 189, into the right atrium 16, through the tricuspid valve 15, and into the right ventricle 13. Since the leaflet clip 40 is typically positioned in the middle of the valve 15 (e.g., similar to the top view of the mitral valve in
The inner control member 108 is further distally advanced relative to the outer tubular sheath 110 so that the basket 102 and cutting loop 104 are deployed, expanded, and positioned in the right ventricle 13. The opening of the basket 102 and the opening of the cutting loop 104 are both or oriented so that they face the leaflet clip 40. For example, a plane 103A of the face of the opening of the basket 102 and the opening of the cutting loop 104 may be an angle 103C within a range of about 0 degrees and 90 degrees relative to an axis 103B of the inner control member 108 (e.g., about 45 degrees). The removal catheter 100 is proximally retracted relative to the inner intermediate catheter 189, so that the cutting loop 104 and basket 102 are positioned over and beyond the leaflet clip 40.
The inner control member 108 is proximally retracted, causing the cinching loop 106 and the cutting loop 104 to decrease in diameter, closing the top opening of the basket 102. As the cutting loop 104 decreases in diameter, RF energy is delivered to the loop 104, allowing the uninsulated portion 104 to cut areas of the leaflet tissue adjacent to the leaflet clip 40 and thereby freeing the leaflet clip 40 from the tricuspid valve 15. The basket 102 and leaflet clip 40 can either be retracted through the inner intermediate catheter 189 or all of the catheters can be removed together as a single unit simultaneously.
It should be understood that any of the embodiments of the present specification can be used according to the access and delivery methods described in this application. Additionally, further methods can be used with these access and delivery methods, such as delivery and implantation of an artificial valve (either mitral or tricuspid valve).
While the previously described removal catheter embodiments have included a basket or similar device to capture the heart valve therapy, such as a leaflet clip 40, different capture approaches and devices are also contemplated.
As seen in
In
In
Additionally, a flow limiter can be used to help limit flow during any of the procedures described in this specification. For example
It can be helpful when performing the cutting procedures of this specification to maintain good mechanical contact or force between the leaflet tissue and the cutting element (e.g., cutting wire 104), particularly when using RF energy as the mechanism for performing the cutting. This contact or force can be important for ensuring that the electrode of the cutting element/loop is not exposed to a large amount of blood.
When using a constant power generator, such as many commercially available RF energy generators, impedance seen by the generator will typically be low (e.g., 0-300 Ohms) when a cutting element is mostly exposed to the patient's blood. This low impedance may result in an insufficient voltage to cut through the tissue. In such circumstances, some RF energy generators will increase the current to maintain a constant power level.
In contrast, when the cutting element is pressed firmly against the patient's tissue and exposed to little, if any, of the patient's blood, the impedance seen by the generator will be relatively higher (e.g., greater than 300 Ohms) or more resistive to the current. This greater resistance may cause the generator to increase the voltage output to try to maintain constant power. Once the voltage reaches a certain level, the tissue cutting process begins and will continue so long as the cutting element is continuously in contact with target tissue.
Capitalizing on this phenomenon is what enables electrosurgery to be performed within the heart and patient's blood pool. Hence, it can be helpful in the context of the present invention to include a mechanism that creates and/or helps maintain pressure or force between the cutting element and the target tissue.
Generally, when considering the removal of an implanted valve clip 40, it can be helpful to consider several factors to ensure adequate mechanical force between the cutting element and the target leaflet tissue. Specifically, 1) the length of the leaflet tissue that is inserted into the arms of the valve clip 40, 2) the chords extending from and around the valve clip 40, and 3) the use of multiple valve clips 40 and their spacing and position angles.
Further, there are potentially at least four different valve clip removal scenarios that may be encountered. Specifically, 1) a cutting loop may be cinched on the atrial side of the valve clip 40 without the need for any further “counter force” against the clip 40 (as described in earlier embodiments/methods of this specification), 2) a counter force on the valve clip 40 may be helpful or needed to stretch the tissues such that the cutting loop can be cinched on the atrial side of the valve clip 40, 3) a counter force may be helpful or needed and the cutting loop must first cut through some leaflet side tissues before it can be cinched on the atrial side of the valve clip 40, and 4) a cutting snare can be used to substantially release the engaged tissue from the clip 40 and then can be used to facilitate engagement of cutting loop and basket.
In the first scenario, it may be possible to place the cutting loop and basket over the valve clip 40 and cinch the cutting loop on the tissue bridge such that the cutting loop is positioned on the atrial side of the valve clip 40 without the use of any further tools, as has been previously described in this specification. This technique was described earlier in this specification. Cinching the cutting loop in this way ensures the cutting element is firmly pressed against tissue and will move through the entire tissue bridge as it is pulled inside the delivery catheter.
In the second scenario, some method of pushing or pulling the valve clip 40 is provided as the cutting loop is retracted or cinched. This counter force helps stretch the tissue into/towards the left ventricle 14 and away from the direction that the cutting loop is being pulled and therefore allows the cutting loop to be positioned and cinched on the atrial side of the valve clip 40. Applying this counter force can be helpful and sometimes even necessary if a relatively large length of leaflet tissue has been inserted into the arms of the clip 40, multiple clips 40 have been implanted (especially closely spaced clips 40), the leaflets are too compliant, the leaflets are too stiff, or a relatively large tissue bridge has been previously created.
In the third scenario, the counter force helps to stabilize the valve clip 40 and leaflets such that the cutting loop can be pulled firmly against the leaflet edge. Once it is firmly pressed against the leaflet tissue, a first cut can be performed by pulling the cutting loop until it is positioned on the atrial side of the valve clip 40, and then the cutting loop can be cinched, and the final cut completed.
In the fourth scenario, removal of the engaged tissues may be necessary to facilitate the snare engagement and allow the snare to provide the counter force to stabilize the valve clip.
In the context of these scenarios, there are several embodiments and methods that can be used to produce this counter force towards/into the left ventricle 14, away from the left atrium 12.
In one example, the steerable catheter 180 used to deliver the cutting and retrieval catheter may be used to press on the valve leaflets 22, 24 and valve clip 40 to create counter force towards the left ventricle 14. For example, a distal edge around its distal opening can be positioned against the valve leaflets and/or the valve clip 40.
In another example, a pushing catheter 470 can be used to push on the valve clip 40 from the left atrial side of the valve clip 40 toward the left ventricle, as seen in
In any of these configurations, the catheter 470 can be pushed against the valve clip 40 from the left atrium 12 towards the left ventricle 14, and then the cutting loop can be positioned between the atrial side of the valve clip 40 and the leaflets 22, 24. Finally, the cutting loop (e.g., of any of the embodiments of this specification) can be activated and the cut through the leaflet tissue completed.
In yet another example, the valve clip 40 can be pulled from a location within the left ventricle 14, further into the left ventricle 14 to create the counter force, allowing the cutting loop to be positioned and to cut the tissue as previously described.
The cutting and capture catheter 403 is generally similar to the previously embodiments and may include any of the variations previously discussed in that regard. For example, the cutting and capture catheter 403 may include a basket 102 and a cutting loop 404 connected to an elongated inner control member 108 that moves all of the components into and out of a tubular jacket or sheath 110.
As best seen in
Second, the basket tip 414 includes an atraumatic distal end shape 414A that helps prevent the basket tip 414 from damaging tissue within the patient. For example, the atraumatic distal end shape 414A can be spherical, rounded, oval, or conical. Again, this basket tip 414 may also be used with any of the other embodiments of this specification.
Returning to
The snare catheter 401 includes a snare loop 420 that is connected on or near the distal end of an inner control member 418 (which is similar to member 108) that moves longitudinally within an outer tubular jacket or sheath 416. This allows the inner control member 418 to move the snare loop 420 into and out of the sheath 416. The outer tubular sheath 416 may be open at the bottom similar to sheath 110 or may include a tip member 422 with an opening in its sidewall that extends into the interior lumen of the sheath 416.
Optionally, the snare loop 420 may include a previously described cutting element (e.g., an RF electrode near its tip) that allows it to engage tissue surrounding the clip and at least partially cut some of this tissue to initially facilitate the capture and removal of the valve clip 40. Additionally cutting and capture procedures can then be performed. This initial removal of at least some of the engaged tissue may be necessary to facilitate the engagement of the snare loop 420 and allow the snare loop 420 to provide the counter force to stabilize the valve clip 40. For example, a channel or valley can be cut into the tissue surrounding the valve clip 40 which can then allow the snare loop 420 to more robustly engage the valve clip 40. One example configuration of this can be seen in
The snare loop 420 can have a variety of different shapes that are configured to grip a valve clip 40. For example,
In another example seen in
The snare loop 424 has an imparted shape-memory shape such that it connects to the inner control member 418 at about 90 degrees. In some circumstances, as that 90-degree bend is pulled into the snare catheter 401, it may angle or deflect the loop 424 downward and could potentially move the loop 424 off the valve clip 40. In contrast, the saddle-shaped snare loop 420 has a distal/downward arc curve, and therefore as the loop 420 is pulled into the snare catheter 401, it helps maintain the original orientation of the loop 420 and thereby better maintains the loop 420 on the valve clip 40.
The snare loop 420 can further include features that enhance its grip on a valve clip 40. For example, a frictional coating or frictional sleeve can be placed over portions of or the entire snare loop, as seen with the snare loop 420 in
While the snare catheter 401 and snare loop 420 is previously described as being used to grasp a valve clip 40, it can be used for other purposes as well. For example, it can be used to capture other tissues. It may be desirable to remove calcified nodules within the valve leaflets to facilitate placement of a valve. It may be used to capture and remove valve leaflet tissue to facilitate flow after a replacement valve is inserted. It may be used to remove chordae tendinea to facilitate motion of the valve. In that respect, the snare loop 420 can be used to grab such tissue while the cutting loop 404 is used to cut the tissue. However, it can also be helpful to include a cutting element (e.g., RF electrode) on the snare loop 420 to help cut such tissue first.
The snare catheter 401 may further include a tip member 422 at the distal end of the outer tubular sheath 416, as best seen in
In contrast, the tip member 422 includes an opening 422A through its side wall, along with an angled or curved surface 422B that is configured to direct the snare loop 420 out of the opening 422A at a generally perpendicular angle relative to an axis of the outer tubular sheath 416 and axis of the valve clip 40.
Additionally, the tip member 422 can include features that help engage and/or create friction with the valve clip 40 so that when the snare loop 420 cinches the valve clip 40 against the tip member 422, the features help prevent the valve clip 40 from slipping out of the snare loop 420. In the example of
In the example of
The snare catheter 401 may also include a handle 440 that is configured to retract the inner control member 418, and therefore the snare loop 420, in a controlled manner. Specifically, the handle 440 allows predetermined and limited amounts of force to be applied to the snare loop 420 while also providing the ability to lock the snare loop 420 position or force at the desired level. This allows the valve clip 40 to be grasped relatively firmly without enough force to break the catheter 401 and further allows this force to be maintained throughout the procedure without the necessity to hold portions of the handle 440 during most of the procedure.
The handle 440 may have different possible mechanisms for controlling and locking the position/force of the snare loop 420.
The force applied to the knob 448 can be limited or can increase in resistance as the knob 448 is pulled out by a spring 450 located in the housing 442. The spring 442 can be connected to either the inner control member 418 or a distal portion 440 of the knob 448, as well as to an interior of the housing 442 such that when the knob 448 is pulled proximally, the spring 450 either compresses or expands to generate increased resistance. Depending on the configuration of the spring 450 (e.g., size, amount of initial compression, spring constant, and similar aspects), the force applied by the spring 450 can be optimized to apply a constant predetermined tension throughout the length the knob 448 can be pulled, or alternately can apply increasing tension the further proximally the knob 448 is pulled.
The handle 440 may also include a locking mechanism that can lock the position of the inner control member 418 relative to the housing 442 and outer sheath 416. In the present example of
The handle may also 440 include a port 452 that is in communication with the interior of the handle housing 442 and outer sheath 416. This port 452 can be used for supplying saline, contrast, or similar fluids during a procedure.
The handle 440 may also include an electrical connection to the RF generator and to the snare loop 420 (if the snare loop includes an RF electrode or similar cutting element) to be used for supplying energy to the cutting snare 420 during a procedure. As previously described, in some circumstances it may be helpful for the snare loop 420 to include a cutting element to cut at least some tissue surrounding a valve clip 40 or other heart valve therapy so that the snare loop 420 can better engage the valve clip 40.
Generally, it may be desirable for both the cutting and capture catheter 403, and the snare catheter 401 to be included and delivered through the same delivery catheter (e.g., steerable catheter 180). However, the cutting and capture catheter 403, and the snare catheter 401 may also be separately delivered in independent delivery catheters or without any overlying catheter, depending on the specific procedure.
First, a delivery catheter (e.g., a steerable delivery catheter 180) containing the cutting and capture catheter 403, and the snare catheter 401 is advanced into the left atrium 12 of the patient's heart. It may be generally desirable for the tip of the catheter 180 to be advanced through the leaflets 22, 24 and into the left ventricle 14 initially. This may help prevent either the cutting and capture catheter 403 or the snare catheter 401 from becoming tangled in any chordae extending from or near the leaflets 22, 24. The basket tip 414 of the basket 102 may be positioned at or partially beyond the opening of the delivery catheter 180 to help create a generally smooth surface that will not “catch” or otherwise get stuck when passing through the leaflets 22, 24 or the nearby chordae.
Next, the cutting and capture catheter 403 and the snare catheter 401 are advanced out of the catheter 180 and into the left ventricle 14. Initially, the opening 422A of the tip member 422 is oriented towards the valve clip 40. If the snare loop 420 is not already deployed outward, the inner control member 418 is moved distally via the handle 440 to cause its deployment and expansion. The snare loop 420 is aligned with the valve clip 40 and then the snare catheter 401 is moved proximally so that the snare loop 420 surrounds the valve clip 40, as seen in
During this time, the basket 102 and cutting loop 404 can be either be positioned in a different or opposite rotational orientation as the snare loop 420, and/or distally beyond the snare loop 420.
Referring to
As seen in
Referring to
In the scenario where the delivery catheter 180 passes back into the left ventricle 14 to then retract the cutting and capture catheter 403 and the snare catheter 401, there is a risk that the chords of the valve can inhibit the delivery catheter 180 from passing back through into the left ventricle 14. For example, the distal end of the delivery catheter 180 may not be tapered enough and therefore may “catch” on the chords.
One solution to this problem is to include a chord dilator that can be positioned partially out of the distal opening of the delivery catheter 180 when transitioning through the leaflets 22, 24 and chords. Such a chord dilator may include a tapered and/or angled distal surface and can be sized to radially occupy most or all of the opening of the delivery catheter 180.
One example of a chord dilator 432 can be seen best in
The chord dilator 432 includes two passages 432A and 4328; one passage 432A to accommodate the snare catheter 401 and another 432B to accommodate the cutting and capture catheter 403. Alternately, the chord dilator 432 may only have a single passage that accommodates only one of the snare catheter 401 or the cutting and capture catheter 403. In either case, the passages preferably allow their respective catheters to rotate within it during a procedure. Additionally, one of the passages may be a “C” shape (i.e., does not completely surround a catheter) such that it allows one of the catheters to decouple from the chord dilator 432. Optionally one, two, or more radiopaque markers 432E may also be included within the chord dilator 432. For example, the radiopaque markers 432E may be located on opposed circumferential sides of the chord dilator 432 and extend at least partially between the proximal and distal end of the chord dilator 432.
When the user desires to move the delivery catheter 180 into the left ventricle to capture the snare catheter 401 and/or the cutting and capture catheter 403, the snare catheter 401 and/or the cutting and capture catheter 403 are moved relative to the delivery catheter 180 so that they position the chord dilator 432 partially into the distal opening of the delivery catheter 180, similar to that seen in
Alternately, the chord dilator 432 may be configured only to connect the snare catheter 401 and the cutting and capture catheter 403, without any specific surfaces for chord dilation. In that respect, the chord dilator 432 may primarily be used to maintain the two catheters parallel to each other and not necessarily for chord dilation, which may be useful for achieving a desired alignment during a procedure.
The chord dilator 432 may alternately include three passages. For example, one passage 432A to accommodate the snare catheter 401, another 432B to accommodate the cutting and capture catheter 403, and another to facilitate a passage of a guidewire. The chord dilator 432 also can be used to facilitate the relative axial alignment of the snare, cutting loop, and basket. The location of the other members relative to the chord dilator 432 changes the length of the free member arms and hence controlling the distance between and angles the axis of the members
While the snare catheter 401 is previously described as being used to grasp a valve clip 40, it can be used for other purposes as well. For example, it can be used to grab or snare a guidewire or a Fogarty balloon during a procedure (e.g., during a transapical approach) to help pull these components through a target valve and prevent them from becoming tangled or stuck.
The removal system 400 is previously described as being delivered through an outer transeptal guide catheter 182 or similar catheter. However, the removal system 400 can be further configured to have a guidewire pathway or passage so that it can be delivered over a guidewire 430. The guidewire may have a more delicate force and stiffness transition to the tissues as the removal system is presented, ensuring safe introductions in to various anatomies.
Other paths are also possible for the guidewire 430. For example,
The guidewire 430 may proximally extend through only the steerable catheter 180, as seen in
Alternately, as seen in
The use of a guidewire 430 for delivery of the removal system 400 may facilitate crossing through a valve with smaller orifices, which is particularly common with valves that have multiple valve clips 40 implanted. Navigating over a guidewire 430 may also allow two valve clips 40 to be removed easier. For example, a catheter with a cutting loop 420 can be advanced over the guidewire 430 and used to cut the leaflet tissue between both valve clips 40, allowing them to spread apart and therefore allow for easier sequential capture via successive removal systems 400.
With regard to the sequential removal, this procedure may include placing a steerable catheter 180 within the left atrium, navigating a guidewire 430 through the target orifice of the valve, advancing a cutting and capture catheter 403 over the guidewire 430, removing the guidewire 430, cutting and extracting the valve clip 40 with the cutting and capture catheter 403, removing the cutting and capture catheter 403, again advancing the guidewire 430 through the target orifice of the valve, and repeating the removal process. The steerable catheter 180 may be left in place after removing the first valve clip 40 if it is sized large enough for complete removal of the valve clip 40; otherwise the steerable catheter 180 can be removed and a second steerable catheter 180 can be placed.
It may also be desirable in some embodiments and procedures for the cutting and capture catheter 403 to have a basket 460 that can expand or stretch from a longitudinally compressed configuration. This may allow for a basket 460 with a single size to accommodate different size valve clips 40, instead of needing several different sized baskets, and may also allow the valve clip 40 to be “tented” by the snare catheter 401. For example,
The longitudinally stretchable functionality of the basket 460 can be achieved in several different ways. For example, the basket 460 can be braided or woven from one or more wires composed of a shape memory material (e.g., Nitinol), which is then heat set to the compressed configuration (
The baskets described in this specification (e.g., basket 102 or 460) have been shown to have a generally cylindrical expanded shape. However, other basket shapes are also possible. For example,
While the inclusion of the basket 102 is desirable for capturing a valve clip 40 or other heart valve therapy, it is also possible to eliminate the basket 102 from the cutting and capture catheter 403, as seen in
The present specification and drawings include many different embodiments and features of removal devices and methods of use thereof. While features or techniques may be depicted in connection with a specific embodiment, it is the intent of the Applicant that any features shown in any of the embodiments can be incorporated in other embodiments. Put another way, any of the features described herein can be mixed and matched with each other and the claims should therefore not be otherwise limited or otherwise restricted to only the embodiments discussed and depicted herein.
As used herein, the terms “substantially” or “generally” refer to the complete or nearly complete extent or degree of an action, characteristic, property, state, structure, item, or result. For example, an object that is “substantially” or “generally” enclosed would mean that the object is either completely enclosed or nearly completely enclosed. The exact allowable degree of deviation from absolute completeness may in some cases depend on the specific context. However, generally speaking, the nearness of completion will be so as to have generally the same overall result as if absolute and total completion were obtained. The use of “substantially” or “generally” is equally applicable when used in a negative connotation to refer to the complete or near complete lack of an action, characteristic, property, state, structure, item, or result. For example, an element, combination, embodiment, or composition that is “substantially free of” or “generally free of” an ingredient or element may still actually contain such item as long as there is generally no measurable effect thereof.
As used herein any reference to “one embodiment” or “an embodiment” means that a particular element, feature, structure, or characteristic described in connection with the embodiment is included in at least one embodiment. The appearances of the phrase “in one embodiment” in various places in the specification are not necessarily all referring to the same embodiment.
As used herein, the terms “comprises,” “comprising,” “includes,” “including,” “has,” “having” or any other variation thereof, are intended to cover a non-exclusive inclusion. For example, a process, method, article, or apparatus that comprises a list of elements is not necessarily limited to only those elements but may include other elements not expressly listed or inherent to such process, method, article, or apparatus. Further, unless expressly stated to the contrary, “or” refers to an inclusive or and not to an exclusive or. For example, a condition A or B is satisfied by any one of the following: A is true (or present) and B is false (or not present), A is false (or not present) and B is true (or present), and both A and B are true (or present).
In addition, use of the “a” or “an” are employed to describe elements and components of the embodiments herein. This is done merely for convenience and to give a general sense of the description. This description should be read to include one or at least one and the singular also includes the plural unless it is obvious that it is meant otherwise.
Still further, the figures depict preferred embodiments for purposes of illustration only. One skilled in the art will readily recognize from the discussion herein that alternative embodiments of the structures and methods illustrated herein may be employed without departing from the principles described herein.
Although the invention has been described in terms of particular embodiments and applications, one of ordinary skill in the art, in light of this teaching, can generate additional embodiments and modifications without departing from the spirit of or exceeding the scope of the claimed invention. Accordingly, it is to be understood that the drawings and descriptions herein are proffered by way of example to facilitate comprehension of the invention and should not be construed to limit the scope thereof.
This application claims priority to U.S. Provisional Application Ser. No. 63/081,504 filed Sep. 22, 2020 entitled Methods/Devices To Secure And Clinch Valve Clip, U.S. Provisional Application Ser. No. 63/144,399 filed Feb. 1, 2021 entitled Leaflet Clip Removal (Snare Shaft Tip), and U.S. Provisional Application Ser. No. 63/187,285 filed May 11, 2021 entitled Clip Removal Avoiding Chord Entanglement, all of which are hereby incorporated herein by reference in their entireties.
| Filing Document | Filing Date | Country | Kind |
|---|---|---|---|
| PCT/US2021/051258 | 9/21/2021 | WO |
| Number | Date | Country | |
|---|---|---|---|
| 63081504 | Sep 2020 | US | |
| 63144399 | Feb 2021 | US | |
| 63187295 | May 2021 | US |
