Patent Grant
11883294
Heart failure can occur when the left ventricle of the heart becomes enlarged and dilated as a result of one or more of various etiologies. Initial causes of heart failure can include chronic hypertension, myocardial infarction, mitral valve incompetency, and other dilated cardiomyopathies. With each of these conditions, the heart is forced to overexert itself in order to provide a cardiac output demanded by the body during various demand states. The result can be an enlarged left ventricle.
A dilated or enlarged heart, and particularly a dilated or enlarged left ventricle, can significantly increase tension and stress in heart walls both during diastolic filling and systolic contraction, which contributes to further dilatation or enlargement of chambers of the heart. Prior treatments for heart failure include pharmacological treatments, assist devices such as pumps, and surgical treatments such as heart transplant, dynamic cardiomyoplasty, and Batista partial left ventriculectomy. These prior treatments are described briefly in U.S. Pat. No. 5,961,440, entitled “Heart Wall Tension Reduction Apparatus and Method,” issued on Oct. 5, 1999, the entirety of which is incorporated by reference herein.
A more recent concept for treating heart failure applies one or more splints onto the heart, to reduce myocardial muscular stresses encountered during pumping. Examples of such approaches are disclosed in U.S. Pat. No. 7,766,812, entitled “Methods and devices for improving mitral valve function,” issued on Aug. 3, 2010, the entirety of which is incorporated herein by reference. One example includes one or more transventricular splints placed across the left ventricle. Each splint may include a tension member extending across the ventricle with anchors disposed on opposite ends of the tension member and placed on the external surface of the heart.
Mitral valve incompetency or mitral valve regurgitation is a common comorbidity of congestive heart failure. As the dilation of the ventricle increases, valve function generally worsens, which results in a volume overload condition. The volume overload condition further increases ventricular wall stress, thereby advancing the dilation process, which further worsens valve dysfunction.
In heart failure, the size of the valve annulus (particularly the mitral valve annulus) increases while the area of the leaflets of the valve remains constant. This may lead to an area of less coaptation of the valve leaflets, and, as a result, eventually to valve leakage or regurgitation. Moreover, in normal hearts, the annular size contracts during systole, aiding in valve coaptation. In heart failure, there is poor ventricular function and elevated wall stress. These conditions tend to reduce annular contraction and distort annular size, often exacerbating mitral valve regurgitation. In addition, as the chamber dilates, the papillary muscles (to which the leaflets are connected via the chordae tendinea) may move radially outward and downward relative to the valve, and relative to their normal positions. During this movement of the papillary muscles, however, the various chordae lengths remain substantially constant, which limits the full closure ability of the leaflets by exerting tension prematurely on the leaflets. This condition is commonly referred to as “chordal tethering.” The combination of annular changes and papillary changes results in a poorly functioning valve.
It can be desirable to provide a therapy which corrects the valve incompetency. A heart with even a small amount of regurgitation may benefit from not only the stress reducing functions of the ventricular splints as described above, but also from an elimination of the regurgitation, which will further off-load pumping requirements of the myocardium.
Surface area of an anchor and/or size of the anchor can correspond to the ability of an anchor to withstand forces due to tension from reshaping the heart and ongoing beating of the heart (although, other design features and material properties may also contribute to the ability of the anchor to withstand tension forces). To be most effective and safe, anchors would ideally be able to withstand high forces, including forces as high as 17 Newtons (N) or higher, while the splint maintains the heart in a desired shape. Further, the anchor should have a large enough surface area to spread out and reduce the pressure on the myocardium. If the pressure gets too high on an area (e.g., a small, focused pressure area) of the heart, this can lead to myocardium necrosis, which can itself lead to migration and sinking of the anchor into the tissue. Accordingly, large anchors, or anchors with a large surface area, may be required, and the larger size/area can make implantation of the anchor difficult and can require opening the heart, chest, and/or sternum, and/or may require other highly invasive procedures.
Currently available methods of mitral valve repair or replacement typically require opening the chest and/or heart, e.g., to gain direct access to the valve and its annulus or another portion of the heart. This type of access typically necessitates a use of cardiopulmonary bypass, which can introduce additional complications to the surgical procedure. Since the implantation of the splints themselves do not require the patient to be on cardiopulmonary bypass, it would be advantageous to devise a technique which could improve the mitral valve without any need for cardiopulmonary bypass. The ability to improve the mitral valve function without the need for cardiopulmonary bypass would be an advantage, both in conjunction with ventricular splinting, and also as a stand-alone therapy. Indeed, it would be desirable to have systems, apparatuses, and methods capable of a deploying an anchor with an ability to withstand high pressures (e.g., an anchor having a large surface area) using a less invasive, or minimally invasive procedure.
Devices and methods for medical treatment that may be used for improving heart valve function are described herein. These may include a self-expandable anchor system and related methods for assisting in treating an apposition of heart valve leaflets so as to improve poorly functioning heart valves, using less invasive treatments/procedures.
Systems, assemblies, apparatuses, and related methods are provided for medical treatment, including for transcatheter medical treatments and/or for treatment of dilated hearts (e.g., dilated left ventricle) or functional mitral valve regurgitation within a human heart. Any treatment of a dilated left ventricle may simultaneously result in treatment (fixing or prevention) of functional mitral valve regurgitation. The systems, assemblies, apparatuses, and methods may include an anchoring system that comprises an anchor for securing a mitral valve splint (“MV Splint”) in the heart. A spade-shaped assembly (while the term “spade-shaped” is used, this is meant to encompasses a variety of different shapes and sizes) may be configured to be deployed in a right ventricle of the heart and to stabilize a catheter during penetrating the septum. An outer curved needle may be configured to penetrate the septum. The outer curved needle may comprise a hollow tube having a multiplicity of slits (e.g., S-shaped slits) disposed along the length of the needle so as to accommodate sharp curving of the needle. The outer curved needle may be further configured to deploy an inner needle into the left ventricle. A trocar catheter may be configured for puncturing tissue within the heart without damaging other nearby tissue. An introducer system or introducer assembly for interventional cardiology procedures may comprise an atraumatic and/or blunt shape introducer to protect nearby tissue within the heart during advancing a guidewire through a moving tissue, such as a beating heart. A threaded introducer may be configured for advancing a guidewire and/or other instruments through a moving tissue, such as a beating heart, in a controlled manner that helps prevent damage to surrounding tissue.
In an exemplary embodiment, an anchoring system for medical treatment, including treatment of heart dilation and/or functional mitral valve regurgitation comprises an anchor that can be used for fixating a splint, e.g., a mitral valve splint within a human heart. The anchoring system may include one or more or all of the following: a spade-shaped assembly configured to be deployed in a right ventricle of the heart and to stabilize a catheter during penetrating the septum between the right ventricle and the left ventricle; a curved needle configured to penetrate the septum, the curved needle comprising a hollow tube having a multiplicity of slits (e.g., S-shaped slits) disposed along the length of the curved needle, the curved needle may be configured to pass through a catheter or a portion of the spade-shaped assembly and may also be configured to deploy an inner needle from the curved needle into the left ventricle; a trocar catheter configured for puncturing tissue; an introducer system for interventional cardiology procedures; and a threaded introducer configured for temporarily anchoring in a moving tissue and allowing advancement of a guidewire and/or other instruments therethrough.
In one exemplary embodiment, an anchor (e.g., of an anchoring system) comprises a ring having a circularly configured wire having atraumatic ends which meet at a break, the wire capable of being expanded into a straightened configuration suitable for loading the anchor into a lumen of a catheter, e.g., a delivery catheter. In one embodiment the ring may be formed of a shape memory material (e.g., nitinol or other shape memory alloy) and/or may have elastic properties. In one embodiment, the ring may be formed from stainless steel or another strong material. In one exemplary embodiment, the atraumatic ends of the wire forming the ring comprise spherical portions of the wire configured to prevent damage to nearby tissues during delivery and deployment of the anchor within the heart. The anchor may also comprise a cover in one or multiple pieces, the cover may be supported by the ring so as to assume a generally circular configuration. The cover may also be configured to contact an exterior surface of the heart and/or allow tissue ingrowth into the cover. A tension member (e.g., a cord, cable, wire, braided fibers, etc.) may be engaged with the cover such that pulling the tension member or cord tightens the cover into a deployed configuration (e.g., a circular, disc-shaped, pie-shaped, or cone-shaped configuration). In one exemplary embodiment, the cover is configured to change from the deployed configuration (e.g., circular, flattened, disc-shaped, pie-shaped, or cone-shaped configuration) to a collapsed or low profile configuration when the cord is loosened. In one exemplary embodiment, the cover may comprise a surface area suitable to eliminate or limit migration of the anchor into tissue of the heart and to withstand forces due to tension of the tension member or cord of 10-25 Newtons (N), 14-20 N, or at least 17 N.
In one exemplary embodiment, the anchor or a portion of the anchor (e.g., the ring and/or the cover) is configured to be stretched/opened/changed from an expanded or deployed configuration (e.g., a circular or ring-shaped configuration) to a low profile configuration (e.g., a straightened configuration) such that the anchor may be loaded into a lumen of a catheter for delivery through a puncture within the heart in the low profile configuration, and wherein the anchor changes from the low profile configuration (e.g., straightened configuration) to the deployed configuration (e.g., the circular or ring-shaped configuration) as it is pushed out of the lumen of the catheter. When in the deployed configuration (e.g., a circular/ring-shaped/pie-shaped/cone-shaped configuration), pulling the tension member or cord draws the cover taut toward the center of the circle/ring, thereby producing the an expanded configuration of the cover (e.g., a circular, flattened/disc-shaped/pie-shaped configuration of the cover) when not tensioned against the heart wall. The tension member or cord can pull the anchor against the exterior surface of the heart wall, myocardium, and/or pericardium such that the anchor lays flat against the surface with the tension member or cord passing through the puncture in the heart wall, myocardium, and/or pericardium; however, as the tension is increased the tension member or cord can pull the center of the anchor inwardly causing the anchor and its cover to take on a cone-like shape.
In one exemplary embodiment, the cover of an anchor may be comprised of a strip of suitable material having a first, straight edge folded over to form a hole or passage extending along the length of the strip and configured to receive the ring, and a second edge comprising a series folded tabs configured to receive the tension member or cord whereby pulling the tension member or cord draws the cover into the circular/disc-shaped/pie-shaped configuration. In one exemplary embodiment, the cover is comprised of any of various polymer materials, such as polyethylene terephthalate (PET), ultra-high-molecular-weight polyethylene (UHMWPE), or other similar material. In one exemplary embodiment, the cover further comprises one or more ribbons of the polymer material woven so as to provide an anchor suitable for contacting an exterior surface of the heart. The cover may comprise or consist of a polymer, PET, polytetrafluoroethylene (PTFE), expanded polytetrafluoroethylene (ePTFE), UHMWPE, a metal, and/or a non-metal (e.g., carbon fibers).
In one exemplary embodiment, an anchor (e.g., of an anchoring system) may comprise a coiled wire. The coiled wire may comprise a base portion and a top portion, the base portion may be configured to contact the exterior surface of the heart, the myocardium, and/or the pericardium, the top portion may be configured to fixedly receive the tension member or a cord drawn through the center of the coiled wire and the puncture in the heart, and the coiled wire may comprise several turns in which the diameter of the coil decreases in passing from the base portion to the top portion. In one exemplary embodiment, the diameter of each adjacent turn of the several turns of the coiled wire may decrease with a difference less than the diameter of the wire so as to configure a cone-shaped anchor possessing a large area of contact with the surface of the heart. In one exemplary embodiment, the diameter of adjacent turns/coils of the several turns/coils decreases with a difference greater than the diameter of the wire so as to configure a telescope-shaped anchor which provides a large contact area that increases as a function of tension in the tension member or cord. In one exemplary embodiment, the coiled wire may be wound so as to form at least a lower level or base portion and an upper level or top portion, the lower level being configured to provide a relatively large area of contact with the exterior surface of the heart while preventing the upper level and the tension member or cord from being drawn under tension into the puncture in the wall of the heart. In one embodiment, multiple coils of the coiled wire may have the same or a similar diameter.
In one exemplary embodiment, a spade-shaped assembly (e.g., of an anchoring system) may comprise a catheter, a needle (e.g., a first needle), and a wire spade. The catheter may include a lumen, and the catheter may be flexible. The needle may include a sharp distal end, which may be configured for puncturing a septum between the right ventricle and a left ventricle of a heart (e.g., a beating heart). The needle may be disposable within the lumen of the catheter and moveable out of the lumen to puncture tissue, e.g., to puncture the septum. The needle may be curved and/or flexible. The needle may freely pass through the lumen, may be connected through controls at a proximal end (e.g., on a proximal handle or orientation handle), and/or may be connected to the catheter by way of a catheter head. The wire spade may be connected to the catheter, may be configured to be deployed in a right ventricle of the heart, and may be configured to contact walls of the right ventricle and thereby stabilize the needle when the needle is used to penetrate the tissue/septum, e.g., stabilize the needle when the needle penetrates the septum between the right ventricle and the left ventricle and enters into the left ventricle. The wires spade may have a variety of shapes and branches. The wire spade may be connected to the catheter by way of a catheter head. The spade-shaped assembly may also comprise an inner needle (e.g., a second needle) disposed within an inner lumen of the first needle, the inner needle may be configured to be advanced out of a lumen of the first needle, across the left ventricle, and configured to puncture a posterior wall of the left ventricle after the first needle has passed through the septum. The spade-shaped assembly may also comprise an orientation handle located at a proximal end of the catheter configured to provide control of an angle between a tip of the needle and the catheter and/or the wire spade. In one exemplary embodiment, the first needle and/or second, inner needle may comprise a hollow tube having a multiplicity of slits (e.g., S-shaped slits, C-shaped slits, V-shaped slits, zig zag slits, straight slits, diagonal slits, parallel slits, and/or other types of slits) disposed along the full length or a portion of the length of the needle. The slits (e.g., S-shaped slits) may be configured to allow the first needle and/or second, inner needle to undergo sharp turns when delivered inside the catheter and then resume a straightened orientation when extended out from the catheter. The slits (e.g., S-shaped slits) may be further configured to provide rigidity to the first needle and/or second, inner needle. In one exemplary embodiment, the slits (e.g., S-shaped slits) are configured to allow the orientation of the first needle and/or second, inner needle to be changed by rotating a proximal end of the first needle and/or second, inner needle extending from the catheter.
In one exemplary embodiment, a trocar catheter (e.g., of an anchoring system) may comprise a cannula being generally elongate and having an interior lumen. The trocar catheter may also include a trocar disposed within the interior lumen and extending to a trocar distal tip comprising one or more surfaces configured to puncture the tissue (e.g., puncture the tissue during rotation of the trocar). A central lumen may pass through the trocar catheter (e.g., through the cannula and/or the trocar) and may be in fluid communication with one or more lateral ports disposed on the trocar distal tip. The central lumen and the one or more lateral ports may be configured for contrast injection. The trocar catheter may include a proximal handle comprising a plunger mechanism and an actuator configured to facilitate advancing the trocar distal tip beyond a distal end of the cannula during puncturing of the tissue. The plunger mechanism may be further configured to withdraw the trocar distal tip into the distal end of the cannula during uses other than puncturing the tissue.
In one exemplary embodiment, an introducer system/assembly comprises a needle catheter having an inner lumen and a beveled edge configured for puncturing tissue and comprises an introducer having a guidewire lumen and an atraumatic and/or blunt shape of its distal end. The introducer may be disposed within the inner lumen of the needle catheter with its atraumatic/blunt shaped distal end extending distally beyond the beveled edge of the needle catheter. A spring may be disposed within the catheter configured to maintain the atraumatic/blunt shape extending distally beyond the beveled edge during uses other than puncturing tissue. A guidewire may be inserted into or otherwise disposed within the guidewire lumen of the introducer, the guidewire may be deliverable while the introducer distal end is extended to protect nearby tissues from damage from the beveled edge of the needle catheter. In one exemplary embodiment, the introducer and the needle catheter are configured such that the atraumatic/blunt shaped distal end of the introducer may be locked into the distally extended position so as to enable pushing against tissue without the beveled edge of the needle catheter puncturing the tissue.
In one exemplary embodiment, a threaded introducer (e.g., of an anchoring system) comprises an elongate member having a proximal head and a distal end. Both the proximal head and the distal end may have atraumatic surface features so as to prevent damage to tissues during delivery of the threaded introducer. A central lumen may extend through the length of the threaded introducer, e.g., from the proximal head to the distal end. The central lumen in the region within the proximal head may be configured to receive a catheter, and the central lumen in the region within the distal end may be configured for injection of contrast fluid (e.g., for imaging procedures). At least one lateral port may be disposed on the distal end and be in fluid communication with the central lumen. A multiplicity of threads may be disposed along the length of the threaded introducer and configured to engage with tissue as the threaded introducer is threaded into the tissue so as to facilitate controlled advancement within a moving tissue (e.g., moving heart tissue).
In one exemplary embodiment, a suture cutter catheter comprises: a moving plate; a blade; and an inflatable balloon, wherein the suture cutter catheter may be configured such that inflation of the balloon causes the moving plate to move toward the blade. The suture cutter catheter may also comprise a spring that biases the moving plate in a direction away from the blade. The suture cutter catheter may also comprise a plastic positioning tube having a lumen through which a suture may be received, the positioning tube attached to the moving plate such that the positioning tube is configured to maintain the suture in a desired position for cutting the suture. Other features described with respect to suture cutter catheters herein may also be included.
In one exemplary embodiment, a catheter/device (e.g., a C-shaped catheter/device or puncture location catheter/device) for identifying a puncture site (e.g., on a wall of a heart) during medical treatment is capable of causing a bend/bulge in a wall of a heart. The catheter/device may comprise: a proximal handle; a positioning tube coupled with the proximal handle, the positioning tube may include an elongate portion and a curved portion, and these may be integral and/or connected together in a variety of ways, e.g., a proximal bend may be positioned between them or connect them. The curved portion may have a radius of curvature configured for extending around a portion of an organ or heart (e.g., around the left side of a heart. An elbow may be disposed at a distal end of the curved portion. The catheter/device may include a guide aligned with a longitudinal axis of the elongate portion, and may include a finger moveable relative to the guide. The elbow may be configured/designed such that the guide and/or finger are oriented and aligned with a longitudinal axis of the elongate portion. The device/catheter may also include an applicator disposed near the proximal handle, the applicator being connected to the finger via a connector that passes within a first lumen of the curved portion, such that the applicator can be manipulated to move the finger relative to the guide.
In one exemplary embodiment, alignment of the finger with the longitudinal axis of the elongate portion may be configured to help indicate a location and orientation of the finger near the posterior wall of the human heart. In one exemplary embodiment, a spring is configured to bias the finger in a retracted configuration such that a pressing force applied to the applicator compresses the spring and transitions the finger to an extended configuration, and wherein upon removal of the pressing force the spring automatically transitions the finger back to the retracted configuration. The positioning tube may comprise one or multiple lumens. A second lumen, different from the first lumen, may be configured for deploying an anchor at the puncture site during medical treatment. The catheter/device may be a C-shaped device/catheter or puncture location device/catheter as described elsewhere herein and may include any of the described features and be used in any of the described methods or steps.
The drawings refer to embodiments of the present disclosure in which:
While the present disclosure is subject to various modifications and alternative forms, specific embodiments thereof have been shown byway of example in the drawings and will herein be described in detail. The invention should be understood to not be limited to the particular forms disclosed, but on the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the present disclosure.
Various aspects of the present disclosure generally relate to systems, assemblies, apparatuses, devices, and methods for medical treatment and/or treating heart conditions, including, by way of example, treating dilation/dilatation (including a dilated left ventricle), valve incompetencies (including mitral valve regurgitation), and other similar heart failure conditions. The systems, assemblies, apparatuses, devices, and methods are adapted for a transcatheter medical treatments that may not require full, open surgery, and can be minimally invasive. Each apparatus or device disclosed herein preferably operates passively in that, once placed in the heart, the device does not require an active stimulus, either mechanical, electrical, or otherwise, to function. Implanting one or more of the devices of the present disclosure operates to assist in an apposition of heart valve leaflets so as to improve valve function. In addition, the devices disclosed herein may either be placed in conjunction with other devices that, or may themselves function to, alter the shape or geometry of the heart, locally and/or globally, and thereby further increase the heart's efficiency. That is, the devices disclosed herein generally facilitate an increased pumping efficiency of the heart by way of an alteration in the heart's shape or geometry and concomitant reduction in stress on heart walls, and through an improvement in valve function.
The present disclosure offers numerous advantages over existing treatments for various heart conditions, including valve incompetencies. The devices disclosed herein are relatively easy to manufacture and use, and the surgical techniques and tools for implanting the devices of the present disclosure do not require the highly invasive procedures of current surgical techniques. For instance, the treatments described herein do not require removing portions of heart tissue, nor do they necessarily require opening the heart chamber or stopping the heart during operation. For these reasons, the treatments and techniques for implanting the devices of the present disclosure convey a reduced risk to the patient as compared with other techniques. The less invasive nature of the treatments and techniques and tools of the present disclosure may further allow for earlier intervention in patients with heart failure and/or valve incompetencies. While often discussed herein in terms of mitral valve treatments, the systems, devices, methods, etc. may be used to treat other heart valves, heart conditions, enlargement of other organs, etc.
In one embodiment, the present disclosure involves geometric reshaping of the heart and treating valve incompetencies. In certain aspects of the present disclosure, substantially an entire chamber geometry is altered so as to return the heart to a more normal state of stress. Models of this geometric reshaping, which includes a reduction in radius of curvature of the chamber walls, can be found in U.S. Pat. No. 5,961,440 incorporated above. Prior to reshaping the chamber geometry, the heart walls experience high stress due to a combination of both the relatively large increased diameter of the chamber and the thinning of the chamber wall. Filling pressures and systolic pressures are typically high as well, further increasing wall stress. Geometric reshaping according to the present disclosure reduces the stress in the walls of the heart chamber to increase the heart's pumping efficiency, as well as to stop further dilatation of the heart.
Although the present disclosure is discussed in connection with treating the mitral valve of the heart, the present disclosure may be applied to various chambers of the heart and for other valves of the heart for similar purposes. More broadly, the systems, apparatuses, methods, etc. disclosed herein may be used in other applications to change the geometries and/or stresses of other parts of the body (e.g., a stomach, bladder, or other part of the body). It also is contemplated that the present disclosure may be used to support an infarcted heart wall so as to prevent further dilatation, or to treat aneurysms in the heart. It is further contemplated that the present disclosure may be placed relative to the heart without altering the shape of the chamber, and only altering the shape of the valve itself.
In the following description, numerous specific details are set forth in order to provide a thorough understanding of the present disclosure. It will be apparent, however, to one of ordinary skill in the art that the invention disclosed herein may be practiced without these specific details. Thus, the specific details set forth are merely exemplary. The specific details may be varied from and still be contemplated to be within the spirit and scope of the present disclosure. In other instances, specific numeric references such as “first anchor” or “first needle” may be made. However, the specific numeric reference should not be interpreted as a literal sequential order but rather interpreted that the “first anchor” or “first needle” is different from a “second anchor” or “second needle.” The term “coupled” is defined as meaning connected either directly to the component or indirectly to the component through another component. Further, as used herein, the terms “about,” “approximately,” or “substantially” for any numerical values or ranges indicate a suitable dimensional tolerance that allows the part or collection of components to function for its intended purpose as described herein.
In general, the present disclosure describes systems, apparatuses, and related methods for medical treatment, e.g., for treatment of heart dilation and any associated functional mitral valve regurgitation within a human heart and/or for transcatheter treatment. In one embodiment, an anchoring system or system for setting an anchor and/or splint may comprise an anchor for fixating a mitral valve splint within the heart. In one exemplary embodiment, the anchor may comprise a cover supported by a ring so as to assume a generally circular or disc-shaped configuration or other configuration to contact an exterior surface of the heart, the myocardium, or the pericardium. The system may include an ultrasound probe for imaging parts of the system and parts of the body to be treated. The ultrasound probe may include a guide attached thereto for guiding various components/instruments of the system during treatment. The system may include a stabilizing assembly (e.g., a spade-shaped assembly) configured to be deployed in a right ventricle of the heart and to stabilize a catheter and/or assembly during penetrating the septum. The stabilizing assembly may include various components including one or more of a catheter, catheter head, stabilizing wire or structure (e.g., a spade-shaped wire), a curved needle, and an inner needle. A curved, bent, or bendable needle may be loaded in the catheter as part of the spade-shaped assembly and may be configured to penetrate a septum (e.g., the septum between the right ventricle and the left ventricle). Optionally, even if the stabilizing assembly is not used, a curved, bent, or bendable needle/catheter may still be used in essentially the same methods. The curved, bent, or bendable needle/catheter may comprise a hollow tube having a multiplicity of slits (e.g., S-shaped slits, C-shaped slits, V-shaped slits, zig zag slits, straight slits, parallel slits, diagonal slits, etc.) disposed along the length of the needle. The slits (e.g., S-shaped slits) allow the needle to undergo sharp turns within the heart. The curved, bent, or bendable needle may be configured to deploy an inner needle (or other device) from a lumen of the curved, bent, or bendable needle and into the left ventricle. The system may include a trocar catheter configured for puncturing body tissue (e.g., heart tissue) without damaging other nearby tissue.
The anchoring system or system for setting an anchor and/or splint may include an introducer system or introducer assembly for interventional cardiology procedures that may comprise an atraumatic/blunt shape introducer inside a needle catheter to protect nearby tissue within the heart during advancing a guidewire or other instrument through a lumen of the introducer. The system may include a threaded introducer, which may act as a temporary anchor and may be configured for advancing a guidewire and/or other instruments (e.g., the anchor or a delivery catheter including the anchor) through a moving tissue, such as a beating heart. In an exemplary embodiment, the threaded introducer comprises a multiplicity of threads disposed along the length of the threaded introducer and configured to rotatably engage with a tissue so as to facilitate advancing within the moving tissue as the threaded introducer is rotated—the treaded catheter may enable the user to control the depth of the tip of the threaded catheter in a moving organ (e.g., myocardium of a beating heart). The system may include a suture cutter catheter for cutting sutures in a remote, difficult to access location, e.g., inside the heart or on a wall of the heart. The system may also include an ultrasound probe (e.g., a trans-vaginal ultrasound probe or other ultrasound probe may be used) for imaging parts of the system and parts of the body to be treated. The ultrasound probe may include a guide attached thereto for guiding various components/instruments of the system during treatment.
A superior anchor 136 is disposed at a first end of the tension member 128 and positioned adjacent to the left ventricle 116. An inferior anchor 140 is disposed at a second end of the tension member 128 and may be positioned adjacent to the right ventricle 120 (e.g., external to the heart outside the right ventricle as shown in
It is contemplated that the self-expandable anchor 148 may be utilized for either or both of the superior and inferior anchors 136, 140. Optionally, different types of anchors may be used for the superior and inferior anchors (e.g., any of the anchors described in this disclosure or other types of anchors). A cover may or may not be used on one or both of the superior and inferior anchor. As will be appreciated, the deployed or expanded configuration (e.g., circular/disc-shaped/pie-shaped/cone-shaped configuration) of the self-expandable anchor 148 shown in
As can be seen in
After initial deployment of the anchor 148 from the catheter 164, the tension member or cord 160 may be pulled, which then draws the central portion of the cover 156 taut toward the center of the ring 152, thereby producing the deployed or expanded configuration (e.g., a circular, flattened configuration, a somewhat convex or cone like configuration, or the disc-shaped/pie-shaped configuration of the cover shown in
The atraumatic ends 172 prevent the ends of the ring 168 from otherwise damaging the delivery catheter, the tissues of the heart 108, or other nearby body tissues during delivery and deployment of the self-expanding anchor 148. Further, the atraumatic ends 172 facilitate loading the self-expanding anchor 148 into the interior lumen of the catheter 164. In one embodiment illustrated in
A wire, member, or cable 174 disposed within a lumen of the notched tube 150 may enable changing the tube from a low-profile configuration (e.g., straight or flattened configuration) as shown, for example, in
The notched tube 150 may comprise atraumatic ends 166. The atraumatic ends 166 may be configured to prevent the ends of the notched tube 150 from damaging a delivery catheter, the tissues of the heart 108, or other nearby body tissues during delivery and deployment of the notched tube 150 to an anchor site, as described herein. The atraumatic ends 166 further facilitate loading the notched tube 150 into the interior lumen of a catheter, such as, for example, the catheter 164. In one embodiment, the atraumatic ends 166 may be comprised of smooth, rounded edges of the notched tube 150. In one embodiment, the atraumatic ends 166 may be comprised of any of various suitably shaped portions as may be deemed appropriate; for example, other shapes/configurations for the atraumatic ends 166 may be comprised of spherical portions, balls, cube-shaped, ovoid shaped, oval shaped, etc. In one embodiment, the atraumatic ends 166 may comprise portions of the ends of the notched tube 150 that are formed into spherical, generally spherical, ellipsoid, and/or ovoid portions. In one embodiment, the atraumatic ends 166 may be comprised of separate components that are fastened onto the ends of the notched tube 150. Any of various techniques may be used to fasten the atraumatic ends 166 onto the ends of the notched tube 150 without limitation. In the deployed or expanded configuration (e.g., as shown in
As illustrated in
The self-expandable anchor 148 may be formed by mounting the cover 156 onto the ring 152 by way of threading the ring 152 through the passage 192, and by threading or weaving the tension member 160 through all of the loops 196. The tension member may optionally be tied to itself in a slip knot or similar adjustable knot that allows the tension member to cinch the loops 196 toward the center of the ring. Optionally, after passing through the loops 196, each end of the tension member may extend to a proximal end of the delivery catheter and pulling at one or both ends may cinch the loops 196 toward the center of the ring. As will be appreciated, upon loosening the tension member 160 within the loops 196, the strip 180 facilitates expanding or transitioning the ring 152 from a deployed or expanded configuration (e.g., a circular or ring-shaped configuration) into a low profile configuration (e.g., straightened configuration), as discussed above, and thus enables the self-expandable anchor 148 to be suitably loaded into the lumen of the catheter 164.
It should be recognized, however, that the anchor 148 need not be limited to the ring 152 and cover 156, but rather various other configurations of anchors are contemplated within the scope and spirit of the present disclosure. For example,
Ring 204 is depicted in
While spokes 212 are depicted in place of a cover in
The tension member 208 may include features the same as or similar to tension member 160 described above and/or may include different design features or characteristics. The spokes 212 may comprise short segments of cord, wire, ribbon, or other material that are tied to the ring 204 and the tension member 208. The material of the spokes may be the same as that used for the cover 156 or tensioning member 160, and may be PET, UHMWPE, PTFE, ePTFE, or other suitable polymers or materials. More or fewer spokes may be used than are shown in
Optionally, an inner ring or hub may be used near the center of the ring 204, and spokes 212 may extend and attach between the ring 204 and the inner ring or hub. During deployment of the anchor, pulling the tension member may cause the inner ring or hub, the spokes 212, and the ring 204 to lay against the exterior surface of the heart 108, as described herein. The inner ring or hub may be constructed of a material the same as or similar to those used for the ring 152 or the tension member 160 or may be constructed of a different material (e.g., may be a metal or steel ring). The spokes may wrap around or through the ring or may be otherwise attached/connected.
The ring 336 may be connected to a tension member directly or may be connected indirectly by connecting to a cover, spokes, ribbons, or an inner ring or hub that connects to the ring 336. The anchor 332 may include a cover and/or spokes that are the same as or similar to the covers 156 or 280 or spokes 212 described above. Optionally, the anchor 332 may include one or more than one ribbon 308 (e.g., a PET ribbon) wound and/or woven to parts of the anchor 296 in various patterns, e.g., in a star-shaped, flower-shaped, triangular, square, pentagonal, or hexagonal pattern. One or more than one ribbon 308 may be woven together and/or woven to the ring 336 so as to form an anchor surface suitable for contacting an exterior surface of the heart 108, the myocardium, or pericardium. More surface area may be created by the ribbons 308 than that shown in
In some embodiments, the expandable balloon 206 may be configured to be filled with a filler material 242 so as to occupy an interior volume of the balloon, or a portion of the interior volume of the balloon, such as, by way of non-limiting example, a circumflex area of the expandable balloon 206. The filler material 242 may be comprised of any material found to be suitable for occupying the interior volume of the balloon, such as, but not limited to, liquid, a liquid that fixates over time (e.g., an epoxy), flexible coils, one or more rings (e.g., self-expandable or manually expandable), mini-spheres or micro-spheres comprised of metal or plastic, other fillers that may be delivered to a balloon via a relatively narrow tube, and a combination of one or more of these. The material may be of a liquid, gaseous, metal, polymer, cloth, or other material. For example, in one embodiment, illustrated in
Various delivery and filling devices and techniques may be used to deliver the anchor 202 and to deliver one or more of a variety of filler materials to the balloon or filling space of the balloon. In one embodiment, the anchor 202 and/or balloon 206 may be delivered using a delivery catheter. The anchor 202 and/or balloon 206 may be contained within a lumen of the delivery catheter until it arrives at a location for deployment (e.g., a posterior wall of a left ventricle) and may be expanded out of the lumen to an expanded or deployed configuration using a filler material, preliminary inflation fluid or material, and/or a pushing device. In one embodiment, the balloon may assume a low profile around an outer wall of an end of a delivery catheter during delivery and be expanded away from the outer wall upon arriving at the deployment location. In one embodiment, a stylet, pushing device, ring, etc. may be used to extend the balloon forward into a stretched, elongated configuration (e.g., similar to balloon 258 as shown in
In general, the filler material may be delivered to the filling catheter/tube 222 by way of various deliver devices or mechanisms. In one embodiment, magazines of filler material may be easily attached to and detached from a main delivery system. In some embodiments, two or more filling catheters/tubes (e.g., two filling catheters/tubes comprising a curved tip) may be used for filling (e.g., symmetrically filling) of the interior 218. In one embodiment, wherein the filler material comprises a wire or coil (e.g., a nitinol wire), a shaped filling catheter comprising two curved tips may be used to insert the nitinol wire into the interior 218 at a 90 degree (or 60-120 degree) turn with respect to the shaft or longitudinal axis or the shaped filling catheter. In one embodiment, the shaped filling catheter/tube may comprise two curves, or may comprise two single curved filling tubes located at a 180-degree angle relative to one another.
In some embodiments, the expandable balloon 206 or expandable balloon 258 may be temporarily expanded to restore its shape after being deployed in the crimped, low-profile configuration shown in
It is contemplated that each of the coiled anchors shown in
Moreover, the anchors shown in
The needle 392 may be curved as shown in
The embodiments of the wire spade 388 illustrated in
In some embodiments the flexible needle 432 may be used to deliver devices by way of the hollow tube 436, such as guidewires or small diameter catheters or needles. In some embodiments, the hollow tube 436 may be used to measure pressure where the distal tip of the needle is located. In some embodiments the flexible needle 432 may be utilized as a guidewire during interventions lacking direct visibility. For example, the flexible needle 432 may be used during percutaneous cardiology or radiology interventions, using ultrasonic, angiogram, and/or fluoroscopy imaging modalities, such as during transcatheter left ventricle remodeling procedures for treating left ventricle dilation and any associated functional mitral regurgitation, e.g., as described herein. During transcatheter left ventricle remodeling, for example, the flexible needle 432 may be delivered through the catheter 444 or catheter 384 to the right ventricle 120 of the heart 108 and then oriented toward the septum 132 with a desired orientation. Upon penetrating the septum 132 and entering the left ventricle 116, the flexible needle 432 may resume the straightened configuration illustrated in
As illustrated in
A spring or other biasing mechanism (not shown) may be included as part of the introducer system/assembly 500. The spring or other biasing mechanism maintains/biases the introducer 508 such that a distal portion of the introducer extends distally beyond the beveled edge 512, e.g., as shown in
The introducer system/assembly 500 may also include a guidewire 516. The introducer 508 may comprise an inner lumen which accommodates a guidewire 516. As shown in
The elongate shaft 524 may comprise one or more threads 544 disposed along the length of the threaded introducer 520. The threads 544 facilitate rotatably engaging the threaded introducer 520 within a tissue, such as by way of non-limiting example, the myocardium of the heart 108. During operation of the threaded introducer 520, rotating the catheter shaft, whether flexible or rigid, causes the threaded introducer 520 to turn whereby the threads 544 become engaged with the myocardium. As the threaded introducer 520 continues turning, the threads 544 draw the threaded introducer deeper into the myocardium, effectively “screwing” the threaded introducer 520 into the myocardium. It will be appreciated, that the threads 544 advantageously eliminate a need for a pushing force that is typically required to puncture the myocardium by way of a needle or trocar. Further, the threaded introducer 520 is particularly advantageous for delivering a catheter into a moving tissue, such as byway of non-limiting example, a beating heart 108. As will be recognized, depth control and location identification often are nearly impossible to observe and control when pushing a needle, catheter, trocar, or other puncturing instrument into a beating heart. The threads 544, however, prevent the tissue from moving relative to the threaded introducer 520 until the surgeon further rotates the catheter shaft. Thus, the threaded introducer 520 provides very accurate depth control during delivery into the beating heart, as well as providing an essentially self-advancing catheter. This also help prevent damage to external or surrounding tissues that might otherwise be damaged as the tissue moves and the physician attempts to puncture the moving tissue.
As stated above, the threaded introducer 520 is particularly well-suited for use during treatment of FMR, wherein it is desirable to cross the septum 132 and the myocardium with a medium size catheter, such as a 10 French-sized catheter. For example, after passing through the septum 132, the threaded introducer 520 may be advanced across the left ventricle 116 to the posterior wall. A needle may be advanced through the central lumen 536 so as to create a surface puncture in the posterior wall to receive the distal end 532. Once the distal end 532 enters the puncture, carefully rotating the catheter shaft screws the threaded introducer 520 into the posterior wall without crossing all the way through the myocardium. Contrast injection may be performed byway of the central lumen 536 and the lateral port so as to help image the area and judge the depth and location of the threaded introducer 520 and/or to view the surrounding tissue and/or other instruments used. In one embodiment, an ultrasound/echo probe may also or alternatively be used. Upon further rotating the catheter shaft, the surgeon may slowly advance the threaded introducer 520 and the catheter through the myocardium into the pericardial cavity without piercing the pericardium. It should be recognized that the smooth surfaces of the threaded introducer 520 and the threads 544 may provide a controlled crossing of the myocardium without damaging the pericardium, the coronary arteries, or other surrounding tissue.
As will be appreciated, some treatments may require passing the catheter beyond the pericardial cavity, and thus call for puncturing the pericardium. Once in the pericardial cavity, the threaded introducer 520 may be advanced to a desired puncture site on the pericardium. A needle may be delivered through the central lumen 536 so as to carefully create a puncture in the pericardium to receive the distal end 536. The catheter shaft may be rotated to engage the threads 544 with the pericardium and then advance the threaded introducer 520 and the catheter shaft through the pericardium. The smooth surfaces of the distal end 532 and the proximal head 528 ensure that the threaded introducer 520 advances beyond the pericardium without damaging the lungs or other nearby organs and tissues of the patient.
The cutter catheter 600 may be assembled inside of a long, flexible catheter shaft. In one embodiment, the outer tube 602 is a long, flexible catheter shaft or a portion of a long, flexible catheter shaft. In one embodiment the outer tube 602 is arranged inside a portion of a separate long, flexible catheter shaft, e.g., in a distal end of the long, flexible catheter shaft. The outer tube 602 may be fixedly attached inside a long, flexible catheter shaft, or may be delivered in a long, flexible delivery catheter to the cutting location. Advantages of the cutter catheter 600 include, without limitation, (1) “unlimited” length, i.e., any length may be used (e.g., the cutter catheter 600 can effectively cut a suture at the end of a very long catheter or tube a long distance into a body), (2) “unlimited” flexibility, i.e., the catheter may have any range of flexibility (e.g., the cutter catheter 600 or a portion thereof can itself be very flexible or the cutter catheter 600 can be delivered/advanced inside a separate, but very flexible catheter, such that the cutter catheter 600 may be navigated through a tortuous path in the body and used a long distance into the body of a patient, and (3) application of a high, controlled force (e.g., the mechanism allows for a high, controlled cutting force even at a remote location a long distance in the body or a long distance from the proximal end of the catheter).
The suture cutter catheter 600 may include a balloon 608 that may be inflatable by a fluid, e.g., by air, water, saline solution, etc. The balloon may be located between a first side of the inner wall of the outer tube 602 and a moving plate 614. Inflation tube 604 may include a lumen in fluid communication with the balloon 608. The inflation tube 604 may be configured for connection to an elongate tube or catheter connected to a fluid source and/or for connection directly to a fluid source. Fluid may flow from the fluid source to the inflation tube 604 and into the balloon 608 to inflate the balloon 608. In one embodiment, the fluid source is high pressure syringe, e.g., as used to inflate coronary balloons. When inflated, the balloon 608 may expand and thereby cause the moving plate 614 to move toward the cut blade 610, which may be located on a second side of the inner wall of the tube, e.g., opposite the balloon 608. The moving plate 614 may be a rigid or semi-rigid plate capable of firmly pressing a suture 620 or other material against the cut blade 610 to cut the suture 620 or other material. The blade 610 may be a sharp blade having a sharp edge 612 configured for easily and cleanly cutting a suture 620 or other material. The moving plate 614 may move toward the blade 610 until the moving plate 614 directly contacts the sharp edge 612 of the cut blade 610, thereby cutting/severing any suture or other material between the moving plate 614 and the blade 610. The moving or pressing force that moves the moving plate 614 toward the blade 610 may be generated by inflating the balloon 608, e.g., by hydraulic action.
The suture cutter catheter 600 may also include a biasing component, mechanism, or spring 616 that biases the moving plate 614 away from the blade 610. The biasing component, mechanism, or spring 616 may connect between the moving plate 614 and the first side of the inner wall of the outer tube 602 opposite the blade 610, e.g., the spring 616 may connect directly to the moving plate 614 and to the first side of the inner wall of the outer tube 602. When the balloon 608 is inflated the moving plate 614 moves away from the first side of the inner wall toward the cut blade 610 thereby expanding/tensioning the biasing component, mechanism, or spring 616. The biasing component, mechanism, or spring 616 biases the moving plate 614 to move toward the first side of the inner wall away from the cut blade 610, so that after the pressing force is no longer supplied by the balloon 608 (e.g., when the balloon deflates or imparts less pressure), the moving plate 614 automatically moves away from the blade 610 or toward the first side of the inner wall of the outer tube 602.
The suture cutter catheter 600 may also include a positioning tube 606. Positioning tube 606 may be a polymer or plastic tube. Optionally, the positioning tube 606 may be constructed of a material that may be readily cut by the blade 610, and/or the positioning tube 606 may include a break or separation in the tube 606 in the region where the cut blade 610 contacts the moving plate 614 to ensure the positioning tube 606 does not interfere with cutting the suture 620 or other material. The positioning tube 606 may include a lumen 618 in which a suture 620 or other material to be cut may be received. The positioning tube 606 may be adhered, bonded, glued, or otherwise affixed to the moving plate 614 to ensure that a suture 620 or other material in the lumen 618 of the positioning tube may be properly positioned/located for cutting, e.g., to ensure a suture 620 or other material is in the proper location between the blade 610 and the moving plate 614 during cutting. The suture 620 or other material may be threaded through the positioning tube 606 before cutting to properly position the suture 620 or other material. For example, a free end of a suture may be threaded through a distal end of the positioning tube 606 and through the lumen 618. The positioning tube 606 may then be advanced along the suture to a point where the cut is desired. When properly positioned as desired, the balloon 608 may be inflated thereby pressing the moving plate 614 to the cut blade 610 until the suture 620 or other material is cut/severed by the cut blade 610. The suture cutter catheter 600 can make it easier to effectively cut thick, strong, or otherwise difficult to cut sutures, lines, members, etc. For example, the suture cutter catheter 600 is effective at cutting sutures, lines, members, etc. made from very strong fibers, like Dyneema fibers or strong Ultra High Molecular Weight Polyethylene (UHMWPE) fibers. The suture cutter catheter 600 could also be used to cut any excess unused portion of a tension member.
The device/catheter 700 may include a proximal handle 702, a positioning tube 704, and/or other features. Proximal handle 702 may facilitate gripping and moving the device/catheter 700. Proximal handle 702 may facilitate navigating the device/catheter 700 through an incision site and to a desired location. This may include navigating the device/catheter 700 around a portion of the heart or another organ, to a desired location/position. For example, proximal handle 702 may be used to direct/navigate the distal end of the device/catheter 700 around the region of a heart including the left ventricle 116 so as to position a distal end/region of the device/catheter 700 at a desired location along a wall of the heart (e.g., at a desired puncture location for puncture through the heart wall or a wall of the left ventricle). The device/catheter 700 may be used to help locate/identify a location outside a posterior side of the human heart 108 (e.g., a location along the posterior wall of the left ventricle at which puncturing would avoid or limit damage to blood vessels, papillary muscles, etc.). Pressing a portion of the device/catheter 700 (e.g., a guide portion 724 and/or a finger 706) into and/or moving the portion along a wall (e.g., posterior wall) of the human heart 108 (or another organ or portion of the body) may cause a bend or bulge in the wall of the heart (or other organ or portion of the body) that is detectable/viewable by way of an epicardial echo probe or ultrasound probe or another imaging device. The device/catheter 700 may thereby enable a surgeon to identify a location on an organ, heart, or portion of the body that is suitable for being punctured during medical treatment (e.g., during FMR treatment) without causing undue damage (e.g., avoiding undesired damage to vessels, papillary muscles, and/or tissue structures within the left ventricle 116 of a heart).
In the embodiment illustrated in
The curved portion 712 may comprise a radius of curvature suitable for extending around the left side of the human heart 108 or for extending around another organ or portion of a body. An elbow portion 720 and a guide portion 724 may be included at a distal end/region of the positioning tube 704. The elbow 720 may be disposed at a distal end of the curved portion 712. The guide portion 724 may be disposed at a distal end of the elbow 720 or an end opposite the curved portion 712. The elbow 720 and/or the guide 724 may be adhered, bonded, glued, or otherwise affixed to the distal end of the curved portion 712. Though, in one embodiment, an elbow portion the same as or similar to elbow 720 and/or a guide portion the same as or similar to guide portion 724 could be made/formed integral with other portions as part of a single-piece positioning tube or device/catheter. In one embodiment, the elbow 720 imparts a 90-degree bend to the distal end of the curved portion 712, such that the guide 724 is oriented toward, and aligned with, a longitudinal axis 728 of the elongate portion 708, as shown for example in
Guide portion 724 may be formed in a variety of sizes and shapes. In one embodiment, the guide portion 714 may be columnar or generally columnar in shape. A front region of guide 724 (e.g., opposite the elbow 720 and/or facing toward the elongate portion 708) may be pressed or pulled against a portion of an organ or part of the body (e.g., a heart) and may cause a bending or bulging in the wall that may be visible with an echo probe or ultrasound probe or other imaging equipment. Doing this may help a user to identify and mark a desired puncture or treatment location on the organ or part of the body (e.g., on a wall of a heart). Guide portion 724 may include a concave or inwardly tapered front region (e.g., on the end opposite elbow portion 720). This front region may be curved into a concave or generally concave region or may be tapered inwardly to form a conical or generally conical region within the front end of the guide 724. This concave or inwardly tapered front region may help receive a puncturing device through the organ or part of the body, e.g., the concave or inwardly tapered front region may help guide and receive a needle or other puncture device passing through a wall of the heart. If the device/catheter 700 has only a single lumen (though some embodiments may have more) and no finger 706, applicator 732, or device connecting these are used (i.e., if these do not block the lumen of the device), then the lumen may be used to help deploy and/or use an anchor or other medical device to the puncture/treatment location. For example, a tension member of an anchor may be passed through the lumen and may be snared by the puncturing device or another device that passes through the puncture, then the puncturing device or snare may be withdrawn through the puncture bringing the tension member with it and leaving the anchor deployed outside the puncture.
The device/catheter 700 may also include a finger 706, which may be coupled with guide portion 724 and/or may reside partially or fully within guide portion 724. Finger 706 may be configured in a variety of shapes and sizes, e.g., columnar, conical, rounded, flat, curved, and many more. Finger 706 may be thick or thin and may be solid or hollow. In one embodiment, the finger 706 may be oriented toward, and aligned with, a longitudinal axis 728 of the elongate portion 708, as shown in
A front region of finger 706 (e.g., facing away from the elbow 720 and/or facing toward the elongate portion 708) may be pressed or moved against a portion of an organ or part of the body (e.g., a heart) to identify and mark the desired puncture or treatment location on the organ or part of the body (e.g., on a wall of a heart). The finger 706 may be slidably coupled with the guide 724. The finger 706 may be configured and designed to be movable and/or may be configured and designed to be transitionable between two or more configurations. Transitioning between the configurations or moving the finger may help the user to identify the location of the finger 706 when viewing the organ or portion of the body (e.g., heart) with an echo probe or ultrasound probe or other imaging equipment, e.g., movement or transitioning of the finger may cause portions of an organ or heart to bend, bulge, or move in a way that can be seen with imaging equipment. If used to identify a desired puncture location on a heart, pressing the finger 706 into and/or moving the finger 706 along the side or wall of the heart may cause a slight bend or bulge in the wall of the heart that may be detectable/viewable by way of an epicardial echo probe or ultrasound probe or other imaging equipment. The finger 706 may thereby aid a surgeon in identifying a location on the wall that is suitable for being punctured (e.g., during FMR treatment) without causing damage to vessels, papillary muscles, and/or tissue structures within the left ventricle 116.
Finger 706 may be configured to retract entirely within the guide 724 or to have a portion of the finger 706 that remains outside the guide 724. In one embodiment, finger 706 may be a wire, a wire-like device, or may be another long, narrow device that can extend from the guide 724 or retract within the guide 724. In one embodiment, finger 706 may be columnar or generally columnar and may act similar to a column or button that pushes out from the guide 724 to contact and press against an organ or part of the body. In one embodiment the finger 706 may have a diameter similar to or slightly less than the guide 724. The finger 706 may slide within the guide 724 to extend out from or retract within the guide 724 and thereby transition between an extended configuration and a retracted configuration. In one embodiment, the finger 706 may include a portion with a larger diameter or width that remains outside the guide 724 (e.g., between the guide 724 and elongate portion 708) and a portion with a smaller diameter or width that slides within and partially outside the guide 724 to transition the finger 706 between an extended configuration and retracted configuration. A larger diameter region of a finger 706 may be conical or generally conical in shape (e.g., may have a region with a continuous transition from a larger diameter to a smaller diameter).
Finger 706 and/or guide 724 may include a concave or inwardly tapered front region (e.g., on the end facing away from elbow portion 720 and toward elongate portion 708). This front region may be curved into a concave or generally concave region or may be tapered inwardly to form a conical or generally conical region within the front end of the finger 706 or guide 724. This concave or inwardly tapered front region may help receive a puncturing device through the organ or part of the body, e.g., the concave or inwardly tapered front region may help guide and receive a needle or other puncture device passing through a wall of the heart.
The finger 706 may be moved and/or transitioned between configurations (e.g., extended and retracted) by way of a long, flexible catheter shaft, wire, tube, pusher, etc. that extends from the finger 706 to an applicator 732, which applicator 732 may be disposed near the proximal end of the catheter/device 700 or near handle 702. The catheter shaft, wire, tube, pusher, etc. may be routed from the finger 706, within a lumen of the curved portion 712, and to the applicator 732. An actuator tube 736 may act as the flexible catheter shaft, wire, tube, pusher, etc. that extends through the curved portion 712 to the finger 706 to cause the finger 706 to move or transition between configurations, or the actuator tube 736 may be provide a connecting lumen through which the flexible catheter shaft, wire, tube, pusher, etc. passes from the applicator 732 to the curved portion 712. The actuator tube 736 may be slidable within or otherwise connected, adhered, bonded, glued, or affixed to the curved portion 712 to ensure that the finger 706 moves as directed by movement of the applicator 732 (e.g., a user should be able to move the applicator 732 to cause the finger to move or transition between configurations).
The device/catheter 700 may further include a spring, or other biasing component, that biases the finger 706 to a retracted configuration (e.g., biases the finger 706 toward or within the guide 724 and/or elbow 720). In one embodiment, the spring may be coupled between the applicator 732 and the actuator tube 736 and/or within the applicator 732, such that when a pressing force is applied to the applicator 732, the spring is compressed and the flexible catheter shaft, wire, tube, pusher, etc. moves distally and pushes the finger 706 to an extended configuration (e.g., such that the finger 706 can push against a wall of a heart, organ, or other part of the body). In one embodiment, the spring may bias the applicator 732 or a portion of the applicator 732 proximally away from the actuator tube 736, such that after the pressing force is no longer applied to the applicator 732 the spring automatically moves the flexible catheter shaft proximally and pulls the finger 706 toward and/or within the guide 724. It should be understood that the spring, or other biasing component, is not to be limited to being disposed between the applicator 732 and the actuator tube 736, but rather the spring, or other biasing component may be disposed in any location of the puncture location catheter 700 that is suitable for biasing the finger 706 toward the guide 724, as described herein. For example, in one embodiment, the spring or biasing component may be disposed within the guide 724.
In one embodiment, e.g., as shown in
In one embodiment, upon withdrawing the puncturing device/needle from the catheter, a snare may be inserted into the catheter and directed through the puncture in the organ (e.g., the puncture in a wall of the heart 108) to capture an end of the tension member 128 extended or pushed out of a lumen (e.g., a second lumen of device/catheter 700). The snare may then be used to draw the tension member 128 through the wall of the organ/heart and to pull the superior anchor 136 from the second lumen into contact with the exterior of the posterior wall of the heart 108. The tension member 128 extend across the left ventricle 116, through the wall of the septum 132 to an inferior anchor deployed at the septum, or through the wall of the septum 132 and across the right ventricle 120 to an inferior anchor outside the right ventricle. The inferior anchor may be mounted onto and/or connected to the end of the tension member 128 and may be positioned adjacent to the right ventricle 120 (e.g., external to the heart outside the right ventricle as shown in
Various methods of medical treatment, methods of treating dilation (e.g., left ventricle dilation) and/or mitral valve regurgitation, methods of implanting and/or securing a mitral valve splint, and other methods are possible and contemplated using one or more of the systems, apparatuses, devices, steps, etc. described above. Also, various parts of the body (including, but not limited to, the heart) may be treated using one or more of the systems, apparatuses, devices, steps, etc. described above. For example, the various puncturing instruments/devices described may be used in many different applications to puncture a wide variety of tissue/body parts in various types of medical treatments. Steps described above and below with respect to the various methods, systems, apparatuses, assemblies, devices, etc. herein may be used in various combinations.
Methods of medical treatment, methods of treating a heart condition, methods of implanting and securing a mitral valve splint, and/or other methods may include any of the steps disclosed herein. For example, methods of treating a heart condition (e.g., left ventricle dilation, mitral valve regurgitation, etc.) may include accessing the heart or one or more portions of the heart (e.g., accessing a right ventricle of the heart). Accessing the heart may be done by first making one or more than one incisions to the body (e.g., the skin) to form one or more than one access points. The access point(s) may be near the chest and/or heart of a patient or may be remote from a patient's chest or heart (e.g., in an arm or leg or neck). Methods may include inserting an instrument into the access point, moving the instrument to the heart, and entering a portion of the heart (e.g., entering the right ventricle). Entering the heart may be by way of an incision, puncture, hole, etc. in a portion of the heart, e.g., by an incision, puncture, hole, etc. in a wall of the right ventricle. Optionally, entering the heart may be done by first entering a blood vessel, then advancing/inserting a medical instrument (e.g., a catheter or other instrument/device/apparatus/assembly described herein) through the blood vessel and into a portion of the heart (e.g., the right ventricle).
Methods may include inserting/advancing a needle catheter (e.g., the same as or similar to needle catheter 504) into the right ventricle of the heart, then through the septum between the right ventricle and the left ventricle. A blunt tip introducer (e.g., the same as or similar to introducer 508) may be inside the needle catheter and a blunt distal end of the introducer needle may be positioned near the posterior/left wall of the heart (i.e., the wall between the left ventricle and the pericardium). Methods may include passing a guide wire through a guidewire lumen in the introducer (e.g., introducer 508). Imaging techniques can be used at various stages of treatment, including to guide the needle catheter to the correct puncture points and/or may be used to position a threaded introducer (e.g., the same as or similar to threaded introducer 520) in the proper location in the posterior/left wall of the heart. The imaging techniques can include introducing one or more contrast solutions through the introducer and using an imaging system to view the contrast solution in the heart. The imaging techniques can also include using an inserted echo or ultrasound probe to view portions of the treatment area (e.g., walls of the heart, puncture devices, an introducer, a finger/guide of a puncture location device, etc.). In one embodiment, a threaded introducer (e.g., the same as or similar to threaded introducer 520) may be advanced to the posterior/left wall of the left ventricle and may be rotated into the left wall of the heart such that the rotation of the threads pulls the threaded introducer into the wall in a controlled manner and anchors the threaded introducer in the left wall. In one embodiment, another conduit, introducer, catheter, needle, puncturing device, etc. could be used to create an incision/puncture through the wall of the organ or heart. A guidewire may be advanced through the introducer, threaded introducer, conduit, needle, and/or an incision/puncture in the wall of the heart (e.g., a posterior and/or left wall).
Methods may comprise advancing a distal end of the delivery catheter over the guidewire and through an introducer (e.g., the threaded introducer), conduit, and/or incision/puncture into the pericardium cavity or outside of the pericardium. The delivery catheter may be loaded with an anchor (e.g., the same as or similar to any of the anchors described above and/or shown in one or more of
The methods disclosed herein may also comprise using an echo or ultrasound probe (e.g., a trans-vaginal ultrasound probe or an ultrasound probe designed for use in treatment of dilation, mitral valve incompetency, mitral valve regurgitation, and other similar conditions) to assist during treatment of conditions of the human heart. The echo/ultrasound probe may have a guide attached thereto, the guide may be configured for or be capable of guiding the delivery catheter to a desired location in the body or heart. The echo/ultrasound probe and guide may be part of an anchoring system or system for setting an anchor described herein. The methods and/or steps described elsewhere herein may be performed in conjunction with using the echo/ultrasound probe, e.g., to identify treatment sites/locations, to navigate the medical instruments/devices to a desired treatment site/location, and/or view the medical instruments/devices as they are used in a remote location in the body.
The methods may comprise loading a medical instrument (e.g., a trocar, trocar catheter, needle, needle catheter, catheter, one of the instruments/devices described herein, etc.) into a guide of the ultrasound probe. The guide may be fastened to an ultrasound probe comprising an elongate shaft extending from a proximal handle to a distal end. The ultrasound probe may be inserted into a patient by way of an incision. The distal end of the ultrasound probe may then be navigated to a location adjacent to an exterior surface of the heart and/or pericardium. A treatment site may be identified on an exterior surface of the heart and/or pericardium using an image(s) (e.g., a live/real-time image) obtained using an ultrasound transducer disposed within the distal end of the ultrasound probe. The medical instrument may be advanced within the guide to the treatment site, and the condition of the heart may be treated. The medical instrument may also be withdrawn from the treatment site. In one embodiment, the method involves using a trans-vaginal ultrasound probe for imaging in the heart. The trans-vaginal ultrasound probe can be used for navigation during the methods and/or steps described herein and to position the introducer correctly in the heart wall. The trans-vaginal ultrasound probe may be smaller than a typical epicardial echo probe. A guide may be included on the trans-vaginal ultrasound probe to connect a puncture needle or the needle catheter thereto to allow parallel insertion of the needle catheter with the ultrasound probe.
In one embodiment, a method for medical treatment (e.g., for treating dilation and mitral valve regurgitation) may comprise: inserting a catheter, a puncturing instrument (e.g., a trocar, trocar catheter, needle, needle catheter, curved needle, introducer, introducer assembly, a sharpened portion of an assembly, etc.) having a sharpened distal tip, guidewire, assembly, and/or other instrument into a right ventricle of a heart (e.g., a beating heart) of a patient. A guidewire may be inserted into the right ventricle before other instruments, and then other instruments may be passed over the guidewire into the right ventricle. Inserting the catheter, puncturing instrument, guidewire assembly, and/or other instrument into the right ventricle of the heart may be accomplished by passing the catheter, puncturing instrument, guidewire, assembly, and/or other instrument through an incision/puncture (e.g., made using a scalpel, introducer, introducer sheath, needle, other puncturing instrument) in a wall of the right ventricle (e.g., a right and/or anterior wall). Access to the wall of the heart may be accomplished via an incision/puncture in the chest near the heart (e.g., a small hole in the 4th inner costal, optionally, 5-7 mm in diameter).
Optionally, inserting the catheter, puncturing instrument, guidewire, assembly, and/or other instrument into the right ventricle of the heart may be accomplished by first passing the catheter, puncturing instrument, guidewire, assembly, and/or other instrument through an incision/puncture in a blood vessel at a point removed/apart from the heart and navigating the catheter, puncturing instrument, guidewire, assembly, and/or other instrument through the blood vessel and into the right ventricle. For example, this could be accomplished by passing the catheter, puncturing instrument, guidewire, assembly, and/or other instrument into a subclavian, innominate vein, superior vena cave (SVC), or inferior vena cava (IVC), e.g., in the region of the neck, clavicle, or upper chest, and navigating the along the vessel through the right atrium, through the tricuspid valve, and into the right ventricle. Incision/puncture locations at various points in the heart may be identified in advance or during operation with imaging equipment.
An inserted catheter may be a directional catheter that is inserted into the right ventricle as discussed above. The directional catheter may be able to transition between a straight or generally straightened configuration to navigate to the right ventricle, then may be transitioned to an angled, bent, or curved configuration to help guide and direct an instrument (e.g., a puncturing instrument) passing through the directional catheter at the septum. This allows the puncturing instrument to curve, bend, or angle toward the septum and puncture the septum as desired, even when inserted from a region remote from the heart.
An inserted assembly may be a septum-puncture assembly that is inserted into the right ventricle as discussed above. The septum-puncture assembly may include a catheter or portion similar to a directional catheter to direct/guide a puncturing instrument at the septum, or may include a permanently angled or curved portion to direct/guide the puncturing instrument at the septum. The septum-puncture assembly may also be or include a stabilization assembly to stabilize the assembly and/or a puncturing instrument in the right ventricle for puncturing the septum. The septum-puncture assembly or stabilization assembly may be the same as or similar to septum-puncture/stabilization assemblies described elsewhere herein (e.g., the assemblies shown in 12A-14C). This assembly may allow a puncturing instrument to curve, bend, or angle toward the septum and puncture the septum as desired, even when inserted from a region remote from the heart. The method may include puncturing a septum of the heart (e.g., the septum between the right ventricle and a left ventricle of the heart) with a puncturing instrument.
The method may include identifying a desired puncture location on a wall of the heart (e.g., on a wall of the left ventricle). A device/catheter (e.g., C-shaped device/catheter or a puncture-location device/catheter, which may be the same as or similar to other such devices/catheter described elsewhere herein and/or shown in
The method may also include creating an incision or hole (e.g., puncturing and/or positioning an introducer) in the left and/or posterior wall of the left ventricle from inside the left ventricle to outside the left ventricle. If the device/catheter above is used to identify the desired puncture location, puncturing the wall may include directing a puncturing instrument and/or introducer at the desired puncture location and/or at a bulge/bend in the wall caused by the device/catheter above. The device/catheter may include a concave or inwardly tapered surface that can help guide and receive the puncturing instrument.
The method may also include deploying an anchor near a puncture location on the wall of the heart (e.g., at the puncture location on the left ventricle wall). If the treatment is remotely done (e.g., access to the heart is from a remote location and through a blood vessel, and incisions are not made to directly access the heart in the region of the incision), then deploying the anchor may involve advancing a delivery catheter through an access vessel, the right ventricle, the septum, and the hole/puncture in the wall of the left ventricle. The delivery catheter may have an anchor (e.g., any of the anchors described herein or shown in the figures) in a low profile configuration in a lumen of the catheter. The method may include deploying a first anchor from the lumen of the delivery catheter and outside the hole such that the first anchor transitions from the low profile configuration to an expanded configuration in a first location outside the heart. The method may also include pulling a tension member attached to the first anchor such that a portion of a cover of the first anchor is pulled toward the center of the expanded configuration (e.g., a circular configuration) to cause the cover to assume a flattened, disc-shape, cone-shape, or other shape/configuration. In one embodiment, the anchor may include a manually expandable ring that can be transitioned from a straightened, low profile configuration to an expanded, ring-like configuration by pulling an actuating wire, member, or cord that pulls the anchor into the expanded configuration. In one embodiment, the anchor may be expandable like a balloon by filling a balloon or cover (or portion thereof) with a filling material like beads, spheres, liquid, epoxy, etc.
If the treatment is not done remotely (e.g., it involves open heart surgery or minimally invasive surgery with local incisions on the chest to access the heart directly, i.e., without first passing through a blood vessel), then the first anchor can still be deployed from a delivery catheter that passes through the right ventricle (possibly accessed from outside the wall of the right ventricle or via an access vessel), the septum, and the hole/puncture in the wall of the left ventricle and then releases the anchor to transition from a low profile configuration to an expanded or deployed configuration similar to the description above with respect to remote access. The delivery catheter may be removed after deploying the anchor, thereby leaving the anchor and tension member or cord in place (e.g., the cord/tension member may remain in the pathway and have an end that extends outside the access site).
Optionally, the first anchor could also be deployed directly to the wall of the left ventricle from an incision in the chest. For example, the C-shaped device/catheter could include a lumen through which the tension member and anchor pass for deployment. Optionally, a second C-shaped device/catheter or other device/catheter could include a lumen through which the tension member and anchor pass for deployment. A snare may be passed from inside the heart to outside the heart via the hole/puncture in the wall of the left ventricle, and the snare could grab or ensnare the tension member. The snare could be withdrawn back into the left ventricle and through the septum (and optionally out of a hole in the wall of the right ventricle) while holding the tension member and bringing the tension member with it. The first anchor could be deployed against the wall of the left ventricle near the hole/puncture, and the tension member could be attached to a second anchor deployed at the septum or outside the right ventricle.
Methods may comprise deploying a second anchor in a second location, the second location being external to the heart outside the right ventricle or inside the right ventricle against a wall of the septum. The tension member may be attached to the first anchor and the second anchor and may be cinched/tensioned/pulled such that the first anchor and the second anchor are pulled toward each other and thereby alter the shape of the heart such that leaflets of the mitral valve overlap and better prevent mitral valve regurgitation. The tension member may then be secured relative to the first anchor and the second anchor such that the first anchor and the second anchor maintain the leaflets of the mitral valve such that they overlap. A clamp, auto-knotting device, crimping device, cord locker, or similar device may be used to lock the tension member relative to an anchor (e.g., the second anchor). Any excess cord or tension member may be cut and removed, e.g., using a suture cutter catheter or other cutting device.
In the methods described herein, the puncturing instrument may be a flexible needle having slits along a length of the flexible needle, and the step of puncturing the septum may include using the flexible needle to penetrate and pass through the septum. The puncturing instrument may be a needle, and the step of puncturing the septum may include deploying a spade-shaped assembly in the right ventricle of the heart to stabilize the needle as the needle penetrates the septum. Optionally, the puncturing instrument may be an introducer assembly including a needle catheter having an introducer disposed in a lumen of the needle catheter, the introducer including an atraumatic distal end, and the step of puncturing the septum may include pushing the introducer assembly against the septum such that the atraumatic distal end of the introducer retracts into the needle catheter and a beveled edge of the needle catheter contacts and punctures the septum, and wherein after the needle catheter passes through the septum, the atraumatic distal end may extend from the needle catheter such that the introducer prevents the beveled edge from causing damage to surrounding tissue. The introducer may be locked in the extended position to prevent damage from the beveled edge. The method may also comprise passing a guidewire through a guidewire lumen in the introducer and into the left ventricle.
The puncturing instrument may be a trocar catheter including a cannula being generally elongate and having an interior lumen; a trocar disposed within the interior lumen and extending to a trocar distal tip comprising one or more surfaces (e.g., grinding plane surfaces) configured to allow the distal tip to puncture heart tissue; and the trocar catheter further comprising a proximal handle comprising controls configured to facilitate advancing the trocar distal tip beyond a distal end of the cannula during puncturing of heart tissue, the controls further configured to withdraw the trocar distal tip into the distal end of the cannula, and the step of puncturing the septum may include extending the trocar distal tip from the cannula, puncturing the septum, and withdrawing the trocar distal tip into the cannula to prevent further puncturing of heart tissue. The trocar may include a central lumen and one or more lateral ports disposed on the trocar distal tip and in fluid communication with the central lumen of the trocar, the central lumen and the one or more lateral ports being configured for contrast injection; and the step of puncturing the septum may include injecting contrast fluid into the heart via the central lumen and the one or more lateral ports, and imaging the trocar catheter and surrounding heart tissue during puncturing the septum. The step of creating a hole in the left and/or posterior wall of the left ventricle from inside the left ventricle to outside the left ventricle may include using a needle, needle catheter, or trocar to penetrate the left and/or posterior wall.
Methods may also comprise using a threaded introducer comprising an elongate member including a proximal head and a distal end; a central lumen extending from the proximal head to the distal end, the central lumen being configured for contrast injection; at least one lateral port disposed on the distal end in fluid communication with the central lumen; and threading disposed along a length of the threaded introducer; and the step of creating a hole in the posterior wall of the left ventricle from inside the left ventricle to outside the left ventricle may include rotating the threaded introducer against the posterior wall such that the threading rotatably engages with the posterior wall thereby advances the threaded introducer into the posterior wall in a controlled manner.
The first anchor may comprise a ring and a cover, the ring having atraumatic ends which meet at a break, the ring being in a straightened configuration in the lumen of a delivery catheter, and when deploying the first anchor from the lumen of the delivery catheter and outside the hole the ring may transition automatically to a ring-shaped configuration thereby causing the first anchor to transition from the low profile configuration to the expanded configuration.
Methods may further comprise suturing a portion of the heart with a suture and using a suture cutter catheter to cut a portion of the suture, wherein the suture cutter catheter comprises an inflatable balloon, a moving plate, and wherein inflation of the balloon causes the moving plate to press the suture into the blade to cut the suture. The suture cutter catheter may be used to cut suture and/or the tension member or excess thereof after cinching and locking the anchors together.
Methods of manufacture of the various systems, apparatuses, devices, etc. described herein may include creating the different components of the various systems, apparatuses, devices, etc., e.g., by mold, injection mold, 3D printing, extrusion, machining, grinding, milling, laser, and/or other methods. Methods of manufacture of the various systems, apparatuses, devices, etc. may also include assembling and/or attaching the components of the various systems, apparatuses, devices, etc. described herein in the arrangements/configurations described herein and/or shown in the figures. Attachments between components may be done by adhering, tying, bonding, fastening, friction fit, and/or otherwise securing the components together.
While the invention has been described in terms of particular variations and illustrative figures, those of ordinary skill in the art will recognize that the invention is not limited to the variations or figures described. In addition, where methods and steps described above indicate certain events occurring in certain order, those of ordinary skill in the art will recognize that the ordering of certain steps may be modified and that such modifications are in accordance with the variations of the invention. Additionally, certain of the steps may be performed concurrently in a parallel process when possible, as well as performed sequentially as described above. To the extent there are variations of the invention, which are within the spirit of the disclosure or equivalent to the inventions found in the claims, it is the intent that this patent will cover those variations as well. Therefore, the present disclosure is to be understood as not limited by the specific embodiments described herein, but only by scope of the appended claims.
This application is a continuation of U.S. application Ser. No. 16/669,447, filed Oct. 30, 2019, now U.S. Pat. No. 11,331,189, which is a continuation of U.S. application Ser. No. 15/353,657, filed Nov. 16, 2016, now U.S. Pat. No. 10,463,492, which claims the benefit of U.S. Application No. 62/256,527, filed Nov. 17, 2015, and the benefit of U.S. Application No. 62/256,524, filed Nov. 17, 2015, the entire disclosures all of which are incorporated by reference for all purposes.
| Number | Name | Date | Kind |
|---|---|---|---|
| 1527291 | Zorraquin | Feb 1925 | A |
| 2623521 | Shaw | Dec 1952 | A |
| 4742829 | Law et al. | May 1988 | A |
| 5098388 | Kulkashi et al. | Mar 1992 | A |
| 5139485 | Smith et al. | Aug 1992 | A |
| 5226890 | Ianniruberto et al. | Jul 1993 | A |
| 5258003 | Ciaglia et al. | Nov 1993 | A |
| 5292310 | Yoon | Mar 1994 | A |
| 5478329 | Ternamian | Dec 1995 | A |
| 5591191 | Kieturakis | Jan 1997 | A |
| 5601537 | Frassica | Feb 1997 | A |
| 5669883 | Scarfone et al. | Sep 1997 | A |
| 5671747 | Connor | Sep 1997 | A |
| 5676682 | Yoon | Oct 1997 | A |
| 5755697 | Jones et al. | May 1998 | A |
| 5810776 | Bacich et al. | Sep 1998 | A |
| 5961440 | Schweich, Jr. et al. | Oct 1999 | A |
| 6007481 | Riek et al. | Dec 1999 | A |
| 6045497 | Schweich, Jr. et al. | Apr 2000 | A |
| 6050936 | Schweich, Jr. et al. | Apr 2000 | A |
| 6156006 | Brosens et al. | Dec 2000 | A |
| 6210336 | Fredriksen | Apr 2001 | B1 |
| 6293952 | Brosens et al. | Sep 2001 | B1 |
| 6616684 | Vidlund et al. | Sep 2003 | B1 |
| 6969354 | Marian | Nov 2005 | B1 |
| 7056294 | Khairkhahan et al. | Jun 2006 | B2 |
| 7241267 | Furia | Jul 2007 | B2 |
| 7766812 | Schroeder et al. | Aug 2010 | B2 |
| 8163013 | Machold et al. | Apr 2012 | B2 |
| 8425402 | Annest et al. | Apr 2013 | B2 |
| 8444566 | Agmon | May 2013 | B2 |
| 8500628 | Frassica et al. | Aug 2013 | B2 |
| 8777841 | Frassica et al. | Jul 2014 | B2 |
| 9011531 | Rourke et al. | Apr 2015 | B2 |
| 20040049211 | Tremulis et al. | Mar 2004 | A1 |
| 20050075723 | Schroeder et al. | Apr 2005 | A1 |
| 20050222488 | Chang et al. | Oct 2005 | A1 |
| 20060052821 | Abbott et al. | Mar 2006 | A1 |
| 20060122633 | To et al. | Jun 2006 | A1 |
| 20060259074 | Kelleher et al. | Nov 2006 | A1 |
| 20070066863 | Rafiee et al. | Mar 2007 | A1 |
| 20070083168 | Whiting et al. | Apr 2007 | A1 |
| 20070203391 | Bloom et al. | Aug 2007 | A1 |
| 20070265658 | Nelson et al. | Nov 2007 | A1 |
| 20080009888 | Ewers et al. | Jan 2008 | A1 |
| 20080249467 | Burnett et al. | Oct 2008 | A1 |
| 20080294251 | Annest et al. | Nov 2008 | A1 |
| 20090088678 | Noda et al. | Apr 2009 | A1 |
| 20090093726 | Takayama et al. | Apr 2009 | A1 |
| 20090118612 | Grunwald et al. | May 2009 | A1 |
| 20100010538 | Juravic et al. | Jan 2010 | A1 |
| 20100016655 | Annest et al. | Jan 2010 | A1 |
| 20100160788 | Davies et al. | Jun 2010 | A1 |
| 20100274081 | Okoniewski | Oct 2010 | A1 |
| 20110178537 | Whitman | Jul 2011 | A1 |
| 20120136435 | Brunnett et al. | May 2012 | A1 |
| 20130030522 | Rowe et al. | Jan 2013 | A1 |
| 20130165735 | Khairkhahan et al. | Jun 2013 | A1 |
| 20130245450 | Prins et al. | Sep 2013 | A1 |
| 20130296902 | Vonderwalde et al. | Nov 2013 | A1 |
| 20130310752 | Kawaura | Nov 2013 | A1 |
| 20140094647 | Schweich, Jr. et al. | Apr 2014 | A1 |
| 20150018876 | Ewers et al. | Jan 2015 | A1 |
| 20150045879 | Longoria et al. | Feb 2015 | A1 |
| 20150105611 | Schweich, Jr. et al. | Apr 2015 | A1 |
| 20160262741 | Gilmore et al. | Sep 2016 | A1 |
| Number | Date | Country |
|---|---|---|
| 2005102181 | Nov 2005 | WO |
| 2012099418 | Jul 2012 | WO |
| 2014134624 | Sep 2014 | WO |
| Entry |
|---|
| Flato et al., Ultrasound-Guided Venous Cannulation in a Critical Care Unit, Rev. bras. ter. intensiva vol. 21 no. 2 São Paulo Apr./Jun. 2009, pp. 1-11. |
| Herlambang, et al., Realtime Integral Videography Using Intra-Operative 3-D Ultrasound for Minimally Invasive Heart Surgery. |
| Number | Date | Country | |
|---|---|---|---|
| 20220273438 A1 | Sep 2022 | US |
| Number | Date | Country | |
|---|---|---|---|
| 62256524 | Nov 2015 | US | |
| 62256527 | Nov 2015 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 16669447 | Oct 2019 | US |
| Child | 17663626 | US | |
| Parent | 15353657 | Nov 2016 | US |
| Child | 16669447 | US |
