Patent Application
20110144637
The present disclosure relates to catheter-based methods, systems, devices for occlusion, and in particular, utilizing measurements of one or more physiological parameters to guide an ablation treatment of cardiac arrhythmias.
Catheter based devices are employed in various medical and surgical applications because they are relatively non-invasive and allow for precise treatment of localized tissues that are otherwise inaccessible. Catheters may be easily inserted and navigated through the blood vessels and arteries, allowing non-invasive access to areas of the body with relatively little trauma. Recently, catheter-based systems have been developed for implementation in tissue ablation for treatment of cardiac arrhythmias such as atrial fibrillation, supra ventricular tachycardia, atrial tachycardia, ventricular tachycardia, ventricular fibrillation, and the like. One such implementation involves the use of fluids with low operating temperatures, or cryogens, to selectively freeze, or “cold-treat”, targeted tissues within the body.
The cryogenic treatment involves cooling a portion of the catheter to a very low temperature through the use of the cryogenic fluid flowing through the catheter. A cryogenic device uses the energy transfer derived from thermodynamic changes occurring in the flow of a cryogen therethrough to create a net transfer of heat flow from the target tissue to the device, through conductive and convective heat transfer between the cryogen and target tissue.
Structurally, cooling can be achieved through injection of high-pressure coolant into a lumen of the catheter. Upon injection, the refrigerant undergoes two primary thermodynamic changes: (i) expanding to low pressure and temperature through positive Joule-Thomson throttling, and (ii) undergoing a phase change from liquid to vapor, thereby absorbing heat of vaporization. The resultant flow of low temperature refrigerant through the device acts to absorb heat from the target tissue and thereby cool the tissue to the desired temperature.
Once refrigerant is injected into the lumen, it may be expanded inside of an expandable chamber, which is positioned proximal to the target tissue. In embodiments, the expandable chamber may also be thermally conductive. Devices with an expandable chamber, such as a balloon, may be employed. Such a device is disclosed in U.S. Pat. No. 7,300,433, Lane et al., which is incorporated herein by reference in its entirety. In such a device, refrigerant is supplied through a catheter lumen into an expandable balloon coupled to such catheter, wherein the refrigerant acts to both: (i) expand the balloon near the target tissue for the purpose of positioning the balloon, and (ii) cool the target tissue proximal to the balloon to cold-treat adjacent tissue.
The expandable chamber may also serve a second function; blocking the flow of blood through the desired treatment site (occlusion). The catheter is typically of a relatively small diameter and long body, generally determined, by the diameter and length of the vascular pathways leading to the ablation site. The coolant in the catheter is highly susceptible to conductive warming effects due to the relative proximity of the catheter (and coolant) to the body tissue and blood. Furthermore, the rate of cooling is limited by the ability to circulate a sufficient mass flow of coolant through the catheter. Yet there is a requirement that the coolant itself be at a sufficiently low temperature, in some cases below freezing, at the location of the ablation.
Radio frequency (RF) catheter ablation is another common implementation of the catheter-based treatment. Arrays of ablation elements including but not limited to geometrically-adjustable electrode arrays, may be configured in a wide variety of ways and patterns on the catheter as disclosed for example in U.S. Application 2007/083194 by Kunis et al., which is incorporated herein by reference in its entirety. Such elements may be coupled to the expandable chamber or other portions of the catheter. RF catheter ablation includes a preliminary step of conventional electrocardiographic mapping followed by the creation of one or more ablated regions (lesions) in the cardiac tissue using RF energy. RF energy applied by the catheter elevates the temperature of the tissue for therapeutic treatment of an arrhythmia. The effectiveness of the RF energy may be limited by the flow of blood; the rapid blood flow carries away the generated heat and causes cooling of the ablating electrodes and/or tissue.
Therefore, blocking the flow of blood using the expandable chamber allows more effective cooling or heating (depending on the treatment method) which facilitates the treatment process and may reduce the treatment period. Effective contact to achieve occlusion may require moving, positioning, anchoring and other mechanisms for locating and stabilizing the conformation of the expandable chamber of the catheter. Moreover, slight changes in orientation may greatly alter the characteristics of the catheter, so that even when the changes are predictable or measurable, it may become necessary to provide positioning mechanisms of high stability or accuracy to assure adequate treatment at the designated sites. Furthermore, one must assure that the ablation activity is effective at the target tissue.
Known techniques for visualizing the contact between the expandable chamber and the target tissue include the use of radiographically opaque contrast medium to enable radiographic-mapping of the target tissue during application and operation of the catheter. Such an imaging technique may not be desirable due to the use of contrast medium and its interaction with the patient tissue. Additionally, it may be desirable to eliminate or minimize the exposure of both patient and clinician to the radiographic-mapping waves used for imaging.
It is desirable therefore, to provide improved catheter systems that are capable of providing an indication of occlusion while eliminating or significantly reducing exposure of the patient and clinician to imaging waves.
Various embodiments of the present disclosure involve measurement of one or more physiological parameters for catheter-based ablation treatment. The catheters comprise a tubular body member having a proximal end, a distal end and a lumen extending therebetween. An expandable chamber in fluid communication with the lumen is disposed at the distal end of the tubular body member. The expandable chamber may be adjusted by inflating or deflating it so as to engage cardiac tissue, such as the pulmonary vein ostial tissue. The catheter may be advanced over a guide wire for delivery to the treatment site. The catheter may have a steerable tip that allows precise positioning of the distal portion such as when the distal end of the catheter needs to access a pulmonary vein of the left atrium of the patient's heart. One or more physiologic sensors may be coupled to the catheter for measurement of a physiological parameter.
According to an embodiment of the disclosure, the physiologic sensor coupled to the catheter may comprise first and second pressure sensors. The first pressure sensor may be disposed on the tubular body member at a location distal to the expandable chamber. The second pressure sensor may be disposed on the tubular body member at a location that is proximal to the expandable chamber. First and second pressure sensors may be employed for a differential measure of pressure at locations that are distal and proximal to the expandable chamber.
According to another embodiment of the disclosure, the physiologic sensor may comprise a single pressure sensor. The sensor may be employed for measurement of an absolute value of the pressure at a region that is distal to the expandable chamber. In a first example, a pressure sensor may be disposed on the tubular body member distal to the expandable chamber. In a second example, an external sensor may be coupled in fluid communication with a lumen of the catheter for measurement of the pressure at a location that is distal to the expandable chamber, whereby the pressure is mechanically coupled to a fluid in the lumen, transmitted via the fluid and sensed by the external sensor.
In another embodiment, the catheter may include a temperature sensor as the physiologic sensor. The temperature sensor may be coupled proximal, distal, or directly on the expandable chamber. Temperature measurements of the regions proximate to the temperature sensor may be obtained by the sensor.
In another embodiment, the catheter includes one or more flow sensors mounted on the tubular body member. At least a first of the one or more flow sensors may be mounted distal to the inflatable balloon assembly. According to an aspect of the disclosure, the flow sensor comprises a calorimetric flow sensor having two temperature sensors that are coupled distal to the expandable chamber for calorimetric flow measurement.
In another embodiment, the present disclosure provides methods for measuring a physiologic parameter at one or more regions separated by an expandable chamber. The catheter may be of the type used for performing intracardiac procedures, typically being percutaneously introduced and advanced from the femoral vein in a patient's leg. Alternative methods involve percutaneous introduction into the jugular vein of the patient's neck, or other anatomical entry point that can be used to access the target location within the patient.
In accordance with an aspect of the disclosure, the method includes treatment of an arrhythmia with a catheter. The catheter may include an expandable chamber for abutting the catheter to a pulmonary vein to occlude blood flow through the vein. In an embodiment, differential pressure measurements of the pressure at locations distal and proximal to the expandable chamber may be obtained. In another embodiment, an absolute pressure measurement of pressure at a location distal to the expandable chamber may be obtained. The differential or absolute pressure measurements may be evaluated to guide the placement of the catheter, and in particular, placing the expandable chamber to occlude blood flow in the pulmonary vein. The differential or absolute pressure measurements may be derived continuously during an insertion and treatment procedure to determine appropriate placement of the catheter. Changes in the differential or absolute pressure may be correlated to mechanical occlusion of the pulmonary vein.
Systems in accordance with embodiments of the present disclosure may include a console for delivery of energy and circulation of a coolant through a catheter. The systems may or may not also include a processing unit for processing signals sensed by sensors positioned on the catheter. The systems may further include a mapping unit that receives information recorded from one or more mapping electrodes positioned on the ablation catheter. The mapping unit may provide electrical activity information to an operator of the system to identify or confirm the location of target tissue.
The following drawings are illustrative of particular embodiments of the present disclosure and therefore do not limit the scope of the disclosure. The drawings (not to scale) are intended for use in conjunction with the explanations in the following detailed description, wherein similar elements are designated by identical reference numerals. Moreover, the specific location of the various features is merely exemplary unless noted otherwise.
The following description is exemplary in nature and is not intended to limit the scope, applicability, or configuration of the present disclosure in any way. Rather, the description provides practical illustrations for implementing exemplary embodiments of the present disclosure. Moreover, for simplicity and discussion, various figures have been disclosed below in the context of either cryogenic or RF ablation; such disclosure, however, is believed applicable to any catheter-based occlusion and treatment system.
To better understand the environment in which the devices and methods of the present disclosure are used, a general overview of an ablation procedure is believed to be useful. In the catheter-based ablation treatment of cardiac arrhythmias, a specific area of cardiac tissue having aberrant conductive pathways, such as atrial rotors, emitting or conducting erratic electrical impulses, is initially localized.
Referring to
To accomplish this, a catheter (
An electrical mapping procedure may be performed to identify or confirm the location of the target cardiac tissue. Next, a treatment medium (e.g., cooling fluid or
RF power) provided by a source external to the patient, is provided through the catheter into the ablating element to ablate the neighboring tissue and form a lesion. The created lesions may be segmented and localized. The lesions may be linear or curvilinear, circumferential and partial circumferential, and/or continuous or discontinuous. The lesions created by the ablation catheters are suitable for inhibiting the propagation of inappropriate electrical impulses in the heart 10 for prevention of reentrant arrhythmias. In general, the goal of catheter ablation therapy is to disrupt the electrical pathways in cardiac tissue to stop the emission of and/or prevent the propagation of erratic electric impulses.
Handle 111 may also include connectors that are coupled directly to an energy source or cryogenic fluid supply/exhaust and control unit or indirectly by way of one or more conduits 113. In the exemplary system, the energy source/fluid supply and exhaust, as well as various control mechanisms for the system are housed in a console 60. However, alternative embodiments may employ a plurality of units to implement the functions of console 60, with each providing a separate function. Console 60 circulates and/or recovers cooling fluid through the catheter body 115 to the patient 12. Additionally, console 60 may provide an exhaust function for the ablation catheter fluid supply.
Catheter body 115 includes one or more lumens for releasing coolant into the expandable chamber 130 responsive to console 60 commands and other control input, such as from the control knobs on handle 111. In the exhaust or recirculation function, console 60 creates a low-pressure environment in the one or more lumens within the catheter body 115. The low-pressure environment draws coolant into lumen 118, away from expandable chamber 130, and towards proximal portion 117. General principles concerning the construction or operation of an exemplary cryogenic system may be found in U.S. Pat. No. 5,281,215 issued to Milder, which is incorporated herein by reference in its entirety. To the extent not previously discussed the materials and methods of construction may be typical for catheters and guide wires used in coronary arteries.
Catheter body 115 includes a distal portion 116. An expandable chamber 130 is coupled proximate to the distal portion 116. Expandable chamber 130 may also be thermally conductive to facilitate conduction of heat to and from the tissue into a medium that may be carried by the chamber 130. Although expandable chamber 130 is shown as a balloon having a single membrane, it should be understood that any known multi-membrane balloon may suitably be used.
In accordance with aspects of the present disclosure, catheter 110 operates to treat vascular tissue of a patient 12 that is adjacent to the expandable chamber 130 by freezing or through RF energy that may be delivered through electrodes (not shown) mounted on the distal end of catheter 110. To achieve this, catheter body 115 may be navigated through the vascular system to the desired vascular tissue such as a vessel 30. Examples of vessel 30 may include a left pulmonary vein, a right pulmonary vein, ostia, or other blood vessel. During deployment of the catheter 110, expandable chamber 130 may be deflated for ease of steering and passage through the vascular system. Once catheter 110 is adjacent the desired site in vessel 30, expandable chamber 130 may be inflated, as discussed generally in U.S. Pat. No. 6,575,966, issued to Lane et al., which is incorporated herein by reference in its entirety. Generally, inflation of expandable chamber 130 will result in radial expansion of expandable chamber 130 to a diameter that is at least as large as that of vessel 30. The expanded expandable chamber 130 may then be advanced to the opening of vessel 30 to achieve contact between expandable chamber 130 and the opening to the interior of vessel 30. When the expandable chamber 130 is properly situated, the blood flow within the vessel 30 will be occluded.
However, the occlusion is predicated upon proper positioning of the expandable chamber 130 to abut with the opening of vessel 30. As previously discussed, proper positioning presents several challenges to the user. These challenges include the difficulty of navigating catheter 110 within the vascular system and the size and nature of the vascular system.
Embodiments of the present disclosure utilize one or more physiologic sensors to ascertain the extent of occlusion (and consequently proper location) of the expandable chamber 130.
In the embodiment, a first pressure sensor 120a is coupled to catheter 110 at a location that is anterior or distal to the expandable chamber 130. In use, sensor 120a is in fluid communication with vessel 30 and measures the pressure of the blood flowing within vessel 30. A second pressure sensor 120b may be coupled to catheter 110 at a location that is posterior or proximal to the expandable chamber 130. Pressure sensor 120b may preferably be used in conjunction with sensor 120a to obtain the differential pressure across expandable chamber 130; i.e., the difference between the pressure in the region that is distal to expandable chamber 130 and the pressure in the region that is proximal to expandable chamber 130. The construction and integration of sensors 120a and 120b into the catheter 110 may resemble that disclosed in U.S. Pat. No. 7,231,829 to Michael Schugt, which is hereby incorporated by reference in its entirety.
Sensor 120b operably measures the blood pressure within a body region 20 that is in fluid communication with vessel 30. In an embodiment, region 20 is an atrial chamber adjacent the vessel 30. Accordingly, a computation of the differential pressure in vessel 30 and region 20 can be computed based on the pressure measurements of sensors 120a and 120b. In another embodiment, region 20 may simply be a location that is more distal within vessel 30.
It should be noted that although sensors 120a and 120b have been disclosed in relation to pressure sensors, other forms of sensors may alternatively be used to measure other physiologic and hemodynamic parameters in either or both of region 20 and vessel 30. For example, other sensors such as a temperature sensor (
Catheter 110 may also include a strain gauge 121 that may be coupled to the expandable chamber 130. The strain gauge 121 functions to measure the force exerted on the circumference of the expandable chamber 130. As such, signals obtained by strain gauge 121 can provide an indication of whether the expandable chamber 130 has achieved complete circumferential contact with vessel 30 based on the force (contact) between the circumference of the expandable chamber 130 and the vessel 30 wall.
System 100 may include an output module 170 that is electrically coupled to first and second pressure sensors 120a, 120b for monitoring information sensed by the first and second pressure sensors 120a, 120b. Output module 170 may include signal processing capability comprising a digital signal processor for receiving input signals from the pressure sensors 120a and 120b. The output module 170 may convert the signals to digital form, process those digital signals, and derive an indication of the differential pressure of the blood pressure in region 20 and vessel 30.
The signal processor may correlate the differential pressure computation with a predetermined value. When complete mechanical occlusion has been achieved, the pressure signal waveform in the vessel 30 converts from the pressure signal waveform of region 20 to that of isolated vessel 30. The predetermined value may be obtained by subtracting the signal waveform of the pressure signal in region 20 from the pressure in vessel 30. Computations of the differential pressure measured in vessel 30 and region 20 may be continuously performed and compared against the predetermined value.
The results of differential pressure computation of the pressure in region 20 and vessel 30 may be delivered to a user via display 171. Additionally or alternatively, the raw signals sensed by pressure sensors 120a and 120b may be received by output module 170 and displayed in raw signal waveform on display 171.
In an embodiment, output module 170 may provide an indication to a user, such as a clinician of whether or not occlusion has been achieved or if changes have arisen based on the sensed signals. For example, output module 170 may include a tactile alarm 173 that is worn by the clinician to provide a vibratory signal to the physician when the signals indicate changes in the level of occlusion. Output module 170 may also activate an audible alarm in response to occlusion changes to alert the clinician to indications of possible changes that may require readjustment of the position of catheter 110 or even termination of the process. In other embodiments, light indicators can be used to instruct the physician about the level of occlusion: for example, a green light indicating occlusion, an orange light indicating partial occlusion and a red light indicating no occlusion.
Catheter 110 may additionally include one or more sensors 152a, 152b for sensing electrical activity of the tissue adjacent the sensors 152a, 12b. Electrical activity signals sensed by sensors 152a, 152b facilitate mapping of the conduction pathways in the tissue. The sensors 152a, 152b may be coupled to output module 170 that performs the mapping procedure to identify or confirm the location of the tissue exhibiting arrhythmia conditions.
Turning now to
In
In an alternative embodiment, the signal waveforms of the pressure measurement in region 20 and vessel 30 may be processed by output module 170 to provide a visual representation of a composite waveform that aggregates the signal waveforms of both region 20 and vessel 30. Alternatively, output module 170 may perform signal processing of the sensed signals to provide other parameters, including but not limited to text, numerical or graphical representations of the differential pressure.
Catheter 510 may be coupled to a console 560 through a tubular connector 509. The connector 509 may be in fluid communication with the lumen 518 to permit pressure wave transmission, via a fluid, from pulmonary vein 506 to connector 509. Console 560 may include control electronics including, but not limited to, a pressure gauge and signal processing circuitry.
In an embodiment, console 560 processes the mechanical pressure exerted on the distal opening of catheter 510 and transmitted through the fluid in lumen 518. To achieve this, fluid such as saline is supplied into the lumen 518 to substantially fill up the lumen 518. As such, when the distal portion 516 of catheter 510 is located within or adjacent pulmonary vein 506, blood flow within the pulmonary vein 506 comes into contact with the distal opening of catheter 510. Occlusion of the pulmonary vein 506 by the expandable chamber 530 may be determined based on the mechanical pressure exerted by this blood flow.
In accordance with principles of this disclosure, the blood flow in the pulmonary vein 506 causes a mechanical deflection of the fluid at the distal opening of lumen 518. The mechanical deflection corresponds to the mechanical pressure exerted by the blood flowing adjacent to the distal portion 516. The mechanical deflection of the fluid at the tip of distal portion 516 is transmitted to the proximal portion of catheter 510. This deflection of the fluid in lumen 518 may be sensed and processed by console 560 which is in fluid communication with the lumen 518. In alternative embodiments, a separate pressure gauge/sensor may be coupled to catheter 510 for determination of the mechanical pressure exerted on the distal portion 516. As such, system 500 correlates the mechanical occlusion at a location distal to the expandable chamber 530 to the pressure exerted on the distal portion 516.
The mechanical pressure signal corresponding to the pressure exerted on the catheter body 516 may be processed and a result of the processing delivered to the user via display 561. The result displayed may be a graphical, text, numerical, pictorial, or any other suitable indication of the determination of occlusion. Additionally or alternatively, the sensed raw signal waveform may be displayed directly on the display 561.
It should be noted that for the cryogenic based ablation, the absolute pressure monitoring illustrated in the embodiment of
In an embodiment, using in-vivo or in-vitro modeling, appropriate temperature profiles as measured by the temperature sensor 600 can be obtained for the case of occlusion, partial occlusion or no occlusion. These profiles can be incorporated into the console (not shown) and compared with real-time measurements to determine occlusion. In an exemplary embodiment, a large temperature change, e.g., greater than five degrees Celsius, as measured by the temperature sensor 600 may be associated with complete occlusion whereas a temperature change of two degrees Celsius or less may be associated with no occlusion. Temperature differences between two and five degrees Celsius may be designated as corresponding to partial occlusion. However, one skilled in the art will appreciate that the temperature variances noted above are merely illustrative and as a matter of routine use, temperature profiles tailored to specific classes of patients can easily be obtained.
In an alternative embodiment, conductive element 615 may serve a dual function, i.e., as a sensor and an electrode. As such, conductive element 615 may be used for electrical mapping or may be used to provide information about tip location during navigation.
In accordance with the present disclosure, operation of flow sensor 800 is characterized as follows: if there is no flow and the fluid is stationary (as in the case of an occluded vessel), there will be a constant temperature difference between the proximal conductive element 805a and the distal conductive element 805b. The temperature of the distal element 805b will correspond generally to the temperature of the heat source and the temperature of the proximal element 805a will correspond generally to the temperature of the stationary blood. On the other hand, if fluid flow is present across the two elements 805a, 805b (as in the case of a partially or non-occluded vessel), the fluid will draw heat away from the heated element 805b and the temperature difference between the two elements 805a, 805b will be smaller or the same. The rate of cooling of element 805b is proportional to flow rate.
At step 410, the physiologic parameter is evaluated to confirm whether the signal information is indicative of an appropriate placement of the expandable chamber 130 that denotes that complete occlusion has been achieved. The evaluation may be performed on the raw sensed signal or information derived from processing the sensed signal. In either event, if the sensed signal is not acceptable, the catheter 110 may be manipulated 420 with the aid of the sensed signals to abut the vessel 30 and achieve complete occlusion. The manipulation may include torquing, advancing, retracting, repositioning, inflating, or deflating the expandable chamber 130.
The tissue ablation may be initiated at step 430 upon confirmation that the expandable chamber 130 has achieved complete occlusion. For example, in a cryogenic ablation, a cooling fluid may be circulated through catheter 110 by console 60 into expandable chamber 130. The energy transfer phenomenon is utilized to create a net transfer of heat from the target tissue on vessel 30 into the cooling fluid. Because of the circulation of cooling fluid by console 60, energy is extracted from the target tissue by the cooling fluid. The rate and magnitude of energy transfer can be controlled by the controls on handle 111. A count of a predetermined duration for circulating the cooling fluid may also be initiated. In the case of RF ablation, RF energy may be delivered from console 60 via electrodes to form the lesions on the desired tissue.
Step 440 denotes an optional process of continual, intermittent or on-demand monitoring of the physiologic parameter to determine the occlusion of the vessel 30. The optional monitoring of the physiologic parameter at step 440 may facilitate the determination of occlusion of vessel 30 during the ablation procedure. Determining whether vessel 30 is continuously occluded during the tissue ablation may be useful because blood flow during the procedure may be undesirable. This is because the blood flow may inhibit effective cooling of the target tissue of vessel 30 due to the presence of heat in the flowing blood or in the case of RF energy, the blood may lower the temperature of the delivered energy. If the monitored physiologic parameter at step 440 indicates that vessel 30 is properly occluded, the ablation is continued 460.
At step 470, the process determines whether the predetermined duration for delivery of the cooling fluid has elapsed. If the duration has not elapsed, the system will maintain the monitoring of the physiologic parameter at step 440 to determine whether the vessel 30 is still completely occluded.
In an alternative embodiment, the monitored physiologic parameter at step 440 may indicate the recurrence of blood flow. Responsive to the indication of recurrence of blood flow at 440, various adjustments 450 may be performed. For instance, the catheter 110 may be repositioned and/or the temperature or flow rate of the cooling fluid may be modified.
In other aspects of the disclosure, the physiologic parameter measurement may be utilized in conjunction with an imaging procedure. For example, imaging may be performed through fluoroscopy to verify proper placement and complete occlusion of the blood vessel 30. However, the physiologic parameter measurements may significantly reduce the imaging time thereby reducing exposure of the patient and clinician to radiation waves of the imaging procedure.
The present disclosure may also be used in combination with devices that deliver one or more forms and types of energy for ablation therapy including but not limited to: sound energy such as acoustic energy and ultrasound energy; electromagnetic energy such as electrical, magnetic, microwave and radiofrequency energies; thermal energy such as heat energy; chemical energy such as energy generated by delivery of a drug; laser or light energy such as infrared and visible light energies; mechanical and physical energy; radiation; and combinations thereof.
In another alternative embodiment, the patient's phrenic nerve may be paced prior to measurement of the physiologic parameter. Methods and devices for phrenic nerve stimulation are known in the art and include U.S. Pat. No. 7,225,019, issued to Jahns, et al., which is incorporated herein by reference in its entirety.
For simplicity and discussion, the sensed signal has been described in conjunction with implanted physiologic sensors. However, this disclosure is not intended to be limiting to such sensors and other suitable sensors for measuring physiological parameters may be substituted without undue experimentation.
