US20020013621A1 - Heart valve holder for constricting the valve commissures and methods of use - Google Patents

Abstract

An improved holder, system and method for implanting a tissue-type prosthetic heart mitral valve that constricts the commissure posts of the valve and allows the user to detach the handle of the holder prior to withdrawing the holder itself. The ability to remove the handle allows a surgeon greater access to suturing the prosthetic valve to the mitral annulus. The holder may include two relatively movable plates, one of which attaches to the valve sewing on the inflow end of the valve ring and the other which attaches via sutures to the valve commissures on the outflow end. Separation of the plates places the sutures in tension and constricts the commissures. An adjusting member or adapter is interposed between the handle and holder to enable separation of the two plates and removal of the handle. The adjusting member or adapter may be packaged with the valve and holder combination, or may be sold as a separate unit, possibly with the handle, so that prior art holders can be retrofit.

Description

RELATED APPLICATION
• The present application is a continuation-in-part of U.S. application Ser. No. 09/626,570, filed Jul. 27, 2000.[0001]
FIELD OF THE INVENTION
• The present invention relates generally to medical devices, and more particularly to an apparatus for facilitating the implantation of a bioprosthetic replacement heart valve, and associated methodology.[0002]
BACKGROUND OF THE INVENTION
• In mammalian animals, the heart is a hollow muscular organ having four pumping chambers: the left and right atria and the left and right ventricles, each provided with its own one-way valve. The natural heart valves are identified as the aortic, mitral (or bicuspid), tricuspid and pulmonary valves and have leaflets to control the directional flow of blood through the heart. The valves are each mounted in an annulus that comprises a dense fibrous ring attached either directly or indirectly to the atrial or ventricular muscle fibers. Various surgical techniques may be used to repair a diseased or damaged valve. In a valve replacement operation, the damaged leaflets are excised and the annulus sculpted to receive a replacement valve.[0003]
• Two primary types of heart valve replacements or prostheses are known. One is a mechanical-type heart valve that uses a ball and cage arrangement or a pivoting mechanical closure to provide unidirectional blood flow. The other is a tissue-type or “bioprosthetic” valve which is constructed with natural-tissue valve leaflets which function much like a natural human heart valve's, imitating the natural action of the flexible heart valve leaflets which form commissures to seal against each other to ensure the one-way blood flow. In tissue valves, a whole xenograft valve (e.g., porcine) or a plurality of xenograft leaflets (e.g., bovine pericardium) provide occluding surfaces that are mounted within a surrounding stent structure. In both types of prosthetic valves, a biocompatible cloth-covered sewing or suture ring is provided on the valve body, for the mechanical type of prosthetic valve, or on the inflow end of the stent for the tissue-type of prosthetic valve.[0004]
• In placing a tissue type prosthetic valve in the mitral position, the commissure posts are on the blind side of the valve and may become entangled with pre-installed sutures, and may damage the annulus or tissue during delivery. The difficulty of the delivery task is compounded if the surgery is through a minimally-invasive access channel, a technique that is becoming more common. The problem of entanglement is termed “suture looping,” and means that the suture that is used to attach or mount the valve to the heart tissue is inadvertently wrapped around the inside of one or more of the commissure post tips. If this occurs, the looped suture may damage one of the tissue leaflets when tightly tied down, or at least may interfere with valve operation and prevent maximum coaptation of the valve leaflets, resulting in a deficiency in the prosthetic mitral valve.[0005]
• Some attempts have been made to overcome these problems in current holders for prosthetic mitral valves. An example of such a holder is U.S. Pat. No. 4,865,600, Carpentier, et al., incorporated herein by reference. Carpentier provides a holder having a constriction mechanism that constricts the commissure posts inwardly prior to implantation. The Carpentier device provides an elongate handle to both hold the valve/valve holder combination during implantation, as well as to cause the commissure posts to constrict inwardly. The valve is connected to the valve holder by the manufacturer using one or more sutures, and the combination shipped and stored as a unit. During the valve replacement procedure, the surgeon connects the handle to the holder and locks a locking nut to hold the commissure posts at a given constricted position. The surgeon then attaches the sewing ring of the valve to the native valve annulus with an array of sutures that has been pre-embedded in the annulus and extended outside the body. The valve is then advanced along the array of sutures to its desired implantation position and the sutures tied off. When the holder is cut free, the commissure posts are released to expand and the holder may be removed using the handle. The inability to remove the elongate handle while maintaining commissure constriction is a detriment. The handle must be attached to the holder so that the commissure posts remain in a constricted position during attachment of the array of sutures to the sewing ring. This can be awkward for manipulation of the valve/valve holder combination during this time-constrained operation. Further, the relatively wide holder periphery may interfere with the attachment step.[0006]
• What is needed then is an improved tissue-type prosthetic valve holder attachable to the inflow end of the valve that can constrict the commissure posts with or without a handle being attached, yet provides improved visibility and accessibility to the surgeon during the valve attachment steps.[0007]
SUMMARY OF THE INVENTION
• The present invention provides a holder for a tissue-type prosthetic heart valve having an inflow end and an outflow end and a flow axis therebetween. The valve includes an annular suture ring at the inflow end attached to a stent having posts circumferentially-spaced about the flow axis that support occluding tissue surfaces of the valve. In this type of valve the posts are cantilevered generally in the outflow direction.[0008]
• The holder includes a valve abutment portion sized and shaped to abut the suture ring at the inflow end of the valve. The holder further includes a commissure post constriction mechanism adapted to constrict the commissure posts radially inward from a relaxed position to a constricted position when actuated by a handle adapted to operatively connect to the commissure post constriction mechanism. A retaining mechanism is also provided that retains the commissure post constriction mechanism in the constricted position after the handle is removed.[0009]
• In one embodiment the commissure post constriction mechanism comprises an adjusting portion and an adjusting member adapted to adjust the distance between the adjusting portion and the valve abutment portion and one or more filaments attached to the adjusting portion and sutured through the end of the commissure posts distal the adjusting portion. When the adjusting member is operated to separate the adjusting portion from the valve abutment portion the adjusting portion pulls the filaments, which in turn urge the end of the commissure posts distal the adjusting portion radially inwardly, to the constricted position.[0010]
• The valve abutment portion may be of a planar shape, with the adjusting portion of a substantially complementary planar shape to the valve abutment portion. It is preferred that the planar shape of the valve abutment portion be comprised of a plurality of tangs radiating from a central body to each cover a portion of the suture ring. In this manner a sufficient amount of the suture ring is left exposed to allow for suturing the suture ring to the native annulus.[0011]
• Adjustment of the distance between the valve abutment portion and the adjusting portion may be achieved by providing a central threaded aperture in the adjusting portion and an adjusting member that cooperates with this threaded aperture. In this construction the end of the adjusting member proximal the valve abutment portion abuts the valve abutment portion during operation. When the adjusting member is advanced through the central aperture of the adjusting portion it pushes the valve abutment portion and the two portions separate.[0012]
• A handle may be operatively connected to the adjusting member to turn it by providing a handle that has an externally threaded end portion and an adjusting member having a central longitudinal threaded bore sized to receive the threaded end of the handle. When the handle is introduced into the bore it is rotated in a first direction and will seat in the threaded bore of the adjusting member. Further rotation of the adjusting member separates the adjusting portion from the valve abutment portion, as recited above, and causes the commissure posts to constrict inwardly.[0013]
• In the prior art the handle would have to remain attached during suturing of the suture ring to the host tissue to keep the commissure posts in the constricted position. The holder with the handle connected were removed by severing the filament(s) and removing the holder, handle and filaments together.[0014]
• In accordance with the present invention, the adjusting member itself may be adapted to be the retaining mechanism. Preferably, the adjusting member threads create a greater frictional resistance with the threaded aperture of the adjusting portion than that between the threaded end of the handle and the threaded bore of the adjusting member. This frictional resistance between the adjusting member and the central aperture allows the handle to be further rotated in a second, opposite direction, and the handle will detach or unscrew from the adjusting member without moving the adjusting member, leaving the commissure posts in the constricted position. The tug of the filaments themselves on the adjusting portion when the commissure posts will cause the adjusting member/central aperture thread interface to bind and so may be used to achieve the requisite additional frictional resistance required for allowing the handle to be unscrewed.[0015]
• In alternative embodiments other mechanisms may be used in accordance with the invention to act as the retaining mechanism. For example, a ratchet assembly may be provided to lock the valve attachment and adjusting portions apart, allowing the handle to be removed while leaving the commissure posts in the constricted position. A ratchet assembly may be comprised of a one or more toothed members affixed to the valve abutment portion that each engage a complementary notch, opening or, for example, a pawl affixed to the adjusting portion. As the valve abutment portion and the adjusting portion are separated by the adjusting member the successive teeth of the toothed member engage the notch, opening or pawl affixed to the adjusting portion, locking the two portions apart.[0016]
• The present invention further provides a method for retrofitting a holder for a tissue-type prosthetic mitral heart valve attachable to a surgical delivery handle. The heart valve is of the type having an inflow end and an outflow end and a flow axis therebetween, and includes an annular suture ring at the inflow end and radially flexible commissure posts circumferentially-spaced around the outflow end that support occluding tissue surfaces of the valve. The holder has a commissure post constriction mechanism releasably attached to the sewing ring at the inflow end of the valve, the mechanism adapted to constrict the valve commissure posts radially inward from a relaxed position to a constricted position when actuated by the delivery handle. The method includes providing a retaining mechanism that retains the commissure post constriction mechanism in the constricted position after the delivery handle is removed. The retaining mechanism may be provided during the holder assembly process so that the retaining mechanism is attached to and shipped as a unit with the prosthetic valve. Alternatively, the retaining mechanism may be provided separately from the holder and valve combination and the method includes coupling the retaining mechanism to the holder at the time of surgical implantation of the valve. The retaining mechanism and delivery handle may be packaged and sold as a unit. The retaining mechanism desirably comprises an adapter that is interposed between and threadingly engaged to the holder and the handle.[0017]
• Further in accordance with the invention a method for replacing a heart valve is provided, comprising the steps of removing an existing heart valve to leave an annulus of that heart valve, attaching a holder of the invention to a prosthetic tissue-type heart valve and constricting the commissure posts of the prosthetic heart valve with a handle; inserting the valve through the annulus of the heart valve; removing the handle while leaving the commissure posts in the constricted position; suturing the tissue-type heart valve to the heart annulus, and detaching the holder from the prosthetic heart valve.[0018]
• After suturing the heart valve to the annulus the surgeon severs the filament, causing the posts of the stent to open to the relaxed, operational position. The severing of the filament(s) also releases the holder from the prosthetic heart valve, allowing it to be removed.[0019]
• A further understanding of the nature and advantages of the present invention are set forth in the following description and claims, particularly when considered in conjunction with the accompanying drawings in which like parts bear like reference numerals.[0020]
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a perspective view of a heart valve holder of the present invention assembled to the inflow side of a tissue-type heart valve;[0021]
• FIG. 2 is a perspective view of the holder/heart valve assembly, showing an actuating and delivery handle attached to the holder;[0022]
• FIG. 3 is a perspective view of the holder/heart valve assembly showing an adjusting portion retracted to cause inward movement of the valve commissure posts;[0023]
• FIG. 4 is a perspective view of the valve holder of the present invention exploded from a tissue-type heart valve;[0024]
• FIG. 5A is a plan view of an adjusting portion of the holder of the present invention;[0025]
• FIG. 5B is a sectional view through the adjusting portion of the holder, take along[0026]line5B-5B of FIG. 5A;
• FIGS. 6A and 6B are partial sectional views of the holder of the present invention attached to a heart valve wherein the commissure posts of the valve are, respectively, relaxed and biased inwardly;[0027]
• FIGS.[0028]7A-7C illustrates several steps in the implantation of a tissue-type valve in the mitral position using the holder of the present invention;
• FIGS. 8A and 8B are partial sectional views of an alternative holder of the present invention attached to a heart valve wherein the commissure posts of the valve are, respectively, relaxed and biased inwardly;[0029]
• FIG. 9A is a perspective view of an exemplary storage and handling clip that attaches to a holder of the present invention;[0030]
• FIGS.[0031]9B-9F are various views of the handling clip of FIG. 9A;
• FIG. 10 is a perspective view of the handling clip attached to a holder and valve combination and placed within a storage container shown in phantom;[0032]
• FIG. 11A is a plan view of a heart valve holder of the prior art attached to a heart valve and delivery handle during a step of implantation into a valve annulus;[0033]
• FIG. 11B is a plan view of a heart valve holder of the present invention attached to a heart valve and delivery handle during a step of implantation into a valve annulus;[0034]
• FIG. 12A is an exploded perspective view of a valve, holder, handle and adapter combination of the present invention;[0035]
• FIGS.[0036]12B-12C are perspective assembled views of the combination of FIG. 12A showing two steps of operation thereof to constrict commissures of the heart valve;
• FIGS.[0037]13A-13C are sectional views of the holder, handle, and adapter combination of FIG. 12 showing several steps of operation;
• FIGS.[0038]14A-14C are several views of an alternative adapter for use with a valve holder of the present invention;
• FIG. 15 is a partial elevational view of the interaction between a pawl on the adapter of FIG. 14 and a raised feature on a valve holder to ensure positive engagement therebetween; and[0039]
• FIGS.[0040]16A-16F are several sectional views of a portion of an alternative holder of the present invention showing a further apparatus for maintaining commissure constriction.
DESCRIPTION OF THE PREFERRED EMBODIMENT
• The present invention provides an improved heart valve holder for tissue-type prosthetic heart valves that facilitates implantation and reduces the chance of suture entanglement. The holder of the present invention is particularly useful for prosthetic mitral heart valves having commissure posts on the outflow side supporting flexible leaflets therebetween. The mitral position is such that the outflow side (and commissure posts) projects distally toward the left ventricle during implantation, and thus the holder must be attached to the inflow (i.e., accessible) side of the valve. Delivery of the valve to the mitral position involves sliding the valve down a plurality of sutures that have been pre-installed around the annulus and then passed through the valve sewing ring. The holder of the present invention constricts the commissure posts radially inward and thus helps prevent the posts from becoming entangled in the array of pre-installed sutures. This benefit is thus particular to the situation where the outflow side (and commissure posts) of the heart valve extends distally during delivery, which is the case in the mitral position. Nonetheless, the holder of the present invention may prove useful for the implantation of heart valves in other than the mitral position, and thus the invention may be applicable thereto.[0041]
• With reference now to FIGS.[0042]1-3 anexemplary holder20 of the present invention is shown attached to a tissue-type heart valve22. Theheart valve22 includes anannular sewing ring24 on an inflow side, and a plurality of commissure posts26 projecting generally axially in the outflow direction. Theholder20 attaches to thesewing ring24 on the inflow side of thevalve22, which also is the proximal (i.e., accessible) side during implantation. That is, commissure posts26 project distally toward the outflow side of thevalve22.
• FIGS. 2 and 3 illustrate a plurality of[0043]flexible leaflets28 that are supported by and extend between the commissure posts26. Theleaflets28 provide the occluding surfaces of thevalve22, and may be made of individual pieces of bovine pericardium, for example. Alternatively, theleaflets28 may be part of an entire xenograft, or homograft. In the former instance, natural porcine (pig) valves are particularly useful. Therefore it should be understood that theleaflets28 may be formed of a variety of materials, none of which is limiting with respect to the present invention. In addition, there are preferably threesuch leaflets28 corresponding to three commissure posts26.
• Various constructions for the[0044]heart valve22 are known, which may include metallic or plastic stent elements, a silicone or urethane insert for thesewing ring24, biocompatible fabric (i.e., polyester) covering around one or more of the elements, etc. In a preferred embodiment, theheart valve22 includes an internal metallic wireform (not shown) having an undulating shape with a plurality of arcuate cusps connected by upstanding commissures. The wireform commissures provide internal structure for the commissure posts26 of the valve, and are somewhat flexible so as to be able to flex or cantilever inward. Theholder20 of the present invention facilitates this flexing, though the invention is generally directed toward causing the inward movement of the commissure posts. Of course, other internal constructions ofheart valve22 having movable commissure posts are available, with which theholder20 of the present invention may function equally as well.
• With reference still to FIGS.[0045]1-3, and also FIG. 4, theholder20 of the present invention includes three relatively movable elements. A plate-likevalve abutment portion40 lies against theinflow side32 of thesewing ring24, and includes a plurality of throughholes42 around its periphery. A plate-likecommissure adjusting portion44 generally mirrors the shape of thevalve abutment portion40, and also includes a plurality of peripheral through holes46. The adjustingportion44 further includes a centrally located and internally threadedboss48 that projects in a proximal direction from the otherwise generally planar adjusting portion. Finally, an adjustingmember50 havingexternal threads52 thereon is sized to mate with theinternal threads54 of theboss48
• A plurality of filaments or[0046]sutures60 are shown in FIGS.1-3 partly extending between thetips62 of the commissure posts26. Because there are threecommissure posts26, there are at least three lengths ofsutures60 extending therebetween in a triangular configuration. Each length ofsuture60 spans two of the commissure posts26, and threads proximally along the post and through thesewing ring24 to be attached to theholder20. This is seen best in the perspective view of FIG. 1. Specifically, each suture60 passes through theholes42 in thevalve abutment portion40 and attaches to the adjustingportion44. The specifies of the attachment of eachsuture60 will be explained below.
• As mentioned, the[0047]abutment portion40, adjustingportion44, and adjustingmember50 are relatively movable. That is, the adjustingportion50 is adapted to cause relative axial displacement between theabutment portion40 and the adjustingportion44. Because theabutment portion40 remains against thesewing ring24, the adjustingportion44 translates proximally away from the abutment portion, and attachedvalve22. This is seen in FIG. 3. Because thesutures60 attach to the adjustingportion44, they are also pulled in the proximal direction. Moreover, because each suture60 threads in a distal direction along and between two of the commissure posts26, proximal movement of the adjustingportion44 thus shortens the amount of each suture between thecommissure post tips62. This shortening causes radially inward movement of thetips62, with the commissure posts26 eventually flexing inward from their structural point of attachment within thevalve22 adjacent thesewing ring24.
• Now with reference to FIGS. 4 and 5A-[0048]5B, structural details of theholder20 of the present invention will be explained. As mentioned above, thevalve abutment portion40 is generally plate-like, and preferably includes a central, generallytriangular body70 having three outwardly extendingtangs72 at the apices thereof. Two throughholes42 are providing in each of thetangs72, spaced apart along an imaginary circle centered in thetriangular body70. Three upstanding pins or legs74 having hooks76 project from the proximal face of thebody70, preferably inward and between each two tangs72.
• The adjusting[0049]portion44, as best seen in FIG. 5A, also includes a generally triangular plate-like body80 that is sized similar to thebody70 of theabutment portion40. In this regard, the adjustingportion44 includes a plurality ofchannels82 on the face opposite thevalve abutment portion40 that received the hooks76 of the upstanding legs74 such that the plate-like bodies70 and80 can be juxtaposed against one another, though their separation distance is limited. The hooks76 thus effectively prevent disengagement of the attachingportion44 and theabutment portion40 once the two are coupled together. The adjustingportion44 also includes three outwardly extendingtangs84 at the apices of thetriangular body80. Like theabutment portion40, two throughholes46 are provided on each of thetangs84, and are spaced apart along an imaginary circle centered in thebody80. Preferably, each throughhole46 in the adjustingportion44 aligns with a throughhole42 in thevalve abutment portion40 when theholder20 is assembled.
• Each[0050]tang84 features asuture cutting guide86 that projects from the proximal face of thebody80. Each cuttingguide86 includes acentral cutting recess88 defined between a pair ofsuture grooves90. A cuttingrecess88 extends generally radially, while thesuture grooves90 are angled with respect thereto. The depth of thesuture grooves90 is less than the depth of the cuttingrecess88, as seen in FIG. 5B, and thus a length ofsuture60 can be strung between thegrooves90 so as to be suspended over the cuttingrecess88. As seen in FIG. 5A, thesuture grooves90 lead into both of the throughholes46 on either side of the cuttingguide86, such that each suture bridges the cuttingrecess88 and may be bent to be secured to or pass through one of the through holes46. The specific arrangement of thesutures60 will be more fully described below.
• With reference still to FIG. 5A, the adjusting[0051]portion44 further includes means for receiving clips on a removable transport template that secures theholder20 andheart valve22 assembly within a storage jar during transportation. Specifically, three clip-receivingnotches100 are equidistantly spaced around the periphery of thebody80. In the illustrated embodiment, thenotches100 are disposed in a counter-clockwise direction adjacent each of the tangs84 (as seen from the proximal face). Each of thenotches100 is spaced from the center of the body80 aradial distance102, as indicated. As seen in the left of FIG. 5A, progressively larger holders will have progressivelylarger tangs84a,84b,84cso as to enable attachment to larger valve sizes. Advantageously, thenotch distance102 remains constant for all the various sizes of theholder20 to provide a one-size-fits-all template attachment means. That is, the same size of storage template can be used for a set of different sizes of holders. This arrangement also reduces the radial profile of the holders for larger sized valves, as the dimension of the template notches with respect to the overall perimeter is progressively reduced. This size reduction further helps to prevent snags as the holder and valve are delivered to the implantation site.
• With reference again to the perspective views of FIGS.[0052]1-3, the arrangement of the discrete lengths ofsutures60 will now be described. There are desirably three equal lengths ofsutures60, each being secured at its free end to the adjustingportion44. Each length ofsuture60 attaches to afirst tang84 of the adjustingportion44, passes through the alignedholes46 and42 (in a first tang of the abutment portion40) and through thesewing ring24 to afirst commissure post26. From there, thesuture60 continues axially to thetip62 of thepost26, and extends across the outflow side of thevalve22 to the tip of asecond commissure post26. The suture then passes proximally along thesecond commissure post26, again throughsewing ring24, and through alignedholes42 and46 insecond tangs72,84, respectively, of theabutment portion40 and adjustingportion44. It should be noted that each of the commissure posts26 desirably has a fabric covering, and thesutures60 pass at least once through the fabric covering at thetip62 of each post.
• At one of its free ends, the[0053]suture60 passes between thesuture grooves90 within one of the cuttinggrooves86. Each length ofsuture60 is secured at both ends to different throughholes46 in the adjustingportion44. Additionally, each two adjacent lengths ofsuture60 are secured to the same throughhole46. That is, as seen in FIG. 1, two lengths of suture,60aand60b, are seen extending along theclosest commissure post26 to the adjustingportion44. The first length60apasses through the left through hole46b, over the cuttingguide86, and is secured to the right through hole46b. The second length60bis secured to the right through hole46band passes distally throughsewing ring24 to thecommissure post26. The second length60bdoes not cross the cuttingguide86, but instead continues to thenext commissure post26 before extending proximally to theholder20 and over its associated cuttingguide86. In this manner, the lengths ofsutures60 can be completely disengaged from thevalve22 by simply making three scalpel cuts in each of the three cutting guides86.
• The[0054]holder20 of the present invention works in conjunction with adelivery handle110, as seen in FIGS. 2 and 4. As seen in FIG. 4, thehandle110 includes ashaft112 terminating in a distal externally threadedrod114. The adjustingmember50 is tubular and includesinternal threads116 that are sized and configured to receive the threadedrod114. In addition, as mentioned above, the adjustingmember50 is externally threaded so as to mate withinternal threads54 on theboss48 of the adjustingportion44. By coupling the adjustingmember50 to theboss48, and then thehandle110 to the adjusting member, thehandle110 connects to theholder20.
• With reference to FIGS. 6A and 6B, use of the[0055]holder20 to radially constrict the commissure posts26 is shown. Specifically, FIG. 6A illustrates theholder20 assembled to theheart valve22 using the aforementioned lengths ofsuture60. In its relaxed configuration, the adjustingportion44 lies flush against theabutment portion42. In this state, the adjustingmember50 is threaded part way into theboss48 such that a distal end contacts the cavity78 in theabutment portion40, but can be further advanced a distance A, as indicated. Thehandle110 is shown also part way engaged with the adjustingmember50, with the threadedrod114 still partly showing.
• Now with reference to FIG. 6B, the[0056]handle110 has been completely screwed into the adjustingmember50, at which point further rotation ofhandle110 causes relative rotation between the adjustingmember50 and the adjustingportion44. In other words, actuation of thehandle110 causes relative axial movement between the adjustingmember50 and adjustingportion44. This axial movement is caused by advancement of the adjustingmember50 within theboss48, which causes the distal end of the adjusting member to push against theabutment member42. Because the adjustingmember50 is thus prevented from relative movement with respect to theabutment member42, further advancement of the adjusting member causes the adjustingportion44 to displace away from theabutment portion42, as indicated by the arrows120. The adjustingportion44 rides upward along the adjustingmember50 until it contacts aproximal shoulder122, with the resulting spacing B between the adjustingportion44 andabutment portion42. Because of the attachment of the lengths ofsuture60 to the adjustingportion44, relative movement of the adjusting portion with respect to theabutment portion42 pulls each length of suture out of thevalve22. This, in turn, causes inward radial contraction of the commissure posts26, as indicated by thearrows124.
• In a preferred embodiment, the frictional resistance to rotation between the adjusting[0057]member50 and the adjustingportion44 is greater than the frictional resistance to rotation between thehandle110 and the adjustingmember50. Consequently, once the commissure posts26 have been radially constricted, as indicated in FIG. 6B, thehandle110 can be removed (unscrewed) from within the adjustingmember50 without causing relative rotation between the adjusting member and the adjustingportion44. Therefore, theholder20 maintains the radially constricted configuration of the commissure posts26. This inequality in frictional rotation can be obtained in a number of ways. For example, the threadedrod114 and associatedinternal threads116 of the adjustingmember50 have a smaller diameter than theexternal threads52 and associatedinternal threads54 of theboss48. Simply by virtue of this size relationship, and corresponding lower surface area in contact, less resistance to rotation of the threaded connection betweenhandle110 and adjustingmember50 is obtained, all else being equal.
• To insure the[0058]handle110 can be removed without reversing the adjustingmember50 with respect to the adjustingportion44, however, the materials are chosen to enhance the inequality in frictional resistance, as mentioned above. That is, the materials of the adjustingmember50 and adjustingportion44 are chosen so as to have a greater frictional resistance to relative sliding movement than between the materials of thehandle110 and adjustingmember50. In one embodiment, the adjustingmember50 and adjustingportion44 are made of the same or different polymers, whilehandle110 is metal. Resistance to relative sliding movement between metal and polymer is generally less than that between two polymers. In a preferred embodiment, both the adjustingmember50 and adjustingportion44 are made of DELRIN, whilehandle110 is made a stainless-steel.
• FIGS.[0059]7A-7C illustrate several steps in the use of thevalve holder20 the present mentioned. FIG. 7A illustrates a portion of the heart H in cross-section, and specifically the left ventricle LV into which the mitral annulus MA opens. A plurality ofsutures130 is shown pre-installed within the mitral annulus MA. In a typical procedure, thesutures130 are brought outside the body and passed through thesewing ring24 of theprosthetic valve22. Thehandle110 attaches to theholder20 of the present invention which in turn is coupled to thevalve22 and operably engaged therewith to radially constrict the commissure posts26. During delivery of thevalve22, this radial constriction of the commissure posts26 helps prevent entangled of the posts with the array ofpre-installed sutures130. Indeed, the access passageway to the mitral annulus MA can be somewhat narrow and nonlinear, making the possibility of suture entanglement problematic. However, radial constriction of the commissure posts26, in conjunction with the barrier provided by the triangular suspension ofsutures60 between the commissure posts, greatly reduces the chance of entanglement. Moreover, thesutures130 are entirely prevented by the triangular suspension ofsutures60 from contacting thevalve leaflets28. Not only does the radial constriction of the commissure posts26 reduce the chance of suture entanglement, but it also reduces the chance of contacting one of the posts with the surrounding anatomy.
• After all the[0060]sutures130 have been pre-installed in the mitral annulus MA and threaded through thesewing ring24, thevalve22 is lowered along the plurality ofsutures130 so that thesewing ring24 contacts and lies flush against the mitral annulus MA, as seen in FIG. 7B. At this stage, thehandle110 is removed from theholder20 to facilitate tying off of each of thesutures130 to secure thevalve22 against the mitral annulus MA. Again, removal of thehandle110 is facilitated by the small frictional resistance to rotation between the handle andholder20, relative to that between the actuating portions of the holder.
• Finally, after securing the[0061]valve22 within the mitral annulus MA, each of the lengths ofsuture60 is severed at the cutting guides86 to facilitate removal of theholder20 from thevalve22. FIG. 7C shows the severed free ends of the points ofsuture60 being pulled from within thevalve22. Theholder20 can be removed using forceps, or handle110 may be reattached to facilitate the removal.
• The present invention contemplates a number of different structures that cause constriction of tissue-type valve commissure posts using a handle, while also permitting removal of the handle without releasing the commissure posts. FIGS. 8A and 8B illustrate a second embodiment of a[0062]holder150 that utilizes a ratchet methodology. Without going into great detail concerning elements of theholder150 that are similar to those described above, the alternative holder relies on one or more toothed or ratchetmembers152 extending proximally from theabutment portion40 to engage complementary opening(s) in the adjustingportion44. As the adjustingportion44 is displaced away from theabutment portion42, ratchetmembers152 retain that spacing, as indicated FIG. 8B. In this way, the relative frictional rotation betweenhandle110, adjustingportion44, and adjustingmember50 is not important. Indeed, thehandle110 and adjustingmember50 can be formed as one-piece, rather than two as shown.
• Now with reference to FIGS.[0063]9A-9F and10, use of aclip160 as mentioned above to attach toholders20 of the present invention during shipping and storage of an attached valve is illustrated. As illustrated, eachclip160 includes a generally planar C-shapeddisk portion162 having asemi-circular handle164 attached thereto. Theclip160 is desirably molded of a suitable polymer, with thehandle164 being formed by a semi-circular strip pivotable with respect to thedisk portion162, with its ends attached by livinghinges165 to a pair ofupstanding bosses166. In this respect, thehandle164 lies generally parallel to the plane of thedisk portion162 until pulled upward by the user.
• Three[0064]fingers168 depend downwardly from thedisk portion162 in the direction opposite the direction that thehandle164 may be lifted. Eachfinger168 includes an inwardly directedpawl170 sized to couple with aholder20 of the present invention. More specifically, the threefingers168 are circumferentially spaced 120° around a common axis of theholder20 andclip160 so as to engage theperipheral notches100 on the adjustingportion44 of the holder. As mentioned previously, theperipheral notches100 for different sized valve holders are radially spaced a consistent distance from the axis. Therefore, thesame size clip160 may be used to couple to a plurality of holders for different sized valves, thus reducing the inventory of clips required. After coupling theclip160 to the holder20 (or adjusting member50), thehandle164 may be used to lower thevalve22 into a storage andshipping container172, as seen in FIG. 10. The periphery of thedisk portion162 is sized to closely fit within thecontainer172, and thus prevents the valve from movement in the container during shipping.
• The[0065]mitral valve holder20 of the present invention provides an additional advantage over earlier mitral valve holders, such as the holder shown in U.S. Pat. No. 4,865,600 to Carpentier, et al. Specifically, prior holders such as that shown in the Carpentier patent were relatively wide in dimension so as to unnecessarily interfere with attachment of the sutures to the valve and the valve to the annulus.
• The holder shown in the Carpentier patent, for example, includes a disk-shaped outer holder plate to which a delivery handle attaches. FIG. 11A illustrates a[0066]prior art holder180 attached to the inflow end of a mitral valve during delivery of the valve into position in anannulus182. Various means are known for obtaining access to theannulus22, such as by using a pair of retractors184 as illustrated to pull surrounding tissue away from surgical field. The outer disk-shapedplate186 of theholder180 may be seen occluding all of the mitral valve except for an outerperipheral portion188 of the sewing ring. A plurality ofsutures190 is shown extending out of the surgical field through thesewing ring188. Thesesutures190 were previously embedded in theannulus182, and threaded through thesewing ring188 at a location outside the patient. Though accomplished more conveniently outside the patient, this pre-threading operation must be done after the surgical site has been exposed, and thus time is of the essence. To prevent perivalvular leakage, the array of sutures must be relatively evenly circumferentially spaced and located along a radial line, and this delicate operation may be impeded by the relatively largesized holder body186, and attendant reduced sewing ring visibility.
• After the pre-threading is complete, the surgeon connects a[0067]handle192 to theholder180 and slides the valve and holder combination down the array ofsutures190 into position in theannulus182. Because the disk-shapedouter plate186 is so large, as seen in FIG. 11A, the surgeon cannot see the leaflets from the inflow side of the valve. Problems sometimes arise when the forwardly directed commissures of the valve become entangled in one or more of the sutures in the array. Such entanglement may be visible through the inflow end of the valve, but as mentioned, that view is blocked by theouter plate186.
• The present invention provides a holder permitting greater visibility of the valve to help alleviate the aforementioned problems associated with the time-critical processes of pre-threading and then sliding the valve and holder into place. FIG. 11B illustrates the[0068]holder20 of the present invention attached to the inflow end of a prosthetic valve having aperipheral sewing ring200. Theholder20 is as described above, and like reference numerals for the various elements will be used. Namely, theholder20 has the approximately triangular-shapedbody80 of the adjustingportion44 with three outwardly extendingtangs84 at the triangle apices. Thetangs84 feature a pair of throughholes46 through which sutures (not shown for clarity) pass to attach the adjustingportion44 to thesewing ring200 of the valve.
• The[0069]body80 includes three generallylinear sides202 extending between the tangs84 (although each side is interrupted by the aforementioned clip-receiving notches100). Thesides202 separate from and expose the surrounding portions of thesewing ring200. Indeed, thesides202 expose the inner volume of the valve, such that leaflets204 of the valve can be seen from the inflow end thereof. It will therefore be appreciated that the task of pre-threading the array of sutures around thesewing ring200 is facilitated by the increased visibility of the sewing ring provided by the triangular-shapedholder20. More specifically, the surgeon can pre-thread the array of sutures around thesewing ring200 with greater confidence that no sutures are placed too far radially inward or outward, and that they are evenly circumferentially spaced. At a minimum, the time needed to complete this task is reduced. Furthermore, as the valve is introduced to the surgical site along the array of sutures, the surgeon can inspect the leaflets204 from the inflow side thus enhancing early detection of any suture looping or entanglement that will be visible from the inflow side in the form of a deformed leaflet.
• The present invention may provide an improved valve holder as described above, or adapters as described below may be used to retrofit valve holders of the prior art. In particular, FIGS.[0070]12A-12C and13A-13C illustrate several embodiments of an adapter system of the present invention for use with a prior art valve holder such as that shown in U.S. Pat. No. 4,865,600 to Carpentier, et al. FIG. 12A shows a tissue-typemitral heart valve210 having asewing ring212, a plurality ofupstanding commissures214 withdistal tips216, and a plurality of tissue-type leaflets218 forming the occluding surfaces of the valve. A conventional holder such as shown in Carpentier, et al. includes alower plate220 configured to abut and attach to thesewing ring212, and anupper plate220 that works in conjunction with thelower plate220 to pull thecommissure tips216 of thevalve210 inward. Thelower plate220 has a generallytriangular body224 having three outwardly projectingtangs226 each with a pair of throughholes228.
• As seen in FIGS. 12B and 12C, three[0071]guide posts230 on thelower plate220 and three lockingposts232 having outwardly directedpawls234 pass through and mate withapertures236 evenly circumferentially spaced around a disk-shapedbody238 of theupper plate222. Theupper plate222 further includes three outwardly directedflanges240 having through holes aligned with the throughholes228 in thelower plate220, and three cuttingguides242 projecting upward from the disk-shapedbody238. In addition, a central internally threadedboss244 is adapted to receive a delivery handle of the prior art, such as shown at246 having a male threadedend248.
• The present invention provides an[0072]adapter250 to be interposed between thedelivery handle246 and internally threadedboss244, having a distal male threadedportion252 and a proximal female threadedportion254. The distal male threadedportion252 is configured to mate with the internally threadedboss244, while the proximal female threadedportion254 receives the threadedend248 of thehandle246.
• Use of the[0073]adapter250 is seen best in FIGS.13A-13C, and generally parallels the function of the adjustingmember50 previously described. As has been described previously, and in the earlier patent to Carpentier, et al., thelower plate220 andupper plate222 work in conjunction with the threaded delivery handle to pull thecommissure tips216 inward. FIG. 12C illustrates the twoplates220,222 separated such that a plurality of sutures connected to theupper plate222 and passing into the valve and between the commissures (seen at260) are placed in tension causing thecommissure tips216 to be pulled inward in the direction of the arrows262. FIGS.13A-13C illustrate the holder in cross-section and isolated from the valve to better illustrate this plate separation. In contrast to the present invention, in the prior art the delivery handle246 had to remain threadingly engaged with theupper plate222 to maintain the plate separation.
• In contrast, the[0074]adapter250 of the present invention permits the delivery handle246 to be removed while maintaining plate separation. FIG. 13A shows theadapter250 threadingly attached to thedelivery handle246. The combination handle246 andadapter250 is then coupled to theupstanding boss244 on theupper plate222 and advanced so that adistal end264 on the adapter contacts acentral pin266 on thelower plate220. Further advancement of thehandle246 andadapter250 combination causes separation between the lower andupper plates220,222. The separation may be limited by contact between the enlargedproximal portion254 with theupstanding boss244, or by engagement of each of the threepawls234 with corresponding features on theupper plate222, both shown in FIG. 13B. Subsequently, thedelivery handle246 may be reversed from engagement with theadapter250 and removed from the surgical site, as seen in FIGS. 12C and 13C. Theadapter250 remains in the position shown in FIG. 13C, maintaining the separation between the lower andupper plates220,222, but not interfering with the implantation operation.
• There are number of ways to ensure that the[0075]handle246 may be retracted from engagement with theadapter250 while leaving the adapter in place. For example, and as mentioned above in conjunction with the earlier embodiment, the coefficient of friction between the materials of the engaging threads can be such that thehandle246 can be easily removed. For example, theupper plate222 is typically molded from a polymer such as Delrin, and theadapter250 can be formed of a similar material to produce a relatively high coefficient of friction between the respective threads. At the same time, thehandle246 may be made of stainless-steel, for example, which produces a lower coefficient friction between themale threads248 and the female threads of theproximal adapter portion254. If theadapter250 is made a suitable polymer, such as the material of the holder, it may be coupled to the holder prior to packaging, shipping and storage. Many tissue-type heart valves are stored in a preservative solution, such as glutaraldehyde, and material of the holder andadapter250 must be able to withstand long periods of immersion in such solutions.
• Alternatively, the[0076]adapter250 may also be made of stainless-steel, with the relative coefficients of friction being favorable for reversal and removal of thehandle246. In this configuration, theadapter250 may be sold as a separate article to be coupled with existing delivery handles to retrofit prior art systems. In this manner, both thehandle246 andadapter250 are able to withstand the high temperatures of steam sterilization, and may be reused.
• Another way to ensure that the[0077]adapter250 remains coupled to theupper plate222 while thehandle246 can be removed is to provide slightly dissimilar thread patterns on the adapter and female threads of theupper plate boss244. As thehandle246 andadapter250 are threadingly engaged to theboss244, the dissimilar threads tend to bind and lock the adapter to theupper plate222. Consequently, thehandle246 can be easily reversed and de-coupled from theadapter250.
• A still further method of preventing the coupling of the[0078]adapter250 andupper plate222, while permitting removal of thehandle246, is to provide a groove, raise rib, or similar expedient on the adapter that engages with a mating feature on the upper plate. For example, although not shown, the lower surface of theproximal portion254 may include a raised radially-directed rib that mates with a groove or similar rib on the upper surface of theboss244. After the twoparts250,222 are threadingly engaged, as seen in FIG. 13B, the raised ribs interfere and prevent disengagement, at least to the extent of withstanding the torque applied upon removal of thehandle246 from engagement with theadapter250.
• A still further configuration in accordance with the present invention is illustrated FIGS.[0079]14A-14C and15. In this embodiment, anadapter280 is provided that includes a distal male threadedportion282, a proximal female threadedportion284 and a generally disk-shapedflange286 interposed therebetween. Theflange286 includes at least one distally-directed tooth orpawl288 close to a peripheral edge. Theadapter280 is shown in FIG. 14C in an orientation in which it may be coupled with a holder located below, and a handle located above. In particular, the handle will couple to the female threadedportion284, while the male threadedportion282 couples with a boss on the holder and causes the aforementioned inward movement of the associated valve commissures.
• FIG. 15 is a partial cutaway that shows engagement of the[0080]pawl288 with an upstanding feature on thevalve holder290, such as a cuttingguide292. That is, rotation of theadapter280 in the direction ofarrow294 causes thepawl288 to cam up and over the cuttingguide292. Because of the shape of thepawl288, theadapter280 cannot be rotated in the opposite direction. Thus, theadapter280 is maintained in its threading engagement with the holder, which maintains the aforementioned inward bias of the valve commissures, and permits removal of the handle. The positive engagement of thepawl288 with the cuttingguide292 ensures that theadapter280 cannot be removed from the holder once coupled thereto. The illustratedadapter280 is representative of one type of adapter that can be used to retrofit existing valve holders. Specifically, theadapter280 can be sold in combination with the valve holder, and be stored with the valve, or can be sold as a separate item to be coupled with handle at the time of surgery.
• FIGS.[0081]16A-16F illustrate portions of an alternative holder of the present invention having an alternative structure for maintaining valve commissure constriction. A segment of avalve abutment portion300 is shown interacting with a segment of an adjustingportion302. Theabutment portion300 and adjustingportion302 may in other respects be identical to those illustrated in FIGS. 4 and 5A-5B. Indeed, theabutment portion300 includes at least oneupstanding leg304 having ahook306, as described previously. In addition to theleg304, anupstanding gap retainer308 is provided, preferably adjacent thereto. Thegap retainer308 includes astop member310 having a lowerangled surface312. In preferred embodiment, there are two or more, preferably three, pairs oflegs304 andgap retainers308. Furthermore, although theleg304 andgap retainer308 are illustrated as separate elements, they may be incorporated into a single upstanding element or leg.
• FIGS.[0082]16A-16C illustrate a process of assembling the holder by insertion of theleg304 andgap retainer308 through anaperture314 provided in the adjustingportion302. As seen, theleg304 andgap retainer308 are cantilevered and spaced apart so that they may be biased toward one another and fit through theaperture314. Both thehook306 and stopmember310 are axially aligned so as to normally interfere with respective sides of theaperture314, and theleg304 andgap retainer308 must be bent to permit passage through theaperture314.
• FIGS.[0083]16D-16F illustrate operation of the holder. FIGS. 16D shows the relative positioning of thevalve abutment portion300 and adjustingportion302 during storage and shipping of the holder and attached valve. Prior to delivery of the valve along a surgical pathway, thevalve abutment portion300 and adjustingportion302 are separated so as to constrict the valve commissures, as was described previously. This separation is desirably accomplished using a handle with or without an adapter. As the adjustingportion302 moves relatively away from theabutment portion300, depicted in FIGS.16E, theaperture314 contacts the lowerangled surface312 of thestop member310 and cams the cantileveredgap retainer308 inward. Subsequently, thegap retainer308 springs upright to its relaxed position, as seen in FIGS.16F, such that thestop member310 again interferes with and contacts the face of the adjustingportion302 and prevents it from moving back toward theabutment portion300. In this manner, a simple and reliable mechanism for maintaining separation of the holder elements provides a positive stop and insurance against inadvertent commissure expansion.
• It will be appreciated that the invention has been described hereabove with reference to certain examples or preferred embodiments as shown in the drawings. Various additions, deletions, changes and alterations may be made to the above-described embodiments and examples without departing from the intended spirit and scope of this invention. Accordingly, it is intended that all such additions, deletions, changes and alterations be included within the scope of the following claims.[0084]

Claims (27)

What is claimed is:

1. A holder for a tissue-type prosthetic mitral heart valve attachable to a surgical delivery handle, the heart valve having an inflow end and an outflow end and a flow axis therebetween, the valve including an annular suture ring at the inflow end and radially flexible commissure posts circumferentially-spaced around the outflow end that support occluding tissue surfaces of the valve, comprising:

a commissure post constriction mechanism releasably attached to the sewing ring at the inflow end of the valve, the mechanism adapted to constrict the valve commissure posts radially inward from a relaxed position to a constricted position when actuated by the delivery handle, and

a retaining mechanism that retains the commissure post constriction mechanism in the constricted position after the delivery handle is removed.

2. The holder ofclaim 1 wherein the commissure post constriction mechanism comprises:

a valve abutment portion sized and shaped to abut the inflow end of the valve;

an adjusting portion coupled to the abutment portion opposite the valve and able to move with respect to the abutment portion; and

one or more filaments attached to the adjusting portion and coupled to the commissure posts that constrict the commissure posts radially inwardly upon movement of the adjusting portion with respect to the abutment portion.

3. The holder ofclaim 2 wherein the commissure post constriction mechanism further comprises:

an adjusting member coupled to the adjusting portion and adapted to move the adjusting portion with respect to the abutment portion.

4. The holder ofclaim 3 wherein the adjusting member is externally threaded, the adjusting portion including a threaded aperture for receiving the external threads of the adjusting member and being open to the abutment portion, such that upon advancement into the threaded aperture the threaded adjusting member contacts the abutment portion and forces the adjusting portion away from the abutment portion.

5. The holder ofclaim 4 wherein the valve abutment portion has a generally planar shape, and the adjusting portion has a substantially complementary planar shape to the valve abutment portion with the threaded aperture extending through an upstanding boss in the center thereof.

6. The holder ofclaim 4 wherein the adjusting member has a central longitudinal threaded bore sized to receive the threaded end of the handle.

7. The holder ofclaim 6 wherein the adjusting member and the threaded aperture in the adjusting portion cooperate to form the retaining mechanism wherein the frictional resistance to rotation therebetween is greater than the frictional resistance to rotation between the threaded end of the handle and the threaded bore of the adjusting member.

8. The holder ofclaim 7 wherein the adjusting member and the threaded aperture in the adjusting portion are each made of a polymer, and the threaded end of the handle is metal.

9. The holder ofclaim 4 wherein the adjusting member and the adjusting portion include interfering structures that engage upon advancement of the adjusting member into the threaded aperture of the adjusting portion to prevent reversal of the adjusting member therefrom.

10. The holder ofclaim 2 wherein the commissure post constriction comprises a ratchet assembly that maintains a space between the valve abutment portion and the adjusting portion and holds the commissure posts in the constricted position after the handle is detached.

11. The holder ofclaim 10 wherein the ratchet assembly comprises one or more ratchet members affixed to the valve abutment portion that each engage a complementary opening in the adjusting portion.

12. The holder ofclaim 2 wherein the commissure post constriction comprises an upstanding leg on the valve abutment portion that maintains a space between the valve abutment portion and the adjusting portion and holds the commissure posts in the constricted position after the handle is detached.

13. A method for retrofitting a holder for a tissue-type prosthetic mitral heart valve attachable to a surgical delivery handle, the heart valve having an inflow end and an outflow end and a flow axis therebetween, the valve including an annular suture ring at the inflow end and radially flexible commissure posts circumferentially-spaced around the outflow end that support occluding tissue surfaces of the valve, the holder having a commissure post constriction mechanism releasably attached to the sewing ring at the inflow end of the valve, the mechanism adapted to constrict the valve commissure posts radially inward from a relaxed position to a constricted position when actuated by the delivery handle, the method including:

providing a retaining mechanism that retains the commissure post constriction mechanism in the constricted position after the delivery handle is removed.

14. The method ofclaim 13 wherein the step of providing includes providing the retaining mechanism during the holder assembly process so that the retaining mechanism is attached to and shipped as a unit with the prosthetic valve.

15. The method ofclaim 13 wherein the step of providing includes providing the retaining mechanism separately from the holder and valve combination and the method includes coupling the retaining mechanism to the holder at the time of surgical implantation of the valve.

16. The method ofclaim 15 including packaging and selling the retaining mechanism and delivery handle as a unit.

17. The method ofclaim 13 wherein the retaining mechanism comprises an adapter that is interposed between and threadingly engaged to the holder and the handle.

18. A kit of storage and handling clips and heart valve holders for different diameter tissue-type prosthetic mitral heart valves, the heart valves each having an inflow end and an outflow end and a flow axis therebetween, each valve including an annular suture ring at the inflow end and radially flexible commissure posts circumferentially-spaced around the outflow end that support occluding tissue surfaces of the valve, the kit comprising:

a set of holders each adapted to attach to the sewing ring at the inflow end of a valve and having a generally planar portion including a plurality of tangs radiating from a central body to cover a portion of the suture ring, the tangs being radially dimensioned to correspond to the diameter of the sewing ring; and each holder including a plurality of peripheral notches in the planar portion; and

a plurality of identical storage and handling clips each having a plurality of fingers for engaging the peripheral notches in any one of the holders.

19. The kit ofclaim 18, wherein the planar portion of each holder is generally triangular in shape with the tangs at the apices, and a peripheral notch located adjacent each tang.

20. The kit ofclaim 18, wherein each clip comprises a disk portion and a handle pivotally attached to one side thereof, with the fingers extending generally axially from the other side thereof.

21. The kit ofclaim 20, wherein there are three fingers in each clip evenly disposed about the axis of the disk portion.

22. A method for replacing a heart valve, comprising the steps of:

providing a prosthetic tissue-type heart valve having an inflow end and an outflow end and a flow axis therebetween and including a suture ring affixed to a stent having commissure posts circumferentially-spaced about the flow axis for supporting occluding surfaces of the valve, the commissure posts being cantilevered generally in the outflow direction;

affixing a holder to the inflow end of the valve;

attaching a handle to the holder and simultaneously constricting the commissure posts of the valve;

inserting the valve to the target annulus of the native heart valve using the handle;

removing the handle while maintaining the commissure posts constricted;

securing the valve to the annulus; and

detaching the holder from the valve.

23. The method ofclaim 22, wherein the holder comprises:

a valve abutment portion sized and shaped to abut the inflow end of the valve;

an adjusting portion coupled to the abutment portion opposite the valve and able to move with respect to the abutment portion; and

one or more filaments attached to the adjusting portion and coupled to the commissure posts that constrict the commissure posts radially inwardly upon movement of the adjusting portion with respect to the abutment portion,

the method including moving the adjusting portion away from the abutment portion when attaching the handle to the holder so that the filaments are pulled by the adjusting portion to cause the commissure posts to constrict radially inward.

24. The method ofclaim 23 wherein the holder further includes an adjusting member coupled to both the abutment portion and the adjusting portion and adapted to transfer movement of the handle to cause the adjusting portion to move with respect to the abutment portion.

25. The method ofclaim 24, wherein the handle includes threads that engage complementary threads on the adjusting member, and the adjusting member includes threads that engage complementary threads on the adjusting portion, wherein the frictional resistance to rotation between the adjusting member and adjusting portion is greater than the frictional resistance to rotation between the handle and the adjusting member, the method including:

fully seating the handle into the adjustment member and advancing the handle and adjustment member further to cause the adjusting portion to move with respect to the abutment portion; and

reversing rotation of the handle to decouple the handle from the adjustment member without reversing the adjustment member from engagement with the adjusting portion.

26. The method ofclaim 23 wherein the abutment portion includes a ratchet member that engages a complementary opening in the adjusting portion to retain the valve in the constricted position after the handle is removed, the method including ratcheting the valve abutment portion and the adjusting portion apart.

27. The method ofclaim 23 wherein the abutment portion includes an upstanding leg having a hook that couples the valve abutment portion and the adjusting portion together and a stop member that maintains a space between the valve abutment portion and the adjusting portion to hold the commissure posts in the constricted position after the handle is removed, the method including displacing the valve abutment portion and the adjusting portion apart until the stop member engages the adjusting portion.

Images