US20040133063A1 - Methods and devices for improving cardiac function in hearts - Google Patents

Abstract

Various methods and devices are disclosed for improving cardiac function in hearts having zones of infarcted (akinetic) and aneurysmal (dyskinetic) tissue regions. The methods and devices reduce the radius of curvature in walls of the heart proximal infarcted and aneurysmal regions to reduce wall stress and improve pumping efficiency. The inventive methods and related devices include splinting of the chamber wall proximal the infarcted region and various other devices and methods including suture and patch techniques.

Description

• This application is a continuation of U.S. patent application Ser. No. 10/136,446 filed May 2, 2002, now pending, which is a continuation of 09/422,328 filed Oct. 21, 1999, now U.S. Pat. No. 6,406,420, issued Jun. 18, 2002, which is a continuation-in-part of U.S. patent application Ser. No. 09/124,286 filed Jul. 29, 1998, now U.S. Pat. No. 6,045,497, issued Apr. 4, 2000, which is a continuation-in-part of U.S. patent application Ser. No. 08/933,456 filed Sep. 18, 1997, now U.S. Pat. No. 5,961,440, issued Oct. 5, 1999, which is a continuation-in-part of U.S. patent application Ser. No. 08/778,277, filed Jan. 2, 1997, now U.S. Pat. No. 6,050,936, issued Apr. 18, 2000.[0001]
FIELD OF THE INVENTION
• The present invention pertains to the field of apparatus for treatment of a failing heart. In particular, the apparatus and its related methods of the present invention is directed toward reducing the wall stress in the failing heart. The present invention further includes methods and devices for improving cardiac function in hearts having discrete zones of infarcted tissue. Such methods and devices reduce the radius of curvature and/or alter the geometry or shape of the infarcted tissue and adjacent regions to thereby reduce wall stress on the heart and improve the heart's pumping performance.[0002]
BACKGROUND OF THE INVENTION
• The syndrome of heart failure is a common course for the progression of many forms of heart disease. Heart failure may be considered to be the condition in which an abnormality of cardiac function is responsible for the inability of the heart to pump blood at a rate commensurate with the requirements of the metabolizing tissues, or can do so only at an abnormally elevated filling pressure. There are many specific disease processes that can lead to heart failure. Typically these processes result in dilatation of the left ventricular chamber. Etiologies that can lead to this form of failure include idiopathic, valvular, viral, and ischemic cardiomyopathies.[0003]
• The process of ventricular dilatation is generally the result of chronic volume overload or specific damage to the myocardium. In a normal heart that is exposed to long term increased cardiac output requirements, for example, that of an athlete, there is an adaptive process of slight ventricular dilation and muscle myocyte hypertrophy. In this way, the heart fully compensates for the increased cardiac output requirements. With damage to the myocardium or chronic volume overload, however, there are increased requirements put on the contracting myocardium to such a level that this compensated state is never achieved and the heart continues to dilate.[0004]
• The basic problem with a large dilated left ventricle is that there is a significant increase in wall tension and/or stress both during diastolic filling and during systolic contraction. In a normal heart, the adaptation of muscle hypertrophy (thickening) and ventricular dilatation maintain a fairly constant wall tension for systolic contraction. However, in a failing heart, the ongoing dilatation is greater than the hypertrophy and the result is a rising wall tension requirement for systolic contraction. This is felt to be an ongoing insult to the muscle myocyte resulting in further muscle damage. The increase in wall stress is also true for diastolic filling. Additionally, because of the lack of cardiac output, there is generally a rise in ventricular filling pressure from several physiologic mechanisms. Moreover, in diastole there is both a diameter increase and a pressure increase over normal, both contributing to higher wall stress levels. The increase in diastolic wall stress is felt to be the primary contributor to ongoing dilatation of the chamber.[0005]
• Prior treatments for heart failure associated with such dilatation fall into three general categories. The first being pharmacological, for example, diuretics and ACE inhibitors. The second being assist systems, for example, pumps. Finally, surgical treatments have been experimented with, which are described in more detail below.[0006]
• With respect to pharmacological treatments, diuretics have been used to reduce the workload of the heart by reducing blood volume and preload. Clinically, preload is defined in several ways including left ventricular end diastolic pressure (LVEDP), or indirectly by left ventricular end diastolic volume (LVEDV). Physiologically, the preferred definition is the length of stretch of the sarcomere at end diastole. Diuretics reduce extra cellular fluid which builds in congestive heart failure patients increasing preload conditions. Nitrates, arteriolar vasodilators, angiotensin converting enzyme (ACE) inhibitors have been used to treat heart failure through the reduction of cardiac workload by reducing afterload. Afterload may be defined as the tension or stress required in the wall of the ventricle during ejection. Inotropes function to increase cardiac output by increasing the force and speed of cardiac muscle contraction. These drug therapies offer some beneficial effects but do not stop the progression of the disease.[0007]
• Assist devices include mechanical pumps. Mechanical pumps reduce the load on the heart by performing all or part of the pumping function normally done by the heart. Currently, mechanical pumps are used to sustain the patient while a donor heart for transplantation becomes available for the patient.[0008]
• There are at least four surgical procedures for treatment of heart failure associated with dilatation: 1) heart transplantation; 2) dynamic cardiomyoplasty; 3) the Batista partial left ventriculectomy; and 4) the Jatene and Dor procedures for ischemic cardiomyopathy, discussed in more detail below. Heart transplantation has serious limitations including restricted availability of organs and adverse effects of immunosuppressive therapies required following heart transplantation. Cardiomyoplasty involves wrapping the heart with skeletal muscle and electrically stimulating the muscle to contract synchronously with the heart in order to help the pumping function of the heart. The Batista partial left ventriculectomy surgically remodels the left ventricle by removing a segment of the muscular wall. This procedure reduces the diameter of the dilated heart, which in turn reduces the loading of the heart. However, this extremely invasive procedure reduces muscle mass of the heart.[0009]
• One form of heart failure, ischemic cardiomyopathy, results from the formation of one or more zones of ischemia, or infarction, of the myocardium. Infarction occurs when blood supply to the heart tissue has been obstructed resulting in a region of tissue that loses its ability to contract (referred to as infarcted tissue). The presence of infarcted tissue may lead to three conditions in the heart causing cardiac malfunction. These conditions are ventricular aneurysms (ventricular dyskinesia), non-aneurysmal ischemic or infarcted myocardium (ventricular akinesia), and mitral regurgitation.[0010]
• Ventricular aneurysms typically result from a transmural myocardial infarction, frequently due to the occlusion of the left anterior descending artery (LAD). This results in a transmural infarcted region of the apical portion of the left ventricle and anterior septal. A ventricular aneurysm is formed when the infarction weakens the heart wall to such an extent that the tissue stretches and thins, causing the left ventricular wall to expand during systole (dyskinesia). FIG. 55 illustrates a ventricular aneurysm A occurring in the apical region of left ventricle LV. As shown by the shaded region in FIG. 55, aneurysm A includes infarcted[0011]tissue24 that results in a reduced wall thickness when compared to adjacent non-infarcted wall regions, as shown by the unshaded regions in FIG. 55. FIG. 55 also shows the septal wall S partially infarcted, again shown by the shaded region. The ventricular aneurysm also may be dyskinetic, meaning that when the ventricle contracts, the aneurysm further dilates, or bulges, outward. The infarcted region of the septal wall S also may be particularly dyskinetic, especially in the case of the infarcted tissue having progressed to an aneurysm.
• The bulge resulting from an aneurysm can have several serious effects on the heart and its performance that can lead to in both morbidity and mortality. For example, because the bulge creates a geometric abnormality as well as a region of non-contracting tissue, thrombosis is more likely to occur in that region. Thrombosis is the formation of a blood clot, or thrombus, that can cause other medical complications, such as a stroke. An ischemic stroke is a blockage of blood flow to the brain that occurs when the thrombus breaks free and is ejected out of the ventricle.[0012]
• Another serious effect this bulging can have is the denigration of the heart's pumping function. The aneurysmal bulge creates problems with pumping function in at least three ways. First, the infarcted tissue does not contribute to the pumping of the ventricle because it does not contract (akinesia). To account for this loss of pumping, remaining portions of the ventricle wall may contract more to maintain cardiac output. If the infarcted region thins and progresses to an aneurysm (dyskinesia), this effect is further exacerbated by the aneurysm expanding with a portion of the blood from the ventricular contraction. This further increases the contractile requirement of the remaining functional myocardium.[0013]
• Second, the aneurysmal bulge alters the geometry of the entire ventricular chamber. Thus the ventricle develops a larger radius of curvature, which directly applies more tension to the heart wall, as characterized by LaPlace's law.[0014]
• Third, over time, the above two conditions lead the functional muscle of the ventricle to work harder than normal. This can lead to continued dilatation of the ventricle, increasing tension in the walls of the heart, with increased myocardial oxygen requirement and further progressing heart failure.[0015]
• Non-aneurysmal ischemic or infarcted myocardium (akinesia) occurs when a major coronary artery is occluded and results in infarction in the myocardial tissue, but without a bulging aneurysm. In a manner similar to an aneurysm, the akinetic ischemic or infarcted zone ceases to participate in the ventricular contraction. This results in the functioning, contractile myocardium needing to contract more to make up for the lack of contraction of the akinetic zone. Typically, the result is the entire ventricle increasing in size, which increases wall stress. Again, since the functioning myocardium must work harder, continuing progression of heart failure can occur.[0016]
• Mitral regurgitation also may result from infarcted tissue, depending on the region of the ventricle that has become infarcted or aneurysmal and any subsequent overall ventricular dilation. Mitral regurgitation is a condition whereby blood leaks through the mitral valve due to an improper positioning of the valve structures that causes it not to close entirely. If the infarcted or aneurysmal region is located in the vicinity of the mitral valve, geometric abnormalities may cause the mitral valve to alter its normal position and dimension, and may lead to annular dilatation and the development of mitral regurgitation.[0017]
• Typical treatments of infarcted tissue, and ventricular aneurysms in particular, include a variety of open surgical procedures. In the case of a ventricular aneurysm, traditionally, a “linear” aneurysmectomy is performed. This procedure involves the removal of aneurysmal portions of the anterior wall along with any thrombus that may exist. FIG. 41 illustrates the result of a conventional surgical method when an aneurysm occurs in the distal left ventricle. According to this method, the region of aneurysmal scar tissue that extends through the entire thickness of the chamber wall (transmural infarction) is removed by incision and the remaining[0018]border zone regions24′ (i.e., regions where infarcted tissue meets non-infarcted muscle) are sewn together with asuture27. In a linear aneurysm repair procedure, the ventricular septal wall S that is infarcted is left untouched. Additionally, the septal wall generally remains untouched because simple excision and suturing does not involve excluding or cutting the septal wall. Usually, only those wall portions having infarcted tissue through their thickness (transmural infarcted) are removed while the portions having infarcted tissue only on an inner wall (endocardial infarcted) are left in place. The term border zone refers to this region of endocardial infarction. This surgical procedure results in some infarcted tissue regions remaining in the heart chamber, particularly any infarcted tissue in the septal wall. The effects of the remaining non-contractile tissue stresses the remaining contractile tissue because this contractile tissue must “make up” for the non-contracting and often dyskinetic tissue. Over time, these effects can continue to lead to progression of heart failure.
• These procedures have to be performed with the patient on cardiopulmonary bypass. The heart also may be stopped in order to perform the surgery. Any thrombus inside the ventricle is removed. Clinical results of this traditional surgical procedure have been mixed with respect to improvement in cardiac function.[0019]
• Newer surgical approaches include the “Dor” and “Jatene” procedures. In the “Dor” procedure, the aneurysm is removed and an endocardial patch is placed to cover the dyskinetic septal wall portion of the aneurysm. In this manner, at least the portion of stroke volume “lost” to dyskinesia is restored. In the “Jatene” technique, a purse string suture is placed at the base of the aneurysm. The infarcted septal wall is circumferentially reduced by inbrication with sutures. The result is that most of the aneurysmal tissue is excluded from the ventricle. These procedures address the infarcted septal wall, generally left untouched in the traditional linear aneurysmectomy, by either exclusion or by the use of a surgical patch. These newer techniques are also used in cases of non-aneurysmal infarctions (akinesia). In these cases, the exclusion or elimination of the infarcted region reduces the size and therefore the radius of the chamber, thereby lowering wall stress.[0020]
• These various described techniques for treating infarcted and aneurysmal tissue regions in the heart wall suffer from limitations and drawbacks. For instance, many of the surgical techniques involve invasive incisions in the heart wall which can be traumatic and risky to patients. Also, while these procedures attempt to improve cardiac function by removal of the aneurysm or infarcted tissue, they only minimally reduce the wall stress of the remaining contractile ventricle. Furthermore, patients typically undergo cardiopulmonary bypass and/or their heart is stopped during many of these surgeries.[0021]
SUMMARY OF THE INVENTION
• The advantages and purpose of the invention will be set forth in part in the description which follows, and in part will be obvious from the description, or may be learned by practice of the invention. The advantages and purpose of the invention will be realized and attained by means of the elements and combinations particularly pointed out in the appended claims.[0022]
• Due to the drawbacks and limitations of the previous techniques for treating dilated, infarcted, and aneurysmal tissue in hearts, there exists a need for alternative methods and devices that are less invasive, pose less risk to the patient, and are likely to prove more clinically effective. The present invention provides improvements in these areas over the existing techniques.[0023]
• One aspect of the present invention pertains to a non-pharmacological, passive apparatus and method for the treatment of a failing heart due to dilatation. The device is configured to reduce the tension in the heart wall. It is believed to reverse, stop or slow the disease process of a failing heart as it reduces the energy consumption of the failing heart, decreases isovolumetric contraction, increases isotonic contraction (sarcomere shortening), which in turn increases stroke volume. The device reduces wall tension during diastole and systole.[0024]
• These apparatus of the present invention which reduce heart wall stress by changing chamber wall geometry can be referred to as “splints”. Splints can be grouped as either “full cycle splints,” which engage the heart to produce a chamber shape change throughout the cardiac cycle, or “restrictive splints,” which do not engage the heart wall at end systole to produce a chamber shape change.[0025]
• In one embodiment, the apparatus includes a tension member for drawing at least two walls of the heart chamber toward each other to reduce the radius or area of the heart chamber in at least one cross sectional plane. The tension member has anchoring members disposed at opposite ends for engagement with the heart or chamber wall.[0026]
• In another embodiment, the apparatus includes a compression member for drawing at least two walls of a heart chamber toward each other. In one embodiment, the compression member includes a balloon. In another embodiment of the apparatus, a frame is provided for supporting the compression member.[0027]
• Yet another embodiment of the invention includes a clamp having two ends biased toward one another for drawing at least two walls of a heart chamber toward each other. The clamp includes at least two ends having atraumatic anchoring members disposed thereon for engagement with the heart or chamber wall.[0028]
• In yet another embodiment, a heart wall tension reduction apparatus is provided which includes a first tension member having two oppositely disposed ends and first and second elongate anchor members. A second tension member can be provided. One of the elongate anchors may be substituted for by two smaller anchors.[0029]
• In an alternate embodiment of the heart wall tension reduction apparatus, an elongate compression member can be provided. First and second elongate lever members preferably extend from opposite ends of the compression member. A tension member extends between the first and second lever members.[0030]
• The compression member of the above embodiment can be disposed exterior to, or internally of the heart. The tension member extends through the chamber or chambers to bias the lever members toward the heart.[0031]
• In yet another embodiment of a heart wall tension reduction apparatus in accordance with the present invention, a rigid elongate frame member is provided. The frame member can extend through one or more chambers of the heart. One or more cantilever members can be disposed at opposite ends of the frame member. Each cantilever member includes at least one atraumatic pad disposed thereon. The atraumatic pads disposed at opposite ends of the frame member can be biased toward each other to compress the heart chamber.[0032]
• One method of placing a heart wall tension apparatus or splint on a human heart includes the step of extending a hollow needle through at least one chamber of the heart such that each end of the needle is external to the chamber. A flexible leader is connected to a first end of a tension member. A second end of the tension member is connected to an atraumatic pad. The leader is advanced through the needle from one end of the needle to the other. The leader is further advanced until the second end of the tension member is proximate the heart and the first end of the tension member is external to the heart. A second atraumatic pad is connected to the first end of the tension member such that the first and second atraumatic pads engage the heart.[0033]
• Yet another method of placing a heart wall tension apparatus on a heart includes the step of extending a needle having a flexible tension member releasably connected thereto through at least one chamber of the heart such that opposite ends of the tension member are external to the chamber and exposed on opposite sides of the chamber. The needle is removed from the tension member. Then first and second atraumatic pads are connected to the tension member at opposite ends of the tension member.[0034]
• In the treatment of heart failure due to infarcted tissue, possibly including an aneurysm as well, another aspect of the invention involves placing the splint relative to the infarcted or aneurysmal zone, and, in a preferred embodiment, diametrically across the infarcted or aneurysmal zone, to decrease the stress on the infarcted tissue and adjacent border zone tissue. An alternative to diametric placement of the splint includes placing one atraumatic anchor member of the splint at the center of the infarcted or aneurysmal region, extending the splint across the entire heart chamber, and placing the second atraumatic anchor member on the opposite chamber wall. In the case of infarcted or aneurysmal tissue in the vicinity of the mitral valve, an aspect of the present invention includes a method of placing the splint adjacent but below the mitral valve to draw the papillary muscles together or the walls of the valve seat together. It is also envisioned to use the splint both as the sole device for treating infarcted tissue and aneurysms or in combination with the surgical techniques described earlier.[0035]
• An external splint, using a compression member, also may be used to treat a heart having infarcted or aneurysmal tissue. The compression member is placed entirely exterior to the heart and positioned so as to result in similar effects as discussed above with reference to the splint.[0036]
• Other inventive methods and devices to treat infarcted tissue and aneurysms include a variety of patching and suturing methods and related devices. Each of these methods and related devices reduces the radius of curvature of the infarcted wall region and adjacent regions and contains the infarcted region to stop further progression.[0037]
• A further aspect of the invention involves the identification of aneurysmal and infarcted regions using any one or more of a variety of devices and methods. These devices and methods, which will be described more specifically herein, include a bipolar electrode, liquid dye injection and tracing, fiber optics, MRI, and ultrasound. These devices can be used to distinguish between healthy and infarcted heart tissue.[0038]
• In accordance with the purposes of the invention as embodied and broadly described herein, methods and related devices for treating a heart having infarcted tissue in one of its chambers are disclosed. In a preferred embodiment of the invention, a method for treating a heart having a zone of infarcted tissue in its chamber includes deforming a wall of the chamber that includes the infarcted tissue such that a radius of curvature of the wall is reduced.[0039]
• In another preferred embodiment of the present invention, the method involves providing at least one tension member having two ends and an anchor on each end. The tension member is positioned transverse to the chamber to reduce the radius of curvature of the wall of the chamber that includes the infarcted tissue and/or to draw the walls containing the infarcted tissue together.[0040]
• In another preferred embodiment, the present invention involves positioning a tension member having anchors on each of its ends transverse to the heart chamber so that the infarcted tissue is drawn toward an interior of the heart chamber. The anchors are placed exterior to the chamber.[0041]
• In yet another preferred embodiment, the present invention includes positioning a compression member having a first end and a second end, each having anchor members around an exterior of the heart. The compression member is positioned so as to surround the chamber with infarcted tissue and to reduce the radius of curvature of the portion of the heart wall that has the infarcted tissue.[0042]
• In accordance with another preferred embodiment, a method of treating a heart having infarcted tissue in one of its chambers involves epicardial suturing around the perimeter of a region of infarcted tissue and pulling free ends of the suture to draw the infarcted tissue region together. The suture is then secured to hold the infarcted tissue together. This suture also may be employed in combination with a myocardial patch or a substantially rigid enclosure member, both of which represent other preferred embodiments of the present invention.[0043]
• In accordance with another preferred embodiment of the present invention, a method of treating a heart having infarcted tissue in one of its chambers involves positioning an enclosure member around a zone of infarcted tissue. During the positioning, the enclosure member has a first configuration. After positioning, the enclosure member is then secured to a wall of the heart and the enclosure member reconfigures to a second configuration. Upon reconfiguration to the second configuration, the radius of curvature of the portion of the heart wall including the infarcted tissue reduces.[0044]
• In accordance with yet another preferred embodiment of the present invention, an apparatus for treating a heart having a zone of infarcted tissue in one of its chambers is provided. The apparatus includes an enclosure member adapted to assume a first configuration during placement of the enclosure member around an infarcted tissue zone. The enclosure member further is adapted to assume a second configuration after securing the enclosure member to a heart wall surrounding the chamber. The second configuration draws the infarcted tissue toward a center of the enclosure member and reduces the radius of curvature of the heart wall.[0045]
• In accordance with another preferred embodiment of the present invention, a device for treating a heart having infarcted tissue in one of its chambers is provided. The device includes a patch adapted to be attached to the heart, with a substantially elongated member secured to the patch. When the patch is placed over the infarcted or aneurysmal tissue region, the elongated member tends to push the infarcted tissue region toward an interior of the heart chamber.[0046]
• In accordance with yet another preferred embodiment of the present invention, a plurality of sutures are attached at one end to points on a chamber wall proximate to an infarcted tissue region and the sutures are extended up through a space defined by an enclosure member to draw the infarcted tissue together and through the enclosure member. The other ends of the sutures are then attached to points on the wall of the chamber to hold the tissue in place.[0047]
• It is to be understood that both the foregoing general description and the following detailed description are exemplary and explanatory only and are not restrictive of the invention, as claimed.[0048]
BRIEF DESCRIPTION OF THE DRAWINGS
• The accompanying drawings, which are incorporated in and constitute a part of this specification, illustrate several embodiments of the invention and, together with the description, serve to explain the principles of the invention. In the drawings,[0049]
• FIG. 1 is a transverse cross-section of the left and right ventricles of a human heart showing the placement of a splint in accordance with the present invention;[0050]
• FIG. 2 is a transverse cross-section of the left and right ventricles of a human heart showing the placement of a balloon device in accordance with the present invention;[0051]
• FIG. 3 is a transverse cross-section of the left and right ventricles of a human heart showing the placement of an external compression frame structure in accordance with the present invention;[0052]
• FIG. 4 is a transverse cross-section of the left and right ventricles of a human heart showing a clamp in accordance with the present invention;[0053]
• FIG. 5 is a transverse cross-section of the left and right ventricles of a human heart showing a three tension member version of the splint of FIG. 1;[0054]
• FIG. 6 is a transverse cross-section of the left and right ventricles of a human heart showing a two tension member version of the splint shown in FIG. 1;[0055]
• FIG. 7 is a vertical cross-sectional view of the left ventricle of a human heart showing an alternate version of the splint in accordance with the present invention;[0056]
• FIG. 8 is an end of the splint shown in FIG. 7;[0057]
• FIG. 9 is a vertical cross-sectional view of a chamber of a human heart showing another alternative embodiment of the splint in accordance with the present invention;[0058]
• FIG. 10 is a vertical cross-section of a chamber of a human heart showing another alternative configuration of splints in accordance with the present invention;[0059]
• FIG. 11 is a vertical cross-sectional view of a chamber of a human heart showing another embodiment of a splint in accordance with the present invention;[0060]
• FIG. 12 is a vertical cross-sectional view of a chamber of a human heart showing another embodiment of the splint in accordance with the present invention;[0061]
• FIG. 13 is a vertical cross-sectional view of a chamber of a human heart showing a compression member version of the splint in accordance with the present invention;[0062]
• FIG. 14 is a vertical cross-sectional view of a chamber of a human heart showing another version of the splint shown in FIG. 13;[0063]
• FIG. 15 is a vertical cross-sectional view of a chamber of a human heart showing a frame member version of the splint in accordance with the present invention;[0064]
• FIG. 16 is an end view of the splint of FIG. 15;[0065]
• FIG. 17 is a vertical cross-section of the left ventricle and atrium, the left ventricle having aneurysmal scar tissue;[0066]
• FIG. 18 is a vertical cross-section of the heart of FIG. 17 showing the splint of FIG. 1 drawing the aneurysmal scar tissue toward the opposite wall of the left ventricle;[0067]
• FIG. 19 is a vertical cross-section of the left ventricle and atrium of a human heart showing a version of the splint of FIG. 1 having an elongate anchor bar;[0068]
• FIG. 20 is a side view of an undeployed hinged anchor member;[0069]
• FIG. 21 is a side view of a deployed hinged anchor member of FIG. 20;[0070]
• FIG. 22 is a cross-sectional view of a captured ball anchor member;[0071]
• FIG. 23 is a perspective view of a cross bar anchor member;[0072]
• FIG. 24 is a cross sectional view of an alternate anchor pad;[0073]
• FIG. 25 is a cross sectional view of an alternate anchor pad;[0074]
• FIG. 26 is a perspective view of yet another alternate embodiment of an anchor pad including an anchor pad loosening device;[0075]
• FIG. 27 is a perspective view of a tension member clip;[0076]
• FIG. 28 is a cross sectional view of an alternate embodiment of a tension member clip;[0077]
• FIG. 29 is a cross sectional view of a heart including a tension member having a heat set end;[0078]
• FIG. 30 is a cross sectional view of the pad including an envelope;[0079]
• FIG. 31 shows the envelope of FIG. 30;[0080]
• FIG. 32 is a side view of a multifilament twisted cable;[0081]
• FIG. 33 is a cross sectional of the cable of FIG. 32;[0082]
• FIG. 34 is a side of a multifilament braided tension member;[0083]
• FIG. 35 is a schematic generally horizontal cross sectional view of the heart showing preferred tension member alignments;[0084]
• FIG. 36 is a idealized cylindrical model of a left ventricle of a human heart;[0085]
• FIG. 37 is a splinted model of the left ventricle of FIG. 36;[0086]
• FIG. 38 is a transverse cross-sectional view of FIG. 15 showing various modeling parameters;[0087]
• FIG. 39 is a transverse cross-section of the splinted left ventricle of FIG. 15 showing a hypothetical force distribution;[0088]
• FIG. 40 is a second transverse cross-sectional view of the model left ventricle of FIG. 15 showing a hypothetical force distribution;[0089]
• FIG. 41 is a transverse, partial cross-section of left and right ventricles showing a traditional surgical method of treating infarcted tissue regions;[0090]
• FIG. 42 is a transverse, partial cross-sectional view of left and right ventricles with an infarcted or aneurysmal region in the apical portion of the left ventricle and a splint according to an embodiment of the invention placed diametrically across the region;[0091]
• FIGS. 43[0092]a-43bare long axis cross-sectional views of left and right ventricles showing a region of infarcted tissue in a portion of the basal left ventricle and a splint according to an embodiment of the invention placed across the infarcted region;
• FIGS. 43[0093]c-43dare short axis cross-sectional views of the heart in FIGS. 43a-43bshown from the perspective of lines c-c and d-d, respectively;
• FIGS. 44[0094]a-44bare short axis cross-sectional views of the left ventricle having an aneurysm and a placement of a splint according to an embodiment of the present invention with respect to the aneurysm to treat the heart;
• FIG. 45 is a short axis cross-sectional view of the right and left ventricles having an infarcted region like that shown in FIG. 43[0095]cand an external splint device according to an embodiment of the present invention placed to treat the infarction;
• FIGS. 46[0096]a-46cshow transverse, partial cross-sectional views of a left ventricle having an infarcted region, illustrating the combined inventive method of surgical removal of the infarcted tissue and placement of a splint according to an embodiment of the present invention;
• FIG. 47 is a short axis cross-sectional view of the left and right ventricles including a view of the mitral valve with an infarcted or aneurysmal region in a portion of the basal left ventricle and a splint according to an embodiment of the invention placed in the vicinity of the mitral valve;[0097]
• FIGS. 48[0098]a-48bare short axis cross-sectional views of the left and right ventricles and a view of the mitral valve with an aneurysmal region in a portion of the basal left ventricle and an external device according to an embodiment of the invention placed in the vicinity of the mitral valve and aneurysm;
• FIGS. 49[0099]a-49bare transverse cross-sections of a left ventricle having an aneurysmal region and the placement of a staked patch according to an embodiment of the present invention;
• FIGS. 50[0100]a-50bare planar views of an infarcted or aneurysmal tissue region with a purse-string suture according to an embodiment of the present invention;
• FIGS. 51[0101]a-51care planar views of an infarcted or aneurysmal tissue region and a purse-string suture and enclosure member according to an embodiment of the present invention;
• FIGS. 52[0102]a-52care planar exterior views of the heart with an infarcted region of tissue in the left ventricle and an enclosure member according to an embodiment of the invention, showing one configuration during application of the member and a second configuration after application of the member;
• FIGS. 53[0103]a-53bare planar views of an infarcted or aneurysmal tissue region and placement of a tie enclosure according to an embodiment of the present invention;
• FIG. 54 is a planar view of yet another embodiment of an enclosure member according to an embodiment of the present invention; and[0104]
• FIG. 55 is a transverse, partial cross-section of left and right ventricles with an aneurysmal region located at an apical portion of the left ventricle and infarcted tissue along the septal wall.[0105]
DESCRIPTION OF THE PREFERRED EMBODIMENTS
• The various aspects of the invention to be discussed herein generally pertain to devices and methods for treating heart conditions, including, for example, dilatation and infarction, including infarction causing aneurysms. For the purposes of providing clarity and consistency throughout the remaining description of the invention, the following terms have the general definitions set forth below:[0106]
• “infarction” or “infarcted”: refers to myocardium (also described as tissue or muscle) that has lost its ability to contract as a result of cellular necrosis, this term can include, for example, aneurysmal tissue and scar tissue that replaces the necrotic cellular muscle tissue;[0107]
• “aneurysm” or “aneurysmal”: refers to infarcted myocardium that is dyskinetic with respect to surrounding portions of the myocardium;[0108]
• “contractile”: refers to myocardium that is not infarcted and has generally retained contractile potential, though this muscle tissue may not be fully contracting given other conditions, e.g. too much wall stress; and[0109]
• “border zone”: refers to chamber wall that has a region of infarcted tissue and a region of contractile tissue through its thickness.[0110]
• These definitions are generally consistent with the accepted definitions recognized by those skilled in the art.[0111]
• The devices of the present invention operate passively in that, once placed in the heart, they do not require an active stimulus either mechanical, electrical, or otherwise, to function. The devices alter the shape or geometry of the heart, both locally and globally, and increase the heart's efficiency by their placement with respect to the heart. That is, the heart experiences an increased pumping efficiency through an alteration in its shape or geometry and concomitant reduction in stress on the heart walls.[0112]
• The inventive devices and methods offer numerous advantages over the existing treatments for various heart conditions. The devices are relatively easy to manufacture and use, and the related surgical techniques for their implementation do not require the invasive procedures of current surgical techniques. For instance, the surgical technique does not necessarily require removing portions of the heart tissue, opening the heart chamber, or stopping the heart. For these reasons, the surgical techniques of the present invention are also less risky to the patient than other techniques.[0113]
• The devices and methods of the present invention used to treat infarcted tissue and aneurysms also are likely to be more effective than prior devices. As will be described, the inventive devices alter the shape or geometry of the chamber, either globally or locally, and reduce the radius of curvature of the chamber wall, resulting in lower stresses in the heart wall. Moreover, with many of the inventive devices there is no need to open the heart chamber to deploy the device, even when the device is deployed on the septal wall. These methods and devices also could be used in conjunction with coronary artery bypass grafting (CABG). In CABG surgery, the use of the inventive methods and related devices allow for quickly reducing stress on the myocardium, which may save “stunned” tissue, i.e., tissue that is being starved of nutrients carried with the blood flow, that otherwise may not be recoverable after a certain time period. Also, the inventive methods and device may hinder further progression or dilation of scarred, non-contractile tissue.[0114]
• The disclosed inventive methods and related devices involve geometric reshaping of the heart. In certain aspects of the inventive methods and related devices, substantially the entire chamber geometry is altered to return the heart to a more normal configuration. FIGS. 36 through 40, which will be described in further detail later, show a model of this geometric reshaping, which includes a reduction in radius of curvature of the chamber walls. Prior to reshaping the chamber geometry, the heart walls experience high stress due to a combination of both the relatively large increased diameter of the chamber and the thinning of the chamber wall. Geometric reshaping according to the present invention reduces the stress in the walls of the heart chamber to increase the heart's pumping efficiency, as well as to stop further dilatation of the heart.[0115]
• Other aspects of the inventive methods and devices involve geometric reshaping a particular area of the chamber and/or reducing the radius of curvature of the chamber wall in that area. When portions of the heart wall form a bulge due to an aneurysm, the radius of much of the heart chamber changes. This increases stress on the heart walls. Additionally, the healthy regions of the heart work harder to pump in order to make up pumping volume due to lost contractility in the infarcted tissue region. Together, these effects limit the pumping effectiveness of the heart and can contribute to further degradation of the heart. Geometrically reshaping the area of the aneurysm by, for example, reducing the radius of curvature of the wall, lowers stress on the wall regions in that vicinity and improves pumping function. In addition, the geometric reshaping permits the scar tissue to heal in a more organized fashion and reduces progression of the scar tissue into other areas and further aneurysmal bulging.[0116]
• Although many of the methods and devices are discussed below in connection with their use in the left ventricle of the heart, these methods and devices may be used in other chambers of the heart for similar purposes. One of ordinary skill in the art would understand that the use of the devices and methods described herein would be substantially the same if employed in other chambers of the heart. The left ventricle has been selected for illustrative purposes because a large number of the disorders that the present invention treats occur in the left ventricle.[0117]
• Reference will now be made in detail to the present preferred embodiments of the invention, examples of which are illustrated in the accompanying drawings. Wherever possible, the same reference numbers will be used throughout the drawings to refer to the same or like parts.[0118]
• FIG. 1 shows a transverse cross-section of a[0119]left ventricle10 and aright ventricle12 of ahuman heart14. Extending through the left ventricle is asplint16 including atension member18 and oppositely disposed anchors20.Splint16, as shown in FIG. 1, has been positioned to draw opposite walls ofleft ventricle10 toward each other to reduce the “radius” of the left ventricular cross-section or the cross-sectional area thereof to reduce left ventricular wall stresses. It should be understood that although thesplint16 and the alternative devices disclosed herein are described in relation to the left ventricle of a human heart, these devices could also be used to reduce the radius or cross-sectional area of the other chambers of a human heart in transverse or vertical directions, or at an angle between the transverse and vertical.
• Those apparatus of the present invention which reduce heart wall stress by changing chamber wall geometry can be referred to as “splints”. “Full cycle splints” engage the heart to produce a chamber shape change throughout the cardiac cycle. “Restrictive splints” do not engage the heart wall at end systole to produce a chamber shape change.[0120]
• FIG. 2 discloses an alternate embodiment of the present invention, wherein a[0121]balloon200 is deployed adjacent the left ventricle. The size and degree of inflation of the balloon can be varied to reduce the radius or cross-sectional area ofleft ventricle10 ofheart14.
• FIG. 3 shows yet another alternative embodiment of the present invention deployed with respect to[0122]left ventricle10 ofhuman heart14. Here acompression frame structure300 is engaged withheart14 atatraumatic anchor pads310. Acompression member312 having anatraumatic surface314 presses against a wall ofleft ventricle10 to reduce the radius or cross-sectional area thereof.
• FIG. 4 is a transverse cross-sectional view of[0123]human heart14 showing yet another embodiment of the present invention. In this case aclamp400 havingatraumatic anchor pads410 biased toward each other is shown disposed on a wall ofleft ventricle10. Here the radius or cross-sectional area ofleft ventricle10 is reduced by clamping off the portion of the wall betweenpads410.Pads410 can be biased toward each other and/or can be held together by a locking device.
• Each of the various embodiments of the present invention disclosed in FIGS.[0124]1-4 can be made from materials which can remain implanted in the human body indefinitely. Such biocompatible materials are well-known to those skilled in the art of clinical medical devices.
• FIG. 5 shows an alternate embodiment of the splint of FIG. 1 referred to in FIG. 5 by the numeral[0125]116. Theembodiment116 shown in FIG. 5 includes threetension members118 as opposed to asingle tension member18 as shown in FIG. 1. FIG. 6 shows yet another embodiment of thesplint216 having fourtension members218. It is anticipated that in some patients, the disease process of the failing heart may be so advanced that three, four or more tension members may be desirable to reduce the heart wall stresses more substantially than possible with a single tension member as shown in FIG. 1.
• FIG. 7 is a partial vertical cross-section of[0126]human heart14 showingleft ventricle10. In FIG. 7, anothersplint embodiment316 is shown having atension member318 extending throughleft ventricle10. On opposite ends oftension member318 are disposed elongate anchors orpads320. FIG. 8 is an end view oftension member318 showingelongate anchor320.
• FIG. 9 shows another embodiment of a[0127]splint416 disposed in a partial vertical cross-section ofhuman heart14.Splint416 includes two elongate anchors orpads420 similar to those shown in FIGS. 7 and 8. In FIG. 9, however, twotension members418 extend throughleft ventricle10 to interconnectanchors420 on opposite sides ofheart14.
• FIG. 10 is a vertical cross section of[0128]heart14 showingleft ventricle10. In this case, twosplints16 are disposed throughleft ventricle10 and vertically spaced from each other to resemble the configuration of FIG. 9.
• FIG. 11 is a vertical cross-sectional view of the left ventricle of[0129]heart14. Two alternate embodiment splints516 are shown extending throughleft ventricle10. Eachsplint516 includes twotension members518 interconnecting two anchors orpads520.
• FIG. 12 is yet another vertical cross-sectional view of[0130]left ventricle10 ofheart14. Analternate embodiment616 of the splint is shown extending throughleft ventricle10.Splint616 includes anelongate anchor pad620 and two shorter anchors orpads621.Splint616 includes twotension members618. Eachtension member618 extends betweenanchors620 andrespective anchors621.
• FIG. 13 is a vertical cross-sectional view of[0131]left ventricle10 ofheart14. Asplint50 is shown disposed onheart14.Splint50 includes acompression member52 shown extending throughleft ventricle10. Opposite ends ofcompression member52 are disposed exterior toleft ventricle10.Lever members54 extend from each end ofcompression member52 upwardly along the exterior surface ofventricle10. Atension member56 extends betweenlever members54 tobias lever members54 towardheart14 to compresschamber10.Compression member52 should be substantially rigid, butlever members54 and to somedegree compression member52 should be flexible enough to allowtension member56 to biaslever members54 towardheart14. Alternately,lever members54 could be hinged tocompression member52 such thatlever members54 could pivot about the hinge when biased towardheart14 bytension member56.
• FIG. 14 shows an[0132]alternate embodiment156 of the splint shown in FIG. 13. In thiscase lever members154 are longer thanmembers54 ascompression member152 ofsplint150 has been disposed to the exterior ofleft ventricle10.
• FIG. 15 is a vertical cross-sectional view of[0133]left ventricle10 ofheart14. An alternate embodiment250 of the splint is shown onheart14. A preferably relativelyrigid frame member256 extends throughventricle10. Disposed on opposite ends offrame256 arecantilever member254. Disposed oncantilever members254 areatraumatic pads258.Cantilever members254 can be positioned alongframe member256 such thatatraumatic pads258 press againstheart14 to compresschamber10. FIG. 16 is an end view offrame member256 showingcantilever members254 andpads258.
• It should be understood that each of the embodiments described above should be formed from suitable biocompatible materials known to those skilled in the art. The tension members can be formed from flexible or relatively more rigid material. The compression members and frame member should be formed from generally rigid material which may flex under load, but generally hold its shape.[0134]
• As will be described in more detail herein, FIG. 17 is a partial vertical cross-section of[0135]human heart14 showingleft ventricle10 and leftatrium22. As shown in FIG. 17,heart14 includes a region ofscar tissue24 associated with an aneurysm or ischemia. As shown in FIG. 17, thescar tissue24 increases the radius or cross-sectional area ofleft ventricle10 in the region affected by the scar tissue. Such an increase in the radius or cross-sectional area of the left ventricle will result in greater wall stresses on the walls of the left ventricle.
• FIG. 18 is a vertical cross-sectional view of the[0136]heart14 as shown in FIG. 17, wherein asplint16 has been placed to draw thescar tissue24 toward an opposite wall ofleft ventricle10. As a consequence of placingsplint16, the radius or cross-sectional area of the left ventricle affected by thescar tissue24 is reduced. The reduction of this radius or cross-sectional area results in reduction in the wall stress in the left ventricular wall and thus improves heart pumping efficiency.
• FIG. 19 is a vertical cross-sectional view of[0137]left ventricle10 and leftatrium22 ofheart14 in which asplint16 has been placed. As shown in FIG. 19,splint16 includes analternative anchor26. Theanchor20 is preferably an elongate member having a length as shown in FIG. 19 substantially greater than its width (not shown).Anchor bar26 might be used to reduce the radius or cross-sectional area of the left ventricle in an instance where there is generalized enlargement ofleft ventricle10 such as in idiopathic dilated cardiomyopathy. In such an instance,bar anchor26 can distribute forces more widely thananchor20.
• FIGS. 20 and 21 are side views of a hinged[0138]anchor28 which could be substituted foranchors20 in undeployed and deployed positions respectively.Anchor28 as shown in FIG. 20 includes two legs similar to baranchor26. Hingedanchor28 could include additional legs and the length of those legs could be varied to distribute the force over the surface of the heart wall. In addition there could be webbing between each of the legs to giveanchor28 an umbrella-like appearance. Preferably the webbing would be disposed on the surface of the legs which would be in contact with the heart wall.
• FIG. 22 is a cross-sectional view of a[0139]capture ball anchor30.Capture ball anchor30 can be used in place ofanchor20.Capture ball anchor30 includes adisk portion32 to distribute the force of the anchor on the heart wall, and arecess34 for receiving aball36 affixed to an end oftension member18.Disk32 andrecess34 include a side groove which allowstension member38 to be passed from an outside edge ofdisk32 intorecess34.Ball36 can then be advanced intorecess34 by drawingtension member18 through anopening38 inrecess34opposite disk32.
• FIG. 23 is a perspective view of a[0140]cross bar anchor40. Thecross bar anchor40 can be used in place ofanchors20. Theanchor40 preferably includes a disk orpad portion42 having across bar44 extending over anopening46 inpad42.Tension member18 can be extended throughopening46 and tied to crossbar42 as shown.
• FIG. 24 is a cross sectional view of an alternate embodiment of[0141]anchor pad340 in accordance with the present invention.Anchor pad340 preferably includes a disc shapedpad portion342. Disc-shapedpad portion342 includesside343, which in use is disposed toward the heart. Aconical aperture348 having slopingsides346 extends throughpad342.Collet344 is disposed withinorifice348. A threadedportion350 ofcollet344 extends fromorifice348opposite side343,nut352 is threaded over threadedportion350.Lumen345 extends throughcollet344. Atension member354 is shown extending throughlumen345.Lumen345 has a diameter such that whennut352 is not tightened on threadedportion350,tension member354 can slide freely throughlumen345. Whennut352 is tightened, it drawscollet344 away fromside343.Collet344 is then pinched betweenwalls346 oforifice348. Whencollet344 is pinched, the size oflumen345 is reduced such thattension member354 can no longer move freely withinlumen345, fixing the position ofpad340 ontension member354.
• FIG. 25 is a cross sectional view of an alternate embodiment of an[0142]anchor pad360 in accordance with the present invention.Anchor pad360 includes a generally disc-shapedpad portion362.Pad362 includes aside363 which when the pad is in use, is disposed toward the heart. Atension member lumen364 extends throughpad362.Lumen364 preferably has a generally conical shapedportion365 disposed towardside363.Tension member370 is shown disposed throughlumen364 in FIG. 25.Pad362 includes a threadedpassage366 extending from an edge ofpad362 tolumen364. Aset screw368 is threaded intopassage366. Setscrew368 can be tightened to engagetension member370 to fix the position ofanchor pad360. When setscrew368 is not tightened, the size oflumen364 is preferably large enough thatanchor pad360 can slide relatively freely overtension member370.
• FIG. 26 is a perspective view of yet another embodiment of[0143]anchor pad380 in accordance with the present invention.Anchor pad380 preferably includes a generally disc-shapedpad portion382 having afirst side383 which in use would be disposed toward the heart and asecond side385.Pad382 as well aspads342 and362 are preferably formed from a metal such as stainless steel alloys or titanium alloys.
• A[0144]tension member fastener384 is formed inpad382 by cutting a series of grooves and apertures throughpad382 fromside385 toside383. Afirst groove386 has a generally horseshoe shape.Second groove388 extends between opposite portions of horseshoe shapedgroove386 to form two oppositely disposedcantilever members387. A relativelylarge aperture394 is formed betweencantilever members387 proximate their free ends. A second andsmaller aperture390 is formed closer to the fixed ends ofcantilever members387.Tension member392 is shown extending throughaperture390.
• As shown in FIG. 26,[0145]tension member392 is clamped betweencantilever members387 such that the location ofpad382 is fixed alongtension member392.Pad382 can be released by using a spreadingdevice396 to spreadcantilever members387 apart. Spreadingdevice396 includes handle398 to spreadingarms400 each having afinger402.Fingers402 can be placed withinaperture394 then aims400 andfingers402 can be spread apart by pivoting them around apin404 such thatcantilevers387 are spread apart and pad382 can move freely alongtension member392. It can be appreciated that althoughspreader396 is shown extending transversely fromtension member392, it could also be configured such thatfingers402 do not curve transversely fromarms400 and thusspreader396 could be disposed parallel totension member392. This would be particularly desirable in a situation whereanchor pad380 was being placed through a port or window during a less invasive splint implantation procedure. It can be appreciated thatcantilever members387 can be held apart such thatpad380 can be moved alongtension member392 by placement of a temporary wedge or pin ingroove388. For example,grooves388 may include an additional small aperture disposed betweenaperture390 andaperture394 into which a pin could be placed to holdopen members387. When it is desired to fix the position ofanchor pad380 ontension member392,device396 could be used to spreadcantilever members387 to remove the pin. The cantilever members could then be released to engagetension member392.Aperture390 ofpad380 can also include a conical portion disposed towardside383 such asconical portion365 ofpad360.
• [0146]Cantilever arms384 are preferably configured such that they do not stresstension member392 beyond its elastic limit. It can also be appreciated that the force developed bycantilever members387 impinging ontension member392 is operator independent and defined by the geometry and material characteristics ofmembers387.
• FIG. 27 is a perspective view of an[0147]anchor pad360 having atension member370 extending therethrough. Afterpad360 is secured totension member370, that portion oftension member370 which extends from the side ofanchor pad360opposite side363 is preferably removed. This can be accomplished by trimmingtension member370 withwire cutter414 or scissors. Althoughanchor pad360 is used here to illustrate trimmingtension member370, it can be appreciated that in each of the embodiments disclosed herein there may be an excess portion of tension member extending from an anchor, which is preferably removed or trimmed.
• FIG. 28 is a cross sectional view of an[0148]alternate embodiment420 of a tension member cutter.Device420 includes an elongateouter tube422 having adistal end424.Tube424 defines alumen423 through which extends asecond tube430 having adistal end428. Extending distally fromdistal end428 are two cuttingarms424 and426 which are shown partially withdrawn intolumen423 and transversely restrained bydistal end424 ofouter tube422. When unrestrained bydistal end424,arms424 and426 are biased apart. Eacharm424 and426 has acutting element425 and427, respectively.Elements425 and427 are shown in contact with each other in FIG. 28. Atension member370 extends betweenarms424 and throughlumen432 ofinner tube430. Arepresentative anchor pad360 is disposedadjacent elements425 and427.Device420 of FIG. 28 is particularly useful when trimming excess tension member using less invasive techniques as it can be readily advanced over a tension member through a port or window trocar.
• FIG. 29 is a vertical cross sectional view of left ventricle B of heart A. A[0149]transventricular splint443 including atension member370 andanchor pads360 are shown disposed on heart A. To the left of heart A as shown in the figure is acoiled portion442 of tension member470. As an alternative to trimming an excess length of tension member,tension member370 could be formed from a shape memory alloy such thatportion442 could be preset to assume a coil shape when warmed to near body temperature.
• Once the length of the tension member has been adjusted, the anchors are secured in place along the tension member and the excess length of tension member removed if desired, the anchor or anchor pads are preferably secured in place on the heart. The anchor or anchor pads are secured such that relatively movement between the anchors or anchor pads and the heart is limited to reduce abrasion of the heart wall. To secure the anchor or anchor pads to heart A, a biocompatible adhesive could be placed between the pad and the heart to adhere the pad to the heart. Alternately, apertures could be provided in the pad such that sutures could be extended through the apertures and into the heart to secure the pad. In addition to sutures, the pad could include threaded apertures into which anchor screws could be advanced through the pad and into the heart wall to secure the pad to the heart.[0150]
• FIG. 30 illustrates yet another alternative approach to securing the anchors or anchor pads to the heart surface. FIG. 30 is a cross sectional view of an[0151]anchor pad340 disposed on heartA. Anchor pad340 is disposed within anenvelope446.Envelope446 includes abottom layer447 disposed betweenanchor pad340 and heart A and atop layer448 disposed on the opposite side ofanchor pad340.Layers347 and340 are held together bysutures449.Bottom layer447 is preferably a mesh or expanded PTFE which has a pore size or intranodial dimension sufficient to promote tissue ingrowth. The pore size is preferably between about 10 and about 100 microns and more preferably, between about 20 and about 40 microns. With respect to expanded PTFE, the intranodial dimension is preferably between about 10 to about 100 microns and more preferably between about 20 to about 40 microns. The top material could also be expanded PTFE or the like having a pore size which preferably does not promote ingrowth and thus resists adhesion to surrounding tissue. As an alternative embodiment, the pores could be formed directly in the pad surface.
• [0152]Envelope446 would preferably be placed aroundpad340 prior to placingpad340 ontension member354. Awindow450 can be provided to provide access tonut352 to secure pads totension member354. After tighteningnut352,window450 can be closed bysuture452. FIG. 31 is a top view ofpad340 andenvelope446 of FIG. 30. It can be appreciated that a similar envelope can be placed around the various anchor pads disclosed herein. The location of the window may have to vary, however, to provide access to the respective means for securing the anchor pads to the tension member.
• The splints of the present invention can be implanted acutely or chronically. When the splints are implanted chronically, it is particularly important that the tension member or members be highly fatigue resistant. Typical materials for the tension member can include, among other biocompatible materials, stainless steel, titanium alloys, NiTi alloys such as Nitinol or elgiloy. In a preferred embodiment, the tension member is a wire having a diameter of between 0.005 to 0.035 inches in diameter or, more preferably, between 0.01 and 0.02 inches in diameter and, most preferably, about 0.014 inches in diameter. The length of the tension member between the pads is preferably about 0.6 to 4 inches, and more preferably, between about 1 to 3 inches and, most preferably, about 2 inches. To improve the fatigue resistance of the metallic tension members, their surface can be electro-polished, buffed or shot peened. Drawing or annealing of the metal will also improve fatigue resistance.[0153]
• The tension member, in a preferred embodiment, articulates with respect to the anchor pad to reduce bending of the tension member at the pad. This can be accomplished by a ball and socket joint shown in FIG. 22, for example. The tension member itself can be made more flexible or bendable by providing a multi-filament tension member such as a braided or twisted wire cable tension member. A multifiber filament structure of numerous smaller wires can then easily, while reducing the stress level on any individual wire as compared to a solid wire of the same diameter as the multifilament bundle. Such a multi-filament tension member can be made from biocompatible materials such as, but not limited to, stainless steel, Nitinol, titanium alloys, LCP (liquid crystal polymer), SpectraJ fiber, kevlar fiber, or carbon fiber. In a preferred embodiment, the multi-filament structure is coated or covered to substantially seal the multi-filament structure. Coatings such as silicone, urethane or PTFE are preferred.[0154]
• FIG. 32 is a side view of multifilament twisted[0155]cable400.Cable400 includes a plurality of wires orfilaments402 twisted about the longitudinal axis ofcable400. FIG. 33 is a transverse cross sectional view ofcable400. In FIG. 33,cable400 includes a surroundingcoating404 not shown in FIG. 32.
• FIG. 34 is a side view of a braided[0156]multifilament tension member410.Tension member410 includes a plurality of filaments orwires412. It can be appreciated that numerous braiding patterns are known to those skilled in the art of multifilament members. It is anticipated that in a preferred embodiment,braided member410 can have an optional core of fibers running parallel to an elongate axis oftension member410. In yet another preferred embodiment,tension member410 could have a solid wire core extending parallel to and along the longitudinal axis oftension member410.
• The tension members and anchors or anchor pads are preferably bio-resistant, i.e., resistant to physiologic attack. To improve bio-resistance, tension member and/or anchors or anchor pads can be coated with carbon material such as glass, pyrolytic carbon, diamond or graphite, zirconium nitrate or oxide. Roughened or porous urethanes, silicone or polymer coatings or sheaths can be used to promote tissue ingrowth to create a biological seal. Hydrophilic and albumin coatings can also be used. Drugs incorporated into a binder coating can also be used to reduce biological attack on the splint and irritation of tissue by the splint. Such drugs include heparin, coumadin, anti-inflammatory steroid or ASA-aspirin. The oxide layer of the underlying metal could also be optimized to improve bio-resistance. This is particularly true for stainless steel, titanium, or nickel titanium on which an oxide layer can be formed by heating the component to improve biocompatibility. Further coatings include calcium hydroxy appetite, beta tricalcium phosphate and aluminum oxide can be applied to the tension member. The tension member and/or pad or anchor pad can at least be, in part, formed from titanium to enhance electronegativity.[0157]
• The anchors or anchor pads and, particularly the tension members are biocompatible, preferably antithrombogenic and made to prevent hemolysis. The coatings used to enhance bio-resistance described above can generally be used to improve biocompatibility. Since the tension member is exposed to significant blood flows through the left ventricle, in a preferred embodiment, the tension member has a generally small size and shape elliptical cross sectional shape to reduce turbulence or drag over the tension member. If such elliptical, transverse cross section tension member were used, it can be appreciated that the narrow end would be preferably oriented toward the direction of blood flow. It is also desirable to select a tension member material and shape which would not vibrate at resonant frequency under the influence of blood flow.[0158]
• Where the tension member passes through the heart wall, various approaches can be taken to reduce or prevent bleeding. For example, the surface of the anchor or anchor pad and/or tension member in contact with the heart wall can be coated or include an ingrowth inducing covering such as collagen, dacron, expanded PTFE or a roughened/porous surface. A clotting inducing substance may also be bound to the tension member and/or anchor or anchor pads, such as avitene or collagen. It is also contemplated that the portion of the heart wall where the tension member passes through could be cauterized. In a preferred embodiment, the tissue can be cauterized by heating the tension member. A glue such as cyanoacrylate can also be disposed between the tension member and the heart wall to reduce or prevent bleeding from the heart wall. Mechanical means such as an O-ring or compression fitting could also be disposed between the heart wall and the tension member to reduce bleeding. A purse string suture can be placed on the heart, around the tension member adjacent the pad as well.[0159]
• The tension member is preferably flexible enough to allow for changing interface conditions between the heart and the splint, and alternating pad orientation throughout the cardiac cycle. The flexibility should be sufficient enough to avoid injury to the heart or bleeding. It is also preferable that if the heart were to contract sufficiently enough to put the tension member in compression that it would readily buckle. Buckling could be promoted by providing a ribbon shaped tension member, chain link tension member, thin wire tension member, bent tension member or multi-filament tension member.[0160]
• The tension member is preferably radiopaque, echo cardiographic visible, or MRI compatible or includes a marker which is radiopaque, echo visible, or MRI compatible. The preferred locations for markers would include the center of the tension member and at the ends of the tension member disposed at the heart walls. The radiopaque markers could be gold or platinum or other biocompatible metal or heavy metal filled polymeric sleeves. With respect to echo compatible or MRI compatible tension members or markers, the tension or marker are preferably non-interfering or visible. Having radiopaque echo compatible or MRI compatible tension members or markers is particularly desirable for follow-up, non-invasive monitoring of the tension member after implantation. The presence of the tension member can be visualized and the distance between two or more markers measured. Integrity of the tension member can be confirmed as well.[0161]
• In a preferred embodiment, the tension member is not conductive to the action potential of muscle. This can be accomplished by insulating the tension member, anchor and/or anchor pad interface or fabricating the tension member anchor and/or anchor pad from a non-conductive metal such as titanium.[0162]
• In addition to monitoring the performance of the tension member by visualization techniques such as fluoroscopy or echo imagery, sensors can advantageously be incorporated into the splints. For example, a strain gauge can be disposed on a tension member to monitor the loading on the member in use. Strain can be related to load as known to those skilled in the art by developing a stress/strain relationship for a given tension member. The strain gauge can be connected by a biocompatible lead to a conventional monitoring device. A pressure gauge formed from, for example, piezo electric material can also be disposed on the tension member to monitor filling pressures or muscle contractility.[0163]
• In a preferred embodiment, a tension member can be slidably enclosed within a tube. If the tension member were to fail, the tube would contain the tension member therein.[0164]
• It is anticipated that the tension member could be connected to a pacing lead. In such an instance, if the tension member were conductive, pacing signals could be conveyed along the tension member from one heart wall to another.[0165]
• In use, the various embodiments of the present invention are placed in or adjacent the human heart to reduce the radius or cross-section area of at least one chamber of the heart. This is done to reduce wall stress or tension in the heart or chamber wall to slow, stop or reverse failure of the heart. In the case of the[0166]splint16 shown in FIG. 1, a cannula can be used to pierce both walls of the heart and one end of the splint can be advanced through the cannula from one side of the heart to the opposite side where an anchor can be affixed or deployed. Likewise, an anchor is affixed or deployed at the opposite end ofsplint16. Additional methods for splint placement are described in more detail in U.S. patent application Ser. No. 09/123,977, filed on Jul. 29, 1998 and entitled “Transventricular Implant Tools and Devices” and incorporated herein by reference.
• It can be appreciated that the methods described above to advance the tension members through the ventricles can be repeated to advance the desired number of tension members through the ventricle for a particular configuration. The length of the tension members can be determined based upon the size and condition of the patient's heart. It should also be noted that although the left ventricle has been referred to here for illustrative purposes, that the apparatus and methods of this invention can also be used to splint multiple chambers of a patient's heart as well as the right ventricle or either atrium.[0167]
• FIG. 35 is a schematic view of generally horizontal cross section of heart A including left ventricle B and right ventricle C. Also shown are left anterior descending artery E, posterior descending artery F, obtuse marginal artery G, postero-medial papillary muscle H and antero-lateral papillary muscle I. Shown in FIG. 35 are three generally horizontal preferred alignments for tension member placement for the splints of the present invention when used for the purpose of treating ventricular dilatation. These alignments generally met three goals of splint positioning including good bisection of the left ventricle, avoidance of major coronary vessels and avoidance of valve apparatus including chordae leaflets and papillary muscles.[0168]Alignment420 can be referred to as the anterior/posterior (AP) position.Alignment422 can be referred as the posterior septal/lateral wall (PSL) position.Alignment424 can be referred to as the anterior septal/lateral wall (ASL) position.
• It can be appreciated that the alignments shown are illustrative only and that the alignments may be shifted or rotated about a vertical axis generally disposed through the left ventricle and still avoid the major coronary vessels and papillary muscles. When the alignment passes through a substantial portion of right ventricle C, it may be desirable to dispose not only two pads on the exterior of the heart at opposite ends of a tension member, but also a third pad within right ventricle C on septal J. The spacing between the third pad and the pad disposed outside the heart proximate left ventricle B preferably defines the shape change of left ventricle B. This will allow the spacing of the third pad relative to the pad disposed outside the heart proximate right ventricle C to define a shape change if any of right ventricle C in view of the spacing between those pads. With the alignments as shown in FIG. 35, the third pad will be unnecessary. It is likely, however, that with[0169]alignments422 and424 in order to achieve the desired shape change of left ventricle B, the exterior pad of the wall proximate the right ventricle C will be drawn into contact with septal J. This will consequently somewhat reduce the volume of right ventricle C.
• FIG. 36 is a view of a cylinder or[0170]idealized heart chamber48 which is used to illustrate the reduction of wall stress in a heart chamber as a result of deployment of the splint in accordance with the present invention. The model used herein and the calculations related to this model are intended merely to illustrate the mechanism by which wall stress is reduced in the heart chamber. No effort is made herein to quantify the actual reduction which would be realized in any particular in vivo application.
• FIG. 37 is a view of the[0171]idealized heart chamber48 of FIG. 36 wherein the chamber has been splinted along its length L such that a “figure eight” cross-section has been formed along the length thereof. It should be noted that the perimeter of the circular transverse cross-section of the chamber in FIG. 36 is equal to the perimeter of the figure eight transverse cross-section of FIG. 37. For purposes of this model, opposite lobes of the figure in cross-section are assumed to be mirror images.
• FIG. 38 shows various parameters of the FIG. 1 cross-section of the splinted idealized heart chamber of FIG. 37. Where l is the length of the splint between opposite walls of the chamber, R[0172]₂is the radius of each lobe, θ is the angle between the two radii of one lobe which extends to opposite ends of the portion of the splint withinchamber48 and h is the height of the triangle formed by the two radii and the portion of the splint within the chamber48 (R₁is the radius of the cylinder of FIG. 36). These various parameters are related as follows:
• h=R[0173]₂COS (θ/2)
• l=2 R[0174]₂SIN (θ/2)
• R[0175]₂=R₁π/(2π−θ)
• From these relationships, the area of the figure eight cross-section can be calculated by:[0176]
• A₂=2π(R₂)²(1−θ/2π)+hl
• Where[0177]chamber48 is unsplinted as shown in FIG. 36 A₁the original cross-sectional area of the cylinder is equal to A₂where θ=1801, h=0 and l=2R₂. Volume equals A₂times length L and circumferential wall tension equals pressure within the chamber times R₂times the length L of the chamber.
• Thus, for example, with an original cylindrical radius of four centimeters and a pressure within the chamber of 140 mm of mercury, the wall tension T in the walls of the cylinder is 104.4 newtons. When a 3.84 cm splint is placed as shown in FIGS. 37 and 38 such that l=3.84 cm, the wall tension T is 77.33 newtons.[0178]
• FIGS. 39 and 40 show a hypothetical distribution of wall tension T and pressure P for the figure eight cross-section. As θ goes from 1801 to 01, tension T[0179]_S, in the splint goes from 0 to a 2T load where the chamber walls carry a T load.
• In yet another example, assuming that the chamber length L is a constant 10 cm, the original radius R[0180]₁, is 4 cm, at a 140 mmHg the tension in the walls is 74.7 N. If a 4.5 cm splint is placed such that l=4.5 cm, the wall tension will then be 52.8 N.
• When a splint is actually placed on the heart, along an alignment such as those shown in FIG. 35, the length l between the two pads as measured along the tension member is preferably 0.4 to about 0.8 and more preferably between about 0.5 to about 0.7 and most preferably about 0.6 times the distance along the length of the tension member at end diastole if the pads were not secured to the tension member and provided no resistance to expansion of the heart. A more detailed discussion of tension member length can be found in U.S. patent application Ser. No. 09/123,977, filed on Jul. 29, 1998 and entitled “Transventricular Implant Tools and Devices” which is incorporated herein by reference.[0181]
• As mentioned earlier, FIG. 17 is a partial vertical cross-section of[0182]human heart14 showingleft ventricle10 and leftatrium22. As shown in FIG. 17,heart14 includes a region ofscar tissue24 associated with an aneurysm. Theaneurysmal scar tissue24 increases the radius or cross-sectional area ofleft ventricle10 in the region affected by the scar tissue. Such an increase in the radius or cross-sectional area of the left ventricle will result in greater wall stresses on the walls of the left ventricle, especially those walls adjacent to the aneurysm.
• In addition to the various uses of the splint to treat ventricular dilatation as heretofore discussed, the inventive splint also can be used to treat infarcted tissue or aneurysms occurring on the heart wall, as illustrated by FIGS. 18 and 42-[0183]44,46, and47. These figures show various placements of a splint to treat infarcted tissue or aneurysms. It is to be understood that variations of these placements that have similar effects are within the scope of this invention.
• FIG. 42 illustrates a method for placing a splint of the present invention to treat a heart with infarcted tissue, including an aneurysm. The particular aneurysm A shown in FIG. 42 affects the ventricular septal wall. FIG. 42 shows a partial transverse cross-section of a human heart having an aneurysm A (shown by shading) in the left ventricle wall. It is contemplated that the methods and devices of this invention also apply to treatment of hearts with akinetic scar tissue that has not progressed past an infarcted stage and into an aneurysmal stage, in which case there would be little or no bulging of the heart wall. Such a condition is shown in FIGS. 43[0184]a-43dto be described shortly. In FIG. 42,splint16 is placed diametrically across aneurysm A to lessen the load carried by the transmuralinfarcted tissue24 forming aneurysm A, as well as any adjacent border zone tissue that may be present. The border zone (although not shown in FIG. 42) is the portion of the heart wall which has a mix ofcontractile tissue24″ andinfarcted tissue24.Anchors20 ofsplint16 are located on the outside of the chamber walls and are placed generally adjacent to the portions of the chamber wall that transition frominfarcted myocardium24 to regions ofcontractile myocardium24″.Tension member18 extends through the heart chamber with each of its ends connecting to opposing anchors20.Anchors20, especially when used to anchorsplint16 on septal wall S, can be of the self-deploying type disclosed in co-pending application U.S. Ser. No. 09/123,977, filed Jul. 29, 1998, entitled “Transventricular Implant Tools and Devices,” the complete disclosure of which is incorporated herein by reference.
• [0185]Splint16 reduces the radius of curvature of the aneurysmal region A and the adjacent regions of the chamber wall. By reducing the radius of curvature in these regions,contractile regions24″ of the myocardium that were under high stress due to geometric abnormalities associated with an aneurysmal region A are relieved from that high stress, thereby resulting in increased pumping ability upon contraction. Even if the infarcted tissue has not led to bulging of the heart wall, reducing the radius of curvature helps to reduce some of the stress in the adjacent contractile myocardium. By increasing the pumping ability of thecontractile myocardium24″, the heart can more easily pump the required blood flow output, helping to offset the pumping lost by theinfarcted muscle24. Those regions of the chamber wall that have only endocardial infarcted tissue, that isborder zone regions24′, likely will experience an increase in their ability to contract and contribute to pumping.
• It is also contemplated to use more than one splint, and splints having different lengths, to optimize the reduction in the radius of curvature of infarcted and aneurysmal regions and adjacent regions. Another contemplated mode of the invention includes closing off the infarcted or aneurysmal region completely by shortening the splint so that the walls adjacent the anchors contact each other. Closing off the infarcted or aneurysmal tissue from the rest of the heart chamber in this way renders this tissue completely non-functional with respect to contributing to the pumping. Shortening the splint to achieve contact of the heart walls may also reduce the risk of embolic thrombus because no blood would be expected to flow into the excluded region. Additionally, the need to remove any thrombus already adhered to the heart wall may be unnecessary because the thrombus would have no way of escaping back into the heart chamber to cause stroke or other malfunctions. If the infarcted or aneurysmal tissue extends to the septal wall of the chamber, the splint would be placed across the chamber so as to exclude the non-contractile tissue of the septal wall as well.[0186]
• As described earlier, FIG. 18 is a vertical cross-sectional view of[0187]heart14 as shown in FIG. 17. FIG. 18 depicts another method of the present invention, whereinsplint16 is placed to draw aneurysm A toward an opposite wall ofleft ventricle10. Ananchor20 ofsplint16 is placed on the outside wall ofheart14, approximately at the center of theinfarcted tissue24 forming aneurysmA. Tension member18, connected to this anchor, is then extended across the chamber of the heart to the opposite wall and connected to anotheranchor20 placed on the outside chamber wall to securesplint16. The radius or cross-sectional area of the left ventricle affected by theinfarcted tissue24 is thereby reduced. The reduction of this radius or cross-sectional area results in reduction in the stress in the left ventricular wall and thus improves heart pumping efficiency. Furthermore,infarcted tissue24 is supported byanchor20 of the splint to prevent any additional bulging of the wall or progression of the infarcted tissue to other areas of the myocardium.
• Bringing[0188]infarcted tissue24 into the chamber, as shown in FIG. 18, likely reduces the risk of thrombosis due to contact between the endocardial infarcted tissue and circulating blood flow occurring in these regions of the chamber. Clots are less likely to form on tissue that is subject to an active flow of blood. The forces associated with such flow diminish stagnation points that allow clots to form and adhere to the wall more readily.
• FIGS. 43[0189]a-43ddepict the use ofsplint16 to treat a heart chamber having a discrete zone of akineticinfarcted myocardium24 that has not yet developed into an aneurysm. FIGS. 43aand43bdepict a long axis (or essentially vertical) cross-sectional view of the heart, with FIG. 43bshowing the placement ofsplint16. FIGS. 43cand43dshow the heart in short axis (or essentially horizontal) cross-section, with placement ofsplint16 shown in FIG. 43d. In FIGS. 43band43d,splint16 is shown treating a heart includinginfarcted tissue24 that does not affect septal wall S. Thus, bothanchors20 are placed on exterior wall portions of left ventricle LV. However, it is contemplated that a splint could be used to alter the geometry of the chamber in cases in which an infarcted region does affect septal wall S.
• By utilizing[0190]splint16, the radius of curvature, particularly with respect to the short axis direction, is reduced. This reduction of curvature facilitates the pumping ability of any portions near theinfarcted region24 that have some contractile potential by reducing wall stress in the region. By allowing this once marginally contractile tissue to increase its contractile ability, the heart improves its ejection fraction, cardiac reserve, and muscle contractibility. Additionally, the remainder of the ventricle also experiences a reduced radius of curvature, as shown in FIGS. 43band43d, further facilitating the contractile ability of the entire ventricle. By improving the contracting ability of the entire chamber, the heart has the ability to account for the lost pumping ability of theinfarcted myocardium24. Left untreated, this condition causes the rest of the ventricle to attempt to contract more, ultimately over-working and weakening the heart to a greater degree.
• FIGS. 44[0191]a-44bshow a cross-sectional view of the left ventricle with an aneurysmal region A. As shown in FIG. 44b,splint16 can also be placed such that oneanchor20 engages approximately the center of the bulge formed by aneurysmA. Tension member18 is then extended through the center of aneurysm A and across left ventricle LV to anchorsplint16 to a point on the surrounding heart wall substantially opposite to aneurysm A. This positioning ofsplint16 tends to bring the aneurysmal bulge in line with the normal curvature of the heart wall. By this placement ofsplint16, it is expected that greater blood flow would occur in the region of aneurysmal tissue A, potentially reducing thrombus formation.
• FIG. 45 shows the use of a completely external device to treat a heart having a zone of[0192]infarcted tissue24. In the embodiment shown in FIG. 45, the external splint device is an external frame generally in the form of aclamp17 withanchor pads21 on each end of the clamp. Theclamp17 is configured to exert a compressive force on the heart wall to cause shape change of the heart chamber. Other external splint devices, in addition to clamp17, that are contemplated for use in treating a heart having infarcted myocardium are disclosed in co-pending U.S. patent application Ser. No. 09/157,486, filed Sep. 21, 1998, and entitled “External Stress Reduction Device and Method,” the complete disclosure of which is incorporated herein by reference. In addition to the benefits described above with respect to using a splint to treat a heart having infarcted tissue, external splint devices such as that shown in FIG. 45 include the potential further advantage of significantly reducing the possibility of thrombus formation resulting from surfaces of devices that contact blood flowing through the chamber.
• Another use for[0193]splint16 in treating heart chambers having infarcted or aneurysmal tissue is shown with reference to FIGS. 46athrough46c. This method combines the use ofsplint16 with the traditional surgical technique in which the infarcted tissue is removed. By using the techniques described later for identifying and distinguishing between healthy tissue and infarcted tissue, all of theinfarcted myocardium24 shown in FIG. 46acan be excised from the chamber, as shown in FIG. 46b. The separated portions of the chamber walls will then be sutured back together.Splint16 is then placed diametrically transverse to the portion ofheart chamber walls24″ that have been partially excised, as shown in FIG. 46c.Anchors20 are placed between the portions of the chamber wall from whichinfarcted tissue24 was removed and portions of the chamber wall that contained contractile tissue throughout its thickness. Because onlycontractile tissue regions24″ would remain after this procedure, as opposed to conventional surgery which leaves some of the infarcted tissue occurring in border zone regions in place, contractile function, and thus cardiac function, likely would improve.Splint16 reduces the radius of curvature in those thinner regions of the walls that remain after the surgery, allowing them to produce stronger contractions and relieving stress in those wall portions.
• If the infarcted tissue is not removed, as shown in FIG. 42, the border zone cannot contribute significantly to the pumping function, for the contractile muscle must contract against the stiffness of the infarcted muscle. But, with the infarcted tissue removed, the thin contractile section of myocardium shown in FIG. 46[0194]ccan be made to contract and contribute to pumping, particularly sincesplint16 has reduced stress enough to allow the thin region of tissue to exert the required pressure to pump. In addition to combining the surgical excision of the infarcted tissue with the use of a splint of the present invention, an external device, likeclamp17 shown in FIG. 45, can also be combined with the surgical technique. Such an external device would be placed with respect to the heart chamber walls such that its anchors are disposed in the approximate locations asanchors20 onsplint16, and the device between the anchors could extend around the portions of the walls that have been sutured together. It is contemplated that thesplint16 could be used in hearts where the aneurysm involves the septal wall of the ventricle. Similar to the splinting shown in FIG. 42, one or both anchor pads could be self-deploying.
• Another use of the splint to treat infarcted or aneurysmal tissue near the base of a mitral valve MV is shown in FIG. 47. In this embodiment, the splint is placed such that its[0195]anchors20 are diametrically opposed to one another across an aneurysm, or generally dilated annular region, located in a portion of the basal left ventricle in the vicinity of mitral valve MV.Anchors20 are placed on the outer wall of left ventricle LV withtension member18 ofsplint16 drawn through the heart chamber and diametrically across the infarcted or aneurysmal region. The dotted line oftension member18 shown in FIG. 47 illustrates thatsplint16 lies below mitral valve MV. Placing the splint in this manner results in the papillary muscles P of mitral valve MV or the leaflets of mitral valve MV being drawn together and reduces the risk of mitral regurgitation. In addition,splint16 reduces the radius of curvature of the aneurysmal or infarcted region. As previously described, this reduction lowers the stress in the heart wall, improving pumping effectiveness. FIG. 47 shows the placement ofsplint16 such that both anchors are disposed on external walls of the left ventricle. It should be noted that the splint also could be placed so that one anchor is disposed on septal wall S, in which case a self-deploying anchor preferably would be used. Also,tension member16 may be made to curve betweenanchors20 in order to avoid damaging internal structures of the ventricle.
• FIGS. 48[0196]a-48bshow the use of an external splint device to treat a heart having an aneurysm A in the vicinity of mitral valve MV. As a result of the aneurysm, the anterior leaflet AL and posterior leaflet PL of mitral valve MV have separated causing mitral regurgitation, as shown in FIG. 48a. FIG. 48bshows the placement of an external splint device having aclamp portion19 connecting twoanchors25. It is contemplated that the external splint device used to treat this particular heart condition may also include aprotrusion19′ as part ofclamp portion19. In placingclamp19 on the heart,protrusion19′ engages aneurysm A so as to push aneurysm A toward a center of the ventricle. Additionally, a stabilizingbar23 could be attached to the end ofprotrusion19′. Stabilizingbar23 is configured to extend through the heart chamber wall and anchor to the edge of posterior leaflet PL of mitral valve MV to bring the leaflet in close proximity to anterior leaflet AL. Such a stabilizing bar may be made of a semi-rigid, or rigid, material such as implantable metals or other suitable material. While FIGS. 48 and 49 show the use of various splints associated with an aneurysm in the vicinity of the mitral valve, it is contemplated to utilize splints also in the case where there is no true aneurysm, but an area of infarcted tissue near the mitral valve.
• The present invention also includes myocardial patches and related methods used to treat aneurysms. FIGS. 49[0197]a-49billustrate one preferred embodiment of the invention. FIG. 49ashows left ventricle LV with an aneurysm A in a portion of the chamber wall. FIG. 49billustrates placement of a stakedpatch72 according to an embodiment of the present invention used to treat aneurysmal bulge A. Stakedpatch72 includes apatch70, made of Dacron or PTFE for example, and an elongated member71 secured to the patch. When stakedpatch72 is secured into position (by sutures or the like) over the surface of aneurysmal bulge A, elongated member71 pushes on the aneurysmal tissue region. Stakedpatch72 pushes bulge A into the heart chamber. This pushing likely will result in an even further reduction in the stresses experienced by the adjacent heart wall due to the reduction in the radius of curvature resulting from drawing adjacent regions in toward each other when the patch is in place. Such further reduction in stress would tend to promote a more organized healing of the scar tissue region and prevent progression of the scar into other healthy myocardium. Additionally, by pushing the bulge into the chamber space, thrombosis is less likely to occur because of the active blood flow past the surface of the bulge.
• As shown in FIG. 49[0198]b, stakedpatch72 has a single stake71 secured to the patch in a substantially perpendicular direction. However, it is contemplated that several stakes could be secured to the patch depending on the size of the affected tissue area to be treated. Additionally, stakes could be secured in various orientations, including skewed orientations, relative to the patch. The stakes have different sizes in order to optimize the degree and direction in which the bulge is pushed in, especially when the bulge has a non-uniform surface configuration. The stakes may be rigid or semi-rigid and may be manufactured from implantable metals and polymers, or other suitable materials of similar characteristics.
• A three-dimensional patch also is contemplated by the present invention. Such a patch could be inflatable or solid. The patch would consist of an essentially flat surface configured to lie flush with the epicardial surface and a bulging surface that would engage with the aneurysmal region to push the aneurysm into the chamber in a manner similar to the stake described above. A suture ring may be placed around the perimeter of the flat surface to secure the patch into place on the heart.[0199]
• A further embodiment of the present invention is a shrinkable patch for treating aneurysms. For example, such a patch may be made of heat-shrinkable material and applied via sutures to the aneurysmal tissue region while the tissue is in a relaxed state. Gentle heat, such as that produced by, for example, a hot air gun, an infrared heating lamp, or other similar heating mechanisms, would then be applied to shrink the patch. This shrinking also will cause the size of the affected area to be decreased by being pulled in tightly with the shrinking patch, thereby reducing the radius of curvature of the adjacent myocardium. The patch may be made of any suitable material compatible with the human body and having heat-shrinking characteristics. Examples of such a material include oriented polyethylene, oriented polypropylene, and a woven Dacron polyester of partially-oriented yarn. Partially-oriented yarn is capable of significant longitudinal shrinkage when heated. Additionally, targeting and heating certain areas yields a non-uniform shrinking that more precisely tailors the resulting configuration of the patch and the affected tissue region.[0200]
• Another embodiment of the present invention, which may be used either alone or in combination with a patch, is a purse-[0201]string suture50, as shown in FIGS. 50a-50b. In this embodiment, asuture50 is placed to encircle theaffected tissue area24, as shown in FIG. 50a.Suture50 has free ends51 that are pulled to draw insuture50 and reduce the perimeter of the affected tissue, as shown in FIG. 50b. Free ends51 are then secured so as to keep the gathered tissue region in place. The securing can be accomplished by tying free ends51 to one another or by some like means. By gathering the infarcted tissue together and reducing the perimeter, tension in the walls adjacent to theinfarcted tissue24 decreases due to the reduction in radius of the wall in that region. Thus, improved contractile function of the adjacent tissue is expected. Purse-string suture50 could be drawn in to such an extent that the outer walls of the perimeter ofinfarcted tissue24 contact each other. Drawing theinfarcted tissue24 to this extent cuts off the tissue completely from the rest of the heart chamber and renders it non-functional. In addition to the purse-string suture50, a patch may be applied to support any bulging tissue area that remains after application ofsuture50, as well as provide a more secure means of maintaining the gathered portions of the myocardium.
• FIGS. 51[0202]a-51cillustrate a further embodiment of the present invention, the combination of a purse-string suture and anenclosure member60. In this embodiment, purse-string suture50 is applied to infarcted oraneurysmal tissue24 as described above with reference to FIGS. 50a-50b. After the suture is pulled tight to gather the affected tissue region in, anenclosure member60 is secured into place. As shown in FIG. 51c,enclosure member60 is placed around the gatheredtissue24 so that substantially all of the infarcted tissue is contained insideenclosure member60. In a preferred form of the invention, sutures are used to secure theenclosure member60 into place, however other securing means are also contemplated.Enclosure member60 preferably is made from a substantially rigid material, for example stainless steel, semi-rigid material, or any other material exhibiting like characteristics such as, for example, polyamide imide, titanium, or ultra high molecular weight polyethelene, in order to carry the load created by the gathered infarcted tissue. Because of its relative rigidity,enclosure member60 withstands the load of the gathered tissue better than sutures alone and contains the progression of the infarcted tissue. Although FIG. 51cshows a ring asenclosure member60, other shapes may be used to serve the inventive purposes. Overall, regardless of the shape ofenclosure member60, its perimeter should be selected to have approximately the same shape as the perimeter of the infarcted tissue region once it has been gathered together by purse-string suture50.
• Another enclosure device is shown in FIGS. 52[0203]a-52c. FIG. 52ashows aregion24 of infarcted myocardium on left ventricle LV. Other heart structure shown in these figures includes the right ventricle RV, the right atrium RA, the superior and inferior vena cavas, and the aorta. Theinventive enclosure member61 of FIGS. 52a-52cis configured to change from a circular shape to an elliptical or oval shape. Such an enclosure member can be fabricated from a shape memory alloy, such as nitinol, or other similar suitable material, and processed such that it has a circular shape at a temperature below its transformation temperature, which is approximately equal to body temperature. Upon reaching the transformation temperature, the ring, comprised of the shape memory material, alters its configuration to the shape of an ellipse or oval, or other suitable configurations. During surgical application, the temperature of the heart is below body temperature and therefore ring61 remains in the circular shape during application ofring61 to the heart, as shown in FIG. 52b. After installation of the ring is complete, the heart reaches normal body temperature, transformingring61 into the elliptical or oval shape, as shown in FIG. 52c. This shape transformation deforms the infarcted region of tissue on the heart wall to change the shape and/or size of the heart chamber, relieve stress on the heart walls, and improve overall contractile function of the heart. In a preferred embodiment,infarcted region24 deforms in a short axis direction, as shown in FIG. 52c.
• Alternatively,[0204]enclosure member61 can be formed of a spring metal, such as, for example, high tensile strength stainless steel. When such a material is used, the enclosure member is initially processed into the elliptical or oval configuration. The enclosure member is then attached around a circular polymer, or other suitable material, sheet to form and maintain a circular shape during attachment of the ring to the ventricle. Once attached, the circular polymer sheet is removed, causing the enclosure member to spring back to its original elliptical shape.
• Other embodiments of the present invention include enclosure members that deform non-uniformly, either by having a non-uniform configuration at the shape memory transformation temperature, or at the initial processing shape of the spring metal. It also should be noted that[0205]enclosure member61 can take on any suitable shape both before application and after, depending on such factors as, for example, the particular infarcted region to be treated and the desired final radius of curvature.
• FIGS. 53[0206]a-53billustrate a tie enclosure, a further embodiment of the invention and a variation on the use of the enclosure member. The tie enclosure includes a plurality ofsutures62 having free ends64.Sutures62 secure around the perimeter of the infarcted oraneurysmal tissue24, as shown in FIG. 53a.Sutures62 are secured atpoints63 usingpledgets65.Enclosure member60 is then placed over the affected tissue region and free ends64 of the plurality ofsutures62 are extended throughenclosure member60 to pullsutures62 throughenclosure member60 as well. By pulling on free ends64 ofsutures62, the infarcted oraneurysmal tissue region24 is again gathered and its perimeter reduced. The tissue is drawn so thatpledgets65 ultimately areadjacent enclosure member60. The tissue, attached to the sutures, is drawn throughenclosure member60, and once in place,enclosure member60 can be sutured to the myocardium. Free ends64 ofsutures62 are drawn untilpledgets65 are brought close toenclosure member60.Sutures62 are then tied to theenclosure member60. Additionally,enclosure member60 may be directly sutured to the myocardium, as shown in FIG. 53b. Again, drawing in the aneurysmal tissue region reduces stress on the chamber walls, hinders the progression of the infarction, and results in a more uniform scar formation, and reduces the radius of curvature, and therefore the stress, in the region of the chamber adjacent the infarction, as well as more global reduction of radius of curvature.
• The tie enclosure also allows for non-uniform drawing in of the affected tissue region by using a plurality of sutures of varying lengths. Thus, the tie enclosure allows for particular regions of the aneurysm or infarction to be targeted and drawn in while others are left intact or drawn in to a lesser degree. This allows for a more precise change in geometrical configuration that may be necessary due to non-uniformities existing in the initial geometry of the infarcted or aneurysmal region.[0207]Enclosure member60 also may be made of a flexible material so as to allowenclosure member60 to take on a non-uniform configuration when sutures62 are drawn and secured.
• As discussed previously,[0208]enclosure member60 may be made of a rigid, semi-rigid, or flexible material, depending on the particular application for which the device will be used. The shape ofenclosure member60 can be that of a ring as shown in FIGS. 53a-53bor can be another shape, as long as the perimeter ofenclosure member60 is less than or equal to that of the drawn in tissue region.
• Using[0209]enclosure member60 andsutures62 in the manner described with respect to FIGS. 53a-53b, wider zones of infarcted or aneurysmal tissue preferentially may be drawn further towardenclosure member60, thereby maximizing the radius reduction in the direction of the widest dimension. This enables portions of the ventricle that are the most affected by the infarction to experience the greatest radius reduction and therefore the greatest stress relief.
• Yet another form of an enclosure member contemplated by the present invention is illustrated in FIG. 54.[0210]Enclosure member65 in FIG. 54 takes the form of a braided ring with a lumen through which tighteningcords66 extend.Enclosure member65 can be sutured into place surrounding an infarcted zone of tissue, with the sutures passing throughenclosure member65 only and not through tighteningcords66. Oncemember65 is secured around the infarcted tissue, tighteningcords66 can be pulled to draw inenclosure member65, causing the infarcted tissue region to be drawn together to thereby reduce the radius of curvature of the heart wall in that location.Enclosure member65 may be made of a relatively flexible material that is either atraumatic itself or is wrapped in an atraumatic material such as Dacron or PTFE for example. Other materials that encompass these characteristics are considered to be within the scope of this invention as well.
• In treating infarcted tissue and aneurysms with the various inventive methods and devices discussed above, it may be necessary to identify and distinguish between the infarcted tissue regions of the chamber wall and the contractile tissue regions of the chamber wall. Thus, a further aspect of the invention consists of the use of various devices for performing such identification in order to achieve precise placement of the inventive devices, including the splints, sutures, patches, and rings. The identification devices can be used either endocardially, epicardially, or transcardially, depending on which treatment procedure is being performed.[0211]
• One such method of identifying infarcted tissue regions from contractile tissue regions involves the use of a bipolar electrode. Using the electrode, differences in impedance sensed by the electrode will indicate regions of infarcted versus contractile tissue.[0212]
• Another method involves the use of fiber optics to distinguish infarcted from contractile regions of tissue. In this case, the fiber optics sense either density or color differences in transmitted or reflected light. Such differences would indicate whether a region contained infarcted tissue or contractile tissue. For instance, a known intensity of light could be directed toward a tissue region, with a known nominal intensity transmitting through contractile tissue regions. Intensities of the transmitted light through the chamber wall could then be measured. Upon sensing a decrease in intensity from the nominal value, the infarcted region could be pinpointed. Border zones also could be sensed in this way by looking for a gradation in transmission differences from the nominal value to a lowest value.[0213]
• Another method to locate regions of infarcted versus contractile tissue can be employed during the surgical procedure itself. This method involves the injection of radioactive media, such as in a thallium scan, with “real-time” imaging of the radiation during the surgery through the use of a Geiger counter contact probe. Higher observed radiation densities indicate regions of perfused tissue. Yet another injection method uses a visible dye injected into coronary vessels to identify contractile perfused tissue. In this identification technique, the dye travels only to contractile tissue, not to infarcted or scarred tissue regions. Finally TEE, or transesophageal echo ultrasounds may be used to detect regions of infarcted tissue.[0214]
• Aside from those listed above, other methods are contemplated to locate infarcted tissue regions. For example, the surgeon may use his fingers to probe the outer surface of the chamber wall and feel for differences in the tissue regions.[0215]
• All of the inventive passive devices to be implanted in the heart may be made of biocompatible material that can remain in the human body indefinitely. Any surface engaging portions of the heart should be atraumatic in order to avoid tissue damage.[0216]
• It will be understood that this disclosure, in many respects, is only illustrative. Changes may be made in details, particularly in matters of shape, size, material, number and arrangement of parts without exceeding the scope of the invention. Accordingly, the scope of the invention is as defined in the language of the appended claims.[0217]
• Other embodiments of the invention will be apparent to those skilled in the art from consideration of the specification and practice of the invention disclosed herein. It is intended that the specification and examples be considered as exemplary only, with a true scope and spirit of the invention being indicated by the following claims.[0218]

Claims (45)

What is claimed is:

1. A method for direct localized therapeutic treatment of myocardial tissue in heart having a pathological condition comprising the steps of:

a. identifying a target region of the myocardium;

b. applying material directly and substantially only to at least a portion of the myocardial tissue of the target region substantially identified in step (a) to physically modify the mechanical properties of said tissue.

2. The method ofclaim 1, wherein the modified mechanical properties include an increase in systolic performance.

3. The method ofclaim 1, wherein the modified mechanical properties include substantially no decrease in global diastolic performance.

4. The method ofclaim 1, wherein the material applied is passive.

5. The method ofclaim 1, wherein said target region includes a myocardial infarct.

6. The method ofclaim 1, wherein said target region at least in part underlies the papillary muscles associated with a cardiac valve.

7. The method ofclaim 6, wherein said cardiac valve is the mitral valve.

8. The method ofclaim 1, wherein said material applied to the myocardial tissue is a device.

9. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a polymer.

10. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a bioactive agent.

11. The method ofclaim 1, wherein said applying step is preceded by performing a mini-thoracotomy.

12. The method ofclaim 1, wherein said applying step includes applying material intramyocardially.

13. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a tension member having a first end and a second end, each of said ends provided with an anchor member.

14. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a braided ring.

15. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a plurality of sutures.

16. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a suture having two free ends and wherein the applying step comprises suturing said suture substantially around a perimeter of said portion of the myocardial tissue and pulling said two free ends to draw said portion of the myocardial tissue together substantially toward a center of said portion of the myocardial tissue.

17. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises an enclosure member having a first configuration and a second configuration and wherein the applying step comprises positioning said enclosure member around said portion of myocardial tissue while said enclosure member is in the first configuration and securing said enclosure member to the myocardial tissue after said positioning step, wherein said enclosure member reconfigures to the second configuration after said securing step.

18. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a plurality of sutures each having first and second ends, each of said first ends adapted to be attached to points on said myocardial tissue, and an enclosure member defining a space therein, wherein said plurality of sutures extend through said space, and wherein said second ends are adapted to be attached to points on said myocardial tissue located outside said space.

19. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises an enclosure member adapted to assume a first configuration during application of said enclosure member to said portion of myocardial tissue, and to assume a second configuration after application of said enclosure member to said portion of myocardial tissue to draw said portion of tissue toward a center of the enclosure member.

20. The method ofclaim 1, wherein said material applied to the myocardial tissue comprises a biocompatible adhesive.

21. The method ofclaim 1, wherein said applying step comprises applying said material completely externally of the myocardium.

22. A method for direct localized therapeutic treatment of myocardial tissue in heart having a athological condition comprising the steps of:

a. identifying a target region of the myocardium;

b. advancing an element across the septum of the heart to deliver material; and

C. applying said material directly and substantially only to at least a portion of the myocardial tissue of the target region substantially identified in step (a) to physically modify the mechanical properties of said tissue.

23. The method ofclaim 22, wherein the modified mechanical properties include an increase in systolic performance.

24. The method ofclaim 23, wherein the modified mechanical properties include substantially no decrease in global diastolic performance.

25. The method ofclaim 22, wherein the material applied is passive.

26. The method ofclaim 22, wherein said target region includes a myocardial infarct.

27. The method ofclaim 22, wherein said target region at least in part underlies the papillary muscles associated with a cardiac valve.

28. The method ofclaim 27, wherein said cardiac valve is the mitral valve.

29. The method ofclaim 22, wherein said material applied to the myocardial tissue is a device.

30. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a polymer.

31. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a bioactive agent.

32. The method ofclaim 22, wherein said applying step is preceded by performing a mini-thoracotomy.

33. The method ofclaim 22, wherein said applying step includes applying material intramyocardially.

34. The method ofclaim 22, further comprising the step of performing an additional therapeutic or diagnostic procedure either before or after said applying step employing access to the heart gained during said advancing step.

35. The method ofclaim 34, wherein said additional therapeutic or diagnostic procedure is one or more procedures selected from the set consisting of pressure monitoring, angiography, ablation, placement of pacing leads, electrophysiology mapping, and placement of LVAD cannulae.

36. The method ofclaim 22, wherein said advancing step comprises advancing an element across the ventricular septum of the heart.

37. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a tension member having a first end and a second end, each of said ends provided with an anchor member.

38. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a braided ring.

39. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a plurality of sutures.

40. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a suture having two free ends and wherein the applying step comprises suturing said suture substantially around a perimeter of said portion of the myocardial tissue and pulling said two free ends to draw said portion of the myocardial tissue together substantially toward a center of said portion of the myocardial tissue.

41. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises an enclosure member having a first configuration and a second configuration and wherein the applying step comprises positioning said enclosure member around said portion of myocardial tissue while said enclosure member is in the first configuration and securing said enclosure member to the myocardial tissue after said positioning step, wherein said enclosure member reconfigures to the second configuration after said securing step.

42. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a plurality of sutures each having first and second ends, each of said first ends adapted to be attached to points on said myocardial tissue, and an enclosure member defining a space therein, wherein said plurality of sutures extend through said space, and wherein said second ends are adapted to be attached to points on said myocardial tissue located outside said space.

43. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises an enclosure member adapted to assume a first configuration during application of said enclosure member to said portion of myocardial tissue, and to assume a second configuration after application of said enclosure member to said portion of myocardial tissue to draw said portion of tissue toward a center of the enclosure member.

44. The method ofclaim 22, wherein said material applied to the myocardial tissue comprises a biocompatible adhesive.

45. The method ofclaim 22, wherein said applying step comprises applying said material completely externally of the myocardium.

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