US20070156217A1 - Apparatus for lead placement on a surface of the heart - Google Patents

Abstract

The methods and apparatus for lead placement on a surface of the heart are employed using an elongated body having proximal and distal end portions. The body defines a lead receiving passageway extending between a proximal inlet and a distal outlet for receiving a lead therethrough for contact with the heart surface. The elongated body is adapted for insertion between a pericardium and an epicardial surface. At least a portion of the body may have a non-circular cross-sectional shape adapted to retain the body orientation between the pericardium and the epicardial surface.

Description

RELATED APPLICATIONS
• This is a divisional of U.S. patent application Ser. No. 10/144,205 titled, METHODS AND APPARATUS FOR LEAD PLACEMENT ON A SURFACE OF THE HEART, filed on May 10, 2002, herein incorporated by reference in its entirety.
BACKGROUND
• This invention relates to methods and apparatus for lead placement and other related procedures on or in connection with the heart.
• Leads are conductive devices or electrodes for temporary or permanent contact or implantation on a heart surface. Leads are well known in the art and commonly have an elongated shape and include a distal end, typically with an electrode alone or in combination with a retention member, such as spiral or barbed, located thereon for attachment to the desired heart surface.
• Leads carry electrical signals to and from the heart for a variety of purposes. One purpose, among many, of lead implantation is to allow pacing of the heart so as to restore the normal sequence of mechanical contractions to the heart. By way of example, but not limitation, leads may be placed on a surface of the heart in conjunction with a biventricular pacemaker, which generates a pacing signal. A proximal end of the lead is connected to the pacemaker while the distal end of the lead is attached to the desired heart location to carry the electrical signal to the heart. Temporary leads may also be used to monitor heart performance, to “map” the heart to identify conductive pathways, to identify sources of aberrant electrical pulses and to carry out various other diagnostic and/or therapeutic procedures.
• A myriad of lead implantation sites relative to treatment of the human heart are also possible. Leads may be placed on an outer (epicardial) surface of the heart, implanted within the heart on an interior (endocardial) heart surface, or placed within the coronary sinus. The human heart is generally situated in a multi-layer membrane or heart sac, commonly known as the pericardium. The space between the pericardium and the outer or epicardial surface of the heart is commonly called the pericardial space. Although it may be technically possible to place leads on the outer surface of the pericardium, it is preferred to place leads within the pericardial space so as to improve the conductivity of the electrical path between the lead and the selected heart tissue.
• Current apparatus and methods for epicardial lead placement often utilize non-minimally invasive medical procedures. These methods may involve a large incision into the chest, thoracotomy or medial sternotomy of a patient and/or opening of the chest cavity for access to the heart. These procedures typically may require the patient to be generally anesthetized, selectively intubated with collapse of a lung. A further major disadvantage of these procedures is that they may require a chest tube following surgery and are often associated with a painful postoperative course.
• Sub-xyphoid access to the heart surfaces has been previously proposed by one of the inventors here in U.S. patent application Ser. No. 09/315,601 filed May 20, 1999 and is incorporated by reference herein. One potential difficulty which needs to be overcome when using the sub-xyphoid route for lead placement is the need for a substantial distal portion of the lead to be orthogonally disposed relative to the selected lead placement site in order to adequately attach the lead on the heart surface. In other words, it has been previously considered that the incident angle of approach of the lead placement apparatus should be disposed at a nearly perpendicular angle relative to the heart surface in order to position the distal outlet in a desired direction for lead placement. Because the angle of approach is so large, it requires a large working volume within the pericardial space. The working space required by the apparatus thus displaces a greater amount of cardiac tissue, which can increase the risk of complications during and after surgery. Therefore, there is a need for apparatus and methods for lead placement which avoid these shortcomings.
• Several devices and methods for minimally invasive access to the epicardial surface of the human heart have been described in co-pending application Ser. Nos. 09/315,601 filed May 20, 1999, and 09/397,392 filed Sep. 16, 1999, both of these applications are hereby incorporated by reference in the present application.
• Another drawback of current lead placement apparatus and methods is that they do not typically incorporate the ability to navigate over the surfaces of the heart for optimal lead placement. In one aspect, it would be desirable to provide an apparatus which permits temporary pacing of the heart so as to determine the optimal lead placement site prior to attachment of the lead to the heart surface. Pacing by temporary electrodes or leads prior to attachment of a permanent lead better ensures that the lead is properly attached to the desired heart location. In another aspect, it would be desirable to have a lead placement apparatus which prevents lead deposition in proximity to a coronary artery. Since coronary arteries surround the exterior of the heart, there is a danger that lead implantation could pierce the artery, resulting in possible bleeding into the pericardial space which may lead to hemodynamic compromise and collapse. Placement of an epicardial lead onto a coronary artery may occlude the artery resulting in infarction of the myocardium perfused by that artery. So, it would be desirable to provide a lead placement apparatus which has the ability to sense when the lead placement apparatus is unduly close to a coronary artery.
• Current lead placement devices also do not provide relative positioning of the distal end of the device so as to orient the distal end in the desired direction for lead placement. Since the surface of the heart is not flat or uniform, the ability to position the distal end against the desired lead placement location is also desirable. Even once the lead placement site is located, the lead placement apparatus desirably should facilitate lead removal from the apparatus.
• Accordingly, it is a general object of the present invention to provide a minimally invasive method and apparatus for placing a lead on a surface of the heart.
• Another object of the present invention is to provide for an apparatus and method for lead placement, which apparatus has a geometry specifically suited for lead placement.
• It is the object of another aspect of the present invention to provide a method and apparatus for temporary pacing of the heart prior to lead placement or in connection with mapping the conductive pathways of the heart tissue.
• It is another object of the present invention to provide a method and apparatus for detecting proximity to the coronary arteries so as to avoid placement of the lead on or near a coronary artery.
• It is a further object of the present invention to provide a method and apparatus which provides a distal end of the apparatus which is adapted to move in at least one plane when force is applied to the apparatus.
• It is yet another object of the present invention to provide a method and apparatus having an expandible member to hold the apparatus adjacent the epicardial surface for lead placement.
• A further object of the present invention is to provide a lead placement apparatus which facilitates lead removal.
• A yet further object of the present invention is to provide a minimally invasive lead placement apparatus having a distal end portion which has an acute angle relative to the longitudinal axis for lead placement.
• These objectives are provided to illustrate the context of the present invention and are not an exclusive listing of the objectives or benefits of the present invention. Not all of these objectives are necessarily met in each apparatus or method of the present invention. Apparatus or methods of the present invention may meet or address one or more, but less than all, of these objects or other objects or benefits of the invention apparent in other parts of this description. Therefore, these objectives are not presented for, and should not be used for, the purpose of limiting the scope of the invention as set forth in the appended claims.
SUMMARY
• The features and objects of the present invention will become apparent upon reference to the following detailed description and attached drawings. Generally speaking, in accordance with one aspect of the present invention, the apparatus includes an elongated body or sheath having a proximal end portion, a distal end portion, and defines a passageway having a proximal inlet and a distal outlet for receiving a lead or conductive member. The distal outlet is generally located adjacent the distal end portion of the body.
• The present invention is particularly well suited for providing a method and apparatus for placing a lead on a surface of the heart, where a substantial length of the body is adapted for insertion between a pericardium and an epicardial surface and the body is adapted for directional control by the user to position the distal outlet at a desired location between the pericardium and the epicardial surface.
• At least a portion of the elongated body also may have a non-circular shape which is adapted to retain the body at a selected angular orientation between the pericardium and the epicardial surface. The non-circular shape may be comprised of convex, concave and planar surfaces, as will be described below. The body may further include a plurality of lumens or passageways for receiving, connecting to, or accommodating a variety of elements such as, for example, a vacuum, an inflation source, an irrigation source, a guide wire, an endoscope, a fiberoptic viewing device, temporary pacing electrodes, a Doppler sensor, a steering member, an expandible member, a flexible or malleable shape-retaining wire, or other like elements for facilitating lead placement in addition to other purposes which will be apparent to one skilled in the art. It is submitted that there are numerous combinations of all or some of these elements and that the combinations shown and described are by way of example and are not intended to limit the scope of the claimed invention.
• Several mechanisms may be utilized in order to position the distal outlet of the body against the selected lead placement site. One way to move the distal end portion of the body is accomplished by employing at least one steering member extending through the elongated body having a distal and proximal end. The steering member moves when force is applied to the proximal end of the steering member. The force may be tensile, compressive or torsional, or a combination thereof. A steering collar can be positioned on the body spaced from the distal end portion to control one or more of the steering members. The steering collar is movable to supply tensile, compressive or torsional movement to the steering members. Movement of the steering members allows movement of the distal end portion of the body in at least one plane although movement in more than one plane is also possible.
• In addition to the steering members, other ways to position the distal end portion of the body utilize a vacuum lumen, an expandible member, and/or a flexible or malleable element. The vacuum lumen may extend through the body between the proximal end portion, which is connected to a vacuum source, and the distal end portion which defines a distal opening of the vacuum lumen so as to create a suction force at the distal outlet and maintain the distal outlet biased against the selected lead placement site. Biasing of the distal outlet against the selected site can also be performed by selective expansion of the expandible member which is carried by the body and disposed in proximity to the distal outlet. One or more expandible members can be utilized and are adapted to expand after insertion of the body into the pericardial space and, by way of example but not limitation, the expandible member may include a balloon and inflation lumen, which fluidly communicates between the balloon and an inflation source, an expandible cage-like member or members, or the like. The expandible members may be mounted at the distal end in an eccentric or concentric fashion. The body may include at least one flexible or malleable wire which preferably, but not exclusively, extends through at least a portion of the body extending from the distal end portion and the flexible wire is well suited to retain a desired shape corresponding to the surface of the selected lead placement site so as to orient the distal end portion of the body for lead placement. Any of the aforementioned ways, either by themselves or in any combination thereof, as well as others may be employed to position the distal outlet against the selected lead placement site.
• The present invention also provides a method and apparatus having a body including at least one temporary pacing electrode disposed in proximity to the distal end portion for contact with the surface of the heart. The temporary pacing electrode may be used in connection with placing a lead on a surface of a human heart and/or allow for the conductive pathways of the heart to be mapped for a variety of purposes. A conductor extends through the elongated body from the electrode to the proximal end portion of the body for attachment to an electric pacing signal source. The temporary pacing electrode is adapted to pace the heart by contact with selected one of a pericardial and epicardial surface. The temporary pacing electrode may be fixed at the distal end or removably inserted through the body.
• In another aspect of the invention, the body of the lead placement apparatus defines a passageway which includes at least one outlet adapted to receive an elongated guide wire and a lead. The passageway has a lead outlet which is sufficiently sized to allow passage of the lead for attachment to the surface of the heart. The lead outlet tapers to a guide wire outlet which is distally located on the body in relation to the lead outlet. The guide wire outlet is sufficiently sized and oriented to allow passage of the guide wire forward of the distal end of the body and to deflect the lead to exit at an angle relative to the longitudinal axis of the body for engagement with heart tissue.
• The present invention also discloses a lead placement apparatus and method for sensing the presence of a coronary artery so as to avoid placement of the lead into a coronary artery. The body includes a Doppler sensor disposed in proximity to the distal outlet and the Doppler sensor is in communication with an operator-readable output device to indicate the presence of a coronary artery in proximity to the distal outlet.
• The present invention further provides an improved epicardial lead construction for ease of placement on an epicardial surface of the heart.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1 is a side view of a first embodiment of a lead placement apparatus of the present invention.
• FIG. 2 is a side view of a second embodiment of a lead placement apparatus of the present invention.
• FIG. 3 is a sectional view of a distal end portion of the lead placement apparatus.
• FIG. 4 is a bottom view of the distal end portion of the lead placement apparatus.
• FIGS. 4A-4C are sectional views of the distal end portion along the lines indicated inFIG. 4 and illustrating the non-circular cross-sectional shape of at least a portion of the body.
• FIG. 5A is a sectional view of the distal end portion, similar toFIG. 4C, including a single steering member.
• FIG. 5B is a sectional view of the distal end portion, similar toFIG. 4C, including a dedicated guide wire lumen.
• FIG. 5C is a sectional view of the distal end portion, similar toFIG. 4C, including a flexible element and having an alternate non-circular cross-sectional shape.
• FIG. 5D is a sectional view of the distal end portion, similar toFIG. 4C, including an inflation lumen and having another non-circular cross-sectional shape.
• FIG. 5E is a sectional view of the distal end portion, similar to4C, including an endoscope lumen and a fluid delivery lumen and illustrating yet another non-circular cross-sectional shape.
• FIG. 6A is a sectional view, similar toFIG. 3, showing a third embodiment of a lead placement apparatus having a monopolar temporary pacing electrode.
• FIG. 6B is a bottom view of the embodiment shown inFIG. 6A.
• FIG. 6C is a sectional view alongline6C-6C inFIG. 6B.
• FIG. 7 is a side view of a fourth embodiment of the lead placement apparatus having an expandible member.
• FIG. 7A is a sectional view alongline7A-7A inFIG. 7.
• FIG. 8 is a perspective view of the distal end portion of a fifth embodiment of a lead placement apparatus having an expandible member shown in an unexpanded condition.
• FIG. 9 is a side elevation view, illustrating the lead placement apparatus ofFIG. 8 between the pericardium and epicardial surface of a heart with the expandible member shown in an expanded condition.
• FIG. 10 is a perspective view of an alternate expandible member which extends fully circumferentially relative to the lead placement apparatus.
• FIG. 11 is a perspective view, similar toFIG. 8, showing another type of an expandible member.
• FIG. 12 is a side elevation view, similar toFIG. 9, showing the expandible member ofFIG. 11 in situ between the pericardium and epicardial surface of a heart.
• FIG. 13 is a perspective view showing a further expandible member which extends fully circumferentially relative to the lead placement apparatus.
• FIG. 14 is an anterior plan view of a patient's chest showing an incision via the sub-xyphoid region.
• FIGS. 14A-14D are sectional elevation views of a patient's chest showing access to the pericardial space via a sub-xyphoid approach.
• FIG. 15 is a longitudinal cross-section of the distal end portion of the lead placement apparatus taken along line15-15 ofFIG. 17, showing insertion of a guide wire into the pericardial space.
• FIG. 16 is a longitudinal section taken along line1616 ofFIG. 17 which shows insertion of a lead into the pericardial space.
• FIG. 17 is a transverse sectional view of the lead placement apparatus ofFIGS. 15 and 16.
• FIG. 18 is an anterior plan view of the patient's heart which shows implantation of a lead and connection of the lead to a pacer signal source.
• FIG. 19 is a perspective view of a sixth embodiment of the lead placement apparatus showing a portion of the apparatus being normally curved relative to the longitudinal axis.
• FIG. 20 is a perspective view of a seventh embodiment of the lead placement apparatus showing a normally straight portion of the apparatus being curved relative to the longitudinal axis as the result of a curved insertion sleeve.
• FIG. 21 is a perspective view of the lead placement apparatus showing movement between a normally curved position and a straight position by applying force to a steering wire.
• FIG. 22 is a perspective view of the lead placement apparatus showing movement between a normally straight position and a curved position by applying force to a steering wire.
• FIG. 23 is a perspective view of an eighth embodiment of the lead placement apparatus.
• FIG. 23A is a perspective view of an alternate temporary pacing electrode for insertion into the apparatus shown inFIG. 23.
• FIG. 23B is a perspective view of a lead for insertion into the apparatus shown inFIG. 23.
• FIG. 24 is a perspective view of a ninth embodiment of the lead placement apparatus having a flexible or malleable element.
• FIG. 25 is an enlarged transverse sectional view of a tenth embodiment of the lead placement apparatus which is adapted to allow removal of a lead in a direction transverse to the longitudinal axis of the apparatus.
• FIG. 26 is a longitudinal sectional view of the apparatus ofFIG. 25 including a lead.
• FIG. 27 is a side view of an eleventh embodiment of the lead placement apparatus which allows lead removal in a transverse direction to the longitudinal axis of the apparatus.
• FIG. 28 is an end view of the embodiment shown inFIG. 27.
• FIG. 29 is a side view of a twelfth embodiment of the lead placement apparatus which allows removal of the lead in a transverse direction to the longitudinal axis of the apparatus.
• FIG. 30 is a sectional view along line30-30 ofFIG. 29.
• FIG. 31 is a perspective view of a thirteenth embodiment of the lead placement apparatus which allows removal of the lead in a transverse direction to the longitudinal axis of the apparatus.
• FIGS. 32A-32B are end views of the embodiment shown inFIG. 31 showing closed and open positions, respectively.
• FIG. 33 is a perspective view of a fourteenth embodiment of the lead placement apparatus which allows removal of the lead in a transverse direction to the longitudinal axis of the apparatus.
• FIG. 34 is a sectional view along line34-34 inFIG. 33.
• FIG. 35 is a longitudinal sectional view of a fifteenth embodiment of the lead placement apparatus which allows removal of the lead in a transverse direction to the longitudinal axis of the apparatus.
• FIG. 36 is a side view of the embodiment shown inFIG. 35 showing removal of a longitudinally disposed portion of the apparatus.
• FIG. 37 is a partial transverse sectional view of the embodiment shown inFIGS. 35-36.
• FIG. 38 is a perspective view of a sixteenth embodiment of the lead placement apparatus which allows removal of the lead in a transverse direction to the longitudinal axis of the apparatus.
• FIG. 39 is a section view along line39-39 ofFIG. 38.
• FIG. 40 is a side view of a seventeenth embodiment of the lead placement apparatus which allows removal of the lead in a transverse direction to the longitudinal axis of the apparatus.
• FIG. 40A is a sectional view alongline40A-40A ofFIG. 40.
• FIG. 41 is a side view of the apparatus ofFIG. 40 in an open position.
• FIG. 41A is a sectional view of alongline41A-41A ofFIG. 41.
• FIG. 42 is a side view of an epicardial lead having an angled distal end portion.
• FIG. 42A is a sectional view alongline42A-42A ofFIG. 42.
• FIG. 43 is a side view of another epicardial lead having a curved distal end portion.
• FIGS. 44-45 are side views of an epicardial lead having a distal end portion which is adapted to move between straight and angled positions, respectively.
• FIG. 45A is a sectional view alongline45A-45A ofFIG. 45.
• FIGS. 46-47 are side views of other epicardial leads having an angled distal end portion.
• FIG. 48 is a side view of another epicardial lead having a distal end portion which is adapted to move between straight and angled positions.
• FIG. 49 is a side view of an epicardial lead including a steering member.
• FIG. 50 is a side view of an epicardial lead having an alternate distal section.
• FIG. 51 is a side elevation view of a prior art epicardial lead placing the lead on a surface of the heart.
• FIG. 52 is a side elevation view of the epicardial lead of the present invention placing the lead on a surface of the heart.
• FIG. 53 a side view of a further embodiment of a lead placement apparatus of the present invention with portions of the apparatus shown in section.
• FIG. 54 is a plan view of the lead placement apparatus ofFIG. 53.
• FIG. 55 is a sectional view along line55-55 ofFIG. 53.
• FIG. 56 is an enlarged partial longitudinal sectional view of the lead placement apparatus ofFIG. 53 with the distal end portion shown in a deflected configuration.
• FIG. 57 is a side view of a still further embodiment of a lead placement apparatus having an expandible member with the distal end portion shown in section.
• FIG. 58 is an enlarged partial longitudinal sectional view of the distal end portion of the lead placement apparatus inFIG. 57.
• FIG. 59 is a partial longitudinal sectional view of the lead placement apparatus inFIG. 57 showing the expandible member in an enlarged configuration.
• FIG. 60 is a side view of the lead placement apparatus inFIG. 53 with portions of the apparatus shown in section showing insertion of a guiding or trocar device.
• FIG. 60A is a cross sectional view alongline60A-60A inFIG. 60.
• FIG. 61 is a side view of the lead placement apparatus, similar toFIG. 60, showing insertion of a Doppler sensor.
• FIG. 62 is a side view of the lead placement apparatus, similar toFIG. 60, showing insertion of a lead.
DETAILED DESCRIPTION
• The present invention provides methods and apparatus for placing a lead on a surface of a human heart. Although the invention will be described by way of example but not limitation in relation to epicardial lead placement, placement of the lead on other heart surfaces is also possible. Such heart surfaces may also include the pericardium and the endocardial surface in addition to the epicardial surface. The manner in which the lead is placed on the heart surface may also vary. By way of example but not limitation, the lead may be implanted or embedded into the surface using a retention member or fastener which penetrates beneath the surface. Different types of retention members may be utilized and it is not intended for the present invention to be limited only to those retention members shown in the drawings since it is realized that many variations may be used to effectuate lead retention without departing from the present invention. Moreover, the lead may be placed on the heart surface for either temporary or permanent use, as needed.
• As shown inFIG. 1, a first embodiment of alead placement apparatus10 of the present invention includes anelongated body12 and defines alongitudinal axis13. Thebody12 includes a proximal end portion generally at14 and a distal end portion generally at16. Thebody12 defines alead receiving passageway18 which extends between aproximal inlet20 anddistal outlet22. Thelead receiving passageway18 is adapted and suitable to receive a lead for attachment to the surface of the heart. The lead is shown, by way of example, inFIG. 16 which will be described below. At theproximal end portion14 of thebody12, ahandle24 may be provided. A preferred approach utilizes a sub-xyphoid approach to place the lead on a heart surface. Other approaches may be utilized without departing from the scope of the claimed invention, such as, for example, intercostal, intravenous and other minimally invasive approaches as well as more invasive approaches, such as open chest procedures.
• Theelongated body12 preferably has sufficient length so as to allow insertion of at least thedistal end portion16 of the body from a sub-xyphoid transcutaneous access opening to the area between the pericardium and the epicardial surface and into a space which is commonly referred to either as the pericardial space. The length of the body will depend on which medical approach is used to gain access to the heart surface. Importantly, the length of the body should be such that thehandle24 remains outside of the patient while the medical procedure is performed so as to allow greater control over the lead placement apparatus. By way of example but not limitation, the length L of thebody14 between the proximal inlet and thedistal outlet22 has a length and a range of 10 cm to 40 cm, preferably 20 cm to 30 cm where a sub-xyphoid approach is used, so that theproximal inlet20 is located outside of the patient.
• InFIG. 1 theproximal inlet20 is disposed at generally theproximal end portion14 of thebody12, although it is spaced from the proximal tip end of the handle. The length L of thebody12 allows extension of thedistal end portion16 into the pericardial space while, at the same time, allowing theproximal inlet20 to extend outside into the pericardial space and, preferably, outside of the incision access location into patient's body. In this way, theproximal inlet20 is accessible to allow insertion of the lead therein. It is also possible to position the proximal inlet at other longitudinal positions along thebody12 as is indicated inFIG. 2 in analternate apparatus26, with like parts being shown with like numbers, except that theproximal inlet28 is positioned at the most proximal end of thehandle24. Theapparatus26 similarly has a length which is sized to allow insertion of thedistal end portion16 into the pericardial space and access to thehandle24 andproximal inlet20 from the outside of the incision access location.
• Non-Circular Shape
• Turning toFIGS. 4-4C, at least a portion of theelongated body12 may have in certain, but not all embodiments of the present invention, a non-circular shape, so described because it has a cross-section which is non-circular as best seen inFIGS. 4 and 5. The non-circular shape may appear in a myriad of different forms, some of which will be shown and described below, but other non-circular shapes are also possible without departing from the present invention. The non-circular shape is associated with at least a portion of the body, preferably, the portion of the body which is inserted into the pericardial space. For example, the non-circular shape extends along thebody12 between theproximal inlet20 and thedistal outlet22 inFIG. 1 or between a portion thereof. In the most preferred form, the portion of thebody12 which contacts the heart surface such as thedistal end portion16 has a non-circular shape. As shown inFIGS. 3-4C, the non-circular shape of thebody12 is generally constant along the body except near thedistal end portion16 where the body gradually tapers.
• InFIG. 4C the non-circular shape includes anupper surface32 which is convex and alower surface34 which is planar. So the cross-sectional shape of thenon-circular portion30 inFIG. 4C has a “D” configuration. It is contemplated that thelower surface34 faces the heart surface in which lead placement is desired and theupper surface32 generally faces away from the desired lead placement site, although other orientations are also possible. As shown inFIGS. 3 and 4B thedistal outlet22 may be defined in thelower surface34 near thedistal end portion16 of the body. So when thedistal outlet22 is placed adjacent the desire lead placement site, the lead can be advanced from the outlet opening in thelower surface34 and directed at the heart tissue. It is realized that other locations of the distal outlet are possible without departing from the present invention.
• As is illustrated best inFIG. 4C, the portion of the body with the non-circular shape preferably has a width, generally indicated at W, which is greater than its thickness, generally indicated at T. When the body is inserted into the pericardial space, the width of thebody12 is oriented in a generally parallel relationship to the heart surfaces. Relative toFIG. 4C, thelower surface34 is disposed adjacent the epicardial surface and at least a portion of theupper surface32 is disposed adjacent the pericardium. Likewise, the thickness of thebody12 is oriented in a generally perpendicular relationship with the heart surfaces, so the non-circular shape of the body attributes a slim profile when inserted into the pericardial space. Also, the working space existing within the pericardial space is more efficiently utilized, and displacement between the epicardial surface and pericardium is minimized when the body is inserted into the pericardial space. It can further be said that the non-circular shape of the body tends to retain the body at a selected angular orientation between the pericardium and the epicardial surface and prevents unplanned rotation of the body about its own axis. This assists in orienting the distal outlet in the desired direction so that it is pointed toward the heart surface.
• FIGS. 5A-5E illustrate variations in thebody12 and like parts will be indicated with like numbers followed by a letter designation of A-E, as appropriate, which corresponds to the appropriate figure.FIGS. 5A and 5B show bodies,12A and12B, respectively, which are shaped similarly to the non-circular shapedbody12 inFIG. 4C, except that the internal arrangement of lumen is varied, as will be described later.FIG. 5C illustrates an alternate non-circular shape of a body12C having an upper surface32C and a lower surface34C which are both convex so as to generally define an oval or eccentric shape.FIG. 5D illustrates another alternate non-circular shape of the body12D having an upper surface32D which is convex and alower surface34D which is concave.FIG. 5E illustrates a body12E having an elongated oval shape where the upper and lower surfaces define substantially planar top and bottom portions which are joined by curved edge portions. The major axis of the oval is oriented along the width and the minor axis is oriented along the thickness.
• As can be seen during insertion of thebody12 into the pericardial space using these alternate shapes, theupper surface32 will be in contact with the pericardium and thelower surface34 which includes the distal outlet of the lead receiving passageway will generally be in contact with the epicardial surface. As the non-circular portion generally has a width which is greater than its thickness and provides a relatively slim profile, insertion of the body into the pericardial space is facilitated. Also, thedistal outlet22 of thelead receiving passageway18 is preferably located in thelower surface34, which faces the epicardial surface. The non-circular shapes shown in the figures are by way of example but not limitation since other combinations may be utilized.
• Turning back toFIGS. 3-4C, thedistal end portion16 of thebody12 illustrated there gradually narrows from a more proximal portion of the body. In particular, thebody12 narrows from the view shown inFIG. 4C to thesuccessive view4B and then4A as the body extends to thedistal end portion16. Although the body is successively thinner inFIGS. 4A and 4B, than inFIG. 4C, thebody12 may retain a non-circular shape.FIGS. 4A and 4B also generally retain the relative proportions of the body where the width which is greater than the thickness.
• Guide Wire Outlet
• FIGS. 3-4B also illustrate aguide wire outlet36 which is formed in thelower surface34 of the body at thedistal end portion16. Theguide wire outlet36 is formed distally relative to the lead outlet ordistal outlet22 and, as shown inFIGS. 3 and 4, theguide wire outlet36 is in communication with thedistal outlet22, and connects to thelead receiving passageway18.
• As shown inFIG. 3, a guide wire38 is received by thelead receiving passageway18 and is inserted from a more proximal portion of thebody12, such as from either of theproximal inlets20 and28 inFIGS. 1 and 2, respectively. The guide wire38 has aproximal end40 and adistal end42 which extends forwardly, or distally, through theguide wire outlet36.
• InFIGS. 3-4B, theguide wire outlet36 is generally defined as a channel extending longitudinally from thedistal outlet22 in the forward direction, similar to the entrance to an igloo. Theguide wire outlet36 is sufficiently sized and oriented to allow passage of the guide wire but prevent passage of the lead. As shown inFIGS. 3-4C, theguide wire outlet36 is sized smaller than the lead outlet and longitudinally oriented in order to avoid extension of the lead beyond thedistal end portion16 of the body.
• During use thedistal end42 of the guide wire extends forwardly of thedistal end portion16 so as to guide theapparatus10 to the selected lead placement site. The guide wire also may bisect the tissue so as to provide a clear working space for lead placement. The guide wire may be removed from the body and successively thicker guide wires may be inserted. Thelead receiving passageway18 may be sized so that it is adapted to receive the guide wire and the lead during use or, alternatively, the guide wire may be removed frompassageway18 prior to lead insertion. After proper placement of the distal end is confirmed, the lead may be inserted. When the distal tip of the lead engages the end of the body, the curved inner surface deflects the lead downwardly through thedistal outlet22.
• Steering Members
• FIGS. 4 and 4C also illustrate steeringmembers52 disposed within thebody12. Thesteering wires52 have adistal end54 and aproximal end56. Thedistal end54 of the steering members is located at a position at or near thedistal end portion16 of the body and extends in a proximal direction towards theproximal end portion14 of the body. Theproximal end56 of the steering members may extend from theproximal end portion14 of thebody12 in a similar manner as described relative to thevacuum lumen44 or it may extend to any of several intermediate positions of the body. Thesteering wires52 may be operatively connected to asteering collar58, as shown inFIGS. 1 and 2, which is disposed at a more proximal portion of thebody12 adjacent thehandle24 and accessible to the doctor.
• Thesteering members52 are made of a suitable material having an elongated shape such as wire, fiber, filament, surgical tape or the like although other materials and forms are possible without departing from the present invention. The steering member may include one or more separate members as shown inFIGS. 4 and 4C, which illustrates two steering members. By pulling on one member and pushing (or at least not pulling) the other, the distal end portion can be deflected in the desired direction. By reversing this action, the tip may be deflected in the opposite direction.
• Thebody12, and in particular, thehandle24 or steeringcollar58 may include, various control elements such as levers, buttons, switches or the like to vary the application of force, the degree of curvature, and the direction of movement. The applied force may be tensile, compressive or rotational or any combination thereof. Tension and compression may be applied directly or indirectly to the steering member by pulling or pushing the steering member at any position along its length whereas rotation occurs by directly or indirectly twisting the steering member. The steering members may be used in combination with the vacuum lumen discussed above or, alternatively, in lieu of the vacuum lumen so as to orient the distal outlet in the desired direction for lead placement.
• In the embodiment shown inFIGS. 4 and 4C, the steering members are each positioned on one side of the body and extend longitudinally relative to the body. So that within a first plane, tensile force applied to theproximal end56 of theleft steering member52 inFIG. 4C will move thedistal end portion16 to the left. Similarly, tensile force applied to the proximal end of the right steering member inFIG. 4C will move the distal end portion to the right.
• As mentioned previously, other types of forces or a combination thereof may be applied to the steering member either directly or indirectly. Also, force can be applied to the steering member so as to move thedistal end portion16 of the body in more than one plane. The resultant movement of thedistal end portion16 will depend on the number and location of steering members disposed within the body as well as the magnitude and type of forces applied. It is realized that one or more steering members may be positioned at different locations and orientations within the body so as to effectuate the desired movement of the distal end portion. Other combinations are possible without departing from the present invention.
• By way of example but not limitation,FIGS. 5A and 5B illustratealternate bodies12A and12B, respectively, each having asingle steering member52A and52B, respectively. InFIG. 5A the steeringmember52A is disposed in an upper left position. InFIG. 5B the steeringmember52B is disposed in a lower right position. So, force applied either directly or indirectly to either steering member will cause deflection of thedistal end portion16.
• In addition, movement of the steering member may increase or decrease the curvature of the distal end portion relative to the remainder of the body as illustrated inFIGS. 21 and 22. Turning briefly toFIGS. 21-22, these figures illustrate other aspects of the steering members of the present invention. InFIG. 21, abody60 includes a steeringmember52 which extends through the body to thedistal end portion16. Thebody60 generally defines alongitudinal axis62 and at least thedistal end portion16 of the body is curved relative to the axis when normally positioned and not acted upon by any force. The body may be curved, for example, to an angle between 10 degrees and 80 degrees relative to thelongitudinal axis62 and preferably between approximately 30 and 60 degrees. The normal or at rest position of the body is illustrated in solid lines and dashed lines represent a position of the body after force has been applied either directly or indirectly to the steering member. The force, indicated at64, may be tensile, compressive or rotational or a combination thereof. When force is applied to the steeringmember52, thedistal end portion16 moves to a less curved position as indicated by dashed lines.
• An alternate body66 is illustrated inFIG. 22, which likewise has a steeringmember52 extending to thedistal end portion16. In this embodiment thedistal end portion16 is normally positioned in alignment with thelongitudinal access62 and force applied to the steeringmember52 moves thedistal end portion16 of the body from the normally aligned straight position to a curved position relative to the longitudinal axis. It is realized that any type of force may be used to move the distal end portion of the body in one or more planes so that the distal end portion of the body may be curved relative to the longitudinal axis in one or more planes in the range approximately of 10 degrees to 80 degrees.
• Turning also toFIGS. 19 and 20, other steering features may be utilized in the present invention.FIGS. 19 and 20 show a least a portion of a body which is curved relative to alongitudinal axis200. InFIG. 19 abody202 having adistal end portion204 is normally curved relative to thelongitudinal axis200 at the distal end portion. The body is made of a flexible or deformable material such as a polymer or plastic or may be made of a rigid material which is adapted to articulate. Adistal outlet206 is defined in the distal end portion for extension of the lead therethrough. Thebody202 is slidably received in anelongated sleeve208. Thesleeve208 has a rigid or semi-rigid, cylindrical shape and defines aninner lumen210 which is sized sufficiently large to receive thebody202 for slidable movement. The sleeve diameter is slightly larger than the diameter of the body and preferably sized so as to fit snugly over the body and prevent incidental moving of the sleeve during insertion of the body into the pericardial space, although it is preferred that there be clearance between the proximal end of the sleeve and the proximal end of the body so as to permit axial movement of the sleeve on the body. The sleeve preferably has sufficient length so that during insertion of the sleeve and body into the pericardial space the sleeve extends from thedistal end206 of the body to a more proximal portion of the body which is located outside of the pericardial space for accessibility by the operator.
• InFIG. 19, thesleeve208 has a linear configuration so that when the sleeve is moved in a position where thesleeve208 is positioned around thedistal end204 of the body, the body is temporarily deformed from its normally curved position to a straight configuration, which may be desired during introduction of the body initially into the patient's chest. When the body is inserted into the pericardial space, thesleeve208 may be moved or retracted proximally relative to thedistal end204 so as to allow the portion of thebody202 which extends distally on the sleeve to resume its normally curved configuration, which may be at any angle between 10 degrees and 80 degrees relative to the longitudinal axis. Selective retraction of the sleeve may permit greater or lesser curvature of the body—depending on the length of the body that extends beyond the distal end of the sleeve.
• FIG. 20 illustrates analternative sleeve212 having a curved portion relative to thelongitudinal axis200. Aninner bore214 sized to receive abody216. Adistal end218 of the sleeve is curved relative to thelongitudinal axis200. The sleeve inFIG. 20 maintains thebody216 in a curved orientation relative to the longitudinal axis where the body, instead of being normally curved, may be normally straight. Then as thebody216 extends from thedistal end218 of the sleeve the distal end of the body will maintain an orientation in the direction pointed by the distal end of the sleeve, or in other words, which is in coaxial alignment with thedistal end218 of the sleeve. The angle of curvature of the sleeve may be between 10 degrees and 80 degrees, for example.
• Plurality of Lumen
• FIGS. 1-5E illustrate a plurality of lumens or passageways defined by thebody12 and these lumens or passageways are adapted to receive or accommodate a myriad of elements. These lumens or passageways may have a variety of different orientations although they generally extend between a distal end or opening and a proximal end or opening.FIGS. 5A-5E illustrate, in cross sectional views, various positions and combinations and orientations of the passageways within the lead placement apparatus, and are intended to be exemplary and not exclusive.
• Turning to more particular embodiments, inFIGS. 1-4 and4C, thebody12 defines avacuum lumen44, which extends between aproximal opening46 and adistal opening48. Theproximal opening46 is located at theproximal end portion14 of the body.FIG. 1 illustrates theproximal opening46 in the form of a rearwardly extending tube for attachment to a suction port of avacuum source50. InFIGS. 3 and 4, thedistal opening48 of thevacuum lumen44 is formed as an annulus or C-shaped configuration partially around thedistal outlet22. This annulus provides a suction force at the distal outlet so as to help hold the distal outlet against the heart surface. Of course, other locations of the vacuum lumen distal opening are possible corresponding to alternate positions on thedistal outlet22. Alternate positions of thevacuum lumen44 in the body are shown inFIGS. 5A-5C, as indicated by correspondingnumbers44A-44C.
• FIGS. 5B-5E briefly illustrate other devices which may be introduced through the body and the associated lumen. For example, the body may include passageways, such as a guide wire lumen68 (FIG. 5B), a lumen for an elongated flexible or malleable element70 (FIG. 5C), an inflation lumen74 (FIG. 5D), an endoscope lumen76 (FIG. 5E), a fluid delivery lumen78 (FIG. 5E), and a lumen for a Doppler sensor80 (FIG. 5E). Each of these will be described in turn with reference to the appropriate figures.
• FIG. 5B illustrates a dedicatedguide wire lumen68 which extends between a guide wire inlet and a guide wire outlet. It is contemplated that the guide wire inlet can be located on a proximal portion of thebody12B. By way of example, but not limitation, the guide wire inlet may be positioned on the body as previously described relative to theproximal inlet20 inFIGS. 1 and 2. Also, in a manner similar to the previously describedguide wire outlet36 inFIGS. 3 and 4, the guide wire outlet of the dedicatedguide wire lumen68 is preferably disposed generally in proximity to thedistal outlet22 although the exact location may vary. For example, the dedicated guide wire outlet may be positioned in thelower surface34 adjacent the distal outlet or positioned, similar to theguide wire outlet36 inFIGS. 3 and 4 (except that the guide wire would be dedicated or separate from the lead receiving passageway18). Other locations for the dedicated guide wire outlet are, of course, possible without departing from the present invention. Additional views of the dedicated guide wire lumen of the present invention are provided byFIGS. 15-17 in accordance with an alternate body design. Turning briefly toFIGS. 15-17, a dedicatedguide wire lumen172 is defined within thebody162 and receives aguide wire190 so as to facilitate identification of a selected lead placement site. Use of the guide wire will be more particularly described relative toFIGS. 15-17 below.
• FIG. 5C illustrates the flexible ormalleable element70 in cross section which will be described in conjunction withFIG. 24. Turning toFIG. 24, theflexible element70 includes a proximal end82 anddistal end84, which is generally coextensive with thedistal end portion16 of thebody86. Theelement70 is disposed within the body and suitable for manual forming into a desired shape, such as a shape which corresponds to a surface of the heart so as facilitate placement of thebody22 adjacent a heart surface. Both the element and the body are sufficiently flexible so as to allow the surgeon to change the curvature of the body.
• Theflexible element70 may be in the form of one or more malleable wires or other like shape-retaining material. InFIG. 24, the flexible element has been formed with several curvatures along it length and thedistal end portion16 is curved relative to thelongitudinal axis13 of the body. The flexible element has the added characteristic that it is malleable, and retains the desired shape once it is positioned. Retention of the desired shape is generally maintained until repositioned by the user. It is also possible that the shape could be retained by various locking mechanisms utilized on or within the body.
• FIG. 5D shows the body5D of a lead placement apparatus which includes theinflation lumen74. In a similar manner as thevacuum lumen44, the inflation lumen generally extends between distal and proximal openings. This feature will be described further in relation toFIGS. 7-8.
• InFIG. 5E, each of theendoscope lumen76 and the fluid delivery lumen78 similarly extend between distal and proximal openings. The endoscope lumen will be described further inFIGS. 8-10. Relative to the fluid delivery lumen78, it permits an introduction of fluid to the heart surface at the selected lead placement site. The fluid delivery lumen may be connected in fluid communication with a fluid source at a proximal end of the lead placement apparatus. A distal opening of the fluid delivery lumen78 is preferably disposed adjacent the distal outlet.
• Temporary Pacing Electrodes
• Turning back toFIGS. 1-4, thebody12 may further include at least onetemporary pacing electrode72. Although the temporary pacing electrode is shown in relation to a non-circular body, it is not intended to limit the temporary pacing electrode as such, and the temporary pacing electrode may be used in any of the illustrated body configurations or others not shown.
• InFIGS. 1-4 onetemporary pacing electrode72 is positioned proximally relative to thedistal outlet22 and anothertemporary pacing electrode72 is positioned distally relative to the distal outlet at thedistal end portion16 of thebody12. InFIG. 4 the distal temporary pacing electrode flanks theguide wire outlet36. The temporary pacing electrodes are preferably disposed in proximity to thedistal outlet22 for contact with the surface of the heart when thebody12 is placed, for example, within the pericardial space, although other locations may also be suitable.
• As shown inFIGS. 3 and 4C, aconductor88 extends from eachtemporary pacing electrode72 to a more proximal portion of thebody12. By way of example, theconductors88 may extend to theproximal end portion14 of the body for connection to an electrical pacing signal source, generally indicated at90 inFIG. 1. Although the conductors are shown as positioned within the body, it is also possible that the conductors may extend outside at least a portion of the body.
• Contact between a heart surface and the temporary pacing electrode allows temporary pacing of the heart prior to lead implantation. Temporary pacing allows different surface areas of the heart to be electrically stimulated, and the effect of such electrical stimulation can be monitored using appropriate devices which are apparent to one skilled in the art. After different areas of the heart are tested for their effect from temporary pacing, the optimal lead implantation site can be determined. The temporary pacing electrode may theoretically be adapted to pace the heart by contact with either one of the epicardial surface or the pericardium, although it is preferred that the temporary pacing electrode pace the heart by contact with the epicardial surface and the use of the temporary pacing electrodes will be described relative to contact with the epicardial surface.
• FIGS. 5A-5E illustrate the conductors, corresponding to referencenumerals88A-88E, respectively, extending through the body, as previously described. The conductors generally extend parallel to the longitudinal axis of the body and, eventually, are connected to the pacing signal source. Variations are possible as to the location of the temporary pacing electrode along the body and within any of the various body shapes without departing from this aspect of the present invention. These alternate positions include but are not limited to the upper surface of the body.
• FIGS. 6A-6C illustrate an alternate embodiment which includes a body, generally indicated at92, having anupper surface91 and alower surface93. A monopolartemporary pacing electrode94 is located at thelower surface93 of the body92 (and could be located in the upper surface if desired). Thebody92 also includes avacuum lumen95, alead receiving passageway97 with adistal outlet99 and aDoppler sensor80. Thevacuum lumen95 has adistal opening96, which is rearwardly positioned relative to thedistal outlet22. The monopolartemporary pacing electrode94 has aconductor98 which extends along the body to a proximal portion of thebody92. InFIGS. 6A-6C the monopolartemporary pacing electrode94 is located adjacent thedistal outlet22 so as to allow for pacing of the heart at a location closely adjacent to theoutlet99 to reflect the electrophysiological consequences of lead placement at that location prior to actual attachment of the lead. As discussed above in relation toFIG. 1, the monopolar temporary pacing electrode is connected via theconductor98 to a suitable pacing signal source typically outside the patient's body.
• Turning briefly toFIGS. 23-23B another variation of the temporary pacing electrode is shown in the form of a removable conductive probe. Abody100 has alead receiving passageway102 extending between adistal end portion103 and aproximal end portion104. At thedistal end portion103, thelead receiving passageway102 terminates in adistal outlet105. Thelead receiving passageway102 of thebody100 may receive a removableelongated probe106 having aproximal end108 and adistal end110.Temporary pacing electrodes112 may be located on thedistal end110 of theelongated probe106.Conductors113 extend through the probe between the proximal anddistal ends108 and110 for connection to a pacing signal source at theproximal end portion104 of thebody100. Theelongated probe106 with thetemporary pacing electrodes112 is inserted into the proximal inlet of thelead receiving passageway102 and extended along the passageway to thedistal end portion103 and through thedistal outlet105. Contact between the conductive electrode(s) and the heart surface allows pacing of the heart. After the pacing the heart with the temporary pacing electrodes to establish the desired location for lead implantation, theprobe106 may be removed from thepassageway102 so as to allow insertion of a lead114 shown inFIG. 23B through thepassageway102. Thedistal end116 of the lead will be attached to the selected lead placement site which was determined by the temporary pacing electrodes to be the suitable lead placement site.
• Although the temporary pacing electrode has been particularly described and shown for used in connection with lead placement, it is contemplated that one or more temporary pacing electrodes may be used for a variety of other medical procedures including but limited to other procedures associated with the heart. For example, the temporary pacing electrode may be used to repeatedly temporarily pace the heart at a plurality of locations as necessary so as to map or analyze the conductive pathways of the heart tissue. The temporary pacing electrode may be disposed on any of the previously described apparatus of the present invention or as a separate conductive probe as described above. Other variations and uses of the temporary pacing electrodes are also possible without departing from this aspect of the present invention.
• Doppler Sensor
• Turning back toFIGS. 6A-6C, theDoppler sensor80 will now be described. TheDoppler sensor80 is preferably disposed adjacent to thedistal outlet99 for the purpose of identifying whether the lead placement outlet is too close to a coronary artery. A conductive element118 having a distal end117 and aproximal end119 is in communication with theDoppler sensor80 at its distal end117. The conductive element118 extends to a more proximal portion of the body for communication with an operator-readable output device, which is shown generally at120 inFIG. 7. InFIG. 6B theDoppler element80 is positioned in thelower surface93 of thebody92 adjacent thedistal outlet99. When thedistal end portion16 of thebody92 is put into contact with a heart surface, use of the Doppler sensor allows for detection of a coronary artery in proximity to thedistal outlet99.
• The structure and function of aDoppler sensor80 is apparent to one skilled in the art and is described in U.S. Pat. No. 4,887,606 to Yock, et al., which is incorporated herein by reference. Variations in the positioning of the Doppler sensor are possible although positions adjacent thedistal outlet99 are preferred in order to more accurately determine the proximity of the coronary to the distal outlet before attachment of the lead. It is also possible to configure theDoppler sensor80 at the end of a removable elongated probe, similar to the removable probe previously described relative toFIGS. 23-23B, so as to allow the Doppler sensor to be removably inserted into the lead receiving passageway prior to insertion of the lead.
• Expandible Member
• Now turning toFIGS. 7-10, a body, generally indicated at122, is similar in some respects to the body ofFIGS. 1-4C with like parts shown with like number. In other respects, thebody122 ofFIGS. 7 and 7A is different in that it includes theinflation lumen74, previously described, and anexpandible member124. InFIGS. 7-10 theexpandible member124 is shown as a balloon although other forms are also possible, some of which will be described below.
• As shown inFIGS. 7 and 7A, the expandiblemember124 is disposed in proximity to thedistal outlet22. InFIG. 7 theballoon124 is positioned on theupper surface32 of the body opposite thedistal outlet22. The balloon extends along theupper surface32 of the body from the very end of thedistal end portion16 to a more proximal location along the body. It can be seen that the body, when it is inserted into a patient adjacent a cardiac surface and theballoon124 is expanded by utilizing an inflation source, the balloon tends to bias thebody122 so that thelower surface34 ordistal outlet22 is oriented and held adjacent the selected heart surface. Theinflation lumen74, as shown in cross section inFIG. 7A, extends along the body and communicates at its distal opening with the expandiblemember124. Aproximal opening126 of theinflation lumen74 is connected to an inflation source, indicated at128. The inflation source is typically filled with a fluid, preferably liquid, although a variety of liquids or gases may be used as will be apparent to one skilled in the art.
• InFIG. 7A the cross-sectional configuration of the body is shown as non-circular although the invention is not limited to a non-circular cross-sectional body shape and other shapes are also possible. The particular body shown inFIGS. 7 and 7A further includes temporary pacing electrodes connected to correspondingconductors88, aDoppler sensor80, and avacuum lumen44 to assist in positioning the body against the epicardial surface—although both an inflation device and a vacuum feature may not be required on the same device. These features are shown by way of example and other combination of features may be used without departing from the scope of this aspect of the invention.
• FIGS. 8-9 illustrate another variation of the balloon-type expandible member with like parts shown with like number. InFIG. 8, abody130 extending between adistal end portion16 and a proximal end portion (not shown) includes anupper surface32 and alower surface34 along its length. At thedistal end portion16, adistal outlet22 is located in thelower surface34 and a portion of the lower surface adjacent thedistal outlet22 has a flattened shape. The expandiblemember132 is located along theupper surface32 and is spaced slightly from thedistal end portion16 of the body, although it could be directly opposite theoutlet22.FIG. 8 illustrates the unexpanded position of the balloon in solid lines, and the expanded position of the balloon as dotted lines. In the unexpanded position the balloon rests substantially against theupper surface32 of the body to provide a generally smooth body surface and a small body profile. In the expanded position, the balloon is spaced from the upper surface of the body.
• FIG. 9 shows the expanded position of the balloon when thebody130 has been inserted into the pericardial space S. Thebody130 has sufficient length so as to allow insertion of the distal end portion into the pericardial space. Thelower surface34 of thebody130 in the vicinity of thedistal outlet22 is oriented towards the epicardial surface E. Once inserted, the expandiblemember132 is inflated from its non-expanded to expanded position as fluid flows through theinflation lumen74 and fills the balloon. The expanded balloon pushes against the pericardium P, thus biasing thelower surface34 of thebody130 into contact with the epicardial surface E, thedistal outlet22 of the body being oriented in the desired direction for lead placement.
• In the particular device illustrated inFIG. 8, the body further includes a dedicatedguide wire lumen68,temporary pacing electrodes72, and theendoscope lumen76, all of which may be used to facilitate lead placement.
• The functions and construction of the various other passageways have been previously described. Theendoscope lumen76 extends through thebody130. Adistal opening136 of the endoscope lumen is located adjacent thedistal outlet22 of thelead receiving passageway18. A proximal opening137 of the endoscope lumen is disposed on a more proximal location of thebody130. An endoscope or fiberoptic viewing device138 which has a proximal anddistal ends140 and142 is connected to a suitable output viewing device, such as a video monitor or the like and inserted into the proximal opening137 of the endoscope lumen, by way of a suitable electrical or fiber optic connection. The distal end142 of the endoscope is advanced to thedistal opening136 and allows for viewing of the selected lead placement site.
• FIG. 10 illustrates anotherbody144 which is similar to thebody130 ofFIGS. 8 and 9 with like parts being shown with like number, except that a balloon-type expandible member146 extends completely around the body. In the illustrated example the expandiblemember146 is spaced a small distance from thedistal outlet22 and is circumferentially disposed on the body. As the expandiblemember146 is inflated to its expanded position, shown in dotted lines inFIG. 10, it expands outwardly relative to the body in a radial direction.
• FIGS. 11-12 illustrate abody148 which is similar to the one shown inFIG. 8, with like parts being shown with like numbers, except the body inFIGS. 11-12 has another type of expandible member, generally indicated at150, which is comprised of a plurality of biasingmembers152 which are longitudinally and laterally disposed relative to the body. The biasingmembers152 are disposed substantially aligned with theupper surface32 in an unexpanded condition. In an expanded position shown inFIG. 1112, the biasingmembers152 form a cage-like structure. As shown inFIG. 12, the expanded biasing members push against the pericardium P in order to bias thelower surface34 in the vicinity of thedistal outlet22 in contact with the epicardial surface E. The biasing members are actuated to their expanded position using a spring, release wire, or other like methods. The biasing members may be normally biased to their expanded position and held in an unexpanded position during insertion by a suitable insertion sleeve, trocar or like device. Alternately, the biasing members may be moved to the expanded position using a mechanical linkage, pull wire or the like, which is actuated from a more proximal portion of thebody150.
• FIG. 13 illustrates analternate body154 similar to the one shown inFIGS. 11-12 except that anexpandible member156 is disposed circumferentially on the distal end portion of the body and spaced a small distance from thedistal outlet22. The expandible member is comprised of biasingmembers157 which are longitudinally and laterally disposed relative to the longitudinal axis of the body.
• Other types of expandible members are possible in addition to the expandible members shown inFIGS. 7-13 without departing from this aspect of the present invention including but not limited to an elastomeric membrane. Also, more than one expandible member may be positioned on the body, and if needed, and these may be positioned at different locations along the body.
• Method of Lead Placement
• FIGS. 14-18 illustrate the method of placing a lead on a heart surface.FIG. 14 shows a patient's chest cavity, including a rib cage RC, a right lung RL, a left lung LL, a xyphoid XP, a heart HT, surrounded by a pericardium P, andpercutaneous incision158. Although the method will be shown and described by employing a preferred sub-xyphoid approach, this approach is by way of example and not limitation as other approaches may be utilized to carry out various aspects of the claimed method with departing from the present invention.FIG. 14 shows a lead placement apparatus, generally indicated at160, which includes a body, generally indicated at162.
• InFIGS. 15-17, thebody162 may have a non-circular shape, such as a convexupper surface164 and a convexlower surface166, and defines alead receiving passageway168 terminating in adistal outlet170. Thebody162 may have a plurality of lumens or passageways to carry out a variety of functions during the lead placement procedure. As shown by way of example but not limitation, these lumen or passageways may include aguide wire lumen172 terminating at a guide wire outlet174,temporary pacing electrodes176 disposed adjacent thedistal outlet170 and connected by way ofconductors178 through the body to a pacing signal source, anendoscope lumen180, and a steering member182.
• Turning back toFIGS. 14-14D theincision158 through the patient's skin is made in the vicinity of the xyphoid XP. Then the guiding ortrocar apparatus160 is inserted through thepercutaneous incision158 to the pericardium P. Access to the pericardial space S as defined between the pericardium P and the epicardial surface E is made using an appropriate dilator device, indicated generally at184, which slices, punctures or otherwise gains access to the pericardial space through the pericardium. These devices will be apparent to one skilled in the art and may include but are not limited to needles, cutting tools, guide wires, dilators, and other devices. It is noted that theincision158 is approximately 3 mm to 5 mm in length and is made in the area of the xyphoid and the costal cartilage CC. A device such as a needle, or the like, may then be advanced through theincision158 toward the heart. A viewing device may be used to aid the advancement of the needle. Access can be made into the pericardium employing known techniques, which by way of example but not limitation these techniques can include a fluoroscopic contrast injection. A thin guide wire, indicated generally at186, such as, for example, a 0.018 inch thickness guide wire is then advanced under fluoroscopic guidance into the pericardial space. Successively thicker guide wires can be inserted and removed sequentially into the pericardial space in order to sufficiently widen the incision for entry of thebody162. The sizes of these guide wires will vary. Examples of successively larger guide wires can range approximately between 0.018-0.05 inch and preferred sizes include 0.035 or 0.038 inch. An introduction sheath, or dilator, indicated generally at188, may be introduced over the guide wire into the pericardial space.FIGS. 14A-14D sequentially illustrate the introduction of theneedle184, theguide wire186, thedilator188, and insertion of thelead placement apparatus160 through thedilator188.
• FIGS. 15 and 16 illustrate insertion of thebody162 into the pericardial space S between the pericardium P and the epicardial surface E. The body is inserted into the pericardial space S a distance of approximately between 20 cm and 30 cm. If the body has a non-circular cross-sectional shape, such shape may extend along all or a portion of the body which is inserted into the pericardial space.
• As can be seen inFIG. 16, thedistal outlet170 is defined in thelower surface166 of thebody162 so that when the body is inserted into the pericardial space thedistal outlet170 is oriented adjacent the epicardial surface E for lead placement.
• InFIG. 15 aguide wire189 having adistal end190 and aproximal end191 is inserted into theguide wire lumen172 and extends forwardly of the guide wire outlet174. Prior to lead placement, theguide wire189 may be used to assist in locating the desired lead placement site such as for example bisecting tissue to create a clear path for lead placement. Thebody162 is moved within the pericardial space until thedistal outlet170 is positioned at a selected lead placement site. Movement of thedistal outlet170 may be effectuated by the steering wire182 where force is applied to the steering member at the proximal end portion of the body. An endoscope or other viewing device may be inserted into theendoscope lumen180 so as to allow viewing of the epicardial surface as well as the selected lead placement site.
• Prior to lead placement the heart is preferably paced utilizing at least onetemporary pacing electrode176 positioned adjacent thedistal outlet170. Pacing of the heart is performed by placing theelectrodes176 in contact with the surface of the heart at a selected location so as to determine whether the selection location is suitable for lead placement. Electrical impulses are supplied to the heart through the temporary pacing electrodes and the effect of the such impulses are transmitted to external viewing devices so as to determine the optimal lead placement site.
• Although the use and function of the temporary pacing electrode has been particularly described in connection with lead placement, it is contemplated that the temporary pacing electrode may be used in connection with a variety of other diagnostic and/or therapeutic medical procedures such as, for example, for mapping and analyzing the conductive pathways of the heart. The temporary pacing electrode may be inserted into the pericardial space either as part of any of the previously described apparatus or a separate pacing apparatus. The temporary pacing electrode may be used repeatedly or sequentially at various locations so as to map and/or analyze the various conductive pathways of the patient's heart.
• FIG. 16 illustrates a lead192 having adistal end194 and a moreproximal end196. The lead is inserted into thelead receiving passageway168. Once the selected lead placement site has been identified, thedistal end194 of thelead192 is advanced through thedistal outlet170 for attachment or engagement to the epicardial surfaceE. The lead192 engages either the epicardial surface E or the endocardial surface, located beneath the epicardial surface or both. Thedistal end194 of the lead preferably has an anchor that secures it to the heart surface. The anchor may take any of several well known forms, such as barb or a curved and pointed end which may be in the form of a screw or helix so as to facilitate attachment. Other shapes will be apparent so as to secure the lead to the heart and different shapes may be appropriate depending on the degree of lead permanence required. The steps of lead placement may be repeated so as to engage a plurality of leads with a surface of the heart.
• FIG. 18 shows the patient's chest after lead placement has occurred. The lead placement apparatus is withdrawn from the patient's chest. A portable pacer source198 may implanted into the subclavicular space, preferably the left subclavicular space, so as to provide an electrical pacing signal to thelead192 by way of a connection between theproximal end196 of the lead and the pacer source198.
• The method has been shown by way of example but not limitation using the above steps. It is realized however that other variations for performing the method of lead implantation are also possible and may be utilized in place of or in addition to the steps of the method already described. For example, the method may be performed utilizing a body having a vacuum lumen describe above relative toFIGS. 3-4C orFIGS. 6A-6C. A vacuum source provides suction to hold the distal outlet against the surface of the heart. In addition, the method of lead placement utilizing the temporary pacing electrodes is not limited to a body having a non-circular shape.
• A method of lead placement includes providing a body having theDoppler sensor80, as shown and described relative toFIGS. 6A-6C, or a separate Doppler sensor. After the body is introduced into the pericardial space, the Doppler sensor is placed in contact with the epicardial surface at a selected location. As discussed relative toFIGS. 6A-6C, the Doppler sensor is located in the lower surface of the body although other positions are possible. Once in contact with the heart surface, the Doppler sensor is activated to detect whether the sensor ordistal outlet22 is in proximity to a coronary artery of the heart. The information is transmitted along the conductive element to the Doppler output device where it is read by the operator. If a coronary artery is detected, the body is moved to another lead placement site. Successive detecting is performed so as to avoid placement of the lead in proximity to a coronary artery. If no coronary artery is detected unduly close to the distal outlet, the lead is advanced from the distal outlet and engaged with one or both of the epicardial and endocardial surfaces of the heart in a similar manner as shown inFIG. 16. Thereafter, the lead placement apparatus may be withdrawn. Although the method may be performed where at least a portion of the body has a non-circular shape, the method of lead placement which includes the Doppler sensor is not limited to a body having a non-circular shape.
• As shown and described inFIGS. 7-13, the expandible member is deployed from an unexpanded position to an expanded position, such as by an inflation source or movement of biasing members. The expandible member is carried by the body and disposed in the vicinity of the distal outlet so as to hold or bias the distal outlet against the selected lead placement site. Amongst the steering members, vacuum lumen and expandible member, any one or a combination thereof may be utilized so as to orient the distal outlet against a selected lead placement site.
• The method of lead placement further may include the introduction of a fluid to the heart surface, in which event the body has a fluid delivery lumen as described in relation toFIG. 5E.
• Lead Removal
• The present invention contemplates a variety of techniques or body designs that facilitate removal of the lead from the body after implantation.FIGS. 25-41A are directed to a body construction and lead arrangement which facilitate removal of the lead from the lead placement apparatus and, in particular, in which the lead is removed from the lead placement apparatus in a direction which is transverse to the longitudinal axis of the body. Transverse lead removal as described below may be incorporated into any one or more previously described aspects of the invention.
• FIGS. 25 and 26 illustrate abody230 having adistal end portion232 and aproximal end portion234. Although the body is shown having a non-circular shape in the transverse direction along at least a portion of the body, other shapes may also be employed.
• InFIG. 25, the body, generally indicated at230, includes a longitudinally extending seam orthin wall portion236, alead receiving passageway238 andpassageways240. Thethin wall portion236 is so called because it is thinner relative to the remaining portions of the body and it is adjacent to or forms a portion of the inner surface of the lead receiving passageway. Thethin wall portion236 extends from adistal end portion232 of the body to a more proximal portion of the body, and may extend to theproximal end portion234 of the body or any intermediate body position. Thethin wall portion236 preferably extends at least along the portion of the body which is inserted into the pericardial space of a patient. Where a sub-xyphoid approach is employed, the length of thethin wall portion236 may range approximately between 10 cm and 40 cm, preferably 20 cm to 30 cm. A lead240 having adistal end244 and a moreproximal end246 is shown inserted into thelead receiving passageway232 during the lead placement procedure.
• In the embodiment ofFIG. 26, thelead242 is removed from the body by separating the body along thethin wall portion236. The thin wall portion may be thin enough or may even be perforated along its length so as to facilitate separation. Such separation may be initiated at thedistal end portion232 of the body or along a more proximal portion and then separation extends axially in an “unzipping” manner, from the initial separation site. By way of example but not limitation,FIG. 26 shows separation of the thin wall portion extending from thedistal end portion232 and extending proximally to create a longitudinally disposed opening along the body. Thereafter, thelead242 may be removed from the body in a transverse direction tolongitudinal axis250 of the body. Although the body is shown-having a plurality ofpassageways240 which may incorporate any combination of features previously described to facilitate lead placement, these passageway are not intended to limit the present invention.
• FIGS. 27 and 28 illustrate an alternative body, generally indicated at252, having adistal end portion254 and aproximal end portion256 and defining a longitudinally disposed channel, generally indicated at258, which extends in a proximal direction from thedistal end portion254. The channel is approximately C-shaped or U-shaped, and has abottom wall257 andside walls259. The channel has atop opening261 to allow for lead removal. Thechannel258 is adapted to receive a lead which is removed through thetop opening261 in a direction which is transverse to the longitudinal direction of the body. Thechannel258 may extend along the entire length of the body or any portion of the body. More specifically, the width of thetop opening261 in the channel is preferably smaller than the diameter of thelead242, to normally retain the lead within the channel. The body is preferably made of resilient polymeric material so that theside walls259 flex outwardly to allow thetop opening261 to widen for removal of the lead.
• FIGS. 29 and 30 illustrate lead removal in accordance with another aspect of the invention. A body, generally indicated at260, has adistal end portion262 and aproximal end portion264 and defines achannel266 which is similar to the channel described in previousFIGS. 27 and 28 having a bottom wall, sides walls and an top opening except that thebody260 inFIGS. 29 and 30 includes an elongated C-shapedportion268 which is received within thechannel266. The C-shapedportion268 has adistal end270 and aproximal end272 and, when assembled with the channel, captures the lead between them.
• Viewed in the transverse direction, as shown inFIG. 30, the C-shapedportion268 is located within thechannel266, and has an outerconvex surface274 that cooperates with the inner concave surface of thechannel266 and is sized slightly smaller than thechannel266 so as to be received therein. The assembly of the C-shapedportion268 and thechannel266 defines alead receiving passageway278 for insertion of the lead. Thebody260 may have a non-circular shape in the transverse direction although other shapes are possible. A plurality ofpassageways280 also may be defined within the body and utilized to incorporate the features previously described. The C-shapedportion268 may be slidably or rotatably received within thechannel266. In this embodiment, the lead may be released in two different ways. First, the C-shapedportion268 may be rotated withinchannel266 until the gaps or slots are aligned, allowing the lead to be removed from the body. Alternatively, the C-shapedportion268 andchannel266 may be peeled apart, revealing the lead located therebetween.
• FIGS. 40-41A employ a similar arrangement, and generally illustrate rotational movement of a longitudinally disposed portion relative to the remainder of the body. A body, generally indicated at282, defines alead receiving passageway284 and has a circular shape in the transverse direction. The body is comprised of inner and outer longitudinally disposedportions286 and287, respectively, which are concentrically positioned relative to one another and together define thelead receiving passageway284 which receives alead288. At least one of the longitudinally disposed portions is rotated relative to the other. Each inner andouter portion286 and287 has anopening289 and291, respectively, which extends longitudinally along each portion. Although each opening may vary in size and may vary relative to one another, the size of each opening is larger than the thickness of the lead so as to allow for lead removal transverse to the longitudinal axis of the body when the openings are aligned.
• InFIGS. 40A and 41A, the outer longitudinally disposedportion287 extends between adistal end portion290 and aproximal end portion292 and defines alongitudinal axis294. The inner longitudinally disposedportion286 is received within thelead receiving passageway284 and extends between adistal end296 and aproximal end298. InFIGS. 40 and 41, at least one of the inner and outer portions may be curved at an acute angle relative to alongitudinal axis294 of the body although other angles of curvature between 10 degrees and 80 degrees are possible. For example, one of the inner and outer shaft may be curved and the other may be straight in a similar manner as described relative toFIGS. 19-20. The longitudinal position of inner andouter portions286 and297 may be fixed relative to one another or capable of relatively slidable movement.
• FIGS. 40 and 40A illustrate a first position of thebody282 where theopenings289 and291 are circumferentially non-aligned relative to one another. Thelead288 is inserted into thepassageway284 and a distal end300 of the lead may be advanced past the distal ends290 and296 of both longitudinally-disposed portions. Removal of the lead may be achieved by rotating at least one of the inner andouter portions286 and287 relative to one another to a second or opened position, as shown inFIGS. 41 and 41A, in which theopenings289 and291 are in circumferential alignment with one another.FIGS. 40A and 41A illustrate rotational movement of the outer longitudinally disposedportion287 relative to the inner longitudinally disposedportion286 in the direction indicated by the arrow inFIG. 40A. Removal of the lead is illustrated by the arrow inFIG. 41.
• Turning back toFIGS. 31-32B, they illustrate another lead placement apparatus having a body, generally indicated at302, which defines alongitudinal axis304 and alead receiving passageway306, and includes distal andproximal end portions308 and310, respectively, and a longitudinally disposed seam indicated generally at312. Thebody306 is designed to separate along the longitudinally disposedseam312 for lead removal in a transverse direction. Theseam312 is defined by interlocking longitudinal edges of the body. One of the longitudinal edges includes aprojection314 and the other longitudinal end includes arecess316 so that when the body defines a closed position as shown inFIG. 32A theprojection314 is seated within therecess316.
• Removal of thelead318 is achieved by separating the seam at one or both of the distal orproximal end portions308 and310. The body is made of any suitable material or combination of materials which imparts flexibility characteristics. Examples of materials include, but are not limited to, polymeric material, common in medical devices. The material may have shape retention characteristics such as by thermoforming or the like, so that the body normally defines a closed position (as seen inFIG. 32A but without the need for interlocking features), but spreads apart easily as seen inFIG. 32B. Alternately, a malleable metal strip may be disposed within the body ofFIG. 32A and surrounded by a non-metal material which maintains a normally closed position. Force applied to the metal strip may separate theprojection314 from therecess316. Although the shape of thebody306 is shown as circular, other shapes, such as the non-circular shapes described above, are also possible without departing from this aspect of the present invention.
• InFIGS. 33 and 34, an alternate body, indicated generally at320, is shown having distal andproximal end portions322 and324, respectively, and including a seam indicated generally at326, which is similar to the body inFIGS. 31-32B, except that the seam is closed by overlappinglongitudinal edges328 and330, respectively, along of thebody320. Theseam326 is axially spaced from a longitudinal axis of thebody332. A lead338 received within thepassageway334 may be removed in a transverse direction, by temporarily spreading the overlapping edges to form a longitudinal gap through which the lead maybe withdrawn as indicated inFIG. 33.
• FIGS. 35-37 illustrate a yet further embodiment of the lead placement apparatus which allows for removal of the lead in a transverse direction. A body, generally indicated at340, includes distal andproximal end portions342 and344, respectively, and defines alead receiving passageway346 extending between the distal and proximal end portions for receiving a lead348. The body includes a longitudinally disposed weakenedportion350 which is bounded between two thin walled portions or other lines ofweakness352. A separate filament or wire is connected to the distal end of the weakenedportion350, or an extension of theportion350 extends in a proximal direction terminating at atab354 which is disposed in a more proximal portion of the body. As illustrated inFIG. 36, removal of the lead148 from thebody340 may be achieved by pulling proximally on the tab354 (or pulling on the wire or filament), as indicated by the arrow, causing separation along the thinwalled portions352, thus opening thepassageway346 so as to allow removal of the lead in a transverse direction.
• InFIGS. 38 and 39 an alternate body, generally indicated at360, is shown similar to the body shown inFIGS. 35-37, except that thebody360 includes a longitudinally disposedslide362 which is slidably moveable relative to the remaining portion of the body in order to allow lead removal in a transverse direction. Thebody360 includes distal andproximal end portions364 and366, respectively and defines apassageway368 for receiving a lead. In the transverse direction shown inFIG. 39 the body may have a circular or other shape and include a longitudinal opening between two longitudinally disposededges367 extending around the circumference of the body. The opening is defined along the body between the distal andproximal end portions364 and366. Eachlongitudinal edge367 may include aprojection369 which also extends along the body and into side slots orrecesses373 of theslide member362.
• As shown inFIG. 38, when the slide is slidably moved in a proximal direction as indicated by the arrow, the opening defined between thelongitudinal edges369 is unobstructed and permits lead removal in a direction which is transverse relative to the body.
• Epicardial Lead
• FIGS. 42 and 42A illustrate an epicardial lead, generally indicated at380, which is comprised of an elongatedouter sheath382 and aninner member384. Theouter sheath382 is made of an insulated material whereas the inner member is conductive. Thesheath382 includes adistal end portion386 and aproximal end portion388 and defines alongitudinal axis390 therebetween. Theouter sheath382 is hollow and is preferably, but not exclusively, cylindrical in cross-sectional shape. Apassageway392 is defined by an inner surface of theouter sheath382 for receiving theinner member384.
• As best seen inFIG. 42, thedistal end386 of thesheath382 is fixed at an acute angle A relative to thelongitudinal axis390. By way of example but not limitation, the angle A is approximately 20 degrees relative to the longitudinal axis. It is realized that other acute angles may be utilized, such as between 10 degrees and 80 degrees, although the preferred range of the angle is between approximately 30 degrees to 60 degrees for directing a contact member toward the surface or the heart. The length of the angled portion of the sheath itself may measure approximately 10 mm to 20 mm.
• As shown inFIG. 42, theinner member384 has adistal section394 and aproximal section396. As with thesheath382, theinner member384 is elongated relative to thelongitudinal axis390 and generally defines a cylindrical cross-sectional shape. At thedistal section394, theinner member384 defines a contact anchor, which may be in the form of a nonlinear shape, preferably but not exclusively in the form of a helical or screw-like shape, so as to facilitate attachment of theinner member384 to the epicardial surface of the heart.FIG. 42A shows theinner member384 as having a solid cylindrical cross-section, although other configurations and shapes are also possible without departing from the present invention. The inner member is preferably made of a flexible or malleable material and comprises one or more conductive elements or wires which may be connected to a pacing signal source at theproximal section396.
• InFIG. 42A thesheath382 and theinner member384 are capable of movement relative to one another so as to implant the inner conductive member on the epicardial surface of the heart. For example, theinner member384 is moved so as to move thedistal section394 of the inner member distally of thedistal end portion386 of theouter sheath382. Any relative movement may be utilized, such as rotational, translational or a combination thereof. In addition, the epicardial lead can be configured to allow movement of the inner member in a direction which is transverse to thelongitudinal axis390 in accordance with previously described aspects of the invention.
• When lead implantation is desired, relative movement between the inner member and the outer sheath causes thedistal section394 of the inner member to be moved through the fixed angle A at thedistal end portion386. As thedistal section394 passes through thedistal end portion386, it assumes the angled position relative to thelongitudinal axis390. Continued relative movement moves thedistal section394 beyond of thedistal end portion386 for contact with the heart of a patient and, in particular, the epicardial surface. Thedistal section394 allows for attachment of the inner member to the epicardial surface of the heart in any conventional manner, without the need for attachment from an orthogonal direction as found in prior art leads. For example, the helical shape of the distal section may be implanted or embedded into the epicardial surface of the heart by simple rotational movement of the inner conductive member.
• Turning briefly toFIG. 51-52,FIG. 52 generally illustrates attachment of theinner member384 of theepicardial lead380 to the epicardial surface E of the heart where the distal section is disposed at an acute angle I, which ranges approximately between 10 degrees and 80 degrees, preferably between 30 degrees and 60 degrees. By contrast,FIG. 51 shows an epicardial lead, generally indicated at398, found within the prior art. The epicardial lead requires the distal end to be disposed at a right angle R1 so that the distal end is perpendicular to the epicardial surface and thus the epicardial lead forms a 90 degree bend relative to radius indicated at R2.
• FIG. 43 illustrates anepicardial lead400 similar to the one shown inFIGS. 42 and 42A, with like parts being shown with like number, except that anouter sheath382 of thelead400 has adistal end portion386 which is fixed into a curved shape relative to the longitudinal axis. The angle, indicated at B, defined by thedistal end portion386 is preferably in the range approximately between 10 degrees and 80 degrees, preferably 30 degrees and 60 degrees. The length of the curved portion of the sheath measures approximately 10 mm to 20 mm.
• FIGS. 44-45A illustrate an epicardial lead, generally at402, which is comprised of an elongated, hollow outerinsulated sheath404 and an innerconductive member406. Thesheath404 includes distal andproximal end portions408 and410, respectively. Likewise, theinner member406 includes distal andproximal sections412 and414, respectively. Theouter sheath404 defines apassageway411 for receiving theinner member406 and alongitudinal axis416. As previously described, theouter sheath404 and theinner member406 are movable relative to one another.
• Adjacent thedistal end portion408 of theouter sheath404, the sheath includes acollar418 having a slopedproximal edge419. As shown inFIG. 44, the proximal edge slopes downwardly in a distal direction to define a gap with the remaining portion of the sheath. Along an upper surface of the sheath, the proximal edge of the collar is pivotally connected at ahinge420 to the remaining portion of thesheath404.
• As shown inFIGS. 44 and 45, thedistal end portion408 of thesheath404 is adapted to move between at least two positions. A first position is illustrated inFIG. 44. Thedistal end portion408 is positioned so that thepassageway411 for receiving theinner member406 is in alignment with thelongitudinal axis416. Along the lower surface of the sheath, the slopedproximal edge419 is spaced from the remaining portion of the sheath. A second position is illustrated inFIG. 45 where thedistal end portion408 is disposed at an angle, indicated at C, relative to thelongitudinal axis416 so that the passageway is disposed at the angle C relative to the longitudinal axis.
• Movement of the distal end portion is preferably controlled by a pre-set thermo-formed position of the distal end, or by a biasing member such as a spring or the like. The distal end portion is preferably biased such that the normal position of the spring results in the second position of the distal end portion shown inFIG. 45. Alternatively, control structures may be carried at theproximal end portion410 for controlling the angular position of the distal end portion. Other control members may be used to vary the angular orientation of thedistal end portion408 apart from the angular positions shown and described above without departing from this aspect of the present invention.
• Numerous variations are also possible so as to permit attachment of the inner member to the epicardial surface of the heart at an acute angle. InFIG. 46, an epicardial lead, generally at422, includes anouter sheath424 and aninner member426. Adistal end portion428 of the outer sheath carries asensor430 such as, for example, a pacing electrode, Doppler sensor, fiber optic viewing device or endoscope which is connected to viewing means at a more proximal portion of theepicardial lead422. Thedistal end portion428 further defines alumen432 extending into the sheath in a proximal direction. Thelumen432 is disposed at an acute angle relative to the longitudinal axis of the body and receives thesensor430 therein. A spring or other biasing member434 is disposed within the lumen so as to normally bias thesensor430 in an extended position, illustrated inFIG. 46. Extension and retraction of the sensor may also be controlled at a more proximal portion of the epicardial lead.
• InFIG. 46, adistal section436 of theinner member426 is preformed at an angle D relative to the longitudinal axis while thesheath426 is aligned relative to alongitudinal axis437. So when thedistal section436 extends distally of thesheath424, the distal section will form the acute angle D relative to the longitudinal axis. The distal section is made of any suitable material which allows it to resume a normally curved position relative to the longitudinal axis of the lead.
• FIG. 47 illustrates another epicardial lead, generally at438, having an outer sheath440 and aninner member442. Adistal end portion444 of the sheath440 is curved at an acute angle, indicated at E, relative to thelongitudinal axis445 of the lead. Thedistal end portion444 includes a transverse opening446 relative to thelongitudinal axis445. A distal section448 of theinner member442 is moved through the sheath440 and extends through the transverse opening446. The transverse opening446 has a convex inner surface, so that when the distal section448 of theinner member442 is advanced, the distal section engages the convex inner surface of the opening446 so as to be disposed at the angle E relative to the longitudinal axis.
• InFIG. 48 an epicardial lead, generally at450, which generally includes anouter sheath451 and aninner member453, includes a steeringmember452, such as a pull wire, having adistal end454 and a proximal end456. Thedistal end454 of the steering member is connected in the vicinity of adistal end portion458 of thesheath451. So thedistal end portion458 is moved upon application of force to the steering member at the proximal end456. Tensile compressive or rotational force may be applied to the steering members so as to move the distal end portion in a desired direction for lead placement.
• InFIG. 49, an alternate epicardial lead, generally at60, utilizes a malleableelongated wire462 which may be shaped to retain a desired angular orientation for lead placement. Thewire462 is similar to that previously described in relation toFIG. 24. Other features may also be utilized to facilitate lead placement in accordance with previously discussed features.
• FIG. 50 shows anepicardial lead464 having a distal section, generally at466, with an alternate shape. Thedistal section466 has anonlinear portion468 as well as alinear portion470. The linear portion is distally located relative to the nonlinear portion and is used like a guide wire which may be used to dissect cardiac tissue and facilitate lead placement. Many other shapes and orientations are possible are possible without departing from this aspect of the present invention.
• FIGS. 53-62 illustrate additional variations in the lead placement apparatus and method of the present invention. InFIGS. 53-56 a lead placement apparatus generally indicated at468 includes an elongated body generally at470. Thebody470 defines a longitudinal axis and generally includes aproximal end portion472 and adistal end portion474. As shown particularly inFIG. 55, the body is illustrated having a circular cross sectional shape although other shapes are also possible. Alead receiving passageway476 is defined within the body extending between aproximal inlet478 and adistal outlet480. Thepassageway476 generally is shown as a centrally located lumen within the body although other positions are possible. One ormore steering members482 are disposed within the body and are adapted to deflect thedistal end portion474 of the body from, for example, a straight configuration shown inFIG. 54 to a curved configuration shown inFIG. 56, when force is applied to at least one of the steering members in the direction indicated by the arrow. Thebody470 also may include at least onetemporary pacing electrode484 and associated conductive element(s)486 which connect to a pacing signal source at adistal end488, preferably outside of the patient's body.
• As shown inFIGS. 53-56, the body is suitably flexible so as to allow deflection of thedistal end portion474 upon application of force to the steering members. The body also has sufficient stiffness so as to allow for rotational movement of the body during the lead placement procedure. The body can be rotated up to 360 degrees relative to its longitudinal axis. It is also possible that a portion of the body may be rotated relative to the remaining portion of the body, for example, the portion of the body extending into the pericardial space may be adapted for rotation up to 360 relative to the handle orproximal end portion472 of the body. Because the tip is deflectable in at least one plane and the body has torsional rigidity that allows it to be rotated, the tip can, in effect, be deflected up to 360 degrees.
• FIGS. 57-59 illustrate an alternatelead placement apparatus490 which is similar to theapparatus468 inFIG. 5356, with like parts being shown with like number, except that the apparatus ofFIGS. 57-59 includes anannular expandible member492, preferably a balloon type expandible member, which is carried by thebody470. As shown inFIG. 58, aninflation lumen494 is disposed within thebody470 and is in fluid communication with an inflation source generally at theproximal end portion472 of the body.FIG. 59 illustrates selective expansion of the balloon.
• InFIGS. 60-60A a guiding ortrocar device496 is illustrated and insertably received within thelead receiving passageway476. It is contemplated that the lead receiving passageway is suitably sized for temporarily receiving devices in addition to a lead during the lead placement procedure. These devices are preferably, but not necessarily, removed from the lead receiving passageway prior to insertion of the lead. A guide wire498 is insertably received within thetrocar device496 and can be advanced beyond thedistal end portion474 of thebody470 so as to help locate the selected lead placement site. As shown inFIG. 61, aDoppler sensor500 is generally disposed in proximity to thedistal outlet480 and is connected through aconductor501 to an operatorreadable output device503. TheDoppler sensor500 may be configured as part of a sensing device which is inserted into thelead receiving passageway476 and advanced through thebody470 to thedistal outlet480 for sensing the proximity of the distal outlet to a coronary artery. Alternatively, the Doppler sensor can be mounted to thedistal end portion474 of the body in proximity to thedistal outlet480.
• FIGS. 60-62 also illustrate a method which utilizes the lead placement apparatus ofFIGS. 53-56. InFIG. 60 thetrocar496 and guide wire498 are inserted into thelead receiving passageway476 and through thebody470 so as to facilitate introduction of the body into the pericardial space. A distal portion of the guide wire498 may extend beyond thedistal end portion474 of thebody470. The guide wire498 may assist in piercing the pericardium or, alternatively, piercing of the pericardium may be performed separately by another appropriate instrument, for example, a needle or other like devices. Thereafter the guide wire and/or thetrocar496 may be inserted into the pericardial space to dilate the initial incision and widen the incision so as to allow insertion of thedistal end portion474 of thebody470 into the pericardial space. The guide wire and trocar are removed from thelead receiving passageway476 and, if necessary, additional guide wires, dilators or other introduction sleeves of larger diameter may be inserted into thelead receiving passageway476 so as to suitably widen the incision for introducing thebody470 into the pericardial space. Once thedistal end portion474 of the body has been introduced into the pericardial space, thedistal outlet480 may be oriented in the desired direction for lead placement using thesteering members482. At least a portion of the body may also be rotated in 360 degrees. Thetemporary pacing electrodes484 may be placed in contact with successive locations of the epicardial surface of the heart for pacing of the heart.
• FIG. 61 illustrates insertion of theDoppler sensor500 into thelead receiving passageway476. TheDoppler sensor500 and its associated sensing device are inserted into the body to detect whether the selected lead placement site is in proximity to a coronary artery. If a coronary artery is detected, then the distal end portion is moved so as to avoid placement of the lead on a coronary artery. For example, thedistal end portion474 may be deflected using the steering members or it may be rotated, as necessary. The Doppler sensor is preferably removed prior to lead placement.
• InFIG. 62, alead504 is inserted into thelead placement device468 at theproximal inlet478 and advanced to thedistal outlet480. The lead is engaged with the selected lead placement site. A suitable retention member may be disposed at the distal end of the lead for attachment to the epicardial or endocardial surface of the heart. Once lead placement is completed, the lead placement apparatus may be withdrawn.
• The lead placement apparatus may be utilized to perform the method in a similar manner as described relative to the lead placement apparatus ofFIGS. 53-56. The expandible member can be enlarged after the distal end portion of the apparatus has been inserted into the pericardial space so as to enlarge the existing working and viewing space at the distal end portion of the body.
• Accordingly, apparatuses and methods for placing a lead on a surface of the heart has been provided that meets all the objects of the present invention. While the invention has been described in terms of certain preferred embodiments, there is no intent to limit the invention to the same. Instead it is to be defined by the scope of the appended claims.

Claims (20)

1. An apparatus for placing a lead on a surface of a human heart, the apparatus comprising:

an elongated body including a proximal end portion and a distal end portion, the elongated body having a length adapted to permit minimally invasive access to the heart, the distal end portion of the elongated body defining a longitudinal axis and having a contact surface generally parallel to the longitudinal axis;

a lead receiving passageway extending through the elongated body to a distal outlet on the contact surface; and

a vacuum lumen extending through the elongated body and having a proximal opening and a distal opening, wherein the distal opening is disposed on the contact surface.

2. The apparatus ofclaim 1 wherein the contact surface is concave in a direction transverse to the longitudinal axis.

3. The apparatus ofclaim 1 wherein the contact surface is planar in a direction transverse to the longitudinal axis.

4. The apparatus ofclaim 1 wherein the distal portion of the elongated body has an upper surface and a lower surface, and the contact surface is on the lower surface.

5. The apparatus ofclaim 4 wherein the upper surface is convex in a direction transverse to the longitudinal axis and the contact surface is shaped to generally conform to an epicardial surface of the heart.

6. The apparatus ofclaim 1 wherein the distal portion of the elongated body has a non-circular cross section in a direction transverse to the longitudinal axis.

7. The apparatus ofclaim 6 wherein the elongated body has a width that is greater than a height of the elongated body in a direction transverse to the longitudinal axis.

8. The apparatus ofclaim 1 wherein a portion of the lead receiving passageway proximally adjacent the distal outlet extends at an acute angle with respect to the longitudinal axis.

9. The apparatus ofclaim 1 further comprising a viewing lumen extending through the elongated body, the viewing lumen having a distal end adjacent the distal outlet.

10. The apparatus ofclaim 1 further comprising a steering member for steering the distal end portion of the elongated body.

11. The apparatus ofclaim 10 wherein the steering member is adapted to steer the distal end portion of the elongated body in a plane parallel to the longitudinal axis of the elongated body.

12. The apparatus ofclaim 1 wherein a portion of the elongated body is curved relative to the longitudinal axis.

13. The apparatus ofclaim 1 wherein the vacuum lumen and the lead receiving passageway are non-concentric.

14. An apparatus for placing a lead on a surface of a human heart, the apparatus comprising:

an elongated body including a proximal end portion and a distal end portion, the elongated body having a length adapted to permit minimally invasive access to the heart, the distal end portion of the elongated body defining a longitudinal axis and having a contact surface generally parallel to the longitudinal axis;

a lead receiving passageway extending through the elongated body to a distal outlet on the contact surface;

a vacuum lumen extending through the elongated body and having a proximal opening and a distal opening, wherein the distal opening is disposed on the contact surface; and

a temporary pacing electrode positioned on the distal end portion of the elongated body.

15. The apparatus ofclaim 14 wherein the temporary pacing electrode is positioned adjacent the distal outlet.

16. The apparatus ofclaim 14 wherein the temporary pacing electrode is adapted for bipolar pacing and sensing.

17. An apparatus for placing a lead on a surface of a human heart, the apparatus comprising:

an elongated body including a proximal end portion and a distal end portion, the elongated body having sufficient length to allow minimally invasive access to the heart, the distal end portion of the elongated body defining a longitudinal axis and having a contact surface generally parallel to the longitudinal axis;

a lead receiving passageway extending through the elongated body to a distal outlet on the contact surface; and

temporary and non-invasive means for holding the distal outlet to the surface of the heart.

18. The apparatus ofclaim 17 wherein the temporary and non-invasive means comprises a vacuum lumen extending through the elongated body and having a proximal opening and a distal opening, wherein the distal opening is adjacent the distal outlet.

19. The apparatus ofclaim 17 further comprising means for pacing the surface of the heart adjacent the distal outlet.

20. The apparatus ofclaim 17 further comprising means for electrically mapping the surface of the heart.

Images