Method and device for percutaneous left ventricular reconstruction

Abstract

A method for reducing left ventricular volume, which comprises identifying infarcted tissue during open chest surgery; reducing left ventricle volume while preserving the ventricular apex; and realigning the ventricular apex, such that the realigning step comprises closing the lower or apical portion of said ventricle to achieve appropriate functional contractile geometry of said ventricle in a dyskinetic ventricle of a heart.

Claims

1. A system for reducing a volume in a heart comprising: a delivery catheter that is insertable endovascularly into the heart; a plurality of guidewires that are simultaneously deliverable from within the delivery catheter, each guidewire of the plurality of guidewires being deliverable across a wall of a chamber of the heart so that a distal end of each guidewire extends beyond the wall and so that each guidewire is laterally offset from an adjacent guidewire; and at least one fixation member that is positionable on a surface of the wall and that is coupleable with at least one guidewire of the plurality of guidewires in a manner such that tension is applicable to the at least one guidewire to cause said fixation member to pull the wall toward an opposing wall of said chamber to close off a lower or apical portion of said chamber.

2. The system of claim 1, wherein the at least one fixation member is coupleable with each guidewire of the plurality of guidewires.

3. The system of claim 2, wherein the at least one fixation member includes a plurality of holes through which the plurality of guidewires are disposed to couple the at least one fixation member with the plurality of guidewires.

4. The system of claim 1, wherein the plurality of guidewires are perforating elements that are configured to penetrate the wall of the chamber.

5. The system of claim 4, wherein the wall of the chamber is a left ventricular wall and the opposing wall of said chamber is a septum, and wherein said perforating elements are configured to perforate the septum and the left ventricular wall while the delivery catheter is positioned within a right ventricle of the heart.

6. The system of claim 1, wherein the fixation member is a collar, a hook, a barb, a fastener, or a clip.

7. The system of claim 1, further comprising a tissue sensing element that is configured to sense infarcted tissue of the wall of the chamber.

8. The system of claim 7, wherein the at least one guidewire is a perforating element that is configured to penetrate the wall of the chamber, and wherein the perforating member comprises the tissue sensing element.

9. The system of claim 1, wherein the delivery catheter is a steerable catheter.

10. The system of claim 1, further comprising a thoracoscope or camera that is positionable into an incision to facilitate visualization of the heart.

11. A method for reducing a volume in a heart comprising: inserting a delivery catheter endovascularly into the heart; simultaneously delivering a plurality of guidewires from within the delivery catheter into the heart; delivering the plurality of guidewires across a wall of a chamber of the heart so that a distal end of each guidewire extends beyond the wall and so that each guidewire is laterally offset from an adjacent guidewire; coupling at least one fixation member that is positionable on a surface of the wall with at least one guidewire of the plurality of guidewires; and applying tension to the at least one guidewire to cause said fixation member to pull the wall toward an opposing wall of said chamber to close off a lower or apical portion of said chamber.

12. The method of claim 11, further comprising coupling the at least one fixation member with each guidewire of the plurality of guidewires and applying tension to each guidewire of the plurality of guidewires to pull the wall toward the opposing wall of said chamber to close off the lower or apical portion of said chamber.

13. The method of claim 12, wherein the at least one fixation member includes a plurality of holes through which the plurality of guidewires are disposed to couple the at least one fixation member with the plurality of guidewires.

14. The method of claim 11, wherein the plurality of guidewires are perforating elements that are configured to penetrate the wall of the chamber.

15. The method of claim 14, wherein the wall of the chamber is a left ventricular wall and the opposing wall of said chamber is a septum, and wherein said perforating elements are configured to perforate the septum and the left ventricular wall while the delivery catheter is positioned within a right ventricle of the heart.

16. The method of claim 11, wherein the fixation member is a collar, a hook, a barb, a fastener, or a clip.

17. The method of claim 11, further comprising sensing infarcted tissue of the wall of the chamber using a tissue sensing element.

18. The method of claim 17, wherein the at least one guidewire is a perforating element that is configured to penetrate the wall of the chamber, and wherein the perforating member comprises the tissue sensing element.

19. The method of claim 11, wherein the delivery catheter is a steerable catheter.

20. The method of claim 11, further comprising positioning a thoracoscope or camera into an incision to facilitate visualization of the heart.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) The present invention has other advantages and features which will be more readily apparent from the following detailed description of the invention and the appended claims, when taken in conjunction with the accompanying drawings, in which:

(2) FIG. 1A is a schematic illustration of a mammalian heart;

(3) FIG. 1B is a schematic showing a sensing catheter that detects the infracted tissue and distinguishes the viable tissue before puncturing the septum and realigning the apex and reducing left ventricular volume;

(4) FIG. 1C illustrates a cross-section of a heart viewed along line A-A in FIG. 1A;

(5) FIG. 2A is a schematic illustration of the use of a suturing device that is used to exclude the infarcted tissue and resulting volume reduction in the left ventricle;

(6) FIG. 2B illustrates a cross-section of a heart viewed along line B-B in FIG. 2A;

(7) FIG. 2C illustrates a cross-section of a heart viewed along line B-B in FIG. 2A and showing the resizing of the ventricle;

(8) FIG. 3 illustrates the manner of direct visualization of the infarcted wall of the left ventricle and guiding the placement of the suture on the left ventricle during LVR;

(9) FIGS. 4A through 4F illustrate the step-by-step procedure for one embodiment of a percutaneous LVR procedure;

(10) FIG. 5 shows a thoracoscopic suction and suturing device that could be used for LVR;

(11) FIGS. 6A and 6B illustrate an epicardial or thorascopic approach to accomplish LVR; and

(12) FIGS. 7A through 7E illustrate implantable devices in accordance with the present invention for use during percutaneous LVR to bring together the infarcted tissue of the septum and the left ventricular wall.

DETAILED DESCRIPTION OF THE INVENTION

(13) FIG. 1A illustrates a mammalian heart 10 and identifies the right ventricle 12, left ventricle 14, left ventricle wall 15 and septum 16. Right ventricle 12 may also be referred to interchangeably herein and in the figures as “RV”. Left ventricle 14 may also be referred to interchangeably herein and in the figures as “LV”. Additionally, left ventricle 14 is also referred to herein as “left ventricle chamber.”

(14) FIGS. 1A-1C and 2A-2C illustrate a method of percutaneously accomplishing left ventricular restoration (“LVR”). In accordance with this method, a catheter 18 with a sensing element 20 is threaded through the femoral vein (not shown) into the right ventricle 12 of heart 10. It is to be understood that the invention is not limited to insertion of catheter 18 via the femoral vein and catheter 18 may be inserted via other arteries or veins. The sensing element 20 locates the infarcted tissue 22 of the interventricular septum 16. A commercially available device (EP Technologies, CA) that has the capability of discerning viable tissue from scar tissue could be used for the sensing purpose. This device operates on the concept of “monophasic action potential” (“MAP”) and allows the operator to determine whether or not the site in contact with the sensing element has the desired properties.

(15) Upon identifying this infarcted tissue, the physician threads the catheter 18 into the left ventricle 14 by advancing a perforating member 30 via a puncture through the tissue so identified in the septum 16. Perforating member 30 may be coextensive with catheter 18 or be fed through catheter 18. Advancing perforating member 30 can also be accomplished by using a retractable pointed element that is disposed at the distal tip of catheter 18. Alternatively, the catheter could be advanced over a steerable, sharp member that separately perforates the infarcted tissue of the septum. Once catheter 18 is in the left ventricle 14, the sensing element 20 is again used to confirm the location of additional infarcted tissue 23 in the left ventricular wall 24. Upon locating the infarcted tissue on the left ventricular wall, the physician advances the perforating member 30 through the tissue so identified until perforating member 30 is external to the ventricle and visible through the epicardium. The perforating member 30 shall then either be fixed on the surface of the heart with a disc or similar fixation member 32, or used to pull or retract additional fixation members or another grasping device, such as a suture (not shown), back through the free wall to the epicardium to the endocardium. Fixation member 32 is typically part of the catheter that is activated by maneuvering or activating something on the catheter

(16) In the former case, perforating member 30, affixed via fixation member 32 to left ventricle wall 15 is withdrawn through the free ventricular wall, back through the dilated left ventricle chamber 14 and back through the septum 16 at the site of the original perforation. As the perforating element 30 is further withdrawn, it will reduce the position of the free wall until that wall becomes contiguous with the septum 16 (or nearly so). Thus, the short axis of the left ventricle 14 is diminished by the extent to which the septum and free LV wall are apposed.

(17) The catheters used for the percutaneous LVR in accordance with the present invention may be steerable/maneuverable catheters as are commonly used in surgical procedures. Suturing devices used in the alternative iterations could be commonly used sutures such as Prolene™, or could be made of shape memory alloys, such as Nitinol™.

(18) The above steps could be accomplished using the following steps and devices:

(19) 1. Continuous direct and non-invasive visualization of the process using endoscopy, echocardiography, or other known non-invasive methods.

(20) 2. Multiple (assuming one will not be adequate to accomplish the restoration) perforating elements with multiple epicardial “discs” or other dispersing or fixation members, which are pulled together simultaneously to reduce the volume of the left ventricle.

(21) 3. A counter, externally compressive maneuver to ensure even reduction of the ventricle with balance movement of each of the multiple discs and evagination of the intervening scar as the reduction is carried out.

(22) 4. Fixation of the penetrating members on the right side if the interventricular septum to cement the reduction. Expanding discs, slats, or other fixation members to distribute the forces over a large area will be used.

(23) 5. The bulk of the device, not the portions of the penetrating members between the free wall discs and the RV septal discs, will be removed from the vascular system. As such, only a remnant, or detachable portion of the members that traversed the septum, LV, and free wall will remain, fixed at both ends with elements that distribute tension over a substantial area to ensure durability. These detachable elements will be a short segment, since the perforated portion will have been shortened as the walls are brought in closer approximation.

(24) 6. Alternatively, the leading edge of the fixation member shall have a retention element, such that the leading edge of the fixation member is retained on the epicardium. Once the leading edge is in place, the catheter is retracted through the puncture that was previously made through the infarcted septum. The retraction of the catheter now leaves the fixation member bridging the wall of the left ventricle and the septum. The trailing edge of the fixation member shall also have a retention element such that the trailing edge of the retention element is on the septum facing the right ventricle. The objective here is to bring together the infarcted tissues of the septum and the left ventricular wall together such that the left ventricular volume is reduced to an appropriate size and shape for a congestive heart failure patient to recover the desired ejection fraction of the heart. With the leading and trailing edge retention devices on the epicardium and the septum, respectively, pulling them away from each other would bring the two walls together and thus result in a reduced volume of the left ventricle. The two walls could also be brought together using suturing devices that are well known in the art.

(25) FIG. 3 illustrates a bimanual strategy to achieve left ventricular restoration. In order to create a bimanual strategy, a direct visualization method from sub-xiphoid or trans-thoracic port access is used to determine the appropriate location of the penetration by the fixation member 32 (not shown in FIG. 3) through the endocardium of the left ventricular wall. An incision is typically made in the patient's chest into which a camera or video device 26 is inserted to provide visualization of the ventricle wall. This element may be used either alone or in combination with other visualization techniques.

(26) The procedure according to one embodiment of the present invention is shown in FIGS. 4A-4F which illustrate vertical cross-section views of heart 10. FIG. 4B is a vertical cross-sectional view of the heart showing a delivery catheter 18 inserted endovascularly into the right ventricle 12 according to an aspect of the present invention. Catheter 18 will be used to sense infarcted tissue, to be excluded, on the wall of septum 16, and to puncture across the septum wall to the left ventricle.

(27) FIGS. 4C and 4D illustrate a guide wire or perforating element (shown as 30 in FIG. 1B) from the catheter of FIG. 4B through the septum wall, across the left ventricular chamber and into the free wall 15 of left ventricle 14 according to an aspect of the present invention.

(28) FIG. 4E illustrates the insertion of a retention element or member 34 into the delivery catheter 18 of FIG. 4D for placement of the tension member outside the free wall with respect for the left ventricle to reduce left ventricular volume according to an aspect of the present invention. Retention element 34 may be a collar, a hook, a barb, a fastener or a clip but the invention is not limited in this respect.

(29) FIG. 4F shows the retention element 34 at the end of the procedure to exclude infarcted or scarred tissues, hence reduce the ventricular volume.

(30) In another embodiment, the procedure utilizes a thoracoscopic surgical approach, i.e., synching the infarcted tissue from the epicardial side as opposed to the endocardial approach described under the percutaneous procedure. FIG. 5 illustrates the use of thoracoscope 28 in this approach. In this iteration, excess portions of the perforating members would be removed after the free wall was reduced and a force dispersing member (not shown) attached.

(31) FIG. 6A illustrates a suction device 40 used to form a dilated left ventricle wall as part of an off-pump epicardial thoracoscopy procedure. Suction device 40 may incorporate a clamp element 42 and a patch 44, which can be made of woven Dacron or extracellular matrix, but is not limited in this regard. After left ventricle 14 is dilated using suction device 40, clamp 42 is applied which brings the walls of the left ventricle 14 together and thus re-sizes the left ventricle 14 to provide decreased heart wall tension and improved ejection fraction. Patch 44 is applied over the clamped portion of the left ventricle. A closure device 46 then provides stitches 48 along the clamped section as illustrated in FIG. 6B.

(32) FIGS. 7A through 7D further illustrate the different device embodiments that could be used for percutaneous LVR. FIG. 7A of the procedure illustrated in FIG. 4C-E, where distal and proximal elements are used to bring the free wall of the left ventricle 14 to be in contact with the wall of septum 16. FIG. 7A is a vertical cross-sectional view of the heart showing a delivery catheter 18 with a curved distal tip inserted into the right ventricle 12 proximate the wall of septum 16 for delivering a tension member or fixation member assembly according to an aspect of the present invention.

(33) Delivery catheter 18, which may also could act as a sensing catheter (such as 30 in FIG. 1B) or contain a tissue-viability-sensing element, is introduced into the right ventricle 12. Upon penetrating the septum and then identifying the infarct area 23 on the left ventricular wall 15, a distal fixation element 32a is deployed to be embedded in the infarct area 23. As catheter 18 is withdrawn through septum 16, a proximal fixation element 32b is deployed to be in contact with the septum 16. The withdrawal of the catheter 18 and the fact that distal fixation element 32a is embedded in the left ventricular wall brings the left ventricular wall closer to the septum 16 and thereby decreases the ventricular volume. Proximal and distal fixation elements 32a, 32b may be disk shaped and may be made of biocompatible materials. Proximal and distal fixation elements 32a, 32b may be provided with one or more retention elements 34 as shown in FIG. 7B. Retention element 34 could be a collar, hook, barb, fastener or a clip to facilitate and secure proximal and distal fixation elements in the appropriate position. These elements could also made of biological materials. Proximal and distal fixation elements 32a, 32b may also be impregnated or loaded with angiogenic factors, drugs, gene-regulated viral vectors, cellular materials, or other substances such that they could promote desired responses.

(34) FIG. 7C illustrates the location of the distal and proximal fixation elements 32a, 32b prior to the ventricle resizing procedure, where they are spaced apart. FIG. 7D illustrates the end of the procedure, wherein by pulling or retracting perforating element 30 between the distal and proximal fixation elements 32a, 32b away from the left ventricular wall, the septum and the left ventricular wall are brought closer and thereby reduce the volume of the left ventricle. The proximal and distal fixation elements 32a, 32b could also be used in a thoracoscopic procedure, where instead of connector being pulled away from the distal element, the connector is now pulled away from the proximal element.

(35) The proximal and distal fixation elements 32a, 32b could also be made of two sub-elements as shown in FIG. 7E. Proximal retaining element 32a may comprise first septum sub-element 36a and second septum sub-element 36b positioned on both side of septum 16. Additionally, distal retaining element 32b, may comprise first left ventricle sub-element 38a and second left ventricle sub-element 38b positioned on both side of left ventricle wall. Such a two-piece structure for the proximal and distal elements would also support the weakened infarcted tissue at the septum and the left ventricular wall.

(36) While there has been shown and described what is considered to be preferred embodiments of the invention, it will, of course, be understood that various modifications and changes in form or detail could readily be made without departing from the spirit of the invention. It is therefore intended that the invention be not limited to the exact forms described and illustrated, but should be constructed to cover all modifications that may fall within the scope of the appended claims.