Body part repositioning apparatus and method

Abstract

A device for manipulating the left atrial appendage (LAA) of a heart, including: an elongated and hollow guide instrument which is shaped and sized to be transvascularly and transseptally introducible into the left atrium (LA); a suction channel passing through the guide instrument, the suction channel terminating with a concave holder, wherein the suction channel and the concave holder are shaped and sized to be enclosed within a lumen of the guide instrument during the transvascular and transseptal introduction into the LA and to forwardly extend from the lumen of the guide instrument after reaching the LA, and wherein the concave holder is configured to radially expand; a loop fastener shaped and sized to be enclosed within the lumen of the guide instrument during the transvascular and transseptal introduction into the LA and to forwardly extend from the lumen of said guide instrument.

Claims

1. A device for manipulating a left atrial appendage (LAA) of a heart, comprising: an elongated and hollow guide instrument which is shaped and sized to be transvascularly and transseptally introducible into a left atrium (LA); a suction channel passing through said guide instrument, said suction channel terminating with a flexible soft holder, wherein said suction channel and said flexible soft holder are shaped and sized to be enclosed within a lumen of said guide instrument during said transvascular and transseptal introduction into said LA and to forwardly extend from said lumen of said guide instrument after reaching the LA, and wherein said flexible soft holder is configured to expand; a suture loop fastener shaped and sized to be enclosed within said lumen of said guide instrument during said transvascular and transseptal introduction into said LA and to forwardly extend from said lumen of said guide instrument, wherein said flexible soft holder is configured to radially expand, wherein said flexible soft holder is configured to be positioned in close juxtaposition with a cavity of the LAA, and to hold and to draw a portion of the LAA into said flexible soft holder upon application of suction through said suction channel so that said held and drawn LAA portion is repositionable to be inverted into the LA by retraction of said flexible soft holder; and wherein said suture loop fastener is configured to be positioned around said repositioned LAA portion, to permanently prevent return of said repositioned LAA portion into said LAA.

2. A device according to claim 1, wherein said flexible soft holder is configured to facilitate application of suction without imparting damage to the repositionable LAA portion.

3. A device according to claim 1, wherein said suture loop fastener comprises a wire shaped as a loop.

4. A device according to claim 1, wherein said flexible soft holder is selected from a cup, a cone, or other semi-spherical shape.

5. A device according to claim 1, wherein said flexible soft holder is made of flexible material.

6. A device according to claim 1, wherein the suture loop fastener is configured to avoid perforation of the LAA when actuated.

7. A device according to claim 1, wherein the suture loop fastener is actuatable from the elongated guide instrument.

8. A device according to claim 7, wherein the suture loop fastener comprises: a) a guide disposed internally within the elongated guide instrument; b) a wire shaped to form a loop, received within, and attached to, said guide; c) an actuator configured to discharge said loop-shaped wire from a distal end of said guide and to cause said discharged loop-shaped wire to completely encircle an intraluminar base of the repositioned LAA portion until fastening is completed, to permanently prevent return of the repositioned LAA portion to its normal position; and d) a detachment facilitating element configured to detach said looped-shaped wire from said guide after fastening is completed.

9. A device according to claim 8, wherein the loop-shaped wire is looped around an axis of the elongated guide instrument.

10. A device according to claim 1, which is suitable such that the repositioned LAA portion is coverable by non-thrombogenic endocardium.

11. A device according to claim 1, wherein when expanded, a tip of said flexible soft holder is wider.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) In the drawings:

(2) FIG. 1 illustrates the insertion of a prior art Watchman occlusion device into the LAA;

(3) All other figures schematically illustrates the operation of a device according to the invention, wherein:

(4) FIG. 2 illustrates the anatomical positioning of the guide instrument into the left atrium before entering the LAA and after inflating the suction catheter;

(5) FIG. 3 illustrates the anatomical positioning of the guide instrument into the LAA before activating the suction device;

(6) FIGS. 4a and 4b illustrate the reshaping of the LAA after pulling back the guide instrument;

(7) FIGS. 5a and 5b illustrate the application of an open clip to the base of the LAA;

(8) FIGS. 6a and 6b schematically illustrate the closed clip, lasso or suture; and

(9) FIGS. 7a and 7b show a device according to one embodiment of the invention.

DETAILED DESCRIPTION OF THE INVENTION

(10) The present invention relates to a catheter-based device and method for the evagination and the grasping, fixating and fastening (collectively referred to herein as “repositioning”) of a body part. In a particularly important application, said body part is the intraatrial left atrial appendage (LAA). Although the invention is in no way limited to use in the LAA, this procedure will be used in the description to follow, to illustrate the device of the invention and its use.

(11) The procedures described herein can be carried out under vision, employing vision techniques such as fluoroscopy and transesophageal echo.

(12) In a specific embodiment of the invention, the device comprises an elongated flexible guide instrument, a suction device and a device suitable to deploy a fastening accessory. Other devices regularly used in endoscopic surgery, such as light sources, cameras etc. can be also carried in the guide instrument, and such conventional apparatus is not described herein in detail, for the sake of brevity.

(13) In a particular embodiment of the invention, the suction device and the device to apply a fastening accessory are located in the lumen of the guide instrument. Said fastening accessory can be of any suitable type and can be made of one piece or of a plurality of pieces. In one embodiment of the invention, the fastening accessory comprises one or more clips. In another embodiment the fastening accessory comprises one or more loops. Different fastening accessories can also be combined and various suitable accessories will be easily evident to the skilled person from the description to follow.

(14) Transapex or transaortal or transatnial external through the pericard Transseptal access to the LLA is usually achieved by introducing a transseptal catheter through the femoral or jugular vein, and advancing the catheter transluminally into the right atrium. After locating the catheter in the right atrium, a long hollow needle is inserted transseptally by force through the fossa ovalis until attaining the left atrium, as seen at 100 in FIG. 1, with reference to the prior art method. Once in the left atrium, the catheter is advanced up to the LAA while monitored by any suitable method, such as echo- and/or fluoroscopic control. The device of the current invention is preferably inserted transseptally.

(15) In one embodiment of the invention the catheter is provided at its tip with a suction channel that terminates in a concave holder selected from a cup, a cone or other semi-spherically shaped device, which is expanded after reaching the left atrium, thus preventing possible atrial and/or appendage wall perforation by the catheter tip. The suction channel can be also used for aspiring blood clots, especially those located in the LAA. Alternatively, a catheter tip can be made of any soft material that is less prone to cause perforation. As will be apparent to the skilled person, this safety feature (or an alternative one) is desirable but the invention can be carried out without it. The catheter is then inserted into the LAA (FIG. 2). Insertion of the catheter can again be guided by any suitable method, such as echo- and/or fluoroscopic control, direct or indirect vision, etc. Once the catheter is located in the LAA and touches the wall of the LAA, suction is applied through a channel connected with tip 201 (FIG. 3), such that tip 201 of catheter 202 holds portion 203 of the left atrial appendage 204 by suction. Thereafter, the catheter is pulled back into the left atrium under guided control, thus repositioning the left atrial appendage 204 into the left atrium (FIGS. 4a and 4b). The repositioned appendage at this time is held by suction. A fastening accessory is applied to the intraluminar base (FIGS. 5a and 5b) of the repositioned left atrial appendage, to permanently prevent its return into the normal position. The fastening accessory can be a clip, suture or loop 206, or an accessory combining a clip and a loop, or any other suitable fastening means. In the example of the loop suitable arrangements are provided, e.g., a screw assembly, to detach it from its guide 205 after fastening is completed. After applying the fastening accessory, suction can be discontinued and the catheter removed (FIGS. 6a and 6b).

(16) At the end of the procedure the LAA is repositioned into the left atrium and held by a fastening accessory. When operating according to the embodiment described above, as well as with other embodiments of the invention, no pins, hooks or other sharp and penetrating parts on the atrial wall are used, and no penetration of atrial wall outside to pericardium is performed.

(17) When operating according to the invention, suction, of up to 1 atmosphere can be employed without substantial fear of damage to the tissue. The force applied to fixate the appendage base with a lasso or clip must be calculated so as not to impart damage. For instance, said force can be up to 3 kg, preferably 2 kg, provided the wire of lasso is at least 0.7 mm nitinol in diameter and the clip bar of the similar size at least are safe.

(18) FIG. 7a and FIG. 7b illustrates the actual size of the suction device employed in in vivo experiments carried out with a pig heart. Pig hearts carry substantial similarity to human hearts in respect of the LAA problem and, therefore, were selected form the experiment.

(19) Experimental Procedure and Selection of Operating Conditions

(20) The above-illustrated procedure was carried out, in vivo, using a nitinol wire of 0.7 mm diameter as a lasso that created the loop 206 of the figures. As said, forces of 2-3 Kg were applied without any damage to the LAA tissue. However, should a practitioner wish to employ different operating conditions than the above, the following procedure should be followed:

(21) 1. Selection of Standard Substrate

(22) A standard substrate, such as a silicone cylinder of 1 cm diameter is selected. Any other suitable soft material can be employed.

(23) 2. Determination of Standard Penetration Depth

(24) The standard penetration depth with the selected material is determined by wrapping a lasso made of 0.7 mm diameter nitinol wire and applying a force of 2 Kg on the wire. When application of the force is completed the wire is removed and the depth to which it has penetrated the selected standard substrate is measured.

(25) 3. Determination of Alternative Operating Conditions

(26) To determine a suitable set of operating conditions with a different type of wire, the selected wire is wrapped around the selected standard substrate as in 2 above, and forces of different magnitude are applied. The depth of penetration with each force applied is then measured. The force to be used with the newly selected wire is that which created a penetration depth essentially of the same magnitude as obtained in (2) above.

(27) In an alternative embodiment of the invention fastening means are used, which are not integral with the guide introduced into the heart. In such a device the fastening means comprise filling means suitable to fill the void created in the outer part of a heart, by the repositioning of the left atrial appendage of the heart. Such filling means comprise, e.g., a biocompatible glue.

(28) An alternative fixation method involves fixating the evaginated appendage in its position achieved after suction and traction, by anchoring it to the cardiac wall, for example to the interatrial septum.

(29) In an alternative embodiment of the invention the device of the invention can be used in endoscopy of gastrointestinal, urinary, airway or any other tract to grasp (with suction) and to put a loop (clip) on polyps, tumors etc. Such uses also form a part of the invention.

(30) The skilled person will devise many other additional uses of the device of the invention. For instance, suction can be applied through the suction channel to remove blood clots from the LAA, prior to any other operations.

(31) As will be apparent to the skilled person from the above description, the invention affords the means for performing an effective and safe procedure, which was not available in the art before the invention. Although the invention has been described using a preferred embodiment by way of illustration, the skilled person will easily appreciate the many alternative ways in which the invention can be carried out.

(32) All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention. To the extent that section headings are used, they should not be construed as necessarily limiting. In addition, any priority document(s) of this application is/are hereby incorporated herein by reference in its/their entirety.