Cuff stitching reinforcement

Abstract

A prosthetic heart valve includes a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end, the stent including a plurality of struts. A cuff may be coupled to the stent so that a flat, bottom edge of the cuff lies adjacent the proximal end of the stent. A pattern of stitches may be circumferentially disposed around the flat bottom edge of the cuff, the pattern of stitches alternating between stitches sewn to the cuff only and stitches sewn to both the cuff and the stent.

Claims

1. A prosthetic heart valve, comprising: a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end; a cuff coupled to the stent and having a top edge and a bottom edge, the top edge being distal to the bottom edge and having a plurality of peaks and the bottom edge lying adjacent the proximal end of the stent; and a plurality of tethers incorporated, independent of the stent, along the top edge of the cuff, the plurality of tethers attaching the plurality of peaks to each other, at least a portion of the plurality of tethers extending distally from and above the top edge and in a space between adjacent peaks of the plurality of peaks, the plurality of tethers being coupled to the cuff only; wherein the plurality of tethers includes at least one vertical tether and at least one horizontal tether; and adjacent ones of the plurality of peaks are coupled to one another via the at least one horizontal tether.

2. The prosthetic heart valve of claim 1, wherein the at least one vertical tether is coupled to the at least one horizontal tether.

3. The prosthetic heart valve of claim 1, wherein the at least one vertical tether includes multiple vertical tethers disposed between the plurality of peaks.

4. The prosthetic heart valve of claim 1, wherein each one of the plurality of peaks has a triangular shape.

5. The prosthetic heart valve of claim 1, wherein each one of the plurality of peaks has a trapezoidal shape.

6. The prosthetic heart valve of claim 1, wherein the bottom edge of the cuff is substantially straight.

7. The prosthetic heart valve of claim 1, wherein the plurality of tethers are in the form of stitches.

8. A prosthetic heart valve, comprising: a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end, the stent including a plurality of struts and a plurality of commissure features; a cuff having a top edge distal to a bottom edge, the cuff coupled to the stent so that a top edge of the cuff lies adjacent the plurality of commissure features, the top edge of the cuff having a plurality of peaks for coupling to the plurality of commissure features; and a plurality of tethers extending from the top edge of the cuff, the plurality of tethers attaching the plurality of peaks to each other, at least a portion of the plurality of tethers extending distally from the top edge and between adjacent peaks of the plurality of peaks, wherein the plurality of tethers includes at least two vertical tethers and at least two horizontal tethers, wherein the at least two vertical tethers and the at least two horizontal tethers attach to one another to create a web, wherein the at least two horizontal tethers are spaced apart from the top edge and from one another by predetermined distances; and wherein the plurality of tethers is coupled to the cuff only.

9. The prosthetic heart valve of claim 8, wherein adjacent ones of the plurality of peaks are coupled to one another via the at least two horizontal tethers.

10. The prosthetic heart valve of claim 8, wherein the at least two vertical tethers includes multiple vertical tethers disposed between the plurality of peaks.

11. The prosthetic heart valve of claim 8, wherein each one of the plurality of peaks has a triangular shape.

12. The prosthetic heart valve of claim 8, wherein each one of the plurality of peaks has a trapezoidal shape.

13. The prosthetic heart valve of claim 8, wherein the bottom edge of the cuff is substantially straight.

14. The prosthetic heart valve of claim 8, wherein the plurality of tethers are in the form of stitches.

Description

BRIEF DESCRIPTION OF THE DRAWINGS

(1) Various embodiments of the presently disclosed heart valves are disclosed herein with reference to the drawings, wherein:

(2) FIG. 1 is a side elevational view of a conventional prosthetic heart valve;

(3) FIG. 2 is a highly schematic cross-sectional view showing another prosthetic heart valve disposed within a native valve annulus;

(4) FIG. 3A is a developed view of a cuff having a series of peaks;

(5) FIG. 3B is a perspective side view of the cuff of FIG. 3A after the attachment portions of the cuff have been coupled together;

(6) FIG. 4A is a partial schematic side view of a first variation of a prosthetic heart valve having a cuff coupled to a stent, the cuff having a plurality of cutouts;

(7) FIG. 4B is a partial schematic side view of a second variation of a prosthetic heart valve having a cuff coupled to a stent, the cuff having a substantially straight inflow edge;

(8) FIGS. 4C-4D are partial schematic side views of examples of cuffs having substantially straight inflow edges;

(9) FIG. 4E is a highly schematic end view of the prosthetic heart valve of FIG. 4B disposed within a native valve annulus;

(10) FIG. 5 is a developed view of a cuff having stitches attached near the inflow end;

(11) FIG. 6 is a highly schematic end view of the prosthetic heart valve of FIG. 5 disposed within a native valve annulus;

(12) FIGS. 7A and 7B are a highly schematic end views of a prosthetic heart valve disposed within a generally elliptical native valve annulus, the prosthetic heart valve having and not having cuff inflow end stitches, respectively; and

(13) FIG. 8 is a developed view of a cuff having stitches attached near the outflow edge.

(14) Various embodiments of the present invention will now be described with reference to the appended drawings. It is to be appreciated that these drawings depict only some embodiments of the invention and are therefore not to be considered limiting of its scope.

DETAILED DESCRIPTION OF THE INVENTION

(15) Inaccurate deployment and anchoring of a prosthetic heart valve may result in the leakage of blood between the implanted heart valve and the native valve annulus, commonly referred to as perivalvular (or “paravalvular”) leakage. In aortic valves, this leakage enables blood to flow from the aorta back into the left ventricle, reducing cardiac efficiency and putting a greater strain on the heart muscle. Additionally, calcification of the aortic valve may affect performance and the interaction between the implanted valve and the calcified tissue is believed to be relevant to leakage, particularly when the native valve leaflets have not first been resected. To reduce the risk of leakage, adequate anchoring and sealing are helpful. Moreover, anatomical variations from one patient to another may affect wear and durability.

(16) As used herein, the term “proximal,” when used in connection with a prosthetic heart valve in the aortic position, refers to the end of the heart valve closest to the heart when the heart valve is implanted in a patient, whereas the term “distal,” when used in connection with a prosthetic heart valve, refers to the end of the heart valve farthest from the heart when the heart valve is implanted in a patient. Also, as used herein, the word “about” is intended to mean that slight variations from absolute are included within the scope of the valve recited, for example, due to manufacturing tolerances.

(17) FIG. 1 shows a collapsible stent-supported prosthetic heart valve 100 including a stent 102 and a valve assembly 104 as is known in the art. The prosthetic heart valve 100 is designed to replace the native tricuspid valve of a patient, such as the native aortic valve. It should be noted that while the inventions herein are described predominantly in connection with their use with a prosthetic aortic valve and a stent having a shape as illustrated in FIG. 1, the valve could be a bicuspid valve, such as the mitral valve, and the stent could have different shapes, such as a flared or conical annulus section, a less-bulbous aortic section, and the like, and a differently shaped transition section.

(18) Prosthetic heart valve 100 will be described in more detail with reference to FIG. 1. Prosthetic heart valve 100 includes expandable stent 102 which may be formed from biocompatible materials that are capable of self-expansion, such as, for example, shape memory alloys, such as the nickel-titanium alloy known as “Nitinol” or other suitable metals or polymers. Stent 102 extends from proximal or annulus end 130 to distal or aortic end 132, and includes annulus section 140 adjacent proximal end 130, transition section 141, and aortic section 142 adjacent distal end 132. Annulus section 140 has a relatively small cross-section in the expanded condition, while aortic section 142 has a relatively large cross-section in the expanded condition. Preferably, annulus section 140 is in the form of a cylinder having a substantially constant diameter along its length. Transition section 141 may taper outwardly from annulus section 140 to aortic section 142. Each of the sections of stent 102 includes a plurality of struts 160 forming cells 162 connected to one another in one or more annular rows around the stent. For example, as shown in FIG. 1, annulus section 140 may have two annular rows of complete cells 162 and aortic section 142 and transition section 141 may each have one or more annular rows of partial cells 162. Cells 162 in aortic section 142 may be larger than cells 162 in annulus section 140. The larger cells in aortic section 142 better enable prosthetic valve 100 to be positioned in the native valve annulus without the stent structure interfering with blood flow to the coronary arteries.

(19) Stent 102 may include one or more retaining elements 168 at distal end 132 thereof, retaining elements 168 being sized and shaped to cooperate with female retaining structures (not shown) provided on a deployment device configured to deploy the prosthetic valve 100 in the native valve annulus of a patient. The engagement of retaining elements 168 with the female retaining structures on the deployment device helps maintain prosthetic heart valve 100 in assembled relationship with the deployment device, minimizes longitudinal movement of the prosthetic heart valve relative to the deployment device during unsheathing or resheathing procedures, and helps prevent rotation of the prosthetic heart valve relative to the deployment device as the deployment device is advanced to the target location and the heart valve deployed.

(20) Prosthetic heart valve 100 includes valve assembly 104, preferably positioned in annulus section 140 of the stent 102 and secured to the stent. Valve assembly 104 includes cuff 176 and a plurality of leaflets 178 which collectively function as a one-way valve by coapting with one another. As a prosthetic aortic valve, valve 100 has three leaflets 178. However, it will be appreciated that other prosthetic heart valves with which the sealing portions of the present disclosure may be used may have a greater or lesser number of leaflets 178.

(21) Although cuff 176 is shown in FIG. 1 as being disposed on the luminal or inner surface of annulus section 140, it is contemplated that cuff 176 may be disposed on the abluminal or outer surface of annulus section 140 or may cover all or part of either or both of the luminal and abluminal surfaces. Both cuff 176 and leaflets 178 may be wholly or partly formed of any suitable biological material or polymer such as, for example, polytetrafluoroethylene (PTFE), ultra-high molecular weight polyethylene, polyurethane, polyvinyl alcohol, silicone or combinations thereof.

(22) Leaflets 178 may be attached along their belly portions to cells 162 of stent 102, with the commissure between adjacent leaflets 178 attached to commissure features 166 of the stent. As can be seen in FIG. 1, each commissure feature 166 may lie at the intersection of four cells 162, two of the cells being adjacent one another in the same annular row, and the other two cells being in different annular rows and lying in end-to-end relationship. Preferably, commissure features 166 are positioned entirely within annulus section 140 or at the juncture of annulus section 140 of stent 102 and transition section 141. Commissure features 166 may include one or more eyelets which facilitate the suturing of the leaflet commissure to stent 102.

(23) Prosthetic heart valve 100 may be used to replace a native aortic valve, a surgical heart valve or a heart valve that has undergone a surgical procedure. Prosthetic heart valve 100 may be delivered to the desired site (e.g., near the native aortic annulus) using any suitable delivery device. During delivery, prosthetic heart valve 100 is disposed inside the delivery device in the collapsed condition. The delivery device may be introduced into a patient using a transfemoral, transapical, transseptal or any other percutaneous approach. Once the delivery device has reached the target site, the user may deploy prosthetic heart valve 100. Upon deployment, prosthetic heart valve 100 expands so that annulus section 140 is in secure engagement within the native aortic annulus. When prosthetic heart valve 100 is properly positioned inside the heart, it works as a one-way valve, allowing blood to flow from the left ventricle of the heart to the aorta, and preventing blood from flowing in the opposite direction.

(24) FIG. 2 is a highly schematic cross-sectional illustration of prosthetic heart valve 200 disposed within native valve annulus 250. As seen in the figure, stent 202 has a substantially circular cross-section which is disposed within the non-circular native valve annulus 250. At certain locations around the perimeter of heart valve 200, crescent-shaped gaps 240 form between the heart valve and native valve annulus 250. Blood flowing through these gaps and past valve assembly 204 of prosthetic heart valve 200 may be undesirable.

(25) FIGS. 3A and 3B illustrate the outer surface of a cuff before coupling to a stent. As shown, cuff 300 includes a generally parallelogram-shaped body 302, a series of trapezoidal or triangular peaks 304a, 304b, and 304c and a pair of attachment portions 306. It will be understood, however, that cuff 300 may be formed in various geometric shapes and that illustrated configurations are merely exemplary. Peaks 304 may be used to couple cuff 300 to a stent. Body 302 extends longitudinally from an inflow end 320 to an outflow end 322, peaks 304a, 304b, and 304c being located near outflow end 322. Attachment portions 306 are adapted to be coupled together to form cuff 300 into the wrapped or assembled configuration shown in FIG. 3B. Attachment portions 306 may overlap one another in the wrapped configuration, and may be coupled together using a suture, an adhesive or any other suitable means. Attachment portions 306 may also abut one another and couple together. Cuff 300 may be placed in the wrapped configuration before being coupled to a stent. Alternatively, cuff 300 may be first coupled to the stent after which attachment portions 306 may be coupled together.

(26) Cuff 300 is coupled to a stent and to a number of leaflets to form a prosthetic heart valve. It will be understood that the components may be assembled using various techniques and in different orders. For example, the cuff may be coupled to the stent followed by the leaflets or the leaflets may be attached to the cuff followed by assembly of both to the stent.

(27) Two variations of the final cuff-stent assembly are described below with reference to FIGS. 4A-C. In a first variation, shown in FIG. 4A, prosthetic heart valve 400A includes stent 410A formed of a plurality of struts 412A, with cuff 420A coupled to the stent. Cuff 420A includes body 422A extending between inflow end 430A and outflow end 432A.

(28) Excess portions of cuff 420A may unduly increase the crimp profile of heart valve 400A and may also impinge on the effective orifice area (e.g., the entrance orifice through which blood flows to the valve assembly). In order to address these concerns, excess portions 440A of body 422A near inflow end 430A may be trimmed using a cutting mandrel, a die or other suitable means. A fixation device may be useful in this trimming process. One fixation device useful for this purpose is shown in U.S. Provisional Patent Application Ser. No. 61/666,174 entitled “VALVE ASSEMBLY FOR CRIMP PROFILE” filed Jun. 29, 2012, the content of which is hereby incorporated by reference herein in its entirety.

(29) The trimming of cuff 420A may be accomplished either prior to or after the attachment of cuff 420A to stent 410A. After completion, cutouts 424A, such as the semicircular cutouts shown in FIG. 4A, are formed in cuff 420A at recurring positions along the edge near inflow end 430A. In this variation, cutouts 424A are configured to mitigate effective orifice area impingement of cuff 420A during forward flow of blood through inflow end 430A. Though cutouts 424A may reduce the crimp profile of the device, in applications where prosthetic heart valve 400A is implanted in an asymmetric annulus or in an annulus having heavily calcified regions as described above with reference to FIG. 2, cutouts 424A may not adequately seal inflow end 430A against the surrounding tissue.

(30) In a second variation, shown in FIG. 4B, prosthetic heart valve 400B includes stent 410B formed of a plurality of struts 412B, with cuff 420B coupled to the stent. Unlike heart valve 400A, cuff 420B of heart valve 400B is not trimmed along either inflow end 430B or outflow end 432B, leaving a substantially flat edge 424B near inflow end 430B. Flat edge 424B may align with the proximal ends of struts 412 near inflow end 430B. Flat edge 424B may present some drawbacks as explained below.

(31) FIGS. 4C-4D are partial schematic side views of examples of cuffs having untrimmed inflow edges. In FIG. 4C, prosthetic heart valve 400C includes stent 410C formed of a plurality of struts 412C, with cuff 420C coupled to the stent. Cuff 420C is rolled on itself near inflow end 430C to create halo 436C, a ring-like portion of cuff 420C that extends past flat edge 424C. Halo 436C may be formed of the same material as cuff 420C or a different material. Additionally, halo 436C may be integrally formed with cuff 420C or may be formed of a different portion of tissue, fabric or other cuff material that is coupled to cuff 420C through adhesive, suture or other suitable techniques. In FIG. 4D, prosthetic heart valve 400D includes stent 410D formed of a plurality of struts 412D, with cuff 420D coupled to the stent. Cuff 420D is rolled on itself near inflow end 430D to create parachute 436D.

(32) FIG. 4E is a highly schematic end view illustrating prosthetic heart valve 400B of FIG. 4B disposed within native valve annulus 250 as seen through inflow end 430B. When cutouts, such as those shown in FIG. 4A, are not formed in cuff 420B, portions of the cuff may bend inwardly during forward flow of blood. Specifically, bent portions 440 of cuff 420B that are not directly attached to struts 412B of stent 410B fold inwardly toward the central axis of prosthetic heart valve 400B, diminishing the effective orifice area 450 through which blood may flow. In some experiments, it has been found that bent portions 440 may diminish the total effective orifice area 450 by as much as about 10% to about 20%. Moreover, blood flowing through regions near bent portions 440 may be directed outside of cuff 420B as opposed to flowing through orifice area 450 of the valve assembly, leading to perivalvular leakage. Thus, bent portions 440 may cause regurgitation and other inefficiencies which reduce cardiac performance Similar issues may also arise in examples having untrimmed portions as shown in FIGS. 4C and 4D.

(33) Several techniques will be described to reduce the formation of bent portions in the cuff and to avoid constriction of the effective orifice area through the prosthetic heart valve. FIG. 5 illustrates one such technique, which uses stitches to reduce bent portions of the cuff. For the sake of illustration, cuff 500 is shown flat, as if stretched out and only a portion of a stent is shown in detail. Cuff 500 includes body 502, a series of large peaks 504a, 504b, and 504c projecting from one edge of body 502, and a pair of attachment portions 506, one on each longitudinal end of body 502. To minimize the formation of bent portions of the cuff during use, as shown in FIG. 4E, a stitching technique may be applied along flat edge 524 of body 502 near inflow end 530. In one example, a stitch pattern P may be disposed along flat edge 524 to eliminate or minimize bending of the cuff.

(34) An enlarged detailed view of FIG. 5 is shown of body 502 as well as portions of select struts 552a, 552b (shown in broken lines) to which body 502 will be attached. For the sake of clarity, the remaining portions of the stent are not shown. As shown in the detailed view, when two struts 552a and 552b join at the inflow end of stent 550, a horseshoe 554 is formed. Stitch pattern P may include a first horseshoe locking stitch L1 anchored at each horseshoe 554. Between adjacent horseshoe locking stitches L1, stitch pattern P may include additional locking stitches L2 sewn to cuff 500 only, as shown in the enlarged detailed view in FIG. 5. Each locking stitch may include two threads that entwine together at the cuff. Although FIG. 5 shows two such locking stitches L2 between adjacent horseshoe locking stitches L1, cuff 500 may include a greater or lesser number of locking stitches L2 as desired. To get from one horseshoe locking stitches L1 to another, any type of stitch may be used though locking stitches L2 are shown which minimize bulkiness. Thus, stitch pattern P may begin at the attachment portion 506 at one end of cuff 500 and form a recurring pattern of a single horseshoe locking stitch L1 coupling cuff 500 to a horseshoe 554 of stent 550 and two additional locking stitches L2 sewn to the cuff only. Stitch pattern P may begin and end in the attachment portions 506 so that the beginning and end knots are hidden when the cuff 500 is fully attached to stent 550 and the attachment portions are joined together.

(35) Such a stitching technique allows the prosthetic heart valve to achieve a small crimp profile when collapsed for delivery, while securing each section of cuff 500 to stent 550 and minimizing bending of cuff tissue into the flow area. Additionally, it is common to create a stent 550 having a fully-expanded diameter that is greater than the diameter the stent will have in use. Thus, stitch pattern P may have the added benefit of ensuring optimal valve performance by limiting cuff 500 from over-expanding outside the optimal use range. Finally, stitch pattern P may reduce or eliminate the inward bending of cuff 500 at inflow end 530, thereby improving sealing by providing a larger landing zone and maintaining the effective orifice area through which blood may flow, while at the same time increasing the landing area along which the native valve annulus may be positioned relative to the prosthetic heart valve allowing easier placement by the physician. Larger landing areas may provide more forgiving placement accuracy. Stitch pattern P may provide these benefits while not unduly increasing the crimp profile of the prosthetic heart valve.

(36) FIG. 6 is a highly schematic end view illustrating prosthetic heart valve 600 disposed within native valve annulus 250. Prosthetic heart valve 600 includes cuff 620 coupled to stent 610. A stitching technique as described with reference to FIG. 5 has been applied to cuff 620. Specifically, stitch pattern P has been applied along the circumference of cuff 620 at its inflow end. Because of the stitching technique, bent portions 630 of the cuff are reduced, leading to a larger effective orifice area 650 through which blood may flow and more adequate sealing with surrounding tissue at the inflow end of prosthetic heart valve 600.

(37) The advantages of the stitching technique described above will also be readily seen when a prosthetic heart valve is implanted in an irregularly-shaped or elliptical native valve annulus. FIGS. 7A and 7B are highly schematic cross-sectional illustrations of prosthetic heart valves 700A and 700B disposed within an elliptical native valve annulus 250. Prosthetic heart valve 700A includes cuff 720A coupled to stent 710A, but does not employ the stitching technique described above. When prosthetic heart valve 700A is deployed in elliptical native annulus 250, bicuspid or mitral valves and subjected to blood flow, bent portions 730A are formed, reducing the effective orifice area 750A through which blood may flow. Prosthetic heart valve 700B is similar to heart valve 700A, and includes cuff 720B coupled to stent 710B. However, in prosthetic heart valve 700B, the stitching technique described above with reference to FIG. 5 has been applied to cuff 720B. When prosthetic heart valve 700B is deployed in elliptical native annulus 250 and subjected to blood flow, the formation of bent portions 730B is minimized, leading to great apposition of cuff 720B to stent 710B, a larger effective orifice area 750B through which blood may flow, and more adequate sealing with surrounding tissue at the inflow end of the prosthetic heart valve.

(38) FIG. 8 illustrates another example of a cuff for promoting the sealing of the prosthetic heart valve against surrounding tissue and maximizing the effective orifice area through which blood may flow through the prosthetic heart valve. Cuff 800 includes body 802, a series of peaks 804a, 804b, and 804c at the outflow end 832 of body 802, and a pair of attachment portions 806, one on each longitudinal end of body 802. Body 802 extends between inflow end 830 and outflow end 832. To minimize the formation of bent portions of the cuff during use, as shown in FIG. 4E, a tethering technique may be applied near outflow end 832 of cuff 800. In one example, a plurality of horizontal tethers T1 may be used to attach peaks 804a, 804b, and 804c to one another. Though cuff 800 is shown in the flat configuration, it will be understood that when the cuff is in the wrapped configuration, one set of tethers T1 attach peak 804a to peak 804c. Vertical tethers T2 attach the horizontal tethers T1 to one another, creating a net-like structure or web. By adding tethers T1 and T2 near outflow end 832 of cuff 800, the landing zone of the prosthetic heart valve is increased without unduly increasing its crimp profile. In general, a longer landing zone corresponds to better sealing. In some variations, instead of using separate horizontal tethers T1 and vertical tethers T2, a preformed webbing, netting or mesh may be attached to the top of body 802 or peaks 804a, 804b, 804c to increase the landing zone in a similar manner.

(39) Although the invention herein has been described with reference to particular embodiments, it is to be understood that these embodiments are merely illustrative of the principles and applications of the present invention. It is therefore to be understood that numerous modifications may be made to the illustrative embodiments and that other arrangements may be devised without departing from the spirit and scope of the present invention as defined by the appended claims.

(40) In some embodiments, a prosthetic heart valve, includes a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end, the stent including a plurality of struts. A cuff may be coupled to the stent so that a flat, bottom edge of the cuff lies adjacent the proximal end of the stent. A pattern of stitches may be circumferentially disposed around the flat bottom edge of the cuff, the pattern of stitches alternating between stitches sewn to the cuff only and stitches sewn to both the cuff and the stent.

(41) In some examples, the pattern of stitches may include a plurality of locking stitches. The pattern of stitches may include a recurring pattern comprised of a first type of stitch and a second type of stitch. The first type of stitch may be a locking stitch sewn to the cuff only. The second type of stitch may be a locking stitch sewn to the cuff and at least a portion of the stent. The recurring pattern may include two adjacent stitches of the first type followed by a single stitch of the second type. The plurality of struts may form horseshoe-shaped portions at the proximal end of the stent, and the pattern of stitches may couple the cuff to the horseshoe-shaped portions. The pattern of stitches may include locking stitches sewn only to the cuff between the horseshoe-shaped portions.

(42) In some embodiments, a prosthetic heart valve may include a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end, the stent including a plurality of struts and a plurality of commis sure features. A cuff may be coupled to the stent so that a top edge of the cuff lies adjacent the plurality of commissure features and a plurality of tethers incorporated along the top edge of the cuff and coupled to the cuff only.

(43) In some examples, the stent may include a plurality of commissure features and the top edge of the cuff includes a plurality of peaks coupled to the commissure features. The plurality of tethers may include at least one vertical tether and at least one horizontal tether. Adjacent ones of the plurality of peaks may be coupled to one another via the at least one horizontal tether. The at least one vertical tether may be coupled to the at least one horizontal tether. The at least one vertical tether may include multiple vertical tethers disposed between the plurality of peaks.

(44) In other embodiments, a method of making a prosthetic heart valve may include (i) providing a collapsible and expandable stent having a proximal end, a distal end, an annulus section adjacent the proximal end and an aortic section adjacent the distal end, the stent including a plurality of struts, (ii) coupling a cuff to the stent so that a flat bottom edge of the cuff lies adjacent the proximal end of the stent, and (iii) sewing a pattern of stitches circumferentially around the flat bottom edge of the cuff, the pattern of stitches alternating between stitches sewn to the cuff only and stitches sewn to both the cuff and the stent.

(45) In some examples, sewing a pattern of stitches may include forming a plurality of locking stitches. Sewing a pattern of stitches may include sewing a recurring pattern comprised of a first type of stitch and a second type of stitch. Sewing a pattern of stitches may include sewing a first type of stitch that is a locking stitch sewn to the cuff only. Sewing a pattern of stitches may include sewing a second type of stitch that is a locking stitch sewn to the cuff and at least a portion of the stent. The plurality of struts may form horseshoe-shaped portions at the proximal end of the stent, and sewing a pattern of stitches may include sewing the cuff to the horseshoe-shaped portions.

(46) It will be appreciated that the various dependent claims and the features set forth therein can be combined in different ways than presented in the initial claims. It will also be appreciated that the features described in connection with individual embodiments may be shared with others of the described embodiments.