U.S. patent application number 09/306448 was filed with the patent office on 2001-11-22 for means and method of replacing a heart valve in a minimally invasive manner.
Invention is credited to CHISTAKIS, GEORGE T., ORTIZ, MARK, SPENCE, PAUL A., WILLIAMSON, WARREN P. IV.
Application Number | 20010044656 09/306448 |
Document ID | / |
Family ID | 39484581 |
Filed Date | 2001-11-22 |
United States Patent
Application |
20010044656 |
Kind Code |
A1 |
WILLIAMSON, WARREN P. IV ;
et al. |
November 22, 2001 |
MEANS AND METHOD OF REPLACING A HEART VALVE IN A MINIMALLY INVASIVE
MANNER
Abstract
A heart valve can be replaced using minimally invasive methods
which include a sutureless sewing cuff that and a fastener delivery
tool that holds the cuff against the patient's tissue while
delivering fasteners to attach the cuff to the tissue from the
inside out. The tool stores a plurality of fasteners and is
self-contained whereby a fastener is delivered and placed all from
inside a vessel. The fasteners are self-forming whereby they do not
need an anvil to be formed. Anchor elements are operated from
outside the patient's body to cinch a prosthesis to an anchoring
cuff of the valve body. The cuff is releasably mounted on the tool
and the tool holds the cuff against tissue and drives the fastener
through the cuff and the tissue before folding over the legs of the
fastener whereby secure securement between the cuff and the tissue
is assured. Fasteners are placed and formed whereby fasteners are
located continuously throughout the entire circumference of the
cuff. A minimally invasive surgical method is disclosed, and a
method and tool are disclosed for repairing abdominal aortic
aneurysms in a minimally invasive manner. Fasteners that are
permanently deformed during the process of attaching the cuff are
disclosed as are fasteners that are not permanently deformed during
the attaching process.
Inventors: |
WILLIAMSON, WARREN P. IV;
(LOVELAND, OH) ; SPENCE, PAUL A.; (LOUISVILLE,
KY) ; CHISTAKIS, GEORGE T.; (TORONTO, CA) ;
ORTIZ, MARK; (MILGORD, OH) |
Correspondence
Address: |
Wood, Herron & Evans, L.L.P.
2700 Carew Tower
441 Vine Street
Cincinnati
OH
45202
US
|
Family ID: |
39484581 |
Appl. No.: |
09/306448 |
Filed: |
May 6, 1999 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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09306448 |
May 6, 1999 |
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08964026 |
Nov 4, 1997 |
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08964026 |
Nov 4, 1997 |
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08802948 |
Feb 21, 1997 |
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6042607 |
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08802948 |
Feb 21, 1997 |
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08606343 |
Feb 23, 1996 |
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5716370 |
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Current U.S.
Class: |
623/2.11 ;
623/2.41; 623/902 |
Current CPC
Class: |
A61B 17/0467 20130101;
A61B 17/072 20130101; A61B 2090/061 20160201; A61F 2/2403 20130101;
A61B 17/064 20130101; A61B 17/0401 20130101; A61B 2017/044
20130101; A61B 2017/07228 20130101; A61B 2090/395 20160201; A61B
2017/0441 20130101; A61B 2017/0464 20130101; A61B 17/0684 20130101;
A61B 2017/0647 20130101; A61B 2017/0649 20130101; A61B 17/115
20130101; A61F 2/2427 20130101; A61B 2017/0406 20130101; A61B
2017/3486 20130101; A61F 2/06 20130101; A61B 17/0469 20130101; A61B
2017/00243 20130101; A61B 2017/047 20130101; A61B 17/0644 20130101;
A61F 2/07 20130101; A61F 2/2409 20130101; A61B 17/0487
20130101 |
Class at
Publication: |
623/2.11 ;
623/2.41; 623/902 |
International
Class: |
A61F 002/24 |
Claims
We claim:
1. In combination: A) a multipart prosthesis which includes (1) a
flexible sewing cuff, (2) a prosthesis valve separate and spaceable
from said flexible sewing cuff, and (3) means for securely
attaching said prosthesis body to said flexible sewing cuff after
said flexible sewing cuff has been attached to a patient; and B) a
tool for attaching said flexible sewing cuff to the patient in a
minimally invasive manner and which includes (1) a housing, (2) an
operating handle mounted on one end of said housing, (3) at least
one fastener stored in said housing, said fastener having an
elastic limit, (4) means for releasably mounting said flexible
sewing cuff to said tool, and (5) a fastener handling means on said
housing and operationally connected to said operating handle to be
controlled by said operating handle for storing said fastener and
securing said fastener through said flexible sewing cuff and into
the patient's tissue from one side of said sewing cuff and the
tissue to attach said flexible sewing cuff to the patient without
deforming said fastener beyond its elastic limit.
2. The tool defined in claim 1 further including means for
separating the tool from the prosthesis.
3. In combination: A) a multipart prosthesis which includes (1) a
flexible sewing cuff, (2) a prosthesis valve separate from said
flexible sewing cuff, and (3) means for attaching said prosthesis
body to said flexible sewing cuff after said flexible sewing cuff
has been placed in a patient; and B) a tool for placing said
flexible sewing cuff in the patient in a minimally invasive manner
and which includes (1) a housing, (2) an operating handle mounted
on said housing, (3) at least one fastener stored in said housing,
said fastener having an elastic limit, (4) means for releasably
mounting said flexible sewing cuff to said tool, and (5) a fastener
handling means on said housing and operationally connected to said
operating handle to be controlled by said operating handle for
storing said fastener and securing said fastener through said
flexible sewing cuff and into the patient's tissue from one side of
said sewing cuff and the tissue to attach said flexible sewing cuff
to the patient without deforming said fastener beyond its elastic
limit.
4. The tool defined in claim 3 wherein each fastener includes a
tissue-penetrating portion and anchoring means on said
tissue-penetrating portion for anchoring said tissue-penetrating
after the tissue-penetrating portion has passed through the
patient's tissue.
5. The tool defined in claim 4 wherein the tissue-penetrating
portion includes two legs and the anchoring means includes a spring
base which is biased to force the legs of the tissue-penetrating
portion into a position in which the legs overlap each other.
6. The tool defined in claim 3 wherein the fastener includes a
helical portion.
7. The tool defined in claim 3 wherein each fastener includes a
tissue-penetrating portion which includes anti-backup barbs.
8. The tool defined in claim 3 wherein said fastener handling means
includes means for storing fasteners and means for opening
fasteners.
9. The tool defined in claim 3 wherein said fastener handling means
includes means for storing fasteners and means for imparting
rotation to said fasteners.
10. The tool defined in claim 3 wherein said fastener handling
means includes means for storing fasteners and means for advancing
fasteners one at a time.
11. The tool defined in claim 1 further including means for
operating said operating handle which includes a housing; a handle
pivotally mounted on said handle; means for translating pivoting
movement of said handle into rotational motion; and means for
connecting the translating means to a fastener.
12. In combination: A) a heart valve prosthesis which includes (1)
a flexible sewing cuff, (2) a prosthesis valve body separate from
said flexible sewing cuff, and (3) means for securely attaching
said valve body to said flexible sewing cuff after said flexible
swing cuff has been placed in a patient; and B) a tool for placing
said flexible sewing cuff in the patient in a minimally invasive
manner and which includes (1) a housing, (2) an operating handle
mounted on said housing, (3) at least one fastener stored in said
housing, said fastener having an elastic limit, (4) means for
releasably mounting said flexible sewing cuff to said tool, and (5)
a fastener handling means on said housing and operationally
connected to said operating handle to be controlled by said
operating handle for storing said fastener and securing said
fastener through said flexible sewing cuff and into the patient's
tissue from one side of said sewing cuff and the tissue to attach
said flexible sewing cuff to the patient without deforming said
fastener beyond its elastic limit.
13. In combination: A) a multipart heart valve prosthesis which
includes (1) a flexible sewing cuff, (2) a prosthesis heart valve
body separate from said flexible sewing cuff, (3) means for
attaching said heart valve body to said flexible sewing cuff after
said flexible sewing cuff has been placed in a patient; and B) a
tool for placing said flexible sewing cuff in the patient in a
minimally invasive manner and which includes (1) a housing, (2) an
operating handle mounted on said housing, (3) at least one fastener
stored in said housing, said fastener having an elastic limit, (4)
means for releasably mounting said flexible sewing cuff to said
tool, and (5) a fastener handling means on said housing and
operationally connected to said operating handle to be controlled
by said operating handle for storing said fastener and securing
said fastener through said flexible sewing cuff and the tissue to
attach said flexible sewing cuff to the patient without deforming
said fastener beyond its elastic limit.
14. In combination: A) a heart valve prosthesis which includes (1)
a flexible sewing cuff, (2) a prosthesis valve separate from said
flexible sewing cuff, and (3) means for securely attaching said
valve body to said flexible sewing cuff after said flexible swing
cuff has been placed in a patient; and B) a tool for placing said
flexible sewing cuff in the patient in a minimally invasive manner
and which includes (1) a housing, (2) an operating handle mounted
on said housing, (3) at least one fastener stored in said housing,
said fastener having an elastic limit, and (4) a fastener handling
means on said housing and operationally connected to said operating
handle to be controlled by said operating handle for storing said
fastener and securing said fastener through said flexible sewing
cuff and into the patient's tissue from one side of said sewing
cuff and the tissue to attach said flexible sewing cuff to the
patient without deforming said fastener beyond its elastic
limit.
15. In combination: A) a heart valve prosthesis which includes (1)
a flexible sewing cuff, (2) a prosthesis valve separate and
spaceable from said flexible sewing cuff, and (3) means for
securely attaching said valve body to said flexible sewing cuff
after said flexible swing cuff has been placed in a patient; and B)
a tool for placing said flexible sewing cuff in the patient in a
minimally invasive manner and which includes (1) a housing, (2) an
operating handle mounted on said housing, (3) at least one fastener
stored in said housing, said fastener having an elastic limit, and
(4) a fastener handling means on said housing and operationally
connected to said operating handle to be controlled by said
operating handle for storing said fastener and securing said
fastener through said flexible sewing cuff and into the patient's
tissue to attach said flexible sewing cuff to the patient without
deforming said fastener beyond its elastic limit.
16. In combination: A) a multipart prosthesis which includes (1) a
flexible sewing cuff, (2) a prosthesis valve separate and spaceable
from said flexible sewing cuff, and (3) said prosthesis valve being
securely attached to said flexible sewing cuff after said flexible
sewing cuff has been attached to a patient; and B) a tool for
attaching said flexible sewing cuff to the patient and which
includes (1) a housing, (2) at least one fastener stored in said
housing in a tissue-penetrating shape and having an elastic limit,
and (3) a fastener handling means on said tool for forcing said
fastener into the patient from one side of said flexible sewing
cuff and the patient's tissue to attach said flexible sewing cuff
to the patient and deforming said fastener beyond its elastic limit
into a cuff-retaining shape.
17. In combination: A) a multipart prosthesis which includes (1) a
flexible sewing cuff, (2) a prosthesis valve separate and spaceable
from said flexible sewing cuff, and (3) said prosthesis valve being
securely attached to said flexible sewing cuff after said flexible
sewing cuff has been attached to a patient; and B) a tool for
attaching said flexible sewing cuff to the patient and which
includes (1) a housing, (2) at least one fastener stored in said
housing, said fastener being self-tapping to penetrate the
patient's tissue when rotated, (3) a fastener handling means on
said tool for imparting rotation to said fastener and forcing said
fastener into the patient's tissue from one side of the patient's
tissue to attach said flexible sewing cuff to the patient.
18. In combination: A) a multipart prosthesis which includes (1) a
flexible sewing cuff, (2) a prosthesis valve separate and spaceable
from said flexible sewing cuff, and (3) said prosthesis valve being
securely attached to said flexible sewing cuff after said flexible
sewing cuff has been attached to a patient; and B) a tool for
attaching said flexible sewing cuff to the patient and which
includes (1) a housing, (2) at least one fastener stored in said
housing, and (3) a fastener handling means on said tool for forcing
said fastener into the patient from one side of the patient's
tissue and attaching said flexible sewing cuff to the patient.
19. In combination: A) a multipart prosthesis which includes (1) a
flexible sewing cuff, (2) a prosthesis valve separate and spaceable
from said flexible sewing cuff, and (3) said prosthesis valve being
securely attached to said flexible sewing cuff after said flexible
sewing cuff has been attached to a patient; B) a fastener for
attaching said sewing cuff to the patient from one side of said
sewing cuff, said fastener having an elastic limit; and C) means
for forcing said fastener through said sewing cuff and attaching
said sewing cuff to the patient without exceeding the elastic limit
of said fastener whereby said fastener is non-formed when said
sewing cuff is attached to the patient by said fastener.
20. In combination: A) a multipart heart valve prosthesis which
includes (1) a flexible sewing cuff, (2) a prosthesis heart valve
separate and spaceable from said flexible sewing cuff, and (3) said
prosthesis heart valve being securely attached to said flexible
sewing cuff after said flexible sewing cuff has been attached to a
patient; B) a fastener for attaching said sewing cuff to the
patient from one side of said sewing cuff, said fastener having an
elastic limit and an initial shape; and C) means for forcing said
fastener through said sewing cuff and attaching said sewing cuff to
the patient without exceeding the elastic limit of said fastener
whereby said fastener is non-formed and not permanently deformed
from the initial shape when said flexible sewing cuff is attached
to the patient by said fastener.
Description
CROSS REFERENCE TO RELATED APPLICATIONS
[0001] The application is a continuation-in-part (CIP) of U.S. Ser.
No. 08/964,026 filed on Nov. 4, 1997, and currently pending, which
is a CIP of U.S. Ser. No. 08/802,948 filed on Feb. 21, 1997 and
currently pending, which is a CIP of U.S. Ser. No. 08/606,343 filed
on Feb. 23, 1996, now U.S. Pat. 5,716,370.
TECHNICAL FIELD OF THE INVENTION
[0002] The present invention relates to the general art of
prosthetic devices, and to the particular field of prosthetic heart
valves and surgical tools, fasteners and techniques associated
therewith.
BACKGROUND OF THE INVENTION
[0003] It is well known that heart diseases may result in disorders
of the cardiac valves. For example, diseases such as rheumatic
fever can cause the shrinking or pulling apart of the valve
orifice, while other diseases may result in endocarditis, an
inflammation of the endocardium or lining membrane of the heart.
The resulting defects in the valves hinder the normal functioning
of the atrioventricular orifices and operation of the heart. More
specifically, defects such as the narrowing of the valve stenosis
and/or the defective closing of the valve, referred to as valvular
insufficiency, result in an accumulation of blood in a heart cavity
or regurgitation of blood past the valve. If uncorrected, prolonged
valvular stenosis or insufficiency may cause damage to the heart
muscle, which may eventually necessitate total valve
replacement.
[0004] These defects may be associated with any of the cardiac
valves. For example, if the mitral valve stenosis connecting the
left auricle with the left ventricle narrows, blood will accumulate
in the left auricle. Similarly, in the case of mitral
insufficiency, the mitral valve does not close perfectly, and blood
in the left ventricle is regurgitated past the closed mitral valve
into the left auricle when the ventricle closes.
[0005] In many cases, complete valve replacement is required.
Mechanical artificial heart valves for humans are frequently
fabricated from titanium, prolitic carbon or tissue, including
tissue from cows, pigs or humans. Such valves have been used
because of their nonthrombogenic properties. Human blood does not
coagulate on contact with such valves. Moreover, they are
lightweight, hard and quite strong. Therefore, such valves have
become widely accepted and used by many surgeons. Any new
prosthetic valve or surgical technique associated therewith should
account for this. One popular prosthetic valve includes such a hard
body and a knit fabric sewing or suture cuff fixedly attached
thereto as by drawstrings made of plastics-type material. The
sewing cuff is sutured in place on the patient's tissue, and that
tissue grows into the fabric providing a secure seal for the
prosthetic valve. As will be discussed below, even though this is a
widely accepted valve, there are problems and drawbacks.
[0006] A standard implantable mechanical heart valve usually has an
annular valve housing or body to provide a passageway for blood.
Occulders are mounted in the annular body and open or close the
blood flow passageway. Usually there are one or two occulders, but
occasionally triple occluder configurations have been proposed. On
the outside of the valve body there is usually an external,
circumferential surface configured as a groove. The purpose of this
groove is to facilitate attachment of the above-discussed suture
ring to the valve body.
[0007] As above mentioned, replacement of heart valves has become a
widely accepted procedure. Currently, as many as eighty thousand
heart valve prostheses are implanted in the United States alone.
This procedure is very expensive. It requires the talents of a
highly skilled surgeon, perfusionist and anesthesiologist as well
as the supporting staff and equipment required to keep the patient
on a heart/lung bypass machine during the operation. While this
procedure currently works very well, operating time is still
extensive and the longer the patient is on bypass equipment, the
greater the risk to the patient. Furthermore, hand suturing is
tedious and time consuming further lengthening the time the patient
is on cardiopulmonary bypass and hypothermia. This may increase the
chances of tissue damage to the patient.
[0008] Therefore, there is a need for a heart valve replacement
procedure that reduces the surgical time required for the
operation.
[0009] Still further, many currently used surgical techniques are
invasive and often require breaking of bones. This increases the
time and difficulty of the recovery. Therefore, there is a need to
develop a prosthetic heart valve and a procedure for implanting
same that reduces the invasiveness of this surgery.
[0010] As above mentioned, hand suturing of prosthetic heart valves
in place is widely accepted. However, this requires the opening of
the patient's chest wall to gain access to the aortic valve through
a transverse incision in the ascending aorta. The distance from the
incision down to the valve is usually two to two and one halve
centimeters with an aortic lumen diameter of between seventeen and
thirty millimeters. This creates a very long and narrow tube into
which the surgeon must place sutures. While this is a tedious
procedure in an "open chest" case, it is very challenging to
accomplish through any small incision between the ribs or through a
thoracic inlet, as would be required in any minimally invasive
procedure. Therefore there is a need for a device and method that
can secure the valve remotely from outside the chest wall.
[0011] A further problem associated with suturing some prostheses
is that the valve is bulky and reduces the inside diameter of the
valve body. A reduced inside diameter of the valve reduces the flow
area of the valve resulting in increased transvalvular pressure
gradients resulting in increased work for the heart muscle. A
reduced flow area for such a valve may adversely influence blood
flow characteristics associated with the valve, thereby adversely
influencing the performance of the valve. This is very
counter-productive to the clinical needs of the prosthesis. It is
very hard to develop a mechanical valve that has the same flow
characteristics of a living tissue valve. This is especially so of
many existing multi-part prostheses. Even the so-called sutureless
valves that have been disclosed in the art may have this problem.
Heart valve designs have been directed toward minimizing the back
pressure or restriction of forward flow by maximizing the
cross-sectional area of the valve within a given outer diameter
base. Housing attachment means within the valve base narrows the
inside diameter of the valve body thereby creating adverse flow
characteristics. Therefore, there is a need for a prosthetic valve
which has the flow area thereof maximized. Reduced flow area may
also result in rapid blood acceleration with a concomitant risk of
red cell hemolysis and activation of sensitive enzyme systems such
as the clotting system.
[0012] Yet a further problem with some prosthetic heart valves and
the implanting procedures associated therewith, is that there are
unwanted projections remaining on the implanted valve. This is
especially so for valves that are sutured in place. Blood clots
tend to form around foreign objects in the body. The body's natural
defenses try to seal off any foreign material and make it
non-threatening. However, there is a danger that the formed blood
clots may dislodge into the patient's blood stream, which may cause
a major problem.
[0013] The sutures used in many existing techniques to sew a cuff
in place are knotted and cut off. This leaves raw edges exposed to
the patient's blood stream. These raw edges of the cut off suture
and knot provide surfaces for clot formation and provide potential
for clots to break off into the bloodstream as they are newly
formed. Loose clots in the bloodstream are dangerous for the
patient as they have the potential for producing a stroke. Clots
forming on sutures may also extend onto the valve and produce
malfunctions by trapping the valve open or shut. It is common
practice to treat a post-surgical patient with heparin or some
other anticoagulant to minimize the production of clots. Therefore,
there is a need for a prosthetic valve and surgical implanting
process that minimizes the amount of foreign objects that remain
exposed to the patient after the valve has been implanted. The
exposed surfaces may also become a site of infection. Circulating
bacteria may become attached and lead to infection at the valve.
These infections are notoriously difficult to treat with
antibiotics.
[0014] Yet another problem arises because it is difficult to effect
a secure fit between the prosthesis and the patient's tissue. If
there are gaps between the lumen and the valve, a leak may develop
causing blood to bypass the valve. This can cause disastrous
problems. Additionally, in many of the prostheses that are
disclosed in the prior art as being sutureless, there is no way to
ensure close approximation of the aortic lumen to the valve base
prior to setting fasteners. This has allowed the lumen to pull away
from the base and create the just-mentioned leak-generated
problems. This is because anatomy is different from patient to
patient. It is impossible to make the entire spectrum of valve
bases to accommodate such differences in anatomy as would be
required by some of the systems presently in use. Additionally,
differences in diameter are not just in diameter of the lumen, but
in the irregularities of the annulus where the valve is to be
placed. Still further, disease and calcification can make the
placement of known valves unmanageable. Whatever the cause of the
imperfect fit between the prosthetic valve and the lumen, the
variation in opening size and/or shape must be accounted for in
placing the prosthesis. A securely anchored and tightly fit
prosthesis is necessary for a successful outcome.
[0015] Furthermore, an improper fit between the prosthetic device
and the lumen may greatly increase the duration of the operation or
require corrective surgery to replace an improperly placed
prosthesis.
[0016] Therefore, there is a need for a prosthesis valve that can
be securely fit to a patient's lumen in an expeditious and reliable
manner.
[0017] While the art contains several teachings which could be
applied to one or more of the above-mentioned problems, such as the
above-discussed cuffs, these disclosures have several drawbacks
which are in addition to those already mentioned. For example,
these prosthetic valves generally include a sewing ring or suture
cuff that has some sort of stiffener therein. An example of such a
stiffener is soft plastic. Plastic, even easily molded plastic, may
require the patient's tissue to be severely handled and still have
puckering even after great precautions have been taken. In this
situation, stiffening elements may be more difficult to handle than
fully flexible elements and may adversely affect the patient's
tissue. Therefore, any new prosthesis valve should use a fully
flexible material to attach that prosthesis to the patient to avoid
the problems of unduly stressing the patient's tissue during the
placement of the valve.
[0018] Dacron, Polyester and Teflon have been a very popular
material for sewing cuffs. It is slightly stretchable, allowing it
to be dilated. Needles readily pass through it without tearing or
snagging the fabric fibers and the Dacron material has exceptional
implant qualities with a proven track record of bioacceptance that
allows ingrowth of endothelial cells. Due to its wide acceptance,
it will be commercially advantageous to incorporate Dacron into any
new prosthesis valve.
[0019] Therefore, there is a need for a prosthesis heart valve
which can be tightly placed in a patient without requiring undue
stressing of the patient's tissue.
[0020] There is yet additional need for a prosthesis heart valve
which can have its size and shape expeditiously adjusted to produce
a secure, non-leaking, fit to the particular patient, again without
placing undue stress on the patient's tissue.
[0021] Still further, it is highly desirable for the surgeon to be
able to adjust the orientation of the valve in situ. This will
permit the prosthesis to be customized to the particular patient.
While many known valves can be moved in place, there is still need
for improvement in the ease and accuracy of such a step.
[0022] Still further, because the position of the junction between
the coronary arteries and the aorta is variable, the choice of the
location of the placement of the prosthesis should be as great as
possible. The high profile of many of the finished sewing cuffs of
the known devices severely limits this choice.
[0023] Still further, in many instances, it is advantageous for the
surgeon to move the prosthesis into various positions relative to
the sewing cuff. This will allow the valve to sit at the same
level, above or below a certain level. For example, it might be
advantageous to seat the valve cuff to be seated above the annulus
to maximize the effective orifice area. It will be advantageous to
be able to place the prosthesis in the most superior position
without interference with the coronary arteries thereby allowing a
larger diameter prosthesis to be placed. A lower profile cuff
allows the surgeon to place the prosthesis as high as possible
without interfering with the coronary artery junction.
[0024] Therefore, there is a need for a prosthetic heart valve that
has a low profile finished cuff whereby the surgeon can have a
greater choice in the superior/inferior placement of the prosthesis
valve.
[0025] Current prosthetic valves are inefficient because the sewing
cuff occupies part of the area available for flow through the
valve. If a very small prosthesis is placed in the annulus, there
can be a mismatch between the patient's cardiopulmonary
requirements and the flow area of the valve. If a patient demands a
high level of flow due to a larger size, a small sized valve may
result in a significant transvalvular gradient. That is, the
pressure in the left ventricle is considerably higher than the
pressure in the aorta. This results in increased work for the left
ventricular muscle and may predispose to myocardial failure.
[0026] If the surgeon suspects that the prosthesis placed is going
to be too small, he may elect to enlarge the aortic root.
Presently, this is accomplished by opening the aortic annulus
opened perpendicular to the plane of the annulus in continuity to
the aortomy. The incision is extended along the anterior leaflet of
the mitral valve for a varying length. A patch of tissue or fabric
material is then stitched to this incision to enlarge it. The
procedure allows the insertion of a larger prosthesis into the
newly enlarged annulus. However, there is an increased risk to the
patient, principally because of the risk of bleeding from the
suture line. This site is virtually inaccessible to repair after
the aorta is closed.
[0027] Therefore, there is a need for a simpler way to expand the
aortic annulus. Dilation is preferred, and thus, there is a further
need to be able to expand the aortic annulus by dilation.
[0028] Still further, in minimally invasive surgery, it is
sometimes difficult to gain access to a proper fastening plane with
a straight instrument. Therefore, it is desirable to be able to use
an articulated or curved shaft for a fastening or stapling
instrument. Still further, it is often desirable to be able to
manipulate the fastening instrument into the most advantageous
orientation with respect to the area being stapled.
[0029] Therefore, there is a need for a fastening instrument that
can be operated to gain access to a great number of fastening
planes.
[0030] Still further, it is often desirable to stretch and
manipulate an element prior to fastening that element to the
patient. This is not always possible in minimally invasive
techniques using instruments that are available prior to the
instruments disclosed herein. Therefore, there is a need for an
instrument that can stretch and shape a flexible element prior to
and during fastening of that element to a patient in a minimally
invasive procedure.
[0031] Still further, tough tissue, calcium deposits and the like
make fastening an element to a patient difficult, especially in the
context of a minimally invasive technique. Therefore, there is need
for an instrument that can force a staple through tough tissue
and/or calcium covered tissue in a minimally invasive technique.
This should be achieved without bunching or damaging the tissue or
the element being stapled.
[0032] Often, in minimally invasive surgery, it is difficult to
place staples in precisely proper locations. This is especially
true if the staples are being placed in a circular pattern. Since
the circumference of a circle is often not evenly divisible by the
width of a staple the gaps between staples are often difficult to
establish with proper accuracy so gaps in the staple coverage or
bunching of either tissue or material is avoided.
[0033] Therefore, there is a need for a device that can be used in
minimally invasive surgery for properly placing staples.
[0034] Staple placement can be effected by manually locating the
staple delivery assembly or by automatically locating the staple
delivery assembly. If a manual location technique is used, it is
desirable that the surgeon be given an opportunity to choose
between a manufacturer's suggestion and his own assessment of the
situation. Therefore there is a need for a stapling device for use
in minimally invasive surgery that will allow a surgeon to manually
locate staples or to select a suggested location for the
staples.
[0035] As above discussed, the placement of staples in a minimally
invasive situation may be difficult to effect in an even manner.
Therefore, there is a need for a means and a method for placing
staples in a pattern wherein the spacing of the staples is even and
no overlap or unwanted gaps occur even if an aorta or other such
organ being stapled is an "off size." bbb
[0036] Still further, it is desirable that a staple used in a
minimally invasive surgical technique drive through the tissue and
the material being attached to the tissue in a manner that is most
effective. Thus, no bunching or gaping should occur, even if the
tissue is tough. The effort to drive the staple through the tissue
should be minimized if possible since the mechanical advantage is
not the most effective in many situations.
[0037] Therefore, there is a need for a staple that can be used in
a minimally invasive surgical technique that can be driven through
tough tissue in an effective manner.
[0038] Still further, there is a need to close the aortomy after
completion of valve replacement surgery. This is now achieved using
sutures. However, this is time consuming. Therefore, there is a
need for a means and a method for closing the aortomy in an
efficient and effective manner.
[0039] The previous co-pending patent applications, the disclosures
of which are incorporated herein by reference, disclose novel ways
to attach heart valve prostheses into human tissue. The present
disclosure deals with more specific areas of the actual fasteners
and fastener deployment mechanisms for accomplishing the fastening
methods. As can be appreciated by the teaching of these and this
disclosure, the invention is much more than merely a fastener type
or delivery device. The invention pertains more broadly to a
methodology and system for stretching the prosthesis and annulus,
providing a flexible prosthesis anchoring ring and means and
devices for deploying the fasteners and fastening the prosthesis to
the tissue.
[0040] The fasteners disclosed in the co-pending applications are
fasteners which are formed using a stationary anvil system and a
moving driver system both of which are located on the same side of
the prosthesis being attached to the patient, and more
specifically, inside the prosthesis and the vessel or on the same
operative side of the tissue. The need for this type of same-side
positioning can be understood from the teaching of the incorporated
material.
[0041] In the case of mitral valve repair, there is no ready access
to the back side of the valve which is in a separate chamber of the
heart. Moreover, there are more problems besides access that
prevent help from outside the lumen in a fastener forming process.
For example, consider the aortic valve. The annulus of the valve
sits at the exit of the left ventricle. The coronary arteries of
the heart (left and right) are above the annulus. In addition, the
aortic annulus is below the junction of the vessel wall with the
myocardium. To gain access to the back of the annulus, it is
required to incise the epicardium. To further complicate matters,
the AV node is very close to the aortic annulus.
[0042] If one tries to deploy a prosthesis fastening device that
uses an outside anvil or support for forming the fasteners, one
encounters many anatomical and surgical problems. First, for
example, the surgeon would have to dissect the coronary arteries
from the bed of the heart in order to "clear" a space below the
coronaries to place such a helping tool. This alone would take an
enormous amount of time and could be very risky. Then, dissection
must proceed into the heart muscle in order to obtain direct
opposition from within the lowest (inferior) portion of the aortic
annulus. Therefore, to have a backing device on the outside of the
annulus one must dissect into the myocardium. This would then risk
intrusion into the AV node and create a very weak area of the heart
which would need surgical closure when the outside component is
removed.
[0043] In addition to the above-mentioned anatomical problems,
there are numerous problems associated with mechanics of aligning a
fastener pusher with a forming device located remotely. The
tolerances required for alignment are very tight in order of only a
few thousandths of an inch outside of which the proper fastener
form will not be generated. Compound this with having to split or
cantilever a forming member to get it around or under the dissected
coronary arteries and it presents a truly monumental task. To
further complicate this arrangement as the aorta or lumen size
changes the corresponding outside forming member must accommodate
these sizes. This would present a serious problem requiring many
different size devices to accommodate varying sizes of human
anatomy. Note also that in some cases, such as AAA procedures,
there will be no way to access the outside of the lumen, so the
very nature of the procedure requires that the delivery of
fasteners be restricted to the inside of the lumen. Thus, prior art
devices, other than the incorporated devices, have significant
drawbacks.
[0044] Furthermore, fatigue resistance is an important factor that
should be considered in placing a prosthesis into a patient,
especially if the prosthesis will be exposed to blood flow in a
heart. Fluid hammer can create significant forces on the prosthesis
and any fasteners used to attach it to the patient. If such forces
are not properly accounted for, problems can arise. Therefore,
there is a need for a fastener placement system that can place
fasteners in a manner so that fluid hammer and/or fatigue will not
create significant problems for the prosthesis.
OBJECTS OF THE INVENTION
[0045] It is a main object of the present invention is to provide a
prosthesis heart valve which can be implanted in a surgical
procedure that is minimally invasive.
[0046] It is another object of the present invention to provide a
prosthesis heart valve that can be implanted in an expeditious
surgical procedure.
[0047] It is another object of the present invention to provide a
prosthesis heart valve that can present the largest possible flow
area to the patient.
[0048] It is another object of the present invention to provide a
prosthesis heart valve that reduces the number of objects exposed
to the patient after implantation.
[0049] It is another object of the present invention to provide a
prosthesis heart valve which can be customized to the particular
patient without placing undue stress on the patient's tissue.
[0050] It is another object of the present invention to provide a
prosthesis heart valve which can utilize widely accepted materials
while still realizing the advantages set forth herein.
[0051] It is another object of the present invention to provide a
prosthesis heart valve which utilizes a fully flexible sewing
cuff.
[0052] It is another object of the present invention to provide a
prosthesis heart-valve which can use a Dacron sewing cuff.
[0053] It is another object of the present invention to provide a
prosthesis heart valve which has a finished cuff that has a low
profile above the valve.
[0054] It is another object of the present invention to provide a
prosthesis heart valve which eliminates suturing as a means for
attaching the prosthetic device to the patient.
[0055] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which is minimally invasive.
[0056] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which is minimally invasive yet which is accurate,
expeditious and results in a firmly, accurately and fixedly placed
prosthetic device.
[0057] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which reduces the amount of stress that is placed on
the patient's tissue during the placement procedure.
[0058] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which does not require opening the patient's chest
wall.
[0059] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which attaches the prosthesis valve with fasteners that
are hidden inside the device whereby the chances of infection and
thrombosis are significantly reduced.
[0060] It is a specific object of the present invention to provide
a surgical technique associated with the implanting of a prosthesis
heart valve which hides the fasteners inside the sewing cuff.
[0061] It is a specific object of the present invention to provide
a surgical technique associated with the implanting of a prosthesis
heart valve which significantly reduces the chances of the cuff
puckering during the implanting procedure.
[0062] It is another specific object of the present invention to
provide a surgical technique associated with the implanting of a
prosthesis heart valve which dilates the graft or cuff and the
lumen together to provide intimate contact during the fastening
procedure.
[0063] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which allows for endoscopic visualization of the
placement of the valve in the heart.
[0064] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which permits both dilation and placement of fasteners
in a sewing ring or graft.
[0065] It is another object of the present invention to provide a
surgical technique associated with the implanting of a prosthesis
heart valve which assures secure attachment of the prosthetic
device to the patient.
[0066] It is another object of the present invention to permit a
surgeon to use a larger valve if such larger valve is
indicated.
[0067] It is another object of the present invention to provide a
means and method wherein the annulus of the aorta can be stretched
as a prosthetic valve is being placed.
[0068] It is another object of the present invention to allow
insertion of a larger prosthesis without opening the annulus and
adding a patch.
[0069] It is another object of the present invention to provide a
means and a method whereby annuloplasty can be performed.
[0070] It is another object of the present invention to provide a
device that will allow the addition of standard sutures to repair
or reinforce any area of potentially weak attachment of the suture
ring to the annulus.
[0071] It is another object of the present invention to provide a
means and a method for minimally invasive surgery which can gain
access to a proper fastening plane.
[0072] It is another object of the present invention to provide a
means and a method for minimally invasive surgery is able to
manipulate the fastening instrument into the most advantageous
orientation with respect to the area being stapled.
[0073] It is another object of the present invention to provide a
means and a method for minimally invasive surgery which can stretch
and manipulate an element prior to fastening that element to the
patient.
[0074] It is another object of the present invention to provide a
means and a method for minimally invasive surgery that can force a
staple through tough tissue and/or calcium covered tissue in a
minimally invasive technique without bunching or damaging the
tissue or the element being stapled.
[0075] It is another object of the present invention to provide a
means and a method for minimally invasive surgery for properly
placing staples.
[0076] It is another object of the present invention to provide a
means and a method for minimally invasive surgery that will allow a
surgeon to manually locate staples or to select a suggested
location for the staples.
[0077] It is another object of the present invention to provide a
means and a method for minimally invasive surgery that includes a
staple that can be used in a minimally invasive surgical technique
that can be driven through tough tissue in an effective manner.
[0078] It is another object of the present invention to provide a
means and a method for minimally invasive surgery for closing an
aortomy in an efficient and effective manner.
[0079] It is another object of the present invention to provide a
fastener that is self forming, that is a fastener that does not
need an anvil to secure it to a patient's tissue.
[0080] It is another object of the present invention to provide a
fastener that is protected from fluid hammer.
[0081] It is another object of the present invention to provide a
fastener that can attach a prosthesis to a patient in a manner such
that the deleterious effects of fastener fatigue are minimized.
[0082] It is another object of the present invention to provide a
fastener that can be used to attach a prosthesis to a patient in a
manner such that the deleterious effects of a failure of one
fastener are minimized.
[0083] It is another object of the present invention to provide a
fastener that can be placed, will approximate tissue, and cinch
that tissue all when controlled only from one side of the
tissue.
[0084] It is another object of the present invention to provide a
prosthesis fastening system which fastens a flexible prosthesis to
human tissue which is resistant to the deleterious effects of
fatigue.
[0085] It is another object of the present invention to provide a
prosthesis fastening system which fastens a flexible prosthesis to
human tissue which has shock absorbing qualities of a non-rigid
assembly.
[0086] It is another object of the present invention to provide a
method to attach a fully flexible prosthesis to tissue with a
segmented array of fasteners whereby delivery of the fasteners is
accomplished entirely from one side of the tissue.
[0087] It is another object of the present invention to provide a
prosthesis fastening system which utilizes a segmented array of
fasteners which allows for the expansion of the aorta during
insertion of the prosthesis in heart surgery,
[0088] It is another object of the present invention to provide a
prosthesis fastening system which utilizes a fastening element
which can grow with the tissue.
[0089] It is another object of the present invention to provide a
prosthesis fastening system which utilizes spring-loaded
fasteners.
[0090] It is another object of the present invention to provide a
prosthesis fastening system that utilizes barbed fasteners.
[0091] It is another object of the present invention to provide a
prosthesis fastening system that utilizes fasteners that are
rotationally delivered.
[0092] It is another object of the present invention to provide a
prosthesis fastening system which utilizes a segmented array of
fasteners which allows the prosthesis to be flexible, moving in
unison to the pulsating nature of heart tissue loading to resist
fatigue of the fasteners used in heart surgery.
[0093] It is another object of the present invention to provide a
prosthesis fastening system with the ability to install a fully
flexible and expandable anchoring system which pre-stretches the
aorta lumen tissue in heart surgery thereby permitting larger
diameter valve to be inserted than is practical with prior art
techniques.
[0094] It is another object of the present invention to provide a
heart valve prosthesis fastening system with a means of fastening
the heart prosthesis all from within a lumen.
[0095] It is another object of the present invention to provide a
prosthesis fastening system which utilizes a fastening means
whereby the fasteners are all hidden from a blood path in heart
surgery.
SUMMARY OF THE INVENTION
[0096] These, and other, objects are achieved by a sutureless
prosthetic heart valve or graft which has a flexible sewing cuff
stapled in place prior to placement of the heart valve body. The
objects are also achieved by a fastener and a tool and a surgical
procedure for effecting placement of the prosthetic valve in a
minimally invasive manner.
[0097] More specifically, the prosthetic valve includes a flexible
sewing cuff, such as Dacron, or the like, which is stapled to heart
tissue using a special tool that is inserted into the patient via
an incision located in the thorax, either via a retrostenal
approach or by removal or separation of the ribs. The tool
releasably carries the cuff and includes means for continuously
pressing the flexible cuff against the patient's tissue during the
stapling procedure whereby the cuff is deformed rather than the
tissue and puckering is essentially eliminated.
[0098] The cuff is attached to the valve body using drawstrings
which extend outside the patient's body. The valve body is
positioned in the in-situ cuff and the drawstrings are operated.
Because the cuff is flexible, stretching of the tissue is minimized
since inaccuracies are, at least, partially, absorbed by the
flexible cuff.
[0099] The system disclosed herein should have improved blood flow
and biological acceptance in the patient because suture knots and
felt pledgets are not used. This provides additional advantages to
use of this system due to a potentially reduced risk of stroke and
infection post-surgery and potential for use of lower doses of
anticoagulant and antibiotics post surgery.
[0100] Still further, due to the minimally invasive nature of the
procedure, there is a possibility of applying the teachings of this
invention to emergency procedures that may be performed outside of
an operating room environment.
[0101] Yet another advantage of the present system is the low
profile of the finished cuff above the valve base. This allows the
surgeon greater choice in the superior/inferior placement of the
valve. This is important because the position where the coronary
arteries join the aorta is extremely variable. The low profile of
the cuff allows for more distance between the cuff and the coronary
junction.
[0102] Because the cuff of the present device is formed of material
that has already been successful and is widely accepted, the
commercial advantages associated with this device are enhanced.
[0103] Due to the surgical techniques that can be utilized with the
present invention, it is possible to use video appliances, such as
miniature video endoscopes.
[0104] One feature of the present invention is that of fatigue
resistance. In mechanical systems which are subjected to repeated
impact or other non-uniform loading, one needs to design for
fatigue resistance. Just as a wire rope is more fatigue resistant
than a single rod, the inventors have taken the approach that
multiple small fasteners joined by a flexible member are much
better suited to handling repeated loading of heart pulsation.
[0105] In the inventive system, each individual fastener will see
only its local loading. Each fastener is isolated from adjacent
fasteners. Therefore loading on one fastener does not influence the
adjacent fasteners with bending moments. The flexing which causes
fatigue will happen between each fastener thereby substantially
reducing flexural loading on individual fasteners, thereby greatly
reducing the chances of flex fatigue.
[0106] More specifically, the inventive system provides the extra
security of having many fasteners in place and the redundancy to
back up a failure of any one fastener. Additionally, since
individual fasteners make up a peripheral plurality of attachment
sites, small gaps between adjacent fasteners are desirable to allow
the aortic wall to relax after insertion of a prosthesis in heart
surgery through normal growth of minor tissue trauma incidents
which will allow for an anchor ring and valve to essentially "sway
with the breeze," but not become dislodged or leak. The inventive
system takes multiple "bites" of tissue to build each on the other
to create a chain of fasteners that each has a positive grip on the
area of tissue within each fastener.
[0107] The fastener system of the present invention has several
features that permits it to overcome the above-discussed problems
and to achieve the above-stated objectives: a plurality of
fastening elements spaced in a staggered but uniform pattern; the
fastening elements are applied from inside the lumen only without
the aid of external anvils or supports; the fasteners penetrate
both the prosthesis and the tissue thereby approximating the
prosthesis and the tissue at the individual fastening element; and
the individual fastening elements can be placed in a pattern that
allows the lumen and the prosthesis to flex without compromising
hemostasis or security.
[0108] The presently disclosed means and method can be used to
perform annuloplasty where the annuloplasty ring is fastened to an
aorta above a leaky but salvageable human tricuspid valve. In this
form, an annuloplasty ring would be constructed so the cuff
material covers a malleable ring whereby the annuloplasty ring is
fastened in place with the disclosed fastener element. The ring
could be malleable metal or plastic to allow the surgeon to shape
it correctly to impart forces in right area. The malleable ring is
then shaped to size or compress the annulus and import a
compressive force on the valve causing the leaflets to close more
securely. This could be applied to mitral and other locations as
well.
[0109] The placed cuff can be inspected by the surgeon to be sure
that it is placed securely. If the surgeon decides that hand-placed
sutures will be helpful, he can place such sutures as needed.
[0110] If desirable, the surgeon can use a staple delivery
mechanism to place staples either according to a prescribed path or
according to his best judgement at the time. The hereinbelow
disclosed device includes a staple delivery instrument that can be
used to place staples one at a time along a predetermined path, or
in conjunction with a guide, automatically along a helical path.
The helical path will place staples in a desired spacing and can be
used with staples of different widths.
[0111] Still further, the device disclosed herein can be used to
close an aortomy. If desired, a surgeon can use the staple delivery
device to place staples along a path set by icons until he becomes
more confident in an automatic placement technique. The instrument
saves time in placing staples.
[0112] Yet another form of the stapling instrument delivers staples
in staggered rows while being able to engage a cuff to force and
stretch that cuff against the patient's tissue to ensure proper
placement of the cuff.
BRIEF DESCRIPTION OF THE DRAWING FIGURES
[0113] FIG. 1 shows a sectional view of a prior art prosthesis
heart valve in place in a patient.
[0114] FIG. 2 is a sectional view of the prosthesis valve of the
present invention installed in the aortic annulus of a patient.
[0115] FIG. 3 is a sectional view of a sutureless cuff used in the
present invention when the cuff has been stapled to the patient and
prior to placement of the prosthetic valve body.
[0116] FIG. 4 is a sectional view of the prosthetic valve of the
present invention after the cuff has been stapled in place and
after the prosthetic valve body has been placed in the cuff and
before the cuff is attached to the valve body.
[0117] FIG. 5 is an enlarged sectional view of the sutureless
prosthetic heart valve of the present invention with two rows of
staples securing the cuff to the patient and the valve base
attached to the cuff.
[0118] FIGS. 6, 7 and 8 illustrate how the sutureless cuff of the
present invention is constructed.
[0119] FIG. 9 is a side and bottom perspective view of a preferred
form of a fastener driving tool used in the present invention.
[0120] FIG. 10 is an exploded perspective view of the tool shown in
FIG. 9.
[0121] FIGS. 11, 12, 13 and 14 illustrate the various positions of
the staple driving mechanism during operation of the fastener
driving tool of the present invention.
[0122] FIG. 15 is a sectional view of the fastener driving tool in
the assembled condition.
[0123] FIG. 16 shows the fastener driving tool in position after
the cuff has been stapled to the patient and prior to movement of
the valve body into position in the in-situ cuff.
[0124] FIG. 17 shows the in-situ cuff with the valve body in place
prior to attaching the valve body to the cuff.
[0125] FIG. 18 shows the cuff attached to the patient and to the
valve body that has been moved from the FIG. 16 position to the
FIG. 17 position.
[0126] FIG. 19A illustrates the torso of a patient having the
prosthetic valve of the present invention being placed using a
fastener driving tool of the present invention in a minimally
invasive surgical procedure according to the teaching of the
present invention.
[0127] FIG. 19B illustrates the tool inserted into an aorta.
[0128] FIG. 20 shows a valve body holding tool inserting a valve
body into an in-situ cuff.
[0129] FIG. 21 shows an alternative form of the tool having two
fastener-delivering heads and which can be used to repair an
aneurysm.
[0130] FIG. 22 is an exploded section of FIG. 21.
[0131] FIG. 23 shows use of the tool shown in FIG. 21 to repair an
abdominal aortic aneurysm.
[0132] FIGS. 24-27 show steps in placing a prosthesis.
[0133] FIG. 28 is an exploded perspective view of another form of
the tool which maintains the handle and shaft stationary during
fastener delivery.
[0134] FIG. 29 illustrates a rotating fastener assembly for use in
the tool shown in FIG. 28.
[0135] FIG. 30 is an assembled view of the FIG. 28 tool.
[0136] FIG. 31 is a perspective view of a staple delivery
instrument.
[0137] FIG. 32 is an exploded perspective view of a staple delivery
assembly.
[0138] FIG. 33 is an exploded perspective view of a staple guide
means for guiding movement of the staple delivery assembly shown in
FIG. 32.
[0139] FIGS. 34a-34e and 34a'-34e' show the steps through which a
staple according to the present invention follows as it is being
forced into and through elements to be stapled.
[0140] FIG. 35 is an exploded perspective view of another form of
staple delivery assembly in which the assembly is returned to an
initial position by an elastomeric element.
[0141] FIG. 36 is a perspective view of another form of staple
delivery instrument according to the present invention.
[0142] FIG. 37 is a perspective view of a head portion of the
staple delivery instrument shown in FIG. 36.
[0143] FIG. 38 is a top plan view of an anchor ring in place in an
aorta illustrating how the means of the present invention can
stretch the ring against the aorta and how the staples of the
present invention attach the ring to the aorta.
[0144] FIGS. 39a-39d illustrate the operation of the staple
delivery instrument shown in FIG. 36.
[0145] FIGS. 40a-40c further illustrate the operation of the FIG.
36 staple delivery instrument.
[0146] FIG. 41 is a perspective view of another form of a staple
delivery instrument.
[0147] FIG. 42 is staple pattern in a cuff that can be established
using the FIG. 41 staple delivery instrument.
[0148] FIGS. 43-45 illustrate the steps in placing a heart valve
onto a cuff that has been stapled to a patient's aorta.
[0149] FIG. 46 is perspective of another staple delivery
instrument.
[0150] FIG. 47 is partial view of the FIG. 46 instrument
illustrating the angled nature of the staple delivery associated
with that instrument.
[0151] FIG. 48 shows an anchor ring placement element that can be
used with the staple delivery instrument shown in FIG. 46.
[0152] FIG. 49 illustrates multiple rows of staples placed using
the staple delivery instrument shown in FIG. 46 and the anchor ring
placement element shown in FIG. 48 and following a staple pattern
established by icons placed on the anchor ring.
[0153] FIGS. 50A and 50B show a staple pattern established "on the
fly" using the FIG. 46 staple delivery instrument and the FIG. 48
anchor ring placement element.
[0154] FIG. 51 is a perspective view of an automatic staple
placement system that uses the staple delivery instrument shown in
FIG. 46.
[0155] FIG. 52 is an elevational view of the FIG. 51 system showing
the FIG. 46 tool in place in the system.
[0156] FIG. 53 is an exploded perspective partial view of the FIG.
51 system.
[0157] FIGS. 54a-54c illustrate helical staple patterns that are
established using the staple system shown in FIG. 51.
[0158] FIG. 55 illustrates the use of the FIG. 46 tool to close an
aortomy.
[0159] FIG. 56 illustrates the closed aortomy showing how the
staple of the present invention brings incised edges together.
[0160] FIG. 57 shows one form of self-forming fastener.
[0161] FIG. 58 shows a tool element that can be used in connection
with the fastener shown in FIG. 57.
[0162] FIG. 59 is a side elevational view of the element shown in
FIG. 58.
[0163] FIG. 60 shows an end of the FIG. 58 element.
[0164] FIG. 61 shows another form of self-forming fastener.
[0165] FIG. 62 shows a tool element which can be used to place the
fastener shown in FIG. 61.
[0166] FIG. 63 shows another form of self-forming fastener.
[0167] FIG. 64 shows another form of self-forming fastener.
[0168] FIG. 65 shows another form of self-forming fastener.
[0169] FIG. 66 shows another form of self-forming fastener.
[0170] FIG. 67 shows a tool element that can be used to place the
self-forming fasteners shown in FIGS. 65 and 66.
[0171] FIG. 68 shows the FIG. 67 tool element in an assembled
condition.
[0172] FIG. 69 shows a tool that can be used in connection with the
FIG. 62 tool element to place fasteners.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENT OF THE
INVENTION
[0173] The invention is a device and method of fastening an aortic
valve prosthesis or vascular graft, into living tissue,
particularly suitable for minimally invasive surgery. In the
preferred embodiment, the heart valve is separable from its sewing
cuff. The valve body has special grooves in its periphery to allow
the valve to be attached to the sewing cuff after it has been
fastened into the annulus of the patient's aorta. The sewing cuff
is specially constructed to provide a means to open up or unfold it
and then detachably retain it to the fastener tool to allow for
remote attachment of the cuff deep in the aortic lumen. Once the
fasteners have been driven and the cuff is securely attached to the
aortic annulus, the cuff attachment means is released and the
fastener driver tool is removed from the heart. The prosthetic
heart valve is then inserted into the aortic lumen and docked to
the cuff. A special element is provided between the heart valve
body and the cuff to signal to the surgeon when the valve body is
properly seated in the in-situ cuff. An annular extension spring
provides tension to hold the valve in place. It provides a tactile
feedback which indicates to the surgeon that the valve body is
securely attached to the cuff. Once the valve body is properly
seated in the cuff, the cuff is attached to the valve body with
drawstrings or the like. It is noted that while drawstrings are one
means for attaching the cuff to the valve body, many other means,
such as will be known to those skilled in the art based on this
disclosure, can also be used without departing from the scope of
this disclosure. Once tightly secured to the valve body, the cuff
drawstrings are trimmed thereby completing the installation.
[0174] Currently-available valve replacements are hand sewn into
the aorta after surgical removal of the defective valve. A critical
component of the present invention is that the cuff is fastened to
the living tissue with a series of metal fasteners or staples. The
staples are arranged in two rows and are staggered to ensure a
secure fit between the cuff and the tissue. The fastener driving
tool has two stapling mechanisms on two different levels with the
staple driving mechanisms on each level being spaced apart by
105.degree. (see FIG. 11). The staples in each row are set two at a
time, preferably 180.degree. apart in each row, with both rows
being set at the same time. The staple mechanisms in one row is off
set from the staple mechanisms in the other row. After forming the
two sets of opposed fasteners, the attachment tool is rotated. This
automatically indexes to the proper fastener offset to create two
staggered rows of fasteners. The offset between staple mechanisms
in the two rows is preferably a 30.degree. index and will provide
twelve fasteners per row for a 19-21 mm aortic annulus. The
fastener driver tool has means to dilate between standard size
valve bodies. Thus, the same fastener driving tool can be used on
all sizes from 19-23 mm and then the next size up would cover
ranges from 23-27 mm, the next 27-32 mm and so forth. This is an
important advantage because the surgeon will always want to place
the largest body in the cuff. Presently, if a surgeon chooses a 19
mm valve and finds the cuff to be slightly loose in the annulus, it
is a major expense to cut loose the 19 mm valve and try again with
a 21 mm valve. The fastener driver tool of the present invention
may include an indicator that indicates to the surgeon when he is
fastening the cuff what size valve the annulus has been stretched
to, thus eliminating guesswork.
[0175] Referring first to FIG. 1, a prior art prosthetic heart
valve H is shown installed in the annulus of an aorta 1 next to a
left ventricle 2. Valve H is secured in place by a series of
sutures 14 which are tied in knots 13. The sutures are most often
used with felt pledgets 15 to spread the load of the sutures evenly
so as not to tear the tissue. Valve H includes a cuff 3 which is
attached to the perimeter of base 12 of valve H in the factory.
Drawstrings 9 and 10 are used to effect this attachment. The cuff
and valve body are implanted as a single unit with the cuff being
hand sewn to the tissue. Leaflets 11 are also shown as is the
distance between the top plane of the valve and the right coronary
artery junction with the aorta. This distance is indicated in FIG.
1 by numeral 6.
[0176] Shown in FIG. 2 is a prosthetic valve 7 embodying the
present invention installed and seated in the annulus of the left
ventricle. Fasteners 23a and 24b are used to fasten sewing cuff 19
to the annulus of the aorta. The fasteners are staples in the
preferred form of the invention. Drawstrings 27 and 28 are used to
secure the cuff to the body 20 of the valve, and an indicating
means 25, such as a garter spring or the like, is located in the
lower section of the cuff. One form of the indicating means
includes a garter spring inside a pocket in the cuff. Indicating
means 25 is used to signal the surgeon when the heart valve body 20
has been seated properly in the cuff 19 prior to activating the
drawstrings. Contact between means 25 and the valve body provides
the surgeon with a tactile signal that the valve body is properly
seated in the in-situ cuff.
[0177] As can be seen by comparing FIGS. 1 and 2, prosthetic device
7 has no sutures, no pledgets and will be installed as two
parts--the cuff followed by the body; whereas, device H has sutures
14, pledgets 15 and is installed as a single unit. However, as can
also be seen, the cuff in both instances is still securely
connected to the valve body and the cuff can remain a flexible
material, such as Dacron or the like whereby the surgeon will still
be able to use familiar material. As will be discussed below, the
cuff 19 is totally flexible so it can be deformed to fit the aorta
rather than requiring the aorta to be deformed to fit the valve as
is the case with the valve shown in FIG. 1. Still further, the
fully flexible nature of the cuff 19 permits easy deformation of
the cuff and thus significantly reduces stress on the tissue
surrounding the prosthesis. Still further, the fully flexible
nature of cuff 19 permits it to be pressed against the tissue at
all times during the installation process so the chance of
puckering or paravalvular leak paths is significantly reduced, if
not completely eliminated. Using staples in place of the hand-set
sutures of the prior art will, as will be understood from the
present disclosure, permit the installation of valve 7 using a
surgical technique that is minimally invasive.
[0178] Cuff 19 is shown in place in the aorta prior to placement of
the valve body in FIG. 3. Fasteners 23a and 24b are shown in two
rows, with staples in one row being offset from corresponding
staples in the other row. Thus, for example, staple 23a' in the top
row corresponds to staple 24b' in the bottom row. The staggered
nature of the staples in the two rows causes the cuff to be set by
a continuous set of staples if the two rows are viewed together.
That is, there is some portion of a fastener connecting the cuff to
the tissue everywhere in the 360.degree. of the circumference of
the cuff. The two rows of staggered fasteners thus forms a means
for connecting of the cuff to the tissue in a continuous manner
about the entire perimeter of the cuff, and eliminates leak
paths.
[0179] As shown in FIG. 3, the drawstrings 27 and 28 of valve 7
extend out of the cuff for a significant distance. As will be
understood from this disclosure, these drawstrings have extensions
27' and 28' which extend out of the patient's body when the valve
is being implanted. The extensions 27' and 28' are connected to the
drawstrings 27 and 28 in the cuff which are means for fixedly
attaching cuff 19 to body 20, and are actuating means attached to
the drawstrings for operating the drawstrings from outside of the
body after the sewing cuff has been attached to the patient to
secure the cuff to the body 20. The prior art valve has no such
drawstring extensions.
[0180] A zig-zag drawstring 26 is connected to extension 28' to be
activated thereby. Drawstring 26 is sewn from top pouch 28 through
the cuff and up again through the top pouch. When the activating
means is activated, drawstring 28' is pulled and drawstrings 26 and
28 are activated. When drawstring 27 is pulled, drawstring 27 is
activated and is pulled into recesses in the body of the valve. The
recesses are shown in FIG. 2 at 28T and 27B respectively. FIG. 4
illustrates how the cuff will be drawn into the recesses of the
valve body during this cinching procedure. In the FIG. 4 condition,
the top cords have not yet been seated. When the cords are pulled
tight and cinched up the zig zag drawstring will automatically pull
the top cords down into the top recess. Further tightening will
cinch the cords tight into the recesses. After tightening, knots
can be defined in the cords to secure the means 27' and 28'. FIG. 5
shows the prosthesis after it has been set and the cuff attached to
the body.
[0181] The sutureless cuff 19 is shown in FIGS. 6, 7 and 8. This
cuff can be expanded for sizing. As shown in FIG. 6, the cuff is
formed of a single, unitary tubular piece of fabric 18 which is
folded over at location 21 to form an inner layer 19I and an outer
layer 190, with top cord 28 and bottom cord 27 being located at
corners in the fabric. Cord 27 is adjacent to guide means 25. As
shown in FIG. 7, stitching 29 and 31 create drawstring pouches 27P
and 28P. A final suture stitch 30 is shown in FIG. 8 completes the
cuff.
[0182] A tool T for placing the cuff in the patient and for
applying the fasteners to attach the cuff to the patient is shown
in FIGS. 9-16. This tool can be inserted into the patient to
initially place the cuff in position, and to set the fasteners to
attach the cuff. The tool is operated from outside the patient's
body so the overall procedure is minimally invasive.
[0183] Tool T broadly includes an operating handle 35 and a
fastener deployment knob 36 on one end of a body 33 which can be
curved if desired. An operating head 37 is on the other end of body
33. Anchor means 28a" are located adjacent to handle 35 and
releasably attach the activating means 28' to the tool so these
activating means are located outside of a patient's body during the
cuff attaching procedure. As will be understood from the teaching
of this disclosure, once the cuff is attached to the patient and
the valve body is in place, the activating means are released from
the tool and are operated to attach the cuff to the body. For the
sake of clarity, the activating means are shown in FIG. 9 released
from the tool. It is also noted that there will be a sleeve on the
shaft to keep the drawstrings from winding up on the shaft.
Alternatively, the drawstrings can extend through the center of the
shaft or held in a coiled at the bottom of the tool.
[0184] Suture stays 32 (see FIG. 9) are attached to the tool head
37, and the cuff is stretched over the head 37. The temporary
suture stays 32 are drawn over the distal and proximal ends in
order to secure the cuff to the head 37 during placement into the
patient's body. The temporary suture stays 32 are tied to post 34
so that once the fasteners are deployed, the suture stays 32 can be
cut to release the cuff 19 from the head 37 to help the surgeon
with alignment of the body 20. The stays 32 act as a hammock or
safety net to prevent the body 20 from being placed too low in the
cuff which would result in the misalignment of lower drawstring 27
into the lower recess 27B. As deployment knob 36 is turned in a
clockwise direction, each half revolution of the knob delivers two
pairs of fasteners through the cuff. During that rotation, the
latter part of the handle movement indexes head 37 inside the cuff
19 staggering the next pair of fasteners to be delivered.
Drawstring activating means 28' is fed up along the shaft of the
tool T to the holding cleats 28a" and are removed from this cleat,
allowing tool T to be removed from the patient. Activation means
27' is retained coiled at the bottom of the instrument. The means
27' will be played out as the tool is removed from the patient
whereby this means 27' will also be located outside the patient for
activation.
[0185] The tool T has several functions. One function is to insert
the cuff into the patient, another is to position the cuff in the
patient, another is to fasten the cuff to the patient, and yet
another is to hold the cuff securely against the patient's tissue
during the fastening procedure. This last function is performed as
a dilation and spreading procedure as will be understood from the
teaching of this disclosure.
[0186] Referring to FIG. 10, head 37 of tool T is shown as
including a housing 50 which includes two sections, upper housing
52 and lower housing 54 both of which are attached to a hexagonal
shaped drive shaft 56 and which are attached together by fasteners,
such as screws 57. Drive shaft 56 is operatively connected to
operating handle 36 to be rotated thereby. The housing sections are
slidably connected to index rings 58 and 60 respectively and the
cuff is connected to the index rings. As will be explained below,
the housings are rotated during the fastening procedure, but the
index rings remain stationary with respect to the housing so the
cuff will remain stationary with respect to the housing. The index
rings fit into grooves, such as groove 64, to be slidably connected
to the housing sections. Upper housing 52 includes an anchor pin
66.
[0187] Also fixedly attached to the housing is a driver head plate
68 so that plate rotates with the housing. Plate 68 includes a top
surface 70 and a bottom surface 72. Two identical fastener driver
accommodating slots are defined on each surface of the driver head
plate. These slots are identified in FIG. 10 by the reference
numerals 80, 82, 84 and 86 and each extends radially of the plate.
The slots are arranged so that top surface-located slots 80 and 82
are offset from each other by 180.degree., and bottom surface
located slots are offset from each other by 180.degree., with the
top surface-located slots being offset from the bottom surface
located slots by 105.degree.. After each fastener is set, the tool
is rotated by 30.degree. whereby the above-discussed stagger is
established for the fasteners. The indexing of the head is achieved
by movement of the handle 36 which is attached to a visually
indicating means whereby a surgeon can keep track of where the
fasteners are being set.
[0188] A cam means is located inside the housing. The cam means
includes two cam plates, 86 and 88. The cam plates are identical,
therefore, only one will be described. Cam plate 86 includes a top
surface 90 and has a hexagonal hole 92 defined therethrough to
attach the cam plate to drive shaft 56 for rotation therewith. An
anti-retrograde means is included on cam plate 86 for preventing
the cam plate from rotating in an undesired direction. Rotation in
an undesired direction may interfere with the firm placement of the
fasteners. The anti-retrograde means includes cleats 94 which are
engaged by a one-way prong which permits rotation of the cam plate
in one direction only. A second larger set of index lugs 95 can be
provided to give feedback to the surgeon at the end of the fastener
cycle. Index gear teeth 96 are defined on the outer peripheral edge
of the cam plate and are operatively connected to index gear teeth
98 on the index ring 58 in a manner that rotates index ring 58 in a
direction opposite to the direction of housing rotation at the same
rate of rotation whereby the index ring remains stationary with
respect to the patient as the housing rotates. This operation keeps
the cuff, which is attached to the index ring, stationary with
respect to the patient. Gears 96 and 98 are operatively coupled
together by pinion 100 that is mounted at one end thereof on driver
head plate 68 and at the other end thereof to the housing section
52, 54. Pinion 100 has a first gear teeth 102 engaging teeth 96 and
second gear teeth 104 engaging gear teeth 98 for transmitting
rotation of the cam plate to the index ring. Each pinion has a
waist section 105 that is received in a pinion slot 107 defined in
driver plate 68.
[0189] A cam 106 is mounted on surface 108 of cam plate 90 and has
an elastomeric band 110 thereon. The cam 106 is shown in FIGS.
10-12 and rotates with the cam plate. The cam has two lobes, 112
and 114 spaced apart by 180.degree. as well as a groove 116 defined
therein for a purpose that will be understood from the ensuing
disclosure. The cams are rotated with respect to the driver head
plate 68 whereby each cam lobe passes each slot 80 and 82 once each
revolution of the drive shaft 56. As will be understood, each
revolution of drive shaft 56 thus drives two fasteners from the top
surface of driver plate and two fasteners from the bottom of the
driver plate. In this manner, even pressure is placed on the cuff
and tissue during each fastener driving step because the slots are
offset from each other by 180.degree. on each surface of the driver
plate. This keeps the cuff and tissue from puckering due to
unbalanced fastener driving forces.
[0190] Each of the slots 80, 82, 84 and 86 has a fastener driver
mechanism 120 accommodated therein. All of the fastener driver
mechanisms are identical, therefore, only one mechanism 120 will be
described. Mechanism 120 includes an anvil 122 mounted on driver
plate 68 to slide thereon, with movement of the anvil in a
direction that is longitudinal with respect to the anvil being
radial with respect to the driver plate. The anvil includes a pin
124 that is slidably received in groove 116 defined in the cam so
the anvil is moved into and out of the slot as the cam rotates.
This anvil movement is timed so fasteners can be driven without
jamming. A lifter spring 130 is mounted under the driver plate to
remain stationary on that plate whereby the anvil moves with
respect to the lifter spring. A driver 144 is slidably mounted in
the slot and is attached to the cam lobe by ring 110 engaging both
the cam lobe and a rider 111. The driver moves radially of the
driver plate and is held against chordal movement with respect to
that driver plate. Therefore, rotation of the cam plate moves the
driver 144 radially inwardly and radially outwardly with respect to
plate 68. The groove 116 is formed so that driver and anvil
movements are in timed relation to each other. The driver includes
two fastener-engaging tips 140 and 142 which are separated by a
U-shaped opening 144 having an anvil-receiving notch 146 located
therein.
[0191] A stack 148 of fasteners, such as staple 150, is contained
in the housing to feed fasteners between the driver head and the
anvil in a manner that is timed to place a fastener in driving
position prior to the driver head moving radially outward in a
fastener driving movement. Opening 144 is sized and shaped so that
lifter spring 130 moves a driven fastener off of the anvil prior to
the anvil moving arcuately away from the driving location and prior
to a new fastener moving into the driving position between the
driver and the anvil. A stack spring 152 is anchored to the housing
section 52 by projection 66 and maintains force on the fasteners
that is directed to feeding fasteners to a fastener-setting
location after a previous fastener has been driven through the cuff
and into the tissue. The anvil folds the fastener in a manner such
that the sharp points 162 of the fastener drive directly through
the cuff and the tissue rather than tear through the cuff and
tissue. The anvil then folds the fastener after that fastener has
pierced the cuff and the tissue to establish the closed fastener.
Each stack spring also has an anti-retrograde spring 166 thereon.
Spring 166 engages cleats 94 on the cam to prevent the cam from
moving in an undesired retrograde direction. Fasteners are retained
into the housing via recesses or doors, such as pocket 170. Each
stack spring 152 also has two wings 167 that engage slots 168
defined in the driver plate to maintain the stack spring in the
proper orientation and position to feed the fasteners, yet which
will permit the stack spring to be removed via the door 170 to load
fasteners. However, the preferred form of the tool is
disposable.
[0192] As above discussed, it is a significant advantage of the
tool T that the cuff is maintained in constant contact with the
tissue during the fastener setting procedure. This advantage is
realized by means of cuff dilation means, such as spring 172,
mounted on the driver plate and extending radially outward from the
outer peripheral edge of that driver plate. The springs curve
gently outward and inward in a U shape to gently engage the cuff
from the inside of that cuff and gently urge it against the tissue.
The springs are mounted on the driver plate by spring-receiving
slots, such as slot 174, defined in the outer peripheral edge of
the driver plate so the spring is maintained on the plate and in
the desired orientation.
[0193] For purposes of clarity, four positions of the fastener
driver mechanism are shown in FIGS. 11, 12, 13 and 14. Beginning a
cycle, a fastener has been driven through the cuff and the adjacent
tissue, and is formed in FIG. 11 when the driver forces the
fastener against the anvil. As the drive shaft is further rotated,
the cam lobe moves from the FIG. 11 position to a retracted
position shown in FIG. 12, with the anvil being pulled back after
the set fastener has been pushed off that anvil by the lifter
spring 130. Continued rotation of the drive shaft rotates the cam
lobe into a loading position shown in FIG. 13 during which time, a
new fastener is fed between the anvil and the driver. Further
rotation of the drive shaft rotates the cam into an advance
position shown in FIG. 14 which forces the driver against the
fastener and the fastener through the cuff and the tissue.
[0194] Once all of the fasteners have been set, sutures 32 are
unfastened from the cleat 34 on the body 33, cut and loosened to
permit the tool to be removed from the patient. Then means 28' is
removed from the cleat on the tool. Then, tool 85 is removed from
the patient which plays out activating means 27' to the outside of
the patient. A prosthetic valve body 20 is then inserted into the
patient using a tool T' shown in FIG. 20, and is placed in position
adjacent to the cuff. The valve body is moved until the surgeon is
notified by the indicating means that the body is in the desired
orientation. The activating means 27' and 28' are then activated to
pull the cuff over and against the body by the above-discussed
action of the drawstrings. Once the drawstrings are operated and
the cuff is held tightly against the body 20, the activating means
can be severed and removed from the patient. The prosthetic valve
is now in place. Any tools can be removed from the patient and
closure can be effected. As above discussed, the fasteners will be
continuous over the entire perimeter of the cuff thereby further
ensuring that no leak paths will develop. The continuous nature of
the fastener coverage is best understood by visualizing a unit
vector UV as shown in FIGS. 3 and 4, which is centered at the
center of the cuff and being two rows thick, that is having a
thickness indicated in FIGS. 3 and 4 by dimension t.sub.v. As this
unit vector moves through 360.degree., it will never be out of
contact with a fastener whereby the entire circumference of the
cuff is fastened to the tissue. The horizontal orientation of the
fasteners further contributes to this feature.
[0195] As shown in FIG. 20, tool 85 includes a handle 162 and a
pair of legs 164 which are spread apart by screwing handle 162 into
the bottom of a holding fixture 164, forcing tapered edge 166 into
the legs. The valve may then be inserted down into the cuff 19
until the garter spring 25 in the cuff is felt to detent into the
lower recess 27B indicating proper seating of the valve body in the
cuff.
[0196] An alternative form of the tool is shown in FIGS. 16-18 and
maintains contact between the tool and the cuff whereby the cuff
can be inverted after the valve body has been moved into position.
The valve body is attached to the tool and to the cuff during
fastening of the cuff to the tissue. After completion of the
fastening step, the valve is pulled up thereby inverting the lower
section of the cuff. The drawstrings are then cinched as above
described.
[0197] As above discussed, the central shaft experiences a
counter-rotation as the driving head is indexed so the cuff is held
stationary with respect to the patient's tissue while the fastener
head is being indexed to the various positions. A further
alternative form of the tool is shown in FIGS. 28 and 30 at T' and
keeps the handle and the shaft stationary while the fastener
delivery system rotates. A rotating fastener assembly 300 is shown
in FIG. 29. Tool T' includes mechanisms necessary to deliver the
fasteners and which are located inside the central shaft. A lever
400 actuates the mechanisms from within the housing. A central bore
402 is defined in the housing of the tool and has a central
retaining stalk 404 therein on which the distal end 406 of the
sewing cuff 19 is located. The heart valve base can also be
attached to the stalk end 406 if the base is attached to the cuff
19 prior to setting the fasteners. The cuff is temporarily attached
to the outer housing 408 and the stalk 404 which remain stationary
during the fastening procedure and the fasteners are delivered in a
coaxial method from between two stationary parts. Within the
central fastener delivery assembly 300 are components similar to
the above-described cam mechanisms needed to drive staples through
the cuff and form them in the annular tissue from within. As above
described, driver mechanisms 301 are diametrically opposed and
offset with respect to each other to create the appropriate
overlapping staple spacing discussed above. Staggering allows two
distinct rows of staples to be formed as above discussed whereby
total coverage of the cuff is effected. Toggle links 303 are used
and are connected to longitudinal drive rods 305. Drive rods 305
translate handle-generated forces into fastener delivery forces at
the toggle links 303. Each toggle link 303 is connected to a staple
driver 307. The fastener assembly 300 is rotated a plurality of
times to form the two rows of staples. Flexible shafts (not shown)
can also be used to permit the driving angle of the fasteners to be
altered as necessary. Flexible shafts can also be used to permit
the tool to operate to drive fasteners from the superior to
inferior side of a suture cuff which might be pre-attached to the
valve body. Such a cuff could be temporarily tied to the stationary
housing. Upon insertion of the valve, cuff and instrument would be
inserted into the annulus. Each fastener would form from the
superior side of the cuff penetrating the cuff and annular tissue
below. Again, as above discussed, one or more complete rows of
fasteners would be formed holding the cuff to the annular
tissue.
[0198] A balloon B (see FIG. 24) is used as a means for anchoring
and positioning. Balloon B can either be attached to the fastener
driving device or be separate. The balloon can be inflated using a
hand pump HB. The balloon is pulled up snugly under the annular
tissue and the device is brought down to it. Then, the tool can be
drawn up close to the balloon trapping the annular tissue and
aligning the tool for forming fasteners.
[0199] A second method (see/FIG. 25) uses levers 450 and links 452
to deploy small flanges 454, around the lower periphery of the
lower housing 54. By actuating a central rod 456, the connecting
links pivot the flanges outwardly providing a lip in which the
surgeon can draw the tool upward locating the staples in the proper
location in relation to the annular tissue.
[0200] A third method (see FIG. 26) uses a clear cylindrical sizing
tool 460 which uses a lip 462 or flange that sits on top of the
annular tissue 464. It also has a special tissue marker mounted on
a central shaft 466. The surgeon will visualize the contact of the
annular tissue from above. The contact with the surface will create
a wetted dark circle when properly seated on the annulus. At that
point, the surgeon rotates the central shaft 466 which creates a
line 468 inside the aorta. This line would have a distance D (FIG.
26) that would correspond to a pointer or landmark to be used to
line up the device in the correct position.
[0201] Still another way (see FIG. 27) to gauge the placement of
the device is to drive sutures 470 below the annulus to create a
safety net 472 that will not allow the device to plunge too deeply
into the left ventricle 2. The device is then inserted until the
resistance of the suture net is felt by the surgeon. Once the cuff
is fastened into the annulus, the sutures can be cut and removed
from the annulus.
[0202] In the interest of completeness, an open thoracotomy
surgical technique for aortic valve replacement will now be
discussed (see FIGS. 19A and 19B). A surgical incision 200 is made
in one of several locations: a midline sternotomy incision; or a
small anterior right or left thoracotomy; or a mini-thoracotomy
(with or without rib removal); or a posterior thoracotomy; or a
suprasternal or supraclavicular approach; or through port sites
(mini incisions) over the chest wall. The pericardium is then
opened. The patient is then placed on cardiopulmonary bypass using:
right atrial cannulation; or femoral vein-femoral artery; or
femoral artery-left atrium; or aortic-left atrial cannulation. The
aorta is dissected for access and clamping. The aorta is then
crossclamped and cardioplegia is delivered through: the aorta,
coronary ostial cannulation or retrograde through the coronary
sinus to arrest the heart. A venting device is then inserted.
[0203] The aortomy is then performed. The aortic valve is excised
and the annulus, aorta and/or the anterior leaflet of the mitral
valve, and septum are debrided as necessary and appropriate. A
device or devices that determine the relative size of the annulus
and that identify the position of the staples and stapling device,
is inserted into the annulus. When appropriate, sizing and
positioning are determined, a biologic marker is circumferentially
traced over the top (most superior) edge of the position/sizing
device, to guide the proper placement of the stapling device. A
balloon or levers can also be used.
[0204] The position/sizing device is then removed and the stapling
device is inserted and positioned in the annulus with the cuff of
the valve. The stapling device is positioned with the cuff lying in
the annulus and the position confirmed by its proximity to the
circle previously marked. The stapling device is enabled to dilate
the annulus with the valve cuff in situ.
[0205] The stapling device is then actuated. The appropriate size
of mechanical valve skeleton is then inserted into the cuff. The
valve and the perivalvular area are tested for proper size and the
device is removed. Once the proper size is established, the
skeleton is removed and the valve base is inserted. The drawstrings
of the cuff are then tightened and tied securely to trap the
mechanical valve to the cuff. This assures that the largest
desirable valve base will be used. The aortomy is closed with
traditional sutures or with vascular staples. The heart is de-aired
and the crossclamp removed. The patient is then removed from
cardiopulmonary bypass and the wounds are closed.
[0206] An alternative technique with the valve pre-attached
includes the following steps. All methods up to and including
placement of the biologic marker circumferentially over the top
edge of the position/sizing device are repeated. Then, the
position/sizing device is removed. The stapling device already
pre-attached to a mechanical or tissue valve of appropriate size is
lowered into the annulus. The stapling device and the cuff of the
valve are positioned in the appropriate place in the annulus using
the biological marker circle previously marked on the aortic wall
for verification. The cuff-valve border at this time would be found
in a slight subannular position.
[0207] The stapling device is then actuated. The drawstrings in the
cuff of the valve are drawn and tied securely to bring the valve in
proximity to the annulus. The remainder of the steps are the same
as above described.
[0208] Yet a third technique for aortic valve replacement is
through the left atrium. This technique includes the following
steps: surgical incisions are made in the manner discussed above;
the pericardium is opened; the patient may or may not then be
placed on cardiopulmonary bypass. The technique then includes the
use of imaging devices (both intra and extra-vascular) being used
to guide the conduct of the operation. Purse string sutures
(access) are then placed on the left atrium and aorta. Flexible
imaging devices and instrumentation is then inserted through the
left atrium (and aorta). The devices are lead through the mitral
valve and into the left ventricle. The aortic valve is then imaged
both through the aorta and left ventricle and is excised.
[0209] The valve stapling device is then inserted through the left
atrium and positioned in the aortic annulus. The stapling device is
then activated and positioning assessed both through the left
ventricle and aorta using the imaging devices. The stapling device
is then removed, and all cannulation sites secured. The heart is
then deaired and taken off cardiopulmonary bypass if appropriate.
The wounds are then closed.
[0210] A minimally invasive surgical procedure is illustrated in
FIGS. 19A and 19B. A torso with an overlapping rib cage is shown.
Access to the aorta is gained through an incision 200 in the
superstenal notch passing below the manubrium or via a
mini-thoracotomy is performed in the area of the first and second
ribs enabling visualization of the aorta. A small incision 202
across the aorta above the annulus is made. The fastener driving
tool T with a cuff attached is inserted through the incision after
the faulty valve has been excised. The knob 36 is rotated while
holding the handle 35 to deploy the fasteners through the cuff 19
and into the aortic annulus. Once the fasteners have been driven
into the aortic annulus, the stay sutures 32 are removed from cleat
34 allowing the head of the instrument to be removed from the
patient's body. Activating means 27' and 28' are also removed from
the cleats 27a" and 28a". The heart valve body is then placed into
a holding fixture, such as the above-discussed fixture, and
inserted into the aortic annulus in the same manner as the tool T.
The valve body is then docked into the sewing cuff 19. The
indicating means provides tactile feedback for the surgeon to
determine when the heart valve body 20 is properly seated.
Temporary stays 32 prevent the heart valve base from descending too
far and aligning the drawstrings with the recesses in the valve
body. Once the lower drawstring has been cinched up, the upper
drawstring is pulled tight. The zig-zag drawstring 26 will then
pull the cords into the top recess 28T.
[0211] As shown in FIGS. 21-23, the system can be used to repair an
abdominal aortic aneurysm (AAA) which may occur because of a
thinning of the aortic wall 250. The wall balloons out under
positive pressure and forms a pouch 252. These aneurysms present
life-threatening consequences for the patient should they rupture.
If detected prior to rupture, a graft 254 can be placed on the
aorta, in an abdominal graft procedure to provide support to the
weakened area of the wall. The graft is usually made from a tube of
Dacron fabric and is most often sutured in place.
[0212] However, using the teaching of the present invention, the
graft can be stapled in place. As shown in FIGS. 21 and 22, the
dilating fastener deployment feature of the present invention
permits fasteners to be formed from the inside toward the outside
of the aortic wall. As shown in FIG. 21, the fastener deployment
device has two driving heads 260 to deliver fasteners through the
graft on either side of the aneurysm 252. At each end of the graft
in FIG. 22 there is a metal ring 266, analogous to the garter
spring discussed above. These rings help to keep the graft open
once it is fastened to the aortic wall. FIG. 23 illustrates access
to the aorta gained through entry in the femoral artery in the
pelvic region. The fastener deployment device, with graft attached,
would be inserted into the femoral artery and fed up to the area of
the aneurysm. The distal head 260 is positioned beyond the aneurysm
and the proximal head 260 is positioned to center the aneurysm
underneath the graft. Fasteners are formed in a manner similar to
that discussed above, completing the installation of the graft.
Stay sutures may be used to hold the graft in place during
fastening.
[0213] During the installation of the fastener driving device, it
will be important to obtain the correct anatomical positioning of
the cuff to be fastened to the annular tissue. FIGS. 24-27 depict
four different ways to accomplish this task. FIG. 24 shows the use
of an inflatable balloon B in the left ventricle 2.
[0214] As discussed above, there are times when a surgeon wishes to
use an articulated or curved shaft to accommodate anatomical
positioning of the instrument. As also discussed above, a curved
shaft may be particularly advantageous in minimally invasive
surgery where access to the proper fastening plane may be difficult
or impossible with an instrument having a straight shaft. In such a
case, instrument 600 shown in FIGS. 31, 36 and 37 is used to drive
fasteners or staples radially outwardly. The advantage of the
radial design is that it simplifies the delivery of longitudinal
forces through the shaft of the instrument.
[0215] Referring to FIG. 31, it is seen that instrument 600
includes proximal end 602 that will be located outside the patient
and which will be operated by the surgeon. Instrument 600 also
includes a distal end 604 which will be located inside the patient
and to which the cuff 19 will be attached and to which the heart
valve 20 will be attached. A housing 608 can be articulated or
flexible so the overall instrument can be bent as needed. Proximal
end 602 contains an index mechanism 610 and a hand wheel 612.
[0216] As can be seen in FIGS. 31 and 41, a pre-fire rod 614
includes a handle 616 and a body 618 which is accommodated in a
bore 622 defined through hand wheel 612 and through housing 608 to
have its distal end 620 located near distal end 604 of the housing
for a purpose that will be understood from the ensuing discussion.
As will be understood, there are aligned bores in instrument 600 so
pre-fire rod 614 will extend through instrument 600 from proximal
end 602 thereof to distal end 604 thereof.
[0217] Index mechanism 610 includes a bracket 624 which is held
stationary with respect to the patient during an operation. Bracket
624 is U-shaped and has two legs 626 which are connected together
by a central leg 628. An index alignment plate 630 is attached to
the distal ends of the legs 626 and includes a plurality of
angularly spaced apart index alignment holes, such as hole 632.
Housing 608 is attached to surface 634 of the index alignment plate
630. Holes 632 are spaced apart a predetermined angular spacing as
determined by the needs of a surgeon as will be understood by one
skilled in the art based on the teaching of this disclosure.
[0218] Two index pins, such as pin 638, are mounted on a lower
surface 640 of a wedge cam driver plate 642 which has an upper
surface 644. Plate 642 is rotatable with respect to plate 630
whereby index pins 638 can be moved from one index hole 632 to
another index hole. Two wedge cams 646 and 648 are each attached at
one end thereof to the driver plate 642 to rotate therewith and
each has a wedge shaped distal end 650 and 652 respectively. Each
distal end 650 and 652 has a terminal end, such as end 654 of end
648 and a surface, such as surface 656 of end 648, that slopes
outwardly from end 654 along the longitudinal direction toward
proximal end 602. As driver plate 642 is moved in longitudinal
directions 660 and 662, ends 648 and 650 are moved in corresponding
directions. The purpose of this movement will be understood from
the ensuing discussion. Each of the wedge cams includes an inner
edge 664 and 666 that is spaced apart from the corresponding inner
edge of the other wedge cam so that a gap 668 is defined
therebetween. Pre-fire rod 614 is accommodated in gap 668 so that
distal end 620 of the pre-fire rod is located adjacent to ends 654
of the wedge cam bodies.
[0219] The pre-fire rod is forced in directions 660 and 662 by
moving handle 616 in the desired direction. Wedge cams 646 and 648
are also moved in directions 660 and 662 by movement of driver
plate 642. Driver plate 642 is moved by turning hand wheel 622 in
directions 670 and 672. A threaded shaft 674 is attached to hand
wheel 612 to be rotated thereby and includes a distal end connected
to driver plate 642. Shaft 674 is threadably accommodated in leg
628 of the bracket 624 to move in directions 660 and 662 in
response to the rotational movement of the hand wheel 612 in
directions 670 and 672. Shaft 674 is coupled to driver plate 642 to
move that plate in directions 660 and 662 but to rotate relative to
the plate so the plate does not rotate with the hand wheel. A
suitable de-coupling joint is used to effect the connection between
shaft 674 and plate 642.
[0220] Operation of the fastening tool described thus far is
understood from FIG. 41. Thus, the wedge cam sloping surfaces 652
are oriented by disengaging index pins 638 from alignment holes
632, rotating driver plate 642 until the index pins are aligned
with the selected holes, and then operating hand wheel 612 to move
in direction 660 until the index pins are suitably seated in the
selected index holes. Pre-fire rod 614 is then forced through the
longitudinal bore until distal end 620 thereof is suitably
positioned. Further operation of either the pre-fire rod or the
hand wheel will operate the fastener mechanism as will be described
below.
[0221] As discussed above, the staple mechanism includes a
plurality of staple assemblies 680 that are angularly spaced apart
as shown in FIG. 36. The staple assemblies are also located in two
rows that are spaced apart longitudinally of the instrument as
indicated by rows R1 and R2. The assemblies are also offset so
staples in row R1 are staggered with respect to staples in row
R2.
[0222] The assemblies are all identical therefore only one assembly
will be described. As shown in FIG. 32, assembly 680 includes an
anvil frame 682 having a base section 684 having sides 686 and 687
each having an inner surface 688 and 689 to define a cavity CA
therebetween. A center anvil 690 is located centrally between the
sides and extends upwardly above base surface 692. A lifter spring
694 is H-shaped and includes a U-shaped front end 696 with two legs
698 and 700 extending therefrom. Spring tabs 702 are located on the
other end of each leg. The lifter spring is curved so front end 696
curves upwardly from base surface 692 when the lifter spring is
seated thereon. Spring tabs 702 engage the anvil frame to hold the
spring in place in the cavity CA. End 696 will be located adjacent
to center anvil 690.
[0223] A driver 704 is wedge shaped and is received in cavity CA.
Driver 704 includes a front edge 706 having two surfaces 708 and
710 thereon with a driver stop 712 on an undersurface thereof. The
legs 708 and 710 will be located adjacent to center anvil 690 when
the driver completes a fastener driving step as will be understood
from the following discussion. An engaging element 714 extends
rearwardly from the driver 704 and includes a hook 716 for engaging
a corresponding groove 717 (see FIG. 33) defined in each of the
wedge cams.
[0224] A W-shaped staple 720 is received in cavity CA and includes
two legs 722 and 724, each having a sharp tip, such as tip 726 that
is forced through the patient's tissue and through the cuff. The
staple further includes a doubly curved center section 730 having a
first curve 732 and 734 connecting each leg to the center section
and a central curve 736. The central curve 730 is located to be
engaged by center anvil 690 when the staple is forced in direction
732 by driver 704 engaging curves 732 and 734. Legs 722 and 724
slidably engage surfaces 688 and 689 to be held straight during the
movement in direction 732 until the legs leave the anvil frame.
Legs 722 and 724 are parallel and pierce the article being stapled
before they are folded over through contact of the section 736 with
center anvil 690.
[0225] As can be understood from the foregoing, as staple 720 is
forced in direction 732, legs 722 and 724 move in direction 732 in
sliding engagement with surfaces 688 and 689. After staple center
section 736 engages center anvil 690, further movement in direction
732 causes the legs 722 and 724 to fold towards each other until
they overlap each other. This is a two step movement of the staple:
a first linear movement of the legs; and then a folding over of the
legs. The first linear movement causes the legs to push through the
tissue and the material of the cuff in a linear direction before
the legs are folded over. Thus, the staple can take a significant
bite our of the material an the tissue before folding. This is
helpful if the tissue is hard or is covered with calcium.
[0226] The staple disclosed herein is narrow in its preform width
and can resist gathering of the cuff and tissue during the forming
process. Staple designs such as box staples gather and bunch
material between the legs of the staples as they are formed.
Bunching is inconsistent with the needs of this device. If a staple
bunches, far too much material in the cuff is used (gathered) and
by the time the staple pattern comes around to making a full
circumferential line, the fabric is too tight and can pull away
from the aorta wall.
[0227] Return movement of the assembly is indicated in FIG. 32 by
arrow 732', and is caused by hook 716 being engaged in groove 717.
The groove is sloped so that as the wedge cam is moved in direction
660, the driver is moved in direction 732, and as the wedge cam is
moved in direction 662, the driver is moved in direction 732'.
[0228] An alternative form of the assembly is shown in FIG. 35 as
assembly 680'. Assembly 680' is similar to assembly 680 except
driver 704' includes a rear projection 734 and two forward
projections 708' and 710' which engage curves 732 and 734 of the
staple to drive the staple as described above. Assembly 680'
includes a U-shaped lifter spring 702' which has two legs 698' and
700' with tabs 702' for engaging recesses 703 to hold the spring in
the anvil frame. Assembly 680' is moved in direction 732 in the
same manner as assembly 680, but includes a post 740 on top of a
frame plate 742 that is fixed to the anvil frame. A garter spring
744 (see also FIG. 36) or the like is wrapped around the posts of
the assemblies 680 to return them in direction 732'. Operation of
assembly 680' is similar to the above-described operation of
assembly 680.
[0229] Operation of the staple is illustrated in FIGS. 34a-34e for
assembly 680 and in FIGS. 34a'-34e' for assembly 680. Thus, FIG.
34a shows a staple in a nested position, FIG. 34b shows the first
step in which the legs of the staple are pushed linearly out of the
anvil frame to advance the staple, FIG. 34C shows the crown or
central curve engaging the center anvil to initiate the folding of
the legs, FIG. 34D shows the legs being folded over and FIG. 34E
shows the staple in its final form.
[0230] Operation of the instrument can be understood from FIGS. 36,
37, 38, 39a-39d, and 40A-40C. As shown, a wedge cam body 750 is
slidably received in housing 608 and has wedge cams 646 and 648
thereon. The wedge cams are inserted into a wedge cam alignment
block 752 via slots, such as slot 754. The wedge cam alignment
block 752 is fixed to a head 756 by fasteners, such as threaded
bolt 758. Head 756 contains all of the above-described assemblies
680 or 680' in staggered rows R1 and R2.
[0231] Wedge cam driver plate 642 is moved in direction 662 to
release index pins 638 from index alignment holes 632 which moves
the wedge cams out of the slots 754. The driver plate 642 is then
rotated in direction 670 or direction 672 to align index pins 638
with new index alignment holes and thus align the wedge cams with
new slots.
[0232] Hand wheel 612 is then rotated to drive plate 642 in
direction 660 to set the wedge cams in the slots near the rear ends
of the staple drivers. Pre-fire rod 614 is then driven down in
direction 660 to move anvil frames radially outward into a pre-fire
position, such as shown for staple 720' in FIG. 36 which drives the
staple through the cuff material and through the tissue. A frame
stop 760 is located on the bottom of each anvil frame and engages a
corresponding shoulder in the instrument to stop movement of the
anvil frame in direction 732 when the pre-fire rod moves past the
anvil frame. Hand wheel 612 is then operated to drive the wedge
cams in direction 660 which drives the staples in direction 732.
This drives the staple through the cuff and through the tissue and
folds the staple legs over as above discussed. The lifter spring
then moves the folded staple over the center anvil 690 to release
the staple from the assembly. A plurality of staples are stored in
the instrument so another staple is ready for deployment as soon as
the operation is complete.
[0233] The hand wheel is then rotated in the opposite direction,
the pre-fire rod moved in the opposite direction, and the staple
assembly is moved back into its rest position.
[0234] Operation of the instrument is shown in FIGS. 39a-39d and
40A-40C. The results of the operation are indicated in FIG. 42 with
three rows of staples being shown in a cuff 19. Once the staples
are deployed, the heart valve can be moved onto the stapled cuff,
and attached thereto as above discussed. This is illustrated in
FIGS. 43-45. As shown in FIG. 38, the staples extend through the
cuff and into the tissue before they are folded over. Thus, as
shown for staple 720a the staple legs extend deep into the tissue
to get full depth bite of tissue before folding, and the cuff is
stretched over the tissue as shown for tissue AT.
[0235] As above discussed, there are times when a surgeon wishes to
apply one staple at a time so better control over the number and
placement of the staples can be exercised. This can be achieve
using instrument 800 shown in FIGS. 46 and 47.
[0236] Instrument 800 fires one staple at a time and can be
positioned as desired prior to firing the staple. As will be
discussed below, using instrument 800, a surgeon can establish any
desired stapling pattern, either one preset on the cuff or one that
the surgeon makes up on the fly. It is noted that the operation of
the staple and the staple forming assembly of instrument 800 is
basically identical to the staple and staple forming assembly
discussed above. Therefore, only the differences between instrument
800 and the above-described assembly will be discussed.
[0237] Instrument 800 includes a hand-grip section 802 on the
proximal end thereof, and a staple forming and deploying assembly
804 on the distal end thereof with a shaft housing 806 connecting
the two ends. Hand-grip section 802 includes a handle 808 on which
a forming trigger 810 is pivotally mounted for movement in
directions 811 and 811', with return spring 812 biasing the trigger
in return direction 811'. A drive bar 814 is connected at a
proximal end thereof to trigger 810 to be moved in directions 811
and 811' with the trigger. Drive bar 814 is located inside housing
806 and has a staple driver 704" on the distal end thereof. Staple
driver 704" is part of a staple driving and forming assembly 680"
which drives staple 720 toward center anvil 690" to move the legs
of the staple outwardly and through the cuff and the tissue and
then to fold the legs over as above discussed. A lifter spring 694"
ejects the staple after it has been formed. A plurality of staples
are stored in a housing 816 on the distal end of the shaft, and a
spring biased magazine guide 818 urges the staples under a transfer
spring 820 mounted on shroud 822 which biases the staples into
position to be moved by the driver 704" upon actuation of forming
trigger 810. Operation of the staple forming assembly will not be
discussed as it was discussed above with reference to FIGS.
34a-34e'.
[0238] As shown in FIG. 47, distal end 804 is angled so a staple
exits that end at an angle .THETA. to the longitudinal centerline
of the instrument. In the preferred embodiment, angle .THETA. is an
acute angle. A flexible section 824 between drive bar 814 and
driver 704" permits the drive bar to move linearly while forcing
the staple at an angle to that movement. The purpose of this angled
discharge is to permit the surgeon to accurately locate the staple
being driven in the exact position he desires. As will also be
understood from the following discussion, this angled discharge
permits the instrument 800 to be used in conjunction with a
plurality of different systems.
[0239] As just mentioned, a surgeon may want to locate each staple
individually. He may use a guide or he may simply locate on the
fly. One form of stapling guide system is shown in FIG. 48. Using
this system, a cuff is first attached to the patient's tissue using
the just discussed staple driving tool, instrument 800, in
conjunction with a guide and support assembly 830. In the interest
of clarity, a cuff that is installed on the patient separate from
the heart valve will be referred to as an anchor ring. Once the
anchor ring is installed on the patient, the heart valve is drawn
to it in the manner discussed above, such as shown in FIGS. 43-45,
for example. As shown in FIG. 48, an anchor ring 19' is releasably
fixed to flexible fingers 832 of a cage, with the top of each
finger being fixed to an index ring 834 and biasing outwardly from
that ring. The anchor ring 19' is positioned on the lower ends of
the fingers and is biased radially outwardly. The index ring 834
has lugs 836 that are fixed to a stationary stabilizer whereby the
guide 830 is held stationary during the operation. The outward flex
of fingers 832 force the ring 19' against the patient's tissue
thereby ensuring a snug fit between the anchor ring and the
patient's tissue, and can accommodate various sizes of aortas.
[0240] As can be seen in FIG. 48, anchor ring 19' includes a
plurality of stapling icons, such as icon 838 to guide a surgeon in
placing the staples. Using icons 838, a stapling pattern shown in
FIG. 49 will be established in ring 19' with staggered rows R1, R2
and R3 of staples. To assist the surgeon in following the icons,
index ring 834 includes a plurality of grooves, such as groove 840
which receive the instrument 800 and serve to position it with
respect to an icon. If a surgeon wishes, he can staple in any
pattern he wishes. This option is illustrated in FIGS. 50A and 50B
which show a scalloped staple pattern that generally follows the
natural cusp shaped curves of a valve annulus could be selected if
desired. Other patterns could also be selected as will occur to
those skilled in the art based on the teaching of this
disclosure.
[0241] As above described, the legs of each staple are first
extended to pierce the cuff and the tissue to approximate the cuff
or anchor ring on the tissue, then the staple is formed. The
instrument is removed from the vicinity of a formed staple and is
moved to the next groove. Once the anchor ring is stapled to the
patient, the cage 830 is removed and the heart valve is located to
be attached to the anchor ring as above described.
[0242] A more automated system for placing an anchor ring on a
patient is illustrated in FIGS. 51-53. This system uses the above
described instrument 849 and includes one system for locating the
anchor ring and a second system for automatically indexing the
location of the staple placement. Both system are shown in FIGS. 51
and 52.
[0243] The anchor ring is placed in the patient by first system 850
which includes two arcuate expander shoes 852 each pivotally
connected at pivot 853 to an expander arm 854 at an arcuate section
856 of that arm located near the distal end of the arm. A pivot 857
is located on the distal end of each expander arm, and the proximal
end of each arm is located outside the patient during use. The
surgeon grasps each of the expander arms near the proximal ends 858
thereof and manipulates these arms to expand the anchor ring
against the patient's tissue. An O-ring 860 exerts a radially
inward bias that opposes outward movement of the expander shoes.
Cuff liners, such as cuff liner 860 are interposed between the
expander shoes and the O-ring and contact the anchor ring. Cuff
liners 862 serve as an outer circumferential edge of the system
849.
[0244] System 849 further includes a top guide element 864. Element
864 includes a central section 866 and two wing sections 868.
Central section 866 accommodates the top end of guide tube 870
through which instrument 800 fits to be guided into stapling
position within the patient. A key hole slot 871 can engage a key
872 (see FIG. 46) on housing 806 of instrument 800 to further
control placement of the instrument. As can be seen in FIG. 52, the
bottom end of guide tube 870 is positioned adjacent to the cuff
liners and is angled with respect to the plane established by the
expander arms. The angled nature of the staple discharge section
discussed above thus places the staples in the proper position for
discharge through the anchor ring and through the patient's tissue
to attach the anchor ring to the tissue. Each element 864 further
includes a plurality of ratchet teeth 870 that engage the expander
arms to hold them in a selected location and orientation.
[0245] The tool shown in FIG. 46 has only one set of drivers and
thus the mechanical complexity is low enough to make manufacturing
efficient. Additionally, since manufacturing small parts is
difficult, and small parts do not handle stresses well, the
reduction in parts for the FIG. 46 tool is advantageous. Use of the
system shown in FIG. 46 is evident from the disclosure herein, and
thus will only be briefly discussed. Once the diseased valve is
removed and the tissue is decalcified, the valve base alignment
ring is placed down into the aorta and is held in place with the
stabilizing arms. Next, the surgeon looks down through the aorta at
the cuff and uses the serrations on the inside of the ring to guide
the staple driving tool toward the cuff. He then extends the legs
of the staple beyond the distal end of the driving instrument and
places the staple according to the icons on the cuff. He then
pushes the staple legs through the cuff to penetrate the aortic
tissue thereby approximating the cuff to the tissue. Subsequently,
he forms the staple with the staple forming device and then removes
the device. The device is then moved to the next serration, thereby
stabilizing the top edge of the staple driving shaft and then
places the protruding staple legs into the next printed icon. The
process is continued until either a helical or circular staple
pattern is established. The process is completed when at least two
overlapping rows of staples are formed in the cuff.
[0246] Once the anchor ring is securely stapled in place, the cuff
is released from its attachment to the expander by cutting sutures
and the tool is removed. Docking sutures which were pulled up out
of the body cavity during the staple forming procedure are then
sewn into the heart valve cuff and the valve is lowered into place
either within the circumference of the anchor ring or superiorly
depending on the configuration of the heart valve prosthesis. If
the surgeon wants to adjust the superior/inferior placement he may
do this by altering the placement of the docking sutures in the
heart valve cuff.
[0247] The second element of the instrument 849 automatically
indexes the location of the staple delivery. The second element
includes a base 872 that is located within the cuff liner and
includes a central internally threaded hole 874 and two pivot
connections 876 to which pivots 857 of the expander arms are
connected. The thread in hole 874 is helical for a purpose that
will be discussed below. An idler plate 878 is mounted on base 872
by pivot pin 880 being inserted into hole 882 defined in base 872.
An idler 884 is rotationally mounted on idler plate 878 and is
engaged by index gear 886 that is also rotationally mounted on
idler plate 878. An idler plate spring 888 is mounted at one end
thereof on base 872 and at the other end thereof to idler plate 878
and is held in place on base 872 by spring 889 mounted on base 872.
Index gear 886 is connected to a distal end of index drive shaft
890, with the proximal end of shaft 890 being attached to an index
wheel 892. Index wheel 892 is rotationally mounted to element 864
at a central location 894 having index indicators 896 thereon.
Index drive shaft 890 is rotated by rotation of index wheel 892,
with index indicators providing a visual indication of the amount
of rotation undergone by the index drive shaft. As shown, rotation
of index gear 856 in direction 897 causes corresponding rotation of
idler 884 in direction 897'. Idler 884 is engaged with flexible
gear rack 900 which is held in place on the cuff liners to engage
the idler 884 to be moved in direction 897" upon rotation of the
idler in direction 897'. Flexible gear rack 900 is fixed to base
872. Since alignment tube 870 is fixed to base 872, tube 870 will
rotate with the base.
[0248] As shown in FIG. 53, heart valve HV is attached to cuff 19
and to heart valve base holder 902. Base holder 902 includes arms
904 radiating outwardly from central section 906 on which an
externally threaded projection 908 is mounted. Thread groove 910 is
helical and matingly engages thread 912 defined on base 876
adjacent to hole 874. A retainer spring 914 ensures proper
engagement between threads 910 and 912. Valve base holder 902 is
released from the heart valve by operating release lever 916
connected to release shaft 918 to lift the shaft 918 upwardly.
Lifting release shaft 918 causes fingers 904 to rotate inwardly to
release the anchor ring from the holder 902. The anchor ring is
firmly secured to the patient when the release lever is operated
and the inwardly rotated arms are flexible enough to move past the
fixed anchor ring.
[0249] It is noted that the anchor ring is fixed to the patient by
the outward flexing of the arms 904, and an initial staple can be
placed to further fix the anchor ring to the patient to begin the
process. Thus, any item fixed to the anchor ring is fixed, and any
other element will move with respect to the anchor ring after that
ring is initially fixed to the patient. Thus, since the base 872 is
not fixed to the anchor ring, it will rotate with respect to the
anchor ring, while base holder 902 is fixed to the anchor ring.
Thus, rotation of shaft 890 rotates the base 872 with respect to
holder 902. Since holder 902 is threadably engaged with base 872,
rotation of base 872 causes the base to move longitudinally on the
holder 872. Thus, base 872 ' moves both rotationally and
longitudinally on the cuff or anchor ring. The staple delivery
location, being fixed to the base, thus moves both rotationally and
longitudinally with respect to the cuff. Such simultaneous
rotational and longitudinal movement causes the staple delivery
location to describe a helical path on the fixed cuff. Such a
helical path is shown in FIGS. 54A-54C, for various sizes of
staples and various staple spacings (21 mm spacing in FIG. 54A, and
21.5 mm spacing in FIG. 54C). This helical path permits a single
line of staples to be set without unwanted gaps and with any degree
of overlap desired.
[0250] The system shown in FIG. 51 assures that each staple is
placed with the proper spacing between staples and that the rows
are properly spaced. In addition, this alignment procedure is very
forgiving and is adjustable to aorta diameter. This is because
staples can be spaced apart a linear distance instead of an arcuate
distance. The staples are placed in a single continuous row which
takes the form of a helix to complete overlapping multiple rows
when the line is long enough to complete two or more revolutions of
the helix. It additionally allows the second revolution of the line
to be placed much closer to the first revolution because the line
is not constrained by packaging multiple driver assemblies. The
line distance is regulated only by how fine or coarse the helix
angle is on the index mechanism.
[0251] Use of the FIG. 51 system is evident from the above
disclosure and thus will only be summarized. The surgeon advances
the staple in the tool to expose the straight legs of the staple,
The straight legs of the staple are then pushed through the cuff to
penetrate the aortic tissue.
[0252] Once the surgeon has felt the penetration of the staples
into the tissue, he then forms the staple. Once the staple is
formed and the lifter spring has lifted the staple off of the
anvil, the staple driving tool is removed from the receptacle.
While holding on to the proximal end of the tool, the index wheel
is rotated one-half of a full rotation as indicted by colored
markers on the index wheel as seen through the index wheel
indicators. The staple driving tool is then again inserted into the
staple alignment receptacle and keyed to maintain staple alignment.
Once again, the staple legs are advanced forward and penetrated
through the cuff and the annular aortic tissue, then the staple is
fully formed. This process is repeated until two full rotations of
the indexing base are accomplished, thus providing two overlapping
helical rows of staples.
[0253] One form of the device has the timing wheel held within the
indexing mechanism. The first step is to place the valve base and
the cuff into the aorta with the index valve holder. The second
step is to dilate the cuff and make it snug against the aorta by
using the dilation control on the index valve holder. The internal
platens, which press the cuff against the annulus expand. By
expanding these platens, the indexing mechanism takes on the
diameter of the distal section. This calibrates the indexing
mechanism for the specific annulus size. An incremental movement of
the index planetary gear will make certain that the receptacle has
indexed the proper amount to ensure that the next staple is fired
precisely one increment from the previous staple, independent of
annulus size. As the index mechanism is shifted to the next
position, the planetary gear ensures that the mechanism will place
the receptacle one increment away. After the staple driving device
has fired the first staple, the driving device is removed from the
instrument and the index holder is indexed to the next position. If
desired, the device can form two rows of staples by extending the
index feature to an upper position after firing a first row of
staples.
[0254] With regard to the index gear 886, it is noted that each
one-half rotation thereof provide one staple increment. The index
spring on the base signals the user when the index gear has made
one-half of a revolution through an audible tactile "click."
Further note that the flexible gear rack is connected at one end to
one of four cuff liner parts and is allowed to float freely from
thereon thereby allowing the index gear rack to expand as the
expander arms push on the cuff liners to accommodate larger or
smaller sizes of aorta. In addition, the gear rack is taller than
the index gear in order to allow the index gear to continue to
engage the index rack as the alignment tube plate rises up the
threads to produce the helical pattern. It is also noted that the
expander arms are made of a slippery polymer to reduce friction
with the cuff liners. Each shoe, through a small dovetail, engages
at least two cuff liners.
[0255] A further use of the instrument 800 is illustrated in FIGS.
55 and 56 for closing the aortomy 920. This procedure is achieved
using staples alone. The surgeon approximates the incised edges of
the aorta with forceps 922, and tool 800 is placed next to the
approximated edges and operated to deploy a staple. Due to the dual
movement of the staple discussed above, the legs of the staple move
through the tissue before they are folded over. As they fold over,
the edges are brought together so formed staple 720f closes the
incision as shown in FIG. 56.
[0256] As discussed above, the primary requirement for a fastener
in the context of the present invention is to be individually
placable and which locally approximates and cinches the tissue from
the operative side of the tissue.
[0257] The related applications referenced above disclose means and
methods for replacing a heart valve in which a flexible cuff is
fixed to a patient's tissue and a prosthesis valve is then docked
to the in-place cuff. Fasteners, such as staples, which have their
shapes permanently changed by a tool are disclosed in these related
applications. However, the cuff mounting procedure taught in these
related applications, based on the teaching of these applications,
can be carried out using a variety of fasteners including, but not
limited to, the permanently altered fasteners mentioned above,
fasteners which have thier shapes changed by a tool during the
process but which return to their initial shapes once they are
fixed to the patient, and fasteners which do not have their shapes
altered by a tool during the cuff-attaching process. The following
disclosure discusses the latter two fastener types.
[0258] The fasteners of the present invention, like nearly all
surgical materials, obey Hooke's law. That is, if they are
subjected to a gradually increasing stress, the ratio of the unit
stress to the unit strain or deformation, is constant until a
certain limiting value of the unit stress, known as the
proportional elastic limit, is reached, see, e.g., "The Making,
Shaping and Treating of Steel" 10th Edition, edited by William T.
Lankford, Jr., Norman L. Samways, Robert F. Craven and Harold E.
McGannon and Published by US Steel and the Association of Iron and
Steel Engineers in 1985, the disclosure of pages 1389-1446 (Chapter
50) being incorporated herein by reference, see also the definition
of Hooke's law in the McGraw-Hill Dictionary of Scientific and
Technical Terms, published by McGraw-Hill Book Company in 1974 and
edited by Daniel N. Lapedes (the disclosure of which is
incorporated herein by reference), which defines Hooke's Law as
"the law that the stress of a solid is directly proportional to the
strain applied to it, "elastic deformation" as "reversible
alteration of the form or dimensions of a solid body under stress
or strain," and conversely "elastic failure" as "failure of a body
to recover its original size and shape after a stress is removed,"
"elasticity" as "the property whereby a solid material changes its
shape and size under action of opposing forces, but recovers its
original configuration when the forces are removed," and "elastic
limit" as "the maximum stress a solid can sustain without
undergoing permanent deformation."
[0259] Surgical fasteners can be treated within their elastic
limit. In this regard, elastic limit is defined in standard
references, such as "Mechanics of Materials" by Seibert Fairman and
Chester S. Cutshall, published by John Wiley & Sons in 1953,
the disclosure of Chapters 1 and 2, pages 1-32, being incorporated
by reference, as the maximum stress that may be applied without
producing a permanent set. Such fasteners will be referred to
herein as elastic fasteners. With elastic fasteners, no permanent
set occurs until after the proportional limit is reached, and the
ratio of stress to corresponding strain for stress below the
proportional limit is defined by ASTM as the modulus of
elasticity.
[0260] Three types of fasteners that can be used to attach a
prosthetic reinforcing cuff to an annulus of an existing valve have
been disclosed. The first type of fastener disclosed requires a
forming step that transfers a force to the fastener that causes the
fastener to exceed its elastic limit thereby changing the actual
shape and size of the fastener. The second type of fastener acts
more like a spring in which it initially changes shape within its
elastic limit and returns to the original shape of the fastener
once application is completed. The third type of fastener does not
operate in the elastic range at all, thereby not changing shape in
any way thus is a "self-retaining" fastener. It maintains its
dimensional status throughout the application of the fastener.
[0261] As mentioned above and in U.S. Pat. No. 5,716,370, the
disclosure of which is incorporated herein by reference, the first
type of fastener uses an installation tool which imparts a force on
the fastener causing it to exceed its elastic limit during
application thereby physically changing the actual shape and size,
and thus is a "tool formed" fastener. The definition of "elastic
limit" in the McGraw-Hill Dictionary of Scientific and Technical
Terms, published by the McGraw-Hill Book Company in 1974 and edited
by Daniel N. Lapedes (the disclosure of which is incorporated
herein by reference) is "the maximum stress a solid can sustain
without undergoing permanent deformation." Thus, from the
foregoing, it can be understood that for materials such as the
fasteners of the present disclosure, which obey Hooke's Law, which
is "the stress of a solid is directly proportional to the strain
applied to it," permanent physical changes resulting from stressing
the fasteners will disappear when the stress is removed providing
the stress does not exceed the proportional elastic limit. After
this limit is exceeded resulting strain does not entirely disappear
when the stress is removed. The part of the strain that remains is
called the permanent set. A surgical staple an example of a
fastener that surpasses its elastic limits and deforms during the
attachment of a prosthesis to an annulus.
[0262] The second type of fastener disclosed as a non-anvil formed
fastener and is a fastener that does not exceed its elastic limit
and does not take a permanent set when used in attaching the
prosthetic reinforcing cuff to the annulus of an existing valve in
the patient, and thus is referred to as a highly elastic fastener.
These fasteners experience what is known as "elastic deformation"
which is defined as "reversible alteration of the form or
dimensions of a solid body under stress or strain." That is, they
have the ability to regain their original, or initial shape and
dimension, whatever that is, after experiencing a change of shape
and/or size, also known as strain, due to the application of
external forces as long as the external forces do not exceed the
"elasticity" which is defined as "the property whereby a solid
material changes it shape and size under action of opposing forces,
but recovers its original configuration when the forces are
removed." When an elastic material is used in this application it
can temporarily change shape during the process of attaching the
prosthetis to an annulus and once attached the fastener will retain
the shape it had prior to attachment.
[0263] The third type of fastener does not see enough force to
experience any elastic deformation or even obtain elasticity
whatsoever, and is referred to as a self-retaining fastener. This
fastener maintains its original shape and dimensions throughout the
fastener application. This is also considered to be a non-anvil
formed fastener, based on a certain amount of force being applied
to it during the application of the prosthetic cuff but not enough
to cause any dimensional change whatsoever. An example of a
non-anvil formed fastener that does not operate in the elastic
range is a self-tapping helical fastener or a barbed fastener.
[0264] Still further, since the present disclosure refers to
fasteners such as staples that have been stressed beyond their
elastic limit whereby when the stressing force is removed the
fasteners retain their stressed shape and do not return to their
initial size and/or shape, as being "tool-formed," a fastener that
has not been stressed beyond its elastic limit and thus will return
to its initial size and/or shape when the stressing force is
removed will be referred to as a "non-formed" or "elastic"
fastener. In other words, a non-formed fastener is a fastener that
has been stressed during a surgical procedure, such as covered in
the present invention, yet is not permanently deformed by such
stress and will return to its initial size, shape and dimensions
when the stressing force is removed.
[0265] With regard to tool-formed fasteners, in order to set a
tool-formed fastener to hold a cuff on a patient, a fastener such
as a staple is stressed by a tool and anvil combination beyond the
elastic limit of the fastener whereby once the forming force (the
external stress) is removed the fastener will not regain its
original shape and will be permanently deformed. Elastic limits for
most materials, including those used in the fasteners of the
present invention, are well documented in standard references, such
as in Table X of the above-referenced "Mechanics of Materials," the
disclosure of which is incorporated herein by reference, as well
standard handbooks such as "Marks' Standard Handbook for Mechanical
Engineers" Seventh Edition Edited by Theodore Baumeister and
published by McGraw-Hill Book Company in 1967, Chapter 5, the
disclosure of Chapter 5 being incorporated herein by reference, as
well as the incorporated US Steel Book. By way of example, the US
Steel book discloses the mechanical properties of stainless steel
on pages 1345-1355, the disclosure of which is incorporated herein
by reference, including the yield strength thereof (see Table 47),
see also the incorporated Mechanical Engineers Handbook, Table 19
(the disclosure of which is incorporated herein by reference) while
the mechanical properties of Titanium are disclosed in the
incorporated Mechanical Engineers Handbook (see Table 21 on page
6-101), the disclosure of which is incorporated herein by
reference. Still further, the incorporated "Mechanics of Materials"
reference includes typical stress-strain diagrams for steel in
FIGS. 26 and 27 on page 25, the disclosure of which is incorporated
herein by reference, that show the proportional limits and
illustrate Hooke's law.
[0266] The above discussion concerned a tool-formed fastener. As
discussed above, the present invention also encompasses elastic
fasteners which can achieve the result of attaching a cuff to a
patient without being permanently deformed during or by the
attaching process or the tools or instruments used to carry out the
process. That is, the results of the present invention can be
achieved using fasteners which, although stressed by the tool used
and during the process of attaching the cuff to the patient using
the fastener are not stressed beyond the elastic limit thereof
whereby once the cuff-attaching procedure is completed and the tool
removed from the fastener, the fastener will regain its original
shape and dimension and will not be permanently deformed, or
non-formed.
[0267] FIGS. 57, 61, 63, 64 and 66 illustrate embodiments of the
non-formed (not permanently deformed by the stresses associated
with carrying out the valve replacement procedures of the present
invention) fastener which achieves these objectives, while FIGS.
58-60, 63 and 67-68 illustrate elements which can be used, either
alone or in combination with tools disclosed hereinabove, to place
these fasteners in a patient to attach a cuff to the patient
without causing either the tool or the process to apply stress to
the fastener sufficient to permanently deform the fastener from its
initial shape. That is neither the tool nor the process applies
stress to the fastener beyond the elastic limit of the fastener
whereby the fastener is non formed and will return to its initial
size, shape and dimensions after the sewing cuff is attached to the
patient using the fastener. This is opposed to the staple form of
the fastener discussed above which is permanently deformed during
the cuff-attaching process, that is, the staple configuration of
the fastener is "formed."
[0268] As shown in FIG. 57, a pre-stressed fastener 1000 is shown
in its initial shape and is monolithic and includes two legs 1002
and 1004 which overlap each other adjacent to tissue penetrating
points 1006 and 1008 respectively. In a free condition, the legs
overlap each other as shown in FIG. 57. Fastener 1000 is used by
storing it in the free condition such as shown in FIG. 57, then
spreading the legs apart as indicated in FIG. 58 by fastener 1000'
before placing and inserting the fastener into and through the
prosthesis and tissue to be connected. The legs are held apart
until the fastener has been placed, and then the legs are released.
The procedure does not exceed the elastic limit of the fastener and
thus the natural resiliency of the fastener causes the legs to
regain the FIG. 57 initial overlapping orientation thereby cinching
the prosthesis and tissue together. Fastener 1000 is formed of
highly elastic material, such as nitinol or stainless steel spring
wire, or the like having a shape memory and is not deformed beyond
its elastic limit by either the tool or the procedure used to
attach a cuff to a patient.
[0269] A tool element 1000.sub.T is shown in FIGS. 58-60 and is
used to place and set fasteners 1000. Tool element 1000.sub.T is
used with a tool that imparts longitudinal movement thereto. Any
tool discussed above can be adapted to impart such longitudinal
motion in a minimally invasive surgery environment. Referring to
FIG. 58, tool element 1000.sub.T includes a fastener track 1010
supported on a tip retractor 1012 and having a cover 1014 thereon.
Fasteners 1000 are stored in track 1010 and move downwardly in the
track 1010 under influence of either a spring-loaded pusher bar or
advancing mechanism associated with the operating tool. After the
fastener reaches the end of the track, it drops off of the track as
can be seen in FIG. 59, and onto two extender pins 1016 and 1018,
best shown in FIG. 60. A hold-down spring 1020 keeps the fastener
properly oriented. Hold down-spring 1020 also moves a fastener off
the track into position to be opened against pins 1016 and 1018. A
retractor back up element 1022 is moved by the longitudinally
moving tool and forces the fastener against the pins 1020 to open
the legs into the position shown for fastener 1000'. Once the
fastener is forced through the prosthesis and tissue, the tool
element 1000.sub.T is twisted to withdraw it from the fastener. As
soon as tool element 1000.sub.T is withdrawn, legs 1002 and 1004
move toward the overlapping position and cinch tissue and
prosthesis together.
[0270] As above discussed, the present invention also encompasses
self-retaining fasteners, and shown in FIG. 61 is one embodiment of
such a self-retaining fastener, and is a helical fastener 2000
which also fulfills the above-discussed criteria for fastening a
prosthesis to a patient and does not experience permanent
deformation during or after the cuff-attaching procedure described
herein. Fastener 2000 includes a polygonal head 2002 and a central
body 2004 with a helical element 2006 thereon. Element 2006 is in
the nature of a screw thread, and upon rotating fastener 2000 in
the manner of a screw, fastener 2000 acts like a self-tapping screw
to force itself into and through a prosthesis and tissue to which
the prosthesis is being attached.
[0271] A tool element 2000.sub.T suitable for use with rotational
fastener 2000 is shown in FIG. 62. Tool element 2000.sub.T can be
used with any tool that imparts rotational motion thereto. Tool
element 2000.sub.T includes a rotation driver element 2010 which is
connected to an element of the operating tool and is located inside
a driver tube 2012 and is connected thereto to impart rotation
thereto as indicated by arrow 2014. Driver tube 2006 fits over
polygonal head 2002 to transfer this rotational motion to fastener
2000 which is located inside an extender tube 2016.
[0272] An operating tool 2000.sub.TR is used to impart rotational
motion to the driver element 2010 and is shown in FIG. 69 as
including a housing 2030 having a proximal end 2032 and a distal
end 2034. Tool 2000.sub.TR translates linear motion of handle 2036
into rotational movement of driver shaft 2038 which is operatively
connected to driver tube 2012 which has a polygonal inside shape
2040 to match the polygonal shape of head 2002. Fasteners 2000 are
located inside tube 2012 to have rotational motion imparted
thereto.
[0273] Handle 2036 moves in direction 2042 relative to stationary
handle portion 2044 about a pivot axis 2046 so end 2048 of handle
2036 moves in direction 2050. End 2048 includes an elongated slot
2052 in which a pin 2054 is located. Pin 2054 is mounted on a
follower sleeve 2056. Sleeve 2056 is constrained so sleeve 2056
moves linearly in direction 2058 when handle 2036 is moved in
direction 2042. A second pin 2060 is mounted on sleeve 2056 and
moves therewith. Sleeve 2060 is located around a driver element
2062 having a helical groove 2064 defined therein to receive pin
2060. Driver element 2062 is rotatably mounted in housing 2030 by
mounts 2066 and flange 2068 SO it can rotate but not translate
under the influence of pin 2060 in groove 2064. Rotation of driver
element 2062 is indicated by arrow 2070.
[0274] Driver element 2062 is operatively connected to shaft 2038
by one-way pawl mechanisms 2072 and 2074 SO rotation in the desired
direction is transmitted. Pawl mechanism 2074 transmits rotational
movement of element 2062 to element 2038, while mechanism 2072
prevents retrograde motion when handle 2036 is moved in the
direction opposite to direction 2042. Tool 2000.sub.TR also
includes a stationary sleeve 2076.
[0275] Using tool 2000.sub.TR in connection with tool element
2000.sub.T, fasteners are deployed in the center of the rotating
tube. The rotating tube has a distal end which has a jaw assembly
to hold the fasten which will extend from the end of the instrument
as it is driven into the prosthesis and tissue. In addition, there
is an indexing mechanism which advances one fastener at a time into
the driving jaw assembly. Rotational mechanisms in the housing then
rotate both the storage tube and the jaw assembly upon actuation of
the handle as above described. The helix essentially screws its way
into the tissue. Once the tissue bunches up against the head of the
fastener, it compresses the tissue to the prosthesis thereby
creating a seal. Other fastener forms can also be used without
departing from the scope of this disclosure which use a load
bearing surface and tissue gathering means and which are not
permanently deformed by or during the cuff-attaching process so
they will regain their initial shape and/or size after completion
process. By this, it is meant that there are essentially two
components of such a fastener, a crown surface which stays on the
outside of the object to be fastened and the fastening mechanism or
extension legs which penetrate through the fastening media into the
tissue to grip the tissue. Yet another form of this non-permanently
deformed helical fastener is shown in FIG. 63 as fastener 2000'
having a polygonal head 2000.sub.H and a helical body 2080 attached
at one end thereof thereto and having a point 2082 at the other end
thereof.
[0276] Yet another form of such non-permanently deformed fastener
is shown in FIG. 64 as fastener 2000". Fastener 2000" includes a
head 2000.sub.H ' having a knurled outer edge 2090 and to which a
helical element 2092 is attached. Element 2092 has a penetrating
point 2094 on the distal end thereof and regains its initial shape
after completion of the surgical process because neither the
process nor the tools used in the process applied sufficient stress
to the fastener to exceed the elastic limit of the fastener.
[0277] Yet another fastener which is not permanently deformed by or
during the process involving the fastener is shown in FIG. 65 as
barbed fastener 2000'" which includes a head 2100 to which a
central base 2102 is attached. Base 2012 has a pointed end 2104 and
anti-back up barbs 2106 mounted thereon. Barbs 2106 extend in a
direction opposite to point 2104 so once the fastener is set, the
barbs will prevent it from moving in an opposite direction. A
centrally located hole 2110 receives a point 2104 of an adjacent
fastener so the fasteners can be stored as indicated in FIG. 67 in
a delivery tool element 2000.sub.T'". Tool element 2000.sub.T'" is
shown in FIGS. 67 and 68 as including a housing 2112 having a
proximal end 2114 and a distal end 2116. Slots 2118 and 2120 are
defined in end 2114 to slidably receive an advance bar 2122 that is
moved longitudinally by a tool operating element that imparts such
longitudinal movement in a minimally invasive surgical setting. Bar
2122 abuttingly contacts an antibackup ratchet 2124 on which
fasteners 2000".DELTA. are releasably mounted. Fastener advance
ratchets 2126 are oriented in the manner of barbs 2106 to allow a
fastener to move past the ratchet but to prevent reverse movement
of such fastener. Bar 2122 is forced downwardly into housing 2112
in direction 2123 and forces the fasteners to exit end 2116 between
arms 2128 and 2130. Fasteners slide over the arms and when set in
the tissue or in the prosthesis, or both, the arms prevent the
fastener from moving backwards in direction 2123'. The tool element
is then withdrawn and the fastener remains in place. An antibackup
post 2132 is also mounted on housing 2112.
[0278] A further form of non-permanently deformed fastener 2000'"
is shown in FIG. 66 as fastener 2000.sup.IV which includes a
circular base 2140 having a base 2102 on one side and a post 2142
on the other side. Base 2102 has a point 2104 on one end and
antibackup barbs 2106 adjacent to the point as discussed above for
fastener 2000'". Post 2142 is attached to base 2140 by a one-way
crimp 2144 and has a removable portion 2146 connected to the base
by a frangible joint 2148. Fastener 2000.sup.IV is used in the
manner of fastener 2000'", is not stressed beyond its elastic limit
during or by the process and thus the use and operation thereof
will not be discussed. Removable portion 2146 is used to place and
set the fastener, and is then removed once the fastener is set. A
tool driver is connected to portion 2146 in the manner of element
2000.sub.T'".
[0279] It is understood that while certain forms of the present
invention have been illustrated and described herein, it is not to
be limited to the specific forms or arrangements of parts described
and shown with the elements being shown, such as the tool T, being
the best mode, but not the only mode.
* * * * *