U.S. patent application number 10/810133 was filed with the patent office on 2004-09-16 for cardiac disease treatment and device.
This patent application is currently assigned to Acorn Cardiovascular, Inc.. Invention is credited to Alferness, Clifton A., Power, John Melmouth, Raman, Jai Shankar.
Application Number | 20040181125 10/810133 |
Document ID | / |
Family ID | 43063443 |
Filed Date | 2004-09-16 |
United States Patent
Application |
20040181125 |
Kind Code |
A1 |
Alferness, Clifton A. ; et
al. |
September 16, 2004 |
Cardiac disease treatment and device
Abstract
A jacket of biological compatible material has an internal
volume dimensioned for an apex of the heart to be inserted into the
volume and for the jacket to be slipped over the heart. The jacket
has a longitudinal dimension between upper and lower ends
sufficient for the jacket to surround a lower portion of the heart
with the jacket surrounding a valvular annulus of the heart and
further surrounding the lower portion to cover at least the
ventricular lower extremities of the heart. The jacket is adapted
to be secured to the heart with the jacket surrounding at least the
valvular annulus and the ventricular lower extremities. The jacket
is adjustable on the heart to snugly conform to an external
geometry of the heart and assume a maximum adjusted volume for the
jacket to constrain circumferential expansion of the heart beyond
the maximum adjusted volume during diastole and to permit unimpeded
contraction of the heart during systole.
Inventors: |
Alferness, Clifton A.;
(Redmond, WA) ; Raman, Jai Shankar; (North
Baldwyn, AU) ; Power, John Melmouth; (Williamstown,
AU) |
Correspondence
Address: |
Attention of Anna M. Nelson
MERCHANT & GOULD P.C.
P.O. Box 2903
Minneapolis
MN
55402-0903
US
|
Assignee: |
Acorn Cardiovascular, Inc.
St. Paul
MN
|
Family ID: |
43063443 |
Appl. No.: |
10/810133 |
Filed: |
March 26, 2004 |
Related U.S. Patent Documents
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Application
Number |
Filing Date |
Patent Number |
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10810133 |
Mar 26, 2004 |
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09880576 |
Jun 13, 2001 |
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09880576 |
Jun 13, 2001 |
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09565621 |
May 4, 2000 |
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6537203 |
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09565621 |
May 4, 2000 |
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09114510 |
Jul 13, 1998 |
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6123662 |
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Current U.S.
Class: |
600/37 ;
600/16 |
Current CPC
Class: |
A61P 9/04 20180101; A61F
2/2481 20130101; A61F 2002/0068 20130101 |
Class at
Publication: |
600/037 ;
600/016 |
International
Class: |
A61N 001/362; A61F
013/00 |
Claims
What is claimed is:
1. A device for treating cardiac disease of a heart having a
longitudinal axis from an apex to a base and having an upper
portion and a lower portion divided by an A-V groove, said heart
including a valvular annulus adjacent said A-V groove and
ventricular lower extremities adjacent said apex, the device
comprising: a jacket of flexible material of knit construction
defining a volume between an open upper end and a lower end, said
jacket dimensioned for said apex of said heart to be inserted into
said volume through said open upper end and for said jacket to be
slipped over said heart, said jacket further dimensioned for said
jacket to have a longitudinal dimension between said upper and
lower ends sufficient for said jacket to constrain said lower
portion with said jacket constraining said valvular annulus and
further constraining said ventricular lower extremities; said
jacket adapted to be secured to said heart with said jacket having
portions disposed on opposite sides of the heart between said
valvular annulus and said ventricular lower extremities; and said
jacket adapted to be adjusted on said heart to snugly conform to an
external geometry of said hieart and assume a maximum adjusted
volume for said jacket to constrain circumferential expansion of
said heart beyond said maximum adjusted volume during diastole and
permit substantially unimpeded contraction of said heart during
systole.
2. A device according to claim 2 wherein: said material is
expandable along a first material axis in response to a force
parallel to said first axis greater than an expansion of said
material along a second axis in response to a force of equal
magnitude parallel to said second axis; said material oriented for
said first axis to extend circumferentially around said
longitudinal dimension.
3. A device according to claim 1 wherein said jacket is open at
said lower end.
4. A device according to claim 1 wherein said jacket is closed at
said lower end.
5. A device according to claim 1 wherein said material is run
resistant.
6. A device according to claim 5 wherein: said material is
expandable along a first material axis in response to a force
parallel to said first axis greater than an expansion of said
material along a perpendicular second axis in response to a force
of equal magnitude parallel to said second axis; said material
oriented for said first axis to extend from said upper end of said
jacket toward said lower end.
7. A device according to claim 1 wherein said material is
sufficiently flexible to gather excess amounts of said material
following placement of said jacket over said heart to snugly
conform said material to an external geometry of said heart.
8. A device according to claim 5 wherein said material is
sufficiently flexible to gather excess amounts of said material
following placement of said jacket over said heart to snugly
conform said material to an external geometry of said heart.
9. A device according to claim 1 wherein said material is selected
from a group of polytetrafluoroethylene, expanded
polytetrafluoroethylene, polypropylene, polyester or stainless
steel.
10. A device according to claim 5 wherein said material is formed
of elongated fibers selected from a group of
polytetrafluoroethylene, expanded polytetrafluoroethylene,
polypropylene, polyester or stainless steel.
11. A device according to claim 1 wherein said jacket is sized to
at least partially cover and constrain said upper portion.
12. A device according to claim 1 further comprising a liner sized
and positioned to be disposed between said heart and said jacket,
said liner formed of an anti-fibrotic material.
13. A device according to claim 1 wherein the jacket is
electrically permeable.
14. A device for treating cardiac disease of a heart having a
longitudinal axis from an apex to a base and having an upper
portion and a lower portion divided by an A-V groove, said heart
including a valvular annulus adjacent said A-V groove and
ventricular lower extremities adjacent said apex, the device
comprising: a jacket of flexible, electrically permeable material
adapted to be secured to said heart with said jacket having
portions disposed on opposite sides of the heart between said
valvular annulus and said ventricular lower extremities; and said
jacket adapted to be adjusted on said heart to snugly conform to an
external geometry of said heart and assume a maximum adjusted
volume for said jacket to constrain circumferential expansion of
said heart beyond said maximum adjusted volume during diastole and
permit unimpeded contraction of said heart during systole.
15. A device according to claim 2 wherein said jacket
circumferentially surrounds said heart.
16. A method for treating cardiac disease of a patient's heart,
said method comprising: surgically accessing said patient's heart
and diaphragm; placing ajacket around said heart, said jacket
comprising a biomedical material having an upper end and a lower
end; adjusting said jacket on said heart to snugly conform to an
external geometry of said heart and assume a maximum adjusted
volume for said jacket to constrain circumferential expansion of
said heart beyond said maximum adjusted volume during diastole and
permitting unimpeded contraction of said heart during systole; and
securing said lower end of said jacket to said diaphragm.
17. A method according to claim 16 wherein said lower end of said
jacket is secured to said diaphragm using sutures.
Description
BACKGROUND OF THE INVENTION
[0001] 1. Field of the Invention
[0002] The present invention pertains to a device and method for
treating heart disease. More particularly, the present invention is
directed to a method and device for treating congestive heart
disease and related valvular dysfunction.
[0003] 2. Description of the Prior Art
[0004] Congestive heart disease is a progressive and debilitating
illness. The disease is characterized by a progressive enlargement
of the heart.
[0005] As the heart enlarges, the heart is performing an increasing
amount of work in order to pump blood each heart beat. In time, the
heart becomes so enlarged the heart cannot adequately supply blood.
An afflicted patient is fatigued, unable to perform even simple
exerting tasks and experiences pain and discomfort. Further, as the
heart enlarges, the internal heart valves cannot adequately close.
This impairs the function of the valves and further reduces the
heart's ability to supply blood.
[0006] Causes of congestive heart disease are not fully known. In
certain instances, congestive heart disease may result from viral
infections. In such cases, the heart may enlarge to such an extent
that the adverse consequences of heart enlargement continue after
the viral infection has passed and the disease continues its
progressively debilitating course.
[0007] Patients suffering from congestive heart disease are
commonly grouped into four classes (i.e., Classes I, II, III and
IV). In the early stages (e.g., Classes I and II), drug therapy is
the commonly proscribed treatment. Drug therapy treats the symptoms
of the disease and may slow the progression of the disease.
Importantly, there is no cure for congestive heart disease. Even
with drug therapy, the disease will progress. Further, the drugs
may have adverse side effects.
[0008] Presently, the only permanent treatment for congestive heart
disease is heart transplant. To qualify, a patient must be in the
later stage of the disease (e.g., Classes III and IV with Class IV
patients given priority for transplant). Such patients are
extremely sick individuals. Class III patients have marked physical
activity limitations and Class IV patients are symptomatic even at
rest.
[0009] Due to the absence of effective intermediate treatment
between drug therapy and heart transplant, Class III and IV
patients will have suffered terribly before qualifying for heart
transplant Further, after such suffering, the available treatment
is unsatisfactory. Heart transplant procedures are very risky,
extremely invasive and expensive and only shortly extend a
patient's life. For example, prior to transplant, a Class IV
patient may have a life expectancy of 6 months to one-year. Heart
transplant may improve the expectancy to about five years.
[0010] Unfortunately, not enough hearts are available for
transplant to meet the needs of congestive heart disease patients.
In the United States, in excess of 35,000 transplant candidates
compete for only about 2,000 transplants per year. A transplant
waiting list is about 8-12 months long on average and frequently a
patient may have to wait about 1-2 years for a donor heart. While
the availability of donor hearts has historically increased, the
rate of increase is slowing dramatically. Even if the risks and
expense of heart transplant could be tolerated, this treatment
option is becoming increasingly unavailable. Further, many
patient's do not qualify for heart transplant for failure to meet
any one of a number of qualifying criteria
[0011] Congestive heart failure has an enormous societal impact. In
the United States alone, about five million people suffer from the
disease (Classes I through IV combined). Alarmingly, congestive
heart failure is one of the most rapidly accelerating diseases
(about 400,000 new patients in the United States each year).
Economic costs of the disease have been estimated at $38 billion
annually.
[0012] Not surprising, substantial effort has been made to find
alternative treatments for congestive heart disease. Recently, a
new surgical procedure has been developed. Referred to as the
Batista procedure, the surgical technique includes dissecting and
removing portions of the heart in order to reduce heart volume.
This is a radical new and experimental procedure subject to
substantial controversy. Furthermore, the procedure is highly
invasive, risky and expensive and commonly includes other expensive
procedures (such as a concurrent heart valve replacement). Also,
the treatment is limited to Class IV patients and, accordingly,
provides no hope to patients facing ineffective drug treatment
prior to Class IV. Finally, if the procedure fails, emergency heart
transplant is the only available option.
[0013] Clearly, there is a need for alternative treatments
applicable to both early and later stages of the disease to either
stop the progressive nature of the disease or more drastically slow
the progressive nature of congestive heart disease. Unfortunately,
currently developed options are experimental, costly and
problematic.
[0014] Cardiomyoplasty is a recently developed treatment for
earlier stage congestive heart disease (e.g., as early as Class III
dilated cardiomyopathy). In this procedure, the latissimus dorsi
muscle (taken from the patient's shoulder) is wrapped around the
heart and chronically paced synchronously with ventricular systole.
Pacing of the muscle results in muscle contraction to assist the
contraction of the heart during systole.
[0015] While cardiomyoplasty has resulted in symptomatic
improvement, the nature of the improvement is not understood. For
example, one study has suggested the benefits of cardiomyoplasty
are derived less from active systolic assist than from remodeling,
perhaps because of an external elastic constraint. The study
suggests an elastic constraint (i.e., a non-stimulated muscle wrap
or an artificial elastic sock placed around the heart) could
provide similar benefits. Kass et al., Reverse Remodeling From
Cardiomyoplasty In Human Heart Failure: External Constraint Versus
Active Assist, 91 Circulation 2314-2318 (1995).
[0016] Even though cardiomyoplasty has demonstrated symptomatic
improvement, studies suggest the procedure only minimally improves
cardiac performance. The procedure is highly invasive requiring
harvesting a patient's muscle and an open chest approach (i.e.,
stemotomy) to access the heart. Furthermore, the procedure is
expensive--especially those using a paced muscle. Such procedures
require costly pacemakers. The cardiomyoplasty procedure is
complicated. For example, it is difficult to adequately wrap the
muscle around the heart with a satisfactory fit. Also, if adequate
blood flow is not maintained to the wrapped muscle, the muscle may
necrose. The muscle may stretch after wrapping reducing its
constraining benefits and is generally not susceptible to
post-operative adjustment. Finally, the muscle may fibrose and
adhere to the heart causing undesirable constraint on the
contraction of the heart during systole.
[0017] In addition to cardiomyoplasty, mechanical assist devices
have been developed as intermediate procedures for treating
congestive heart disease. Such devices include left ventricular
assist devices ("LVAD") and total artificial hearts ("TAH"). An
LVAD includes a mechanical pump for urging blood flow from the left
ventricle and into the aorta. An example of such is shown in U.S.
Pat. No. 4,995,857 to Arnold dated Feb. 26, 1991. LVAD surgeries
are still in U.S. clinical trials and not generally available. Such
surgeries are expensive. The devices are at risk of mechanical
failure and frequently require external power supplies. TAH
devices, such as the celebrated Jarvik heart, are used as temporary
measures while a patient awaits a donor heart for transplant.
[0018] Other attempts at cardiac assist devices are found in U.S.
Pat. No. 4,957,477 to Lundbck dated Sep. 18, 1990, U.S. Pat. No.
5,131,905 to Grooters dated Jul. 21, 1992 and U.S. Pat. No.
5,256,132 to Snyders dated Oct. 26, 1993. Both of the Grooters and
Snyders patents teach cardiac assist devices which pump fluid into
chambers opposing the heart to assist systolic contractions of the
heart. The Lundbck patent teaches a double-walled jacket
surrounding the heart. A fluid fills a chamber between the walls of
the jacket. The inner wall is positioned against the heart and is
pliable to move with the heart. Movement of the heart during
beating displaces fluid within the jacket chamber.
[0019] Commonly assigned U.S. Pat. No. 5,702,343 to Alferness dated
Dec. 30, 1997 teaches a jacket to constrain cardiac expansion
during diastole. The present invention pertains to improvements to
the invention disclosed in the '343 patent.
SUMMARY OF THE INVENTION
[0020] According to a preferred embodiment of the present
invention, a method and device are disclosed for treating
congestive heart disease and related cardiac complications such as
valvular disorders. The invention includes a jacket of biologically
compatible material. The jacket has an internal volume dimensioned
for an apex of the heart to be inserted into the volume and for the
jacket to be slipped over the heart. The jacket has a longitudinal
dimension between upper and lower ends sufficient for the jacket to
surround a lower portion of the heart with the jacket surrounding a
valvular annulus of the heart and further surrounding the lower
portion to cover at least the ventricular lower extremities of the
heart. The jacket is adapted to be secured to the heart with the
jacket surrounding at least the valvular annulus and the
ventricular lower extremities. The jacket is adjustable on the
heart to snugly conform to an external geometry of the heart and
assume a maximum adjusted volume for the jacket to constrain
circumferential expansion of the heart beyond the maximum adjusted
volume during diastole and to permit unimpeded contraction of the
heart during systole. In one embodiment, a lower end of the jacket
can be secured to the patient's diaphragm after placement around
the heart.
BRIEF DESCRIPTION OF THE DRAWINGS
[0021] FIG. 1 is a schematic cross-sectional view of a normal,
healthy human heart shown during systole;
[0022] FIG. 1A is the view of FIG. 1 showing the heart during
diastole;
[0023] FIG. 1B is a view of a left ventricle of a healthy heart as
viewed from a septum and showing a mitral valve;
[0024] FIG. 2 is a schematic cross-sectional view of a diseased
human heart shown during systole;
[0025] FIG. 2A is the view of FIG. 2 showing the heart during
diastole;
[0026] FIG. 2B is the view of FIG. 1B showing a diseased heart;
[0027] FIG. 3 is a perspective view of a first embodiment of a
cardiac constraint device according to the present invention;
[0028] FIG. 3A is a side elevation view of a diseased heart in
diastole with the device of FIG. 3 in place;
[0029] FIG. 4 is a perspective view of a second embodiment of a
cardiac constraint device according to the present invention;
[0030] FIG. 4A is a side elevation view of a diseased heart in
diastole with the device of FIG. 4 in place;
[0031] FIG. 5 is a cross-sectional view of a device of the present
invention overlying a myocardium and with the material of the
device gathered for a snug fit;
[0032] FIG. 6 is an enlarged view of a knit construction of the
device of the present invention in a rest state; and
[0033] FIG. 7 is a schematic view of the material of FIG. 6.
DESCRIPTION OF THE PREFERRED EMBODIMENT
[0034] With initial reference to FIGS. 1 and 1A, a normal, healthy
human heart H' is schematically shown in cross-section and will now
be described in order to facilitate an understanding of the present
invention. In FIG. 1, the heart H' is shown during systole (i.e.,
high left ventricular pressure). In FIG. 1A, the heart H' is shown
during diastole (i.e., low left ventricular pressure).
[0035] The heart H' is a muscle having an outer wall or myocardium
MYO' and an internal wall or septum S'. The myocardium MYO' and
septum S' define four internal heart chambers including a right
atrium RA', a left atrium LA', a right ventricle RV' and a left
ventricle LV'. The heart H' has a length measured along a
longitudinal axis AA'-BB' from an upper end or base B' to a lower
end or apex A'.
[0036] The right and left atria RA', LA' reside in an upper portion
UP' of the heart H' adjacent the base B'. The right and left
ventricles RV', LV' reside in a lower portion LP' of the heart H'
adjacent the apex A'. The ventricles RV', LV' terminate at
ventricular lower extremities LE' adjacent the apex A' and spaced
therefrom by the thickness of the myocardium MYO'.
[0037] Due to the compound curves of the upper and lower portions
UP', LP', the upper and lower portions UP', LP' meet at a
circumferential groove commonly referred to as the A-V groove AVG'.
Extending away from the upper portion UP' are a plurality of major
blood vessels communicating with the chambers RA', RV', LA', LV'.
For ease of illustration, only the superior vena cava SVC' and a
left pulmonary vein LPV' are shown as being representative.
[0038] The heart H' contains valves to regulate blood flow between
the chambers RA', RV', LA', LV' and between the chambers and the
major vessels (e.g., the superior vena cava SVC' and a left
pulmonary vein LPV'). For ease of illustration, not all of such
valves are shown. Instead, only the tricuspid valve TV' between the
right atrium RA' and right ventricle RV' and the mitral valve MV'
between the left atrium LA' and left ventricle LV' are shown as
being representative.
[0039] The valves are secured, in part, to the myocardium MYO' in a
region of the lower portion LP' adjacent the A-V groove AVG' and
referred to as the valvular annulus VA'. The valves TV' and MV'
open and close through the beating cycle of the heart H.
[0040] FIGS. 1 and 1A show a normal, healthy heart H' during
systole and diastole, respectively. During systole (FIG. 1), the
myocardium MYO' is contracting and the heart assumes a shape
including a generally conical lower portion LP'. During diastole
(FIG. 1A), the heart H' is expanding and the conical shape of the
lower portion LP' bulges radially outwardly (relative to axis
AA'-BB').
[0041] The motion of the heart H' and the variation in the shape of
the heart H' during contraction and expansion is complex. The
amount of motion varies considerably throughout the heart H'. The
motion includes a component which is parallel to the axis AA'-BB'
(conveniently referred to as longitudinal expansion or
contraction). The motion also includes a component perpendicular to
the axis AA'-BB' (conveniently referred to as circumferential
expansion or contraction).
[0042] Having described a healthy heart H' during systole (FIG. 1)
and diastole (FIG. 1A), comparison can now be made with a heart
deformed by congestive heart disease. Such a heart H is shown in
systole in FIG. 2 and in diastole in FIG. 2A. All elements of
diseased heart H are labeled identically with similar elements of
healthy heart H' except only for the omission of the apostrophe in
order to distinguish diseased heart H from healthy heart H'.
[0043] Comparing FIGS. 1 and 2 (showing hearts H' and H during
systole), the lower portion LP of the diseased heart H has lost the
tapered conical shape of the lower portion LP' of the healthy heart
H'. Instead, the lower portion LP of the diseased heart H bulges
outwardly between the apex A and the A-V groove AVG. So deformed,
the diseased heart H during systole (FIG. 2) resembles the healthy
heart H' during diastole (FIG. 1A). During diastole (FIG. 2A), the
deformation is even more extreme.
[0044] As a diseased heart H enlarges from the representation of
FIGS. 1 and 1A to that of FIGS. 2 and 2A, the heart H becomes a
progressively inefficient pump. Therefore, the heart H requires
more energy to pump the same amount of blood. Continued progression
of the disease results in the heart H being unable to supply
adequate blood to the patient's body and the patient becomes
symptomatic insufficiency.
[0045] For ease of illustration, the progression of congestive
heart disease has been illustrated and described with reference to
a progressive enlargement of the lower portion LP of the heart H.
While such enlargement of the lower portion LP is most common and
troublesome, enlargement of the upper portion UP may also
occur.
[0046] In addition to cardiac insufficiency, the enlargement of the
heart H can lead to valvular disorders. As the circumference of the
valvular annulus VA increases, the leaflets of the valves TV and MV
may spread apart. After a certain amount of enlargement, the
spreading may be so severe the leaflets cannot completely close (as
illustrated by the mitral valve MV in FIG. 2A). Incomplete closure
results in valvular regurgitation contributing to an additional
degradation in cardiac performance. While circumferential
enlargement of the valvular annulus VA may contribute to valvular
dysfunction as described, the separation of the valve leaflets is
most commonly attributed to deformation of the geometry of the
heart H. This is best described with reference to FIGS. 1B and
2B.
[0047] FIGS. 1B and 2B show a healthy and diseased heart,
respectively, left ventricle LV', LV during systole as viewed from
the septum (not shown in FIGS. 1B and 2B). In a healthy heart H',
the leaflets MVL' of the mitral valve MV' are urged closed by left
ventricular pressure. The papillary muscles PM', PM are connected
to the heart wall MYO', MYO, near the lower ventricular extremities
LE', LE. The papillary muscles PM', PM pull on the leaflets MVL',
MVL via connecting chordae tendineae CT', CT. Pull of the leaflets
by the papillary muscles functions to prevent valve leakage in the
normal heart by holding the valve leaflets in a closed position
during systole. In the significantly diseased heart H, the leaflets
of the mitral valve may not close sufficiently to prevent
regurgitation of blood from the ventricle LV to the atrium during
systole.
[0048] As shown in FIG. 1B, the geometry of the healthy heart H' is
such that the myocardium MYO', papillary muscles PM' and chordae
tendineae CT' cooperate to permit the mitral valve MV' to fully
close. However, when the myocardium MYO bulges outwardly in the
diseased heart H (FIG. 2B), the bulging results in displacement of
the papillary muscles PM. This displacement acts to pull the
leaflets MVL to a displaced position such that the mitral valve
cannot fully close.
[0049] Having described the characteristics and problems of
congestive heart disease, the treatment method and apparatus of the
present invention will now be described.
[0050] In general, a jacket of the invention is configured to
surround the myocardium MYO. As used herein, "surround" means that
jacket provides reduced expansion of the heart wall during diastole
by applying constraining surfaces at least at diametrically
opposing aspects of the heart. In some preferred embodiments
disclosed herein, the diametrically opposed surfaces are
interconnected, for example, by a continuous material that can
substantially encircle the external surface of the heart.
[0051] With reference now to FIGS. 3, 3A, 4 and 4A, the device of
the present invention is shown as a jacket 10 of flexible,
biologically compatible material. The jacket 10 is an enclosed knit
material having upper and lower ends 12, 14. The jacket 10, 10'
defines an internal volume 16, 16' which is completely enclosed but
for the open ends 12, 12' and 14'. In the embodiment of FIG. 3,
lower end 14 is closed. In the embodiment of FIG. 4, lower end 14'
is open. In both embodiments, upper ends 12, 12' are open.
Throughout this description, the embodiment of FIG. 3 will be
discussed. Elements in common between the embodiments of FIGS. 3
and 4 are numbered identically with the addition of an apostrophe
to distinguish the second embodiment and such elements need not be
separately discussed.
[0052] The jacket 10 is dimensioned with respect to a heart H to be
treated. Specifically, the jacket 10 is sized for the heart H to be
constrained within the volume 16. The jacket 10 can be slipped
around the heart H. The jacket 10 has a length L between the upper
and lower ends 12, 14 sufficient for the jacket 10 to constrain the
lower portion LP. The upper end 12 of the jacket 10 extends at
least to the valvular annulus VA and further extends to the lower
portion LP to constrain at least the lower ventricular extremities
LE.
[0053] Since enlargement of the lower portion LP is most
troublesome, in a preferred embodiment, the jacket 10 is sized so
that the upper end 12 can reside in the A-V groove AVG. Where it is
desired to constrain enlargement of the upper portion UP, the
jacket 10 may be extended to cover the upper portion UP.
[0054] Sizing the jacket 10 for the upper end 12 to terminate at
the A-V groove AVG is desirable for a number of reasons. First, the
groove AVG is a readily identifiable anatomical feature to assist a
surgeon in placing the jacket 10. By placing the upper end 12 in
the A-V groove AVG, the surgeon is assured the jacket 10 will
provide sufficient constraint at the valvular annulus VA. The A-V
groove AVG and the major vessels act as natural stops for placement
of the jacket 10 while assuring coverage of the valvular annulus
VA. Using such features as natural stops is particularly beneficial
in minimally invasive surgeries where a surgeon's vision may be
obscured or limited.
[0055] When the parietal pericardium is opened, the lower portion
LP is free of obstructions for applying the jacket 10 over the apex
A. If, however, the parietal pericardium is intact, the
diaphragmatic attachment to the parietal pericardium inhibits
application of the jacket over the apex A of the heart. In this
situation, the jacket can be opened along a line extending from the
upper end 12' to the lower end 14' of jacket 10'. The jacket can
then be applied around the pericardial surface of the heart and the
opposing edges of the opened line secured together after placed on
the heart. Systems for securing the opposing edges are disclosed
in, for example, U.S. Pat. No. 5,702,343, the entire disclosure of
which is incorporated herein by reference. The lower end 14' can
then be secured to the diaphragm or associated tissues using, for
example, sutures, staples, etc.
[0056] In the embodiment of FIGS. 3 and 3A, the lower end 14 is
closed and the length L is sized for the apex A of the heart H to
be received within the lower end 14 when the upper end 12 is placed
at the A-V groove AVG. In the embodiment of FIGS. 4 and 4A, the
lower end 14' is open and the length L' is sized for the apex A of
the heart H to protrude beyond the lower end 14' when the upper end
12' is placed at the A-V groove AVG. The length L' is sized so that
the lower end 14' extends beyond the lower ventricular extremities
LE such that in both of jackets 10, 10', the myocardium MYO
surrounding the ventricles RV, LV is in direct opposition to
material of the jacket 10, 10'. Such placement is desirable for the
jacket 10, 10' to present a constraint against enlargement of the
ventricular walls of the heart H.
[0057] After the jacket 10 is positioned on the heart H as
described above, the jacket 10 is secured to the heart. Preferably,
the jacket 10 is secured to the heart H through sutures. The jacket
10 is sutured to the heart H at suture locations S
circumferentially spaced along the upper end 12. While a surgeon
may elect to add additional suture locations to prevent shifting of
the jacket 10 after placement, the number of such locations S is
preferably limited so that the jacket 10 does not restrict
contraction of the heart H during systole.
[0058] To permit the jacket 10 to be easily placed on the heart H,
the volume and shape of the jacket 10 are larger than the lower
portion LP during diastole. So sized, the jacket 10 may be easily
slipped around the heart H. Once placed, the jacket's volume and
shape are adjusted for the jacket 10 to snugly conform to the
external geometry of the heart H during diastole. Such sizing is
easily accomplished due to the knit construction of the jacket 10.
For example, excess material of the jacket 10 can be gathered and
sutured S" (FIG. 5) to reduce the volume of the jacket 10 and
conform the jacket 10 to the shape of the heart H during diastole.
Such shape represents a maximum adjusted volume. The jacket 10
constrains enlargement of the heart H beyond the maximum adjusted
volume while preventing restricted contraction of the heart H
during systole. As an alternative to gathering of FIG. 5, the
jacket 10 can be provided with other ways of adjusting volume. For
example, as disclosed in U.S. Pat. No. 5,702,343, the jacket can be
provided with a slot. The edges of the slot can be drawn together
to reduce the volume of the jacket.
[0059] The jacket 10 is adjusted to a snug fit on the heart H
during diastole. Care is taken to avoid tightening the jacket 10
too much such that cardiac function is impaired. During diastole,
the left ventricle LV fills with blood. If the jacket 10 is too
tight, the left ventricle LV cannot adequately expand and left
ventricular pressure will rise. During the fitting of the jacket
10, the surgeon can monitor left ventricular pressure. For example,
a well-known technique for monitoring so-called pulmonary wedge
pressure uses a catheter placed in the pulmonary artery. The wedge
pressure provides an indication of filling pressure in the left
atrium LA and left ventricle LV. While minor increases in pressure
(e.g., 2-3 mm Hg) can be tolerated, the jacket 10 is snugly fit on
the heart H but not so tight as to cause a significant increase in
left ventricular pressure during diastole.
[0060] As mentioned, the jacket 10 is constructed from a knit,
biocompatible material. The knit 18 is illustrated in FIG. 6.
Preferably, the knit is a so-called "Atlas knit" well known in the
fabric industry. The Atlas knit is described in Paling, Warp
Knitting Technology, p. 111, Columbine Press (Publishers) Ltd.,
Buxton, Great Britain (1970).
[0061] The Atlas knit is a knit of fibers 20 having directional
expansion properties. More specifically, the knit 18, although
formed of generally inelastic fibers 20, permits a construction of
a flexible fabric at least slightly expandable beyond a rest state.
FIG. 6 illustrates the knit 18 in a rest state. The fibers 20 of
the fabric 18 are woven into two sets of fiber strands 21a, 21b
having longitudinal axes X.sub.a and X.sub.b. The strands 21a, 21b
are interwoven to form the fabric 18 with strands 21a generally
parallel and spaced-apart and with strands 21b generally parallel
and spaced-apart.
[0062] For ease of illustration, fabric 18 is schematically shown
in FIG. 7 with the axis of the strands 21a, 21b only being shown.
The strands 21a, 21b are interwoven with the axes X.sub.a and
X.sub.b defining a diamond-shaped open cell 23 having diagonal axes
A.sub.m. In a preferred embodiment, the axes A.sub.m are 5 mm in
length when the fabric 18 is at rest and not stretched. The fabric
18 can stretch in response to a force. For any given force, the
fabric 18 stretches most when the force is applied parallel to the
diagonal axes A.sub.m. The fabric 18 stretches least when the force
is applied parallel to the strand axes X.sub.a and X.sub.b. The
jacket 10 is constructed for the material of the knit to be
directionally aligned for a diagonal axis A.sub.m to be parallel to
the heart's longitudinal axis AA-BB
[0063] While the jacket 10 is expandable due to the above described
knit pattern, the fibers 20 of the knit 18 are preferably
non-expandable. While all materials expand to at least a small
amount, the fibers 20 are preferably formed of a material with a
low modulus of elasticity. In response to the low pressures in the
heart H during diastole, the fibers 20 are non-elastic. In a
preferred embodiment, the fibers are 70 Denier polyester. While
polyester is presently preferred, other suitable materials include
polytetrafluoroethylene (PTFE), expanded PTFE (ePTFE),
polypropylene and stainless steel.
[0064] The knit material has numerous advantages. Such a material
is flexible to permit unrestricted movement of the heart H (other
than the desired constraint on circumferential expansion). The
material is open defining a plurality of interstitial spaces for
fluid permeability as well as minimizing the amount of surface area
of direct contact between the heart H and the material of the
jacket 10 (thereby minimizing areas of irritation or abrasion) to
minimize fibrosis and scar tissue.
[0065] The open areas of the knit construction also allows for
electrical connection between the heart and surrounding tissue for
passage of electrical current to and from the heart. For example,
although the knit material is an electrical insulator, the open
knit construction is sufficiently electrically permeable to permit
the use of trans-chest defibrillation of the heart. Also, the open,
flexible construction permits passage of electrical elements (e.g.,
pacer leads) through the jacket. Additionally, the open
construction permits other procedures, e.g., coronary bypass, to be
performed without removal of the jacket.
[0066] A large open area for cells 23 is desirable to minimize the
amount of surface area of the heart H in contact with the material
of the jacket 10 (thereby reducing fibrosis). However, if the cell
area 23 is too large, localized aneurysm can form. Also, a strand
21a, 21b can overly a coronary vessel with sufficient force to
partially block the vessel. A smaller cell size increases the
number of strands thereby decreasing the restricting force per
strand. Preferably, a maximum cell area is no greater than about
6.45 cm.sup.2 (about 2.54 cm by 2.54 cm) and, more preferably, is
about 0.25 cm.sup.2 (about 0.5 cm by 0.5 cm). The maximum cell area
is the area of a cell 23 after the material of the jacket 10 is
fully stretched and adjusted to the maximum adjusted volume on the
heart H as previously described.
[0067] The fabric 18 is preferably tear and run resistant. In the
event of a material defect or inadvertent tear, such a defect or
tear is restricted from propagation by reason of the knit
construction.
[0068] With the foregoing, a device and method have been taught to
treat cardiac disease. The jacket 10 constrains further undesirable
circumferential enlargement of the heart while not impeding other
motion of the heart H. With the benefits of the present teachings,
numerous modifications are possible. For example, the jacket 10
need not be directly applied to the epicardium (i.e., outer surface
of the myocardium) but could be placed over the parietal
pericardium. Further, an anti-fibrosis lining (such as a PTFE
coating on the fibers of the knit) could be placed between the
heart H and the jacket 10. Alternatively, the fibers 20 can be
coated with PTFE.
[0069] The jacket 10 is low-cost, easy to place and secure, and is
susceptible to use in minimally invasive procedures. The thin,
flexible fabric 18 permits the jacket 10 to be collapsed and passed
through a small diameter tube in a minimally invasive
procedure.
[0070] The jacket 10 can be used in early stages of congestive
heart disease. For patients facing heart enlargement due to viral
infection, the jacket 10 permits constraint of the heart H for a
sufficient time to permit the viral infection to pass. In addition
to preventing further heart enlargement, the jacket 10 treats
valvular disorders by constraining circumferential enlargement of
the valvular annulus and deformation of the ventricular walls.
[0071] The jacket 10, including the knit construction, freely
permits longitudinal and circumferential contraction of the heart H
(necessary for heart function). Unlike a solid wrap (such as a
muscle wrap in a cardiomyoplasty procedure), the fabric 18 does not
impede cardiac contraction. After fitting, the jacket 10 is
inelastic to prevent further heart enlargement while permitting
unrestricted inward movement of the ventricular walls. The open
cell structure permits access to coronary vessels for bypass
procedures subsequent to placement of the jacket 10. Also, in
cardiomyoplasty, the latissimus dorsi muscle has a variable and
large thickness (ranging from about 1 mm to 1 cm). The material of
the jacket 10 is uniformly thin (less than 1 mm thick). The thin
wall construction is less susceptible to fibrosis and minimizes
interference with cardiac contractile function.
[0072] Animal test studies on the device show the efficacy of the
invention. Test animals were provided with the device 10 of FIG. 3.
The animals' hearts were rapidly paced to induce enlargement. After
six weeks, animals without the device experienced significant heart
enlargement while those with the device experienced no significant
enlargement. Further, animals with the device had significantly
reduced mitral valve regurgitation.
[0073] In addition to the foregoing, the present invention can be
used to reduce heart size at the time of placement in addition to
preventing further enlargement. For example, the device can be
placed on the heart and sized snugly to urge the heart to a reduced
size. More preferably, the heart size can be reduced at the time
ofjacket placement through drugs (e.g., dobutamine, dopamine or
epinephrine or any other positive inotropic agents) to reduce the
heart size. The jacket of the present invention is then snugly
placed on the reduced sized heart and prevents enlargement beyond
the reduced size.
[0074] From the foregoing, a low cost, reduced risk method and
device are taught to treat cardiac disease. The invention is
adapted for use with both early and later stage congestive heart
disease patients. The invention reduces the enlargement rate of the
heart as well as reducing cardiac valve regurgitation.
* * * * *