U.S. patent application number 16/902373 was filed with the patent office on 2020-10-01 for prosthetic heart valve.
The applicant listed for this patent is Edwards Lifesciences Corporation. Invention is credited to George Bakis, Alexander J. Siegel.
Application Number | 20200306037 16/902373 |
Document ID | / |
Family ID | 1000004896961 |
Filed Date | 2020-10-01 |
![](/patent/app/20200306037/US20200306037A1-20201001-D00000.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00001.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00002.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00003.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00004.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00005.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00006.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00007.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00008.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00009.png)
![](/patent/app/20200306037/US20200306037A1-20201001-D00010.png)
View All Diagrams
United States Patent
Application |
20200306037 |
Kind Code |
A1 |
Siegel; Alexander J. ; et
al. |
October 1, 2020 |
PROSTHETIC HEART VALVE
Abstract
The present disclosure is directed to embodiments of
catheter-based prosthetic heart valves, and in particular,
prosthetic heart valves having sealing members configured to seal
the interface between the prosthetic valve and the surrounding
tissue of the native annulus in which the prosthetic valve is
implanted. In one embodiment, a prosthetic heart valve includes a
collapsible and expandable annular frame, a collapsible and
expandable valve member mounted within the annular frame, and a
collapsible and expandable sealing skirt mounted on the annular
frame, wherein the sealing skirt is a pile fabric and can contact
tissue surrounding the prosthetic valve when the prosthetic valve
is implanted within a native valve annulus.
Inventors: |
Siegel; Alexander J.;
(Irvine, CA) ; Bakis; George; (La Habra Heights,
CA) |
|
Applicant: |
Name |
City |
State |
Country |
Type |
Edwards Lifesciences Corporation |
Irvine |
CA |
US |
|
|
Family ID: |
1000004896961 |
Appl. No.: |
16/902373 |
Filed: |
June 16, 2020 |
Related U.S. Patent Documents
|
|
|
|
|
|
Application
Number |
Filing Date |
Patent Number |
|
|
16827612 |
Mar 23, 2020 |
|
|
|
16902373 |
|
|
|
|
16150035 |
Oct 2, 2018 |
10595993 |
|
|
16827612 |
|
|
|
|
14561102 |
Dec 4, 2014 |
10098734 |
|
|
16150035 |
|
|
|
|
61912231 |
Dec 5, 2013 |
|
|
|
Current U.S.
Class: |
1/1 ; 264/263;
264/269; 623/1.26; 623/2.24 |
Current CPC
Class: |
A61F 2240/001 20130101;
A61F 2250/006 20130101; A61F 2/2475 20130101; A61F 2250/0069
20130101; A61F 2210/0076 20130101; A61F 2/24 20130101; A61F 2/2418
20130101; A61F 2/2436 20130101; A61F 2250/0039 20130101; A61F
2220/0075 20130101; A61F 2/2439 20130101; A61F 2/2415 20130101;
B29C 49/26 20130101; B29K 2705/00 20130101; B29C 49/24 20130101;
B29K 2101/12 20130101; B29C 63/34 20130101; B29C 2049/2404
20130101 |
International
Class: |
A61F 2/24 20060101
A61F002/24; B29C 49/24 20060101 B29C049/24; B29C 49/26 20060101
B29C049/26 |
Claims
1. A prosthetic heart valve, comprising: a collapsible and
expandable annular frame that is configured to be collapsed to a
radially collapsed state for mounting on a delivery apparatus and
expanded to a radially expanded state inside the body, the frame
having an inflow end, an outflow end, and a longitudinal axis
extending from the inflow end to the outflow end, the frame
comprising a plurality of struts defining a plurality of rows of a
plurality of cells; a collapsible and expandable valve member
mounted within the annular frame; and a collapsible and expandable
sealing skirt mounted on the annular frame, wherein the sealing
skirt comprises a pile fabric and can contact tissue surrounding
the prosthetic valve when the prosthetic valve is implanted within
a native valve annulus.
2. The prosthetic heart valve of claim 1, wherein the pile fabric
is made of loop yarn.
3. The prosthetic heart valve of claim 2, wherein the loop yarn
comprises polyethylene terephthalate loop yarn.
4. The prosthetic heart valve of claim 1, wherein the sealing skirt
is sutured to the struts of the frame.
5. The prosthetic heart valve of claim 1, wherein the sealing skirt
extends beyond the inflow end of the prosthetic heart valve.
6. The prosthetic heart valve of claim 1, wherein the struts of the
frame are arranged in a plurality of circumferentially extending
rows of struts, and wherein the sealing skirt comprises an upper
edge and a lower edge, wherein the upper edge has an undulating
shape that corresponds to one of the circumferentially extending
rows of struts and the lower edge is straight.
7. The prosthetic heart valve of claim 1, wherein the sealing skirt
covers an entirety of a row of cells at the inflow end of the
frame.
8. The prosthetic heart valve of claim 1, further comprising an
additional fabric skirt positioned radially outward from the valve
member and radially inward from the sealing skirt.
9. The prosthetic heart valve of claim 8, wherein the valve member
comprises a plurality of leaflets, each having an inflow end
portion sutured to the additional fabric skirt along a scalloped
shaped suture line.
10. The prosthetic heart valve of claim 9, wherein the sealing
skirt covers an entirety of a row of cells at the inflow end of the
frame and wherein the additional fabric skirt covers an entirety of
another row of cells above an upper edge of the sealing skirt.
11. The prosthetic heart valve of claim 1, wherein the pile fabric
is made of textured yarn.
12. A prosthetic heart valve, comprising: a collapsible and
expandable annular frame that is configured to be collapsed to a
radially collapsed state for mounting on a delivery apparatus and
expanded to a radially expanded state inside the body, the frame
having an inflow end, an outflow end, and a longitudinal axis
extending from the inflow end to the outflow end, the frame
comprising a plurality of struts defining a plurality of rows of a
plurality of cells; a collapsible and expandable valve member
mounted within the annular frame, wherein the valve member
comprises a plurality of leaflets; a collapsible and expandable
first fabric skirt sutured to the struts of the frame, wherein each
leaflet has an inflow end portion sutured to the first fabric skirt
along a scalloped shaped suture line; and a collapsible and
expandable second fabric skirt positioned radially outward from the
first fabric skirt, wherein the second fabric skirt comprises a
pile fabric and can contact tissue surrounding the prosthetic valve
when the prosthetic valve is implanted within a native valve
annulus.
13. The prosthetic heart valve of claim 12, wherein the pile fabric
is made of loop yarn.
14. The prosthetic heart valve of claim 13, wherein the loop yarn
comprises polyethylene terephthalate loop yarn.
15. The prosthetic heart valve of claim 12, wherein the struts of
the frame are arranged in a plurality of circumferentially
extending rows of struts, including a first row of struts and a
second row of struts positioned above the first row of struts, and
wherein the second fabric skirt comprises an upper edge and a lower
edge, wherein the upper edge has an undulating shape that
corresponds to the first rows of struts and the lower edge is
straight.
16. The prosthetic heart valve of claim 15, wherein the first
fabric skirt comprises an upper edge and a lower edge, wherein the
upper edge of the first fabric skirt has an undulating shape that
corresponds to the second row of struts.
17. The prosthetic heart valve of claim 16, wherein the second
fabric skirt covers an entirety of a row of cells at the inflow end
of the frame.
18. The prosthetic heart valve of claim 17, wherein the first
fabric skirt covers an entirety of a row of cells defined between
the first and second row of struts.
19. A prosthetic heart valve, comprising: a collapsible and
expandable annular frame that is configured to be collapsed to a
radially collapsed state for mounting on a delivery apparatus and
expanded to a radially expanded state inside the body, the frame
having an inflow end, an outflow end, and a longitudinal axis
extending from the inflow end to the outflow end, the frame
comprising a plurality of circumferentially extending rows of
struts defining a plurality of rows of a plurality of cells,
wherein the rows of struts include a first row of struts and a
second row of struts positioned above the first row of struts; a
collapsible and expandable valve member mounted within the annular
frame, wherein the valve member comprises a plurality of leaflets;
a collapsible and expandable first fabric skirt comprising an upper
edge and a lower edge, wherein the upper edge of the first fabric
skirt has an undulating shape that corresponds to first row of
struts, wherein the upper edge of the first fabric skirt is sutured
to the struts of the first row of struts, wherein each leaflet has
an inflow end portion sutured to the first fabric skirt along a
scalloped shaped suture line; and a collapsible and expandable
second fabric skirt positioned radially outward from the first
fabric skirt, wherein the second fabric skirt comprises an upper
edge and a lower edge, wherein the upper edge of the second fabric
skirt has an undulating shape that corresponds to the second row of
struts, wherein the upper edge of the second fabric skirt is
sutured to the struts of the second row of struts, wherein the
second fabric skirt comprises a pile fabric made of loop yarn and
can contact tissue surrounding the prosthetic valve when the
prosthetic valve is implanted within a native valve annulus.
Description
CROSS-REFERENCE TO RELATED APPLICATIONS
[0001] This application is a continuation of U.S. patent
application Ser. No. 16/827,612, filed Mar. 23, 2020, which is a
continuation of U.S. patent application Ser. No. 16/150,035, filed
Oct. 2, 2018, now granted as U.S. Pat. No. 10,595,993, which is a
division of U.S. patent application Ser. No. 14/561,102 filed Dec.
4, 2014, now granted as U.S. Pat. No. 10,098,734, which claims the
benefit of U.S. Provisional Application No. 61/912,231, filed Dec.
5, 2013. Each of the foregoing is incorporated herein by
reference.
FIELD
[0002] The present disclosure concerns embodiments of a prosthetic
valve (e.g., prosthetic heart valve) and a delivery apparatus for
implanting a prosthetic valve, including introducer sheaths.
BACKGROUND
[0003] Prosthetic cardiac valves have been used for many years to
treat cardiac valvular disorders. The native heart valves (such as
the aortic, pulmonary and mitral valves) serve critical functions
in assuring the forward flow of an adequate supply of blood through
the cardiovascular system. These heart valves can be rendered less
effective by congenital, inflammatory, or infectious conditions.
Such damage to the valves can result in serious cardiovascular
compromise or death. For many years the definitive treatment for
such disorders was the surgical repair or replacement of the valve
during open-heart surgery, but such surgeries are prone to many
complications. More recently, a transvascular technique has been
developed for introducing and implanting a prosthetic heart valve
using a flexible catheter in a manner that is less invasive than
open heart surgery.
[0004] In this technique, a prosthetic valve is mounted in a
crimped state on the end portion of a flexible catheter and
advanced through a blood vessel of the patient until the prosthetic
valve reaches the implantation site. The prosthetic valve at the
catheter tip is then expanded to its functional size at the site of
the defective native valve, such as by inflating a balloon on which
the prosthetic valve is mounted. Alternatively, the prosthetic
valve can have a resilient, self-expanding stent or frame that
expands the prosthetic valve to its functional size when it is
advanced from a delivery sheath at the distal end of the
catheter.
[0005] The native valve annulus in which an expandable prosthetic
valve is deployed typically has an irregular shape mainly due to
calcification. As a result, small gaps may exist between the
expanded frame of the prosthetic valve and the surrounding tissue.
The gaps can allow for regurgitation (leaking) of blood flowing in
a direction opposite the normal flow of blood through the valve. To
minimize regurgitation, various sealing devices have been developed
that seal the interface between the prosthetic valve and the
surrounding tissue.
SUMMARY
[0006] The present disclosure is directed to embodiments of
catheter-based prosthetic heart valves, and in particular,
prosthetic heart valves having sealing members configured to seal
the interface between the prosthetic valve and the surrounding
tissue of the native annulus in which the prosthetic valve is
implanted. The present disclosure also discloses new methods of
making an introducer sheath with an inner liner for percutaneous
insertion of a medical device into a patient.
[0007] In one representative embodiment, a prosthetic heart valve
comprises a collapsible and expandable annular frame that is
configured to be collapsed to a radially collapsed state for
mounting on a delivery apparatus and expanded to a radially
expanded state inside the body. The frame has an inflow end, an
outflow end, and a longitudinal axis extending from the inflow end
to the outflow end, and comprises a plurality of struts defining a
plurality of rows of a plurality of cells. The prosthetic heart
valve also comprises a collapsible and expandable valve member
mounted within the annular frame, and a collapsible and expandable
skirt assembly mounted within the annular frame. The skirt assembly
comprises an upper skirt, a lower skirt, and a sealing skirt. The
upper and lower skirts prevent the sealing skirt from contacting
the valve member and can also couple the valve member to the
annular frame. When the annular frame is expanded to its radially
expanded state, portions of the sealing skirt protrude outwardly
through cells of the frame.
[0008] In particular embodiments, the sealing skirt is made of loop
yarn. In further embodiments, the sealing skirt is mounted within
the annular frame of the prosthetic heart valve by sutures that
secure the sealing skirt and the lower skirt to the frame of the
prosthetic heart valve. In additional embodiments, from the
longitudinal axis of the prosthetic heart valve, the valve member
is positioned radially outward from the lower skirt, the upper
skirt is positioned radially outward from the valve member; and the
sealing skirt is positioned radially outward from the upper skirt.
In more embodiments, an outflow portion of the lower skirt is
sutured to an inflow portion of the valve member; and the inflow
portion of the valve member is sutured to an inflow portion of the
upper skirt.
[0009] In another representative embodiment, a method of making an
introducer sheath with an inner liner for percutaneous insertion of
a medical device into a patient is provided. The method comprises
inserting a metal sleeve into a mold, inserting a polymer tube
comprising a closed end and an open end into the metal sleeve, and
pressurizing and heating the polymer tube to cause the polymer tube
to expand against an inner surface of the metal sleeve so as to
form the inner liner of the sheath.
[0010] In particular embodiments of the method, the preform
cylindrical polymer tube is made of nylon-12, polyethylene, or
fluorinated ethylene propylene (FEP). In further embodiments, the
inner liner formed from the polymer tube has a radial wall
thickness of from about 0.025 mm (about 0.001 inch) to about 0.075
mm (about 0.003 inch). In still more embodiments, the metal sleeve
has a radial wall thickness of from about 0.05 mm (about 0.002
inch) to about 0.15 mm (about 0.006 inch). Pressurizing and heating
the polymer tube can comprise injecting heated compressed gas into
the polymer tube. Alternatively, pressurizing the polymer tube can
comprise injecting compressed gas into the polymer tube and heating
the polymer tube can comprise heating with a heat source separate
from the pressurized gas. In several embodiments, the introducer
sheath is configured for percutaneous insertion of a prosthetic
heart valve through the femoral artery of the patient.
[0011] In several embodiments, the method can include forming an
introducer sheath with an inner liner and an outer liner for
percutaneous insertion of the medical device into the patient. In
some embodiments of the method, a preform cylindrical polymer tube
is used to form the outer liner. In particular embodiments, the
preform cylindrical polymer tube used to form the outer liner can
be made of nylon-12, polyether block amides, or polyethylene. In
further embodiments, the outer liner has a radial wall thickness of
from about 0.012 mm (about 0.0005 inch) to about 0.075 mm (about
0.003 inch).
[0012] The foregoing and other objects, features, and advantages of
the invention will become more apparent from the following detailed
description, which proceeds with reference to the accompanying
drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
[0013] FIG. 1 is a perspective view of a prosthetic valve that can
be used to replace the native aortic valve of the heart, according
to one embodiment.
[0014] FIG. 2 is a perspective view of a portion of the prosthetic
valve of FIG. 1 illustrating the connection of two leaflets to the
support frame of the prosthetic valve.
[0015] FIG. 3 is side elevation view of the support frame of the
prosthetic valve of FIG. 1.
[0016] FIG. 4 is a perspective view of the support frame of the
prosthetic valve of FIG. 1.
[0017] FIG. 5A is a cross-sectional view of the heart showing the
prosthetic valve of FIG. 1 implanted within the aortic annulus.
[0018] FIG. 5B is an enlarged view of FIG. 5A illustrating the
prosthetic valve implanted within the aortic annulus, shown with
the leaflet structure of the prosthetic valve removed for
clarity.
[0019] FIG. 6 is a perspective view of the leaflet structure of the
prosthetic valve of FIG. 1 shown prior to being secured to the
support frame.
[0020] FIG. 7 is a cross-sectional view of the prosthetic valve of
FIG. 1.
[0021] FIG. 8 is a cross-sectional view of an embodiment of a
delivery apparatus that can be used to deliver and implant a
prosthetic valve, such as the prosthetic valve shown in FIG. 1.
[0022] FIGS. 8A-8C are enlarged cross-sectional views of sections
of FIG. 8.
[0023] FIG. 9 is an exploded view of the delivery apparatus of FIG.
8.
[0024] FIG. 10 is a side view of the guide catheter of the delivery
apparatus of FIG. 8.
[0025] FIG. 11 is a perspective, exploded view of the proximal end
portion of the guide catheter of FIG. 10.
[0026] FIG. 12 is a perspective, exploded view of the distal end
portion of the guide catheter of FIG. 10.
[0027] FIG. 13 is a side view of the torque shaft catheter of the
delivery apparatus of FIG. 8.
[0028] FIG. 14 is an enlarged side view of the rotatable screw of
the torque shaft catheter of FIG. 13.
[0029] FIG. 15 is an enlarged perspective view of a coupling member
disposed at the end of the torque shaft.
[0030] FIG. 16 is an enlarged perspective view of the threaded nut
used in the torque shaft catheter of FIG. 13.
[0031] FIG. 17 is an enlarged side view of the distal end portion
of the nose cone catheter of the delivery apparatus of FIG. 8.
[0032] FIG. 17A is an enlarged, cross-sectional view of the nose
cone of the catheter shown FIG. 17.
[0033] FIG. 17B is an enlarged cross-sectional view of the distal
end portion of the delivery apparatus of FIG. 8 showing the stent
of a prosthetic valve retained in a compressed state within a
delivery sheath.
[0034] FIG. 18 is an enlarged side view of the distal end portion
of the delivery apparatus of FIG. 8 showing the delivery sheath in
a delivery position covering a prosthetic valve in a compressed
state for delivery into a patient.
[0035] FIG. 19 is an enlarged cross-sectional view of a section of
the distal end portion of the delivery apparatus of FIG. 8 showing
the valve-retaining mechanism securing the stent of a prosthetic
valve to the delivery apparatus.
[0036] FIG. 20 is an enlarged cross-sectional view similar to FIG.
19, showing the inner fork of the valve-retaining mechanism in a
release position for releasing the prosthetic valve from the
delivery apparatus.
[0037] FIGS. 21 and 22 are enlarged side views of distal end
portion of the delivery apparatus of FIG. 8, illustrating the
operation of the torque shaft for deploying a prosthetic valve from
a delivery sheath.
[0038] FIGS. 23-26 are various views of an embodiment of a
motorized delivery apparatus that can be used to operate the torque
shaft of the delivery apparatus shown in FIG. 8.
[0039] FIG. 27 is a perspective view of an alternative motor that
can be used to operate the torque shaft of the delivery apparatus
shown in FIG. 8.
[0040] FIG. 28A is an enlarged view of a distal segment of the
guide catheter shaft of FIG. 10.
[0041] FIG. 28B shows the cut pattern for forming the portion of
the shaft shown in FIG. 28A, such as by laser cutting a metal
tube.
[0042] FIG. 29A is an enlarged view of a distal segment of a guide
catheter shaft, according to another embodiment.
[0043] FIG. 29B shows the cut pattern for forming the shaft of FIG.
29A, such as by laser cutting a metal tube.
[0044] FIG. 30 is a perspective view of a prosthetic valve secured
to the end of a delivery apparatus, according to one
embodiment.
[0045] FIG. 31 is a perspective view of a prosthetic valve that can
be used to replace the native aortic valve of the heart, according
to another embodiment.
[0046] FIG. 32 is a perspective view of the leaflet structure, also
showing the skirt including an upper and lower skirt, of the
prosthetic valve of FIG. 31 shown prior to being secured to the
support frame.
[0047] FIG. 33 is a cross-sectional view of the prosthetic valve of
FIG. 31 illustrating the configuration of the valve frame, the
leaflets, the upper skirt, the lower skirt, and the sealing skirt,
in one embodiment.
[0048] FIG. 34 is a diagram of the sealing skirt before attachment
to the valve frame, in one embodiment.
[0049] FIG. 35 is a perspective view of a prosthetic valve
including a sealing skirt that can be used to replace the native
aortic valve of the heart, according to one embodiment.
[0050] FIG. 36 is a perspective view of a portion of the prosthetic
valve of FIG. 35 illustrating the sealing skirt and its connection
to the support frame of the prosthetic valve, in one
embodiment.
[0051] FIG. 37 is a perspective view similar to FIG. 36
illustrating a modification of the sealing skirt.
[0052] FIG. 38 is a perspective view similar to FIG. 36
illustrating a modification of the sealing skirt.
[0053] FIG. 39 is a perspective view of a portion of the prosthetic
valve of FIG. 35 illustrating another configuration of the sealing
skirt.
[0054] FIG. 40A is a perspective view of an introducer sheath,
according to another embodiment.
[0055] FIG. 40B is an enlarged, perspective view of the sleeve of
the introducer sheath of FIG. 40A.
[0056] FIG. 41 is an enlarged, perspective view of another
embodiment of a sleeve that can be used with the introducer sheath
of FIG. 40A.
[0057] FIG. 42 is an end view of a sleeve that can be used with the
introducer sheath of FIG. 40A.
[0058] FIG. 43 is a perspective view of a segment of a sleeve of an
introducer sheath, according to another embodiment.
[0059] FIG. 44 is a side elevation view of a metal sleeve for an
introducer sheath, according to another embodiment.
[0060] FIG. 45 shows the cut pattern for forming the metal sleeve
of FIG. 43.
[0061] FIG. 46 shows the cut pattern for forming the metal sleeve
of FIG. 44.
[0062] FIG. 47 shows a cut pattern similar to FIG. 46 but having
narrower apertures.
[0063] FIGS. 48 and 49 are cross-sectional views illustrating a
method of molding an inner liner for a metal sleeve of an
introducer sheath.
DETAILED DESCRIPTION
[0064] For purposes of this description, certain aspects,
advantages, and novel features of the embodiments of this
disclosure are described herein. The described methods, systems,
and apparatus should not be construed as limiting in any way.
Instead, the present disclosure is directed toward all novel and
nonobvious features and aspects of the various disclosed
embodiments, alone and in various combinations and sub-combinations
with one another. The disclosed methods, systems, and apparatus are
not limited to any specific aspect, feature, or combination
thereof, nor do the disclosed methods, systems, and apparatus
require that any one or more specific advantages be present or
problems be solved.
[0065] Although the operations of some of the disclosed methods are
described in a particular, sequential order for convenient
presentation, it should be understood that this manner of
description encompasses rearrangement, unless a particular ordering
is required by specific language set forth below. For example,
operations described sequentially may in some cases be rearranged
or performed concurrently. Moreover, for the sake of simplicity,
the attached drawings may not show the various ways in which the
disclosed methods, systems, and apparatus can be used in
conjunction with other systems, methods, and apparatus.
[0066] As used herein, the terms "a", "an", and "at least one"
encompass one or more of the specified element. That is, if two of
a particular element are present, one of these elements is also
present and thus "an" element is present. The terms "a plurality
of" and "plural" mean two or more of the specified element.
[0067] As used herein, the term "and/or" used between the last two
of a list of elements means any one or more of the listed elements.
For example, the phrase "A, B, and/or C" means "A", "B", "C", "A
and B", "A and C", "B and C", or "A, B, and C".
[0068] As used herein, the term "coupled" generally means
physically coupled or linked and does not exclude the presence of
intermediate elements between the coupled items absent specific
contrary language.
[0069] Referring first to FIG. 1, there is shown a prosthetic
aortic heart valve 10, according to one embodiment. The prosthetic
valve 10 includes an expandable frame member, or stent, 12 that
supports an expandable valve member, which in the illustrated
embodiment comprises a flexible leaflet section 14. The prosthetic
valve 10 is radially compressible to a compressed state for
delivery through the body to a deployment site and expandable to
its functional size shown in FIG. 1 at the deployment site. In
certain embodiments, the prosthetic valve 10 is self-expanding;
that is, the prosthetic valve can radially expand to its functional
size when advanced from the distal end of a delivery sheath.
Apparatuses particularly suited for percutaneous delivery and
implantation of a self-expanding prosthetic valve are described in
detail below. In other embodiments, the prosthetic valve can be a
balloon-expandable prosthetic valve that can be adapted to be
mounted in a compressed state on the balloon of a delivery
catheter. The prosthetic valve can be expanded to its functional
size at a deployment site by inflating the balloon, as known in the
art.
[0070] The illustrated prosthetic valve 10 is adapted to be
deployed in the native aortic annulus, although it also can be used
to replace the other native valves of the heart (the mitral,
tricuspid, and pulmonary valves). Moreover, the prosthetic valve 10
can be adapted to replace other valves within the body, such venous
valves.
[0071] FIGS. 3 and 4 show the stent 12 without the leaflet section
14 for purposes of illustration. As shown, the stent 12 can be
formed from a plurality of longitudinally extending, generally
sinusoidal-shaped frame members, or struts, 16. The struts 16 are
formed with alternating bends and are welded or otherwise secured
to each other at nodes 18 formed from the vertices of adjacent
bends so as to form a mesh structure. The struts 16 can be made of
a suitable shape memory material, such as the nickel titanium alloy
known as Nitinol, that allows the prosthetic valve to be compressed
to a reduced diameter for delivery in a delivery apparatus (such as
described below) and then causes the prosthetic valve to expand to
its functional size inside the patient's body when deployed from
the delivery apparatus. If the prosthetic valve is a
balloon-expandable prosthetic valve that is adapted to be crimped
onto an inflatable balloon of a delivery apparatus and expanded to
its functional size by inflation of the balloon, the stent 12 can
be made of a suitable ductile material, such as stainless
steel.
[0072] The stent 12 has an inflow end 26 and an outflow end 27. The
mesh structure formed by struts 16 comprises a generally
cylindrical "upper" or outflow end portion 20, an outwardly bowed
or distended intermediate section 22, and an inwardly bowed "lower"
or inflow end portion 24. The intermediate section 22 desirably is
sized and shaped to extend into the sinuses of Valsalva in the
aortic root to assist in anchoring the prosthetic valve in place
once implanted. As shown, the mesh structure desirably has a curved
shape along its entire length that gradually increases in diameter
from the outflow end portion 20 to the intermediate section 22,
then gradually decreases in diameter from the intermediate section
22 to a location on the inflow end portion 24, and then gradually
increases in diameter to form a flared portion terminating at the
inflow end 26.
[0073] When the prosthetic valve is in its expanded state, the
intermediate section 22 has a diameter D.sub.1, the inflow end
portion lower section 24 has a minimum diameter D.sub.2, the inflow
end 26 has a diameter D.sub.3, and the outflow end portion 20 has a
diameter D.sub.4, where D.sub.2 is less than D.sub.1 and D.sub.3,
and D.sub.4 is less than Dz. In addition, D.sub.1 and D.sub.3
desirably are greater than the diameter of the native annulus in
which the prosthetic valve is to be implanted. In this manner, the
overall shape of the stent 12 assists in retaining the prosthetic
valve at the implantation site. More specifically, and referring to
FIGS. 5A and 5B, the prosthetic valve 10 can be implanted within a
native valve (the aortic valve in the illustrated example) such
that the lower section 24 is positioned within the aortic annulus
28, the intermediate section 22 extends above the aortic annulus
into the sinuses of Valsalva 56, and the lower flared end 26
extends below the aortic annulus. The prosthetic valve 10 is
retained within the native valve by the radial outward force of the
lower section 24 against the surrounding tissue of the aortic
annulus 28 as well as the geometry of the stent. Specifically, the
intermediate section 22 and the flared lower end 26 extend radially
outwardly beyond the aortic annulus 28 to better resist against
axial dislodgement of the prosthetic valve in the downstream and
upstream directions (toward and away from the aorta). Depending on
the condition of the native leaflets 58, the prosthetic valve
typically is deployed within the native annulus 28 with the native
leaflets 58 folded upwardly and compressed between the outer
surface of the stent 12 and the walls of the sinuses of Valsalva
56, as depicted in FIG. 5B. In some cases, it may be desirable to
excise the leaflets 58 prior to implanting the prosthetic valve
10.
[0074] Known prosthetic valves having a self-expanding frame
typically have additional anchoring devices or frame portions that
extend into and become fixed to non-diseased areas of the
vasculature. Because the shape of the stent 12 assists in retaining
the prosthetic valve, additional anchoring devices are not required
and the overall length L of the stent can be minimized to prevent
the stent upper portion 20 from extending into the non-diseased
area of the aorta, or to at least minimize the extent to which the
upper portion 20 extends into the non-diseased area of the aorta.
Avoiding the non-diseased area of the patient's vasculature helps
avoid complications if future intervention is required. For
example, the prosthetic valve can be more easily removed from the
patient because the stent is primarily anchored to the diseased
part of the native valve. Furthermore, a shorter prosthetic valve
is more easily navigated around the aortic arch.
[0075] In particular embodiments, for a prosthetic valve intended
for use in a 22-mm to 24-mm annulus, the diameter D.sub.1 is from
about 28 mm to about 32 mm, with about 30 mm being a specific
example; the diameter D.sub.2 is from about 24 mm to about 28 mm,
with about 26 mm being a specific example; the diameter D.sub.3 is
from about 28 mm to about 32 mm, with about 30 mm being a specific
example; and the diameter D.sub.4 is from about 24 mm to about 28
mm, with about 26 mm being a specific example. The length L in
particular embodiments is from about 20 mm to about 24 mm, with
about 22 mm being a specific example.
[0076] Referring to FIG. 1, the stent 12 can have a plurality of
angularly spaced retaining arms, or projections, in the form of
posts 30 (three in the illustrated embodiment) that extend from the
stent upper portion 20. Each retaining arm 30 has a respective
aperture 32 that is sized to receive prongs of a valve-retaining
mechanism that can be used to form a releasable connection between
the prosthetic valve and a delivery apparatus (described below). In
alternative embodiments, the retaining arms 30 need not be provided
if a valve-retaining mechanism is not used.
[0077] As best shown in FIGS. 6 and 7, the leaflet assembly 14 in
the illustrated embodiment comprises three leaflets 34a, 34b, 34c
made of a flexible material. Each leaflet has an inflow end portion
60 and an outflow end portion 62. The leaflets can comprise any
suitable biological material (e.g., pericardial tissue, such as
bovine or equine pericardium), bio-compatible synthetic materials,
or other such materials, such as those described in U.S. Pat. No.
6,730,118, which is incorporated herein by reference. The leaflet
assembly 14 can include an annular reinforcing skirt 42 that is
secured to the inflow end portions of the leaflets 34a, 34b, 34c at
a suture line 44 adjacent the inflow end of the prosthetic valve.
The inflow end portion of the leaflet assembly 14 can be secured to
the stent 12 by suturing the skirt 42 to struts 16 of the lower
section 24 of the stent (best shown in FIG. 1). As shown in FIG. 7,
the leaflet assembly 14 can further include an inner reinforcing
strip 46 that is secured to the inner surfaces of the inflow end
portions 60 of the leaflets.
[0078] Referring to FIGS. 1 and 2, the outflow end portion of the
leaflet assembly 14 can be secured to the upper portion of the
stent 12 at three angularly spaced commissure attachments of the
leaflets 34a, 34b, and 34c. As best shown in FIG. 2, each
commissure attachment can be formed by wrapping a reinforcing
section 36 around adjacent upper edge portions 38 of a pair of
leaflets at the commissure formed by the two leaflets and securing
the reinforcing section 36 to the edge portions 38 with sutures 48.
The sandwiched layers of the reinforcing material and leaflets can
then be secured to the struts 16 of the stent 12 with sutures 50
adjacent the outflow end of the stent. The leaflets therefore
desirably extend the entire length or substantially the entire
length of the stent from the inflow end 26 to the outflow end 27.
The reinforcing sections 36 reinforces the attachment of the
leaflets to the stent so as to minimize stress concentrations at
the suture lines and avoid "needle holes" on the portions of the
leaflets that flex during use. The reinforcing sections 36, the
skirt 42, and the inner reinforcing strip 46 (FIG. 7) desirably are
made of a bio-compatible synthetic material, such as
polytetrafluoroethylene (PTFE), or a woven fabric material, such as
woven polyester (e.g., polyethylene terephthalate) (PET),
DACRON.RTM.).
[0079] FIG. 7 shows the operation of the prosthetic valve 10.
During diastole, the leaflets 34a, 34b, 34c collapse to effectively
close the prosthetic valve. As shown, the curved shape of the
intermediate section 22 of the stent 12 defines a space between the
intermediate section and the leaflets that mimics the sinuses of
Valsalva. Thus, when the leaflets close, backflow entering the
"sinuses" creates a turbulent flow of blood along the upper
surfaces of the leaflets, as indicated by arrows 52. This
turbulence assists in washing the leaflets and the skirt 42 to
minimize or reduce clot formation.
[0080] The prosthetic valve 10 can be implanted in a retrograde
approach where the prosthetic valve, mounted in a crimped state at
the distal end of a delivery apparatus, is introduced into the body
via the femoral artery and advanced through the aortic arch to the
heart, as further described in U.S. Patent Application Publication
No. 2008/0065011, which is incorporated herein by reference.
[0081] FIGS. 8 and 9 show a delivery apparatus 100, according to
one embodiment, that can be used to deliver a self-expanding
prosthetic valve, such as prosthetic valve 10 described above,
through a patient's vasculature. The delivery apparatus 100
comprises a first, outermost or main catheter 102 (shown alone in
FIG. 10) having an elongated shaft 104, the distal end of which is
coupled to a delivery sheath 106 (FIG. 18; also referred to as a
delivery cylinder). The proximal end of the main catheter 102 is
connected to a handle of the delivery apparatus. FIGS. 23-26 show
an embodiment of a handle mechanism having an electric motor for
operating the delivery apparatus. The handle mechanism is described
in detail below. During delivery of a prosthetic valve, the handle
can be used by a surgeon to advance and retract the delivery
apparatus through the patient's vasculature. Although not required,
the main catheter 102 can comprise a guide catheter that is
configured to allow a surgeon to guide or control the amount the
bending or flexing of a distal portion of the shaft 104 as it is
advanced through the patient's vasculature, such as further
described below. Another embodiment of a guide catheter is
disclosed in U.S. Patent Application Publication No. 2008/0065011,
which is incorporated herein by reference.
[0082] As best shown in FIG. 9, the delivery apparatus 100 also
includes a second, intermediate catheter 108 (also referred to
herein as a torque shaft catheter) having an elongated shaft 110
(also referred to herein as a torque shaft) and an elongated screw
112 connected to the distal end of the shaft 110. The shaft 110 of
the intermediate catheter 108 extends coaxially through the shaft
104 of the main catheter 102. The delivery apparatus 100 can also
include a third, nose-cone catheter 118 having an elongated shaft
120 and a nose piece, or nose cone, 122 secured to the distal end
portion of the shaft 120. The nose piece 122 can have a tapered
outer surface as shown for atraumatic tracking through the
patient's vasculature. The shaft 120 of the nose-cone catheter
extends through the prosthetic valve 10 (not shown in FIGS. 8-9)
and the shaft 110 of the intermediate catheter 108. In the
illustrated configuration, the innermost shaft 120 is configured to
be moveable axially and rotatably relative to the shafts 104, 110,
and the torque shaft 110 is configured to be rotatable relative to
the shafts 104, 120 to effect valve deployment and release of the
prosthetic valve from the delivery apparatus, as described in
detail below. Additionally, the innermost shaft 120 can have a
lumen for receiving a guide wire so that the delivery apparatus can
be advanced over the guide wire inside the patient's
vasculature.
[0083] As best shown in FIG. 10, the outer catheter 102 can
comprise a flex control mechanism 168 at a proximal end thereof to
control the amount the bending or flexing of a distal portion of
the outer shaft 104 as it is advanced through the patient's
vasculature, such as further described below. The outer shaft 104
can comprise a proximal segment 166 that extends from the flex
control mechanism 168 and a distal segment 126 that comprises a
slotted metal tube that increases the flexibility of the outer
shaft at this location. The distal end portion of the distal
segment 126 can comprises an outer fork 130 of a valve-retaining
mechanism 114 (FIGS. 8 and 8B) that is configured to releasably
secure a prosthetic valve 10 to the delivery apparatus 100 during
valve delivery, as described in detail below.
[0084] FIG. 28A is an enlarged view of a portion of the distal
segment 126 of the outer shaft 104. FIG. 28B shows the cut pattern
that can be used to form the distal segment 126 by laser cutting
the pattern in a metal tube. The distal segment 126 comprises a
plurality of interconnected circular bands or links 160 forming a
slotted metal tube. A pull wire 162 can be positioned inside the
distal segment 126 and can extend from a location 164 of the distal
segment 126 (FIGS. 10 and 12) to the flex control mechanism. The
distal end of the pull wire 162 can be secured to the inner surface
of the distal segment 126 at location 164, such as by welding. The
proximal end of the pull wire 162 can be operatively connected to
the flex control mechanism 168, which is configured to apply and
release tension to the pull wire in order to control bending of the
shaft, as further described below. The links 160 of the shaft and
the gaps between adjacent links are shaped to allow bending of the
shaft upon application of light pulling force on the pull wire 162.
In the illustrated embodiment, as best shown in FIG. 12, the distal
segment 126 is secured to a proximal segment 166 having a different
construction (e.g., one or more layers of polymeric tubing). In the
illustrated embodiment, the proximal segment 166 extends from the
flex control mechanism 168 to the distal segment 126 and therefore
makes up the majority of the length of the outer shaft 104. In
alternative embodiments, the entire length or substantially the
entire length of the outer shaft 104 can be formed from a slotted
metal tube comprising one or more sections of interconnected links
160. In any case, the use of a main shaft having such a
construction can allow the delivery apparatus to be highly
steerable.
[0085] The width of the links 160 can be varied to vary the
flexibility of the distal segment along its length. For example,
the links within the distal end portion of the slotted tube can be
relatively narrower to increase the flexibility of the shaft at
that location while the links within the proximal end portion of
the slotted tube can be relatively wider so that the shaft is
relatively less flexible at that location.
[0086] FIG. 29A shows an alternative embodiment of a distal
segment, indicated at 126', which can be formed, for example, by
laser cutting a metal tube. The segment 126' can comprise the
distal segment of an outer shaft of a delivery apparatus (as shown
in FIG. 12) or substantially the entire length of an outer shaft
can have the construction shown in FIG. 29A. FIG. 29B shows the cut
pattern for forming the segment 126'. In another embodiment, a
delivery apparatus can include a composite outer shaft comprising a
laser-cut metal tube laminated with a polymeric outer layer that is
fused within the gaps in the metal layer. In one example, a
composite shaft can comprise a laser cut metal tube having the cut
pattern of FIGS. 29A and 29B and a polymeric outer layer fused in
the gaps between the links 160 of the metal tube. In another
example, a composite shaft can comprise a laser cut metal tube
having the cut pattern of FIGS. 28A and 28B and a polymeric outer
layer fused in the gaps between the links 160 of the metal tube. A
composite shaft also can include a polymeric inner layer fused in
the gaps between the links 160 of the metal tube.
[0087] Referring to FIGS. 8A and 11, the flex control mechanism 168
can comprise a rotatable housing, or handle portion, 186 that
houses a slide nut 188 mounted on a rail 192. The slide nut 188 is
prevented from rotating within the housing by one or more rods 192,
each of which is partially disposed in a corresponding recess
within the rail 192 and a slot or recess on the inside of the nut
188. The proximal end of the pull wire 162 is secured to the nut
188. The nut 188 has external threads that engage internal threads
of the housing. Thus, rotating the housing 186 causes the nut 188
to move axially within the housing in the proximal or distal
direction, depending on the direction of rotation of the housing.
Rotating the housing in a first direction (e.g., clockwise), causes
the nut to travel in the proximal direction, which applies tension
to the pull wire 162, which causes the distal end of the delivery
apparatus to bend or flex. Rotating the housing in a second
direction (e.g., counterclockwise), causes the nut to travel in the
distal direction, which relieves tension in the pull wire 162 and
allows the distal end of the delivery apparatus to flex back to its
pre-flexed configuration under its own resiliency.
[0088] As best shown in FIG. 13, the torque shaft catheter 108
includes an annular projection in the form of a ring 128 (also
referred to as an anchoring disc) mounted on the distal end portion
of the torque shaft 110 adjacent the screw 112. The ring 128 is
secured to the outer surface of the torque shaft 110 such that it
cannot move axially or rotationally relative to the torque shaft.
The inner surface of the outer shaft 104 is formed with a feature,
such as a slot or recess, that receives the ring 128 in such a
manner that the ring and the corresponding feature on the inner
surface of the outer shaft 104 allow the torque shaft 110 to rotate
relative to the outer shaft 104 but prevent the torque shaft from
moving axially relative to the outer shaft. The corresponding
feature on the outer shaft 104 that receives the ring 128 can be
inwardly extending tab portions formed in the distal segment 126,
such as shown at 164 in FIG. 12. In the illustrated embodiment (as
best shown in FIG. 14), the ring 128 is an integral part of the
screw 112 (i.e., the screw 112 and the ring 128 are portions of
single component). Alternatively, the screw 112 and the ring are
separately formed components but are both fixedly secured to the
distal end of the torque shaft 110.
[0089] The torque shaft 110 desirably is configured to be rotatable
relative to the delivery sheath 106 to effect incremental and
controlled advancement of the prosthetic valve 10 from the delivery
sheath 106. To such ends, and according to one embodiment, the
delivery apparatus 100 can include a sheath retaining ring in the
form of a threaded nut 150 mounted on the external threads of the
screw 112. As best shown in FIG. 16, the nut 150 includes internal
threads 152 that engage the external threads of the screw and
axially extending legs 154. Each leg 154 has a raised distal end
portion that extends into and/or forms a snap fit connection with
openings 172 in the proximal end of the sheath 106 (as best shown
in FIG. 18) so as to secure the sheath 106 to the nut 150. As
illustrated in FIGS. 17B and 18, the sheath 106 extends over the
prosthetic valve 10 and retains the prosthetic valve in a radially
compressed state until the sheath 106 is retracted by the user to
deploy the prosthetic valve.
[0090] As best shown in FIGS. 21 and 22, the outer fork 130 of the
valve-retaining mechanism comprises a plurality of prongs 134, each
of which extends through a region defined between two adjacent legs
154 of the nut so as to prevent rotation of the nut relative to the
screw 112 upon rotation of the screw. As such, rotation of the
torque shaft 110 (and thus the screw 112) causes corresponding
axial movement of the nut 150. The connection between the nut 150
and the sheath 106 is configured such that axially movement of the
nut along the screw 112 (in the distal or proximal direction)
causes the sheath 106 to move axially in the same direction
relative to the screw and the valve-retaining mechanism. FIG. 21
shows the nut 150 in a distal position wherein the sheath 106 (not
shown in FIG. 21) extends over and retains the prosthetic valve 10
in a compressed state for delivery. Movement of the nut 150 from
the distal position (FIG. 21) to a proximal position (FIG. 22)
causes the sheath 106 to move in the proximal direction, thereby
deploying the prosthetic valve from the sheath 106. Rotation of the
torque shaft 110 to effect axial movement of the sheath 106 can be
accomplished with a motorized mechanism or by manually turning a
crank or wheel (e.g., as described in U.S. Patent Application
Publication No. 2012/0239142, which is incorporated by reference
herein in its entirety).
[0091] FIG. 17 shows an enlarged view of the nose cone 122 secured
to the distal end of the innermost shaft 120. The nose cone 122 in
the illustrated embodiment includes a proximal end portion 174 that
is sized to fit inside the distal end of the sheath 106. An
intermediate section 176 of the nose cone is positioned immediately
adjacent the end of the sheath in use and is formed with a
plurality of longitudinal grooves or recessed portions 178. The
diameter of the intermediate section 176 at its proximal end 180
desirably is slightly larger than the outer diameter of the sheath
106. The proximal end 180 can be held in close contact with the
distal end of the sheath 106 to protect surrounding tissue from
coming into contact with the metal edge of the sheath. The grooves
178 allow the intermediate section to be compressed radially as the
delivery apparatus is advanced through an introducer sheath. This
allows the nose cone 122 to be slightly oversized relative to the
inner diameter of the introducer sheath. FIG. 17B shows a
cross-section the nose cone 122 and the sheath 106 in a delivery
position with the prosthetic valve retained in a compressed
delivery state inside the sheath 106 (for purposes of illustration,
only the stent 12 of the prosthetic valve is shown). As shown, the
proximal end 180 of the intermediate section 176 can abut the
distal end of the sheath 106 and a tapered proximal surface 182 of
the nose cone can extend within a distal portion of the stent
12.
[0092] As noted above, the delivery apparatus 100 can include a
valve-retaining mechanism 114 (FIG. 8B) for releasably retaining a
stent 12 of a prosthetic valve. The valve-retaining mechanism 114
can include a first valve-securement component in the form of an
outer fork 130 (as best shown in FIG. 12) (also referred to as an
"outer trident" or "release trident"), and a second
valve-securement component in the form of an inner fork 132 (as
best shown in FIG. 17) (also referred to as an "inner trident" or
"locking trident"). The outer fork 130 cooperates with the inner
fork 132 to form a releasably connection with the retaining arms 30
of the stent 12.
[0093] The proximal end of the outer fork 130 is connected to the
distal segment 126 of the outer shaft 104 and the distal end of the
outer fork is releasably connected to the stent 12. In the
illustrated embodiment, the outer fork 130 and the distal segment
126 can be integrally formed as a single component (e.g., the outer
fork and the distal segment can be laser cut or otherwise machined
from a single piece of metal tubing), although these components can
be separately formed and subsequently connected to each other. The
inner fork 132 can be mounted on the nose catheter shaft 120 (as
best shown in FIG. 17). The inner fork 132 connects the stent to
the distal end portion of the nose catheter shaft 120. The nose
catheter shaft 120 can be moved axially relative to the outer shaft
104 to release the prosthetic valve from the valve-retaining
mechanism, as further described below.
[0094] As best shown in FIG. 12, the outer fork 130 includes a
plurality of angularly-spaced prongs 134 (three in the illustrated
embodiment) corresponding to the retaining arms 30 of the stent 12,
which prongs extend from the distal end of distal segment 126. The
distal end portion of each prong 134 includes a respective opening
140. As best shown in FIG. 17, the inner fork 132 includes a
plurality of angularly-spaced prongs 136 (three in the illustrated
embodiment) corresponding to the retaining arms 30 of the stent 12,
which prongs extend from a base portion 138 at the proximal end of
the inner fork. The base portion 138 of the inner fork is fixedly
secured to the nose catheter shaft 120 (e.g., with a suitable
adhesive) to prevent axial and rotational movement of the inner
fork relative to the nose catheter shaft 120.
[0095] Each prong of the outer fork 130 cooperates with a
corresponding prong 136 of the inner fork to form a releasable
connection with a retaining arm 30 of the stent. In the illustrated
embodiment, for example, the distal end portion of each prong 134
is formed with an opening 140. When the prosthetic valve is secured
to the delivery apparatus (as best shown in FIG. 19), each
retaining arm 30 of the stent 12 extends inwardly through an
opening 140 of a prong 134 of the outer fork and a prong 136 of the
inner fork is inserted through the opening 32 of the retaining arm
30 so as to retain the retaining arm 30 from backing out of the
opening 140. FIG. 30 also shows the prosthetic valve 10 secured to
the delivery apparatus by the inner and outer forks before the
prosthetic valve is loaded into the sheath 106. The threaded nut
150 can be seen positioned between the prongs of the outer fork
130. The prosthetic valve 10 is ready to be compressed and loaded
into the sheath 106 of a delivery apparatus. Retracting the inner
prongs 136 proximally (in the direction of arrow 184 in FIG. 20) to
remove the prongs from the openings 32 is effective to release the
prosthetic valve 10 from the retaining mechanism. When the inner
fork 132 is moved to a proximal position (FIG. 20), the retaining
arms 30 of the stent can move radially outwardly from the openings
140 in the outer fork 130 under the resiliency of the stent. In
this manner, the valve-retaining mechanism 114 forms a releasable
connection with the prosthetic valve that is secure enough to
retain the prosthetic valve relative to the delivery apparatus to
allow the user to fine tune or adjust the position of the
prosthetic valve after it is deployed from the delivery sheath.
When the prosthetic valve is positioned at the desired implantation
site, the connection between the prosthetic valve and the retaining
mechanism can be released by retracting the nose catheter shaft 120
relative to the outer shaft 104 (which retracts the inner fork 132
relative to the outer fork 130).
[0096] Once the prosthetic valve 10 is loaded in the delivery
sheath 106, the delivery apparatus 100 can be inserted into the
patient's body for delivery of the prosthetic valve. In one
approach, the prosthetic valve can be delivered in a retrograde
procedure where delivery apparatus is inserted, for example, into a
femoral artery and advanced through the patient's vasculature to
the heart. Prior to insertion of the delivery apparatus, an
introducer sheath can be inserted into the femoral artery followed
by a guide wire, which is advanced through the patient's
vasculature through the aorta and into the left ventricle. The
delivery apparatus 100 can then be inserted through the introducer
sheath and advanced over the guide wire until the distal end
portion of the delivery apparatus containing the prosthetic valve
10 is advanced to a location adjacent to or within the native
aortic valve.
[0097] Thereafter, the prosthetic valve 10 can be deployed from the
delivery apparatus 100 by rotating the torque shaft 110 relative to
the outer shaft 104. As described below, the proximal end of the
torque shaft 110 can be operatively connected to a manually
rotatable handle portion or a motorized mechanism that allows the
surgeon to effect rotation of the torque shaft 110 relative to the
outer shaft 104. Rotation of the torque shaft 110 and the screw 112
causes the nut 150 and the sheath 106 to move in the proximal
direction toward the outer shaft (FIG. 22), which deploys the
prosthetic valve from the sheath. Rotation of the torque shaft 110
causes the sheath to move relative to the prosthetic valve in a
precise and controlled manner as the prosthetic valve advances from
the open distal end of the delivery sheath and begins to expand.
Hence, unlike known delivery apparatus, as the prosthetic valve
begins to advance from the delivery sheath and expand, the
prosthetic valve is held against uncontrolled movement from the
sheath caused by the expansion force of the prosthetic valve
against the distal end of the sheath. In addition, as the sheath
106 is retracted, the prosthetic valve 10 is retained in a
stationary position relative to the ends of the inner shaft 120 and
the outer shaft 104 by virtue of the valve-retaining mechanism 114.
As such, the prosthetic valve 10 can be held stationary relative to
the target location in the body as the sheath is retracted.
Moreover, after the prosthetic valve is partially advanced from the
sheath, it may be desirable to retract the prosthetic valve back
into the sheath, for example, to reposition the prosthetic valve or
to withdraw the prosthetic valve entirely from the body. The
partially deployed prosthetic valve can be retracted back into the
sheath by reversing the rotation of the torque shaft, which causes
the sheath 106 to advance back over the prosthetic valve in the
distal direction.
[0098] In known delivery devices, the surgeon must apply push-pull
forces to the shaft and/or the sheath to unsheathe the prosthetic
valve. It is therefore difficult to transmit forces to the distal
end of the device without distorting the shaft (e.g., compressing
or stretching the shaft axially), which in turn causes uncontrolled
movement of the prosthetic valve during the unsheathing process. To
mitigate this effect, the shaft and/or sheath can be made more
rigid, which is undesirable because the device becomes harder to
steer through the vasculature. In contrast, the manner of
unsheathing the prosthetic valve described above eliminates the
application of push-pull forces on the shaft, as required in known
devices, so that relatively high and accurate forces can be applied
to the distal end of the shaft without compromising the flexibility
of the device. In certain embodiments, as much as about 90 N (about
20 lb) of force can be transmitted to the end of the torque shaft
without adversely affecting the unsheathing process. In contrast,
prior art devices utilizing push-pull mechanisms typically cannot
exceed about 20 N (5 lb) of force during the unsheathing
process.
[0099] After the prosthetic valve 10 is advanced from the delivery
sheath and expands to its functional size (the expanded prosthetic
valve 10 secured to the delivery apparatus is depicted in FIG. 30),
the prosthetic valve remains connected to the delivery apparatus
via the retaining mechanism 114. Consequently, after the prosthetic
valve is advanced from the delivery sheath, the surgeon can
reposition the prosthetic valve relative to the desired
implantation position in the native valve such as by moving the
delivery apparatus in the proximal and distal directions or side to
side, or rotating the delivery apparatus, which causes
corresponding movement of the prosthetic valve. The retaining
mechanism 114 desirably provides a connection between the
prosthetic valve and the delivery apparatus that is secure and
rigid enough to retain the position of the prosthetic valve
relative to the delivery apparatus against the flow of the blood as
the position of the prosthetic valve is adjusted relative to the
desired implantation position in the native valve. Once the surgeon
positions the prosthetic valve at the desired implantation position
in the native valve, the connection between the prosthetic valve
and the delivery apparatus can be released by retracting the
innermost shaft 120 in the proximal direction relative to the outer
shaft 104, which is effective to retract the inner fork 132 to
withdraw its prongs 136 from the openings 32 in the retaining arms
30 of the prosthetic valve (FIG. 20). Slightly retracting of the
outer shaft 104 allows the outer fork 130 to back off the retaining
arms 30 of the prosthetic valve, which slide outwardly through
openings 140 in the outer fork to completely disconnect the
prosthetic valve from the retaining mechanism 114. Thereafter, the
delivery apparatus can be withdrawn from the body, leaving the
prosthetic aortic valve 10 implanted within the native valve (such
as shown in FIGS. 5A and 5B).
[0100] The delivery apparatus 100 has at its distal end a
semi-rigid segment comprised of relatively rigid components used to
transform rotation of the torque shaft into axial movement of the
sheath. In particular, this semi-rigid segment in the illustrated
embodiment is comprised of the prosthetic valve and the screw 112.
An advantage of the delivery apparatus 100 is that the overall
length of the semi-rigid segment is minimized because the nut 150
is used rather than internal threads on the outer shaft to affect
translation of the sheath. The reduced length of the semi-rigid
segment increases the overall flexibility along the distal end
portion of the delivery catheter. Moreover, the length and location
of the semi-rigid segment remains constant because the torque shaft
does not translate axially relative to the outer shaft. As such,
the curved shape of the delivery catheter can be maintained during
valve deployment, which improves the stability of the deployment. A
further benefit of the delivery apparatus 100 is that the ring 128
prevents the transfer of axial loads (compression and tension) to
the section of the torque shaft 110 that is distal to the ring.
[0101] In an alternative embodiment, the delivery apparatus can be
adapted to deliver a balloon-expandable prosthetic valve. As
described above, the valve retaining mechanism 114 can be used to
secure the prosthetic valve to the end of the delivery apparatus.
Since the stent of the prosthetic valve is not self-expanding, the
sheath 106 can be optional. The retaining mechanism 114 enhances
the pushability of the delivery apparatus and prosthetic valve
assembly through an introducer sheath.
[0102] FIGS. 23-26 illustrate the proximal end portion of the
delivery apparatus 100, according to one embodiment. The delivery
apparatus 100 can comprise a handle 202 that is configured to be
releasably connectable to the proximal end portion of a catheter
assembly 204 comprising catheters 102, 108, 118. It may be
desirable to disconnect the handle 202 from the catheter assembly
204 for various reasons. For example, disconnecting the handle can
allow another device to be slid over the catheter assembly, such as
a valve-retrieval device or a device to assist in steering the
catheter assembly. It should be noted that any of the features of
the handle 202 and the catheter assembly 204 can be implemented in
any of the embodiments of the delivery apparatuses disclosed
herein.
[0103] FIGS. 23 and 24 show the proximal end portion of the
catheter assembly 204 partially inserted into a distal opening of
the handle 202. The proximal end portion of the main shaft 104 is
formed with an annular groove 212 (as best shown in FIG. 24) that
cooperates with a holding mechanism, or latch mechanism, 214 inside
the handle. When the proximal end portion of the catheter assembly
is fully inserted into the handle, as shown in FIGS. 25 and 26, an
engaging portion 216 of the holding mechanism 214 extends at least
partially into the groove 212. One side of the holding mechanism
214 is connected to a button 218 that extends through the housing
of the handle. The opposite side of the holding mechanism 214 is
contacted by a spring 220 that biases the holding mechanism to a
position engaging the main shaft 104 at the groove 212. The
engagement of the holding mechanism 214 within the groove 212
prevents axial separation of the catheter assembly from the handle.
The catheter assembly can be released from the handle by depressing
button 218, which moves the holding mechanism 214 from locking
engagement with the main shaft. Furthermore, the main shaft 104 can
be formed with a flat surface portion within the groove 212. The
flat surface portion is positioned against a corresponding flat
surface portion of the engaging portion 216. This engagement holds
the main shaft 104 stationary relative to the torque shaft 110 as
the torque shaft is rotated during valve deployment.
[0104] The proximal end portion of the torque shaft 110 can have a
driven nut 222 (FIG. 26) that is slidably received in a drive
cylinder 224 (FIG. 25) mounted inside the handle. The nut 222 can
be secured to the proximal end of the torque shaft 100 by securing
the nut 222 over a coupling member 170 (FIG. 15). FIG. 26 is a
perspective view of the inside of the handle 202 with the drive
cylinder and other components removed to show the driven nut and
other components positioned within the drive cylinder. The cylinder
224 has a through opening (or lumen) extending the length of the
cylinder that is shaped to correspond to the flats of the nut 222
such that rotation of the drive cylinder is effective to rotate the
nut 222 and the torque shaft 110. The drive cylinder can have an
enlarged distal end portion 236 that can house one or more seals
(e.g., O-rings 246) that form a seal with the outer surface of the
main shaft 104 (FIG. 25). The handle can also house a fitting 238
that has a flush port in communication with the lumen of the torque
shaft and/or the lumen of the main shaft.
[0105] The drive cylinder 224 is operatively connected to an
electric motor 226 through gears 228 and 230. The handle can also
house a battery compartment 232 that contains batteries for
powering the motor 226. Rotation of the motor in one direction
causes the torque shaft 110 to rotate, which in turn causes the
sheath 106 to retract and uncover a prosthetic valve at the distal
end of the catheter assembly. Rotation of the motor in the opposite
direction causes the torque shaft to rotate in an opposite
direction, which causes the sheath to move back over the prosthetic
valve. An operator button 234 on the handle allows a user to
activate the motor, which can be rotated in either direction to
un-sheath a prosthetic valve or retrieve an expanded or partially
expanded prosthetic valve.
[0106] As described above, the distal end portion of the nose
catheter shaft 120 can be secured to an inner fork 132 that is
moved relative to an outer fork 130 to release a prosthetic valve
secured to the end of the delivery apparatus. Movement of the shaft
120 relative to the main shaft 104 (which secures the outer fork
130) can be effected by a proximal end portion 240 of the handle
that is slidable relative to the main housing 244. The end portion
240 is operatively connected to the shaft 120 such that movement of
the end portion 240 is effective to translate the shaft 120 axially
relative to the main shaft 104 (causing a prosthetic valve to be
released from the inner and outer forks). The end portion 240 can
have flexible side panels 242 on opposite sides of the handle that
are normally biased outwardly in a locked position to retain the
end portion relative to the main housing 244. During deployment of
the prosthetic valve, the user can depress the side panels 242,
which disengage from corresponding features in the housing and
allow the end portion 240 to be pulled proximally relative to the
main housing, which causes corresponding axial movement of the
shaft 120 relative to the main shaft. Proximal movement of the
shaft 120 causes the prongs 136 of the inner fork 132 to disengage
from the apertures 32 in the stent 12, which in turn allows the
retaining arms 30 of the stent to deflect radially outwardly from
the openings 140 in the prongs 134 of the outer fork 130, thereby
releasing the prosthetic valve.
[0107] FIG. 27 shows an alternative embodiment of a motor,
indicated at 300, that can be used to drive a torque shaft (e.g.,
torque shaft 110). In this embodiment, a catheter assembly can be
connected directly to one end of a shaft 302 of the motor, without
gearing. The shaft 302 includes a lumen that allows for passage of
an innermost shaft (e.g., shaft 120) of the catheter assembly, a
guide wire, and/or fluids for flushing the lumens of the catheter
assembly.
[0108] Alternatively, the power source for rotating the torque
shaft 110 can be a hydraulic power source (e.g., hydraulic pump) or
pneumatic (air-operated) power source that is configured to rotate
the torque shaft. In another embodiment, the handle can have a
manually movable lever or wheel that is operable to rotate the
torque shaft 110.
[0109] In another embodiment, a power source (e.g., an electric,
hydraulic, or pneumatic power source) can be operatively connected
to a shaft, which is turn is connected to a prosthetic valve 10.
The power source is configured to reciprocate the shaft
longitudinally in the distal direction relative to a valve sheath
in a precise and controlled manner in order to advance the
prosthetic valve from the sheath. Alternatively, the power source
can be operatively connected to the sheath in order to reciprocate
the sheath longitudinally in the proximal direction relative to the
prosthetic valve to deploy the prosthetic valve from the
sheath.
[0110] Referring to FIG. 31, there is shown a prosthetic aortic
heart valve 410, according to another embodiment. Similar to the
prosthetic valve 10, the prosthetic valve 410 includes an
expandable frame member, or stent, 412 that supports an expandable
valve member, which in the illustrated embodiment comprises a
flexible leaflet section 414. Also, the prosthetic valve 410 is
radially compressible to a compressed state for delivery through
the body to a deployment site and expandable to its functional size
shown in FIG. 31 at the deployment site. In certain embodiments,
the prosthetic valve 410 is self-expanding; that is, the prosthetic
valve can radially expand to its functional size when advanced from
the distal end of a delivery sheath. In other embodiments, the
prosthetic valve can be a balloon-expandable prosthetic valve that
can be adapted to be mounted in a compressed state on the balloon
of a delivery catheter. The prosthetic valve can be expanded to its
functional size at a deployment site by inflating the balloon, as
known in the art. Apparatuses particularly suited for percutaneous
delivery and implantation of the prosthetic valve 10 (such as those
described herein) are also suitable for percutaneous delivery and
implantation of the prosthetic valve 410. The illustrated
prosthetic valve 410 is adapted to be deployed in the native aortic
annulus, although it also can be used to replace the other native
valves of the heart (the mitral, tricuspid and pulmonary valves).
Moreover, the prosthetic valve 410 can be adapted to replace other
valves within the body, such venous valves.
[0111] The frame member 412 of the prosthetic valve 410 can have
the same overall shape and construction as the frame member 12 of
the prosthetic valve 10. Thus, similar to the frame member 12, the
frame member 412 can be formed from a plurality of longitudinally
extending, generally sinusoidal shaped frame members, or struts,
416. Referring to FIG. 31, the stent 412 has an inflow end 426 and
an outflow end 427, and the mesh structure formed by the struts 416
comprises a generally cylindrical "upper" or outflow end portion
420, an outwardly bowed or distended intermediate section 422, and
an inwardly bowed "lower" or inflow end portion 424. Further, the
stent 412 can have a plurality of angularly spaced retaining arms,
or projections, in the form of posts 430 (three in the illustrated
embodiment) that extend from upper portion of the stent 412. Each
retaining arm 430 has a respective aperture 432 that is sized to
receive prongs of a valve-retaining mechanism that can be used to
form a releasable connection between the prosthetic valve and a
delivery apparatus (described above). In alternative embodiments,
the retaining arms 430 need not be provided if a valve-retaining
mechanism is not used. In further embodiments, the retaining arms
430 can extend from the lower portion of the stent 424, for
example, for applications involving antegrade implantation of the
valve (e.g., the delivery apparatus is inserted through a surgical
opening in the wall of the left ventricle of the heart in a
transventricular approach, such as an opening made at the bare spot
on the lower anterior ventricle wall).
[0112] The leaflet assembly 414 of the prosthetic aortic heart
valve 410 is similar to the leaflet assembly 14 of the prosthetic
aortic heart valve 10, although there are several differences,
described below. For example, with reference to FIGS. 32 and 33,
the leaflet assembly 414 comprises three leaflets 434a, 434b, 434c
made of a flexible material. Each leaflet has an inflow end portion
460 and an outflow end portion 462. The leaflets can comprise any
suitable biological material (e.g., pericardial tissue, such as
bovine or equine pericardium), bio-compatible synthetic materials,
or other such materials, such as those described in U.S. Pat. No.
6,730,118, which is incorporated herein by reference. The leaflet
assembly 414 can include an annular reinforcing skirt assembly 442
that is secured to the inflow end portions of the leaflets 434a,
434b, 434c at a suture line 444 adjacent the inflow end of the
prosthetic valve. The inflow end portion of the leaflet assembly
414 can be secured to the stent 412 by suturing the skirt assembly
442 to the struts 416 of the lower section 424 of the stent (best
shown in FIG. 31).
[0113] With reference to FIG. 33, the skirt assembly 442 can
include an upper skirt 443 and a lower skirt 445. The inflow end
portions 460 of the leaflets 434a, 434b, and 434c can be positioned
between an upper portion 447 of the lower skirt 445 and a lower
portion 454 of the upper skirt 443, with the upper skirt desirably
having an outward placement compared to the lower skirt. The upper
skirt 443, the inflow end portions 460 of the leaflets 434a, 434b,
434c, and the lower skirt 445 can be secured by sutures along a
scalloped or undulating suture line 444 adjacent the inflow end of
the prosthetic valve (FIG. 31). The inflow end portion of the
leaflet assembly 414 can be secured to the stent 412 by suturing
the upper skirt 443, the lower skirt 445, or both the upper skirt
443 and the lower skirt 445 to the struts 416 of the lower section
424 of the stent via sutures 455 (best shown in FIG. 31). The skirt
assembly 442 (including the upper skirt 443 and the lower skirt
445), desirably can be made of a bio-compatible synthetic material,
such as polytetrafluoroethylene (PTFE), or a woven fabric material,
such as woven polyester (e.g., polyethylene terephthalate) (PET),
DACRON.RTM.). The upper skirt 443 and the lower skirt 445 can be
made of the same, or different, material.
[0114] As best shown in FIG. 32, the outflow end portion of upper
skirt 443 can be shaped to substantially align with the undulating
or zigzag shape formed by the struts 416 of the lower section 424
of the stent, e.g., for ease of securing the upper skirt to the
struts of the stent by suture. For example, the upper skirt 443 can
include an upper edge 456 shaped to correspond to the shape of the
second lowermost row of cells of the frame member 412. The inflow
end portion of upper skirt 443 can have an undulating lower edge
458 that substantially aligns with the undulating suture line 444
and the scalloped or undulating shape of the inflow portions of the
leaflets 443a, 443b, and 443c. The outflow end portion of the lower
skirt 445 can be shaped to have an undulating shape that
substantially corresponds with the undulating suture line 444. The
inflow end portion 454 of the upper skirt 443 and the outflow end
portion 447 of the lower skirt 445 overlap each other on opposite
sides of the leaflet inflow end portions at least enough to secure
the upper skirt and lower skirt by sutures along the suture line
444. The inflow end portion of the lower skirt 445 typically
extends to the inflow end 426 of the stent, although other
configurations are possible. For example, the inflow end portion of
the lower skirt 445 can be shaped to include a lower edge shaped to
correspond to the shape of a lowermost row of cells of the
frame.
[0115] The outflow end portion of the leaflet assembly 414 can be
secured to the upper portion of the stent 412 at three angularly
spaced commissure attachments of the leaflets 434a, 434b, 434c, in
a manner similar to the configuration used to secure the outflow
end portion of the leaflet assembly 14 to the upper portion of the
stent 12 at three angularly spaced commissure attachments of the
leaflets 34a, 34b, 34c (as best shown in FIG. 2).
[0116] FIG. 33 shows the operation of the prosthetic valve 410.
During diastole, the leaflets 434a, 434b, 434c collapse to
effectively close the prosthetic valve. As shown, the curved shape
of the intermediate section 422 of the stent 412 defines a space
between the intermediate section and the leaflets that mimics the
sinuses of Valsalva. Thus, when the leaflets close, backflow
entering the "sinuses" creates a turbulent flow of blood along the
upper surfaces of the leaflets, as indicated by arrows 452. This
turbulence assists in washing the leaflets and the skirt assembly
442 to minimize clot formation.
[0117] Referring to FIGS. 33 and 35, the prosthetic valve 410 can
further include a sealing skirt 449 positioned at the lower section
424 of the stent. The sealing skirt 449 provides an additional
barrier against paravalvular leakage following implantation of the
stent in a subject by providing material at the inflow end portion
of the stent that protrudes outwardly through the openings of the
cells of the frame and contacts surrounding tissue of the native
annulus, thereby minimizing or reducing paravalvular leakage. The
sealing skirt is desirably supported by the upper skirt 443 and the
lower skirt 445, which prevent the sealing skirt 449 from
contacting the leaflets 434a, 434b, and 434c of the leaflet
assembly 414. The upper skirt 443 and the lower skirt 445
additionally provide support to ensure that the material of the
sealing skirt 449 extends outwardly between cells formed by the
struts 416 of the stent 412 to seal against the surrounding
annulus.
[0118] FIG. 34 depicts an embodiment of the sealing skirt 449 prior
to attachment to the stent. The outflow end portion 451 of the
sealing skirt 449 can have an undulating or zigzag shape that has
an upper edge shaped to correspond to the shape of the upper
boundary of a lower most row of cells of the frame formed by the
struts 416 of the stent 412. In alternative embodiments, the
outflow end portion 451 of the sealing skirt 449 can have a
substantially straight edge that does not align with the undulating
or zigzag shape formed by the struts 416 of the stent 412; instead
the outflow end portion 451 of the sealing skirt 449 can transect
the lower most row of cells of the frame formed by the struts 416
of the stent 412 (see, e.g., FIG. 38). The inflow end portion 453
of the sealing skirt 449 typically extends to the inflow end 426 of
the stent (see, e.g., FIGS. 35 and 36), although other
configurations are possible. For example, the sealing skirt 449 can
have an upper edge and a lower edge shaped to correspond to the
shape of a lower most row of cells formed by the struts 416 of the
inflow end 426 of the stent such that the sealing skirt 449 only
occludes the openings in the lowermost row of cells (see, e.g.,
FIG. 37). In additional embodiments, the inflow end portion of the
sealing skirt 449 can be constructed to extend beyond the inflow
end 426 of the stent (see, e.g., FIG. 38). In several embodiments,
the inflow end portion 453 of the sealing skirt 449 can be shaped
to substantially align with the inflow end portion of the lower
skirt 445.
[0119] Referring to FIGS. 35-39, the sealing skirt 449 can be
secured to the struts 416 of the lower portion of the stent 412
with sutures 455. The sutures 455 can secure the sealing skirt 449
to the struts 416 of the lower portion of the stent 412, and
optionally can also secure the upper skirt 443 and/or the lower
skirt 445 to the struts 416 of the lower portion of the stent 412.
The sealing skirt 449 desirably is made of a bio-compatible
synthetic material, such as polytetrafluoroethylene (PTFE), or a
woven fabric material, such as woven polyester (e.g., polyethylene
terephthalate) (PET), DACRON.RTM.). In several embodiments, the
sealing skirt comprises a plush or pile material, such as a loop
yarn, which functions as a filler material in that fibers of the
sealing skirt can extend outwardly through openings in the frame
and fill spaces between the frame and the native annulus. The plush
or pile material is also compressible, thus minimizing the crimp
profile of the sealing skirt 449. In some embodiments, the sealing
skirt can be made of a PET loop yarn or polyester 70/20 textured
yarn. In additional embodiments, the sealing skit can be made of
polyester multifilament partially oriented yarn (poy); a polyester
2-ply multifilament yarn; a polyester film; a knitted polyester; a
woven polyester; and/or a felted polyester. Such materials are
available commercially, for example, from Biomedical Structures
(Warwick, R.I.) and ATEX Technologies (Pinebluff, N.C.).
[0120] With reference to FIG. 39, the illustrated embodiment of the
sealing skirt 449 can be made of a relatively less bulky, non-plush
or non-pile material (e.g., woven PET fabric) and secured (e.g.,
with sutures 455) to the frame member 412 such that portions of the
sealing skirt protrude radially outwardly through the cells of the
frame member 412 to seal against the surrounding annulus. In such
embodiments, the sealing skirt can be secured by sutures 455 such
that slack material of sealing skirt 449 bulges or protrudes
through the lowermost cells formed by the struts 416 of the frame
member 412. The lower skirt 445 supports the sealing skirt 449 (and
can be secured to the frame member 412 with the same sutures 455 as
used to secure the sealing skirt 449) to prevent the slack material
of the sealing skirt from protruding inwardly towards the
longitudinal axis of the valve 410 and contacting the leaflets. In
such embodiments, the length of the sealing skirt 449 is typically
longer than that of the inner circumference of the lower portion of
the frame member 412. FIG. 39 provides a perspective view depicting
a portion of the frame member 412 and the sealing skirt 449;
however, for clarity of illustration, the upper skirt 443, the
lower skirt 445 and the leaflet assembly 434 are not depicted.
[0121] The dimensions of the sealing skirt 449 can be adjusted to
obtain the desired amount of material protruding from an expanded
annular frame, depending on the type of material used for the
sealing skirt. For example, in embodiments where the sealing skirt
449 is constructed of a plush or pile material (such as a loop
yarn) having fibers that protrude outwardly between the cells of
the frame member 412, the length of the sealing skirt (in an
unrolled or flattened configuration prior to mounting on the frame)
can be substantially the same as the circumference of the lower
portion of the frame member 412. In other embodiments, the length
of the sealing skirt prior to mounting on the annular frame is at
least about 5% (such as at least about 10%, at least about 15%, at
least about 20%, at least about 25%) longer than the circumference
of the expanded annular frame of the stent, to allow for additional
material to protrude between the cells of the frame member 412.
[0122] Although description of the sealing skirt 449 above is made
with reference to prosthetic heart valve 410, the sealing skirt can
also be included on prosthetic heart valve 10, for example, by
modifying the dimensions of the sealing skirt 449 as needed to
secure the sealing skirt 449 to skirt assembly 42 of heart valve
10.
[0123] The prosthetic valve 410 can be implanted in a retrograde
approach where the prosthetic valve, mounted in a crimped state at
the distal end of a delivery apparatus (e.g., the delivery
apparatus 100), is introduced into the body via the femoral artery
and advanced through the aortic arch to the heart, as further
described in U.S. Patent Application Publication No. 2008/0065011,
which is incorporated herein by reference. The prosthetic valve 410
can also be implanted in a retrograde approach where the prosthetic
valve, mounted in a crimped state at the distal end of a delivery
apparatus (e.g., the delivery apparatus 100), is introduced into
the body via the left or right subclavian artery and advanced to
the heart. In further embodiments, the prosthetic valve 410 can be
implanted in an antegrade approach where the prosthetic valve,
mounted in a crimped state at the distal end of a delivery
apparatus, is introduced into the body and advanced
transventricularly (see, e.g., U.S. Pat. No. 8,439,970, which is
incorporated herein by reference. For transventricular implant
applications, the retaining arms 430 can be included on the lower
portion of the stent.
[0124] Prior to insertion of the delivery apparatus, an introducer
sheath can be inserted into the artery followed by a guide wire,
which is advanced through the patient's vasculature through the
aorta and into the left ventricle. The delivery apparatus can then
be inserted through the introducer sheath and advanced over the
guide wire until the distal end portion of the delivery apparatus
containing the prosthetic valve 410 is advanced to a location
adjacent to or within the native aortic valve.
[0125] Known introducer sheaths typically employ a sleeve made from
polymeric tubing having a radial wall thickness of from about 0.025
mm (about 0.010 inch) to about 0.04 mm (about 0.015 inch). FIG. 40A
shows an embodiment of an introducer sheath, indicated at 500, that
employs a thin metallic tubular layer that has a much smaller wall
thickness compared to known devices. In particular embodiments, the
wall thickness of the sheath 500 is from about 0.0012 mm (about
0.0005 inch) to about 0.05 mm (about 0.002 inch). The introducer
sheath 500 includes a proximally located housing or hub 502 and a
distally extending sleeve or cannula 504. The housing 502 can house
a seal or a series of seals as known in the art to minimize blood
loss. The sleeve 504 comprises a tubular layer or sleeve 506 that
is formed from a metal or metal alloy, such as Nitinol or stainless
steel, and desirably is formed with a series of circumferentially
extending or helically extending slits or openings to impart a
desired degree of flexibility to the sleeve.
[0126] As shown in FIG. 40B, for example, the tubular layer 506 is
formed (e.g., laser cut) with an "I-beam" pattern of alternating
circular bands 507 and openings 508 with axially extending
connecting portions 510 connecting adjacent bands 507. Two adjacent
bands 507 can be connected by a plurality of angularly spaced
connecting portions 510, such as four connecting portions 510
spaced about 90 degrees from each other around the axis of the
sleeve, as shown in the illustrated embodiment. The sleeve 504
exhibits sufficient flexibility to allow the sleeve to flex as it
is pushed through a tortuous pathway without kinking or buckling.
FIG. 41 shows another pattern of openings that can be laser cut or
otherwise formed in the tubular layer 506. The tubular layer in the
embodiment of FIG. 41 has a pattern of alternating bands 512 and
openings 514 with connecting portions 516 connecting adjacent bands
512, the openings 514 and connecting portions 516 each arranged in
a helical pattern along the length of the sleeve. In alternative
embodiments, the pattern of bands and openings and/or the width of
the bands and/or openings can vary along the length of the sleeve
in order to vary stiffness of the sleeve along its length. For
example, the width of the bands can decrease from the proximal end
to the distal end of the sleeve to provide greater stiffness near
the proximal end and greater flexibility near the distal end of the
sleeve.
[0127] As shown in FIG. 42, the sleeve 504 can have a thin outer
layer or liner 518 extending over the tubular layer 506, the outer
layer 518 made of a low friction material to reduce friction
between the sleeve and the vessel wall into which the sleeve is
inserted. The sleeve 504 can also have a thin inner layer or liner
520 covering the inner surface of the tubular layer 506 and made of
a low friction material to reduce friction between the sleeve and
the delivery apparatus that is inserted into the sleeve. The inner
and outer layers can be made from a suitable polymer, such as PET,
PTFE, FEP, and/or polyether block amide (PEBAX.RTM.). The inner and
outer liners, and the tubular layer, are sized appropriately for
the desired application of the introducer sheath 500. In particular
embodiments, the inner liner 520 can have a radial wall thickness
in the range of from about 0.0012 mm (about 0.0005 inch) to about
0.012 mm (about 0.005 inch) (such as from about 0.025 mm (about
0.001 inch) to about 0.075 mm (0.003 inch), for example about 0.06
mm (about 0.0025 inch)). In particular embodiments, the outer liner
518 has a radial wall thickness in the range of about from about
0.0012 mm (0.0005 inch) to about 0.012 mm (about 0.005 inch) (such
as from about 0.012 mm (about 0.0005 inch) to about 0.075 mm (0.003
inch), for example about 0.025 mm (about 0.001 inch)). In
particular embodiments, the tubular layer 506 can have a radial
wall thickness in the range of from about 0.0012 mm (about 0.0005
inch) to about 0.025 mm (about 0.01 inch) (such as from about 0.05
mm (about 0.002 inch) to about 0.15 mm (about 0.006 inch), for
example about 0.05 mm (about 0.002 inch) or about 0.1 mm (about
0.004 inch)).
[0128] Together, the inner liner 520, the tubular layer 506, and
the outer layer 518, have a wall thickness that can vary based on
the desired final product. In some embodiments, the inner liner
520, the tubular layer 506, and the outer layer 518, together can
have a radial wall thickness in the range of from about 0.05 mm
(about 0.002 inch) to about 0.5 mm (about 0.02 inch) (such as from
about 0.09 mm (about 0.0035 inch) to about 0.3 mm (about 0.012
inch). As such, the sleeve 504 can be provided with an outer
diameter that is about 1-2 Fr smaller than known devices. The
relatively smaller profile of the sleeve 504 improves ease of use,
lowers risk of patient injury via tearing of the arterial walls,
and increases the potential use of minimally invasive procedures
(e.g., heart valve replacement) for patients with highly calcified
arteries, tortuous pathways or small vascular diameters.
[0129] The inner liner 520 can be applied to the interior of the
tubular layer 506, for example, using a two-stage molding process.
In one step, a preform, cylindrical polymer tube or parison 522
(FIG. 48) with an open end 524 and a closed end 526 is formed,
e.g., by an injection molding or extrusion process. The tube 522
has an outer diameter less than that of the inner diameter of the
tubular layer 506, and a wall thickness designed to provide an
appropriate thickness for the inner liner 520 of the tubular layer
506, following blow molding. In one embodiment, the tube 522 can
have a wall thickness of from about 0.025 mm (about 0.001 inch) to
about 0.1 mm (about 0.004 inch) (such as from about 0.05 mm (about
0.002 inch) to about 0.075 mm (about 0.003 inch), such as about
0.06 mm (about 0.0025 inch)). Appropriate material for the polymer
tube can be selected based on the desired finished product. In some
embodiments, the polymer tube 522 is made of nylon-12,
polyethylene, fluorinated ethylene propylene, and/or polyether
block amide (e.g., PEBAX.RTM. 72D). The length of the tube 522 can
be varied depending on the length of the tubular layer 506, and is
typically longer than that of the tubular layer 506. In another
step, heat and pressure are applied to the tube 522 to form the
inner liner 520 by blow molding.
[0130] FIGS. 48 and 49 depict an exemplary method of using blow
molding to apply the tube 522 to the tubular layer 506 to form the
inner liner 520. The tubular layer 506 is inserted into mold 528.
The mold 528, which has an inner diameter that is slightly larger
than the outer diameter of the tubular layer 506 such that the
sleeve can be easily inserted into and removed from the mold,
prevents any appreciable radial expansion of the sleeve during the
pressurization step (described below). The mold 528 can be
constructed to be non-expandable during blow molding of the tube
522. The mold 528 can have a cylindrical inner surface 529 that
corresponds to the shape of the outer surface of the tubular layer
506. Thus, when the tube 522 is pressurized (discussed in detail
below), the inner surface of the mold prevents the tubular layer
506 from expanding/deforming under pressure from the expanding tube
522 and prevents portions of the tube 522 from expanding radially
outwardly through the openings 508 in the tubular layer 506.
[0131] The tube 522 with the open end 524 and the closed end 526 is
inserted into the tubular layer 506, as shown in FIG. 48. The
closed end 526 can extend beyond one end of the tubular layer 506,
and the open end 524 can extend beyond the other end of tubular
layer 506.
[0132] Heat and pressure are applied to the tube 522 to cause the
tube to expand against the inner surface of the tubular layer 506
to form an expanded polymer tube 530. The heat and pressure can be
applied sequentially (e.g., heat is applied, then pressure), or
simultaneously. For example, the heat and pressure can be applied
simultaneously by injecting heated compressed gas or liquid into
the open end 524 of the tube 522. Alternatively, the heat can be
applied by heating the mold 528, and the tube 522 can be
pressurized by injecting compressed gas or liquid into the open end
524 of the tube 522. For example, the entire assembly including the
mold 528, the tubular layer 506, and the tube 522 can be immersed
in a heated fluid. In this regard, the wall of the mold can have
one or more apertures that allow the heated fluid (e.g., a heated
liquid such as water) to flow through the apertures and contact the
tube 522 to facilitate heating of the tube. Various other types of
heat sources, such as resistive, conductive, convective, and
infrared heat sources, can be used to apply heat to the tube 522.
Optionally, the tube 522 can be stretched axially concurrently with
heating and/or pressurizing, or in one or more separate stretching
steps performed at separate times from heating and/or
pressurizing.
[0133] Portions of the expanded tube 530 extending beyond the
either end of tubular layer 506 can be trimmed to form the inner
liner 520 of tubular layer 506. In some embodiments, the inner
liner 520 can expand into the openings 508 of the tubular layer 506
during the molding process, and remain in the openings following
the molding process. In other embodiments, the inner liner 520 does
not expand into and/or remain into the openings 508 of the tubular
layer 506 during the molding process. The specific heat and
pressure conditions (including the duration for which the heat and
pressure should be applied, as well as cooling conditions) for blow
molding the inner liner 520 of the tubular layer 506 can be varied
as desired, and typically will depend on the starting materials and
desired finished product. In some embodiments, the tube 522 is
heated to about 125.degree. C. (about 255.degree. F.) and
pressurized to about 80 kPa (about 12 psi) for a period of time
sufficient to form inner liner 520. Further, general methods of
blow molding are known to the person of ordinary skill in the art
(see, e.g., U.S. Patent Application Publication No. 2011/0165284,
which is incorporated by reference herein in its entirety).
[0134] The outer layer 518 of the sheath can be applied over and
secured to the outer surface of the tubular layer 506 using
conventional techniques or mechanisms (e.g., using an adhesive or
by thermal welding). In one embodiment, the outer layer is formed
by shrink wrapping a polymer tubular layer to tubular layer 506.
Appropriate material for the outer layer 518 can be selected based
on the desired finished product. In some embodiments, the outer
layer 518 is made of nylon-12, polyether block amide (PEBAX.RTM.,
e.g., PEBAX.RTM. 72D), and/or polyethylene. The outer layer 518 can
be applied to the tubular layer 506 before or after the inner layer
520 has been formed using the molding process described above.
[0135] In a modification of the introducer sheath 500, the sheath
can have inner and outer layers 520, 518, respectively, which are
secured to a metal sleeve (e.g., sleeve 504) only at the proximal
and distal ends of the metal sleeve. The inner and outer polymeric
layers can be bonded to the metal sleeve (or to each other through
the gaps in the metal sleeve), for example using a suitable
adhesive or by thermal welding. In this manner, the metal sleeve is
unattached to the inner and outer polymeric layers between the
proximal and distal ends of the sleeve along the majority of the
length of the sleeve, and therefore is "free-floating" relative to
the polymeric layers along the majority of the length of the
sleeve. This construction allows the adjacent bands of metal to
bend more easily relative to the inner and outer layers, providing
the sheath with greater flexibility and kink-resistance than if the
inner and outer layers were bonded along the entire length of the
sleeve.
[0136] FIG. 43 shows a segment of an alternative metal sleeve,
indicated at 600, that can be used in the introducer sheath 500.
The sheath 500 in this embodiment desirably includes inner and
outer polymeric layers, which desirably are secured to the metal
sleeve only at its proximal and distal ends as discussed above. The
sleeve 600 includes a plurality of circular bands or rings 602
interconnected by two links, or connecting portions, 604, extending
between each pair of adjacent rings. Each pair of links connecting
two adjacent bands 602 desirably are spaced about 180 degrees from
each other and desirably are rotationally offset by about 90
degrees from an adjacent pair of links, which allows for
multi-axial bending.
[0137] FIG. 44 shows side view of a segment of another embodiment
of a metal sleeve, indicated at 700, that can be used in the
introducer sheath 500. The sleeve 700 has the same cut pattern as
the sleeve 600, and therefore has circular bands 702 and two links
704 connecting adjacent bands, and further includes two cutouts, or
apertures, 706 formed in each band 702 to increase the flexibility
of the sleeve. The cutouts 706 desirably have a generally
elliptical or oval shape, but can have other shapes as well. Each
cutout 706 desirably extends about 180 degrees in the
circumferential direction of the sleeve and desirably is rotational
offset by about 90 degrees from a cutout 706 in an adjacent band
702.
[0138] In particular embodiments, the metal sleeve of an introducer
sheath has a wall thickness in the range of from about 0.05 mm
(about 0.002 inch) to about 0.015 mm (about 0.006 inch). In one
implementation, a sheath has a metal sleeve having a wall thickness
of about 0.05 mm (about 0.002 inch) and an inner diameter of about
5.8 mm (about 0.229 inch), an inner polymeric layer having a wall
thickness of about 0.06 mm (about 0.0025 inch), an outer polymeric
layer having a wall thickness of about 0.025 mm (about 0.001 inch),
and a total wall thickness (through all three layers) of about 0.14
mm (about 0.0055 inch). In another implementation, a sheath has a
metal sleeve having a wall thickness of about 0.1 mm (about 0.004
inch) and an inner diameter of about 5.8 mm (about 0.229 inch), an
inner polymeric layer having a wall thickness of about 0.06 mm
(about 0.0025 inch), an outer polymeric layer having a wall
thickness of about 0.025 mm (about 0.001 inch), and a total wall
thickness (through all three layers) of about 0.2 mm (about 0.0075
inch). FIG. 45 shows the cut pattern for forming the metal sleeve
600 of FIG. 43. FIG. 46 shows the cut pattern for forming the metal
sleeve 700 of FIG. 44. FIG. 47 shows a cut pattern similar to the
cut pattern of FIG. 46, but including cutouts 706 that are narrower
than the cutouts shown in FIG. 46.
TABLE-US-00001 TABLE 1 Minimum bend Minimum bend radius allowing
Wall thickness radius without passage of of metal sleeve Material
visual kink 16-Fr dilator 0.1 mm (0.004'') Nitinol 2.5 cm (1'') 2.5
cm (1'') 0.1 mm (0.004'') Stainless steel 2.5 cm (1'') 2.5 cm (1'')
0.1 mm (0.002'') Nitinol 15 cm (6'') 2.5 cm (1'') 0.05 mm (0.002'')
Stainless steel 15 cm (6'') 2.5 cm (1'') 0.05 mm (0.002'')
Stainless steel 5 cm (2'') 2.5 cm (1'') (wide rings)
[0139] Table 1 above demonstrates the bend performance of several
metal sleeves. Each metal sleeve had an inner diameter of about 5.8
mm (about 0.229 inch). Each sleeve was formed with the cut pattern
shown in FIG. 44, except for the last sleeve in Table 1, which was
formed with the cut pattern shown in FIG. 43. All of the sleeves in
Table 1 provide device deliverability at a relatively small bend
radius (2.5 cm, 1 inch). Furthermore, it was found that the metal
sleeves recover their circular cross-sectional shapes even after
passing a delivery device through a visibly kinked section of the
sleeve.
[0140] In view of the many possible embodiments to which the
principles of the disclosed invention may be applied, it should be
recognized that the illustrated embodiments are only preferred
examples and should not be taken as limiting the scope of the
disclosure. Moreover, additional embodiments are disclosed in U.S.
Patent Application Publication No. 2010/0049313 (U.S. patent
application Ser. No. 12/429,040) and U.S. Patent Application
Publication No. 2012/0239142 (U.S. patent application Ser. No.
13/405,119), each of which is incorporated herein by reference.
Accordingly, the scope of the disclosure is defined by the
following claims. We therefore claim all that comes within the
scope and spirit of these claims.
* * * * *