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|United States Patent Application
Kuehn, Stephen T.
;   et al.
August 26, 2004
Mitral and tricuspid valve repair
A novel approach to mitral or tricuspid valve repair involves the
performance of an edge-to-edge fastening/securing of opposing heart valve
leaflets through a catheter entering the heart. Thus, a device is
introduced including a leaflet fastener applicator through a cardiac
catheter or other suitable catheter. The leaflet fastener applicator and
cardiac catheter can be formed into a kit. A gripper can be used to hold
the heart valve leaflets while they are fastened.
Kuehn, Stephen T.; (Woodbury, MN)
; Hinnenkamp, Thomas F.; (White Bear Lake, MN)
; Holmberg, William R.; (New Richmond, WI)
; Bergman, Darrin J.; (Shoreview, MN)
; Moore, Scott D.; (Columbia Heights, MN)
; Shepherd, Terry L.; (Shoreview, MN)
Hallie A. Finucane
Altera Law Group
6500 City West Parkway
St. Jude Medical, Inc.
February 23, 2004|
|Current U.S. Class:
||606/108; 623/2.11 |
|Class at Publication:
||606/108; 623/002.11 |
||A61F 011/00; A61F 002/24|
What is claimed is:
1. A kit comprising a cardiac catheter and a leaflet fastener applicator,
said cardiac catheter having suitable dimensions for deployment and
insertion into a human heart in the vicinity of the mitral or tricuspid
valve, said leaflet fastener applicator having a size allowing insertion
through said cardiac catheter and being capable of holding portions of
opposing heart valve leaflets.
2. The kit of claim 1 wherein said fastener applicator comprises opposing
jaws, one of said jaws having a site for holding a tack and the second of
said jaws having a site for holding a cap.
3. The kit of claim 1 wherein said fastener applicator comprises a
4. The kit of claim 1 wherein said fastener applicator comprises a needle
and suture, which passes through a leaflet.
5. The kit of claim 1 wherein said fastener applicator comprises sets of
opposing arms where each set has suitable dimensions for holding a heart
6. The kit of claim 1 wherein said fastener applicator comprises a ring.
7. The kit of claim 1 wherein said fastener applicator comprises a clip
button including a first element with spikes and a second element that
clips onto said first element.
8. The kit of claim 1 further comprising a gripper, said gripper including
a tube having a proximal end and a distal end, opposing gripper arms at
said distal end of said tube, and an actuator at said proximal end of
said tube such that motion of said actuator changes the relative position
of said gripper arms.
9. The kit of claim 1 further comprising a gripper, said gripper having a
suitable opening for the application of suction to a heart valve.
10. The kit of claim 1 further comprising instructions describing use of
said cardiac catheter and said leaflet fastener applicator.
11. A method of repairing a valve of a beating heart, said method
comprising: a) inserting the distal end of a catheter into the heart to
provide access to said valve; and b) fastening together portions of
leaflets of said valve using a leaflet fastener applicator inserted
through said catheter.
12. The method of claim 11 wherein the catheter is inserted through an
opening in the wall of said beating heart.
13. The method of claim 11 wherein the catheter is introduced into the
heart by way of a blood vessel.
14. The method of claim 11 wherein said fastening of said opposing
leaflets comprises placement of a sharp projection through said leaflets.
15. The method of claim 11 wherein said fastening of said leaflets
comprises suturing together said opposing leaflets.
16. The method of claim 11 further comprising gripping said leaflets with
a gripper prior to fastening said leaflets.
17. The method of claim 16 wherein said gripper comprise a tube having a
proximal end and a distal end, opposing gripper arms at said distal end
of said tube, and an actuator at said proximal end of said tube such that
motion of said actuator change the relative position of said gripper
18. The method of claim 16 wherein said gripper has a suitable opening for
the application of suction to a heart valve.
19. The method of claim 11 further comprising inserting a wire through
said wall of said heart to initiate an opening through which said cardiac
catheter is inserted.
20. The method of claim 11 further comprising making an incision in the
wall of the heart for said insertion of said catheter.
21. A device comprising a catheter and a leaflet fastener applicator, said
catheter having a proximal end, a distal end and suitable dimensions for
insertion into a heart, said leaflet fastener applicator passing through
said catheter such that an actuating element projects from said proximal
end of said catheter while a fastening element projects from said distal
end of said catheter.
22. The device of claim 21 wherein said actuating element comprises a
length of suture extending to said distal end of said leaflet fastener
23. The device of claim 21 wherein said actuating element comprises a
lever that controls the delivery of a fastener.
24. The device of claim 21 further comprising a gripper inserted through
said cardiac catheter such that gripping appendages project from said
distal end and an actuating element projects from said proximal end,
where said actuating element controls said gripping appendages.
25. A heart valve leaflet fastener comprising two pairs of arms, each pair
having a suitable size for fastening heart valve leaflets and said two
pairs of arms capable of fastening two adjacent leaflets.
26. The heart valve leaflet fastener of claim 26 wherein said arms flex
relative to a central core, and wherein said fastener has a locked
position where each said pair of arms meet under tension.
27. The heart valve leaflet fastener of claim 26 wherein one of said arms
of each pair includes a projection for piercing a leaflet.
28. A heart valve gripper/fastener applicator comprising a gripper and a
fastener applicator wherein said gripper and said fastener applicator
extend from a single shaft.
29. The gripper/fastener of claim 28 wherein said gripper comprises two
30. The gripper/fastener of claim 28 wherein said fastener comprises two
opposing jaws, one of said jaws having a site for holding a tack and the
second of said jaws having a site for holding a cap.
31. A heart valve leaflet fastener applicator comprising two opposing
jaws, one of said jaws having a site for holding a tack and the second of
said jaws having a site for holding a cap.
32. The heart valve leaflet fastener applicator of claim 31 wherein said
jaw having a site for holding a tack further comprises a slot wherein a
tack can be shifted to a position opposite said site for holding a cap.
33. A gripper comprising a plunger that slides over an inner shaft and
arms having suitable dimensions for gripping heart valve leaflets, said
plunger slides such that interaction of heart valve leaflets with said
plunger directs said leaflets toward said arms.
34. The gripper of claim 33 wherein said plunger is a balloon plunger that
can be inflated and deflated.
35. A fastener applicator comprising a first shaft, a first portion of a
button clip having a sharp projection for piercing a heart valve leaflet,
a second shaft that slides over said first shaft, and a second portion of
said button clip having an opening to engage the projection of said first
portion of said button clip, said second portion of said button clip
sliding over said first shaft and not over said second shaft such that
second shaft can direct said second portion toward said first portion.
BACKGROUND OF THE INVENTION
 The invention relates to the repair of mitral and tricuspid valves
exhibiting valve regurgitation. More particularly, the invention relates
to apparatus and methods suitable for a less invasive repair of a mitral
or tricuspid heart valve.
 Mitral regurgitation, i.e., backward leakage of blood at the mitral
heart valve, results in reduced pumping efficiency. Furthermore,
compensatory mechanisms such as hypertrophy and dilation of the ventricle
suggest early treatment to prevent progressive deterioration of
ventricular function. Diagnosis of mitral regurgitation can be performed
using visualization with transesophageal echocardiography or by
echocardiodiography. In particular, defective leaflet coaptation and the
site and direction of the regurgitant flow can be examined to evaluate
likely modes of failure.
 Mitral valve prolapse, i.e., myxomatous degeneration of mitral
valve leaflets, is the most common cause of mitral regurgitation in North
America. Rheumatic heart disease was the most common cause of mitral
regurgitation in the U.S.A. thirty years ago and is still the most common
cause of mitral regurgitation in developing countries. Chronic rheumatic
heart disease results in retraction, deformity and rigidity of one or
both mitral valve cusps as well as structural abnormalities in the
commissures, chordae tendinae and papillary muscles. Ischemic mitral
regurgitation (IMR), i.e., anemia of the valve tissue due to reduced
arterial blood flow feeding the valve tissue, is the second most common
cause of mitral valve regurgitation. Studies suggest that annular
irregularities and posterior papillary muscle fibrosis with scarring of
the underlying ventricular wall may be associated with IMR.
 Many cases of mitral regurgitation can be repaired by modifications
of the original valve in a procedure generally referred to as
valvuloplasty. These repair procedures typically involve a full
sternotomy and quadrangular resection of the anterior leaflet, while on
cardiopulmonary bypass. Repairs can also involve reattachment of chordae
tendinae, which tether the valve leaflets, or removal of leaflet tissue
to correct misshapen or enlarged valve leaflets. In some cases, the base
of the valve is secured using an annuloplasty ring. Valves that are
heavily calcified or significantly compromised by disease may need to be
 As an alternative to these repair techniques, an edge-to-edge
suturing of the anterior and posterior mitral valve leaflets can be
performed. Commonly referred to as a "bow-tie" repair, edge-to-edge
suturing ensures leaflet coaptation without performing a quadrangular
resection of the anterior leaflet. The bow-tie repair generally involves
the use of a centrally located suture, although a suture can be placed
close to a commissure, or multiple sutures can be used to complete the
repair. A centrally placed suture creates a double orifice valve, which
resembles a bow-tie.
 The bow-tie repair procedure has been applied using invasive
procedures by placing the patient on extracorporeal circulation. An
incision is made to provide access into the left atrium of the heart.
Following suturing, the atrium is closed. Such repairs can result in a
significant decrease in mitral regurgitation along with a corresponding
increase in the ejection fraction.
SUMMARY OF THE INVENTION
 In a first aspect, the invention relates to a kit including a
cardiac catheter and a leaflet fastener applicator. The cardiac catheter
generally has suitable dimensions for deployment and insertion into a
human heart in the vicinity of the mitral or tricuspid valve. The leaflet
fastener applicator generally has a size allowing insertion through the
cardiac catheter and is capable of holding portions of opposing heart
 In another aspect, the invention relates to a method of repairing
the mitral or tricuspid valve of a beating heart, the method including:
 a) inserting the distal end of a catheter into the heart to provide
access to the valve; and
 b) fastening together portions of leaflets of the valve using a
leaflet fastener applicator inserted through the catheter.
 In another aspect, the invention relates to a device including a
catheter and a leaflet fastener applicator. The catheter has a proximal
end, a distal end and suitable dimensions for insertion into a heart. The
leaflet fastener applicator passes through the catheter such that an
actuating element projects from the proximal end of the catheter while a
fastening element projects from the distal end of the catheter.
 In another aspect, the invention relates to a heart valve leaflet
fastener including two pairs of arms. Each pair of arms is of a suitable
size for fastening heart valve leaflets together. The two pairs of arms
are capable of fastening two adjacent leaflets.
 In another aspect, the invention relates to a heart valve
gripper/fastener applicator including a gripper and a fastener applicator
wherein the gripper and the fastener applicator extend from a single
 In another aspect, the invention relates to a heart valve leaflet
fastener applicator including two opposing jaws. One of the jaws has a
site for holding a tack, and the second jaw has a site for holding a cap.
 In another aspect, the invention relates to a gripper including a
plunger that slides over an inner shaft, and arms having suitable
dimensions for gripping heart valve leaflets. The plunger slides such
that the interaction of heart valve leaflets with the plunger directs the
leaflets toward the arms.
 In another aspect, the invention relates to a fastener applicator
including a first shaft, a first portion of a button clip having a sharp
projection for piercing a heart valve leaflet, a second shaft that slides
over the first shaft, and a second portion of the button clip having an
opening to engage the projection of the first portion of the button clip.
The second portion of the button clip slides over the first shaft and not
over the second shaft such that the second shaft can direct the second
portion toward the first portion.
BRIEF DESCRIPTION OF THE DRAWINGS
 FIG. 1 is a side view of one embodiment of a cardiac catheter.
 FIG. 2 is a perspective view of the proximal end of the cardiac
catheter of FIG. 1.
 FIG. 3 is a side view of a suture knot securing two leaflets
 FIG. 4 is a side view of a knot pusher.
 FIG. 5 is a perspective view of sutured heart valve leaflets being
secured with a suture clip with a portion of a cardiac catheter cut away
to expose structure within the catheter.
 FIG. 6 is a perspective view of endoscopic scissors being used to
cut a suture.
 FIG. 7 is a perspective view of heart valve leaflets secured with
attached wires that have suture attached at one end.
 FIG. 8 is a side view of heart valve leaflets each pierced by a
barbed needle where the barbed needles are attached to each other with
 FIG. 9 is an enlarged view of a barbed needle of FIG. 8.
 FIG. 10 is a side view of a push rod useful for the deployment of
the barbed needles of FIG. 8.
 FIG. 11 is a side view of barbed needles with flexible wire
attached to the needle.
 FIG. 12 is a side view of heart valve leaflets with the barbed
needles of FIG. 11 piercing the heart valve leaflets and a push rod
gripping the suture connecting the two barbed needles.
 FIG. 13A is a side view of a fastener with a corresponding
applicator inserted between two heart valve leaflets prior to deployment.
 FIG. 13B is a side view of the fastener and applicator of FIG. 13A
with arms extended on either side of the heart valve leaflets.
 FIG. 13C is a side view of the fastener and applicator of FIG. 13 A
where the arms are being pushed together to grab the leaflets.
 FIG. 13D is a side view of the fastener and applicator reaching a
locked position where the leaflets are held firmly in place.
 FIG. 13E is a side view of the leaflets secured in place by the
fastener of FIG. 13A after the applicator is removed.
 FIG. 13F is a sectional view of the engagement mechanism used to
secure and detach the fastener of FIG. 13A from the applicator used to
deploy the fastener.
 FIG. 14A is a perspective view of a gripper/fastener with spring
loaded arms being deployed from a cardiac catheter with a portion of the
cardiac catheter cut away to expose structure within the catheter.
 FIG. 14B is a perspective view of the gripper/fastener of FIG. 14A
with two spring loaded arms being free of the cardiac catheter with a
portion of the cardiac catheter cut away to expose structure within the
 FIG. 14C is a perspective view of the spring loaded fastener of
FIG. 14A deployed holding heart valve leaflets following release of the
deployment device with a portion of the cardiac catheter cut away to
expose structure within the catheter.
 FIG. 14D is a perspective view of an alternative embodiment of the
arms of the spring loaded fastener where the arms are curved.
 FIG. 15 is a side view of a needle fastener with a suction based
 FIG. 16 is side view of a gripper mounted adjacent a fastener
applicator being directed toward heart valve leaflets.
 FIG. 17 is an enlarged perspective view of the gripper and fastener
applicator of FIG. 16.
 FIG. 18A is a sectional side view of the gripper of FIG. 17.
 FIG. 18B is an exploded side view of an alternative embodiment of
the gripper of FIG. 18A, the alternative embodiment being based on a cam,
where the rod and moveable jaw have been removed from the remainder of
 FIG. 18C is a side view of the embodiment shown in FIG. 18B.
 FIG. 18D is a view down the end of the shaft from the proximal end
toward the jaws, where the ball of the cam is shown in both an open and
 Fiqs. 19A-C are sectional views of the fastener applicator of FIG.
17 where the section in FIG. 19B is taken at a right angle relative to
the sections in FIGS. 19A and 19C. Hidden structures are shown with
 FIG. 19D is a side view of the tack and cap of FIG. 19A secured
together, shown in phantom.
 FIG. 20 is a side view of a gripper with a plunger used to direct
the leaflets to gripper arms.
 FIG. 21 is a side view of an alternative embodiment of a gripper
with spring loaded arms and a balloon plunger that directs the leaflets
to the spring loaded arms.
 FIG. 22 is a side view of hooks used as gripper elements.
 FIG. 23 is a side view of a spring fastener with a suction based
 FIG. 24 is a side view of heart valve leaflets secured with a
spring fastener of FIG. 23.
 FIG. 25 is a perspective view of a portion of a clip button held by
a deployment device, the clip button being useful for fastening heart
 FIG. 25A is a perspective view of the tip of a first applicator.
 FIG. 26 is a perspective view of the clip button of FIG. 25 and
associated deployment devices, with the two portions of the clip button
 FIG. 27 is a front view of a first portion of the clip button of
 FIG. 28 is a side view of the first portion of the clip button of
 FIG. 29 is a side view of the second portion of the clip button of
 FIG. 30 is a rear view of the second portion of the clip button of
 FIG. 31 is a side view of the second portion of the clip button of
FIG. 26 rotated 90 degrees relative to the view in FIG. 29.
 FIG. 32 is a side view of the two portions of the clip button of
FIG. 26 fastened together.
 FIG. 33 is a sectional side view of a spring loaded ring in a
 FIG. 34 is a sectional side view of the spring loaded ring of FIG.
33 in an extended position.
 FIG. 35 is a side view of a crimp ring in an uncrimped position.
 FIG. 36 is a side view of the crimp ring of FIG. 35 following
 FIG. 37 is a perspective view of a ring fastener being positioned
with an applicator toward heart valve leaflets, where a portion of the
cardiac catheter is cut away to permit the visibility of structure within
 FIG. 38 is a perspective view of the applicator of FIG. 37
following deployment of the ring fastener.
 FIG. 39 is a side view of one embodiment of an automatic suture
device positioned near heart valve leaflets.
 FIG. 40 is a side view of the automatic suture device of FIG. 39
gripping the heart valve leaflets with needles.
 FIG. 41 is a sectional view of one of the needles of the automatic
suture device of FIG. 39.
 FIG. 42 is sectional view of the automatic suture device of FIG. 39
with an ultrasonic welder positioned for placement at its ultimate
 FIG. 43 is a side view of an alternative embodiment of an automatic
 FIG. 44 is a perspective view of the automatic suture device of
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
 Methods have been developed for performing less invasive mitral
valve repairs. While the discussion focuses on the repair of mitral heart
valves, the repair approaches can be used for the repair of tricuspid
valves using straightforward modification of the described procedures and
instruments. In particular, the repairs can be performed on a beating
heart such that the patient does not have to be placed on cardiopulmonary
 Access into the heart for mitral valve repair is obtained by
securing a passageway from the exterior of the body into the body and
into the heart to provide access into the left atrium or left ventricle.
With suitable instruments inserted through the passageway, the mitral
leaflets are grabbed, and the edges of the leaflets are secured together.
The gripping and securing or fastening procedures can be performed
simultaneously in some embodiments of the invention, or they can be
performed separately. A suitable method of visualization may be used to
guide the manipulations. Manipulations to the mitral valve can be
conducted under ultrasound or fluoroscopy to show correct placement of
the devices and of the repair and to verify effectiveness of the repair.
 One approach to introduce the instruments into the heart involves
the direct introduction of a passageway through the wall of the heart. To
introduce the passageway or a cardiac catheter into the body, a small
incision is made in the chest. Instruments generally used to position
catheters can be used to guide the cardiac catheter to the heart and into
the heart wall, as described further below. Use of properly selected
instruments for the introduction of the cardiac catheter reduces the
amount of trauma to the heart. Upon completion of the mitral valve
repair, the instruments are removed through the cardiac catheter, the
cardiac catheter is removed, and the incision in the heart wall is
repaired, for example, with suture.
 Alternatively, the instruments can be introduced into the heart by
a vascular approach. In these approaches, a catheter is introduced into
an artery or vein and directed into the heart. These vascular approaches
are described further below.
 Suitable gripping and fastening instruments have appropriate
dimensions to fit through the cardiac catheter into the heart. In
general, the instruments have a tubular section or shaft between a distal
end and a proximal end. The tubular section may be flexible. The distal
end of the instrument is inserted through the cardiac catheter into the
heart. The gripping and/or securing/fastening elements are located at the
distal end of the instrument. One or more actuating elements are located
at the proximal end.
 In some embodiments, a single element performs the gripping and
fastening functions. In other words, a fastening element grips the tissue
during the fastening process such that a separately identifiable gripping
element is not present. For example, suture can be placed through each
leaflet such that tightening of the suture draws the two portions of the
 Alternatively, the gripping and fastening elements can be distinct,
separate instruments. For certain embodiments, functionally distinct
gripping and fastening elements can be integrated into a single
instrument such that a single tubular section is needed. Alternatively,
the distinct gripping and fastening elements can be located on separate
instruments, each having a separate tubular section. If the gripping and
fastening elements are located on separate instruments, the tubular
sections of the instruments can have suitable dimensions such that the
two tubular sections can be inserted simultaneously through a single
cardiac catheter. Alternatively, one or more additional cardiac catheters
can be introduced into the heart to provide separate instrument
passageways for the gripping and fastening instruments and any other
instruments used to facilitate the procedure. Also, one or more
additional cardiac catheters can be used to provide a means of direct
 The mitral valve repair device generally includes a
gripper/fastener applicator instrument, and may include a cardiac
catheter or other suitable catheter. The cardiac catheter generally has
an elongated tubular section and proximal and distal ends each with an
opening. For example, the cardiac catheter can be a catheter introducer
used for standard intravascular placement or a similar instrument. An
embodiment of a cardiac catheter 126 is displayed in FIG. 1. Proximal end
102 includes opening 104, as shown in FIG. 2, through which a
gripper/fastener applicator instrument is introduced. Proximal end 102
preferably includes a hemostasis valve 106 to prevent blood from flowing
out of the cardiac catheter. Standard designs used in the catheter art
can be used for the hemostasis valve.
 Tubular section 108 of cardiac catheter 100 preferably is flexible
so that it can be guided through the body to the desired location.
Generally, tubular section 108 has a length from about 4 cm to about 15
cm and a diameter from about3 mm (9 French (F)) to about 10 mm (30 F),
more preferably from about 3 mm (9 F) to about 8 mm (24 F). However,
tubular section 108 can be selected to have a suitable length appropriate
for the specific procedure used. Tubular section 108 preferably has a
tapered end 110 to assist with introduction of cardiac catheter 100 into
 The gripper/fastener applicator instrument can have one functional
element that accomplishes both the gripping and fastening operations
simultaneously (e.g., FIG. 19), or two functional elements with one
element performing the gripping and a second performing the fastening
(e.g., FIG. 17). Two functional elements can be integrated together on a
single instrument, or they can operate together as two separate
instruments through the cardiac catheter(s). One or more cardiac
catheters can be used, as needed or desired. Specific embodiments are
 A first type of gripper/fastener applicator has one functional
device that accomplishes both gripping and fastening functions. Several
embodiments of the first type of gripper/fastener applicator can be based
on attachment of suture that is tied off to secure. the leaflets
 Referring to FIG. 3, sutures 120 placed through the respective
valve leaflets 122, 124 can be tied outside of the body. Sutures 120 can
be positioned using a needle or needles that are passed through leaflets
and withdrawn through cardiac catheter 126. A knot pusher 130 (FIG. 4)
can be used to push a knot tied outside of the body to the leaflets such
that the knot pulls the leaflets together. Variations on the design of
the needle and the knot pusher can be used to accomplish the same
purposes. Alternatively, rather than tying a knot, a suture clip 132 can
be used to fasten sutures 120, as shown in FIG. 5. Suture clip 132 is
pushed into place up to leaflets 122, 124 with a clip pusher 134. Suture
clip 132 is shaped such that suture can be fed through clip 132 only in
one direction. Once sutures 120 are tied or clipped, suture 120 can be
cut with endoscopic scissors 136, as shown in FIG. 6, or other similar
 Another suture based gripper/fastener embodiment is depicted in
FIG. 7. Instead of passing suture through each leaflet, the suture 150
can be secured to the edge of leaflets 122, 124 with a piece of wire 152
at one end of suture 150. Wire 152 can be sharpened spiral or coiled
wire, such as a pacemaker lead. Wire 152 can be crimped on the edge of a
particular leaflet 122, 124. As described above, the suture can be tied
outside the heart, the knot can be pushed to the leaflets, and the suture
150 can be cut.
 Another embodiment of a single element gripper/fastener applicator
involves the use of barbed needles. Referring to FIG. 8, a barbed needle
200 penetrates each leaflet 122, 124. If the repair requires further
securing of the leaflets, additional needles may be deployed. Barbed
needles 200 are connected to each other by suture 206. Each needle 200
can include a plurality of barbs 208 (FIG. 9). Barbed needles 200 can be
deployed individually with a push rod 210 (FIG. 10). Push rod 210
generally has releasable jaws 212 for holding barbed needles 200 during
deployment. Jaws 212 are activated by lever 214 at the handle end 216 of
push rod 210. Alternatively, suitable push rods or other mechanical
trigger actuators, such as spring activated mechanisms, can be used to
deploy barbed needles 200.
 In order to use a short enough piece of suture 206 to hold the
leaflets closed while having enough flexibility to deploy barbed needles
200, the embodiment in FIG. 8 can be modified as shown in FIG. 11. Each
barbed needle 222 has a wire 224 extending from needle 222. Suture 226
connects the two wires 224. Barbed needles 222 can be deployed in the
same way as depicted in FIG. 8. Referring to FIG. 12, push rod 210 with
jaws 212 or a similar device can be passed into the heart through cardiac
catheter 126 to grab suture 226. Push rod 210 is rotated to wind suture
226 and ultimately to wind wires 224. The winding of wires 224 draws
barbed needles 222 closer together, resulting in leaflets 122, 124 being
drawn closer together. Wires 224 preferably are made of material, such as
stainless steel, which is malleable enough that they can be wound
together with forces transmitted through the suture yet resilient enough
that the wires do not unwind from the load transmitted by leaflets 122,
 Alternatively, suture can be connected directly to each barbed
needle and looped around the other needle. Pulling each suture then draws
each barb to the other. Additional knots can be pushed down from outside
the body through cardiac catheter 126 to secure the two sutures together.
 In other embodiments of a single element gripper/fastener
applicator, a gripping/fastener applicator device is deployed and later
released using an applicator. For example, referring to FIG. 13A, a
deploying wand 250 is inserted through cardiac catheter 126. Outer sleeve
254 holds gripper arms 256, 258, 260, 262 in place against inner core
264. Deploying wand 250 is inserted between leaflets 122, 124. Referring
to FIG. 13B, outer sleeve 254 is pulled away from gripper arms 256, 258,
260, 262 to permit gripper arms to extend once the outer sleeve 254 no
longer holds them in place.
 With gripper arms 256, 258, 260, 262 extending on both side of
leaflets 122, 124, inner core 264 is pulled inward and outer sleeve 254
is pushed outward in the direction of arrow 266 (FIG. 13C), such that
arms are being pushed together to grab the leaflets. Referring to FIG.
13D, gripper arms 256, 258, 260, 262 hold leaflets 122, 124 in place. The
position of gripper arms 256, 258, 260, 262 along inner core 264 is
locked in place by stops 270. Gripper arms 256, 258, 260, 262 are
extended beyond an equilibrium position such that restorative forces tend
to pull gripper arms toward inner core 264. Referring to FIG. 13E, end
272 of inner core 264, while gripping and fastening leaflets 122, 124, is
released from the remaining portions of inner core 264 by disengaging a
locking mechanism thereby securing the leaflets with the fastening
device. Inner core 264 is removed through cardiac catheter 126. The
locking mechanism can have any of a variety of conventional structures,
so as to grip and fasten leaflets 122, 124. One embodiment of a suitable
locking mechanism is depicted in FIG. 13F. Pivoting latches 280 lock into
flanges 282. Wires 284 can be used to release latches 280 from flanges
282. Gripper arms 256, 258, 260, 262 generally have a length from about 2
mm to about 10 mm. Inner core 264 generally has a diameter from about 1
mm to about 8 mm.
 A similar embodiment of the invention is depicted in FIG. 14. In
single element gripper/fastener applicator 300, arms 302, 304, 306, 308
are spring loaded. As arms 302, 304, 306, 308 are pushed free of the end
310 of cardiac catheter 126., they extend due to the spring loading
feature. In FIG. 14B, gripper/fastener applicator 300 is depicted with
arms 302, 306 extended. Arms 302, 306 have pointed tips 314, 316 that can
pierce leaflets 122, 124. As depicted in FIG. 14C, once arms 304, 308 are
free of the cardiac catheter 126, arms 304, 308 extend on one side of the
leaflets to grasp leaflets 122, 124 along with arms 302, 306, which
extend on the other side of leaflets 122, 124. Arms 304, 308 have clasps
322, 324 that engage pointed tips 314, 316 such that arms 302, 304, 306,
308 firmly grasp leaflets 122, 124 therebetween. Grasper/fastener
applicator 300 is released from applicator 326 by rotating knob 328 such
that knob 328 passes through passageway 330 within base 332. In an
alternative embodiment, arms 302, 304, 306, 308 are curved as depicted in
 The second type of gripper/fastener applicator has two distinct
elements, a gripper element and a fastener applicator element. The
gripper element and the fastener applicator element can be located at the
respective distal ends of two distinct shafts. For certain embodiments
the gripper element and the fastener applicator elements can be
integrated on a single shaft and may be adapted to move relative to one
another as appropriate for the procedure that is being performed, i.e.,
gripping or fastening. In this way, a single shaft can be guided through
the cardiac catheter.
 An embodiment of a distinct gripper and a fastener applicator
integrated onto a single shaft is depicted in FIG. 15. Gripper/fastener
applicator 340 has a spiral needle 342, which spirals around inner
catheter 344. The first step involves applying suction through an
internal lumen of inner catheter 344 by way of openings 346 to grasp and
position a leaflet against inner catheter 344. Once the leaflets are
grasped by suction, spiral needle 342 is advanced and rotated. Rotation
of outer sleeve 343 results in the passage of spiral needle 342 through
leaflets 122, 124. Spiral needle 342 is mounted on outer sleeve 343 that
rotates around inner catheter 344. The outer sleeve can be threaded to
provide appropriate pitch and number of rotations. To hold the leaflets
in place, spiral needle 342 is disengaged from outer sleeve 343 by
disengaging a clamp or the like at the end 345 of outer sleeve 343. If
desired, the needle can be crimped to ensure permanent attachment. The
suction based gripper of FIG. 15 can be used also with other types of
 Referring to FIGS. 16-17, device 400 includes a gripper 402 and a
fastener applicator 404 that extend from a shaft 406. Gripper 402 and
fastener applicator 404 can be adjacent each other, as shown in FIG. 17.
Alternatively, gripper 402 and fastener applicator 404 may move relative
to each other by sliding in a tube, track, or similar mechanisms. The
relative position of gripper 402 and fastener applicator 404 can be
reversed. In FIG. 17, with fastener applicator 404 in a distal withdrawn
position, gripper 402 can grab leaflets 122, 124. Then, fastener
applicator 404 can be opened in the withdrawn position and slid forward
to apply a tack on captured leaflet edges. Therefore, gripper 402
preferably is oriented relative to leaflets 122, 124 as shown in FIG. 16.
 One embodiment of gripper 402 is depicted in FIG. 18A. In this
embodiment, claw gripper 412 has opposing jaws 414, 416, which meet at
serrated edges 418, 420 in a closed orientation. Serrated edges 418, 420
assist with the gripping of the leaflets 122, 124. The extension of rod
422 alters the relative position of jaws 414, 416 by moving a lever 424.
Rod 422 extends through shaft 406 to the distal end of shaft 406 such
that a physician can manipulate rod 422 outside of the patient. The
length of jaws 414, 416 should be appropriate for the jaws to reach
leaflets 122, 124 at the maximum anticipated spacing between leaflets
122, 124. If desired, grippers 412 can be used with a shaft separate from
a shaft holding a fastener applicator element. Grippers 412 are designed
to grip leaflets 122, 124 as depicted in FIGS. 16, 17 and 18.
 As an alternative to the lever mechanism shown in FIG. 18A, a cam
can be used to rotate the jaw, as depicted in FIGS. 18B-D. In particular,
jaw 411 rotates around pivot 413. Rotation of rod 415 causes ball 417 to
change position relative to the position of rod 415. Ball 417 fits into
track 419 in the end of jaw 411. Also, ball 417 fits into a notch in an
off center position in the end of rod 415 such that rotation of rod 415
moves ball 417 up or down. Lowering of the ball results in the opening of
jaw 411 relative to jaw 421. Rod 415 is rotated using lever 423, as shown
in FIG. 18D. Generally a half rotation of rod 415 results in motion of
jaw 411 from a closed position to its open. position.
 As depicted in FIG. 17, fastener applicator 404 applies a fastener,
such as a tack. Further details about fastener applicator 404 can be seen
in FIG. 19. Fastener applicator 404 holds tack 424 and cap 426 in
separate housings for deployment. When jaws 428, 430 are opened by the
movement of lever 432 in the direction shown by the arrow 431 in FIG.
19A, rod 434 slides tack 424 within track 436 to a position aligning cap
426 with tack 424, as shown in FIGS. 19B and 19C. Jaws 428, 430 rotate
relative to each other by way of lever arm 438 or other mechanical link,
such as a cam. When jaws 428, 430 subsequently are closed, tack 424
engages cap 426, as shown in FIG. 19D, thereby fastening leaflets 122,
124. Jaws 428, 430 can be opened to release tack 424 and fastened
leaflets 122, 124.
 While the above grippers and fastener applicators can be used for
an atrial or ventricular approach, other designs for the gripper are
particularly adapted for gripping leaflets from an atrial approach.
Referring to FIG. 20, gripper 438 includes graspers 440 used to grasp
each leaflet 122, 124. To push the leaflets toward graspers 440, plunger
446 includes two or more arms 450, 452. In an alternative embodiment
depicted in FIG. 21, a balloon plunger 454 is used. Balloon plunger 454
is deflated for delivery and removal of the instrument through cardiac
catheter 126 and inflated within the heart for use to guide the leaflets
to the graspers 440.
 With either embodiment of the plunger, shaft 456 can be pulled to
draw spring loaded graspers 440 toward plunger 446 or 454 to grip
leaflets 122, 124 within grasper 440. Alternatively, plunger 446 or 454
can push leaflets 122, 124 toward graspers 440. In any case, as plunger
446 or 454 reaches a certain position relative to graspers 440 so that
graspers 440 are within reach of leaflets 122, 124, shaft 456 is pulled
back to retract graspers 440, which clasp leaflets 122, 124 between
graspers 440 and grasper tube 441. Once leaflets 122, 124 are clasped,
plunger 446, 454 can be removed. After leaflets 122, 124 are fastened,
graspers 440 can be released by extending shaft 456 such that gripper 438
can be withdrawn. Graspers 440 should be less than about 10 mm in length.
Graspers 440 can be curved.
 Another approach to grasping the leaflets from the atrial side is
depicted in FIG. 22. Hooks 470, 472 are deployed through cardiac catheter
126 to grab leaflets 122, 124. Hooks 470, 472 preferably have sharp tips
480, 482 without barbs. With leaflets 122, 124 held in place, a variety
of fasteners, as described throughout, can be used to fasten leaflets
122, 124. Once leaflets 122, 124 are fastened securely, hooks 470, 472
can be released and removed by pushing hooks 470, 472 to release the
respective leaflets 122, 124 and rotating hooks 470, 472 such that they
do not grab leaflets 122, 124 when withdrawn.
 Once one embodiment of grasper is holding the leaflets, another
type of grasper generally can be substituted for that grasper to hold the
leaflets. A wider variety of graspers are suitable for grasping already
held leaflets. In this way, a fastener applicator can be used with a more
appropriate grasper, if desired. Furthermore, multiple grippers can be
used to grasp the leaflets to be fastened. For instance, a hook as shown
in FIG. 22 can be used to grab one leaflet while jaws such as shown in
FIGS. 18A-D can be used to grab the other leaflet. As another example,
two sets of jaws can be used, each grabbing one leaflet.
 With respect to fastener applicators, a spring fastener embodiment
is depicted in FIGS. 23-24. Leaflets 122, 124 are drawn into cavities
500, 502 with suction similar to that applied by the device in FIG. 15.
Vacuum is applied by way of lumen 504. Spring 506 is pushed and rotated
using rotating shaft 508. End 510 of spring 506 catches a leaflet such
that rotating the spring 506 causes spring 506 to spiral through leaflets
122, 124 as shown in FIG. 24, fastening leaflets 122, 124 together. After
spring 506 is placed through the leaflets, vacuum is released and lumen
504 is withdrawn.
 Referring to FIGS. 25-32, another embodiment of a fastener
applicator uses a fastener clip button 540 which includes a first portion
542 and a second portion 544. Referring to FIGS. 27 and 28, first portion
542 includes spikes 546 extending from a first surface 548 of base 550.
Base 550 has notches 552 at the edge of second surface 554 at a position
rotated 90 degrees relative to spikes 546. The center of base 550 has an
opening 556 with wings 558 oriented toward notches 552. Second surface
554 includes indentations 560 adjacent opening 556 oriented toward spikes
 Referring to FIGS. 29-31, second portion 544 includes perforations
566 which have a diameter equal to or slightly smaller than spikes 546.
Tabs 568 extend from first surface 570 of base 572. Tabs 568 include lips
574 that can engage notches 552. Base 572 includes an opening 578 with
wings 580. Base 572 is slightly noncircular to allow for tabs 568.
 FIG. 32 displays first portion 542 engaged with second portion 544.
When portions 542, 544 are engaged, spikes 546 engage perforations 566
and tabs 568 engage notches 552. The leaflets are positioned in the
separation between base 550 and base 572.
 Referring to FIG. 25, to deploy clip button 540, first portion 542
is positioned with first applicator 580. First applicator 580 includes a
central core 582 with a knob 584 at the end of the central core 582, as
shown in FIG. 25A. Knob 584 engages indentations 560 when first portion
is positioned on first applicator 580, and can pass through wings 558
when oriented accordingly for removal of first applicator 580. First
applicator 580 also includes tubular portion 588, which slides over
central core 582. When knob 584 engages indentations 560 and tubular
portion 588 engages first surface 548, first portion 542 is held firmly
by first applicator 580. Preferably, first portion 542 is placed in
position near the leaflets prior to grasping of the leaflets by a
gripper. Once grasped, the leaflets can be pierced with spikes 546 of
first portion 542.
 After spikes 546 are inserted through the leaflets, tubular portion
588 can be removed through cardiac catheter 126. Then, second applicator
590 can be slid over central core 582, as shown in FIG. 26. Second
applicator 590 is used to engage second portion 544 with first portion
542. Second applicator 590 can push second portion 544 into place, or,
alternatively, second applicator 590 can hold second portion 544 using a
fastener such as threads or a clamp, as first portion 542 is pulled
against it. After second portion 544 engages first portion 542, second
applicator 590 is removed through cardiac catheter 126. Central core 582
is removed by first rotating knob 584 such that knob 584 passes through
wings 558 and 580. Clip button 540 remains fastened to the mitral valves
 Another embodiment of a fastener uses a deformable ring. Different
variations of the ring are available. A first embodiment of a spring
loaded ring is depicted in FIGS. 33 and 34. Spring loaded ring 600 has a
first spike 632 at the end of crescent portion 604. Second spike 606 is
initially located in cavity 608 within crescent portion 604. Spring 610
is located between second spike 606 and surface 612. A button lock 614
holds second spike 606 within crescent portion 604 until deployment of
spring loaded ring 600. When the lock 614 is released, first spike 602
and second spike 606 pierce the leaflets and secure them together.
Alternative embodiments of the spring loaded ring can employ dual springs
with a spike being propelled by each spring. If desired, the spikes can
be retractable such that the ring is used to hold the leaflets while
another fastening approach is used to secure the leaflets.
 Referring to FIGS. 35 and 36, crimp ring 630 includes points 632,
634 and handles 636, 638. Between handles 636, 638 is a notch 641. Notch
640 provides a weak location for bending points 632, 634 toward each
other, as shown in FIG. 36. Crimp ring 630 is placed near the grasped
leaflet. Then, handles 636, 638 are rotated away from each other to place
the crimp ring 630 in the closed crimped position shown in FIG. 36 with
points 632, 634 piercing respective leaflets.
 Rings such as spring loaded ring 600 and crimp ring 630 can be
applied with an applicator 640, as depicted in FIGS. 37 and 38. Ring 642
is brought up to leaflets 122, 124 and deformed to pierce leaflets 122,
124. Applicator 641 can include lever arms 650 and/or other implements to
assist with deployment of rings 600 or 630. For example, for spring
loaded ring 600, either lever arms 650 or another implement releases lock
614. For crimp ring 630, lever arms 650 hold handles 636, 638 and rotate
handles to crimp the ring to bring points 632, 634 toward each other.
 An automatic suture device can be used as a fastener. One
embodiment of an automatic suture device is described in U.S. Pat. No.
5,417,700, to Egan, incorporated herein by reference. Referring to FIGS.
39-42, suture device 658 includes hollow needles 660, 662, which can
rotate to pierce leaflets 122, 124. Suture 664 (FIG. 42) is threaded
through channel 666 (FIG. 41) within hollow needles 660, 662. Suture 664
can be secured with an ultrasonic weld formed between weld anvil 668 and
welding horn 670. Suture 664 can be pulled tight prior to welding.
 An alternative embodiment of an automatic suture device is shown in
FIGS. 43 and 44. The suture device 700 includes a curved needle 702.
Needle 702 has a point 704 and a blunt end 706. Needle 702 lies within
slot 708. Suture 710 is threaded through channel 712. Suture 710 exits
channel 712, crosses to the opposite opening into slot 708, circumscribes
slot 708 and attaches to needle 702 at blunt end 706.
 Suture 710 is pulled, which rotates needle 702, impaling leaflets
122, 124 with point 704. Needle 702 is rotated about 360 degrees such
that needle 702 has passed through leaflets 122, 124. Following complete
rotation of needle 702, suture 710 is threaded through leaflets 122, 124.
Withdrawal of suture device 700 through the catheter introducer pulls
suture 710 through leaflets 122, 124. Suture 710 can be tied, as
described above with respect to FIG. 3, to secure leaflets 122, 124.
Alternatively, a suture clip 132 can be used to secure suture 710, as
shown in FIG. 5.
 All of the devices described above can be constructed from standard
biocompatible materials including a variety of metals, such as stainless
steel and titanium, and polymers, such as polysulfone. The materials can
be selected as appropriate for a particular application. Furthermore, the
fasteners can be coated with a surface modifier such as
polytetrafluoroethylene (PTFE), i.e., Teflon.RTM., or an antimicrobial
coating, such as silver metal or a silver compound. Antimicrobial metal
coatings are further described in copending and commonly assigned U.S.
patent application Ser. No. 08/974,992 to Ogle et al., entitled "Medical
Article with Adhered Antimicrobial Metal," incorporated herein by
 Surgical Procedure
 In preferred embodiments of the procedure, the repairs are
performed on a beating heart. Alternatively, the heart can be stopped
during the procedure. Cardioplegia, i.e., stopped cardiac contraction,
can be induced by certain chemicals such as cold potassium-containing
solutions that are introduced into the myocardium. The chemical induction
of cardioplegia requires the isolation of the heart and ascending aorta
from the rest of the patient's vascular system. Procedures using
cardioplegia are less desirable since they require cardiopulmonary
bypass, which increases patient risk factors.
 For cardiac catheter based embodiments, one or more access points
are used along the patient's chest, generally positioned between adjacent
ribs. The access points provide access to the heart. Incisions are made
to initiate the access points. Trocar sheaths, such as those used for the
performance of laparoscopic procedures, can facilitate use of the access
points as described in published PCT application WO 94/18881 to Stanford
Surgical Technologies, Inc., incorporated herein by reference.
Alternatively, soft tissue retractors, such as those used in pediatric
open chest procedures can be utilized to facilitate use of the access
points. Suitable location of the access point(s) can be determined based
on the approach appropriate for the gripper/fastener applicator to be
 Once the heart is accessed, a guide wire can be inserted through
the wall of the heart either near the apex of the heart into the left
ventricle or near the top of the heart into the left atrium. A dilator
can be slid over the guide wire to expand the opening into the heart.
Suitable guidewires and dilators are available from Daig Corp.,
Minnetonka, Minn. A cardiac catheter with a hemostasis valve, described
above, is deployed over the dilator. The cardiac catheter provides
access. into the heart to deliver the repair device or devices.
 Alternatively, a cardiac catheter can be inserted through an
incision in the wall of the heart at the desired location. As during
normal cannulation, a purse string suture can be applied at the point
where the cardiac catheter enters the heart to reduce any bleeding. The
suture can be applied, for example, using a piece of suture with a needle
on both ends. The needles can be manipulated using forceps or the like.
After the desired stitching is performed, the needles can be cut off
using endoscopic scissors. Additional cardiac catheters can be placed
near or into the heart, as desired.
 Once the cardiac catheter is in place, the gripper/fastener
instruments can be directed at the mitral or tricuspid valve to perform
the repair. All of the instruments are designed such that the appropriate
manipulations by the appropriate health care professional are performed
at the proximal end of the cardiac catheter.
 Following completion of the bow-tie repair, the cardiac catheter is
removed. The procedures used to deploy the cardiac catheter preferably
minimize the damage to the heart muscle by separating the tissue without
significantly tearing the tissue. Nevertheless, stitches or staples can
be used to close the incision at the point where the cardiac catheter was
inserted. Once access to the heart has been closed, the incision
providing access into the chest cavity is closed.
 Alternatively, a less invasive, percutaneous vascular approach can
be used. There are two, alternative, percutaneous vascular approaches to
positioning the catheter for the medical procedure. One is to introduce
the catheter into the femoral artery by a standard introducer sheath and
advance it up the aorta, across the aortic valve into the left ventricle
and then position its tip under the mitral annulus. This is commonly
referred to as the "retrograde" approach.
 The other approach, commonly referred to as the transseptal
approach, is to introduce a transseptal sheath apparatus, a long single
plane curve introducer, into the right femoral vein and advance it
through the inferior vena cava into the right atrium. A puncture is then
made through the fossa ovalis in the intraatrial septum, and the
apparatus is advanced into the left atrium where the trocar and dilator
of the apparatus is removed, leaving the sheath in position in the left
atrium. Once the valve is accessed, the repair can be completed as
 Edge-to-edge mitral valve repair provides a simple and effective
repair technique relative to complex and surgically demanding approaches
of chordal shortening, resectioning, chordal transposition or artificial
chordae replacement. The edge-to-edge repair is particularly effective
with severe isolated mitral regurgitation or in association with coronary
artery bypass surgery. The present approach provides the benefits of the
edge-to-edge repair without the trauma of open heart surgery and
cardiopulmonary bypass. Thus, the procedure can be accomplished
concomitant with coronary artery bypass graft (CABG) or as a stand alone
outpatient procedure in a cardiac catheterization laboratory. The
advantages include reduced cost, hospitalization and patient recovery
times. With minimal trauma to the patient, it may be desirable to perform
the repair earlier before the disease has progressed to a serious level.
Thus, more repair procedures may be performed, preventing further
progression of the disease, obviating the need for more serious invasive
 The instruments described above may be distributed in the form of a
kit. Generally, the kit includes a fastener applicator and a suitable
cardiac catheter or other catheter for a vascular approach. The kit may
also include a suitable gripper for use with the fastener applicator.
Alternatively, the kit may include only a fastener (fastener applicator)
and/or a gripper. The kit preferably includes instructions for the
performance of mitral and/or tricuspid valve repair. In particular, the
instructions can describe the particular use of the fastener applicator
and/or the grippers.
 Although the present invention has been described with reference to
preferred embodiments, workers skilled in the art will recognize that
changes may be made in form and detail without departing from the spirit
and scope of the invention.
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