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    • 专利摘要:
    systems and methods for quickly positioning surgical heart valves. a quick-connect heart valve prosthesis that is quickly and easily implanted during a surgical procedure is provided. the heart valve includes a substantially non-expandable, non-compressible prosthetic valve, thereby allowing fixation in the annular space without sutures. a small number of guide sutures can be provided for the orientation of the aortic valve. the prosthetic valve can be a commercially available valve with a seam ring with the frame attached to it. the frame may expand from a tapered positioning state to a tapered expanded state, and may include meshed uprights connected between axially extending pins. a system and method for positioning includes an integrated grip rod and balloon catheter. a valve holder is stored with the heart valve and the handle stem easily attaches to it to perfect the valve preparation steps.
    公开号:BR112013005665B1
    申请号:R112013005665-7
    申请日:2011-08-12
    公开日:2020-09-01
    发明作者:Rafael Pintor；Michael J. Scott；Thomas Chien；Harvey H. Chen；August R. Yambao；Lawrence J. Farhat；Andrew Phung；William C. Brunnett；Carey Cristea；Faisal Kalam；Sara M. Walls；Kevin W. Zheng；Qinggang Zeng
    申请人:Edwards Lifesciences Corporation；
    IPC主号:
    专利说明:

    FIELD OF THE INVENTION
    The present invention relates generally to prophetic valves for implantation in body channels. More specifically, the present invention relates to single surgical prosthetic heart valves configured to be surgically implanted in less time than current valves, and associated valve delivery systems. BACKGROUND OF THE INVENTION
    In vertebrate animals, the heart is a hollow muscular organ that has four pumping chambers as seen in Figure 1 - the left and right atria and the left and right ventricles, each provided with its own unidirectional valve. Natural heart valves are identified as aortic, mitral (or bicuspid), tricuspid and pulmonary, and are each mounted within an annular space that comprises dense fibrous rings attached either directly or indirectly to the atrial and ventricular muscle fibers. Each annular space defines a flow orifice.
    The atria are the blood-receiving chambers, which pump blood into the ventricles. The ventricles are the blood discharge chambers. A wall composed of fibrous and muscular parts, called the interatrial septum, separates the right and left atria (see Figures 2 to 4). The fibrous interatrial septum is a materially stronger tissue structure compared to the heart's most friable muscle tissue. An anatomical mark on the interatrial septum is an oval depression, the size of a fingerprint called an oval fossa, or fossa ovalis (shown in Figure 4).
    The synchronous pumping actions of the right and left sides of the heart constitute the cardiac cycle. The cycle begins with a period of ventricular relaxation, called ventricular diastole. The cycle ends with a period of ventricular contraction, called ventricular systole. The four valves (see Figures 2 and 3) ensure that blood does not flow in the wrong direction during the cardiac cycle; that is, to ensure that blood does not flow back from the ventricles into the corresponding atrium, or to flow back from the arteries into the corresponding ventricles. The mitral valve is between the left atrium and the left ventricle, the tricuspid valve between the left atrium and the right ventricle, the pulmonary valve is at the opening of the pulmonary artery, and the aortic valve is at the opening of the aorta.
    Figures 2 and 3 show the anterior portion (A) of the annular space of the mitral valve that touches the non-coronary leaflet of the aortic valve. The annular space of the mitral valve is in the vicinity of the circumflex branch of the left coronary artery, and the posterior side (P) is close to the coronary bell and its tributaries.
    Various surgical techniques can be used to repair a diseased or damaged valve. In a valve replacement operation, damaged leaflets are excised and the annular space sculpted to receive a replacement valve. Due to aortic stenosis and other heart valve diseases, thousands of patients undergo surgery each year when the defective native heart valve is replaced with a prophetic, bioprosthetic or mechanical valve. Another less drastic method for treating defective valves is through repair or reconstruction, which is typically used for minimally calcified valves. The problem with surgical therapy is the significant injury it imposes on these chronically ill patients with high rates of morbidity and mortality associated with surgical repair.
    When the valve is replaced, surgical implantation of the prophetic valve typically requires open chest surgery during which the heart is stopped and the patient placed on a cardiopulmonary bypass (a so-called "heart-lung machine"). In a common surgical procedure, the diseased native valve leaflets are excised and a prosthetic valve is sutured in the surrounding tissue in the annular valve space. due to the trauma associated with the procedure and the consequent duration of extracorporeal blood circulation, some patients do not survive the surgical procedure or die soon after it. It is well known that the risk to the patient increases with the amount of time required in cardiopulmonary bypass. Due to these risks, a substantial number of patients with defective valves are considered inoperable because their condition is too fragile to support the procedure. By some estimates, approximately 30 to 50% of patients suffering from aortic stenosis who are older than 80 years old cannot be operated on to replace aortic valve.
    Due to the disadvantages associated with conventional open heart surgery, percutaneous and minimally invasive surgical proposals are gaining intense attention. In one technique, a prosthetic valve is configured to be implanted in a much less invasive procedure through catheterization. For example, U.S. Patent Number 5,411,552 to Andersen et al. describes a collapsible valve percutaneously introduced into a compressed state through a catheter and expanded in the desired position by balloon inflation. Although these remote implantation techniques have shown great promise for treating certain patients, replacing a valve through surgical intervention is still the preferred treatment procedure. An obstacle to accepting remote implantation is the resistance of doctors who are understandably anxious about converting from an effective, if imperfect, regime to a new proposal that promises great results but is relatively strange. In conjunction with the understandable precaution exercised by surgeons in switching to new heart valve replacement techniques, regulatory bodies around the world are moving slowly as well. Numerous successful clinical trials and follow-up studies are in process, but many more experiments with these new technologies will be required before they are fully accepted.
    Consequently, there is a need for an improved device and associated method of use in which the prosthetic valve can be surgically implanted into a body canal in a more efficient procedure that reduces the time required for extracorporeal circulation. It is desirable that such a device and method be able to assist patients with defective valves that are considered inoperable because their condition is too fragile to withstand an extensive conventional surgical procedure.
    Furthermore, surgeons report that one of the most difficult tasks when attempting a minimally invasive heart valve implantation or implantation through a small incision is to tie the suture knots that hold the valve in position. A typical attic valve implant uses 12-24 sutures (commonly 15) evenly distributed around and manually tied on one side of the seam ring. The nodes directly behind the commissure pins of a prosthetic aortic valve are specifically challenging due to space constraints. Eliminating the need to tie the suture knots or even reducing the number of knots to those that are more accessible would greatly facilitate the use of smaller incisions which reduces the risk of infection, reduces the need for blood transfusions and allows for faster recovery compared with patients whose valves are implanted through total sternotomy commonly used for the implantation of a heart valve.
    The present invention addresses these needs and others. SUMMARY OF THE INVENTION
    Various embodiments of the present application provide prophetic valves and methods of use to replace a defective native valve in a human heart. Certain modalities are specifically well suited for use in a surgical procedure to quickly and easily replace a heart valve while minimizing the time using an extracorporeal circulation (ie, bypass pump).
    In one embodiment, a method for treating a native aortic valve in a human heart to replace the function of the aortic valve, comprises: 1) accessing a native valve through an opening in a chest; 2) placing guide sutures within the annular space; 3) advance the heart valve within a number of the annular space; and 4) plastically expand a metallic anchoring skirt over the heart valve to mechanically engage in the annular space in a fast and efficient way.
    Native leaflets can be removed before applying the prosthetic valve. Alternatively, native leaflets can be left in place to shorten the surgery time and provide a stable base for attaching the anchoring skirt to the native valve. In an advantage of this method, the native leaflets recede inward to improve the fixation of the metallic anchoring skirt within the body channel. When the native leaflets are left in place, a balloon or other expansion member can be used to push the valve leaflets out of the way and thereby dilate the native valve prior to implantation of the anchoring skirt. The native annular space can be expanded between 1.0-5 mm from its initial orifice size to accommodate a larger prosthetic valve.
    In a preferred aspect, a heart valve includes a prosthetic valve that defines a non-expandable, non-collapsible orifice therein and an expandable anchoring skirt that extends from an inflow end thereof. The anchoring skirt has a contracted state for application to an implant position in an expanded state configured for an outward connection in the surrounding annular space. Desirably, the anchoring skirt is plastically expandable.
    In another aspect, a prosthetic heart valve for implantation in an annular heart valve space comprises: a. a non-expandable, non-collapsible annular support structure that defines a flow orifice and has an inflow end; B. valve leaflets attached to the support structure and mounted to alternately open and close through the flow orifice; ç. a plastically expandable frame having a first end extending around the flow orifice and connected to the valve at the inflowing end of the support structure, the frame having a second end projecting in the direction of inflow away from the support structure and being able to assume a contracted state for application in an implant position and a wider expanded state for external contact with an annular space; and d. a fabric covering around the plastically expandable frame that includes an enlarged sealing flange that surrounds the second end.
    Preferably, the support structure includes a plurality of commissure pins that project in a direction of outflow, and the valve leaflets are flexible and attach to the support structure and the commissure pins and mounted to alternately open and close through the hole flow. Also, a sealing ring desirably circumscribes an inflow end of the support structure. The enlarged sealing flange that surrounds the second end of the plastically expandable frame is spaced from the permeable suture ring to help conform the frame to the aortic annular space.
    In one embodiment, the heart valve comprises a commercially available prosthetic valve that has a sewing ring, and the anchoring skirt fastens to the sewing ring. The contracted state of the anchoring skirt can be tapered, tapering inward from the first end towards the second end, while in the expanded state the frame is tapered, but tapering out from the first end towards the second end. The anchoring skirt preferably comprises a plurality of radially expandable uprights at least some of which are arranged in rows, and in which the furthest row has the greatest capacity for expansion from the contracted state to the expanded state. The sewing ring may comprise a solid but compressible material that is relatively rigid in order to provide a seal against the annular space and has a shape of concave inflow that conforms to the annular space.
    A method of applying and implanting a prosthetic heart valve system is also described here, which comprises the steps of: a. providing a heart valve that includes a prosthetic valve that has an expandable frame, the frame having a contracted state for application in an implant position and an expanded state configured for an outward connection in the annular space, the heart valve being mounted on a support which has a nearest cube and a lumen through it, the nearest cube connected at the far end of a handle rod that has a lumen through it, b. advance the heart valve with the frame in its contracted state to an implant position adjacent to the annular space; ç. passing a first balloon catheter through the lumens of the grip rod and support and into the heart valve, and inflating a balloon over the first balloon catheter; d. deflate the balloon and withdraw the first balloon catheter from inside the heart valve, and remove the first balloon catheter from the grip rod; and. insert a second balloon catheter into the grip rod and pass the second balloon catheter through the lumens of the grip rod and support and into the heart valve, and inflate a balloon over the second balloon catheter to expand the frame.
    The method may involve increasing the orifice size of the annular space of the heart valve by 1.0-5.0 mm by expanding the frame plastically. In one embodiment, the prosthetic valve of the valve component is selected to have an orifice size that matches the increased orifice size of the heart valve annular space.
    The heart valve in the aforementioned method may include a non-expandable, non-collapsible orifice, with the expandable frame comprising an anchoring skirt extending from an inflow end thereof. The anchoring skirt can have a plurality of radially-
    expandable, where a row farther from the prosthetic valve has alternating peaks and valleys. The farthest end of the anchorage skirt desirably has the greatest capacity for expansion from the contracted state to the expanded state so that the peaks in the furthest row of the prosthetic valve project outwardly into the surrounding left ventricular outflow tract.
    One method of the method also includes mounting the heart valve on a support that has a closer hub and a lumen through it. The support mounts over the farthest end of the grip rod that has a lumen through it, and the method includes passing a balloon catheter through the lumen of the grip rod and support and into the heart valve, and inflating the balloon over the balloon catheter to expand the anchoring skirt. The cardiac valve mounted on the support can be packed separately from the grip rod and the balloon catheter. Desirably, the contracted state of the expandable frame / anchoring skirt is tapered, and the balloon over the balloon catheter has an expanded end farther away than its nearest end in order to apply an expansion deflection to the anchoring skirt and not on the prosthetic valve. In a preferred embodiment, the distant and closest balloon diameters are essentially the same, the balloon being generally symmetrical across an axial midline, and the balloon midline is positioned near the farthest end of the frame before inflation. The delivery system that includes the valve support is designed to position the balloon within the heart valve so that it inflates within the anchoring skirt, not within the actual valve components.
    Preferably, a valve delivery system includes an integrated balloon catheter and a tubular handle rod through which the catheter extends. A farther end of the handle stem includes an adapter which matches a heart valve holder, and a locking sleeve to quickly connect the delivery system to the heart valve holder. The balloon of the balloon catheter resides inside the adapter and can be moved farther into position to expand the anchoring skirt. A tubular balloon introducer glove attached when removing the heart valve from the storage jar facilitates the passage of the balloon through the heart valve.
    Another aspect described here is a system for applying a heart valve that includes a valve that has a non-expandable, non-collapsible orifice, and an expandable frame that extends from its inflow end, the frame having a contracted state for application in a position implant and an expanded state. The delivery system includes a valve support connected at one end closest to the heart valve, a balloon catheter that has a balloon, and a soft grip rod configured to attach to an end closest to the valve support and that has a lumen for the passage of the catheter, the balloon extending farther through the handle rod, passing through the support and through the heart valve.
    The balloon catheter desirably has an inflation tube that extends through the lumen of the grip rod, and the OD of the inflation tube is greater than 90% of the ID of the grip rod lumen. The prosthetic valve can be a commercially available valve that has a sewing ring, and where the frame attaches to the sewing ring. The contracted state of the frame is preferably tapered, tapering in a more distant direction. In addition, the balloon may include a visible midline that is positioned near the farthest end of the frame before inflation. In a preferred embodiment, the cardiac valve mounted on the support is packaged separately from the grip rod and the balloon catheter. The malleable handle rod can be made of aluminum.
    In one embodiment, the expandable structure is an expandable anchoring skirt formed of plastically deformable uprights surrounded by a fabric cover, and an enlarged sealing flange surrounds the second end of the plastically expandable frame spaced from a permeable seam ring on the valve for help conform the frame to the aortic annular space.
    A further understanding of the nature and advantages of the present invention is presented in the following description and in the claims, specifically when considered in conjunction with the accompanying drawings in which equal parts receive the same reference numbers. BRIEF DESCRIPTION OF THE DRAWINGS
    The invention will now be explained and other advantages and features will appear with reference to the accompanying schematic drawings in which: Figure 1 is an anterior anatomical view of a human heart, with broken portions in section to see the internal cardiac chambers and the adjacent structures; Figure 2 is an anatomical top view of a human heart showing the tricuspid valve inside the right atrium, the mitral valve inside the left atrium, and the aortic valve between them, with the tricuspid and mitral valves open and the aortic and pulmonary valves closed during ventricular diastole (ventricular filling) of the cardiac cycle; Figure 3 is an anatomical top view of a section of the human heart shown in Figure 2, with the tricuspid and mitral valves closed and the aortic and pulmonary valves open during ventricular systole (ventricular emptying) of the cardiac cycle; Figure 4 is an anatomical anterior perspective view of the left and right atria, with broken portions in section to show the interior of the cardiac chambers and associated structures, such as the fossa ovalis, the coronary sinus, and the great cardiac vein; Figure 5 A and 5B are perspective views of an exemplary prosthetic heart valve of the present application mounted on a valve support; Figures 6A and 6B are perspective views of the valve support of Figures 5A and 5B separate from the heart valve; Figure 7 A-7D are orthogonal views of the exemplary prosthetic heart valve and the valve support; Figures 8A-8C are seen in elevation, plane, and in section of the exemplary valve support; Figure 9 is an exploded view of a subset of the internal structural band of the exemplary prosthetic heart valve; Figure 10 is a perspective view of an additional valve subset of a wire shape covered with undulating fabric, and Figure 10A is a detailed cross-sectional view of its cusp portion; Figure 11 is a perspective view of the band subset and a suture permeable seam ring joined, and Figure 11A is a radial sectional view through its cusp portion; Figures 12A and 12B are viewed in perspective of inflow and outflow, respectively, of a surgical heart valve before coupling with an inflow anchoring skirt to form the prosthetic heart valve of the present application; Figure 13 is an exploded view of a portion of an anchoring skirt covered with tissue for coupling to the surgical heart valve; Figure 14 is an exploded view of the anchor skirt portion covered with a fabric of Figure 13 and a lower sealing flange attached thereto to form the inflow anchorage skirt; Figure 15A shows the surgical heart valve above the tissue-covered anchoring skirt and schematically shows a method for coupling the two elements, while Figure 15B illustrates a plastically expandable internal stent structure of the anchoring skirt and the pattern of coupling sutures passed through it; Figures 16A-16J are a sectional view in perspective of an annular aortic space showing a portion of the adjacent left ventricle below the ascending aorta, and illustrating a number of steps for positioning an exemplary prosthetic heart valve described here, namely: Figure 16A shows a preliminary step in the preparation of an aortic annular space to receive the heart valve including the installation of guide sutures; Figure 16B shows the heart valve mounted on a more distant section of an application handle that advances to the position within the aortic annular space along the guide sutures; Figure 16C shows the heart valve in a desired implant position in the aortic annular space, and during the placement of suture loops; Figure 16D shows a forceps folding out the upper ends of the suture loops to improve access to the heart valve and the implantation site; Figure 16E shows an application system before advancing an expansion balloon; 16F shows the application system after advancing a balloon of expansion; 16G shows the balloon of the inflated balloon catheter to expand the anchoring skirt; Figure 16H shows the balloon deflated and stretched; Figure 161 shows the uncoupling and removal of the balloon catheter from the valve support after removing the loops; Figure 16J shows the prosthetic heart valve fully implanted with the guide sutures tied over the face closest to a sewing ring; Figure 17 is a perspective view showing an exemplary prosthetic heart valve coupled to the valve support together with the components of a storage pot; Figure 18 is a perspective view of the heart valve and support mounted on a storage clamp that mounts inside the storage pot; Figure 18A is a bottom plan view of the valve support mounted within the storage clamp; Figure 19A is a perspective view showing a balloon introducing sleeve over the end of a manipulation rod being inserted through an inflow end of the prosthetic heart valve mounted within the storage clamp within the storage pot (dashed); Figure 19B shows the heart valve / support and storage clamp assembly being removed from the storage pot using the handling rod after attaching the balloon introducing sleeve to the valve support; Figure 19C shows the heart valve and support being removed laterally from inside the storage clamp; Figure 20 is an exploded perspective view of the balloon introducing sleeve and the handling rod; Figures 21A-21E are various views showing details of the balloon introducing glove. Figure 22 is an exploded perspective view of components of a prosthetic heart valve delivery system of the present application; Figure 23 is an assembled perspective view of the prosthetic heart valve delivery system of Figure 22; Figures 24A-24C illustrate several steps in coupling the application system of Figure 23 to the heart valve / support assembly mounted on the end of the handling rod shown in Figure 19C; Figures 25 and 25A are seen in perspective and in longitudinal section of a locking glove of the exemplary heart valve delivery system; Figures 26 and 26A-26B are seen in perspective, from the end, and longitudinal section of a heart valve delivery system adapter that couples the heart valve support; Figure 27 is a longitudinal cross-sectional view taken along line 27-17 of Figure 24C showing the way in which the adapter and locking sleeve engage the heart valve holder and the balloon introducer sleeve; Figure 28 is a perspective view showing the heart valve / support assembly mounted on the end of the delivery system with the handling rod removed, and illustrating the pliable nature of an elongated handling rod of the delivery system; Figure 29 is a perspective view of advancing the heart valve / support assembly over the end of the delivery system towards a target aortic annular space, again illustrating the advantageous malleability of the elongated delivery system handling rod; Figures 30 and 30A are seen in elevation and broken longitudinal section, respectively, of the heart valve delivery system with a balloon catheter in a recessed position; Figures 31 and 31A are seen in elevation and broken longitudinal section, respectively, of the heart valve delivery system with a balloon catheter in an extended position; Figure 32 is a perspective view of the nearest end of the exemplary heart valve delivery system of the present application showing an exploded locking clip thereof, while Figures 33A and 33B are seen in elevation and broken longitudinal section, respectively , of the heart valve delivery system with a balloon catheter held in the recessed position by the locking clamp; Figures 34-36 are seen in an alternative embodiment to prevent premature placement of the balloon catheter in the valve delivery system using an articulated lever; Figures 37A-37C are perspective views that illustrate the placement of the balloon catheter through the prosthetic heart valve and expansion of the balloon to expand the anchoring skirt, analogous to Figures 16E-16G; Figure 38 is a partial sectional view of the heart valve delivery system that has the prosthetic heart valve and the valve support on it and in the advanced balloon configuration of Figure 31 A; Figure 39 is a partial sectional view similar to Figure 38 and showing the movement of a balloon extension wire to compress a spring upon balloon inflation; Figure 40 is similar to Figure 38 and shows the return movement of the balloon extension wire and the spring when deflating the balloon; Figures 4142 are seen in perspective and in section of an exemplary stepped balloon construction used in the valve application system described here; Figures 43-45 are an outside and cross-sectional view of a farther end of a balloon extension wire and a farther shaped end of the exemplary balloon catheter; Figures 46A and 46B are views of the exemplary prosthetic heart valve described here, shown respectively assembled and with an expandable skirt exploded from a valve component; Figures 47-48 are views of the exemplary prosthetic heart valve that schematically show the methods for crimping the expandable skirt in a conical application configuration; Figures 49-50 schematically illustrate an alternative system that includes mechanical fingers to expand the prosthetic heart valve skirt stent described herein; Figures 51-54 schematically illustrate alternative valve systems for a fluid used to inflate the balloon over the catheter described herein that prevent premature balloon positioning; Figure 55 is a perspective view of an exemplary prosthetic heart valve that has commercially available valve components coupled with a skirt stent minus a surrounding tissue cover, and Figure 55A is a radial cross-sectional view through a cusp portion of the heart valve with the tissue cover of the skirt stent shown; Figure 56 is an exploded elevation view of the prosthetic heart valve of Figure 55; Figure 57 is a perspective view of an alternative prosthetic heart valve similar to that shown in Figure 55 but having a different firmer seam range; and Figures 58A and 58B are seen in radial section through the prosthetic heart valve of Figure 57 which illustrates alternative constructions. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
    The present invention attempts to overcome the disadvantages associated with conventional, open heart surgery, while also adopting some of the newer technology techniques which shorten the duration of the treatment procedure. The prophetic heart valves of the present invention are primarily intended to be applied and implanted using conventional surgical techniques, including the aforementioned open heart surgery. There are a number of proposals in such surgeries, all of which result in the formation of a direct access path to the annular space of a specific cardiac valve. For clarification, a direct access route is one that allows a direct view (that is, with the naked eye) of the annular space of the heart valve. In addition, it will be recognized that the modalities of the prophetic heart valves described here can also be configured for application using percutaneous proposals, and those minimally invasive surgical proposals and require remote valve implantation using indirect visualization. However, the last two proposals - percutaneous and minimally invasive - are invariably based on collapsible / expandable valve constructions. And, although certain aspects described herein may be useful for such valves and techniques, the primary focus and main advantages of the present application is the scope of non-expandable "surgical" valves introduced in conventional modes.
    A primary aspect of the present invention is a "unitary" prosthetic heart valve in which a tissue anchor is implanted at the same time as a valve member resulting in certain advantages. The exemplary unit prosthetic heart valve of the present invention is a hybrid valve member, if desired, with both non-expandable and expandable portions. By using an expandable anchoring skirt or stent on a non-expandable valve member, the duration of the anchoring operation is greatly reduced compared to a conventional sewing procedure using a suture net. The expandable anchoring skirt can simply be radially expanded outwardly in contact with the implantation site, or it can be provided with an additional anchoring means, such as barbs. As stated, the conventional open heart proposal and cardiopulmonary bypass familiar to cardiac surgeons are used. However, due to the expandable anchoring skirt, the time to deviate is greatly reduced by the relative speed of the implant in contrast to the previous time-consuming knotting process.
    For definition purposes, the terms "stent" or "coupling stent" refer to a structural component that is able to anchor in the tissue of an annular heart valve space. The coupling stents described herein are more typically tubular stents, or stents that have varying shapes or diameters. A stent is usually formed from a biocompatible metal frame, such as stainless steel or Nitinol. More preferably, in the context of the present invention, stents are made from a laser cut tube of a plastically expandable metal. Other coupling stents that could be used with the valves of the present invention include rigid rings, spiral-wound tubes, and other such tubes that fit tightly within an annular valve space and define an orifice through it for the passage of blood . It is entirely conceivable, however, that the coupling stent could be separate clips or hooks that define a continuous periphery. Although such devices sacrifice some contact uniformity, and speed and ease of positioning, they could be configured to work in conjunction with a specific valve member.
    A distinction between self-expanding and bolus-expandable stents exists in the field. A self-expanding stent can be crimped or otherwise compressed into a small tube and has sufficient elasticity to jump out on its own when a restriction such as an outer sheath is removed. In contrast, a balloon expansion stent is made of a material that is substantially less elastic, and really must be plastically expanded from the inside to shape when converting from a contracted diameter to an expanded one. It should be understood that the term balloon-expandable stents includes plastically expandable stents, whether or not a balloon is used to actually expand them (for example, a device with mechanical fingers could expand the stent). The stent material deforms plastically after the application of a deformation force such as an inflation balloon or mechanical expansion fingers. Consequently, the term "balloon-expandable stent" should be understood as referring to the material or type of the stent as opposed to the specific expansion medium.
    The term "valve member" refers to that component of a heart valve that has fluid occlusion surfaces to prevent blood flow in one direction while allowing it in another as mentioned above, various constructions of valve members are available , including those with flexible leaflets and those with rigid leaflets, or even a ball and cage arrangement. The leaflets can be bioprosthetic, synthetic, metallic, or other suitable means. In a preferred embodiment, the non-expandable valve member is a standard "shelf" surgical valve of the type that has been successfully implanted using sutures for many years, such as the Carpentier-Edwards PERIMOUNT Magna® Aortic Heart Valve available from Edwards Lifesciences of Irvine, California, although the autonomous nature of the valve member is not absolutely required. In this sense, a "shelf" prosthetic heart valve is suitable for sale and independent use, typically including a non-expandable, non-collapsible support structure that has a sewing ring capable of being implanted using sutures through the sewing ring in a procedure open-heart surgery.
    A primary focus of the present invention is a prosthetic heart valve that has a single stage implantation in which a surgeon attaches a hybrid valve that has an anchoring skirt and a valve member to an annular valve space as a unit or part (for example, example, a "unitary" valve). Certain characteristics of the hybrid anchoring skirt and valve member are described in U.S. Patent Copending Publication Number 2010-0161036, filed on December 10, 2009, the content of which is expressly incorporated herein. It should be noted that the application of a "two-stage" prosthetic valve described in the aforementioned publication refers to the two primary steps of a) anchoring the structure in the annular space, and then b) connecting a valve member, which is not necessarily limits the valve to just two parts. Likewise, the valve described here is especially beneficial in a single-stage implant procedure, but it does not necessarily limit the total system to just one part. For example, the heart valve described here could also use an expandable base stent which is then reinforced by the subsequently implanted heart valve. As the heart valve has a non-expandable and non-collapsible annular support structure and a plastically expandable anchoring skirt, it effectively resists the retreat of a self-expanding base stent. That said, several claims attached to this may exclude more than one part.
    As an additional definition point, the term "expandable" is used here to refer to a component of the heart valve capable of expanding from a first application diameter to a second implantation diameter. An expandable structure, therefore, does not mean one that can undergo a slight expansion from an increase in temperature, or another such incidental cause such as fluid dynamics acting on the leaflets or commissures. On the contrary, "non-expandable" should not be interpreted to mean completely rigid or dimensionally stable, since some slight expansion of conventional "non-expandable" heart valves, for example, can be observed.
    In the description that follows, the term "body channel" is used to define a conduit or blood vessel within the body. Of course, the specific application of the prosthetic heart valve determines the body channel in question. An aortic valve replacement, for example, would be implanted within, or adjacent to, the aortic annular space. Likewise, a mitral valve replacement would be implanted in the mitral annular space. Certain features of the present invention are specifically advantageous for one implantation site or the other, specifically the aortic annular space. However, unless the combination is structurally impossible, or excluded by claim language, any of the cardiac valve modalities described herein could be implanted in any body channel.
    A "quick connect" aortic valve bioprosthesis described herein is a surgically implanted medical device for the treatment of aortic valve stenosis. The exemplary quick-connect device comprises an implantable bioprosthesis and an application system for its positioning. The device, application system and method of use take advantage of the proven hemodynamic performance and durability of commercially available non-expandable prosthetic heart valves, while improving ease of use and reducing total procedure time. This is mainly done by eliminating the need to suture the bioprosthesis over the native annular space as is currently done by standard surgical practice, and typically requires 12-24 sutures manually tied around the valve perimeter. Also, the technique can prevent the need to extract the calcified valve leaflets and unclog or smooth the annular valve space.
    Figures 5A and 5B show an exemplary hybrid prosthetic heart valve 20 of the present application mounted on a valve support 22, while Figures 6A and 6B show valve support 22 separate from the heart valve 20. As mentioned, the prosthetic heart valve 20 desirably includes a valve member 24 having an anchoring skirt 26 attached to an inflow end thereof. The heart valve member 24 is desirably non-collapsible and non-expandable, while the anchoring skirt 26 can expand from the contracted state shown to an expanded state, as will be described. In embodiments, valve member 24 comprises a Carpentier-Edwards PERIMOUNT Magna® Aortic Heart Valve available from Edwards Lifesciences of Irvine, California, while anchorage skirt 26 includes a plastic-expandable internal frame or stent covered with tissue.
    Valve support 22, as seen in detail in Figures 6A and 6B, and also in Figures 7A-7D and 8A-8C, includes a central tubular hub portion 30 that has internal threads 31, and a plurality of stabilizing legs 32 that project axially and radially out of these. Each of the three stabilizer legs 32 contacts and attaches to a cusp portion 34 of the valve member 24 between the commissure pins 35 (see Figure 5A). An upper end of the hub portion 30 also has a star-shaped hole 36 that provides a specific valve-sized keyed coupling with an application system, as will be explained. Details of both valve support 22 and valve member 24, and their interaction, will be provided below. Suffice it to say at this point, that valve holder 22 sutures the valve member 24 from the time of manufacture to the time of implantation, and is stored with the valve member.
    In one embodiment, the support 22 is formed of a rigid polymer such as Delrin polypropylene which is transparent to increase the visibility of an implant procedure. As best seen in Figure 8B, support 22 exhibits openings between stabilizing legs 32 to provide a surgeon with good visibility of the valve leaflets. and the transparency of the legs additionally facilitates visibility and allows light to be transmitted through them to minimize shadows.
    Figures 7-8 also illustrate a series of hollow holes 37 in the legs 32 that allow the connecting sutures to be passed through the fabric at the cusps 34 of the prosthetic valve member 24 and through a cutting guide on each leg. As is known in the art, cutting an intermediate length of a suture that is connected to the support 22 and passes through the valve allows the support to be pulled free of the valve when desired. Each leg 32 extends radially outward and downwardly of portion 30 in a substantially constant thickness to a farther foot 38 which is substantially wider. The furthest foot 38 can be twice the width of the upper portion of the respective leg 32. The hollow holes 37 pass through circumferentially external points of each furthest foot 38 and are thus significantly spaced for each leg 32. This provides a total of six attachment points between the support 22 and the valve member 24, all in the cusp regions 34. Furthermore, each leg 32 extends downwards to the center or nadir of each portion of the cusp 34, which allows the surgeon better access behind and adjacent to the commissure pins. Furthermore, the expanded nature of the feet 38 and the double attachment points on them provide an extremely robust holding force between the support and the arch. The configuration of the wide feet 38 and the holes drilled over them forms a type of inverted Y shape. The anterior fasteners were either attached to the top of the commissure pins, or to a single point on the nadir of each cusp. Such fasteners left the valve with a tendency to twist or deform from contact with the operating room or anatomical surfaces.
    Figures 9-15 illustrate a number of steps in the construction of the prosthetic heart valve 20.
    Figure 9 illustrates a subset of inner structural band 40 that includes an inner polymer band 42 that has three vertical pins 44 and a lower cutout ring 46, and a more rigid outer band 48 that has a cutout shape to conform to the lower ring 46. The band subset 40 is formed by positioning the polymer band 42 within the rigid band 48 and securing them together with sutures through aligned holes, for example.
    Figure 10 is a perspective view of an additional subset of a wavy fabric covered wire shape 50. Figure 10A is a detailed cross-sectional view of a wire shape cusp portion 50 showing an inner wire member 52 covered with fabric that defines a tubular portion 54 and a flap that protrudes outward 56. The wire shape 50 defines three vertical commissure pins 58 and three convex cusps downward 60. This is a standard shape for the three leaflet heart valves and issue the peripheral edges of the three native aortic leaflets. The shape of the wire shape 50 coincides with the upper edge of the band subset 40, and defines the flow outlet edge of the prosthetic valve 20. The band subset 40 and the wire form 50 are then joined with a fabric interface and an outer sewing ring, and then with flexible leaflets as shown.
    Figure 11 is a perspective view of the band subassembly 40 and the seam ring 62 assembled, while Figure 11A shows details through its cusp portion. The two structural bands 42, 48 are of the same height in the cusp region and covered by a fabric cover 64 that is wrapped in a peripheral flap 66. The seam ring 62 comprises a permeable inner suture member 68 that has a trunk shape - conical and covered by a second fabric cover 70. The two fabric covers 64, 70 are sewn together at a lower junction point 72.
    Figures 12A and 12B are seen in inflow and outflow perspectives, respectively, of the surgical heart valve member 24 before coupling with an inflow anchoring skirt to form the prosthetic heart valve 20. Although construction details are not shown, three flexible leaflets 74 are attached along the wavy wire shape 50 and then in the combination of the web subset 40 and the sewing ring 62 shown in Figure 11. In a preferred embodiment, each of the three leaflets includes flaps that project outwards that pass through the inverted U-shaped commissure pins 58 and wrap around the fabric-covered commissure pins 75 (see Figure 11) of band subset 40. The entire structure at the commissures is covered with a secondary fabric for form the valve commissures 35 as seen in Figure 15A.
    As previously stated, the complete valve member 24 shown in Figures 12A and 12B provides the occlusion surfaces for the prosthetic heart valve 20 described herein. Although a stand-alone flexible leaflet valve member 24 (i.e., capable of an independent surgical implant) is described and illustrated, alternative valve members that have rigid leaflets, or are not fully stand-alone can be replaced. In various preferred embodiments, valve leaflets can be taken from another human heart (corpse), a cow (bovine), a pig (swine valve) or a horse (equine). In other preferred variations, the valve member may comprise mechanical components rather than biological tissue.
    A feature of the valve member 24 that is considered specifically important is the seam ring 62 that surrounds its inflow end. As will be seen, the sewing ring 62 is used to secure the anchoring skirt 26 to the valve member 24. Furthermore, the sewing ring 62 has an outward flange that contacts the flow outlet side of the annular space part , while the anchoring skirt 26 expands and contracts the opposite ventricular side of the annular space, therefore holding the heart valve 20 in the annular space on both sides. Furthermore, the presence of the seam ring 62 provides an opportunity for the surgeon to use conventional sutures to secure the heart valve 20 in the annular space as a contingency.
    The preferred seam ring 62 defines a relatively flat flow top or outlet face and an undulating bottom face. The cusps of the valve structure stub the upper side of the seam ring opposite locations where the lower side defines the peaks. In contrast, the valve commissure pins align with the locations where the bottom face of the sewing ring defines valleys. The undulating shape of the lower face advantageously coincides with the anatomical contours of the aortic side of the AA annular space, that is, the supra-annular shelf. Ring 62 preferably comprises a permeable suture material such as a wrapped synthetic fabric or an inner silicone core covered with synthetic fabric. In the latter case, the silicone can be molded to define the contour of the underside and the fabric covering conforms to it.
    Now with reference to Figures 13 and 14, the assembly of the fabric covered anchor skirt 26 will be described. It should first be noted that the size of the anchoring skirt 26 will vary depending on the total size of the heart valve 20. Therefore the following discussion applies to all sizes of valve components, with the dimensions staggered accordingly.
    The general function of the anchoring skirt 26 is to provide the means for attaching the prosthetic valve member 24 to the native aortic root. This fixation method is planned as an alternative to the current standard surgical method of suturing aortic valve bioprostheses to the annular space of the aortic valve, and is performed in much less time. In addition, this fixation method improves ease of use by eliminating most if not all sutures. The anchoring skirt 26 can be a pre-crimped, expandable, stent, 316L stainless steel balloon stent, desirably covered with a polyester fabric to help seal against paravalvular leaks and promote tissue growth once implanted within the annular space. The anchoring skirt 26 transitions between the tapered constricted shape of Figures 5A-5B to its expanded expanded shape shown in Figure 16J described below.
    The anchoring skirt 26 comprises an internal stent structure 80, a fabric cover 82, and a lower sealing flange as band 84. The internal stent structure 80 will be described in greater detail below, but preferably comprises a plastic tubular member expandable that has a wavy or cut top 86. The stent structure 80 mounts within a tubular section of tissue 82 which is then pulled taut around the stent structure, inside and out, and sewn into it to form the intermediate fabric covered structure 88 in Figure 13. During this assembly process, the stent structure 80 is desirably tubular, although the structure will later be crimped to a conical shape as seen in Figure 18B, for example. A specific sequence for securing the tubular tissue section 82 around the stent structure 80 includes providing longitudinal suture markers (not shown) at 120 ° locations around the tissue to allow recording with commissure characteristics similarly circumferentially spaced on the stent structure. After surrounding the stent structure 80 with tissue 82, a series of longitudinal sutures in each of the three locations at 120 ° holds the two components together. Furthermore, a series of stitches is provided along the undulating upper end 86 of the stent structure 80 to complete the tissue wrap. In one embodiment, the tubular section of fabric comprises a PTFE fabric, although other biocompatible fabrics may be used.
    Subsequently, the lower sealing flange 84 shown in Figure 14 is circumferentially fastened around a lower edge of the intermediate fabric covered structure 88. First, a linear band 90 of a single layer of fabric, preferably mesh, is formed in a ring and its ends sutured together using a butt joint (not shown). The ring is placed around the intermediate fabric covered structure 88, aligned with its lower edge, and sewn to it. Preferably, a series of points is formed at and adjacent to the previously described commissure markers. Alternatively, two circumferential lines of points can be provided around the lower sealing flange 84 to provide greater anchorage.
    The material of the lower sealing flange 84 may vary, but preferably provides a compressible flange around the lower edge of the anchoring skirt 26. For example, the lower sealing flange 84 can be a single layer mesh PTFE fabric. or multiple layers, Teflon, a silicone ring covered with fabric, or other similar devices. Furthermore, the sealing flange 84 may not comprise any fabric, but it may be a hydrophilic coating, fibrin glue, or other such substance that helps prevent leakage around the exterior of the anchoring skirt 26. The main functions of the layers of tissue covering the 88 structure are to help prevent paravalvular leaks and provide a means to securely encapsulate any calcium nodules on the aortic valve leaflets (if left in place) and / or the aortic valve annular space. Covering the entire anchoring skirt 26 eliminates exposed metal and reduces the risk of thromboembolic events and abrasion. In a preferred embodiment, the sealing flange 84 has an axial dimension between approximately 2-5 mm, and is spaced from the upper end 86 of the structure 80 by a distance ranging between 2-5 mm. The lower end of the structure can also be cut out to accompany the upper end 86, in which case the sealing flange 84 can also undulate to maintain a uniform distance with the upper end 86. If a mesh PTFE fabric, the sealing flange 84 desirably has a radial thickness of at least twice the thickness of the tubular tissue 82.
    Figure 15A shows the surgical heart valve member 24 above the tissue covered anchorage skirt 26 and a method for coupling the two elements using sutures. Figure 15B illustrates the internal stent structure 80 with the tissue cover removed to indicate a preferred pattern of coupling sutures passed through it.
    The anchoring skirt 26 preferably attaches to the seam ring 62 during the manufacturing process in a manner that preserves the integrity of the ring and prevents the reduction of the effective orifice area (EOA) of the valve. Desirably, the anchoring skirt 26 will be continuously sutured to the ring 62 in a manner that maintains the contours of the ring. In this regard, sutures can be passed through openings or eyelets 92 arranged along the first or upper end 86 of the internal stent structure 80. Other connection solutions include teeth or hooks that extend into the stent, ties, Velcro, fittings , stickers, etc. Alternatively, the anchoring skirt 26 can be more rigidly connected to rigid components within the prosthetic valve member 24.
    The internal stent structure 80 is seen in greater detail in Figures 13 and 15B. The internal stent structure 80 can be similar to an expandable stainless steel stent used in the Edwards SAPIEN Transcontinent Heart Valve. However, the material is not limited to stainless steel, and other materials such as Co-Cr alloys, etc., can be used. Finally, the internal stent structure 80 takes on a crimped, tuned configuration that facilitates insertion through the calcified native aortic valve (see Figure 7A). In the tuned configuration, a lower edge 94 of structure 80 describes a circle having a smaller diameter than a circle described by the upper end 86. The upper end 86 follows an undulating path with arched valleys and alternating pointed peaks that generally correspond to the undulating contour on the underside of the seam ring 62 (see Figure 5B). The middle section of structure 80 has three rows of expandable risers 98 in a sawtooth pattern between the axially extending risers 100. The axially extending risers 100 are out of phase with the peaks and valleys of the upper end 86 of the stent. The reinforcement ring defined by the upper end of the thicker wire 86 is discontinuous around its periphery and has a substantially constant wire thickness or diameter interrupted by the eyes mentioned above. Note that the fixing sutures ensure that the peaks of the upper end 86 of the skirt 26 fit closely to the valleys of the seam ring 62, which are located over the commissures of the valve.
    The minimum ID of the upper end 86 of the covered skirt 26 will always be greater than the ID of the prosthetic valve member 24 to which it attaches. For example, if the upper end 86 attaches to the bottom side of the seam ring 62, which surrounds the valve support structure, this will by definition be greater than the support structure ID (which defines the valve orifice and corresponding identified valve size).
    An exemplary implant procedure for the prosthetic heart valve 20 will now be described with reference to Figures 16A-16J, which are seen in cross-section through an isolated AA aortic annular space showing a portion of the adjacent LV left ventricle and the ascending aorta AO with sinus cavities. The two coronary arteries CA are also shown. As will be explained, the anchoring skirt 26 is positioned against the native leaflets or, if the leaflets are extracted, against the clear AA aortic annular space as shown.
    In the following procedural drawings, heart valve 20 is oriented with an inflow end downwards and a flow outlet end upwards. Therefore, the terms inflow and down can be used interchangeably at times, as can the terms flow out and up. Furthermore, the terms closer and more distant are defined from the perspective of the surgeon who applies the valve inflow end first, and thus closer is synonymous with upward or outward flow, and further away with downward or inflow.
    An implant procedure involves applying heart valve 20 and expanding the anchoring skirt 26 into the aortic annular space. Since the valve member 24 is not expandable, the entire procedure is typically done using the conventional open-heart technique. However, as the anchoring skirt 26 is implanted by simple expansion, with reduced sutures, the entire operation takes less time. This hybrid proposal will also be much more comfortable for family surgeons with open heart procedures and commercially available heart valves.
    Furthermore, the change in relatively small procedure coupled with the use of approved heart valves should create a much easier regulatory path than strictly expandable remote procedures. In addition, the surgeon's acceptance of the quick connect heart valve 20 will be greatly rationalized with a commercial heart valve that is already approved such as Magna® Aortic Heart Valve.
    Figure 16A shows a preliminary step in preparing an AA aortic annular space to receive the heart valve 20, including the installation of guide sutures 102. The AA aortic annular space is shown schematically isolated and it must be understood that several anatomical structures are not shown for clarity. The AA annular space includes a fibrous ring of tissue that protrudes into the surrounding cardiac walls. The AA annular space defines an orifice between the ascending aorta AO and the left ventricle LV. Although not shown, the native leaflets project into the AA annular space to form a one-way valve in the orifice. The leaflets can be removed before the procedure, or left in place as mentioned above. If the leaflets are removed, part of the calcified annular space can also be removed, such as with a scraper. The ascending aorta AO begins in the AA annular space with three protrusions or sinuses outward, two of which are centered on the coronary ostium CO (openings) that lead to the coronary arteries CA. As will be seen below, it is important to orient the prosthetic valve member 24 so that its commissure pins are not aligned and thus do not block the CO coronary ostium.
    The surgeon secures the guide sutures 102 in three evenly spaced locations around the AA annular space. In the illustrated embodiment, the guide sutures 102 attach at locations below or corresponding to the coronary ostium CA (i.e., two guide sutures are aligned with the ostium, and the third centered below the non-coronary sinus). The guide sutures 102 are shown to be linked twice through the annular space AA on the outflow side or from the ascending aorta to the inflow or ventricular side. Of course, other methods of suturing or bandaging can be used depending on the surgeon's preference.
    Figure 16B shows the guide sutures 102 that have been secured so that each extends in pairs of free lengths from the annular space AA and out of the operating location. The heart valve 20 mounts over a more distant section of an application system 110 and the surgeon advances the valve to the position within the AA aortic annular space along the guide sutures 102. That is, the surgeon inserts the three pairs of sutures guide 102 through evenly spaced locations around the seam ring 62. If the guide sutures 102, as illustrated, anchor in the annular space AA below the aortic sinuses, they pass through the ring 62 halfway between the commissure pins valve. Thus, the guide sutures 102 pass through the seam ring 62 on the valve cusps and are less likely to be entangled with the valve commissure pins. Furthermore, the exemplary ring 62 has an undulating inflow side so that the cusp locations are axially thicker than the commissure locations, which provides more material for attaching the guide sutures 102.
    Figure 16C shows the heart valve in the desired implant position in the AA aortic annular space, and during the placement of tubular suture loops. The seam ring 62 is positioned supra-annularly, or above the narrowest point of the AA aortic annular space, to allow selection of an orifice size larger than a valve placed intra-annularly. Furthermore, with the expansion of annular space using the anchoring skirt 26, and the supra-annular placement, the surgeon can select a valve that is one or two increments in size larger than previously conceivable. An expansion balloon 112 over the application system 110 can be seen just beyond the farthest end of the anchoring skirt 26.
    The surgeon applies a plurality of suture loops 120 below each free length of the guide sutures 102 in contact with the upper or outflow side of the seam ring 62. Loops 120 allow downward pressure to be applied to ring 62 and so on valve 20 during the implantation procedure, which helps to ensure a good seating of ring 62 on the annular space AA. Loops 120 also provide rigid closures around each of the flexible guide sutures 102 which helps to prevent entanglement with other mobile surgical instruments, as will be appreciated. As there are three pairs of 102 guide sutures (six free lengths, three loops 120 are used, although more or less possible. Loops 120 are typically members like medical grade plastic tubular straws.
    Figure 16D shows a forceps 122 securing the upper ends of the suture loops 120, and folding a pair outward to improve access to heart valve 20 and the implant site.
    Figure 16E shows all the suture loops 120 folded out and most of the delivery system 110. Although described in greater detail below, delivery system 110 includes a pliable grip rod 130 for handling the heart valve 20 on support 22. Application system 110 is in a configuration before advancing expansion balloon 112.
    Figure 16F shows the delivery system after advancing the expansion balloon 112. The balloon 112 projects downward through valve 20, and into the left ventricle. As will be explained below, the delivery system 110 provides a binary position shift of the balloon 112, or substantially recessed within the grip rod 130 or advanced precisely as much as necessary to expand the anchoring skirt 26 of the prosthetic heart valve 20.
    Figure 16G shows the inflated balloon 112 to expand the anchoring skirt 26 against the ventricular side of the aortic annular space. The balloon 112 desirably has a tapered profile that expands the anchoring skirt 26 to an expanded tapered state. Not only does this conform better to the sub-annular contours, it over-extends the annular space a little so that a larger valve can then be used without expansion. An advantage of using a plastically expandable stent is the ability to expand the native annular space to receive a larger valve size than would otherwise be possible with conventional surgery. Desirably, the left ventricular outflow tract (LVOT) is significantly expanded by at least 10%, or, for example, by 1-5 mm, and the surgeon can select a heart valve 20 with a larger orifice diameter with respect to to an unexpanded annular space. Even an increase of 1 mm in the size of the annular space is significant since the gradient is considered to be proportional to the high radius at 4- power.
    The balloon 112 is desirably tuned to have an angle between approximately 0-45 °, and most preferably it is approximately 38 ° (0 ° being a cylindrical expansion). Alternatively, the balloon 112 may include non-axisymmetric curves or contours to deform the anchoring skirt 26 to various desired shapes to better fit within the specific annular space. Indeed, several potential forms are described in U.S. Patent Publication 2008-0021546, entitled System for Positioning Balloon Expandable Heart Valves, published on January 24, 2008, the description of which is expressly incorporated herein.
    Figure 16H then illustrates balloon 112 deflated and rewound. A spring mechanism within the delivery system 110 together with longitudinal pleats in the balloon 112 to facilitate re-winding the balloon when deflated in an extremely narrow configuration which makes removal easier.
    Figure 161 shows the retraction of balloon 112 and the entire application system 110 of valve support 22 before or after the removal of loops 120, which happens only as a contingency. Although not shown, the most common procedure after balloon and skirt 26 expansion involves the surgeon cutting the connecting sutures between valve support 22 and prosthetic valve member 24, and removing the entire application system. Cutting an average length of each suture connecting the support 22 to the valve member 24 allows the delivery system 110 with the support at the far end to be pulled free of the valve 20. However, delivery system 110 also features a simple coupling and detachment mechanism explained below that allows the surgeon to easily remove the system 110 from the support 22 which remains attached to the valve 20, as shown in Figure 161. This detachment may be necessary to replace the balloon catheter, as as if the original balloon develops a leak or for some other reason does not deploy properly. This "quick release" arrangement allows the surgeon to change catheters quickly while leaving valve 20 in place.
    Finally, Figure 16J shows the prosthetic heart valve 20 fully implanted with the guide sutures 102 tied over the face closest to a sewing ring 62. The guide sutures 102 are primarily to rotationally orient the heart valve 20 as it rests against the aortic annular space and to define a plane for axial positioning. As such, guide sutures 102 are not believed to be strictly necessary to secure heart valve 20 in the annular space. Furthermore, although we were shown to attach the guide sutures 102, other devices such as staples or braces could be used to speed up the process.
    The placement of guide sutures 102 on the cusps of the native valve and prosthesis separates the knots from the commissures, thus increasing accessibility. Also, the number of nodes is reduced to three between the commissure pins, instead of multiple nodes (12-24) as before, some of which were behind the commissure pins. The use of three sutures correctly positions the valve 20 and the centering of the sutures between the commissure pins is the most accessible to tie the knots because the cusps are the lowest points in the annular space. Placing nodes (or staples) at the lowest point in the annular space also helps to minimize the risk of coronary occlusion.
    Figure 17 illustrates an exemplary arrangement of components for storing the prosthetic heart valve 20 after manufacture and before use. This "wet" storage arrangement applies to the illustrated heart valve 20 shown, which includes conventional bioprosthetic leaflets, but could also be used for bioprosthetic leaflets that have been dried and also for mechanical valves.
    Heart valve 20 is shown attached to the aforementioned support 22 and above a storage clamp 140 that fits inside a storage pot 142 that has a lid 144. Figure 18 illustrates heart valve 20 and support 22 mounted on the clamp storage 140. The inflating end of the heart valve 20, and specifically the expandable anchoring skirt 26, faces upwards in these mounting arrangements. This orientation allows a technician to insert a handling rod and a leaflet separating sleeve described below through the center of the heart valve 20 on the inflow to the outflow side. Typically, prophetic aortic valves are stored with the flow outlet side and the commissures pointing upwards so that a handle can be attached to a vertical fastener, and this is the standard application orientation.
    If the prosthetic heart valve 20 has conventional bioprosthetic leaflets, they require a liquid condom for long-term storage. Therefore, a condom such as glutaraldehyde is provided in pot 142.
    Figure 18A is a bottom view of the valve support 22 mounted within the storage clamp 140 which, together with Figure 18, illustrates a structure that indicates to an assembler that the two components are not properly coupled. More specifically, with reference back to Figure 6A, the central tubular hub portion 30 of the support 22 has a plurality of flaps or ears that project outward on three evenly spaced sides to couple the storage clamp 140. On two sides, as shown, these include a small ear 150 on the flow outlet end of the holder spaced from a longer ear 152 through a gap. On the third side, as best seen in Figure 18, a single elongated ear 154 extends the length of the central hub portion 30. The clearances between the ears 150, 152 receive the inner edges of a central opening of the storage clip 140, while that the elongated ear 154 extends out through a side outlet slot 156. Since the elongated ear 154 is uninterrupted, if an assembler inserts the holder 22 into the central opening of the storage clamp 140 in another than the orientation shown, the ear 154 will press away from the two semicircular sides of the storage clip 140 and prevent the clip from fitting into the storage pot 142.
    Figures 19A-19C illustrate several steps in removing the prosthetic heart valve 20 from storage pot 142. A user holds a handling rod 160 that has a balloon introducing sleeve 162 mounted on its farthest end. The balloon introducing sleeve 162, shown in more detail in Figures 21A-21E, includes external threads 164 that couple the internal threads 31 on the valve support 22. Inserting the sleeve 162 through valve 20 on the inflow side, the user screws the sleeve inside the support 22. The prosthetic heart valve 20 attached to the support 22 can then be removed from the pot 142, which also removes the storage clamp 140, as seen in Figure 19B. Figure 19C shows the user detaching valve holder 22 from storage clip 140 by pulling it laterally through outlet slot 156 (Figure 18A).
    Fixing the introducer sleeve 162 in this way provides several benefits. First and foremost, sleeve 162 defines a hole drilled at the level of valve leaflets 74 for the passage of a balloon catheter on the outflow side. Typically three valve leaflets 74 cover the orifice defined by the valve support structure and have free edges that stick together or "combine" generally along three spaced 120 ° line segments that intersect at the center line. This configuration mimics a native valve and works well by allowing blood to flow in one direction but not the other. Although extremely durable in use, valve leaflets 74 are relatively fragile and susceptible to damage from contact with solid objects during the implantation procedure, especially if they are made of bioprosthetic tissue such as bovine pericardium or a porcine xenograft. Consequently, the introducer sleeve 162 removes the leaflets 74 and provides a protective barrier between them and a balloon catheter that passes through the valve, as will be seen below. Without sleeve 162 a balloon catheter would need to force its passage backwards through the combined leaflet-free edges. An additional benefit of the spacer sleeve 162 is the ease with which it is mounted on the support 22. The fixation through the valve 20 on the support 22 is intuitive, and the removal of the handling rod 160 is simple. Valve assembly 20 and holder 22 are stored together before use, often in a glutaraldehyde storage solution or other preservative. The introducer sleeve 162 is preferably not pre-affixed to the support 22 to avoid causing any indentation in the leaflets 74 of long-term contact with them. That is, booklets 74 are stored in their relaxed or combined state.
    At this stage, the user can easily rinse the prosthetic heart valve storage solution 20 while it remains on the end of the manipulation rod 160. Furthermore, as will be explained below, the manipulation rod 160 provides a convenient tool for positioning the heart valve 20 and support 22 for coupling with the delivery system 110. Before a detailed explanation of this coupling, and the delivery system components, a better understanding of the configuration and function of the balloon introducer sleeve 162 is required.
    Figure 20 shows the balloon introducing sleeve 162 exploded from the handling rod 160. The handling rod 160 includes an elongated linear grip preferably tubular that ends on a circular flange 166 just before a far end 168 which has an outer profile substantially in star shape.
    The balloon introducing sleeve 162 as seen in Figures 21A-21E is substantially tubular and includes a first enlarged end 170 that has an inner hole with a star-shaped profile that matches the outer star-shaped profile of the farthest end 168 of the handling rod 160. Indeed, the farthest end 168 of the handling rod 160 mounts snugly within the first end 170 of the sleeve 162 to the circular flange 166. Figures 21D and 21E illustrate a circular groove 172 formed just inside the mouth of the first end 170 which is dimensioned to receive a similarly formed rib (not shown) provided on the farthest end 168 of the manipulation rod 160. The coupling between the rib and the circular groove 172 provides adequate interference between the two components that prevents the their detachment until the application of a limit longitudinal separation force. This separation force is greater than the combined weight of the heart valve 20, the support 22, and the storage clamp 140, but small enough that a user can easily pull them away. It should be noted that the alternating ribs and channels of the respective male and female star-shaped components are tuned in the direction of their coupling ends so that they can be quickly connected even with some misalignment.
    The tubular sleeve 162 includes the aforementioned outer threads 164 adjacent to the first enlarged end 170, and has a substantially constant outer diameter for a second end 174 except for a circular groove 176. The inner lumen of the sleeve 162 extends away from the first end 170 by a short distance in a portion of constant diameter 180 and then includes a thinning that narrows 182 leading to a second portion of constant diameter 184 that extends to the second end 174. The functional advantages of these surfaces, along with the overall purpose of the glove 162 will be described below.
    Figure 22 is an exploded view of the prosthetic heart valve delivery system 110, while Figure 23 shows the assembled system. Although not shown, a protective balloon glove will be placed around balloon 112 for protection during transport. The protective sleeve is a tubular component with an enlarged farthest end, the diameter of which is greater than the introducer lumen ID to ensure that the balloon protector is removed before the two components are connected. On its nearest end, system 110 includes an end cap 190 that has a luer adapter 192, a balloon extension spring 194, a spring compression pin 196, a balloon displacer 198, an inflation tube 199, and a balloon extension wire 200. In the middle portion of the system 110 includes a centering washer 202, a cable 204, and the aforementioned soft grip rod 130. Finally, the most distant components of system 110 include a tubular locking sleeve 206, a valve support adapter 208, the expansion balloon 112, and a molded insert bridge 210. The entire system preferably has a length of closest end of the luer adapter 192 to the balloon wire tip 210 between approximately 100 and 500 mm.
    Figure 23 shows the end cap 190 and the balloon displacer 198 joined, preferably with an adhesive or other such coupling. The end cap assembly 190 and the balloon displacer 198 can be moved linearly with respect to cable 204. The malleable handle rod 130 extends farther from cable 204 and is preferably attached to it with adhesive or the like. The valve support adapter 208 attaches to a far end of the handle stem 130, but the locking sleeve 206 slides over the handle.
    One aspect of the present application that is quite significant is the integration of a balloon catheter itself into the delivery system 110. Namely, previous systems for the application of prophetic heart valves in this way included separate introducer and balloon catheter elements , where the balloon catheter inserts through the tubular introducer. Although such a system can function properly for its intended purpose, a balloon catheter integrated within the delivery system 110 provides distinct advantages. First of all, if there is a problem with the balloon, such as a perforation, the surgeon does not need to retract the entire balloon catheter through the introducer and introduce another, which is time consuming. Instead, application system 110 is merely decoupled from valve support 22, and a replacement application system 110 coupled to the support. Secondly, and perhaps more evident, a single application system 110 replacing multiple parts speeds up the entire process and facilitates the practicality of use. The surgeon no longer needs to couple multiple parts together before attaching to the heart valve holder, or handling a separate balloon catheter in relation to an introducer tube. Sliding a balloon catheter through an elongated introducer creates the risk of bulges and balloon tearing. Finally, the amount of packaging is reduced accordingly.
    Figures 24A-24C illustrate several steps in coupling the delivery system 110 to the prosthetic heart valve assembly 20 and support 22 which is secured over the end of the handling rod 160. As explained above, the balloon introducer sleeve 162 threads with the support 22. A portion of the sleeve 162 that terminates within the second end 174 projects from within the support 22 and has a tubular entry path for the balloon wire tip 210 and the balloon 112, as seen in Figure 24A. The user inserts the application system 110 through the introducer sleeve 162 until a more distant shoulder 212 from the valve support adapter 208 contacts the support 22.
    Figures 25 and 25A show details of locking sleeve 206, and Figures 26 and 26A-26B illustrate support adapter 208. With reference specifically to Figure 26B, adapter 208 includes an elongated hollow hole 214 which receives the second end 174 of the introducer sleeve 162. A plurality of cantilevered fingers 216 extends longitudinally along the adapter 208, ending at the far end 212. Each of the fingers 216 includes an inwardly directed shoulder 218. Sliding the adapter 208 over the introducer sleeve 162 so that the furthest shoulder 212 contacts a face closer to the support 22 brings the shoulders 218 over the external groove 176 (see Figure 21A).
    Figures 24B and 24C show the advancement of the locking sleeve 206 along the elongated handle rod 130 and on the support adapter 208. The final configuration of Figure 24C is also shown in a sectional view in Figure 27. How the hole locking sleeve 206 mounts fitted around adapter 208, swinging fingers 216 are retained in their orientation aligned with the shoulders 218 within groove 176 of sleeve 162. Locking sleeve 206 desirably couples the outside of the adapter 208 to prevent the two parts from moving apart easily. Alternatively, a separate retainer or hitch can be provided for added security. Finally, when locking sleeve 206 is in the position of Figure 24C, delivery system 110 is securely coupled to valve holder 22. Furthermore, balloon 112 extends through balloon introducing sleeve 162 and slightly out of the end of inflow of the expandable skirt 26.
    Another advantageous feature of the present application is a keyed coupling between the delivery systems 110 and the supports 22 for the same size of heart valves. As seen previously in Figure 6A, the hub portion 30 of the support 22 has an internal star-shaped hole 36 which is sized and patterned to be keyed to an external star-shaped edge 220 provided on the support adapter 208 ( see Figures 26A and 26B). As the balloon catheter is integrated with the delivery system 110, and each balloon catheter is sized for a specific valve, only the delivery system 110 which is designed for this specific valve must be attached to its support. That is, each expansion skirt 26 must be expanded to a specific diameter, which requires different sizes of balloons 112. Consequently, each combination of valve support and a differently sized application system has a unique star-shaped pattern which prevents assembly with a different size.
    Typically, the delivery system is packaged separately from the heart valve and support, and this switching arrangement prevents misuse of the wrong delivery system. In addition, if the balloon breaks and another application system must be quickly obtained and used, the keying arrangement prevents the wrong application system from being replaced. There are typically 6-8 valve sizes in 2mm increments, so a similar number of single keyed couplings will be provided. Furthermore, the described star-shaped pattern allows for coupling in a plurality of rotational orientations. In a preferred embodiment, the user must rotate the application system 110 no more than 30 ° before the star-shaped edge 220 of the adapter 208 coincides with the inner star-shaped hole 36 of the holder 22. This is extremely beneficial if changing the application system 110, because the original elongated handle rod 130 can be bent in a specific orientation (see below) which is much easier to replicate if the keyed features do not need to be oriented in just one or two angular relations.
    Figure 28 is a perspective view showing the assembly of the heart valve 20 and the support 22 mounted on the end of the delivery system 110 with the handling rod 160 removed. In a preferred embodiment, the elongate handle rod 130 is malleable or foldable in various forms. Figure 29 also shows the advantageous malleability of the handle rod of elongated application system 130. This folding ability of the handle rod 130 significantly improves the ability of a surgeon to correctly position the heart valve 20 as it advances towards the annular space. Frequently, access passages into the heart during a surgical procedure are somewhat confined, and may not provide a linear approach to the annular space. Consequently, the surgeon bends the handle rod 130 to suit the specific surgery.
    Various materials and constructions can be used to provide a malleable tube for use as the grip rod 130. For example, a plurality of Loc-Line connectors should be used which provide axial rigidity with flexing flexibility. The grip rod 130 must be axially rigid so that it can confidently position the heart valve within the annular space. Another example is a plastic tube that has a metal spiral embedded in it to prevent bending. In a preferred embodiment, an aluminum tube that has a chromate coating (for example, Iridite) is used. Aluminum is specifically well suited to form small tubes that can be bent without bending, but must be coated with Iridite or similar to prevent deterioration within and reaction with the body. A highly desirable feature of the handle rod 130 is its resistance to recoil. Aluminum provides an insignificant level of indentation that allows the surgeon to bend the rod 130 to conform to the anatomy of a specific patient without worrying that the handle rod will change its shape once folded. On the other hand, although stainless steel is sufficient if it remains straight, any bending will be followed by an indentation so that the surgeon cannot be sure of the final stem orientation. As mentioned, Loc-Line connectors may work, but a solid rod that is easy to sterilize is preferred.
    The limit on the recoil can be quantified by bending different materials and evaluating the force required to bend together with the amount of recoil. For these tests, the bending force is the peak force required to bend the pliable part of a fully assembled application system to 90 ° with a radius of 38.1 mm (1.5 "). The indentation is the degree of indentation after the malleable handle is bent as such. For example, a 5o indentation means that the 90 ° bend angle has recovered to an 85 ° bend angle. A number of materials are suitable for use as the application system 130, specifically various biocompatible metals and alloys Stainless steel (SS) has a better kickback property than aluminum (Al), meaning that it recedes less, however it requires a much higher bending force due to the its higher tension property. An SS rod handle will need to be relatively thin to reduce the required force, and could be made with longitudinal slits to reduce the bending force even more. However, the cost of an SS handle with slits is much larger than that of a Al's handle. Al is preferred for its low recoil tendency and is relatively easy to bend.
    Figures 30 and 30A are seen in elevation and broken longitudinal section, respectively, of the heart valve delivery system 110 with a balloon 112 in a recessed position, while Figures 31 and 31A are seen similarly with the balloon 112 extended. The balloon catheter of the delivery system 110 has two binary longitudinal positions in relation to the cable 204 and its associated structures. In a recessed position shown in Figures 30 and 30A, the end cap 190 connected, balloon displacer 198, inflation tube 199, and balloon 112 are recessed to the left with respect to cable 204. Note the spacing A between the furthest shoulder 230 of the balloon displacer 198 and the centering washer 202 within the cable 204. The balloon 112 partially resides within the support adapter 208 in this position. Once the balloon catheter is moved to the right, as seen in Figures 31 and 31A, spacing A disappears and balloon 112 projects out from inside the support adapter 208.
    The application system 110 provides an extremely precise system for positioning the balloon 112 in relation to the heart valve, specifically the anchoring skirt 26. Due to the simple coupling between the support adapter 208 and the handle rod 130, very few tolerance are introduced. The support adapter 208 is fixed on the elongated handle rod 130, which in turn is on the cable 204. The movement of the balloon catheter structures in relation to the cable 204 thus displaces the balloon 112 in a 1: 1 correspondence with respect to the support 22 and the fixed heart valve 20. Furthermore, a pair of small resilient retainers 232 provided on the balloon displacer 198 couple similarly sized cutouts 234 on the nearest end of cable 204. This locks the position of the balloon catheter with respect to cable 204, or in other words locks the position of the balloon 112 with respect to the anchoring skirt 26.
    The balloon inflation tube 199 and the balloon extension wire 200 are formed of materials that have column strength but are relatively flexible in folding. As further explained below, the yarn may be Nitinol while the inflation tube 199 is desirably formed of a braided reinforced thermoplastic elastomer (TPE) such as a polyether block starch known under the PEBAX® brand name (Arkema Colombes, France).
    As the folding system 110 can be subjected to several bends in use, care must be taken to ensure that the concentric tubes and wire do not introduce misalignment. That is, objects with a smaller diameter tend to travel shorter paths within larger concentric tubes, this causes them to extend out of the far end of the tubes after being bent. As such, the balloon inflation tube 199 is desirably adjusted to match the inner diameter of the soft grip rod 130. In one embodiment, the outer tube of the soft grip rod 130 has an OD of 5.004 ± 0.076 mm (0.197 ± 0.003 ") and an ID of 3.886 ± 0.051 mm (0.153 ± 0.002"). The balloon inflation tube 199 has an OD of 3.556 ± 0.051 mm (0.140 ± 0.002 ") and an ID of 2.896 ± 0.051 mm (0.114 ± 0.002"). This means that the difference in radii between the ID of the largest tube 130 and the OD of the smaller tube 199 is only 0.165 mm [(3,886-3,556) ^ - 2], and the OD of the smaller tube is more than 90% (91 , 5%) of the largest tube ID. This close match of tube sizes ensures that the axial position of the balloon 112, which is attached to the end of the balloon inflation tube 199, does not shift much from the axial position of the prosthetic heart valve 20, which is attached in relative to the end of the soft grip rod 130. The balloon extension wire 200 has a size relative to the ID of the balloon inflation tube 199 sufficient to allow a good flow of saline when filling the balloon 112. In one embodiment, the wire 200 has an OD of 0.94 + 0.137-0.025 mm (0.037 + 0.0027-0.001 ").
    The present delivery system advantageously prevents premature advancement of the balloon catheter so that the balloon 112 remains recessed within the confines of the prosthetic heart valve 20 during advancement of the valve in position within the aortic annular space. As will be readily apparent, the surgeon advances the entire delivery system 110 with the heart valve 20 at its farthest end through the open chest cavity or orifice and through the aortic arch and below the ascending aorta to the implant position. Pushing over the end closest to the delivery system 110 runs the risk of accidentally displacing the balloon catheter in relation to the cable 204 before the desired positioning stage. A protruding balloon 112 can damage the coronary ostium or make insertion difficult by increasing the profile of the device. Consequently, the present application contemplates several means to physically prevent the movement of the balloon catheter, preferably coupled with a visual reminder not to unfold the catheter prematurely.
    For example, Figure 32 is a perspective view of the nearest end of the e-xemplar heart valve delivery system 110 showing an exploded locking clip 240 thereof. As seen in Figures 33A and 33B, the locking clip 240 fits on the outside of the end cap 190 and the cable 204 and secures the balloon catheter in a recessed position presenting a physical barrier for the relative movement of these two elements. The locking clip 240 includes a semitubular body 242 that ends in a thumb rest 244 on its farthest end. The semitubular body 242 has internal characteristics that coincide with the external characteristics on the cable 204. Specifically, although not shown, the interior of the semitubular body 242 has circumferential ribs that couple the closest end of the cable 204 and both frictionally couple the cable and provide an impediment to axial movement further from the clamp in relation to the cable. Locking clamp 240 forks on two elongated rails 246 that extend closer to the body 242 and are together on a closer bridge 248 that has an inwardly directed node 250 (Figure 33B). Node 250 mounts snugly within the luer of the luer adapter 192 and provides a physical barrier and a visual indicator to prevent premature attachment of a balloon inflation source. In addition, internal features on the two elongated rails 246 couple corresponding contours on the balloon catheter end cap 190.
    The clamp 240 mounts to the delivery system 110 as shown with the balloon catheter in the retracted position. First, node 250 inserts into luer adapter luer 192, and then clamp 240 fits over end cap 190 and cable 204. The connection between clamp 240 and application system 110 is by friction and the clamp can be easily removed, but provides a physical barrier and a visual reminder to prevent the balloon catheter from unfolding further and connecting a source of balloon inflation. Furthermore, the thumb support 244 on the clamp 240 provides a convenient ergonomic feature that makes it easy to control the advance of the system. After the surgeon advances the system and prosthetic heart valve 20 to the position within the aortic annular space, he / she removes the clamp 240 to allow the balloon catheter to unfold and the connection of an inflation source. Staple 240 is typically plastic and is discarded.
    Other possible barriers to the deployment of balloon catheter / premature balloon inflation are contemplated. In a configuration shown in Figures 34 and 35, a toggle lever 260 connects to both end cap 190 and cable 204 and can be moved in any direction to alternately unfold and retract the balloon catheter. More specifically, the toggle lever 260 includes a thumb piece 262 that protrudes out of the delivery system 110, a hinge 264 mounted to the handle 204, and a locking end 266 that mounts within the axial space between the end cap 190 and the cable 204 in the recessed position in Figure 34. A cam connection 268 pivots halfway along the thumb piece 262 and pivots at its opposite end to the end cap 190.
    The recessed position of Figure 34 corresponds to the recessed position of the balloon catheter in the delivery system 110 as in Figure 31. In this state, the locking end 266 mounts snugly between the facing surfaces of the end cap 190 and the cable 204 spaced, and thus it presents a physical barrier for the further advancement of the end cap and the balloon catheter within the delivery system 110. At the appropriate time, the surgeon articulates the articulated lever 260 in the direction of the arrow 270 in Figure 35 which simultaneously removes the locking end 266 between end cap 190 and cable 204 and pulls the end cap towards the cable by virtue of the meat connection 268. The articulation of the articulated lever 260 in its full length unfolds the balloon catheter completely and moves the balloon 112 to its appropriate position within the anchoring skirt 26. That is, the distance traveled by the end cap 190 from the cable 204 is calibrated to be precisely the same distance needed to advance the balloon 112 to a location for the proper expansion of the anchoring skirt 26 which ensures its optimal hemodynamic performance. Consequently, not only does the articulated lever 260 prevent premature deployment of the balloon catheter, but it also ensures its advance before balloon inflation, and in doing so ensures a precise advance. In addition, due to the connected nature of the toggle lever 260, there are no loose parts to interfere with the procedure or potentially be poorly located during surgery. Additional details on ensuring the correct positioning of the balloon 112 within the skirt 26 are provided below.
    When the surgeon pushes the toggle lever 260 to the forward position, it desirably fits into some feature on the handle 204 to signal the complete deployment and keep it in place. For example, Figure 36 shows a farther end 272 of lever 260 captured within a notch or complementary recess on the outside of cable 204. Of course, numerous other such configurations are possible, and in general the toggle lever 260 and its interaction with end cap 190 and cable 204 are exemplary only. Alternatives such as slides, rotating buttons or levers, colored or even illuminated indicators, etc., are contemplated. The purpose of such alternatives is to prevent premature advancement of the balloon catheter, to ensure advancement before balloon inflation, and to ensure accurate advancement within the anchoring skirt 26 of the prosthetic heart valve 20.
    Other devices for preventing balloon catheter deployment / premature balloon inflation are contemplated, including physical impediments such as the articulated lever 260 described above as well as visual or audible indicators to prevent deployment. For example, an alternative configuration that prevents the flow of balloon inflation fluid prior to catheter advancement is seen in Figures 52-54 and described below.
    Figures 37A-37C are perspective views that illustrate the deployment of the balloon catheter through the prosthetic heart valve and the expansion of the balloon to expand the anchoring skirt, similar to Figures 16E-16G.
    Figure 37C shows the balloon 112 inflated to expand and position the anchoring skirt 26 against the annular space. The anchoring skirt 26 transitions between its contracted conical state and its expanded, generally tubular or slightly conical state. A simple interference between the anchoring skirt 26 and the annular space may be sufficient to anchor the heart valve 20, or interacting characteristics such as projections, hooks, splinters, fabric, etc. can be used. For example, a farther end of the anchoring skirt (see lower edge 94 in Figure 15B) may expand more than the rest of the anchoring skirt so that peaks in the row of the furthest risers project outward into the surrounding annular space.
    Also, balloon 112 may have an expanded end farther away than its nearest expanded end in order to apply more force to the free end of the anchoring skirt 26 than to the prosthetic valve member 24. Thus, the prosthetic valve 24 and the flexible leaflets therein are not subject to high expansion forces of the balloon 112.
    When assembled as seen in Figure 30A, an elongated (unnumbered) lumen extends from the nearest luer adapter 192 into the balloon 112. The luer adapter 192 provides a fixing nipple for an inflation system (not shown) for the inflation of balloon 112. Balloon 112 is desirably inflated using a sterile, controlled, pressurized physiological saline solution. The lumen passes through the end cap 190, of the balloon displacer 198, and then through the inflation tube 199 which is attached at one end to the displacer and at the other end to an end closest to the balloon. The balloon displacer 198 thus moves the end closest to the balloon.
    The present application also provides an improved balloon 112 and a system for positioning and removing it. As seen in the deflated views, the balloon 112 preferably comprises a plurality of longitudinal pleats which help to reduce its radial configuration for passage through the delivery system 110. Furthermore, the balloon extension wire 200 extends through the balloon inflation tube 199, through the expansion balloon 112, and ends at a shaped balloon wire tip 210 affixed to the farthest end of the balloon. The path of the wire 200 is seen in the sectional views of Figures 30A and 31A. Although the nearest end of balloon 112 grips inflation tube 199, and from there to cable 204, the farthest tip 210 does not. Instead, the wire 200 attaches to the spring compression pin 196 which translates into a lumen within the nearest end cap 190, and engages the balloon extension spring 194 there. In this regard, the balloon extension wire 200 moves independently within the delivery system 110 instead of being fixedly attached. This, in turn, allows the furthest end of balloon 112 to move relative to the nearest end. This arrangement is best seen in Figures 38-40.
    The exemplary delivery system balloon 112 has a relatively high diameter-to-length ratio compared to other surgical balloons, such as those used to expand cardiovascular stents. This makes it specifically difficult for balloon 112 to return to a small geometry upon deflation after positioning. Balloons of such size reasons tend to "butterfly" forming wings that prevent removal through the valve support without applying high forces, which can cause damage to the valve itself. The exemplary delivery system 110 and balloon 112 include several advances over previous heart valve delivery systems that facilitate atraumatic removal of balloon 112. First, as mentioned above, a series of longitudinal pleats are formed by heat on the wall of the balloon. balloon 112 to facilitate self-collapse during deflation. In addition, the farthest end of the balloon 112 moves relative to the nearest end to allow the balloon to stretch during deflation. This elongation occurs automatically by virtue of the wire 200 which is spring-tensioned to stretch the balloon longitudinally. It should be noted that the easy deflation and removal of balloon 112 allows for rapid replacement of the balloon catheter in the event of a problem, such as insufficient inflation.
    Figure 38 is a sectional view with the advanced balloon 112 as in Figure 31 A. In this configuration, the spring 194 has a length of xi, and the spring compression pin 196 is all to the right within the far end. In this "resting" state with the balloon 112 deflated, the spring 194 can be relaxed or under a slight compressive preload. Subsequently, saline is introduced through the nearest luer connector 192 and moves further along the length of the balloon catheter components to inflate the balloon 112. The inflation of the balloon 112 causes a radial expansion but an axial shortening , thus moving the farthest tip 210 to the left as shown in Figure 39. This in turn displaces the balloon extension wire 200 and the spring compression pin 196 attached to the left against the resilience of the spring 194. Finally, the spring is compressed to a second shorter length X2. In a preferred embodiment, the spring 194 undergoes a complete compression for its solid length in order to provide a positive stop on the movement closer to the wire 200 and the more distant tip of balloon 210 attached. This helps to ensure proper expansion of the anchoring skirt 26, as will be more fully explained. Moving closer to the farthest tip 210 against the reaction force of the spring 194 places the yarn 200 in compression.
    Finally, Figure 40 illustrates deflation of balloon 112 by pulling a vacuum through the inflation movement and the return movement to the right of the farthest tip 210 and the balloon extension wire 200. This movement is encouraged, and in fact forced , by expanding the spring 194. The force of the spring 194 is calibrated so as to elongate the pleated balloon 112 so that it assumes its radially constricted anterior diameter, or as close as possible to it. Furthermore, the wire 200 can be rotated around its geometric axis to further encourage the constriction of the balloon 112 by causing the pleats to additionally bend in a helical mode. This can be accomplished by extending a portion of the wire 200 from the end closest to the luer connector 192 so that it is gripped and rotated by forceps, or otherwise by providing a lever or thumb plunger (not shown) attached to the wire and projecting laterally of the system. Furthermore, the spring compression pin 196 can be constrained to move within a helical track. In the latter case, pin 196 may include a bayonet-like assembly that locks into restraints at both ends of the helical track. The spring-tensioned elongation and the consequent radial contraction of the balloon 112 facilitates its removal closer through the now positioned prosthetic heart valve 20.
    As mentioned above, the balloon 112 desirably has a trunk-conical profile that expands the anchoring skirt 26 to an expanded trunk-conical state. More typically, and as shown in Figure 39, balloon 112 is generally spherical when expanded. In spite of everything, the spherical balloon will expand to form the anchoring skirt 26 in a conical trunk shape due to the connection at one end of the internal stent structure 80 in the heart valve seam ring 62 (see Figures 15A / 15B). To ensure sufficient and appropriate outward expansion of the anchoring skirt 26, the balloon 112 is axially positioned so that a median line 280 indicated around its maximum circumference (equatorial line) registers with the farthest end 282 of the skirt. In doing this, the widest part of the balloon 112 corresponds to the end of the skirt 26, which tends to expand the skirt conically. A tolerance of 1-2 mm between the location of the midline 280 and the farthest end 282 of the skirt is acceptable, which can occur for different sizes of valves and associated skirt 26.
    As seen in Figures 41-42 an exemplary stepped balloon construction is shown in which the balloon 112 is desirably shaped displaced to form the midline 280 as a small step in the balloon wall. That is, the opposite balloon mold halves will have a slightly different diameter, so that a physical step in the final product is formed - the midline 280. Alternatively, the midline 280 can be formed by a small equatorial rib or indentation formed in the molding process, or even with an ink marking, although the latter may not be suitable for surgical application. The midline 280 will be visible over the balloon 112 in both its deflated and inflated state, and is extremely useful as a reference line during the assembly and quality control of the 110 application system. For example, the components system 110 are mounted and the location of the balloon 112 in its forward position is checked against the anchoring skirt 26. As the balloon 112 shortens when it is inflated, the reference midline 280 would be beyond the far end 282 of the exit 26 when balloon 112 is deflated, a location that can be easily inspected during assembly.
    Although Figures 41 and 42 illustrate a molded geometric shape of the expansion balloon 112, in use, saline or other fluid injected into the balloon cavity will result in a more rounded inflated shape, as seen in Figure 39. The exemplary molded shape shown is preferred due to the relatively large diameter to which the furthest end of the anchor skirt structure 26 expands. More specifically, the exemplary shape includes tubular ends closest and farthest 290 to which the elongated elements of the balloon catheter are attached. A pair of tapered side walls 292 slopes outward toward the midline of balloon 112 from tubular ends 290, while a pair of displaced axial side walls 294, 296 completes balloon 112, expanding from the midline or equator. One or the other of the side walls 294, 296 has a larger diameter, with the axial side walls being joined on a step 298 that indicates the equatorial midline 280 of balloon 112. Again, this construction can be formed using a displaced mold, in that one mold half is larger than the other.
    Another advance related to balloon 112 is in the steps to calibrate its filling capacity. Existing balloon catheters are calibrated by monitoring the injected volume to expand the balloon to a desired diameter. In contrast, the balloon 112 of the delivery system 110 is pressure calibrated. One or more balloons are tested during the verification test to see how much pressure is required to expand an anchor skirt 26 to a specific diameter, depending on the desired final size of the skirt. During assembly, each balloon is inflated to see if it expands into the expected range. In use, a pressure gauge is attached to the filling line to monitor the filling pressure. The surgeon inflates to the target pressure, and as an additional confirmation can check the resulting skirt expansion visually or with the aid of a microscope or radiographic markers and the like.
    It should be noted that the enlarged form of the expanded anchoring stent 26 (see Figure 16H or Figure 46A, below) can help to optimize the flow through the prosthetic heart valve in relation to a valve without the skirt. In some patients, ventricular hypertrophy tends to cause a bulging into the left ventricular wall just below the aortic valve. The conical skirt 26 will expand outward against this anomaly, and in doing so it will expand the inflow passage to the aortic valve.
    The balloon extension wire 200 seen extending the length of the delivery system in Figures 38-40 flexes to adapt to the folding of the surrounding handle rod 130 (for example, see Figure 29). In a preferred embodiment, wire 200 is Nitinol, although other suitable metals such as stainless steel could be used. Nitinol combines good column strength with excellent flexibility. However, the delivery system 110 will be provided in a size network for differently sized orifice prophetic heart valves, and the larger balloons will exert significant compressive force on the wire 20 when inflated. To prevent the wire 200 from warping, and in place of stiffening the wire, a short hypotube 201 can be provided, as seen in Figures 22 and 39. The hypotube 201 attaches to the wire 200 at its farthest end, as being molded together with balloon wire and catheter tip 210 or other suitable means. Hypotube 201 provides additional column resistance to wire 200 along its length that projects out of inflation tube 199 and into balloon 112. Hypotube 201 ends just beyond the nearest end of balloon 112 so as not to interfere much with the total flexibility of the 110 application system. The 201 sub-tube can be made of a suitable metal such as Stainless Steel or a rigid polymer such as Nylon. Hypotube 201 has an OD of 1.5 ± 0.13 mm (0.059 ± 0.005 "), an ID of 1.04 ± 0.08 mm (0.041 ± 0.003") and a length of approximately 45.0 mm (1 , 77 ").
    Figures 43-45 are an external and cross-sectional view of an end furthest from the balloon extension wire 200 and a molded tip of the furthest insert 210 over it - Figure 45B shows the final assembly in section, with the farthest end of the wire 200 embedded within the tip 210, while the other views illustrate an assembly process for it. The molded insert tip 210 provides an anchor for the furthest end of the wire 200 which experiences high axial forces during balloon expansion. More specifically, and as explained above with reference to Figure 39, the balloon expansion causes an outward expansion and an axial shortening so that the farthest tubular end 290 (see Figure 42) moves in a closer direction. The wire 200 attaches to the farthest tubular end 290 through the molded insert tip 210, and thus both move closer together as well. As previously described, inflation of balloon 112 places the yarn 200 in compression. Consequently, the connection between wire 200 and tip 210, and between tip 210 and tubular end 290 of balloon 112 must be relatively robust to prevent leakage or the wire breaking free of the tip. Furthermore, manufacturing concerns require as few steps as possible to form this important construction.
    Consequently, the farthest end of the wire 200 is turned on itself in a J-shaped fold 300. The fold 300 is then placed inside an insert mold into which the material is injected to form the molded tip 210, in the combination shown in Figure 45A. The shape of the tip 210 after molding is seen in Figures 44A-44D. Tip 210 after molding includes a closer portion that has a cylindrical stem region 302 and a semi-spherical bulb 304, a more distant portion that includes a tubular mandrel alignment conduit 306, and a narrow bridge 308 between them, identified in Figure 44C. The mandrel alignment conduit 306 provides a convenient handle for keeping the tip 210 and the wire 200 securely centered within the tubular end 290 farthest from the balloon 112 during a heat melting step, typically with laser adhesion. After adhering the balloon 112 to the tip 210, the mandrel alignment line 306 is cut into the bridge 308, resulting in the shape of a rounded end for an atraumatic application as seen in Figure 45B. The final tip 210 desirably has a relatively short axial length between approximately 5-8 mm. The length of the wire 200 can be 300-400 mm, and has a diameter of 1 mm or less.
    An alternative set is seen in Figure 45C, where the J-shaped fold 300 over the end of the wire 200 has been replaced by a drop 300 '. The drop 300 'can be fused at the end of the wire 200 or adhered to it. Indeed, the drop 300 'represents numerous other enlargements that could be used on the end of the wire 200 to prevent it from leaving free of the shaped tip 210. For example, the end of the wire 200 could be compressed into a drop or a flat head , similar to a rivet, or the drop 300 'could have a different shape such as a square to provide some torsional strength.
    The materials of the flask 112 and the tip 210 are desirably similar to facilitate their adhesion by applying heat to their interface. For example, flask 112 and tip 210 may be formed from Nylon or a high hardness thermoplastic elastomer (TPE) such as PEBAX®. The farthest tubular end 290 of the balloon 112 fits snugly around the stem region 302 and touches a small shoulder 310 at the beginning of the semi-spherical bulb 304. This heat fusion construction coupled with the physical coupling between the balloon end and the shoulder 310 provides a redundant fastening system with high axial tensile strength. That is, the fixing system prevents the uncoupling of tip 210 from balloon 112, and also effectively resists the separation that leads to leakage. Furthermore, the J-300 fold features a type of anchor within the material of the molded tip 210. Tensile tests have shown that the assembly can withstand 18.1 kg (40 lb) of traction without the wire 200 being free of tip 210.
    An important aspect of the present heart valve delivery system is the configuration of the expandable anchoring skirt 26 in terms of its construction within the heart valve and also its shape when expanding. Figures 46A and 46B illustrate the exemplary prosthetic heart valve 20 both assembled and with the exploded anchoring skirt 26 of valve component 24. Again, valve member 24 can be a commercial "off-the-shelf" prosthetic valve such as Carpentier-Edwards PERIMOUNT Magna® Aortic Heart Valve available from Edwards Lifesciences. The anchoring skirt 26 primarily includes the plastically expandable internal structure or stent 80, with a fabric cover not shown for clarity.
    As mentioned, the anchoring skirt 26 attaches to an inflow end of the valve member 24, typically through sutures through the upper end 86 of the stent structure 80 connected to the fabric over the valve member 24, or to the seam ring 62 The specific seam ring 62 shown includes an undulating inflow contour that plunges, or in the direction of inflow, in the regions of the valve cusps 34, and arches upward, in the direction of outflow, in the regions of the valve commissures 35 This undulating shape generally accompanies the inflow end of the heart valve member wire shape 50 (see Figure 10) which rests within the seam ring 62. The top-cut end 86 of the stent structure 80 also conforms to this undulating shape, with peaks aligned with valve commissures 35 and valleys aligned with valve cusps 34. Additional details on exemplary valve / stent constructions are provided below with reference to Figures 55-58.
    Referring back to Figures 46-48, the stent structure 80 of the anchoring skirt 26 can initially be formed in several ways. For example, a tubular portion of a suitable metal such as stainless steel can be laser cut to length and form the lattice of interconnected uprights in the form of a boundary. Other methods including wire bending and the like are also possible. The resulting stent structure 80 is initially tubular when attached to the valve member 24, and is then crimped in the conical shape shown in Figures 47A and 47B in a first crimp step. Preferably, an inwardly distributed crimp force is applied at uniform locations around the stent structure 80, as indicated by the arrows in the figures. The structure 80 is fixed together and thus articulates inwardly around its cut-out upper end 86. The crimp forces are applied starting at approximately the level of the unequal upper end valleys 86, as schematically indicated in Figure 48A, leaving a short axial distance where the stent structure 80 remains cylindrical.
    In a second preferred crimp step, shown in Figure 48B, inward forces are applied unevenly to wind the lower or farthest end of the stent structure 80 inward resulting in a somewhat more spherical end. To avoid causing an overlap between the uprights of the plastically expandable stent structure 80, the forces are desirably applied more at three locations distributed 120 ° apart so that a flat bottom view (see Figure 7D) shows the lower end having a trilus shape - bular instead of circular. This helps to reduce the front end profile of the valve without compromising the ability of the stent structure 80 to expand freely to the shape in Figure 46A. Regardless of the crimp method, the inflation balloon 112 finally expands out the inflating end of the stent structure 80 to form the conical shape of Figures 46A and 46B.
    It should be mentioned that as an alternative to a balloon, a mechanical expander can be used to expand the anchoring skirt 26 shown above. For example, a mechanical expander may include a plurality of expandable fingers actuated by a device such as a syringe, as seen in U.S. Copending Patent Publication Number 2010-0161036, filed December 10, 2009, incorporated above. The fingers are axially fixed, but able to articulate or flex with respect to a drum. The farthest end of a plunger has an outside diameter that is larger than the diameter circumscribed by the inner surfaces of the expandable fingers, so that a movement further away from the plunger with respect to the drum gradually acts like flesh the fingers out into the coupling stent. Therefore, the term "plastically expandable" encompasses materials that can be substantially deformed by an applied force to assume a different shape. Some self-expanding stents can be deformed to a degree by an applied force beyond their maximum expanded dimension, but the primary cause of the shape change is the elastic recoil as opposed to a plastic deformation.
    According to an alternative embodiment, Figures 49-50 show an expansion system that includes mechanical fingers 320 in conjunction with an inflatable balloon 322 to expand the anchoring skirt 26. Figure 50A illustrates mechanical fingers 320 surrounding balloon 322 and extending from a cable clamp member 324 which is partially inserted into the inflow end of a prosthetic heart valve 20 as described herein. The assembly of the fixing member 324, the mechanical fingers 320 and the balloon 322 is shown in cross section in Figure 49. The cable fixing member 324 includes a lumen 326 through it which has an internal thread 328 on a closer end . A malleable handle such as that described above can be threaded over the end closest to the fixing member 329 to supply an inflation fluid to the balloon 322.
    The mechanical fingers 320 can be pivoted around a far end of the fixing member 324, such as with integral hinges 330 as seen in Figure 49 and in the detail of Figure 50E. In a preferred embodiment, integral hinges 330 are each formed by a V-shaped notch which has an included angle ψ which limits movement out of fingers 320. Fingers 320 can be slightly tuned to be radially thicker at the most distant ends. As the assembly inserts into the heart valve 20, as from the position in Figure 50A to the position in Figure 50B, the inflow aspect of the valve that has the anchoring skirt 26 eventually contacts the outer surfaces of the fingers 320. A relative movement The additional adjustment increases the friction fit between the inside of the skirt 26 and the outside of the fingers 320 (forcing the fingers inward against the resilience of the balloon 322) until a series of outwardly-held retentions 340 engage the stent structure uprights. 80, as seen in Figure 50E. The retainers 340 comprise small angled cutouts that define hooks on the furthest ends of the fingers 320, the cutouts being oriented at an angle 0 with the radial that optimally captures the amounts of the anchoring skirt 26. This locks the position of the mechanical fingers 320 in in relation to the anchoring skirt 26. The balloon 322 inflation, as seen in Figure 50E, articulates the mechanical fingers 320 outwardly around the integral hinges 330, forcing the farthest end of the anchoring skirt 26 out in contact with the anatomy surrounding. The V-shaped notches that form the integral hinges 330 limit the rotation outward of each of the fingers 320 to a predetermined magnitude in order to avoid overextending the anchoring skirt 26.
    In use, the mechanical fingers expansion set 320, the balloon 322, and the fixing member 324 are inserted through the inflow aspect of the prosthetic heart valve 20 until locked in position with the retainers 340 coupling with the farthest end of the exit 26. Subsequently, a hollow malleable handle rod can be attached to the end closest to the fixing member 324. Alternatively, the prosthetic heart valve 20 can be sutured and fixed in place with the expander assembly inserted but without a grip attached. Upon satisfactory placement of the valve 20 in place, a conventional inflation device together with the handle can be connected to the fixing member 324 to inflate the balloon 322, deflation of the balloon 322 after the installation of the heart valve 20 causes the mechanical fingers 320 pivot inwards again. The fingers 320 can be adhered to the outside of the balloon 322 to facilitate its retraction inward when the vacuum is applied to the balloon.
    Alternatives to the expansion set of Figures 49-50 include mechanical fingers that are not attached to a cable fixing member. In this way, an inflation balloon causes a direct radial expansion of the fingers instead of a joint movement. Furthermore, an elongated malleable handle can be provided as a piece with the holding member 324 instead of a threaded coupling.
    As previously mentioned, the present application contemplates several alternatives to ensure that the valve inflation balloon does not inflate prematurely. For example, Figures 51-54 schematically illustrate systems where a fluid orifice used to inflate the balloon over the catheter must first be opened before the balloon expands.
    Figure 51 is an elevation view of a portion of the end closest to an alternative delivery system 110 similar to the views of Figures 34-36, and showing the relatively movable end cap 190 and a handle 204. A tubular extension 350 the end cap 190 shown schematically in Figure 52A includes a farther closed end 352 and a pair of side holes 354 just near the farthest end. Tubular extension 350 fits snugly into a hole 356 formed at one end closest to cable 204. Before balloon expansion, components are positioned as seen in Figure 52B, with the farthest end of tubular extension 350 positioned within the hole 356 so that the side holes 354 are blocked. Moving further away from end cap 190 as seen in Figure 52C causes tubular extension 350 to project from inside hole 356 into a larger chamber 358, thereby exposing side holes 354 so that fluid can be injected towards the most distant balloon. In this configuration, end cap 190 must first move further away from cable 204 before fluid can be injected to inflate the balloon.
    Figure 53 also shows a portion of the end closest to an alternative delivery system 110 similar to the views in Figures 34-36, with end cap 190 relatively movable and cable 204. A tubular extension 360 of end cap 190 shown exploded in Figure 54A again includes a farther end closed by a plunger 362 and has a pair of side holes 363 just near the farthest end. The tubular extension 350 mounts tightly inside a hole 366 formed at one end closest to the cable 204. Before the balloon expansion, the components are positioned as seen in Figure 54B, with the plunger 362 sealed against the opening of the hole 366 so that the side holes 364 are blocked. The further movement of the end cap 190 as seen in Figure 54C causes the plunger 362 to move into a larger chamber 368, thereby opening the side holes 364 so that fluid can be injected towards the farthest balloon. Again, this configuration ensures that end cap 190 must first move farther away from cable 204 before fluid can be injected to inflate the balloon.
    Various heart valves can be used in combination with the application system components described herein, and any combination not otherwise explicitly described is contemplated. For example, Figure 55 is a perspective view of an exemplary prosthetic heart valve 400 that has a commercially available valve member 402 coupled with an anchor stent 404 minus a surrounding tissue covering. Figure 55A is a radial cross-sectional view through a cusp portion of heart valve 400 with a tissue cover 406 of the skirt stent 404 shown. Finally, Figure 56 is an exploded elevation view of the prosthetic heart valve 400 of Figure 55. The specific valve member 402 shown is the Carpentier-Edwards PERIMOUNT Magna® Aortic Heart Valve available from Edwards Lifesciences of Irvine, CA. As seen in Figure 55A, the Magna valve has a structure that includes a wire shape 410 wrapped in a fabric cover 412 and attached to a fabric covered axial band structure 414 with flexible bioprosthetic leaflets 414 sandwiched between them. A highly flexible seam ring 416 fastens to the outer perimeter of web structure 414 as shown. Finally, the fabric-covered anchor skirt 404 is attached in a top joint to an inflow end of the Magna valve, such as with sutures through the respective fabric covers and desirably through the stent structure of the skirt 404 and through openings in band structure 414, as described above. The sewing ring 416 attaches to the web structure 414 along a seam line, making it easily flexed out. In addition, the sewing ring 416 has a relatively thin-walled silicone insert 418 with a honeycomb structure. This is an advantage for conventional valves, but not as desirable for valves as described herein.
    In contrast, Figure 57 shows an alternative prosthetic heart valve 420 similar to that shown in Figure 55, but having a different, firmer seam ring 422. Specifically, Figures 58A and 58B are seen in radial section through the prosthetic heart valve 420 illustrating the alternative constructions of the sewing ring 422. Like elements will be given equal numbers.
    In both Figures 58A and 58B the seam ring 422 attaches to the outside of the band structure 414 along a cylindrical seam region 424, which helps to reduce the upward and downward bending of the seam ring 422. Secondly, the sewing ring 422 in Figure 58A comprises a solid but compressible material that is relatively rigid in order to provide a seal against the annular space and has a concave inflow shape that conforms to the annular space. Desirably, the sewing ring 422 includes a closed cell foam insert 430 within a fabric cover. There are no cavities / cells, which makes the seam ring 422 soft to the surrounding tissue but relatively rigid in the whole. Furthermore, the concave inflow side coincides with that of the annular space for a better seal between them. Figure 58B shows an additional reinforcement member 432 embedded within the insert 430 which further stiffens the sewing ring 422. Reinforcement member 432 may be metallic, such as stainless steel or the like. Both sewing rings 422 are more rigid than the Magna sewing ring and thus create a better seal against the annular space of the aortic valve as opposed to the expanded outward anchoring skirt within the left ventricle. The combination provides a relatively safe anchoring structure for the valves described here, and helps to prevent paraventricular leakage around the outside of the valve by matching the shape of and firmly holding the soft material against the annular space.
    Again, the fabric-covered anchor skirt 404 is attached to a butt joint at an inflow end of the Magna valve, such as with sutures through the stent structure of the skirt 404 and through openings in the band structure 414. Furthermore, the lower end of the seam ring 422 desirably overlaps the anchoring skirt 404 by a short distance and the seam 424 extends down between them. This further improves the rigidity of the joint, thus improving the seating and sealing against the annular aortic space. Although not shown, the sewing ring 422 can be annular, but it is desirably slightly cut to better conform to the annular aortic space. The 422 rigid cut-out sewing ring helps the surgeon to quickly place the prosthetic valve in place by providing a firm platform to match the contours of the undulating aortic annular space.
    It should be noted that a sewing ring itself may not be necessary with the heart valve present as the primary function of such a component is to provide a platform through which to pass a number of anchoring sutures around the valve periphery, which it is not used here except perhaps for several (eg 3) guide sutures. Consequently, the valve members described herein could be coupled to the anchoring skirt directly without a seam ring. To help prevent leakage, a peripheral seal such as a fabric skirt can be added in place of the sewing ring. Also, a number of tabs extending outside the valve structure could be used to anchor the guide sutures which replace the sewing ring for this purpose.
    The system described here is also desirably used with a specific valve space sizing technique. The sizing device (not shown) includes a catheter rod that has a flexible balloon over a far end that can be inflated with saline. An intravascular ultrasound imaging probe (IVUS) extends through the catheter and into the flexible balloon. After preparing the patient for surgery, but before the introduction of the delivery system 110, the balloon catheter is introduced into the annular valve space. The balloon is filled to a desired pressure, and the IVUS probe is advanced through the catheter and into the balloon. As the balloon conforms to the anatomical cavity that surrounds it, the IVUS probe measures the size of this cavity.
    The advantage of being able to expand the native annular space with the expandable skirt to receive a larger valve size than would otherwise be possible with conventional surgery was mentioned above. Another way to perform such an enlargement is to use a conical dilator, such as a Hagar dilator. The conical dilator has a maximum diameter that is larger than the predicted valve diameter. By passing the dilator into the annular space before installing the valve, a larger valve can be selected. Furthermore, the larger valve temporarily mounts within the annular space, but the resilience of the tissue constricts around the valve for safer anchoring.
    Although the invention has been described in its preferred modalities, it must be understood that the words that have been used are words of description and not of limitation. Therefore, changes can be made to the attached claims without departing from the true scope of the invention.
    权利要求:
    Claims (12)
    [0001]
    1. Prosthetic heart valve (20) for implantation in an annular heart valve (AA) space comprising: a non-expandable, non-collapsible annular support structure (24) that defines a flow orifice and that has an inlet flow; valve leaflets (74) attached to the support structure (24) and mounted to alternately open and close through the flow orifice; a plastically expandable frame (80) having a first end that extends around the flow orifice and connected to the valve (20) at the flow inlet of the support structure (24), the frame (80) having a second end that extends projects in the direction of flow away from the support structure (24) and being able to assume a contracted state for application in an implant position and a wider expanded state for external contact with an annular space (AA) ; and a fabric (82) covering around the plastically expandable frame (80), the prosthetic heart valve (20) being characterized by the fact that a sealing flange (84) is circumferentially coupled around the second end of the plastically expandable frame (80).
    [0002]
    2. Heart valve (20) according to claim 1, characterized by the fact that the support structure includes a plurality of commissure pins (35) that project in a direction of outflow, and the valve leaflets ( 74) are flexible and are attached to the support structure (24) and the commissure pins (35).
    [0003]
    3. Heart valve (20) according to claim 1, characterized by the fact that in the contracted state the frame (80) is conical, tapering inwards from the first end towards the second end.
    [0004]
    Heart valve (20) according to claim 3, characterized in that in the expanded state the frame (80) is tapered, tapering outward from the first end towards the second end.
    [0005]
    5. Heart valve (20) according to claim 1, characterized by the fact that it also includes a seam ring (62) that circumscribes the flow inlet of the support structure (24), in which the frame (80) attaches to the sewing ring (62).
    [0006]
    6. Heart valve (20) according to claim 5, characterized by the fact that the prosthetic valve (20) comprises a commercially available valve and the permeable suture ring is a seam ring (62) of the same that has a plastically expandable frame (80) connected to the seam ring (62).
    [0007]
    Heart valve (20) according to claim 5, characterized in that the seam ring (62) comprises a solid but compressible material that is relatively rigid in order to provide a seal against the annular space (AA) and has a concave flow shape that conforms to the annular space (AA).
    [0008]
    8. Prosthetic heart valve system (110) comprising: a heart valve that includes a prosthetic valve (20); a valve support (22) connected to a proximal end of the heart valve (20); a balloon catheter having a balloon (112); and a handle rod (130) configured to couple with a proximal end of the valve support (22) and which has a lumen configured for passage of the catheter, the balloon (112) extending distally through the handle rod (130) , passing the valve support (22) and through the heart valve (20), the prosthetic heart valve system (110) being characterized by the fact that the handle rod (130) is malleable and the prosthetic valve (20) is configured as defined in claims 1 to 7.
    [0009]
    9. Prosthetic heart valve system (110), according to claim 8, characterized by the fact that the contracted state of the frame (26) is conical and decreases in the distal direction, in which the balloon (112) also includes a line visible average positioned near the distal end of the frame (26) before inflation.
    [0010]
    10. Prosthetic heart valve system (110) according to claim 8, characterized in that the heart valve (20) mounted on the valve support (22) is packaged separately from the handle stem (130) and the balloon of the catheter.
    [0011]
    11. Prosthetic heart valve system (110) according to claim 8, characterized in that the malleable handle rod (130) is made of aluminum.
    [0012]
    12. Prosthetic heart valve system (110) according to claim 8, characterized by the fact that the balloon catheter has an inflation tube (199) that extends through the lumen of the handle rod (130) 10 and the The OD of the inflation tube (199) is greater than 90% of the handle rod lumen ID (130).
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    公开号 | 公开日
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    法律状态:
    2018-12-26| B06F| Objections, documents and/or translations needed after an examination request according art. 34 industrial property law|
    2020-07-07| B09A| Decision: intention to grant|
    2020-09-01| B16A| Patent or certificate of addition of invention granted|Free format text: PRAZO DE VALIDADE: 20 (VINTE) ANOS CONTADOS A PARTIR DE 12/08/2011, OBSERVADAS AS CONDICOES LEGAIS. |
    优先权:
    申请号 | 申请日 | 专利标题
    US38193110P| true| 2010-09-10|2010-09-10|
    US61/381,931|2010-09-10|
    US13/167,639|2011-06-23|
    US13/167,639|US8641757B2|2010-09-10|2011-06-23|Systems for rapidly deploying surgical heart valves|
    PCT/US2011/047625|WO2012033604A2|2010-09-10|2011-08-12|Systems and methos for rapidly deploying surgical heart valves|
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