WO2003053248A2 - Method and system for treatment of atrial tachyarrhythmias - Google Patents
Method and system for treatment of atrial tachyarrhythmias Download PDFInfo
- Publication number
- WO2003053248A2 WO2003053248A2 PCT/US2002/039440 US0239440W WO03053248A2 WO 2003053248 A2 WO2003053248 A2 WO 2003053248A2 US 0239440 W US0239440 W US 0239440W WO 03053248 A2 WO03053248 A2 WO 03053248A2
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- WO
- WIPO (PCT)
- Prior art keywords
- shapeable
- section
- shapeable section
- jaws
- lesions
- Prior art date
Links
- 238000000034 method Methods 0.000 title claims abstract description 77
- 230000001746 atrial effect Effects 0.000 title description 17
- 208000001871 Tachycardia Diseases 0.000 title description 3
- 230000003902 lesion Effects 0.000 claims abstract description 95
- 238000002679 ablation Methods 0.000 claims abstract description 46
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- 239000012781 shape memory material Substances 0.000 claims abstract description 11
- 238000007493 shaping process Methods 0.000 claims abstract 11
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- 230000007246 mechanism Effects 0.000 abstract description 6
- 210000002216 heart Anatomy 0.000 description 13
- 210000005247 right atrial appendage Anatomy 0.000 description 13
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- 238000001356 surgical procedure Methods 0.000 description 7
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- HLXZNVUGXRDIFK-UHFFFAOYSA-N nickel titanium Chemical compound [Ti].[Ti].[Ti].[Ti].[Ti].[Ti].[Ti].[Ti].[Ti].[Ti].[Ti].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni].[Ni] HLXZNVUGXRDIFK-UHFFFAOYSA-N 0.000 description 2
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Classifications
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
- A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
- A61B18/14—Probes or electrodes therefor
- A61B18/1442—Probes having pivoting end effectors, e.g. forceps
-
- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
- A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
- A61B18/14—Probes or electrodes therefor
- A61B18/1402—Probes for open surgery
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
- A61B17/28—Surgical forceps
- A61B17/29—Forceps for use in minimally invasive surgery
- A61B2017/2926—Details of heads or jaws
- A61B2017/2945—Curved jaws
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00315—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body for treatment of particular body parts
- A61B2018/00345—Vascular system
- A61B2018/00351—Heart
- A61B2018/00357—Endocardium
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- A—HUMAN NECESSITIES
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- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00571—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body for achieving a particular surgical effect
- A61B2018/00577—Ablation
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00636—Sensing and controlling the application of energy
- A61B2018/00773—Sensed parameters
- A61B2018/00791—Temperature
- A61B2018/00797—Temperature measured by multiple temperature sensors
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
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- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2018/00636—Sensing and controlling the application of energy
- A61B2018/00773—Sensed parameters
- A61B2018/00791—Temperature
- A61B2018/00821—Temperature measured by a thermocouple
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
- A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
- A61B18/14—Probes or electrodes therefor
- A61B2018/1405—Electrodes having a specific shape
- A61B2018/1425—Needle
- A61B2018/1432—Needle curved
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
- A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
- A61B18/14—Probes or electrodes therefor
- A61B18/1442—Probes having pivoting end effectors, e.g. forceps
- A61B2018/146—Scissors
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- A—HUMAN NECESSITIES
- A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
- A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
- A61B2218/00—Details of surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
- A61B2218/001—Details of surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body having means for irrigation and/or aspiration of substances to and/or from the surgical site
- A61B2218/002—Irrigation
Definitions
- the present invention relates to surgical tools and procedures generally and relates more particularly to the use of ablation to create elongated lesions to treat atrial fibrillation or other medical conditions.
- the Maze HI procedure In patients with chronic atrial fibrillation having tachycardia that resistant to medical treatment, the Maze HI procedure has been employed. This procedure controls propagation of the depolarization wavefronts in the right and left atria by means of surgical incisions through the walls of the right and left atria. The incisions create blind or dead end conduction pathways, which prevent re-entrant atrial tachycardias from occurring.
- a maze type procedure may be performed using one or more bipolar electrosurgical hemostats, which apply ablation energy (e.g. RF energy) across the walls of the left and right atria by means of delivery means (e.g. electrodes) located on either side of the atrial walls.
- ablation energy e.g. RF energy
- delivery means e.g. electrodes
- the hemostats are provided with elongated R-F electrodes capable of assuming various straight and curved configurations.
- a bipolar electrosurgical hemostat is provided, shapeable, for example, to a set of configurations adapted to allow the physician to approximate the incisions that would occur during the Maze IH procedure as described in the book 'Cardiac Surgery Operative Technique' by Donald B. Doty, M.D. at pages 410-419, incorporated herein by reference in its entirety, and herafter referred to as the "Doty reference”.
- Other curved configurations may also be accomplished, using the shapeable hemostat of the present invention, to allow approximation of the incisions that would be provided by other forms of the Maze procedure or to perform other ablation procedures.
- the shapeable hemostat according to a preferred embodiment of the present invention is provided with elongated jaws that carry electrodes or other means for applying ablation energy to a patent's heart.
- the jaws of the hemostat may each carry a single, elongated electrode or may each carry a series of electrodes. While the preferred embodiment of the invention as disclosed takes the form of a hemostat with R-F electrodes extending along both jaws, it is believed the invention may also usefully be practiced in a device having only a single elongated shapeable electrode or series of electrodes, for application of ablation energy to only the inner or outer surface of the wall of a heart chamber.
- the jaws are fabricated of or provided with a core formed of a shape memory material, e.g. a nickel titanium alloy such as Nitinol, a copper-nicel aluminum or copper zinc aluminum alloy (SME brass) or a plastic having shape memory properties.
- a shape memory material e.g. a nickel titanium alloy such as Nitinol, a copper-nicel aluminum or copper zinc aluminum alloy (SME brass) or a plastic having shape memory properties.
- the shape memory material is not itself biocompatble, it should be encased in a biocompatible covering, e.g. encapsulated within the material of the jaws.
- the material chosen preferably displays its memorized configuration at a temperature above the temperature to which it will be heated during the ablation procedure. This temperature will be dependant on the construction of the jaws of the hemostat, and will vary depending on the degree of thermal insulation between the electrode and the shape memory material.
- the transition temperature should be above 50 degrees Celsius. In any case, the transition temperature should be well above body
- the transition temperature should be below the temperature to which it will be heated to resume its memorized configuration, e.g. less than 100 degrees Celsius, if heated using boiling water, above 100 degrees Celsius if placed in a heater.
- the specific composition of the alloy or plastic material can be chosen to control transition temperature, using standard techniques.
- the jaws of the hemostat may thereby be shaped at room temperature and will retain their shape during subsequent use in the body to ablate tissue.
- the memorized configuration may be straight or curved.
- the jaws of the hemostat are shaped manually or with the use of a bending fixture to exhibit a desired configuration for use in producing a particular lesion.
- these lesions may be produced as part of a procedure corresponding to a Maze type procedure.
- the shape memory material in the jaws of the hemostat is heated to a temperature above its transition temperature so that the jaws return to their memorized configuration and may then either be used in this configuration to produce the next lesion or may be again shaped to an alternative desired configuration. This process is continued until all desired lesions have been produced. Because the jaws are returned to their memorized configuration, e.g.
- the jaws may be heated by any convenient means, for example by placement in hot water, placement in or on an electric heater, or by means of resistive heaters built into the jaws themselves.
- the configurations assumable by the hemostat jaws maybe straight, curved or bent, adapted to an individual patient according to the judgment of the physician.
- the physician may be provided with a set of bending fixtures to provide a pre-determined set of curved configurations, each configuration associated with one or more of a predetermined set of desired lesions.
- hemostats particularly adapted for treatment of atrial fibrillation during open chest surgery, with the patient undergoing cardiopulmonary bypass.
- the present invention is also believed applicable to closed chest procedures, in which the heart is observed thoracoscopically and access is provided by means of thoracoscopic surgical ports. It is believed the invention is also applicable to other procedures involving creation of a set of elongated lesions in heart tissue or elsewhere in the body.
- Figure 1A illustrates an electrosurgical hemostat according to the present invention having two elongated jaws that exhibit a memorized, generally straight configuration.
- Figure IB illustrates an alternative configuration for the tips of the jaws of the hemostat illustrated in Figure 1A.
- Figures 2A, 2B, 2C, 2D and 2E all illustrate cross section through alternative embodiments for the jaws of the hemostat otherwise as illustrated in Figure 1A.
- Figure 3 illustrates a side view of an electrosurgical hemostat according to the present invention, shaped to display a bent configuration.
- Figure 4 illustrates a side view of an electrosurgical hemostat according to the present invention, shaped to display a first, curved configuration.
- Figure 5 illustrates a side view of an electrosurgical hemostat according to the present invention, shaped to display a second, curved configuration.
- Figures 6A, 6B and 6C illustrate operation of a first bending fixture according to the present invention.
- Figures 7A, 7B and 7C illustrate operation of a second bending fixture according to the present invention.
- Figures 8 A and 8B illustrate operation of a third bending fixture according to the present invention.
- Figures 9A through 9M are a series of drawings illustrating schematically a surgical procedure performed using an electrosurgical hemostat according to the present invention and illustrating schematically the various incisions and lesions produced.
- the embodiment of the invention as disclosed in the present application includes a shapeable electrosurgical hemostat and mechanisms for causing the jaws of the hemostat to assume predetermined configurations particularly adapted to perform an ablation procedure modeled on the Maze III procedure as described in the Doty reference, cited above.
- predetermined configurations particularly adapted to perform an ablation procedure modeled on the Maze III procedure as described in the Doty reference, cited above.
- other predetermined sets of configurations may be substituted and/or the physician may simply manually shape the jaws of the electrodes to his liking.
- the set of configurations is described in more detail below.
- FIG. 1A illustrates a top plan view of a hemostat provided according to the present invention.
- the hemostat may be approximately 31 centimeters in overall length as illustrated at B2, with jaws of approximately 8 centimeters in length, as illustrated at Al.
- the hemostat includes two elongated handle members 12 and 14, each provided with a finger loop at its proximal end. A conventional hemostat locking mechanism 14 is also provided.
- the handles of the hemostat may be fabricated of stainless steel or other readily resterilizable material. Alternatively, the handles 11 and 12 might be fabricated of a biocompatible plastic and/or the hemostat may be disposable.
- Electrodes 25 and 25 are preferably spaced approximately 0 to 7 mm from one another, more preferably 1 to 5 from one another, to facilitate uniform contact along opposite sides of a patient's atrial wall.
- the atrial wall is compressed between electrodes 24 and 25, and R-F energy is applied between the electrodes in order to create an elongated continuous lesion extending through the cardiac tissue.
- a linear lesion is produced. I the particular embodiment illustrated, the jaws exhibit a memorized, generally straight configuration.
- the electrodes 24 and 25 are preferably configured to allow fluid - assisted cardiac ablation, of the type generally described in US Patent No. 6,096,037 issued to Mulier, incorporated herein by reference in its entirety.
- each of the electrodes is provided with an electrical conductor, 20, 23, allowing delivery of R-F electrical energy to the electrodes 24 and 25, respectively and with a fluid lumen 21 , 22, allowing for delivery of saline solution or other conductive fluid to and along the length of electrodes 24 and 25.
- resistive heaters are included, arranged along the length of the jaws 18, 19, additional conductors 20A and 23A are provided in order to power the heaters.
- FIGs 2A through 2D discussed below.
- one jaw of the hemostat of Figure 1 A is inserted into the interior right or left atrium through an incision provided in the wall of the left or right atrium, while the other jaw remains outside of that chamber.
- the jaws are pressed together, somewhat compressing the atrial wall between the jaws, to provide for continuous contact along the length of the jaws on both sides of the atrial wall.
- the ablation jaws in some cases may instead be arranged along opposing external surfaces of an organ, for example opposite sides of an atrial appendage or along opposite sides of the tissue adjacent the bases of the right or left pulmonary veins.
- RF energy is delivered between the electrodes. Delivery of energy or power to assure a complete lesion may be accomplished by measurement of impedance between the electrodes, as in US Patent No. 6,133,592, issued to Taylor, US Patent No. 5,718,701, issued to Shai, et al or US patent No. 5,357,956, issued to Nardella, or allowed Pending US Application No. 09/347,635, filed July 6, 1999 by Hoey et al, all incorporated herein by reference in their entireties. Alternatively, thermocouples or other temperature sensors may be added to the jaws of the hemostat and delivery of energy or power controlled as in US Patent No. 5, 685,878, issued to -Falwell, et al., US Patent No.
- Figure IB illustrates such an alternative hemostat jaw construction, wherein hemostat jaws 18A and 19A correspond generally to jaws 18 and 19 in Figure 1A, and carry electrodes 24A and 25 A which also correspond to electrodes 24 and 25 in Figure 1 A.
- the distal tips 15 and 17 of the jaws are sharpened to a point or an edge so that either may be used to directly penetrate the atrial wall, eliminating the necessity of a separate incision.
- FIGS 2A through 2E are cross sectional views through the jaws of a hemostat as in Figure 1A, illustrating possible alternative constructions.
- the jaws 18 and 19 are made of metallic cores 26, 28, of shape memory metal such as Nitinol, covered by insulative coatings or paint, 27, 29.
- Resistive heaters 34 and 35 are optionally provided, extending along the cores 26, 28.
- Electrodes 24 and 25 take the form of elongated conductive coils, 30A, 33A, carrying tubes 31 A, 32A, of expanded PTFE, through which a conducted fluid such as saline solution may be delivered along the length of the electrode coils 30 A, 33 A.
- the lumens of the EPTFE tubes 31 A, 32A may be sealed at their distal extremities.
- Figure 2B illustrates a first alternative embodiment, corresponding generally to that illustrated in Figure 2A, with identically numbered elements corresponding to those illustrated in 2A.
- the configuration of the conductive coil, 3 IB, 32B and the expanded PTFE tubes, 32B, 33B is reversed, so that the coils are located within the
- FIG. 2A illustrates a third embodiment according to the present invention.
- elements correspond to identically numbered elements in Figure 2A.
- the jaws 18, 19, take the form of molded plastic members with cores formed of shape memory metal rods 36, 37.
- FIG. 2D illustrates a fourth embodiment according to the present invention.
- Elements correspond to identically labeled elements in Figure 2A.
- the jaws 18, 19 are molded plastic members and the elecfrodes 24, 25 take the form of tubes of shape memory metal, provided with a series of holes 41, 42, open to the lumen of the tube.
- conductive fluid is delivered through the lumen of the tube and to the tissue through the holes 41, 42, and no separate fluid delivery tube is required.
- Figure 2E illustrates a fifth embodiment according to the present invention.
- Elements correspond to identically labeled elements in Figure 2A.
- the jaws 18, 19, take the form of molded plastic members with cores 38, 39, formed of shape memory metal. Cores 38 and 39 are rectangular in cross section, encouraging bending of the jaws in parallel planes. This feature may be particularly desirable if bending of the jaws manually, without bending fixtures, is to be performed.
- Figures 3 - 5 illustrate various curved and bent configurations of the hemostat of Figure 1 A, adapted to perform an ablation procedure analogous to the Maze III procedure. While electrodes are not illustrated in these figures, they should be understood to be present and to correspond with those illustrated in Figures 2A - 2E. Similarly, While conductors and fluid lumens are not illustrated in Figures 3 - 5, they should be understood to be present and correspond to those as illustrated in Figure 1A.
- Figure 3 illustrates a side view of the hemostat of Figure 1A wherein the jaws 18 and 19 are shaped to describe a generally straight distal portion extending over a length E2, which may be, for example, 5 V. centimeters.
- the jaws are bent at C2 around a radius of approximately .5 centimeters and describe an angle D2 of approximately 60 degrees, as illustrated.
- Figure 4 illustrates a side view of the hemostat of Figure 1 A wherein the jaws 18 and 19 are shaped to define a distal, generally straight portion E3 extending for approximately 2 centimeters, and are curved around a radius C3 of approximately 3 centimeters, to define an angle D3 of approximately 65 degrees.
- Figure 5 illustrates a side view of the hemostat of Figure 1A wherein the jaws 18 and 19 are shaped to define a generally straight distal portion extending over a length E4 of approximately 3 centimeters, and curved around a radius C4 of approximately 5 centimeters to define an angle D5 of approximately 60 degrees.
- Figures 6A, B & C illustrate a first fixturing system for bending jaws of a hemostat as illustrated in Figure 1 A to assume a desired curved configuration.
- the apparatus illustrated in Figures 6A through 6C is intended to assure that the jaws assume the desired curved configurations and that they also remain parallel to one another, facilitating their use to provide bipolar ablation along the entire length of the electrodes on the jaws.
- Figure 6 A shows the first component 600 of the fixturing system in side view, with jaw 19 of the hemostat of Figure 1A visible mounted within the component.
- the component includes a flexible backbone 620, for example, fabricated of spring steel, to which a series of upwardly extending members 602, 604, 606, 608 are mounted.
- Each of these members, 602, 604, 606 and 608 is one of a set of three members arranged to engage both jaws of the hemostat and retain them in a parallel configuration.
- Each of the members is provided with a hole 610, 612, 614 for engaging a pin on the second component of the fixturing system, discussed below in conjunction with Figure 6C.
- Figure 6B illustrates a cross-sectional view through the first component 600 of the fixturing system illustrating upwardly extending member 604 and its corresponding associated upwardly extending members 622 and 624.
- Members 604, 622 and 624 together define two openings, which receive the jaws 18 and 19 of the hemostat as illustrated.
- Members 604, 622, 624 may be spread apart from one another slightly, due to the resilience of the base member 620, to allow insertion of the jaws 18 and 19 of the hemostat.
- Members 622 and 624 are provided with holes, 626 and 628, aligned with hole 612 in member 604.
- Figure 6C illustrates the second component of the fixturing system, comprising a metal plate 630 having a plurality of holes arranged corresponding to desired curved configurations to be displayed by the hemostat jaws. As illustrated, pins 632, 634, 636, and 638 are inserted in one set of holes to define a first curved configuration. Unused holes 640, 642, and 646 are employed to create alternative curved configurations.
- the first component 600 of the fixturing system mounted to the jaws 18 and 19 of the hemostat is fitted to the second component 630 by bending the jaws of the hemostat so that the pins 632, 634, 636 and 638 pass through the holes defined in the upwardly extending members, assuring the displayed curvature of the hemostat is as desired.
- the hemostat is then removed from the fixturing member and employed to create a lesion having a configuration corresponding to the provided curvature.
- the configuration of the hemostat is to be altered before the next lesion is produced, it is heated to cause it to resume its original memorized configuration, for example, a straight configuration as illustrated in Figure 1 A.
- the hemostat may be used to create a lesion in this configuration or may be reshaped to display a different curved configuration using the fixture system.
- the advantage of the step of heating the hemostat jaws to assume their previous memorized confirmation as opposed to simply re-bending the jaws to assume a second curved configuration is that it eliminates any set bends or kinks that might interfere with the jaws assuming their desired new configuration.
- Figures 7A through 7C illustrate a second fixturing system which may be used to impart desired predefined curves or may be used to assist the physician in providing manually shaped curves while retaining the jaws of the hemostat in a parallel configuration.
- the fixturing system of Figures 7A through 7C includes a first component
- This first component includes a flexible base member 720, which may be fabricated of spring steel or other flexible material having a strong tendency to bend only in a single plane. Attached to base member 720 is a coil 722 having an interior lumen specifically configured to receive the two jaws 18 and 19 of the hemostat. As illusfrated, jaw 19 as visible inserted into the coil 722.
- Figures 7B illustrates the first component of the fixturing system in cross section.
- the coil 722 provides a generally rectangular internal lumen in which the jaws 18 and 19 of the hemostat are mounted. Individual coils are provided with a depression 724 which defines the desired spacing between the jaws during the bending operation.
- the physician may bend the jaws manually, assuring that they remain in a parallel configuration.
- the first component of the fixture is simply removed from the jaws by sliding it off the distal ends of the jaws.
- the first component 700 may be used in conjunction with a second fixturing component 730 to provide a predefined curve.
- Fixturing component 730 is provided with two generally sfraight recesses 732 which have a depth adapted to provide any desired straight distal portion of the jaws as configured.
- the depths of the recesses 732 and 734 may correspond to lengths of the straight portions E2, E3, or E4, as illustrated in Figures 3, 4 and 5 respectively.
- the second component 730 of the fixturing system includes a defined curved surface 736, around which the first fixturing component 700, carrying the jaws 18 and 19 of the hemostat, is bent to provide a defined curvature corresponding to the curvature of the surface 736.
- component 730 each having a different defined curved surface and recesses of differing depths for receiving the distal ends of the hemostat jaws may be provided to provide a family of desired curved configurations.
- FIGs 8A and 8B illustrate a third fixturing system, employing fixturing components similar to fixturing components 730, illusfrated in Figure 7C.
- Fixturing component 800 is provided with two inwardly extending recesses 802 and 804, corresponding generally to recesses 732 and 734 in the fixturing component illustrated in Figure 7C. In a similar fashion, they are provided with a depth that corresponds to the length of any sfraight, distal portion desired for the jaws.
- the component 800 is provided with two grooves 806 and 808, extending along a desired curvature for the hemostat.
- a raised portion 810 separates the grooves and defines the desired inter-jaw spacing during the bending operation.
- the combination of the recesses 802, 804, the grooves 806 and 808 and the raised portion 810 provide a mechanism for retaining the jaws in a parallel configuration while bending them to assume the desired curvature.
- Figure 8B illustrates the jaws 18 and 19 of the hemostat inserted into the recesses 802 and 804 of the fixturing component 800, and bent around the component, arranged within the grooves 806 and 808. After bending, the hemostat is simply removed from the fixturing component 800 and may be employed to create the lesion having a configuration corresponding to the curvature provided by the fixturing component 800.
- a set of components similar to fixturing 800 would be provided, each having recesses of a desired depth to define any straight distal portion of the jaws, and having grooves extending around a predefined desired curvature to define the curved portion of the jaws.
- the memorized configuration of the hemostat jaws is a sfraight configuration.
- this is probably the most desirable embodiment.
- the fixturing devices as illusfrated in Figures 6A - 8B may be modified to provide a mechanism for bending the hemostat jaws to assume a straight configuration.
- the curvature defined by the fixturing mechanism is preferably is somewhat greater than the ultimately desired curvature, due to the fact that some elastic rebound of the hemostat jaws after bending is to be expected.
- each fixture must be designed to provide for some degree of over-bending as compared to the desired ultimate configuration.
- a specific degree of over-bending provided by any particular fixture will, of course, be a function of the specific shape memory material chosen and of the specific configuration of the shape memory material.
- the heating step is generally conceived of as occurring external to the body, as a relatively elevated temperature may be generally be required.
- the step of heating the forceps jaws might occur internal to the patient's body, for example, in those embodiments in which resistive heaters are provided, extending along the jaws.
- the hemostat might remain within the patient's body while electrical power is applied to cause the resistive heaters to in turn cause the hemostats to resume to their memorized straight or curved configurations.
- FIGS 9A - 9M are schematic drawings which illustrate a procedure performed using the bipolar electrosurgical hemostats described above to obtain a result analogous to the Maze III procedure as described in the Doty reference cited above.
- the lesions produced using the hemostats correspond to incisions as described in this reference, and the correspondence of the lesions to the incisions is described below.
- Figure 9 A is a schematic drawing illustrating the structure of the right and left atria, 500, 502, respectively, as viewed from a lower aspect, including tricuspid valve 16 and mitral valve 14 and as viewed from a more superior aspect, including the bases of the pulmonary veins 512and the bases of the superior vena cava and inferior vena cava, 508 and 510 respectively, which enter the right atrium 500.
- the right and left atrial appendages are also illustrated schematically at 504 and 506, respectively.
- the structures as illusfrated in Figure 9A are correspondingly numbered in Figures
- Figure 9B illusfrates the first step of the procedure, comprising removal of the right atrial appendage 504.
- Right atrial appendage 504 is removed by means of an incision 507, which may be made by means of a scalpel or scissors.
- a thoracoscopic tool may be substituted, preferably one capable of simultaneously cutting and stapling the remnant of the right atrial appendage.
- Figure 9C illustrates the second step of the procedure, as performed using an open chest approach.
- the elecfrosurgical hemostat of the present invention with the jaws in the sfraight configuration as illusfrated Figure 1A, with one jaw 19 of the hemostat inserted into the right atrium through the opening left by removal of the right atrial appendage and the other jaw 18arranged along the exterior surface of the heart. Jaws 18 and 19 are inserted until they extend to a point 520 located approximately at the mid point of the right atrium, approximately 5 centimeters from the opening 505 left by removal of the right atrial appendage.
- the jaws 18 and 19 are compressed and RF energy is applied between the elecfrodes located in jaws 18 and 19 to create an elongated lesion, extending through the tissue of the right atrial wall, to provide a block against passage of depolarization waves there across.
- various hemostats will be described, but now specifically illustrated. Instead, the lesions to be produced by the hemostats will be illusfrated by means of beaded lines, so that their interconnection and their relationship to the structures of the left and right atria 502, 500, may be understood. It should be understood that the hemostats are to be placed with their jaws extending along the lesions as illustrated, unless otherwise specified.
- the lesion produced may be made by inserting the jaw of an elecfrosurgical hemostat as illustrated in conjunction Figure 1A, but having a sharpened tip as illusfrated in Figure IB, directly through the heart wall at point 520, and the jaws advanced to the sealed remnant of the removal of the right atrial appendage to define a corresponding lesion.
- Figure 9D illusfrates the next step in the procedure and also illustrates lesion 522 produced by the application of the elecfrosurgical hemostat with jaws retaining the sfraight configuration as illustrated in Figure 1 A.
- Lesion 522 corresponds generally to the incision illusfrated at step Al as described in the Doty reference.
- a local access incision is cut, at a point approximately midway between the inferior vena cava and superior vena cava (510, 508).
- Lesions 526 and 528 extending from access incision 524 to the superior and inferior vena cava, respectively, are produced by inserting one jaw of a hemostat as illusfrated in Figure 1A through the access incision 524 and arranging the jaws of the hemostat to extend on either side of atrial tissue from the incision 524 to the superior vena cava and inferior vena cava, respectively.
- the jaws of the hemostat may be configured as illustrated in Figure 3.
- the lesions 528 and 526 so produced correspond to the incisions illusfrated at step B as described in the Doty reference.
- hemostats having sharpened jaws as illustrated in Figure IB might be employed, with the sharpened tip of a jaw employed to create the access incision 524.
- FIG 9E illustrates the next step in the procedure.
- one jaw of the hemostat having a configuration as illusfrated in Figure 1 A or Figure 3 is inserted through access incision 524, and the jaws are arranged along either side of the atrial wall to create lesion 530, extending to the annulus of tricuspid valve 516, terminating at a point 534 approximately at the center of the posterior leaflet 532.
- This lesion should extend as close as possible to the tricuspid annulus.
- This lesion corresponds generally to the incision illustrated at steps D and E as described in the Doty reference.
- cryo-ablation may be performed at the tricuspid annulus at the terminus of lesion 530, by means of a cryo-probe inserted through the opening 505 in the remnant of the right atrial appendage.
- cryo-ablation corresponds generally to that illustrated at step F as described in the Doty reference.
- the cryo-probe might be inserted through access lesion 524 or might be inserted transvenously.
- FIG 9F illustrates the next step of the procedure.
- lesion 536 is created using the distal portion of the jaws of a hemostat configured as in Figure 1 A.
- One jaw of the hemostat is inserted through the opening 505 in the remnant of the right atrial appendage, and the jaws are arranged to extend along either the right afrial wall to the annulus of the tricuspid valve 516 at the midpoint of the anterior leaflet 538.
- This lesion corresponds generally to the incision illustrated at steps H and I as described in the Doty reference. Care must be taken during this step to avoid the right coronary artery.
- cryo-ablation may be applied at the tricuspid annulus at point 540, at the termination of lesion 536.
- cryo-ablation may be provided by means of a cryo-probe inserted via the opening 505 in the remnant of the right atrial appendage, through access lesion 524, or, alternatively be means of a cryo-probe inserted transvenously.
- Cryo- ablation corresponds generally to that illusfrated at step J as described in the Doty reference.
- Figure 9G illusfrates the next step of the procedure which is the creation of an incision 542 extending through the left atrial wall, posterior to the inter atrial groove, near the orifices of the right pulmonary veins.
- incision 542 may be made conventionally by means of scissors or a scalpel.
- Incision 542 corresponds to the incision illustrated at step K as described in the Doty reference.
- incision 542 might be replaced by a simple access incision made by means of the sharpened tip of one of the jaws of the hemostats used to create the lesions surrounding the orifices of the pulmonary veins, as discussed below.
- Figure 9H illustrates the next step of the procedure, which is the creation of lesions 543 and 546.
- Lesions 543 and 546 may be accomplished by insertion of the hemostat having jaws re-shaped to the curved configuration as illusfrated in Figure 5, reversing the orientation of the hemostat between lesions, to create two curved lesions extending around the base of the pulmonary veins 512 and meeting at a point 544, to complete the lesion path.
- Lesions 543 and 546 correspond generally to the incisions illustrated at steps L and N as described in the Doty reference.
- lesions approximating the incisions illustrated at steps L and N may be produced by compressing the atrial wall tissue adjacent the bases of the left pulmonary veins between jaws of the hemostat illusfrated in Figure 4A or 5A applied epicardially to produce a lesion encircling the bases of the left pulmonary veins and repeating the procedure to correspondingly produce a lesion encircling the bases of the right pulmonary veins.
- Figure 91 illusfrates the next step of the procedure, in which the hemostat is reshaped to display the more sharply curved configuration as illustrated in Figure 4 is employed to create lesion 548.
- Lesion 548 is created by inserting one jaw of the hemostat, into incision 542, the other into access incision 524, and compressing the atrial septum therebetween.
- the jaws are arranged so that they define a curved lesion extending along the atrial septum, extending to a point above the fossa ovalis, near but not into the tendon of Todaro.
- lesion 544 should be understood to correspond to the incision illusfrated at step M as described in the Doty reference.
- Figure 9J illusfrates the next step in the procedure, comprising the removal of left atrial appendage 506 by means of an incision 550.
- this incision might be made by means of a scissors or scalpel.
- this incision might be made by means of a thoracoscopically introduced, preferably one capable of simultaneously cutting and stapling the remnant of the right atrial appendage.
- Lesion 552 may be created using the hemostat reshaped to display the more gently curved configuration illusfrated in Figure 5 to create a curved lesion departing from lesion 546 and extending to the opening 550 in the right atrial appendage. As with lesions 543 and 546, the lesion may be produced by inserting one jaw of the hemostat through the incision 542, and compressing the left afrial wall between the jaws of the hemostat. Lesion 552 might also be performed prior to removal of the left atrial appendage, in conjunction with creation of lesions 543 and 546. In some embodiments of the invention, lesion 542 might be replaced by a simple incision extending from the opening 550 of the remnant of the left atrial appendage, and then later repaired by suture
- Figures 9L illusfrates the next step of the procedure, comprising the creation of lesion 558.
- Lesion 558 is created using the hemostat configured as in Figures 5, one jaw being inserted through incision 542 and compressing the left atrial wall between the jaws of the hemostat to create a lesion extending from lesion 543 to the mid point 560 of the annulus of the posterior mitral valve.
- Lesion 558 corresponds to the incision illusfrated at step S as described in the Doty reference. Care must be exercised during this incision to prevent damage to the circumflex artery and the coronary sinus.
- cryo-ablation may be provided at the mid-point 560 of the posterior mitral valve annulus, by means of a cyro-probe introduced through the opening 550 through the remnant of a left atrial appendage, or through incision 542.
- cryo ablation may be provided by means of transvenous cyro-ablation catheter.
- Cryo-ablation corresponds generally to that illustrated at step J as described in the Doty reference.
- Figure 9M illustrates the final steps of the procedure, comprising closing of the openings 505 and 550 into the remnants of the right and left atrial appendages, respectively, by means of sutures 554 and 556.
- these openings may have previously been closed in conjunction with their creation, by means of staples, or otherwise, by means of thoracoscopic surgical tools.
- incision 542 is shown as closed by means of sutures 560 as discussed above, in some embodiments, incision 542 may have been replaced by simple puncture incision, which might be closed by means of staple, sutures, or otherwise, applied thoracoscopically. Access in incision 524 is similarly closed at this time.
- the hemostat as illustrated in Figures 1 A through 5, discussed above, has the general configuration of a conventional hemostat, as would be employed in the context of an open chest procedure.
- similarly configured hemostat jaws may be employed on a thoracoscopically introduced instrument to create the various lesion patterns.
- Modifications to the specific configurations of the disclosed hemostat may be desirable in conjunction with adapting the hemostat to thoracoscopic use or in conjunction with adapting the hemostat set to other versions of the Maze or Maze type procedures or to procedures performed elsewhere on the heart or other organs. Such modifications are believed to be within the scope of the invention.
- hemostat disclosed in the present application is preferably provided with R-F electrodes to create elongated lesions
- the invention may also usefully be practiced in conjunction with hemostats employing microwave, heat, cyro-ablation or other ablative techniques to create the various lesions provided by the method.
- hemostats disclosed in the present application are provided with a single elongated electrode extending along each jaw, embodiments in which multiple electrodes arrayed along each jaw are employed are also believed useful in practicing the invention.
- the present invention is also believed useful in the context ablation devices employing only a single elongated, electrode or a single series of elecfrodes.
Abstract
Description
Claims
Priority Applications (4)
Application Number | Priority Date | Filing Date | Title |
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DE60230998T DE60230998D1 (en) | 2001-12-11 | 2002-12-10 | SYSTEM FOR GENERATING LESIONS |
EP02792349A EP1455654B1 (en) | 2001-12-11 | 2002-12-10 | System for providing lesions |
AU2002357808A AU2002357808A1 (en) | 2001-12-11 | 2002-12-10 | Method and system for treatment of atrial tachyarrhythmias |
DK02792349T DK1455654T3 (en) | 2001-12-11 | 2002-12-10 | System for providing lesions |
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US10/016,299 | 2001-12-11 | ||
US10/016,299 US6656175B2 (en) | 2001-12-11 | 2001-12-11 | Method and system for treatment of atrial tachyarrhythmias |
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WO2003053248A2 true WO2003053248A2 (en) | 2003-07-03 |
WO2003053248A3 WO2003053248A3 (en) | 2004-02-26 |
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PCT/US2002/039440 WO2003053248A2 (en) | 2001-12-11 | 2002-12-10 | Method and system for treatment of atrial tachyarrhythmias |
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EP (1) | EP1455654B1 (en) |
AT (1) | ATE421294T1 (en) |
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- 2002-12-10 WO PCT/US2002/039440 patent/WO2003053248A2/en not_active Application Discontinuation
- 2002-12-10 ES ES02792349T patent/ES2320108T3/en not_active Expired - Lifetime
- 2002-12-10 AT AT02792349T patent/ATE421294T1/en not_active IP Right Cessation
- 2002-12-10 DK DK02792349T patent/DK1455654T3/en active
- 2002-12-10 AU AU2002357808A patent/AU2002357808A1/en not_active Abandoned
- 2002-12-10 EP EP02792349A patent/EP1455654B1/en not_active Expired - Lifetime
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2003
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Also Published As
Publication number | Publication date |
---|---|
ATE421294T1 (en) | 2009-02-15 |
AU2002357808A8 (en) | 2003-07-09 |
US7347858B2 (en) | 2008-03-25 |
EP1455654B1 (en) | 2009-01-21 |
EP1455654A2 (en) | 2004-09-15 |
WO2003053248A3 (en) | 2004-02-26 |
US20030109863A1 (en) | 2003-06-12 |
DE60230998D1 (en) | 2009-03-12 |
US6656175B2 (en) | 2003-12-02 |
ES2320108T3 (en) | 2009-05-19 |
AU2002357808A1 (en) | 2003-07-09 |
US20040078069A1 (en) | 2004-04-22 |
DK1455654T3 (en) | 2009-03-30 |
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