EP2037812A2 - Méthodes et appareil de traitement de la fibrillation auriculaire - Google Patents

Méthodes et appareil de traitement de la fibrillation auriculaire

Info

Publication number
EP2037812A2
EP2037812A2 EP07799466A EP07799466A EP2037812A2 EP 2037812 A2 EP2037812 A2 EP 2037812A2 EP 07799466 A EP07799466 A EP 07799466A EP 07799466 A EP07799466 A EP 07799466A EP 2037812 A2 EP2037812 A2 EP 2037812A2
Authority
EP
European Patent Office
Prior art keywords
tissue
membrane
barrier
catheter
ablation
Prior art date
Legal status (The legal status is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the status listed.)
Withdrawn
Application number
EP07799466A
Other languages
German (de)
English (en)
Other versions
EP2037812A4 (fr
Inventor
Vahid Saadat
Ruey-Feng Peh
Edmund A. Tam
David Miller
Chris A. Rothe
Current Assignee (The listed assignees may be inaccurate. Google has not performed a legal analysis and makes no representation or warranty as to the accuracy of the list.)
Voyage Medical Inc
Original Assignee
Voyage Medical Inc
Priority date (The priority date is an assumption and is not a legal conclusion. Google has not performed a legal analysis and makes no representation as to the accuracy of the date listed.)
Filing date
Publication date
Application filed by Voyage Medical Inc filed Critical Voyage Medical Inc
Publication of EP2037812A2 publication Critical patent/EP2037812A2/fr
Publication of EP2037812A4 publication Critical patent/EP2037812A4/fr
Withdrawn legal-status Critical Current

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Classifications

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Definitions

  • the present invention relates generally to medical devices used for accessing, visualizing, and/or treating regions of tissue within a body. More particularly, the present invention relates to methods and apparatus for accessing, visualizing, and/or treating conditions such as atrial fibrillation and monitoring the ablation treatment within a patient heart.
  • Another conventional device utilizes an inflatable balloon which is typically introduced intravascularly in a deflated state and then inflated against the tissue region to be examined. Imaging is typically accomplished by an optical fiber or other apparatus such as electronic chips for viewing the tissue through the membrane(s) of the inflated balloon. Moreover, the balloon must generally be inflated for imaging.
  • Other conventional balloons utilize a cavity or depression formed at a distal end of the inflated balloon. This cavity or depression is pressed against the tissue to be examined and is flushed with a clear fluid to provide a clear pathway through the blood.
  • imaging balloons have many inherent disadvantages.
  • such balloons generally require that the balloon be inflated to a relatively large size which may undesirably displace surrounding tissue and interfere with fine positioning of the imaging system against the tissue.
  • the working area created by such inflatable balloons are generally cramped and limited in size.
  • inflated balloons may be susceptible to pressure changes in the surrounding fluid. For example, if the environment surrounding the inflated balloon undergoes pressure changes, e.g., during systolic and diastolic pressure cycles in a beating heart, the constant pressure change may affect the inflated balloon volume and its positioning to produce unsteady or undesirable conditions for optimal tissue imaging.
  • these types of imaging modalities are generally unable to provide desirable images useful for sufficient diagnosis and therapy of the endoluminal structure, due in part to factors such as dynamic forces generated by the natural movement of the heart.
  • anatomic structures within the body can occlude or obstruct the image acquisition process.
  • the presence and movement of opaque bodily fluids such as blood generally make in vivo imaging of tissue regions within the heart difficult.
  • CT computed tomography
  • MRI magnetic resonance imaging
  • fluoroscopic imaging is widely used to identify anatomic landmarks within the heart and other regions of the body.
  • fluoroscopy fails to provide an accurate image of the tissue quality or surface and also fails to provide for instrumentation for performing tissue manipulation or other therapeutic procedures upon the visualized tissue regions.
  • fluoroscopy provides a shadow of the intervening tissue onto a plate or sensor when it may be desirable to view the intraluminal surface of the tissue to diagnose pathologies or to perform some form of therapy on it.
  • a tissue imaging system which is able to provide real-time in vivo images of tissue regions within body lumens such as the heart through opaque media such as blood and which also provide instruments for therapeutic procedures upon the visualized tissue are desirable.
  • tissue imaging and manipulation apparatus that may be utilized for procedures within a body lumen, such as the heart, in which visualization of the surrounding tissue is made difficult, if not impossible, by medium contained within the lumen such as blood, is described below.
  • a tissue imaging and manipulation apparatus comprises an optional delivery catheter or sheath through which a deployment catheter and imaging hood may be advanced for placement against or adjacent to the tissue to be imaged.
  • the deployment catheter may define a fluid delivery lumen therethrough as well as an imaging lumen within which an optical imaging fiber or assembly may be disposed for imaging tissue.
  • the imaging hood maybe expanded into any number of shapes, e.g., cylindrical, conical as shown, semi-spherical, etc., provided that an open area or field is defined by the imaging hood.
  • the open area is the area within which the tissue region of interest may be imaged.
  • the imaging hood may also define an atraumatic contact lip or edge for placement or abutment against the tissue region of interest.
  • the distal end of the deployment catheter or separate manipulatable catheters maybe articulated through various controlling mechanisms such as push-pull wires manually or via computer control [0012]
  • the deployment catheter may also be stabilized relative to the tissue surface through various methods. For instance, inflatable stabilizing balloons positioned along a length of the catheter may be utilized, or tissue engagement anchors may be passed through or along the deployment catheter for temporary engagement of the underlying tissue.
  • fluid may be pumped at a positive pressure through the fluid delivery lumen until the fluid fills the open area completely and displaces any blood from within the open area.
  • the fluid may comprise any biocompatible fluid, e.g., saline, water, plasma, FluorinertTM, etc., which is sufficiently transparent to allow for relatively undistorted visualization through the fluid.
  • the fluid may be pumped continuously or intermittently to allow for image capture by an optional processor which may be in communication with the assembly.
  • the tissue imaging and treatment system may generally comprise a catheter body having a lumen defined therethrough, a visualization element disposed adjacent the catheter body, the visualization element having a field of view, a transparent fluid source in fluid communication with the lumen, and a barrier or membrane extendable from the catheter body to localize, between the visualization element and the field of view, displacement of blood by transparent fluid that flows from the lumen, and a piercing instrument translatable through the displaced blood for piercing into the tissue surface within the field of view.
  • the imaging hood may be formed into any number of configurations and the imaging assembly may also be utilized with any number of therapeutic tools which may be deployed through the deployment catheter.
  • the tissue visualization system may comprise components including the imaging hood, where the hood may further include a membrane having a main aperture and additional optional openings disposed over the distal end of the hood.
  • An introducer sheath or the deployment catheter upon which the imaging hood is disposed may further comprise a steerable segment made of multiple adjacent links which are pivotably connected to one another and which may be articulated within a single plane or multiple planes.
  • the deployment catheter itself may be comprised of a multiple lumen extrusion, such as a four-lumen catheter extrusion, which is reinforced with braided stainless steel fibers to provide structural support.
  • the proximal end of the catheter may be coupled to a handle for manipulation and articulation of the system.
  • the various assemblies may be configured in particular for treating conditions such as atrial fibrillation while under direct visualization.
  • the devices and assemblies may be configured to facilitate the application of energy to the underlying tissue in a controlled manner while directly visualizing the tissue to monitor as well as confirm appropriate treatment.
  • the imaging and manipulation assembly may be advanced intravascularly into the patient's heart, e.g., through the inferior vena cava and into the right atrium where the hood may be deployed and positioned against the atrial septum and the hood may be infused with saline to clear the blood from within to view the underlying tissue surface.
  • a piercing instrument e.g., a hollow needle
  • a guidewire may then be advanced through the piercing instrument and introduced into the left atrium, where it may be further advanced into one of the pulmonary veins.
  • the piercing instrument may be withdrawn or the hood may be further retracted into its low profile configuration and the catheter and sheath may be optionally withdrawn as well while leaving the guidewire in place crossing the atrial septum.
  • a dilator may be advanced along the guidewire to dilate the opening through the atrial septum to provide a larger transseptal opening for the introduction of the hood and other instruments into the left atrium.
  • Further examples of methods and devices for transseptal access are shown and described in further detail in commonly owned U.S. Pat. App. 11/763,399 filed June 14, 2007, which is incorporated herein by reference in its entirety. Those transseptal access methods and devices may be fully utilized with the methods and devices described herein, as practicable.
  • the deployment catheter and/or hood may be articulated to be placed into contact with or over the ostia of the pulmonary veins.
  • the open area within the hood may be cleared of blood with the translucent or transparent fluid for directly visualizing the underlying tissue such that the tissue may be ablated.
  • An ablation probe which may be configured in a number of different shapes, may be advanced into and through the hood interior while under direct visualization and brought into contact against the tissue region of interest for ablation treatment.
  • One or more of the ostia may be ablated either partially or entirely around the opening to create a conduction block, hi performing the ablation, the hood may be pressed against the tissue utilizing the steering and/or articulation capabilities of the deployment catheter as. well as the sheath.
  • a negative pressure may be created within the hood by drawing in the transparent fluid back through the deployment catheter to create a seal with respect to the tissue surface.
  • the hood may be further approximated against the tissue by utilizing one or more tissue graspers which may be advanced through the hood, such as helical tissue graspers, to temporarily adhere onto the tissue and create a counter-traction force.
  • tissue graspers which may be advanced through the hood, such as helical tissue graspers, to temporarily adhere onto the tissue and create a counter-traction force.
  • the hood may be used to visually confirm that the appropriate regions of tissue have been ablated and/or that the tissue has been sufficiently ablated. Visual monitoring and confirmation may be accomplished in real-time during a procedure or after the procedure has been completed.
  • the hood may be utilized postoperatively to image tissue which has been ablated in a previous procedure to determine whether appropriate tissue ablation had been accomplished.
  • one or more ostia of the pulmonary veins or other tissue regions within the left atrium may be ablated by moving the ablation probe within the area defined by the hood and/or moving the hood itself to tissue regions to be treated, such as around the pulmonary vein ostium.
  • Visual monitoring of the ablation procedure not only provides real-time visual feedback to maintain the probe-to-tissue contact, but also provides real-time color feedback of the ablated tissue surface as an indicator when irreversible tissue damage may occur. This color change during lesion formation may be correlated to parameters such as impedance, time of ablation, power applied, etc.
  • real-time visual feedback also enables the user to precisely position and move the ablation probe to desired locations along the tissue surface fore creating precise lesion patterns.
  • the visual feedback also provides a safety mechanism by which the user can visually detect endocardial disruptions and/or complications, such as steam formation or bubble formation.
  • any resulting tissue debris can be contained within the hood and removed from the body by suctioning the contents of the hood proximally into the deployment catheter before the debris is released into the body.
  • the hood also provides a relatively isolated environment with little or no blood so as to reduce any risk of coagulation.
  • the displacement fluid may also provide a cooling mechanism for the tissue surface to prevent over-heating by introducing and purging the saline into and through the hood.
  • the hood may be utilized to visually evaluate the post-ablation lesion for contiguous lesion formation and/or for visual confirmation of any endocardial disruptions by identifying cratering or coagulated tissue or charred tissue. If determined desirable or necessary upon visual inspection, the tissue area around the pulmonary vein ostium or other tissue region may be ablated again without having to withdraw or re-introduce the ablation instrument.
  • ablation probe having at least one ablation electrode utilizing, e.g., radio-frequency (RP), microwave, ultrasound, laser, cryo-ablation, etc.
  • RP radio-frequency
  • variously configured ablation probes may be utilized, such as linear or circularly-configured ablation probes depending upon the desired lesion pattern and the region of tissue to be ablated.
  • the ablation electrodes may be placed upon the various regions of the hood as well.
  • Ablation treatment under direct visualization may also be accomplished utilizing alternative visualization catheters which may additionally provide for stability of the catheter with respect to the dynamically moving tissue and blood flow.
  • one or more grasping support members may be passed through the catheter and deployed from the hood to allow for the hood to be walked or moved along the tissue surfaces of the heart chambers.
  • Other variations may also utilize intra-atrial balloons which occupy a relatively large volume of the left atrium and provide direct visualization of the tissue surfaces.
  • a number of safety mechanisms may also be utilized. For instance, to prevent the inadvertent piercing or ablation of an ablation instrument from injuring adjacent tissue structures, such as the esophagus, a light source or ultrasound transducer may be attached to or through a catheter which can be inserted transorally into the esophagus and advanced until the catheter light source is positioned proximate to or adjacent to the heart. During an intravascular ablation procedure in the left atrium, the operator may utilize the imaging element to visually (or otherwise such as through ultrasound) detect the light source in the form of a background glow behind the tissue to be ablated as an indication of the location of the esophagus.
  • Another safety measure which may be utilized during tissue ablation is the utilization of color changes in the tissue being ablated.
  • One particular advantage of a direct visualization system described herein is the ability to view and monitor the tissue in real-time and in detailed color.
  • ablating the pulmonary vein ostia and/or endocardiac tissue under direct visualization provides real-time visual feedback on contact between the ablation probe and the tissue surface as well as visual feedback on the precise position and movement of the ablation probe to create desired lesion patterns.
  • Real-time visual feedback is also provided for confirming a position of the hood within the atrial chamber itself by visualizing anatomical landmarks, such as a location of a pulmonary vein ostium or a left atrial appendage, a left atrial septum, etc.
  • Real-time visual feedback is further provided for the early detection of endocardiac disruptions and/or complications, such as visual detection of steam or bubble formation.
  • Real-time visual feedback is additionally provided for color feedback of the ablated endocardiac tissue as an indicator when irreversible tissue damage occurs by enabling the detection of changes in the tissue color.
  • the hood itself provides a relatively isolated environment with little or no blood so as to reduce any risk of coagulation.
  • the displacement fluid may also provide a cooling mechanism for the tissue surface to prevent over-heating.
  • direct visualization further provides the capability for visually inspecting for contiguous lesion formation as well as inspecting color differences of the tissue surface. Also, visual inspection of endocardiac disruptions and/or complications is possible, for example, inspecting the ablated tissue for visual confirmation for the presence of tissue craters or coagulated blood on the tissue.
  • the hood also provides a barrier or membrane for containing the disruption and rapidly evacuating any tissue debris.
  • the hood provides for the establishment of stable contact with the ostium of the pulmonary vein or other targeted tissue, for example, by the creation of negative pressure within the space defined within the hood for drawing in or suctioning the tissue to be ablated against the hood for secure contact.
  • an ablation probe may be introduced through the tissue imaging and manipulation catheter and the ablation process may be monitored under direct visualization, as described above. Additional features or instruments may be included and utilized with the catheter for detecting parameters of the tissue before, during, and/or after the ablation process to further monitor the ablation procedure aside from visualizing. For example, parameters such as detecting the thickness of a penetrated tissue region, temperature, impedance characteristics, etc. may also be detected and monitored.
  • One mechanism for detecting such parameters includes the use of one or more ablation needle electrodes having temperature sensors positioned within and projecting from the end of one or more corresponding probe shafts which may be advanced through the hood. These ablation electrodes may pierce into and ablate the tissue while monitoring a temperature of the treated tissue. Moreover, the ablation electrodes may also be configured in various configurations for creating different lesion patterns, e.g., linear, circular, etc. Aside from temperature sensing, the needle ablation electrodes may also be configured to sense tissue impedance, thereby enabling the user to determine when the needle electrode has been advanced into or entirely through the tissue to be treated.
  • the transmural needle assembly itself may generally comprise a distal end effector having the interrogation needle and with optional integrated ablation capabilities, a catheter body connecting the interrogation needle with the handle assembly.
  • the handle assembly may generally comprise a needle penetration depth indicator and an actuator, e.g., a push/turn knob, for advancing or retracting the distal transmural needle probe.
  • the needle body itself may have a diameter of, e.g., 0.005 in., with an outer diameter thin wall needle having a plurality of pores or openings defined along the needle body.
  • the outer surface of the needle may be also largely insulated except for a short exposed segment at the distal traumatic end, e.g., the piercing tip. Proximal to the needle is an ablation surface that can be incorporated to provide ablation energy.
  • the sensor assembly contained within the needle lumen may comprise one or more sensors for detecting and monitoring various tissue parameters such as temperature, impedance, etc.
  • the impedance sensor may immediately detect an increase in impedance due to the intrinsic material property difference between blood and tissue. This change in impedance detected will alert the user that the transmural needle is in contact with the tissue. Impedance detected by sensor can also be used to verify if the needle is inserted into the desired tissue by comparing with the expected impedance of the target tissue, from standard impedance values determined by the resistivity of the tissue and geometry of the electrode.
  • a thin layer of saline infused and formed around the needle within the tissue may act as a conductive medium to channel radiation energy to additional tissue surfaces. This in turn helps to create a wider lesion using the same amount of power on the ablation electrode without tissue dessication and/or blood coagulation. It may also help to cool the area around the needle.
  • Fig. IA shows a side view of one variation of a tissue imaging apparatus during deployment from a sheath or delivery catheter.
  • Fig. IB shows the deployed tissue imaging apparatus of Fig. IA having an optionally expandable hood or sheath attached to an imaging and/or diagnostic catheter.
  • Fig. 1C shows an end view of a deployed imaging apparatus.
  • Figs. ID to IF show the apparatus of Figs. IA to 1C with an additional lumen, e.g., for passage of a guidewire therethrough.
  • FIGs. 2A and 2B show one example of a deployed tissue imager positioned against or adjacent to the tissue to be imaged and a flow of fluid, such as saline, displacing blood from within the expandable hood.
  • a flow of fluid such as saline
  • Fig. 3 A shows an articulatable imaging assembly which may be manipulated via push-pull wires or by computer control.
  • Figs. 3B and 3C show steerable instruments, respectively, where an articulatable delivery catheter may be steered within the imaging hood or a distal portion of the deployment catheter itself may be steered.
  • Figs. 4A to 4C show side and cross-sectional end views, respectively, of another variation having an off-axis imaging capability.
  • FIG. 5 shows an illustrative view of an example of a tissue imager advanced intravascularly within a heart for imaging tissue regions within an atrial chamber.
  • Figs. 6A to 6C illustrate deployment catheters having one or more optional inflatable balloons or anchors for stabilizing the device during a procedure.
  • FIGs. 7A and 7B illustrate a variation of an anchoring mechanism such as a helical tissue piercing device for temporarily stabilizing the imaging hood relative to a tissue surface.
  • FIG. 7C shows another variation for anchoring the imaging hood having one or more tubular support members integrated with the imaging hood; each support members may define a lumen therethrough for advancing a helical tissue anchor within.
  • Fig. 8 A shows an illustrative example of one variation of how a tissue imager may be utilized with an imaging device.
  • Fig. 8B shows a further illustration of a hand-held variation of the fluid delivery and tissue manipulation system.
  • Figs. 9A to 9C illustrate an example of capturing several images of the tissue at multiple regions.
  • Figs. 1OA and 1OB show charts illustrating how fluid pressure within the imaging hood may be coordinated with the surrounding blood pressure; the fluid pressure in the imaging hood may be coordinated with the blood pressure or it may be regulated based upon pressure feedback from the blood.
  • Fig. 1 IA shows a side view of another variation of a tissue imager having an imaging balloon within an expandable hood.
  • Fig. 1 IB shows another variation of a tissue imager utilizing a translucent or transparent imaging balloon.
  • Fig. 12A shows another variation in which a flexible expandable or distensible membrane may be incorporated within the imaging hood to alter the volume of fluid dispensed.
  • FIGs. 12B and 12C show another variation in which the imaging hood may be partially or selectively deployed from the catheter to alter the area of the tissue being visualized as well as the volume of the dispensed fluid.
  • Figs. 13 A and 13B show exemplary side and cross-sectional views, respectively, of another variation in which the injected fluid may be drawn back into the device for minimizing fluid input into a body being treated.
  • Figs. 14A to 14D show various configurations and methods for configuring an imaging hood into a low-profile for delivery and/or deployment.
  • Figs. 15A and 15B show an imaging hood having an helically expanding frame or support.
  • FIGs. 16A and 16B show another imaging hood having one or more hood support members, which are pivotably attached at their proximal ends to deployment catheter, integrated with a hood membrane.
  • FIGs. 17A and 17B show yet another variation of the imaging hood having at least two or more longitudinally positioned support members supporting the imaging hood membrane where the support members are movable relative to one another via a torquing or pulling or pushing force.
  • Figs. 18A and 18B show another variation where a distal portion of the deployment catheter may have several pivoting members which form a tubular shape in its low profile configuration.
  • Figs. 19A and 19B show another variation where the distal portion of deployment catheter may be fabricated from a flexible metallic or polymeric material to form a radially expanding hood.
  • FIGs. 2OA and 20B show another variation where the imaging hood may be fonned from a plurality of overlapping hood members which overlie one another in an overlapping pattern.
  • FIGs. 21 A and 21B show another example of an expandable hood which is highly conformable against tissue anatomy with varying geography.
  • FIG. 22A shows yet another example of an expandable hood having a number of optional electrodes placed about the contact edge or lip of the hood for sensing tissue contact or detecting arrhythmias.
  • Fig. 22B shows another variation for confonning the imaging hood against the underlying tissue where an inflatable contact edge may be disposed around the circumference of the imaging hood.
  • Fig. 23 shows a variation of the system which may be instrumented with a transducer for detecting the presence of blood seeping back into the imaging hood.
  • Figs. 24A and 24B show variations of the imaging hood instrumented with sensors for detecting various physical parameters; the sensors may be instrumented around the outer surface of the imaging hood and also within the imaging hood.
  • Figs. 25A and 25B show a variation where the imaging hood may have one or more LEDs over the hood itself for providing illumination of the tissue to be visualized.
  • Figs. 26A and 26B show another variation in which a separate illumination tool having one or more LEDs mounted thereon maybe utilized within the imaging hood.
  • Fig. 27 shows one example of how a therapeutic tool may be advanced through the tissue imager for treating a tissue region of interest.
  • Fig. 28 shows another example of a helical therapeutic tool for treating the tissue region of interest.
  • Fig. 29 shows a variation of how a therapeutic tool may be utilized with an expandable imaging balloon.
  • Figs. 30A and 3OB show alternative configurations for therapeutic instruments which may be utilized; one variation is shown having an angled instrument arm and another variation is shown with an off-axis instrument arm.
  • Figs. 3 IA to 31C show side and end views, respectively, of an imaging system which may be utilized with an ablation probe.
  • Figs. 32A and 32B show side and end views, respectively, of another variation of the imaging hood with an ablation probe, where the imaging hood may be enclosed for regulating a temperature of the underlying tissue.
  • Figs. 33A and 33B show an example in which the imaging fluid itself may be altered in temperature to facilitate various procedures upon the underlying tissue.
  • Figs. 34A and 34B show an example of a laser ring generator which may be utilized with the imaging system and an example for applying the laser ring generator within the left atrium of a heart for treating atrial fibrillation.
  • Figs. 35A to 35C show an example of an extendible cannula generally comprising an elongate tubular member which may be positioned within the deployment catheter during delivery and then projected distally through the imaging hood and optionally beyond.
  • FIGs. 36A and 36B show side and end views, respectively, of an imaging hood having one or more tubular support members integrated with the hood for passing instruments or tools therethrough for treatment upon the underlying tissue.
  • Figs. 37A and 37B illustrate how an imaging device may be guided within a heart chamber to a region of interest utilizing a lighted probe positioned temporarily within, e.g., a lumen of the coronary sinus.
  • Figs. 38A and 38B show an imaging hood having a removable disk- shaped member for implantation upon the tissue surface.
  • Figs. 39A to 39C show one method for implanting the removable disk ofFigs. 38A and 38B.
  • Figs. 40A and 40B illustrate an imaging hood having a deployable anchor assembly attached to the tissue contact edge and an assembly view of the anchors and the suture or wire connected to the anchors, respectively
  • Figs. 41 A to 41D show one method for deploying the anchor assembly of Figs. 40A and 4OB for closing an opening or wound.
  • Fig. 42 shows another variation in which the imaging system may be fluidly coupled to a dialysis unit for filtering a patient's blood.
  • FIGs. 43 A and 43B show a variation of the deployment catheter having a first deployable hood and a second deployable hood positioned distal to the first hood; the deployment catheter may also have a side- viewing imaging element positioned between the first and second hoods for imaging tissue between the expanded hoods.
  • Figs. 44A and 44B show side and end views, respectively, of a deployment catheter having a side-imaging balloon in an un-inflated low-profile configuration.
  • Figs. 45 A to 45C show side, top, and end views, respectively, of the inflated balloon of Figs. 44A and 44B defining a visualization field in the inflated balloon.
  • Figs. 46A and 46B show side and cross-sectional end views, respectively, for one method of use in visualizing a lesion upon a vessel wall within the visualization field of the inflated balloon from Figs. 45A to 45C.
  • FIGs. 47 A to 470 illustrate an example for intravascularly advancing the imaging and manipulation catheter into the heart and into the left atrium for ablating tissue around the ostia of the pulmonary veins for the treatment of atrial fibrillation.
  • FIGs. 48 A and 48B illustrate partial cross-sectional views of a hood which is advanced into the left atrium to examine discontiguous lesions.
  • Fig. 49 A shows a perspective view of a variation of the transmural lesion ablation device with, in this variation, a single RF ablation probe inserted through the working channel of the tissue visualization catheter.
  • Fig. 49B shows a side view of the device performing tissue ablation within the hood under real time visualization.
  • Fig. 49C shows the perspective view of the device performing tissue ablation within the hood under real time visualization.
  • Fig. 5OA shows a perspective view of a variation of the device when an angled ablation probe is used for linear transmural lesion formation.
  • Fig. 5OB shows a perspective view of another variation of the device when a circular ablation probe is used for circular transmural lesion formation.
  • Fig. 51 A shows a perspective view of another variation of the transmural lesion ablation device with a circularly-shaped RF electrode end effector placed on the outer circumference of an expandable membrane covering the hood of the tissue visualization catheter.
  • Fig. 5 IB shows a perspective view of another variation of an expandable balloon also with a circularly-shaped RF electrode end effector and without the hood.
  • Fig. 52 shows a perspective view of another variation of the transmural lesion ablation device with RF electrodes disposed circumferentially around the contact lip or edge of the hood.
  • Figs. 53A and 53B show perspective and side views, respectively, of another variation of the transmural lesion ablation device with an ablation probe positioned within the hood which also includes at least one layer of a transparent elastomeric membrane over the distal opening of the hood.
  • Fig. 54A shows a perspective view of another variation of the transmural lesion ablation device having an expandable linear ablation electrode strip inserted through the working channel of the tissue visualization catheter.
  • Fig. 54B shows the perspective view of the device with the linear ablation electrode strip in its expanded configuration.
  • Figs. 55A and 55B illustrate perspective views of another variation where a laser probe, e.g., an optical fiber bundle coupled to a laser generator, may be inserted through the work channel of the tissue visualization catheter and activated for ablation treatment.
  • a laser probe e.g., an optical fiber bundle coupled to a laser generator
  • Fig. 55C shows the device of Figs. 55A and 55B performing tissue ablation or transmural lesion formation under direct visualization while working within the hood of the visualization catheter apparatus.
  • Fig. 56 shows a partial cross-sectional view of the tissue visualization catheter with an inflated occlusion balloon to temporarily occlude blood flow through the pulmonary vein while viewing the pulmonary vein's ostia.
  • Fig. 57 shows a perspective view of first and second tissue graspers deployed through the hood for facilitating movement of the hood along the tissue surface.
  • Figs. 58A to 58C illustrate the tissue visualization catheter navigating around a body lumen, such as the left atrium of the heart, utilizing two tissue graspers to "walk" the catheter along the tissue surface.
  • Fig. 59 shows a partial cross-sectional view of the tissue visualization catheter in a retroflexed position for accessing the right inferior pulmonary vein ostium.
  • Fig. 60 show a partial cross-sectional view of the tissue visualization catheter intravascularly accessing the left atrium via a trans- femoral introduction through the aorta, the aortic valve, the left ventricle, and into the left atrium.
  • Fig. 61A shows a side view of the tissue visualization catheter retroflexed at a tight angle accessing the right inferior pulmonary vein ostium with a first tissue grasper and length of wire or suture configured as a pulley mechanism.
  • Fig. 6 IB illustrates the tissue visualization catheter pulling itself to access the right inferior PV ostium at a tight angle using a suture pulley mechanism.
  • Fig. 61C illustrates the tissue visualization catheter prior to the suture being tensioned.
  • Fig. 61D illustrates the tissue visualization catheter being moved and approximated towards the ostium as the suture is tensioned.
  • Fig. 62A shows a partial cross-sectional view of a tissue visualization catheter having an intra-atrial balloon inflated within the left atrium.
  • Fig. 62B shows the partial cross-sectional view with a fiberscope introduced into the balloon interior.
  • Fig. 62C shows the partial cross-sectional view with the fiberscope advancing and articulating within the balloon.
  • Fig. 62D shows the partial cross-sectional view of the intra-atrial balloon having radio-opaque fiducial markers and an ablation probe deployed within the balloon.
  • Fig. 63 shows a detail side view of an ablation probe deployed within the balloon and penetrating through the balloon wall.
  • Figs. 64A and 64B show perspective views of ablation needles deployable from a retracted position to a deployed position.
  • Fig. 64C shows the perspective view of an ablation needle having a bipolar electrode configuration.
  • Fig. 65A to 65E illustrate a stabilizing catheter accessing the left atrium with a stabilizing balloon deployed in the right atrium and examples of the articulation and translation capabilities for directing the hood towards the tissue region to be treated.
  • Fig. 66A to 66E illustrate another variation of a stabilizing catheter accessing the left atrium with proximal and distal stabilizing balloons deployed about the atrial septum and examples of the articulation and translation capabilities for directing the hood towards the tissue region to be treated.
  • Fig. 67A to 67F illustrate another variation of a stabilizing catheter accessing the left atrium with a combination of proximal and distal stabilizing balloons deployed about the atrial septum and an intra-atrial balloon expanded within the left atrium with a hollow needle for piercing through the balloon and deploying the hood external to the balloon.
  • Fig. 68 A illustrates a side view of the tissue visualization catheter deploying an intra-atrial balloon with an articulatable imager capturing multiple images representing different segments of the heart chamber wall from different angles.
  • Fig. 68B schematically illustrates the mapping of the multiple captured images processed to create a panoramic visual map of the heart chamber.
  • Fig. 69 A shows a partial cross-sectional view of the tissue visualization catheter in the left atrium performing RF ablation, with a light source or ultrasound crystal source inserted transorally into the esophagus to prevent esophageal perforation.
  • Figs. 69B and 69C illustrate the image viewed by the user prior to the ablation probe being activated.
  • Figs. 69D and 69E illustrate the image viewed by the user of the ablated tissue changing color as the ablation probe heats the underlying tissue.
  • Figs. 69F and 69G illustrate the image viewed by the user of an endocardiac disruption and the resulting tissue debris captured or contained within the hood.
  • Fig. 69H illustrates the evacuation of the captured tissue debris into the catheter.
  • Figs. 691 to 69K illustrate one method for adhering the tissue to be ablated via a suction force applied to the underlying tissue to be ablated.
  • Fig. 7OA shows a perspective view of one variation of the tissue thickness monitoring and treatment device with a hood at the distal end, a sheath covering the body of the apparatus and sensor probes extended from one or more lumens within the device.
  • Figs. 7OB and 7OC show perspective and detail perspective views, respectively, of the needle electrodes positioned upon their respective shafts and having one or more temperature sensors disposed therein.
  • Fig. 71 shows a variation of the perspective view of the hood having a balloon inflated therein with, e.g., contrast medium, for visualizing underlying tissue surfaces.
  • Fig. 72A to 72E illustrate perspective views of one method where the balloon may be utilized for effecting ablation treatment.
  • Figs. 73A to 73F illustrate detailed side views of the hood in contact with the tissue surface with saline flow injected into the hood while creating a transmural lesion on the target tissue wall with the sensor and treatment probe retracting proximally after treatment.
  • Figs. 74A to 74C illustrate partial cross-sectional views of a treatment probe creating transmural lesions within the right atrium as well as the left atrium.
  • Figs. 75 A and 75B shows perspective views of a variation of the probes arranged linearly for creating linear lesions.
  • Figs. 76A and 76B show yet another configuration where a circular lesion can be created in single step via an ablation needle probe end effector.
  • Figs. 77A to 77C show an assembly view of another variation on the transmural tissue parameter detection needle with expanded views of the distal end effector and the proximal handle.
  • Fig. 77D shows a detail perspective view of the interrogation needle.
  • Fig. 78 schematically illustrates the impedance sensing utilizing two simple impedance electrodes.
  • Fig. 79 schematically illustrates impedance sensing with high impedance bioamplifier.
  • Figs. 80A and 80B illustrate perspective views of a fiber optic temperature sensor monitoring color changes in a thermo-sensitive layer of dye as the dye changes from a first color which is indicative of a first temperature to a second color which is indicative of a second temperature.
  • Fig. 81 shows a graph illustrating the relationship between the fluorescent decay rate, ⁇ , of light intensity versus time.
  • Fig. 82 shows a graph illustrating the relationship between the time of decay rate and temperature.
  • Fig. 83 shows a perspective view of the transmural handle assembly.
  • Figs. 84A and 84B illustrate side views of the transmural subsurface interrogation needle in the retracted position and the handle indicating a retracted needle position, respectively.
  • Figs. 85 A and 85B illustrate side views of the transmural subsurface interrogation needle advanced partially into the tissue while sensing impedance and the handle indicating a penetration depth of the needle, respectively.
  • Figs. 86A and 86B illustrate side views of the transmural subsurface interrogation needle fully penetrated into the tissue and infusing saline and the handle indicating a deployed needle position, respectively.
  • Figs. 87A and 87B illustrate a gradient of heated tissue extending from the electrode disposed upon the catheter body to the temperature sensor within the needle.
  • FIGs. 88A and 88B show perspective views of the interrogation needle and catheter body advanced through the deployment catheter and into and through the hood ablating and/or detecting tissue parameters, respectively.
  • Figs. 89A and 89B show perspective views of another variation having a plurality of the transmural needles arranged in a ring configuration along a support ring positioned around a circumference of the opening of the hood.
  • Figs. 9OA and 9OB show perspective views of a plurality of transmural needles arranged into a linear configuration along a linear ablation electrode.
  • Fig. 9OC illustrates the device of Figs. 9OA and 9OB positioned over the tissue for treatment and/or detection.
  • Fig. 91 shows a detail perspective view of another variation of the transmural subsurface interrogation needle where several additional temperature sensors may be placed along the length of the needle.
  • Figs. 92A and 92B illustrate side views of the transmural subsurface interrogation needle fully penetrated into the tissue while sensing temperature along the needle and the handle indicating a deployed needle position, respectively.
  • Fig. 93 A shows yet another variation of the transmural subsurface interrogation needle which includes an intramural cooling needle having a cooling probe which may be advanced from the catheter body adjacent to the interrogation needle and pierced into the tissue.
  • Fig. 93B illustrates the device of Fig. 93 A placed over the tissue for treatment and/or detection.
  • Fig. 94 shows a side view of another variation of the transmural subsurface interrogation needle with a plurality of impedance and temperature sensors along the needle.
  • Figs. 95A and 95B show side and perspective views, respectively, of another variation of the transmural subsurface interrogation needles attached circumferential and distally on a lumen.
  • Fig. 96 shows a side view of a variation of the transmural subsurface interrogation needle at the distal end of an ablation probe with pivoting capabilities.
  • Figs. 97A and 97B show side and end views, respectively, of another variation of the transmural needle where the needle projects radially from a side surface of the electrode of the catheter.
  • Figs. 98 A and 98B show side views of another variation of the transmural needle having a helical configuration instead of a straight needle configuration and the needle creating relatively wide lesions in tissue..
  • Fig. 99 shows yet another variation of the transmural needle with one or more transparent visualization balloons fixed along the length of the transmural needle.
  • Figs. IOOA and IOOB show side and detailed side views, respectively, of a variation of the transmural subsurface interrogation needle positioned upon a robotic precision control system.
  • a tissue-imaging and manipulation apparatus described below is able to provide real-time images in vivo of tissue regions within a body lumen such as a heart, which is filled with blood flowing dynamically therethrough and is also able to provide intravascular tools and instruments for performing various procedures upon the imaged tissue regions.
  • Such an apparatus may be utilized for many procedures, e.g., facilitating transseptal access to the left atrium, cannulating the coronary sinus, diagnosis of valve regurgitation/stenosis, valvuloplasty, atrial appendage closure, arrhythmogenic focus ablation, among other procedures.
  • tissue imaging and manipulation assembly 10 may be delivered intravascularly through the patient's body in a low-profile configuration via a delivery catheter or sheath 14.
  • tissue imaging and manipulation assembly 10 may be delivered intravascularly through the patient's body in a low-profile configuration via a delivery catheter or sheath 14.
  • tissue such as the mitral valve located at the outflow tract of the left atrium of the heart
  • it is generally desirable to enter or access the left atrium while minimizing trauma to the patient.
  • tissue such as the mitral valve located at the outflow tract of the left atrium of the heart
  • transseptal procedure or septostomy To non-operatively effect such access, one conventional approach involves puncturing the intra-atrial septum from the right atrial chamber to the left atrial chamber in a procedure commonly called a transseptal procedure or septostomy.
  • transseptal access to the left atrial chamber of the heart may allow for larger devices to be introduced into the venous system than can generally be introduced percutaneously into the arterial system.
  • imaging hood 12 may be advanced relative to catheter 14 and deployed from a distal opening of catheter 14, as shown by the arrow. Upon deployment, imaging hood 12 may be unconstrained to expand or open into a deployed imaging configuration, as shown in Fig. IB. Imaging hood 12 may be fabricated from a variety of pliable or conformable biocompatible material including but not limited to, e.g., polymeric, plastic, or woven materials. One example of a woven material is Kevlar® (E. I.
  • imaging hood 12 may be fabricated from a translucent or opaque material and in a variety of different colors to optimize or attenuate any reflected lighting from surrounding fluids or structures, i.e., anatomical or mechanical structures or instruments. In either case, imaging hood 12 may be fabricated into a uniform structure or a scaffold-supported structure, in which case a scaffold made of a shape memory alloy, such as Nitinol, or a spring steel, or plastic, etc., maybe fabricated and covered with the polymeric, plastic, or woven material.
  • a shape memory alloy such as Nitinol, or a spring steel, or plastic, etc.
  • imaging hood 12 may comprise any of a wide variety of barriers or membrane structures, as may generally be used to localize displacement of blood or the like from a selected volume of a body lumen or heart chamber, m exemplary embodiments, a volume within an inner surface 13 of imaging hood 12 will be significantly less than a volume of the hood 12 between inner surface 13 and outer surface 11.
  • Imaging hood 12 may be attached at interface 24 to a deployment catheter 16 which may be translated independently of deployment catheter or sheath 14. Attachment of interface 24 may be accomplished through any number of conventional methods.
  • Deployment catheter 16 may define a fluid delivery lumen 18 as well as an imaging lumen 20 within which an optical imaging fiber or assembly may be disposed for imaging tissue.
  • imaging hood 12 When deployed, imaging hood 12 may expand into any number of shapes, e.g., cylindrical, conical as shown, semi-spherical, etc., provided that an open area or field 26 is defined by imaging hood 12. The open area 26 is the area within which the tissue region of interest may be imaged.
  • Imaging hood 12 may also define an atraumatic contact lip or edge 22 for placement or abutment against the tissue region of interest.
  • the diameter of imaging hood 12 at its maximum fully deployed diameter is typically greater relative to a diameter of the deployment catheter 16 (although a diameter of contact lip or edge 22 may be made to have a smaller or equal diameter of deployment catheter 16).
  • the contact edge diameter may range anywhere from 1 to 5 times (or even greater, as practicable) a diameter of deployment catheter 16.
  • Fig. 1C shows an end view of the imaging hood 12 in its deployed configuration. Also shown are the contact lip or edge 22 and fluid delivery lumen 18 and imaging lumen 20.
  • the imaging and manipulation assembly 10 may additionally define a guidewire lumen therethrough, e.g., a concentric or eccentric lumen, as shown in the side and end views, respectively, of Figs. ID to IF.
  • the deployment catheter 16 may define guidewire lumen 19 for facilitating the passage of the system over or along a guidewire 17, which may be advanced intravascularly within a body lumen. The deployment catheter 16 may then be advanced over the guidewire 17, as generally known in the art.
  • the displacing fluid may be pumped at positive pressure through fluid delivery lumen 18 until the fluid fills open area 26 completely and displaces any fluid 28 from within open area 26.
  • the displacing fluid flow may be laminarized to improve its clearing effect and to help prevent blood from re-entering the imaging hood 12.
  • fluid flow may be started before the deployment takes place.
  • the displacing fluid also described herein as imaging fluid, may comprise any biocompatible fluid, e.g., saline, water, plasma, etc., which is sufficiently transparent to allow for relatively undistorted visualization through the fluid.
  • any number of therapeutic drugs may be suspended within the fluid or may comprise the fluid itself which is pumped into open area 26 and which is subsequently passed into and through the heart and the patient body.
  • deployment catheter 16 may be manipulated to position deployed imaging hood 12 against or near the underlying tissue region of interest to be imaged, in this example a portion of annulus A of mitral valve MV within the left atrial chamber.
  • the translucent fluid 28, such as saline may then be pumped through fluid delivery lumen 18, intermittently or continuously, until the blood 30 is at least partially, and preferably completely, displaced from within open area 26 by fluid 28, as shown in Fig. 2B.
  • contact edge 22 need not directly contact the underlying tissue, it is at least preferably brought into close proximity to the tissue such that the flow of clear fluid 28 from open area 26 may be maintained to inhibit significant backflow of blood 30 back into open area 26.
  • Contact edge 22 may also be made of a soft elastomeric material such as certain soft grades of silicone or polyurethane, as typically known, to help contact edge 22 conform to an uneven or rough underlying anatomical tissue surface.
  • the fluid 28 may be pumped temporarily or sporadically only until a clear view of the tissue is available to be imaged and recorded, at which point the fluid flow 28 may cease and blood 30 may be allowed to seep or flow back into imaging hood 12. This process may be repeated a number of times at the same tissue region or at multiple tissue regions.
  • a number of articulation and manipulation controls may be utilized.
  • one or more push-pull wires 42 may be routed through deployment catheter 16 for steering the distal end portion of the device in various directions 46 to desirably position the imaging hood 12 adjacent to a region of tissue to be visualized.
  • deployment catheter 16 and imaging hood 12 may be articulated into any number of configurations 44.
  • the push-pull wire or wires 42 may be articulated via their proximal ends from outside the patient body manually utilizing one or more controls.
  • deployment catheter 16 maybe articulated by computer control, as further described below.
  • an articulatable delivery catheter 48 which may be articulated via one or more push-pull wires and having an imaging lumen and one or more working lumens, may be delivered through the deployment catheter 16 and into imaging hood 12. With a distal portion of articulatable delivery catheter 48 within imaging hood 12, the clear displacing fluid may be pumped through delivery catheter 48 or deployment catheter 16 to clear the field within imaging hood 12. As shown in Fig. 3B, the articulatable delivery catheter 48 maybe articulated within the imaging hood to obtain a better image of tissue adjacent to the imaging hood 12.
  • articulatable delivery catheter 48 may be articulated to direct an instrument or tool passed through the catheter 48, as described in detail below, to specific areas of tissue imaged through imaging hood 12 without having to reposition deployment catheter 16 and re-clear the imaging field within hood 12.
  • a distal portion of the deployment catheter 16 itself may comprise a distal end 49 which is articulatable within imaging hood 12, as shown in Fig. 3C. Directed imaging, instrument delivery, etc., may be accomplished directly through one or more lumens within deployment catheter 16 to specific regions of the underlying tissue imaged within imaging hood 12.
  • Visualization within the imaging hood 12 may be accomplished through an imaging lumen 20 defined through deployment catheter 16, as described above. In such a configuration, visualization is available in a straight-line manner, i.e., images are generated from the field distally along a longitudinal axis defined by the deployment catheter 16.
  • an articulatable imaging assembly having a pivotable support member 50 may be connected to, mounted to, or otherwise passed through deployment catheter 16 to provide for visualization off-axis relative to the longitudinal axis defined by deployment catheter 16, as shown in Fig. 4A.
  • Support member 50 may have an imaging element 52, e.g., a CCD or CMOS imager or optical fiber, attached at its distal end with its proximal end connected to deployment catheter 16 via a pivoting connection 54.
  • imaging element 52 e.g., a CCD or CMOS imager or optical fiber
  • optical fibers 58 may be passed through deployment catheter 16, as shown in the cross-section of Fig. 4B, and routed through the support member 50.
  • the use of optical fibers 58 may provide for increased diameter sizes of the one or several lumens 56 through deployment catheter 16 for the passage of diagnostic and/or therapeutic tools therethrough.
  • electronic chips such as a charge coupled device (CCD) or a CMOS imager, which are typically known, may be utilized in place of the optical fibers 58, in which case the electronic imager may be positioned in the distal portion of the deployment catheter 16 with electric wires being routed proximally through the deployment catheter 16.
  • the electronic imagers maybe wirelessly coupled to a receiver for the wireless transmission of images.
  • Support member 50 may be pivoted via connection 54 such that the member 50 can be positioned in a low-profile configuration within channel or groove 60 defined in a distal portion of catheter 16, as shown in the cross-section of Fig. 4C.
  • support member 50 can be positioned within channel or groove 60 with imaging hood 12 also in its low-profile configuration.
  • imaging hood 12 may be expanded into its deployed configuration and support member 50 may be deployed into its off-axis configuration for imaging the tissue adjacent to hood 12, as in Fig. 4A.
  • Other configurations for support member 50 for off-axis visualization may be utilized, as desired.
  • Fig. 5 shows an illustrative cross-sectional view of a heart H having tissue regions of interest being viewed via an imaging assembly 10.
  • delivery catheter assembly 70 may be introduced percutaneously into the patient's vasculature and advanced through the superior vena cava SVC and into the right atrium RA.
  • the delivery catheter or sheath 72 may be articulated through the atrial septum AS and into the left atrium LA for viewing or treating the tissue, e.g., the annulus A, surrounding the mitral valve MV.
  • deployment catheter 16 and imaging hood 12 may be advanced out of delivery catheter 72 and brought into contact or in proximity to the tissue region of interest.
  • delivery catheter assembly 70 may be advanced through the inferior vena cava IVC, if so desired.
  • other regions of the heart H e.g., the right ventricle RV or left ventricle LV, may also be accessed and imaged or treated by imaging assembly 10.
  • the delivery catheter or sheath 14 may comprise a conventional intra- vascular catheter or an endoluminal delivery device.
  • robotically-controlled delivery catheters may also be optionally utilized with the imaging assembly described herein, in which case a computer-controller 74 may be used to control the articulation and positioning of the delivery catheter 14.
  • a computer-controller 74 may be used to control the articulation and positioning of the delivery catheter 14.
  • An example of a robotically-controlled delivery catheter which may be utilized is described in further detail in US Pat.
  • one or more inflatable balloons or anchors 76 may be positioned along the length of catheter 16, as shown in Fig. 6 A.
  • the inflatable balloons 76 may be inflated from a low-profile into their expanded configuration to temporarily anchor or stabilize the catheter 16 position relative to the heart H.
  • Fig. 6B shows a first balloon 78 inflated while Fig. 6C also shows a second balloon 80 inflated proximal to the first balloon 78.
  • the septal wall AS maybe wedged or sandwiched between the balloons 78, 80 to temporarily stabilize the catheter 16 and imaging hood 12.
  • a single balloon 78 or both balloons 78, 80 may be used. Other alternatives may utilize expandable mesh members, malecots, or any other temporary expandable structure.
  • the balloon assembly 76 may be deflated or re-configured into a low-profile for removal of the deployment catheter 16.
  • anchoring mechanisms may be optionally employed for temporarily holding the imaging hood 12 against the tissue. Such anchoring mechanisms may be particularly useful for imaging tissue which is subject to movement, e.g., when imaging tissue within the chambers of a beating heart.
  • a tool delivery catheter 82 having at least one instrument lumen and an optional visualization lumen may be delivered through deployment catheter 16 and into an expanded imaging hood 12.
  • anchoring mechanisms such as a helical tissue piercing device 84 may be passed through the tool delivery catheter 82, as shown in Fig. 7A, and into imaging hood 12.
  • the helical tissue engaging device 84 may be torqued from its proximal end outside the patient body to temporarily anchor itself into the underlying tissue surface T. Once embedded within the tissue T, the helical tissue engaging device 84 may be pulled proximally relative to deployment catheter 16 while the deployment catheter 16 and imaging hood 12 are pushed distally, as indicated by the arrows in Fig. 7B, to gently force the contact edge or lip 22 of imaging hood against the tissue T. The positioning of the tissue engaging device 84 may be locked temporarily relative to the deployment catheter 16 to ensure secure positioning of the imaging hood 12 during a diagnostic or therapeutic procedure within the imaging hood 12.
  • tissue engaging device 84 may be disengaged from the tissue by torquing its proximal end in the opposite direction to remove the anchor form the tissue T and the deployment catheter 16 may be repositioned to another region of tissue where the anchoring process may be repeated or removed from the patient body.
  • the tissue engaging device 84 may also be constructed from other known tissue engaging devices such as vacuum-assisted engagement or grasper- assisted engagement tools, among others.
  • a helical anchor 84 is shown, this is intended to be illustrative and other types of temporary anchors may be utilized, e.g., hooked or barbed anchors, graspers, etc.
  • the tool delivery catheter 82 may be omitted entirely and the anchoring device may be delivered directly through a lumen defined through the deployment catheter 16.
  • Fig. 7C shows an imaging hood 12 having one or more tubular support members 86, e.g., four support members 86 as shown, integrated with the imaging hood 12.
  • the tubular support members 86 may define lumens therethrough each having helical tissue engaging devices 88 positioned within.
  • the helical tissue engaging devices 88 may be urged distally to extend from imaging hood 12 and each may be torqued from its proximal end to engage the underlying tissue T.
  • Each of the helical tissue engaging devices 88 maybe advanced through the length of deployment catheter 16 or they may be positioned within tubular support members 86 during the delivery and deployment of imaging hood 12. Once the procedure within imaging hood 12 is finished, each of the tissue engaging devices 88 may be disengaged from the tissue and the imaging hood 12 may be repositioned to another region of tissue or removed from the patient body.
  • the fluid delivery system 90 may generally comprise a pump 92 and an optional valve 94 for controlling the flow rate of the fluid into the system.
  • a fluid reservoir 96 fluidly connected to pump 92, may hold the fluid to be pumped through imaging hood 12.
  • An optional central processing unit or processor 98 may be in electrical communication with fluid delivery system 90 for controlling flow parameters such as the flow rate and/or velocity of the pumped fluid.
  • the processor 98 may also be in electrical communication with an image recorder and/or viewer 100 for directly viewing the images of tissue received from within imaging hood 12.
  • Imager recorder and/or viewer 100 may also be used not only to record the image but also the location of the viewed tissue region, if so desired.
  • processor 98 may also be utilized to coordinate the fluid flow and the image capture.
  • processor 98 may be programmed to provide for fluid flow from reservoir 96 until the tissue area has been displaced of blood to obtain a clear image. Once the image has been determined to be sufficiently clear, either visually by a practitioner or by computer, an image of the tissue may be captured automatically by recorder 100 and pump 92 may be automatically stopped or slowed by processor 98 to cease the fluid flow into the patient.
  • Other variations for fluid delivery and image capture are, of course, possible and the aforementioned configuration is intended only to be illustrative and not limiting.
  • Fig. 8B shows a further illustration of a hand-held variation of the fluid delivery and tissue mam ' pulation system 110.
  • system 110 may have a housing or handle assembly 112 which can be held or manipulated by the physician from outside the patient body.
  • the fluid reservoir 114 shown in this variation as a syringe, can be fluidly coupled to the handle assembly 112 and actuated via a pumping mechanism 116, e.g., lead screw.
  • Fluid reservoir 114 may be a simple reservoir separated from the handle assembly 112 and fluidly coupled to handle assembly 112 via one or more tubes. The fluid flow rate and other mechanisms may be metered by the electronic controller 118.
  • Deployment of imaging hood 12 may be actuated by a hood deployment switch 120 located on the handle assembly 112 while dispensation of the fluid from reservoir 114 may be actuated by a fluid deployment switch 122, which can be electrically coupled to the controller 118.
  • Controller 118 may also be electrically coupled to a wired or wireless antenna 124 optionally integrated with the handle assembly 112, as shown in the figure.
  • the wireless antenna 124 can be used to wirelessly transmit images captured from the imaging hood 12 to a receiver, e.g., via Bluetooth® wireless technology (Bluetooth SIG, Inc., Bellevue, WA), RP, etc., for viewing on a monitor 128 or for recording for later viewing.
  • Articulation control of the deployment catheter 16, or a delivery catheter or sheath 14 through which the deployment catheter 16 maybe delivered may be accomplished by computer control, as described above, in which case an additional controller may be utilized with handle assembly 112.
  • handle assembly 112 may incorporate one or more articulation controls 126 for manual manipulation of the position of deployment catheter 16.
  • Handle assembly 112 may also define one or more instrument ports 130 through which a number of intravascular tools may be passed for tissue manipulation and treatment within imaging hood 12, as described further below.
  • fluid or debris may be sucked into imaging hood 12 for evacuation from the patient body by optionally fluidly coupling a suction pump 132 to handle assembly 112 or directly to deployment catheter 16.
  • fluid may be pumped continuously into imaging hood 12 to provide for clear viewing of the underlying tissue.
  • fluid may be pumped temporarily or sporadically only until a clear view of the tissue is available to be imaged and recorded, at which point the fluid flow may cease and the blood may be allowed to seep or flow back into imaging hood 12.
  • Figs. 9A to 9C illustrate an example of capturing several images of the tissue at multiple regions.
  • Deployment catheter 16 may be desirably positioned and imaging hood 12 deployed and brought into position against a region of tissue to be imaged, in this example the tissue surrounding a mitral valve MV within the left atrium of a patient's heart.
  • the imaging hood 12 may be optionally anchored to the tissue, as described above, and then cleared by pumping the imaging fluid into the hood 12. Once sufficiently clear, the tissue may be visualized and the image captured by control electronics 118.
  • the first captured image 140 may be stored and/or transmitted wirelessly 124 to a monitor 128 for viewing by the physician, as shown in Fig. 9A.
  • the deployment catheter 16 may be then repositioned to an adjacent portion of mitral valve MV, as shown in Fig. 9B, where the process may be repeated to capture a second image 142 for viewing and/or recording.
  • the deployment catheter 16 may again be repositioned to another region of tissue, as shown in Fig. 9C, where a third image 144 may be captured for viewing and/or recording.
  • This procedure may be repeated as many times as necessary for capturing a comprehensive image of the tissue surrounding mitral valve MV, or any other tissue region.
  • the pump maybe stopped during positioning and blood or surrounding fluid may be allowed to enter within imaging hood 12 until the tissue is to be imaged, where the imaging hood 12 may be cleared, as above.
  • the fluid when the imaging hood 12 is cleared by pumping the imaging fluid within for clearing the blood or other bodily fluid, the fluid may be pumped continuously to maintain the imaging fluid within the hood 12 at a positive pressure or it may be pumped under computer control for slowing or stopping the fluid flow into the hood 12 upon detection of various parameters or until a clear image of the underlying tissue is obtained.
  • the control electronics 118 may also be programmed to coordinate the fluid flow into the imaging hood 12 with various physical parameters to maintain a clear image within imaging hood 12.
  • Fig. 1OA shows a chart 150 illustrating how fluid pressure within the imaging hood 12 may be coordinated with the surrounding blood pressure.
  • Chart 150 shows the cyclical blood pressure 156 alternating between diastolic pressure 152 and systolic pressure 154 over time T due to the beating motion of the patient heart.
  • the fluid pressure of the imaging fluid, indicated by plot 160, within imaging hood 12 may be automatically timed to correspond to the blood pressure changes 160 such that an increased pressure is maintained within imaging hood 12 which is consistently above the blood pressure 156 by a slight increase ⁇ P, as illustrated by the pressure difference at the peak systolic pressure 158.
  • This pressure difference, ⁇ P may be maintained within imaging hood 12 over the pressure variance of the surrounding blood pressure to maintain a positive imaging fluid pressure within imaging hood 12 to maintain a clear view of the underlying tissue.
  • One benefit of maintaining a constant ⁇ P is a constant flow and maintenance of a clear field.
  • Fig. 1OB shows a chart 162 illustrating another variation for maintaining a clear view of the underlying tissue where one or more sensors within the imaging hood 12, as described in further detail below, may be configured to sense pressure changes within the imaging hood 12 and to correspondingly increase the imaging fluid pressure within imaging hood 12. This may result in a time delay, ⁇ T, as illustrated by the shifted fluid pressure 160 relative to the cycling blood pressure 156, although the time delays ⁇ T may be negligible in maintaining the clear image of the underlying tissue.
  • Predictive software algorithms can also be used to substantially eliminate this time delay by predicting when the next pressure wave peak will arrive and by increasing the pressure ahead of the pressure wave's arrival by an amount of time equal to the aforementioned time delay to essentially cancel the time delay out.
  • imaging hood 12 The variations in fluid pressure within imaging hood 12 may be accomplished in part due to the nature of imaging hood 12.
  • An inflatable balloon which is conventionally utilized for imaging tissue, may be affected by the surrounding blood pressure changes.
  • an imaging hood 12 retains a constant volume therewithin and is structurally unaffected by the surrounding blood pressure changes, thus allowing for pressure increases therewithin.
  • the material that hood 12 is made from may also contribute to the manner in which the pressure is modulated within this hood 12.
  • a stiffer hood material, such as high durometer polyurethane or Nylon, may facilitate the maintaining of an open hood when deployed.
  • a relatively lower durometer or softer material such as a low durometer PVC or polyurethane, may collapse from the surrounding fluid pressure and may not adequately maintain a deployed or expanded hood.
  • Fig. 1 IA shows another variation comprising an additional imaging balloon 172 within an imaging hood 174.
  • an expandable balloon 172 having a translucent skin may be positioned within imaging hood 174.
  • Balloon 172 may be made froin any distensible biocompatible material having sufficient translucent properties which, allow for visualization therethrough.
  • balloon 172 may be filled with a fluid, such as saline, or less preferably a gas, until balloon 172 has been expanded until the blood has been sufficiently displaced.
  • the balloon 172 may thus be expanded proximal to or into contact against the tissue region to be viewed.
  • the balloon 172 can also be filled with contrast media to allow it to be viewed on fluoroscopy to aid in its positioning.
  • the imager, e.g., fiber optic, positioned within deployment catheter 170 may then be utilized to view the tissue region through the balloon 172 and any additional fluid which may be pumped into imaging hood 174 via one or more optional fluid ports 176, which may be positioned proximally of balloon 172 along a portion of deployment catheter 170.
  • balloon 172 may define one or more holes over its surface which allow for seepage or passage of the fluid contained therein to escape and displace the blood from within imaging hood 174.
  • Fig. 1 IB shows another alternative in which balloon 180 may be utilized alone.
  • Balloon 180, attached to deployment catheter 178 maybe filled with fluid, such as saline or contrast media, and is preferably allowed to come into direct contact with the tissue region to be imaged.
  • Fig. 12A shows another alternative in which deployment catheter 16 incorporates imaging hood 12, as above, and includes an additional flexible membrane 182 within imaging hood 12.
  • Flexible membrane 182 may be attached at a distal end of catheter 16 and optionally at contact edge 22.
  • Imaging hood 12 may be utilized, as above, and membrane 182 may be deployed from catheter 16 in vivo or prior to placing catheter 16 within a patient to reduce the volume within imaging hood 12. The volume may be reduced or minimized to reduce the amount of fluid dispensed for visualization or simply reduced depending upon the area of tissue to be visualized.
  • FIGs. 12B and 12C show yet another alternative in which imaging hood 186 may be withdrawn proximally within deployment catheter 184 or deployed distally from catheter 186, as shown, to vary the volume of imaging hood 186 and thus the volume of dispensed fluid.
  • Imaging hood 186 maybe seen in Fig. 12B as being partially deployed from, e.g., a circumferentially defined lumen within catheter 184, such as annular lumen 188. The underlying tissue may be visualized with imaging hood 186 only partially deployed.
  • imaging hood 186' maybe fully deployed, as shown in Fig. 12C, by urging hood 186' distally out from annular lumen 188.
  • FIGs. 13 A and 13B show perspective and cross-sectional side views, respectively, of yet another variation of imaging assembly which may utilize a fluid suction system for minimizing the amount of fluid injected into the patient's heart or other body lumen during tissue visualization.
  • Deployment catheter 190 in this variation may define an inner tubular member 196 which may be integrated with deployment catheter 190 or independently translatable. Fluid delivery lumen 198 defined through member 196 may be fluidly connected to imaging hood 192, which may also define one or more open channels 194 over its contact lip region.
  • Fluid pumped through fluid delivery lumen 198 may thus fill open area 202 to displace any blood or other fluids or objects therewithin. As the clear fluid is forced out of open area 202, it may be sucked or drawn immediately through one or more channels 194 and back into deployment catheter 190. Tubular member 196 may also define one or more additional working channels 200 for the passage of any tools or visualization devices. [0206] In deploying the imaging hood in the examples described herein, the imaging hood may take on any nmnber of configurations when positioned or configured for a low-profile delivery within the delivery catheter, as shown in the examples of Figs. 14Ato 14D. These examples are intended to be illustrative and are not intended to be limiting in scope. Fig.
  • FIG. 14A shows one example in which imaging hood 212 may be compressed within catheter 210 by folding hood 212 along a plurality of pleats.
  • Hood 212 may also comprise scaffolding or frame 214 made of a super-elastic or shape memory material or alloy, e.g., Nitinol, Elgiloy, shape memory polymers, electroactive polymers, or a spring stainless steel.
  • the shape memory material may act to expand or deploy imaging hood 212 into its expanded configuration when urged in the direction of the arrow from the constraints of catheter 210.
  • Fig. 14B shows another example in which imaging hood 216 may be expanded or deployed from catheter 210 from a folded and overlapping configuration.
  • Frame or scaffolding 214 may also be utilized in this example.
  • FIG. 14C shows yet another example in which imaging hood 218 may be rolled, inverted, or everted upon itself for deployment
  • Fig. 14D shows a configuration in which imaging hood 220 may be fabricated from an extremely compliant material which allows for hood 220 to be simply compressed into a low-profile shape. From this low-profile compressed shape, simply releasing hood 220 may allow for it to expand into its deployed configuration, especially if a scaffold or frame of a shape memory or superelastic material, e.g., Nitinol, is utilized in its construction.
  • a scaffold or frame of a shape memory or superelastic material e.g., Nitinol
  • helical frame 230 may be integrated with the imaging hood 12 membrane.
  • helical frame 230 may expand into a conical or tapered shape.
  • Helical frame 230 may alternatively be made out of heat-activated Nitinol to allow it to expand upon application of a current.
  • FIGs. 16 A and 16B show yet another variation in which imaging hood
  • hood support members 232 integrated with the hood membrane. These longitudinally attached support members 232 may be pivotably attached at their proximal ends to deployment catheter 16.
  • One or more pullwires 234 may be routed through the length of deployment catheter 16 and extend through one or more openings 238 defined in deployment catheter 16 proximally to imaging hood 12 into attachment with a corresponding support member 232 at a pullwire attachment point 236.
  • the support members 232 may be fabricated from a plastic or metal, such as stainless steel. Alternatively, the support members 232 may be made from a superelastic or shape memory alloy, such as Nitinol, which may self-expand into its deployed configuration without the use or need of pullwires.
  • a heat-activated Nitinol may also be used which expands upon the application of thermal energy or electrical energy.
  • support members 232 may also be constructed as inflatable lumens utilizing, e.g., PET balloons.
  • the one or more pullwires 234 may be tensioned from their proximal ends outside the patient body to pull a corresponding support member 232 into a deployed configuration, as shown in Fig. 16B, to expand imaging hood 12.
  • deployment catheter 16 may be pulled proximally into a constraining catheter or the pullwires 234 may be simply pushed distally to collapse imaging hood 12.
  • FIGs. 17A and 17B show yet another variation of imaging hood 240 having at least two or more longitudinally positioned support members 242 supporting the imaging hood membrane.
  • the support members 242 each have cross- support members 244 which extend diagonally between and are pivotably attached to the support members 242.
  • Each of the cross-support members 244 may be pivotably attached to one another where they intersect between the support members 242.
  • a jack or screw member 246 may be coupled to each cross-support member 244 at this intersection point and a torquing member, such as a torqueable wire 248, may be coupled to each jack or screw member 246 and extend proximally through deployment catheter 16 to outside the patient body.
  • the torqueable wires 248 may be torqued to turn the jack or screw member 246 which in turn urges the cross-support members 244 to angle relative to one another and thereby urge the support members 242 away from one another.
  • the imaging hood 240 maybe transitioned from its low-profile, shown in Fig. 17 A, to its expanded profile, shown in Fig. 17B, and back into its low-profile by torquing wires 248.
  • Figs. 18A and 18B show yet another variation on the imaging hood and its deployment.
  • a distal portion of deployment catheter 16 may have several pivoting members 250, e.g., two to four sections, which form a tubular shape in its low profile configuration, as shown in Fig. 18A.
  • pivoting members 250 When pivoted radially about deployment catheter 16, pivoting members 250 may open into a deployed configuration having distensible or expanding membranes 252 extending over the gaps in-between the pivoting members 250, as shown in Fig. 18B.
  • the distensible membrane 252 may be attached to the pivoting members 250 through various methods, e.g., adhesives, such that when the pivoting members 250 are fully extended into a conical shape, the pivoting members 250 and membrane 252 form a conical shape for use as an imaging hood.
  • the distensible membrane 252 may be made out of a porous material such as a mesh or PTFE or out of a translucent or transparent polymer such as polyurethane, PVC, Nylon, etc.
  • Figs. 19A and 19B show yet another variation where the distal portion of deployment catheter 16 may be fabricated from a flexible metallic or polymeric material to form a radially expanding hood 254.
  • a plurality of slots 256 may be formed in a uniform pattern over the distal portion of deployment catheter 16, as shown in Fig. 19 A.
  • the slots 256 may be formed in a pattern such that when the distal portion is urged radially open, utilizing any of the methods described above, a radially expanded and conically-shaped hood 254 may be formed by each of the slots 256 expanding into an opening, as shown in Fig. 19B.
  • a distensible membrane 258 may overlie the exterior surface or the interior surface of the hood 254 to form a fluid-impermeable hood 254 such that the hood 254 may be utilized as an imaging hood.
  • the distensible membrane 258 may alternatively be formed in each opening 258 to form the fluid-impermeable hood 254.
  • the imaging hood may be formed from a plurality of overlapping hood members 260 which overlie one another in an overlapping pattern.
  • each of the hood members 260 may extend radially outward relative to deployment catheter 16 to fomi a conically-shaped imaging hood, as shown in Fig. 2OB.
  • Adjacent hood members 260 may overlap one another along an overlapping interface 262 to form a fluid-retaining surface within the imaging hood.
  • the hood members 260 may be made from any number of biocompatible materials, e.g., Nitinol, stainless steel, polymers, etc., which are sufficiently strong to optionally retract surrounding tissue from the tissue region of interest.
  • the imaging hood may be alternatively configured to contact the tissue surface at an acute angle.
  • An imaging hood configured for such contact against tissue may also be especially suitable for contact against tissue surfaces having an unpredictable or uneven anatomical geography.
  • deployment catheter 270 may have an imaging hood 272 that is configured to be especially compliant.
  • imaging hood 272 may be comprised of one or more sections 274 that are configured to fold or collapse, e.g., by utilizing a pleated surface.
  • sections 274 when imaging hood 272 is contacted against uneven tissue surface T, sections 274 are able to conform closely against the tissue. These sections 274 may be individually collapsible by utilizing an accordion style construction to allow conformation, e.g., to the trabeculae in the heart or the uneven anatomy that may be found inside the various body lumens.
  • Fig. 22A shows another variation in which an imaging hood 282 is attached to deployment catheter 280.
  • the contact lip or edge 284 may comprise one or more electrical contacts 286 positioned circumferentially around contact edge 284.
  • the electrical contacts 286 may be configured to contact the tissue and indicate affirmatively whether tissue contact was achieved, e.g., by measuring the differential impedance between blood and tissue.
  • a processor e.g., processor 98, in electrical communication with contacts 286 may be configured to determine what type of tissue is in contact with electrical contacts 286.
  • the processor 98 may be configured to measure any electrical activity that may be occurring in the underlying tissue, e.g., accessory pathways, for the purposes of electrically mapping the cardiac tissue and subsequently treating, as described below, any arrhythmias which maybe detected.
  • Fig. 22B Another variation for ensuring contact between imaging hood 282 and the underlying tissue may be seen in Fig. 22B. This variation may have an inflatable contact edge 288 around the circumference of imaging hood 282. The inflatable contact edge 288 may be inflated with a fluid or gas through inflation lumen 289 when the imaging hood 282 is to be placed against a tissue surface having an uneven or varied anatomy.
  • the inflated circumferential surface 288 may provide for continuous contact over the hood edge by confo ⁇ ning against the tissue surface and facilitating imaging fluid retention within hood 282.
  • various instrumentation may be utilized with the imaging and manipulation system. For instance, after the field within imaging hood 12 has been cleared of the opaque blood and the underlying tissue is visualized through the clear fluid, blood may seep back into the imaging hood 12 and obstruct the view.
  • One method for automatically maintaining a clear imaging field may utilize a transducer, e.g., an ultrasonic transducer 290, positioned at the distal end of deployment catheter within the imaging hood 12, as shown in Fig. 23.
  • the transducer 290 may send an energy pulse 292 into the imaging hood 12 and wait to detect back-scattered energy 294 reflected from debris or blood within the imaging hood 12. If back-scattered energy is detected, the pump may be actuated automatically to dispense more fluid into the imaging hood until the debris or blood is no longer detected.
  • sensors 300 may be positioned on the imaging hood 12 itself, as shown in Fig. 24A, to detect a number of different parameters.
  • sensors 300 may be configured to detect for the presence of oxygen in the surrounding blood, blood and/or imaging fluid pressure, color of the fluid within the imaging hood, etc. Fluid color may be particularly useful in detecting the presence of blood within the imaging hood 12 by utilizing a reflective type sensor to detect back reflection from blood. Any reflected light from blood which may be present within imaging hood 12 may be optically or electrically transmitted through deployment catheter 16 and to a red colored filter within control electronics 118. Any red color which may be detected may indicate the presence of blood and trigger a signal to the physician or automatically actuate the pump to dispense more fluid into the imaging hood 12 to clear the blood.
  • Alternative methods for detecting the presence of blood within the hood 12 may include detecting transmitted light through the imaging fluid within imaging hood 12. If a source of white light, e.g., utilizing LEDs or optical fibers, is illuminated inside imaging hood 12, the presence of blood may cause the color red to be filtered through this fluid. The degree or intensity of the red color detected may correspond to the amount of blood present within imaging hood 12.
  • a red color sensor can simply comprise, in one variation, a phototransistor with a red transmitting filter over it which can establish how much red light is detected, which in turn can indicate the presence of blood within imaging hood 12. Once blood is detected, the system may pump more clearing fluid through and enable closed loop feedback control of the clearing fluid pressure and flow level.
  • any number of sensors may be positioned along the exterior 302 of imaging hood 12 or within the interior 304 of imaging hood 12 to detect parameters not only exteriorly to imaging hood 12 but also within imaging hood 12. Such a configuration, as shown in Fig. 24B, may be particularly useful for automatically maintaining a clear imaging field based upon physical parameters such as blood pressure, as described above for Figs. 1OA and 1OB.
  • one or more light emitting diodes may be utilized to provide lighting within the imaging hood 12. Although illumination may be provided by optical fibers routed through deployment catheter 16, the use of LEDs over the imaging hood 12 may eliminate the need for additional optical fibers for providing illumination.
  • the electrical wires connected to the one or more LEDs may be routed through or over the hood 12 and along an exterior surface or extruded within deployment catheter 16.
  • One or more LEDs may be positioned in a circumferential pattern 306 around imaging hood 12, as shown in Fig. 25A, or in a linear longitudinal pattern 308 along imaging hood 12, as shown in Fig. 25B.
  • Other patterns, such as a helical or spiral pattern, may also be utilized.
  • LEDs may be positioned along a support member forming part of imaging hood 12.
  • a separate illumination tool 310 may be utilized, as shown in Fig. 26A.
  • An example of such a tool may comprise a flexible intravascular delivery member 312 having a carrier member 314 pivotably connected 316 to a distal end of delivery member 312.
  • One or more LEDs 318 may be mounted along carrier member 314.
  • delivery member 312 maybe advanced through deployment catheter 16 until carrier member 314 is positioned within imaging hood 12.
  • carrier member 314 may be pivoted in any number of directions to facilitate or optimize the illumination within the imaging hood 12, as shown in Fig. 26B.
  • the LEDs may comprise a single LED color, e.g., white light.
  • LEDs of other colors e.g., red, blue, yellow, etc.
  • sources of infrared or ultraviolet light may be employed to enable imaging beneath the tissue surface or cause fluorescence of tissue for use in system guidance, diagnosis, or therapy.
  • the imaging assembly may also be utilized to provide a therapeutic platform for treating tissue being visualized.
  • deployment catheter 320 may have imaging hood 322, as described above, and fluid delivery lumen 324 and imaging lumen 326.
  • a therapeutic tool such as needle 328 may be delivered through fluid delivery lumen 324 or in another working lumen and advanced through open area 332 for treating the tissue which is visualized.
  • needle 328 may define one or several ports 330 for delivering drugs therethrough.
  • needle 328 may be advanced and pierced into the underlying tissue where a therapeutic agent may be delivered through ports 330.
  • Fig. 28 shows another alternative in which deployment catheter 340 may have imaging hood 342 attached thereto, as above, but with a therapeutic tool 344 in the configuration of a helical tissue piercing device 344. Also shown and described above in Figs. 7A and 7B for use in stabilizing the imaging hood relative to the underlying tissue, the helical tissue piercing device 344 may also be utilized to manipulate the tissue for a variety of therapeutic procedures.
  • the helical portion 346 may also define one or several ports for delivery of therapeutic agents therethrough.
  • Fig. 29 shows a deployment catheter 350 having an expandable imaging balloon 352 filled with, e.g., saline 356.
  • a therapeutic tool 344 as above, may be translatable relative to balloon 352.
  • a stop 354 maybe formed on balloon 352 to prevent the proximal passage of portion 346 past stop 354.
  • FIG. 3OA shows one variation of an angled instrument 360, such as a tissue grasper, which maybe configured to have an elongate shaft for intravascular delivery through deployment catheter 16 with a distal end which may be angled relative to its elongate shaft upon deployment into imaging hood 12.
  • the elongate shaft may be configured to angle itself automatically, e.g., by the elongate shaft being made at least partially from a shape memory alloy, or upon actuation, e.g., by tensioning a pullwire.
  • Fig. 3OB shows another configuration for an instrument 362 being configured to reconfigure its distal portion into an off-axis configuration within imaging hood 12. In either case, the instruments 360, 362 may be reconfigured into a low-profile shape upon withdrawing them proximally back into deployment catheter 16.
  • Fig. 3 IA shows a probe 370 having a distal end effector 372, which may be reconfigured from a low- profile shape to a curved profile.
  • the end effector 372 may be configured as an ablation probe utilizing radio-frequency energy, microwave energy, ultrasound energy, laser energy or even cryo-ablation. Alternatively, the end effector 372 may have several electrodes upon it for detecting or mapping electrical signals transmitted through the underlying tissue.
  • an additional temperature sensor such as a thermocouple or thermistor 374 positioned upon an elongate member 376 may be advanced into the imaging hood 12 adjacent to the distal end effector 372 for contacting and monitoring a temperature of the ablated tissue.
  • Fig. 3 IB shows an example in the end view of one configuration for the distal end effector 372 which may be simply angled into a perpendicular configuration for contacting the tissue.
  • Fig. 31C shows another example where the end effector may be reconfigured into a curved end effector 378 for increased tissue contact.
  • Figs. 32A and 32B show another variation of an ablation tool utilized with an imaging hood 12 having an enclosed bottom portion.
  • an ablation probe such as a cryo-ablation probe 380 having a distal end effector 382 may be positioned through the imaging hood 12 such that the end effector 382 is placed distally of a transparent membrane or enclosure 384, as shown in the end view of Fig. 32B.
  • the shaft of probe 380 may pass through an opening 386 defined through the membrane 384.
  • the clear fluid may be pumped into imaging hood 12, as described above, and the distal end effector 382 may be placed against a tissue region to be ablated with the imaging hood 12 and the membrane 384 positioned atop or adjacent to the ablated tissue.
  • the imaging fluid may be warmed prior to dispensing into the imaging hood 12 such that the tissue contacted by the membrane 384 may be warmed during the cryo-ablation procedure.
  • the fluid dispensed into the imaging hood 12 may be cooled such that the tissue contacted by the membrane 384 and adjacent to the ablation probe during the ablation procedure is likewise cooled.
  • the imaging fluid may be varied in its temperature to facilitate various procedures to be performed upon the tissue.
  • the imaging fluid itself may be altered to facilitate various procedures.
  • a deployment catheter 16 and imaging hood 12 may be advanced within a hollow body organ, such as a bladder filled with urine 394, towards a lesion or tumor 392 on the bladder wall.
  • the imaging hood 12 may be placed entirely over the lesion 392, or over a portion of the lesion.
  • a cryo-fluid i.e., a fluid which has been cooled to below freezing temperatures of, e.g., water or blood, may be pumped into the imaging hood 12 to cryo-ablate the lesion 390, as shown in Fig. 33B while avoiding the creation of ice on the instrument or surface of tissue.
  • the fluid may be warmed naturally by the patient body and ultimately removed.
  • the cryo-fluid may be a colorless and translucent fluid which enables visualization therethrough of the underlying tissue.
  • An example of such a fluid is FluorinertTM (3M, St. Paul, MN), which is a colorless and odorless perfluorinated liquid.
  • FluorinertTM 3M, St. Paul, MN
  • the use of a liquid such as FluorinertTM enables the cryo-ablation procedure without the formation of ice within or outside of the imaging hood 12.
  • hyperthermic treatments may also be effected by heating the FluorinertTM liquid to elevated temperatures for ablating the lesion 392 within the imaging hood 12.
  • FluorinertTM may be utilized in various other parts of the body, such as within the heart.
  • Fig. 34A shows another variation of an instrument which may be utilized with the imaging system.
  • a laser ring generator 400 may be passed through the deployment catheter 16 and partially into imaging hood 12.
  • a laser ring generator 400 is typically used to create a circular ring of laser energy 402 for generating a conduction block around the pulmonary veins typically in the treatment of atrial fibrillation.
  • the circular ring of laser energy 402 may be generated such that a diameter of the ring 402 is contained within a diameter of the imaging hood 12 to allow for tissue ablation directly upon tissue being imaged.
  • Signals which cause atrial fibrillation typically come from the entry area of the pulmonary veins into the left atrium and treatments may sometimes include delivering ablation energy to the ostia of the pulmonary veins within the atrium.
  • the ablated areas of the tissue may produce a circular scar which blocks the impulses for atrial fibrillation.
  • it may be generally desirable to maintain the integrity and health of the tissue overlying the surface while ablating the underlying tissue. This may be accomplished, for example, by cooling the imaging fluid to a temperature below the body temperature of the patient but which is above the freezing point of blood (e.g., 2° C to 35° C).
  • the cooled imaging fluid may thus maintain the surface tissue at the cooled fluid temperature while the deeper underlying tissue remains at the patient body temperature.
  • the laser energy or other types of energy such as radio frequency energy, microwave energy, ultrasound energy, etc.
  • both the cooled tissue surface as well as the deeper underlying tissue will rise in temperature uniformly.
  • the deeper underlying tissue, which was maintained at the body temperature will increase to temperatures which are sufficiently high to destroy the underlying tissue.
  • the temperature of the cooled surface tissue will also rise but only to temperatures that are near body temperature or slightly above.
  • one example for treatment may include passing deployment catheter 16 across the atrial septum AS and into the left atrium LA of the patient's heart H.
  • the imaging hood 12 and laser ring generator 400 may be positioned adjacent to or over one or more of the ostium OT of the pulmonary veins PV and the laser generator 400 may ablate the tissue around the ostium OT with the circular ring of laser energy 402 to create a conduction block. Once one or more of the tissue around the ostium OT have been ablated, the imaging hood 12 may be reconfigured into a low profile for removal from the patient heart H. [0236]
  • One of the difficulties in treating tissue in or around the ostium OT is the dynamic fluid flow of blood through the ostium OT. The dynamic forces make cannulation or entry of the ostium OT difficult.
  • an extendible cannula 410 having a cannula lumen 412 defined therethrough, as shown in Fig. 35 A.
  • the extendible cannula 410 may generally comprise an elongate tubular member which may be positioned within the deployment catheter 16 during delivery and then projected distally through the imaging hood 12 and optionally beyond, as shown in Fig. 35B.
  • the imaging hood 12 has been desirably positioned relative to the tissue, e.g., as shown in Fig.
  • the extendible cannula 410 may be projected distally from the deployment catheter 16 while optionally imaging the tissue through the imaging hood 12, as described above.
  • the extendible cannula 410 may be projected distally until its distal end is extended at least partially into the ostium OT.
  • an instrument or energy ablation device may be extended through and out of the cannula lumen 412 for treatment within the ostium OT.
  • the cannula 410 may be withdrawn proximally and removed from the patient body.
  • the extendible cannula 410 may also include an inflatable occlusion balloon at or near its distal end to block the blood flow out of the PV to maintain a clear view of the tissue region.
  • the extendible cannula 410 may define a lumen therethrough beyond the occlusion balloon to bypass at least a portion of the blood that normally exits the pulmonary vein PV by directing the blood through the cannula 410 to exit proximal of the imaging hood.
  • imaging hood 12 may have one or more tubular support members 420 integrated with the hood 12.
  • Each of the tubular support members 420 may define an access lumen 422 through which one or more instruments or tools may be delivered for treatment upon the underlying tissue.
  • One particular example is shown and described above for Fig. 1C.
  • Various methods and instruments may be utilized for using or facilitating the use of the system. For instance, one method may include facilitating the initial delivery and placement of a device into the patient's heart.
  • a separate guiding probe 430 may be utilized, as shown in Figs. 37A and 37B.
  • Guiding probe 430 may, for example, comprise an optical fiber through which a light source 434 may be used to illuminate a distal tip portion 432.
  • the tip portion 432 may be advanced into the heart through, e.g., the coronary sinus CS, until the tip is positioned adjacent to the mitral valve MV.
  • the tip 432 may be illuminated, as shown in Fig. 37A, and imaging assembly 10 may then be guided towards the illuminated tip 432, which is visible from within the atrial chamber, towards mitral valve MV.
  • the imaging system may be utilized to facilitate various other procedures.
  • the imaging hood of the device in particular may be utilized.
  • a collapsible membrane or disk-shaped member 440 may be temporarily secured around the contact edge or lip of imaging hood 12.
  • the imaging hood 12 and the attached member 440 may both be in a collapsed configuration to maintain a low profile for delivery.
  • both the imaging hood 12 and the member 440 may extend into their expanded configurations.
  • the disk-shaped member 440 may be comprised of a variety of materials depending upon the application.
  • member 440 may be fabricated from a porous polymeric material infused with a drug eluting medicament 442 for implantation against a tissue surface for slow infusion of the medicament into the underlying tissue.
  • the member 440 may be fabricated from a non- porous material, e.g., metal or polymer, for implantation and closure of a wound or over a cavity to prevent fluid leakage.
  • the member 440 maybe made from a distensible material which is secured to imaging hood 12 in an expanded condition. Once implanted or secured on a tissue surface or wound, the expanded member 440 may be released from imaging hood 12. Upon release, the expanded member 440 may shrink to a smaller size while approximating the attached underlying tissue, e.g., to close a wound or opening.
  • One method for securing the disk-shaped member 440 to a tissue surface may include a plurality of tissue anchors 444, e.g., barbs, hooks, projections, etc., which are attached to a surface of the member 440.
  • Other methods of attachments may include adhesives, suturing, etc. hi use, as shown in Figs. 39A to 39C, the imaging hood 12 may be deployed in its expanded configuration with member 440 attached thereto with the plurality of tissue anchors 444 projecting distally.
  • the tissue anchors 444 may be urged into a tissue region to be treated 446, as seen in Fig. 39A, until the anchors 444 are secured in the tissue and member 440 is positioned directly against the tissue, as shown in Fig. 39B.
  • a pullwire may be actuated to release the member 440 from the imaging hood 12 and deployment catheter 16 may be withdrawn proximally to leave member 440 secured against the tissue 446.
  • FIG. 4OA illustrates an imaging hood 12 having a deployable anchor assembly 450 attached to the tissue contact edge 22.
  • Fig. 4OB illustrates the anchor assembly 450 detached from the imaging hood 12 for clarity.
  • the anchor assembly 450 may be seen as having a plurality of discrete tissue anchors 456, e.g., barbs, hooks, projections, etc., each having a suture retaining end, e.g., an eyelet or opening 458 in a proximal end of the anchors 456.
  • a suture member or wire 452 may be slidingly connected to each anchor 456 through the openings 458 and through a cinching element 454, which may be configured to slide uni-directionally over the suture or wire 452 to approximate each of the anchors 456 towards one another.
  • Each of the anchors 456 may be temporarily attached to the imaging hood 12 through a variety of methods. For instance, a pullwire or retaining wire may hold each of the anchors within a receiving ring around the circumference of the imaging hood 12. When the anchors 456 are released, the pullwire or retaining wire may be tensioned from its proximal end outside the patient body to thereby free the anchors 456 from the imaging hood 12.
  • the deployment catheter 16 and imaging hood 12 may be delivered intravascularly into, e.g., a patient heart. As the imaging hood 12 is deployed into its expanded configuration, the imaging hood 12 may be positioned adjacent to the opening or wound 460, as shown in Fig. 41 A. With the anchor assembly 450 positioned upon the expanded imaging hood 12, deployment catheter 16 may be directed to urge the contact edge of imaging hood 12 and anchor assembly 450 into the region surrounding the tissue opening 460, as shown in Fig. 41B.
  • the anchors may be released from imaging hood 12 leaving the anchor assembly 450 and suture member 452 trailing from the anchors, as shown in Fig. 41C.
  • the suture or wire member 452 may be tightened by pulling it proximally from outside the patient body to approximate the anchors of anchor assembly 450 towards one another in a purse- string manner to close the tissue opening 462, as shown in Fig. 41D.
  • the cinching element 454 may also be pushed distally over the suture or wire member 452 to prevent the approximated anchor assembly 450 from loosening or widening.
  • FIG. 43A and 43B show a variation of the deployment catheter 480 having a first deployable hood 482 and a second deployable hood 484 positioned distal to the first hood 482.
  • the deployment catheter 480 may also have a side- viewing imaging element 486 positioned between the first and second hoods 482, 484 along the length of the deployment catheter 480.
  • such a device may be introduced through a lumen 488 of a vessel VS, where one or both hoods 482, 484 may be expanded to gently contact the surrounding walls of vessel VS.
  • the clear imaging fluid may be pumped in the space defined between the hoods 482, 484 to displace any blood and to create an imaging space 490, as shown in Fig. 43 B.
  • the imaging element 486 may be used to view the surrounding tissue surface contained between hoods 482, 484.
  • Other instruments or tools may be passed through deployment catheter 480 and through one or more openings defined along the catheter 480 for additionally performing therapeutic procedures upon the vessel wall.
  • FIG. 44A to 45B Another variation of a deployment catheter 500 which may be used for imaging tissue to the side of the instrument may be seen in Figs. 44A to 45B.
  • Figs. 44A and 44B show side and end views of deployment catheter 500 having a side- imaging balloon 502 in an un-inflated low-profile configuration.
  • a side-imaging element 504 may be positioned within a distal portion of the catheter 500 where the balloon 502 is disposed.
  • balloon 502 When balloon 502 is inflated, it may expand radially to contact the surrounding tissue, but where the imaging element 504 is located, a visualization field 506 may be created by the balloon 502, as shown in the side, top, and end views of Figs. 45 A to 45B, respectively.
  • the visualization field 506 may simply be a cavity or channel which is defined within the inflated balloon 502 such that the visualization element 504 is provided an image of the area within field 506 which is clear and unobstructed by balloon 502.
  • deployment catheter 500 may be advanced intravascularly through vessel lumen 488 towards a lesion or tumor 508 to be visualized and/or treated. Upon reaching the lesion 508, deployment catheter 500 may be positioned adjacently to the lesion 508 and balloon 502 may be inflated such that the lesion 508 is contained within the visualization field 506.
  • balloon 502 Once balloon 502 is fully inflated and in contact against the vessel wall, clear fluid may be pumped into visualization field 506 through deployment catheter 500 to displace any blood or opaque fluids from the field 506, as shown in the side and end views of Figs. 46A and 46B, respectively.
  • the lesion 508 may then be visually inspected and treated by passing any number of instruments through deployment catheter 500 and into field 506.
  • the various assemblies may be configured in particular for treating conditions such as atrial fibrillation while under direct visualization.
  • the devices and assemblies may be configured to facilitate the application of energy to the underlying tissue in a controlled manner while directly visualizing the tissue to monitor as well as confirm appropriate treatment.
  • the imaging and manipulation assembly maybe advanced intravascularly into the patient's heart H, e.g., through the inferior vena cava IVC and into the right atrium RA, as shown in Figs. 47 A and 47B.
  • hood 12 may be deployed and positioned against the atrial septum AS and the hood 12 may be infused with saline to clear the blood from within to view the underlying tissue surface, as described above.
  • Hood 12 may be further manipulated or articulated into a desirable location along the tissue wall, e.g., over the fossa ovalis FO, for puncturing through to the left atrium LA, as shown in Fig. 47C.
  • hood 12 has been desirably positioned over the fossa ovalis
  • a piercing instrument 510 e.g., a hollow needle, may be advanced from catheter 16 and through hood 12 to pierce through the atrial septum AS until the left atrium LA has been accessed, as shown in Fig. 47D.
  • a guidewire 17 may then be advanced through the piercing instrument 510 and introduced into the left atrium LA, where it may be further advanced into one of the pulmonary veins PV, as shown in Fig. 47E. With the guidewire 17 crossing the atrial septum AS into the left atrium LA, the piercing instrument 510 may be withdrawn, as shown in Fig.
  • hood 12 may be further retracted into its low profile configuration and catheter 16 and sheath 14 may be optionally withdrawn as well while leaving the guidewire 17 in place crossing the atrial septum AS, as shown in Fig. 47G.
  • catheter 16 and sheath 14 may be optionally withdrawn as well while leaving the guidewire 17 in place crossing the atrial septum AS, as shown in Fig. 47G.
  • FIG. 47G Although one example is illustrated for crossing through the septal wall while under direct visualization, alternative methods and devices for transseptal access are shown and described in further detail in commonly owned U.S. Pat. App. 11/763,399 filed June 14, 2007, which is incorporated herein by reference in its entirety. Those transseptal access methods and devices may be fully utilized with the methods and devices described herein, as practicable.
  • an optional dilator 512 may be advanced through sheath 14 and along guidewire 17, as shown in Fig. 47H, where it may be used to dilate the transseptal puncture through the atrial septum AS to allow for other instruments to be advanced transseptally into the left atrium LA, as shown in Fig. 471.
  • hood 12 With the transseptal opening dilated, hood 12 in its low profile configuration and catheter 16 may be re-introduced through sheath 16 over guidewire 17 and advanced transseptally into the left atrium LA, as shown in Fig. 47J.
  • guidewire 17 may be withdrawn prior to or after introduction of hood 12 into the left atrium LA.
  • deployment catheter 16 and/or hood 12 may be articulated to be placed into contact with or over the ostia of the pulmonary veins PV, as shown in Fig. 47L.
  • the open area within hood 12 maybe cleared of blood with the translucent or transparent fluid for directly visualizing the underlying tissue such that the tissue may be ablated, as indicated by the circumferentially ablated tissue 514 about the ostium of the pulmonary veins shown in Fig. 47M.
  • hood 12 may be used to visually confirm that the appropriate regions of tissue have been ablated and/or that the tissue has been sufficiently ablated. Visual monitoring and confirmation may be accomplished in real-time during a procedure or after the procedure has been completed. Additionally, hood 12 may be utilized postoperatively to image tissue which has been ablated in a previous procedure to determine whether appropriate tissue ablation had been accomplished. In the partial cross-sectional views of Figs.
  • hood 12 is shown advanced into the left atrium LA to examine discontiguous lesions 520 which have been made around an ostium of a pulmonary vein PV. If desired or determined to be necessary, the untreated tissue may be further ablated under direct visualization utilizing hood 12.
  • an ablation probe 534 having at least one ablation electrode 536 utilizing, e.g., radio-frequency (RP), microwave, ultrasound, laser, cryo-ablation, etc. may be advanced through deployment catheter 16 and into the open area 26 of hood 12, as shown in the perspective view of Fig. 49 A.
  • RP radio-frequency
  • Hood 12 is also shown with several support struts 530 extending longitudinally along hood 12 to provide structural support as well as to provide a platform upon which imaging element 532 may be positioned.
  • imaging element 532 may comprise a number of imaging devices, such as optical fibers or electronic imagers such as CCD or CMOS imagining elements. In either case, imaging element 532 may be positioned along a support strut 530 off-axis relative to a longitudinal axis of catheter 16 such that element 532 is angled to provide a visual field of the underlying tissue and ablation probe 536.
  • Figs. 49B and 49C show side and perspective views, respectively, of hood 12 placed against a tissue region T to be treated where the translucent or transparent displacing fluid 538 is injected into the open area 26 of hood 12 to displace the blood therewithin. While under direct visualization from imaging element 532, the blood may be displaced with the clear fluid to allow for inspection of the tissue T, whereupon ablation probe 536 may be activated and/or optionally angled to contact the underlying tissue for treatment.
  • Fig. 5OA shows a perspective view of a variation of the ablation probe where a distal end effector 542 of the probe 540 may be angled along pivoting hinge 544 from a longitudinal low-profile configuration to a right-angled straight electrode to provide for linear transmural lesions.
  • Probe 540 is similarly configured to the variation shown in Figs. 3 IA and 3 IB above. Utilizing this configuration, an entire line of tissue can be ablated simultaneously rather than a spot of tissue being ablated.
  • Fig. 5OB shows another variation where an ablation probe 546 may be configured to have a circularly-shaped ablation end effector 548 which circumscribes the opening of hood 12. This particular variation is also similarly configured to the variation shown above in Fig. 31C.
  • the diameter of the probe 548 may be varied and other circular or elliptical configurations, as well as partially circular configurations, may be utilized to provide for the ablation of an entire ring of tissue
  • the saline flow from the hood 12 can be controlled such that the saline is injected over the heated electrodes after every ablation process to cool the electrodes. This is a safety measure which may be optionally implemented to prevent a heated electrode from undesirably ablating other regions of the tissue inadvertently.
  • Fig. 51A shows an embodiment of hood 12 having an expandable distal membrane 550 covering the open area of hood 12.
  • a circularly- shaped RF electrode end effector 552 having electrodes 554 spaced between insulating sections 556 may be coated or otherwise disposed, e.g., by chemical vapor deposition or any other suitable process, circumferentially around the expandable distal membrane 550.
  • the electrode end effector 552 may be energized by an external power source which is in electrical communication by wires 558.
  • electrode end effector 552 may be retractable into the work channels of deployment catheter 16.
  • Imaging element 532 may be attached to a support strut of the hood 12 to provide the visualization during the ablation process, as described above, for viewing through the clear fluid infused within hood 12.
  • Fig. 5 IB shows a similar variation where an inflatable balloon 560 is utilized and hood 12 has been omitted entirely, hi this case, electrode end effector 552 may be disposed circumferentially over the balloon distal end in a similar manner.
  • circular transmural lesions may be created by inflating infusing saline into hood 12 to extend membrane 550 or directly into balloon 560 such that pressure may be exerted upon the contacted target tissue, such as the pulmonary ostia area, by the end effector 552 which may then be energized to channel energy to the ablated tissue for lesion formation.
  • the amount of power delivered to each electrode end effector 552 can be varied and controlled to enable the operator to ablate areas where different segments of the tissue may have different thicknesses, hence requiring different amounts of power to create a lesion.
  • FIG. 52 illustrates a perspective view of another variation having a circularly-shaped electrode end effector 570 with electrodes 572 spaced between insulating sections 574 and disposed circumferentially around the contact lip or edge of hood 12.
  • This variation is similar to the configuration shown above in Fig. 22 A.
  • electrode end effector 570 in this variation may be utilized to contact the tissue and to create circularly-shaped lesions around the target tissue.
  • the hood 12 may have an open field which is uncovered and clear to provide direct tissue contact between the hood interior and the underlying tissue to effect any number of treatments upon the tissue, as described above.
  • imaging hood 12 may utilize other configurations, as also described above.
  • An additional variation of the imaging hood 12 is shown in the perspective and side views, respectively, of Figs. 53 A and 53B, where imaging hood 12 includes at least one layer of a transparent elastomeric membrane 580 over the distal opening of hood 12.
  • An aperture 582 having a diameter which is less than a diameter of the outer lip of imaging hood 12 may be defined over the center of membrane 580 where a longitudinal axis of the hood intersects the membrane such that the interior of hood 12 remains open and in fluid communication with the environment external to hood 12.
  • aperture 582 may be sized, e.g., between 1 to 2 mm or more in diameter and membrane 580 be made from any number of transparent elastomers such as silicone, polyurethane, latex, etc. such that contacted tissue may also be visualized through membrane 580 as well as through aperture 582.
  • Aperture 582 may function generally as a restricting passageway to reduce the rate of fluid out-flow from the hood 12 when the interior of the hood 12 is infused with the clear fluid through which underlying tissue regions maybe visualized. Aside from restricting out-flow of clear fluid from within hood 12, aperture 582 may also restrict external surrounding fluids from entering hood 12 too rapidly.
  • aperture 582 may be aligned with catheter 16 such that any instruments (e.g., piercing instruments, guidewires, tissue engagers, etc.) that are advanced into the hood interior may directly access the underlying tissue uninhibited or unrestricted for treatment through aperture 582. In other variations wherein aperture 582 may not be aligned with catheter 16, instruments passed through catheter 16 may still access the underlying tissue by simply piercing through membrane 580.
  • Fig. 54A shows yet another variation where a single RF ablation probe
  • first half 592 and second half 594 may open up laterally via a hinged pivot 602 into a "Y" configuration to expose an ablation electrode strip 596 connected at attachment points 598, 600 to halves 592, 594, respectively and as shown in the perspective view of Fig. 54B.
  • Tension is created along the axis of the electrode strip 596 to maintain its linear configuration. Linear transmural lesion ablation may be then accomplished by channeling energy from the RF electrode to the target tissue surface in contact while visualized within hood 12.
  • Figs. 55 A and 55B illustrate perspective views of another variation where a laser probe 610, e.g., an optical fiber bundle coupled to a laser generator, may be inserted through the work channel of the tissue visualization catheter.
  • laser energy 612 maybe channeled through probe 610 and applied to the underlying tissue T at different angles 612' to form a variety of lesion patterns, as shown in Fig. 55C.
  • occluding the blood flow through the pulmonary veins PV may facilitate the visualization and stabilization of hood 12 with respect to the tissue, particularly when applying ablation energy.
  • guidewire 17 may be advanced into the pulmonary vein PV to be treated.
  • An expandable occlusion balloon 620 either advanced over guidewire 17 or carried directly upon guidewire 17, may be advanced into the pulmonary vein PV distal to the region of tissue to be treated where it may then be expanded into contact with the walls of the pulmonary vein PV, as shown in Fig. 56.
  • occlusion balloon 620 With occlusion balloon 620 expanded, the vessel may be occluded and blood flow temporarily halted from entering the left atrium LA. Hood 12 may then be positioned along or around the ostium OT and the contained space encompassed between the hood 12 and occlusion balloon 620 may be infused with the clear fluid 528 to create a cleared visualization area 622 within which the ostium OT and surrounding tissue may be visualized via imaging element 532 and accordingly treated using any of the ablation instruments described herein, as practicable.
  • Fig. 57 shows a perspective view of hood 12 with a first tissue grasping support member 630 having a first tissue grasper 634 positioned at a distal end of member 630.
  • a distal portion of member 630 may be angled via first angled or curved portion 632 to allow for tissue grasper 634 to more directly approach and adhere onto the tissue surface.
  • second tissue grasping support member 636 may extend through hood 12 with second angled or curved portion 638 and second tissue grasper 640 positioned at a distal end of member 638.
  • first and second tissue graspers 634, 640 maybe deployed and advanced distally of hood 12.
  • First tissue grasper 634 may be advanced into contact with a first tissue region adjacent to the ostium OT and torqued until grasper 634 is engaged to the tissue, as shown in Fig. 58 A.
  • second tissue grasper 640 may be moved and positioned against a tissue region adjacent to first tissue grasper 636 where it may then be torqued and temporarily adhered to the tissue, as shown in Fig. 58B.
  • first grasper 636 may be released from the tissue and hood 12 and first tissue grasper 636 may be angled to another region of tissue utilizing first second grasper 640 as a pivoting point to facilitate movement of hood 12 along the tissue wall, as shown in Fig. 58C. This process may be repeated as many times as desired until hood 12 has been positioned along a tissue region to be treated or inspected.
  • FIG. 59 shows another view illustrating first tissue grasper 634 extended from hood 12 and temporarily engaged onto the tissue adjacent to the pulmonary vein, specifically the right inferior pulmonary vein PV RI which is generally difficult to access in particular because of its close proximity and tight angle relative to the transseptal point of entry through the atrial septum AS into the left atrium LA.
  • catheter 16 retroflexed to point hood 12 generally in the direction of the right inferior pulmonary vein PV RI and with first tissue grasper 634 engaged onto the tissue, hood 12 and deployment catheter 16 may be approximated towards the right inferior pulmonary vein ostium with the help of the grasper 634 to inspect and/or treat the tissue.
  • tissue visualization catheter to access the left atrium LA of the heart H to inspect and/or treat the areas around the pulmonary veins PV.
  • deployment catheter 16 may be advanced through the aorta AO, through the aortic valve AV and into the left ventricle LV, through the mitral valve MV and into the left atrium LA.
  • a helical tissue grasper 84 may be extended through hood 12 and into contact against the desired tissue region to facilitate inspection and/or treatment.
  • the first tissue grasper 634 can be used optionally to loop a length of wire or suture 650 affixed to one end of hood 12 and through the secured end of the first grasper 634, as shown in Fig. 61A.
  • the suture 650, routed through catheter 16, can be subsequently pulled from its proximal end from outside the patient body (as indicated by the direction of tension 652) to provide additional pulling strength for the catheter 16 to move distally along the length of member 630 like a pulley system (as indicated by the direction of hood movement 654, as illustrated in Fig. 61B.
  • Figs. 61C and 61D further illustrate the tightly-angled configuration which catheter 16 and hood 12 must conform to and the relative movement of tensioned suture 650 with the resulting direction of movement 654 of hood 12 into position against the ostium OT.
  • the hood 12 may also provide additional pressure on the target tissue to provide a better seal between the hood 12 and the tissue surface.
  • Fig. 62A shows sheath 14 positioned transseptally with a transparent intra-atrial balloon 660 inflated to such a size as to occupy a relatively large portion of the atrial chamber, e.g., 75% or more of the volume of the left atrium LA.
  • Balloon 660 may be inflated by a clear fluid such as saline or a gas. Visualization of tissue surfaces in contact against the intra-atrial balloon 660 becomes possible as bodily opaque fluids, such as blood, is displaced by the balloon 660. It may also be possible to visualize and identify a number of ostia of the pulmonary veins PV through balloon 660. With the position of the pulmonary veins PV identified, the user may orient instruments inside the cardiac chamber by using the pulmonary veins PV as anatomical landmarks.
  • Figs. 62B and 62C illustrate an imaging instrument, such as a fiberscope 662, advanced at least partially within the intra-atrial balloon 660 to survey the cardiac chamber as well as articulating the fiberscope 662 to obtain closer images of tissue regions of interest as well as to navigate a wide range of motion.
  • Fig. 62D illustrates a variation of balloon 660 where one or more radio-opaque fiducial markers 664 may be positioned over the balloon such that a position and inflation size of the balloon 660 may be tracked or monitored by extracorporeal imaging modalities, such as fluoroscopy, magnetic resonance imaging, computed tomography, etc.
  • a needle catheter 666 having a piercing ablation tip 668 may be advanced through a lumen of the deployment catheter and into the interior of the balloon 660.
  • the needle catheter 666 may be articulated to direct the ablation tip 668 to the tissue to be treated and the ablation tip 668 may be simply advanced to pierce through the balloon 660 and into the underlying tissue, where ablation treatment may be effected, as shown in Pig. 63.
  • the needles projecting from ablation tip 668 are sized sufficiently small in diameter and are gently inserted through the balloon 660, leakage or bursting of the balloon 660 may be avoided.
  • balloon 660 may be fabricated from a porous material such that the injected clear fluid, such as saline, may diffuse out of the balloon 660 to provide a medium for RF tissue ablation by enabling a circuit between the positive and negative electrode to be closed through the balloon wall by allowing the diffused saline to be an intermediate conductor.
  • Other ablation ⁇ instruments such as laser probes can also be utilized and inserted from within the balloon 660 to access the tissue region to be treated.
  • Figs. 64A and 64B illustrate detail views of a safety feature where one or more ablation probes 672 are deployable from a retracted configuration, as shown in Fig. 64A, where each probe is hidden its respective opening 670 when unused. This prevents an unintended penetration of the balloon 660 or inadvertent ablation to surrounding tissue around the treatment area.
  • the one or more probes 672 may be projected from their respective openings 670, as shown in Fig. 64B.
  • the ablation probes 672 may be configured as a monopolar electrode assembly.
  • Fig. 64C illustrates a perspective view of an ablation catheter 666 configured as a bipolar probe including a return electrode 674.
  • FIG. 65A shows a stabilizing sheath 14 which may be advanced through the inferior vena cava IVC, as above, in a flexible state.
  • sheath 14 Once sheath 14 has been desirably positioned within the right atrium RA 3 its configuration may be optionally locked or secured such that its shape is retained independently of instruments which may be advanced therethrough or independently of the motion of the heart.
  • Such a locking configuration may be utilized via any number of mechanisms as known in the art.
  • sheath 14 may have a stabilizing balloon 680, similar to that described above, which may be expanded within the right atrium RA to inflate until the balloon 680 touches the walls of the chamber to provide stability to the sheath 14, as shown in Fig. 65B.
  • the tip of the sheath 14 maybe further advanced to perform a transseptal procedure to the left atrium LA utilizing any of the methods and/or devices as described in further detail in U.S. Pat. App. 11/763,399 filed June 14, 2007, which has been incorporated above.
  • an articulatable section 682 may be steered as indicated by the direction of articulation 684 into any number of directions, such as by pullwires, to direct the sheath 14 towards a region of tissue to be treated, such as the pulmonary vein ostium, as shown in Fig. 65C.
  • a region of tissue to be treated such as the pulmonary vein ostium, as shown in Fig. 65C.
  • the steerable section 682 desirably pointed towards the tissue to be treated, the amount of force transmission and steering of the tissue visualization catheter towards the tissue region is reduced and simplified.
  • Fig. 65D shows illustrates an example of the telescoping capability of the deployment catheter 16 and hood 12 from the steerable sheath 14 into the left atrium LA, as indicated by the direction of translation 686.
  • Fig. 65E also illustrates an example of the articulating ability of the sheath 14 with deployment catheter 16 and hood 12 extended from sheath 14, as indicated by the direction of articulation 690.
  • Deployment catheter 16 may also comprise a steerable section 688 as well.
  • hood 12 maybe directed to any number of locations within the right atrium RA to effect treatment.
  • Figs. 66 A and 66B illustrate yet another variation where sheath 14 may be advanced transseptally at least partially along its length, as shown in Fig. 66 A, as above.
  • a proximal stabilization balloon 700 inflatable along the atrial septum within the right atrium RA and a distal stabilization balloon 702 inflatable along the atrial septum within the left atrium LA may be inflated along the sheath 14 to sandwich the atrial septum AS between the balloons 700, 702 to provide stabilization to the sheath 14, as shown in Fig. 66B.
  • a separate inner sheath 704 may be introduced from sheath 14 into the left atrium LA.
  • Inner sheath 704 may comprise an articulatable section 706 as indicated by the direction of articulation 708 and as shown in Fig. 66C.
  • inner sheath 704 may also be translated distally further into the left atrium LA as indicated by the direction of translation 710 to establish as short a trajectory for hood 12 to access any part of the left atrium LA tissue wall.
  • deployment catheter 16 may be advanced with hood 12 to expand within the left atrium LA with a relatively direct approach to the tissue region to be treated, such as the ostium OT of the pulmonary veins, as shown in Fig. 66E.
  • Figs. 67A and 67B illustrate yet another variation where sheath 14 may be advanced at least partially through the atrial septum AS and proximal and distal stabilization balloons 700, 702 may be expanded against the septal wall. Similar to the variation above in Figs. 62 A to 62C, an intra-atrial balloon 660 may be expanded from the distal opening of sheath 14 to expand and occupy a volume within the right atrium RA. Fiberscope 662 may be advanced at least partially within the intra-atrial balloon 660 to survey the cardiac chamber, as illustrated in Fig. 67C.
  • inner sheath 704 may be introduced from sheath 14 into the left atrium LA and articulated and/or translated to direct its opening towards the targeted tissue region to be treated.
  • a penetrating needle 720 having a piercing tip 722 and a hollow lumen sufficiently sized to accommodate hood 12 and deployment catheter 16, may be advanced from inner sheath 704 and into contact against the balloon 660 to pierce through and access the targeted tissue for treatment, as shown in Figs. 67D and 67E.
  • penetrating needle 720 may be withdrawn to allow for the advancement of hood 12 in its low profile shape to be advanced through the pierced balloon 660 or hood 12 and deployment catheter 16 may be advanced distally through the lumen of needle 720 where hood 12 may be expanded externally of balloon 660.
  • catheter 16 With the hood 12 deployed, catheter 16 may be retracted partially into inner sheath 704 such that hood 12 occupies and seals the pierced opening through balloon 660.
  • Hood 12 may also placed into direct contact with the targeted tissue for treatment externally of balloon 660, as illustrated in Fig. 67F.
  • a direct visual image of the atrial chamber may be provided through the balloon interior. Because an imager such as fiberscope 662 has a limited field of view, multiple separate images captured by the fiberscope 662 may be processed to provide a combined panoramic image or visual map of the entire atrial chamber.
  • An example is illustrated in Fig. 68 A where a first recorded image 730 (represented by “A”) may be taken by the fiberscope 662 at a first location within the atrial chamber.
  • a second recorded image 732 (represented by "B”) may likewise be taken at a second location adjacent to the first location.
  • a third recorded image 734 (represented by "C”) may be taken at a third location adjacent to the second location.
  • the individual captured images 730, 732, 734 can be sent to an external CPU via wireless technology such as Bluetooth® (BLUETOOTH SIG, INC, Bellevue, WA) or other wireless protocols while the tissue visualization catheter is within the cardiac chamber.
  • the CPU can process the pictures taken by monitoring the trajectory of articulation of the fiberscope or CCD camera, and process a two- dimensional or three-dimensional visual map of the patient's heart chamber simultaneously while the pictures are being taken by the catheter utilizing any number of known imaging software to combine the images into a single panoramic image 736 as illustrated schematically in Fig. 68B.
  • the operator can subsequently use this visual map to perform a therapeutic treatment within the heart chamber with the visualization catheter still within the cardiac chamber of the patient.
  • the panoramic image 736 of the heart chamber generated can also be used in conjunction with conventional catheters that are able to track the position of the catheter within the cardiac chamber by imaging techniques such as fluoroscopy but which are unable to provide direct real time visualization.
  • a potential complication in ablating the atrial tissue is potentially piercing or ablating outside of the heart H and injuring the esophagus ES (or other adjacent structures), which is located in close proximity to the left atrium LA. Such a complication may arise when the operator is unable to estimate the location of the esophagus ES relative to the tissue being ablated.
  • a light source or ultrasound transducer 742 maybe attached to or through a catheter 740 which can be inserted transorally into the esophagus ES and advanced until the catheter light source 742 is positioned proximate to or adjacent to the heart H.
  • the operator may utilize the imaging element to visually (or otherwise such as through ultrasound) detect the light source 742 in the form of a background glow behind the tissue to be ablated as an indication of the location of the esophagus ES.
  • Different light intensities providing different brightness or glow in the tissue can be varied to represent different safety tolerances, e.g., the stronger the light source 742, the easier detection of the glow in the left atrium LA by the imaging element and potentially greater safety margin in preventing an esophageal perforation.
  • An alternative method is to insert an ultrasound crystal source at the end of the transoral catheter instead of a light source.
  • An ultrasound crystal receiver can be attached to the distal end of the hood 12 in the left atrium LA.
  • the distance between the ablation tool and the esophagus ES can be calculated by a processor.
  • a warning e.g., in the form of a beep or vibration on the handle of the ablation tools, can activate when the source in the heart H approaches the receiver located in the esophagus ES indicating that the ablation probe is approaching the esophagus ES at the ablation site.
  • the RF source can also cut off its supply to the electrodes when this occurs as part of the safety measure.
  • Another safety measure which may be utilized during tissue ablation is the utilization of color changes in the tissue being ablated.
  • One particular advantage of a direct visualization system described herein is the ability to view and monitor the tissue in real-time and in detailed color.
  • Imaging element 532 may provide the off-axis visualization of the ablation probe 536 placed against the tissue surface for treatment, as illustrated in Fig. 69B by the displayed image of a representative realtime view that the user would see on monitor 128.
  • the resulting color change of the ablated tissue 744 may be detected and monitored on monitor 128 as the ablated tissue 744 turns from a pink color to a pale white color indicative of ablation or irreversible tissue damage, as shown in Fig. 69D.
  • the user may monitor the real-time image to ensure that an appropriate amount and location of tissue is ablated and is not over-heated by tracking the color changes on the tissue surface.
  • the real-time image may be monitored for the presence of any steam or micro-bubbles, which are typically indications of endocardial disruptions, emanating from the ablated tissue. If detected, the user may cease ablation of the tissue to prevent any further damage from occurring. [0288] hi another indication of tissue damage, Figs.
  • tissue debris 747 e.g., charred tissue fragments, coagulated blood, etc., resulting from an endocardial disruption or tissue "popping" effect.
  • the resulting tissue crater 746 may be visualized, as shown in Fig. 69F, as well as the resulting tissue debris 747.
  • ablation may be ceased by the user and the debris 747 may be contained within hood 12 and prevented from release into the surrounding environment, as shown in Fig. 69G.
  • the contained or captured debris 747 within hood 12 may be evacuated and removed from the patient body by drawing the debris 747 via suction proximally from within hood 12 into the deployment catheter, as indicated by the direction of suction 748 in Fig.
  • Figs. 691 to 69K Yet another method for improving the ablation treatment upon the tissue and improving safety to the patient is shown in Figs. 691 to 69K.
  • the hood 12 may be placed against the tissue to be treated T and the blood within the hood 12 displaced by saline, as above and as shown in Fig. 691.
  • negative pressure may be formed within the hood 12 by withdrawing the saline within the hood 12 to create a suction force until the underlying tissue is drawn at least partially into the hood interior, as shown in Fig. 69 J.
  • the temporarily adhered tissue 749 maybe in stable contact with hood 12 and ablation probe 536 may be placed into contact with the adhered tissue 749 such that the tissue 749 is heated in a consistent manner, as illustrated in Fig. 69K. Once the ablation has been completed, the adhered tissue 749 may be released and hood 12 may be re-positioned to effect further treatment on another tissue region.
  • an ablation probe may be introduced through the tissue imaging and manipulation catheter and the ablation process may be monitored under direct visualization, as described above. Additional features or instruments may be included and utilized with the catheter for detecting parameters of the tissue before, during, and/or after the ablation process to further monitor the ablation procedure aside from visualizing. For example, parameters such as detecting the thickness of a penetrated tissue region, temperature, impedance characteristics, etc. may also be detected and monitored. [0291] One variation is shown in the perspective view of Fig. 7OA which illustrates hood 12 in its expanded configuration disposed at the distal end of deployment catheter 16 along with imaging element 532, as described previously.
  • one or more lumens or working channels are defined through which one or more ablation needle electrodes 750 disposed upon the end of one or more corresponding probe shafts 752 may be advanced. Additionally, one or more optional temperature sensors may be positioned within the needle electrodes 750 for detecting the temperature rise of the ablated tissue, as described in further detail below.
  • Fig. 7OB shows a perspective view of the hood 12 and the needle electrodes 750 disposed upon their respective probe shafts 752.
  • this example illustrates three needle electrodes adjacently positioned with respect to one another, one or two needle electrode or more than three needle electrodes may be utilized.
  • the one or more needle electrodes 750 are able to transverse along the axis of the working channels.
  • Fig. 7OC shows a detailed perspective view of the needle electrodes 750 extending from the probe shafts 752.
  • Each needle electrode may be comprised of a needle body having a diameter of, e.g., about 0.022 inches (or a range between 50% greater or smaller).
  • the body of the needle is covered by an insulation coating 756 and projects to a piercing tip 754 for piercing into and/or through tissue.
  • the base of each needle may also include an exposed ablation return electrode 758, e.g., an RF electrode, for performing transmural lesion ablation on the tissue which is pierced by the tip 754.
  • one or more of the needles may also include a temperature sensing element 760, e.g., thermocouple sensor, thermistor, etc. positioned within the lumen of the needle.
  • a temperature sensing element 760 e.g., thermocouple sensor, thermistor, etc.
  • the sensing element 760 may be used to detect whether the needle electrodes 750 have penetrated beyond the tissue to be treated to whether the needle electrodes 750 have penetrated into an underlying tissue layer, e.g., a fat layer, which may be of a different or higher impedance than the targeted tissue.
  • Fig. 71 shows another variation of the hood 12 after being deployed into the open configuration which may be utilized with the ablation probes to effect ablation treatment.
  • a clear balloon 770 may be inflated with, e.g., contrast solution, within the open hood 12.
  • the inflated balloon 770 dispels opaque bodily fluids that may be within the interior of the hood 12 and when contacted against a tissue surface, allows the imaging element 532 to visualize the tissue surface.
  • Figs. 72A to 72E illustrate one method where the balloon 770 may be utilized for effecting ablation treatment. Initially as the deployment catheter 16 is directed towards the tissue region to be ablated, the hood 12 is deployed as shown in the perspective views of Figs. 72A and 72B. Balloon 770 may be inflated within hood 12, as shown in Fig.
  • the balloon 770 and hood 12 may be pressed against the tissue region T sufficiently to displace the underlying bodily fluid 772 from between the balloon surface and the tissue surface.
  • the imaging element 532 may be used to clearly visualize through the balloon 770 to the underlying tissue surface to confirm the location of the hood 12 against the appropriate region of tissue to be treated, as shown in Fig. 72D. If the hood 12 needs to be relocated, it may be simply repositioned with the balloon 770 remaining inflated.
  • Figs. 73 A to 73F illustrate a detailed side view of hood 12 in contact with the tissue surface T with saline flow from the irrigation channel of catheter 16 injected into hood 12 while under visualization from imaging element 532.
  • the needle electrodes 750 may be deployed and advanced into hood 12, as shown in Fig. 73B.
  • the piercing needles 754 may be advanced until the exposed ablation return electrodes 758 are contacted against the tissue surface, as illustrated in Figs. 73C and 73D.
  • sensors 760 positioned within the needles may be used to detect and monitor the temperature and/or impedance of the tissue T that is in contact.
  • a change in impedance detected by the sensors 760 occurs when the needle begins its entry into the tissue. If the sensors 760 enter a layer beneath the tissue layer, a higher impedance reading will result as fat generally has a higher impedance value compared to tissue.
  • This change in impedance detected may indicate to the user to activate the ablation procedure through the needle exposed by insulation 756 and the electrodes 758 at the base of the needle to commence ablation on the tissue T for a depth of, e.g., 15 mm.
  • the average thickness of the tissue wall typically ranges from between 8 mm to 15 mm.
  • An ablation to an exemplary depth of, e.g., 15 mm, may help to ensure that a transmural lesion fully through tissue to the fat layer is created, unlike current RF devices that create discontinuous lesions or lesions that do not extend all the way through the tissue.
  • a lesion 780 created thoroughly penetrated through the tissue wall is created.
  • the imaging element 532 may provide real-time in vivo visual confirmation of the formation and position of the lesion 780 before fully withdrawing hood 12 and catheter 16, as shown in Fig. 73F.
  • the visual confirmation also provides a method for verifying the ablation area and allows users to repeat the ablation process if any interruption were to occur during any stage of the procedure. The entire process can be repeated at another target area until the desired transmural lesion scar pattern is created.
  • Fig. 74A shows a partial cross-sectional view of the apparatus creating transmural lesions 782 in the right atrium RA of the heart via intravascular access through the inferior vena cava IVC as a possible variation of the application. As shown in Fig.
  • hood 12 and catheter 16 may be introduced into the left atrium transseptally utilizing any of the methods and instruments as described in U.S. Pat. App. 11/763,399 filed June 14, 2007, which has been incorporated by reference above, to create additional transmural lesions 784 around the ostia of the pulmonary veins utilizing the ablation electrodes 750, as shown in Fig. 74C.
  • Multiple ablation probes positioned in a variety of arrangements can be deployed to ablate linear or circular lesions while also detecting and monitoring the ablation process. Similar to configurations described above, for instance in Fig. 5OA, Figs.
  • 75A and 75B show an additional configuration where a linear lesion can be created in a single step by arranging a plurality of ablation probes 798 perpendicularly relative to one or more deployable arms 794, 796.
  • the deployable a ⁇ n or arms 794, 796 may be folded and hidden within the stem 790 and upon deployment, the arm or arms 794, 796 may swing about a hinge or pivot 792 to open, e.g., into a T-shape as shown in Fig. 75B.
  • the probe needles 798 located along the deployed arm or arms 794, 796 may then be swung from a parallel to a perpendicular configuration relative to the stem 790 before a liner transmural lesion is carried out as described above.
  • one or more the probe needles 798 may each contain a temperature sensor within the needle body to detect and monitor the condition of the tissue being ablated.
  • Figs. 76A and 76B show yet another configuration where a circular lesion can be created in single step via an ablation needle probe end effector 800.
  • the ablation needles 802 maybe longitudinally aligned in a low-profile configuration, as shown in the perspective view of Fig. 76A.
  • each of the needles 802 may reconfigure, either via actuation from the user or self-configuring, into its deployed radially projecting position, as shown in Fig. 76B.
  • the ablation needles 802 may be expanded into a variety of shapes, such as a circular shape as shown or in other configurations. This configuration may be particularly useful in ablation of the left atrium tissue in or around the ostia of the pulmonary veins.
  • one or more of the ablation needles 802 may contain a temperature sensing probe positioned within the needle itself for insertion into the tissue for detecting and monitoring temperature and/or impedance during the ablation process. [0302] Fig.
  • transmural needle assembly 810 may be used in conjunction with the tissue visualization catheter for advancement through the hood 12.
  • the transmural needle assembly 810 may generally comprise a distal end effector having interrogation needle 818 and with optional integrated ablation capabilities, a catheter body 816 (e.g., cylindrical extrusions such as catheters, introducers and/or sheaths, etc.) connecting the interrogation needle 818 with handle assembly 812.
  • Interrogation needle assembly 818 and catheter body 816 may be introduced into the deployment catheter 16 from its proximal end and advanced therethrough into and through hood 12.
  • handle assembly 812 may generally comprise a needle penetration depth indicator 814 and an actuator, e.g., a push/turn knob, for advancing or retracting the distal transmural needle probe.
  • Fig. 77C shows a perspective view of the interrogation needle 818 which includes an ablation electrode 820 positioned upon a distal end of catheter body 816 and a first temperature sensor 826 positioned over the electrode 820.
  • Piercing needle 822 may adjustably extend distally from electrode 820 terminating in piercing tip 824.
  • the sensor assembly 828 which is used to detect the various tissue parameters may be seen contained within the lumen of needle 822.
  • Fig. 77D shows a detail perspective view of the interrogation needle
  • the needle body itself 822 may have a diameter of, e.g., 0.005 in., with an outer diameter thin wall needle having a plurality of pores or openings 836 defined along the needle body.
  • the outer surface of the needle 822 may be also largely insulated 834 except for a short exposed segment at the distal traumatic end, e.g., the piercing tip 824.
  • Proximal to the needle 822 is an ablation surface 820 that can be incorporated to provide ablation energy, as described above.
  • the sensor assembly 828 contained within the needle lumen may comprise one or more sensors for detecting and monitoring various tissue parameters.
  • a second temperature sensor 830 may be included along with an optional impedance sensor 832.
  • One variation for impedance sensor 832 may utilize two electrodes.
  • V and I represent voltage 846 and current, respectively.
  • Impedances 840, 842 (Ze) and 844 (Z L ) represent the impedances of the first and second electrodes and load (e.g., from blood, tissue, fat etc.), respectively. Either the voltage 846 is applied and the current I measured or the current is applied and the voltage is measured. These may be AC signals at a frequency high enough such that the tissue is not stimulated, hi addition the frequency may be chosen to optimally differentiate between different loads of interest.
  • Electrode impedances may be lumped together with specific load impedances that are desired, particularly since Ze can be greater than the value of Z L and especially for small surface area electrodes.
  • Ze is a function of the electrode material and the geometry of the electrode. As the electrode becomes smaller the value of Ze increases.
  • One method for compensating for this is to use a four-point method, shown in Fig. 79.
  • V or current I is imposed across the two electrodes, as before; however, two additional electrodes 848 (E 3 ) and 850 (E 4 ) are introduced and are attached to a high input impedance bioamplifier 852, which simply measures the voltage (V MEASURED ) between the two electrodes.
  • the bioamplifier 852 has a high input impedance (Z ⁇ » Ze)
  • the impedance of the electrodes 848 (E 3 ) and 850 (E 4 ) is negligible.
  • the electrodes 848 (E 3 ) and 850 (E 4 ) measure a voltage across the spatial region of interest which has a current flowing through it that is imposed by the two first electrodes. Again the ratio V/I is a measure of the impedance as the whole four electrode assembly is moved around a region of interest.
  • E 3 can be mounted on the distal impedance sensor 832, while E 4 can be affixed on the wall of the transmural needle 822.
  • thermo-sensitive layer of dye such as sensitive phosphorescent (phosphor)
  • phosphor sensitive phosphorescent
  • the thermo-sensitive layer of dye may change from a first color 862 which is indicative of a first temperature to a second color 864 which is indicative of a second temperature different from the first temperature, as shown respectively in Figs. 80A and 80B.
  • the rate of change of color of the projected light detected by the fiberscope 860 may be used to determine the local distal temperature of the transmural needle 822.
  • the relationship between the fluorescent decay rate, ⁇ , of light intensity versus time, as shown in Fig 81, as well as the relationship between the decay rate and temperature, as shown in Fig. 82, may be utilized by a processor to correlate and calculate the local temperature.
  • the handle assembly 812 may include a needle penetration depth indicator 814 along the handle, as shown in the perspective view of Fig. 83.
  • the indicator 814 may show the depth of tissue penetration made by the transmural needle 822 at the distal end relative to the end of the catheter body 816 by having a position marker 870 moving along a series of gradations 872 as indicative of the depth.
  • the projection of transmural needle 822 may be controlled by needle advancement control 874, e.g., a push/pull mechanism or rotation knob at the end of handle 812.
  • needle advancement control 874 e.g., a push/pull mechanism or rotation knob at the end of handle 812.
  • impedance sensor 832 within needle 822 may record the impedance of the surrounding fluid (either the surrounding blood 880 or infused saline when the tissue is visualized within hood 12) or the space above the target tissue, as shown in Fig. 84A. Additionally and/or alternatively, the temperature may also be detected within needle 822 by temperature sensor 830 within needle 822, which should correlate with the temperature detected by temperature sensor 826.
  • the position indicator 870 along handle 870 in this configuration shows the position at a datum or reference location, as seen in Fig. 84B, indicating that needle 822 is fully retracted.
  • impedance sensor 832 may immediately detect an increase in impedance due to the intrinsic material property difference between blood 880 and tissue T. This change in impedance detected will alert the user that the transmural needle 822 is in contact with the tissue T. Impedance detected by sensor 832 can also be used to verify if the needle 822 is inserted into the desired tissue by comparing with the expected impedance of the target tissue T, from standard impedance values determined by the resistivity of the tissue and geometry of the electrode. As shown in Fig. 85B, the positional marker 870 along handle 812 indicates to the user the depth that the needle 822 has punctured into tissue T.
  • Fig. 86A illustrates when the transmural needle 822 has fully penetrated the entire layer of target tissue T. The user will be alerted that a complete transmural penetration is made when impedance sensor 832 shows a change in impedance due to contact with a different material, such as endocardium tissue, pericardium tissue, blood, fat, etc. Moreover, the position indicator 870 on handle 812 at this instance indicates the thickness of the target tissue layer and the depth to make a full transmural penetration, as shown in Fig. 86B.
  • saline 882 may be infused into the surrounding tissue from the pores or openings 836 along the wall of transmural needle 822 while the ablation electrode 820 at the distal end of catheter body 816 is charged.
  • the thin layer of saline formed around the needle 822 within the tissue T may act as a conductive medium to channel radiation energy to additional tissue surfaces. This in turn helps to create a wider lesion using the same amount of power on the ablation electrode 820 without tissue dessication and/or blood coagulation. It may also help to cool the area around the needle 822.
  • a bipolar RF electrode positioned between needle tip 824 and ablation electrode 820 or even a ring electrode can be also constructed to further create wider lesions.
  • the lesion may start at the needle 822 and then grow radially from there. This may be advantageous for targeting with the needle sensors 828 (impedance and temperature) followed up by a discrete lesion targeting that region in the mid myocardial wall.
  • Alternative RF ablation techniques include simultaneous RF applied through the needle 822 and ablation electrode 820 where the amplitude of the RF is controlled separately and modulated by feedback from the temperature sensors 826, 830.
  • Fig. 87A shows an optional subsequent method to ensure the entire depth of the tissue layer is ablated to form full transmural lesions. This may be accomplished by determining the temperature at the tissue surface and at the distal adjacent end of the tissue layer using temperature sensors 826 and 830, respectively. After puncturing through the entire layer of the target tissue T, the transmural needle 822 maybe retracted slightly for a distance not more than approximately, e.g., 0.5 mm, as shown. The ablation electrode 820 may then be powered to ablate the target tissue T beginning at its surface, as indicated by the zone of heated tissue 890 emanating from electrode 820 shown in Fig. 87A.
  • the tissue T may be heated to a temperature of at least 50° C to irreversibly injure or ablate the tissue.
  • Full transmural ablation is accomplished when temperature sensor 826 detects a surface temperature exceeding 50° C or at a temperature where the tissue T begins to show signs of ablation, which may be visually detected as described above. This may be followed by holding the ablation electrode 820 at its position until the temperature sensor 830 positioned within needle 822 also detects a temperature reading above 50° C or any other temperature that indicates the entire depth of tissue as being fully ablated.
  • Fig. 87B shows a gradient of heated tissue 892 through tissue T which extends from electrode 820 to temperature sensor 830 within needle 822.
  • 88A shows a perspective view of the interrogation needle 818 and catheter body 816 advanced through deployment catheter 16 and into and through hood 12 for ablation and/or detection of the tissue parameters.
  • Fig. 88B shows an example where interrogation needle 818 may be advanced into the underlying tissue for ablation and detection while under direct visualization by imaging element 532.
  • the transmural ablation may be performed within hood 12 when the opaque bodily fluid, such as blood, has been displaced from hood 12 with saline.
  • Figs. 89 A and 89B show perspective views of another variation having a plurality of the transmural needles 902 arranged in a ring configuration along a support ring 900 positioned around a circumference of the opening of hood 12.
  • the transmural needles 902 arranged in such a configuration may be able to facilitate ring ablations and ensure the ablated ring lesion fully penetrates the target tissue layer T to form full transmural lesions, as described above.
  • a plurality of transmural needles can be arranged into a linear configuration along a linear ablation electrode as shown in Figs. 9OA and 9OB.
  • the transmural needles 916 arranged in this configuration can facilitate transmural linear ablation.
  • the linear distal segment 912 can be rotated 90 degrees at the joint 914 to become parallel relative to support arm 910 as well as to the axis of deployment catheter 16 from its perpendicular configuration, as shown in Fig. 9OB.
  • segment 912 may be retractable into catheter 16.
  • Fig. 9OC illustrates an example of the segment 912 deployed with transmural needles 916 advanced into the target tissue T while under visualization from imaging element 532 with hood 12.
  • Fig. 91 shows a detail perspective view of another variation of the transmural subsurface interrogation needle where several additional temperature sensors may be placed along the length of the needle, e.g., within each pore or opening. Saline may be infused through the openings, as above, past the temperature sensors or the saline may be omitted entirely.
  • a first temperature sensor 920 may be positioned at a first proximal location along the needle
  • second temperature sensor 922 may be positioned at a second location distal to the first location
  • third temperature sensor 924 may be positioned at a third location distal to the second location
  • fourth temperature sensor 926 may be positioned at . a fourth location distal to the third location.
  • Fig. 92A shows temperatures sensors 920, 922, 924 positioned within the tissue layer.
  • a temperature profile of the entire tissue layer along the axis of the needle can be determined.
  • the warmest tissue region is typically about 3.2 mm to 3.4 mm away from the tissue-electrode interface when ablation electrode 820 with saline irrigation 928 and/or surface cooling is used.
  • Fig. 92B shows the position indicator 870 correlating to a needle position extending through the length of the tissue T.
  • Fig. 93 A shows yet another variation of the transmural subsurface interrogation needle which includes an intramural cooling needle 930 having a cooling probe 932 which may be advanced from catheter body 816 adjacent to the interrogation needle and pierced into the tissue adjacent to the interrogation needle as well.
  • the intramural cooling needle 930 may have an outer diameter of, e.g., 0.005 in. or less, may extend about 3 mm to 4 mm (or preferably about 3.4 mm) from the catheter body into the tissue, as indicated by depth 934.
  • Cooling probe 932 may be configured to cool the tissue in contact with the needle at the distal end.
  • cooling probe 932 may help cool the mid-section (approximately 3.2 mm to 3.6 mm away from contact surface) of the tissue layer where peak tissue temperature is likely to occur when ablated with electrode 820. This may also help generate a linear temperature profile across the ablated tissue consequently allowing for a wider and dimensionally more evenly distributed transmural lesion to be formed and further reducing the risk of endocardiac disruptions.
  • the cooling intensity and position can be changed accordingly by monitoring the temperature profile of the tissue provided by the transmural subsurface interrogation needle. Fig.
  • Fig. 94 shows yet another variation of a transmural interrogation needle with plurality of impedance sensors to provide an impedance profile across a target tissue. Similar to the variation above for determining temperature profile, a plurality of impedance sensors can be fixed along the longitudinal axis of the needle. As shown, first impedance sensor 942, second impedance sensor 944, and third impedance sensor 946 may be located along the length of the needle body. In this configuration, an impedance profile across the tissue layer will be recorded instead of a single impedance reading.
  • the entire dome surface proximal of the needle can be a junction that functions as the proximal impedance sensor 940.
  • the plurality of temperature sensors 920, 922, 924 may also be similarly aligned in an alternating manner along the needle to detect the temperature profile as well.
  • the plurality of impedance sensors along the needle shaft can be arranged in a bipolar configuration for measuring signals from tissue immediately proximate to the needle. This can also be an extension of the four point impedance method described above to more than two electrodes placed between the two electrodes that inject either the signal for the impedance measurement.
  • the plurality of impedance electrodes 940, 942, 944, 946 can also be used for targeting of ablation sites within the myocardium by using signal characteristics or pacing methods such as pace mapping or entrainment mapping. Pacing can be done in a monopolar configuration using a far-field return electrode for the pacing pulse. This may increase the spatial resolution of the pacing method to a discrete single electrode on the interrogation needle, rather than two electrodes when bipolar pacing is performed.
  • Figs. 95 A and 95B show side and perspective views of yet another variation of the transmural subsurface interrogation needle without ablation features and fixed circumferentially at the distal end of a lumen that fits a conventional ablation catheter 950.
  • This configuration allows for transmural ablation to be conducted with any ablation catheter chosen by the user.
  • One or more transmural interrogation needles 952, 954 may be positioned adjacent to ablation probe 536. As the needles 952, 954 may extend past the ablation probe 536, the needles may be pierced into the targeted tissue T distal to ablation probe 536.
  • transmural needle 964 may extend distally from ablation probe 960 along a flexible segment 962 which allows for needle 964 to be bent temporarily.
  • the flexible segment 962 can be made from coils or springs or other plastic/elastomeric materials.
  • the inclusion of flexible segment 962 allows for the ablation catheter 960 to pivot when the transmural needle 964 is penetrated into the target tissue T. This allows the user more angles of freedom to ablate such as when utilizing the side surfaces of the ablation catheter 960 against the tissue surface, as illustrated.
  • Figs. 97A and 97B show side and end views, respectively, of another variation of the transmural needle 974 where the needle 974 projects radially from a side surface of electrode 972 of the catheter 970.
  • needle 974 With needle 974 positioned at a radial location, it may always be positioned on the outside of the deflection angle of the catheter 970, as indicated by the direction of catheter deflection 976.
  • This particular variation may be effective for high-torque catheters that are designed to optimally deflect in a fixed plane.
  • the needle 974 can be extended out of the distal tip with a rapid exchange capability allowing the insertion of a straight needle or one that is curved such that it always deploys opposed to any deflection in the catheter.
  • Figs. 98 A and 98B show another variation of the transmural needle having a helical configuration instead of a straight needle configuration.
  • the needle 980 may simply be rotated into the tissue T.
  • temperature and/or impedance sensors 828 may be mounted at the distal and proximal end of the needle 980.
  • helical needle 980 can also include a plurality of temperature and/or impedance sensor rings along the axis of the needle.
  • Fig. 99 shows yet another variation of the transmural needle with one or more transparent visualization balloon 990 fixed along the length of the transmural needle 822.
  • the balloon 990 can be inflated lateral to the needle to provide visualization of tissue surface when the balloon 990 is pressed against tissue and when an imaging element is proximal to the balloon 990. " When the balloon 990 is deflated, transmural penetration and ablation with the needle 822 can be performed as described above by penetrating the needle 822 into the target tissue. In this configuration, the balloon 990 can also be re-inflated to expand lesion width and/or to visualize the surface condition of the lesion walls.
  • the transmural needle is configured with a robotic precision control assembly 1000 as described in U.S. Pat. Pub. 2006/0084945 Al filed July 6, 2005, which is incorporated herein by reference in its entirety.
  • Hood 12 may be mounted at the distal end of a robotic precision motion control catheter 1002 and articulated via articulatable section 1004.
  • the transmural needle 816 maybe advanced within hood 12, as shown in Fig. 10OB, while under visualization from imaging element 532 and with the robotic catheter 1000 controlling movement of hood 12, transmural needle 816 may be moved precisely along the tissue surface during the subsurface interrogation and ablation procedure.

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Abstract

Appareil et méthodes de traitement de la fibrillation auriculaire donnant la possibilité de surveiller les tissus à retirer avec visualisation directe des paramètres tissulaires (tels que température et impédance), ceci avant, pendant et après l'ablation. Ce système peut faire appel à un cathéter de déploiement auquel est fixé un capuchon d'imagerie déployable en position dépliée. Le capuchon d'imagerie est amené contre les tissus à représenter7visualiser dans une lumière du corps normalement remplie d'un liquide organique opaque tel que du sang. Un liquide translucide ou transparent peut être pompé dans le capuchon d'imagerie jusqu'à ce qu'il chasse le sang et dégage une région claire de tissus à représenter au moyen d'un élément imageur du cathéter de déploiement. Une sonde d'ablation et une ou plusieurs aiguilles d'interrogation dotées de capteurs peuvent être avancées dans les tissus à retirer et à surveiller. Une variante concerne l'emploi d'une sonde d'ablation et d'interrogation combinée.
EP07799466A 2006-07-10 2007-07-10 Méthodes et appareil de traitement de la fibrillation auriculaire Withdrawn EP2037812A4 (fr)

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US80692606P 2006-07-10 2006-07-10
US80692306P 2006-07-10 2006-07-10
US80692406P 2006-07-10 2006-07-10
US89147207P 2007-02-23 2007-02-23
PCT/US2007/073184 WO2008008796A2 (fr) 2006-07-10 2007-07-10 Méthodes et appareil de traitement de la fibrillation auriculaire

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