WO2011072186A1 - Dispositifs d'occlusion veineuse et méthodes d'ablation à base de cathéter - Google Patents

Dispositifs d'occlusion veineuse et méthodes d'ablation à base de cathéter Download PDF

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Publication number
WO2011072186A1
WO2011072186A1 PCT/US2010/059795 US2010059795W WO2011072186A1 WO 2011072186 A1 WO2011072186 A1 WO 2011072186A1 US 2010059795 W US2010059795 W US 2010059795W WO 2011072186 A1 WO2011072186 A1 WO 2011072186A1
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Prior art keywords
catheter
expandable chamber
sensors
sensor
pressure
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PCT/US2010/059795
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English (en)
Inventor
Jean-Luc Pageard
Teresa A. Mihalik
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Medtronic Cryocath Lp.
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Application filed by Medtronic Cryocath Lp. filed Critical Medtronic Cryocath Lp.
Priority to CA2785814A priority Critical patent/CA2785814C/fr
Priority to EP10795866.2A priority patent/EP2512329B1/fr
Publication of WO2011072186A1 publication Critical patent/WO2011072186A1/fr

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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/02—Detecting, measuring or recording pulse, heart rate, blood pressure or blood flow; Combined pulse/heart-rate/blood pressure determination; Evaluating a cardiovascular condition not otherwise provided for, e.g. using combinations of techniques provided for in this group with electrocardiography or electroauscultation; Heart catheters for measuring blood pressure
    • A61B5/021—Measuring pressure in heart or blood vessels
    • A61B5/0215—Measuring pressure in heart or blood vessels by means inserted into the body
    • A61B5/02158—Measuring pressure in heart or blood vessels by means inserted into the body provided with two or more sensor elements
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/02—Detecting, measuring or recording pulse, heart rate, blood pressure or blood flow; Combined pulse/heart-rate/blood pressure determination; Evaluating a cardiovascular condition not otherwise provided for, e.g. using combinations of techniques provided for in this group with electrocardiography or electroauscultation; Heart catheters for measuring blood pressure
    • A61B5/026—Measuring blood flow
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/24—Detecting, measuring or recording bioelectric or biomagnetic signals of the body or parts thereof
    • A61B5/25—Bioelectric electrodes therefor
    • A61B5/279—Bioelectric electrodes therefor specially adapted for particular uses
    • A61B5/28—Bioelectric electrodes therefor specially adapted for particular uses for electrocardiography [ECG]
    • A61B5/282—Holders for multiple electrodes
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/68—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient
    • A61B5/6846—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient specially adapted to be brought in contact with an internal body part, i.e. invasive
    • A61B5/6847—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient specially adapted to be brought in contact with an internal body part, i.e. invasive mounted on an invasive device
    • A61B5/6852—Catheters
    • A61B5/6853—Catheters with a balloon
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/68—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient
    • A61B5/6846—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient specially adapted to be brought in contact with an internal body part, i.e. invasive
    • A61B5/6867—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient specially adapted to be brought in contact with an internal body part, i.e. invasive specially adapted to be attached or implanted in a specific body part
    • A61B5/6869—Heart
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B5/00—Measuring for diagnostic purposes; Identification of persons
    • A61B5/68—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient
    • A61B5/6846—Arrangements of detecting, measuring or recording means, e.g. sensors, in relation to patient specially adapted to be brought in contact with an internal body part, i.e. invasive
    • A61B5/6885—Monitoring or controlling sensor contact pressure
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
    • A61B18/04—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating
    • A61B18/12—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by heating by passing a current through the tissue to be heated, e.g. high-frequency current
    • A61B18/14—Probes or electrodes therefor
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B2017/00017—Electrical control of surgical instruments
    • A61B2017/00022—Sensing or detecting at the treatment site
    • A61B2017/00039—Electric or electromagnetic phenomena other than conductivity, e.g. capacity, inductivity, Hall effect
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B2017/00017—Electrical control of surgical instruments
    • A61B2017/00022—Sensing or detecting at the treatment site
    • A61B2017/00084—Temperature
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/00234—Surgical instruments, devices or methods, e.g. tourniquets for minimally invasive surgery
    • A61B2017/00238—Type of minimally invasive operation
    • A61B2017/00243—Type of minimally invasive operation cardiac
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00—Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/22—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for
    • A61B2017/22051—Implements for squeezing-off ulcers or the like on the inside of inner organs of the body; Implements for scraping-out cavities of body organs, e.g. bones; Calculus removers; Calculus smashing apparatus; Apparatus for removing obstructions in blood vessels, not otherwise provided for with an inflatable part, e.g. balloon, for positioning, blocking, or immobilisation
    • A61B2017/22065—Functions of balloons
    • A61B2017/22067—Blocking; Occlusion
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
    • A61B2018/00005—Cooling or heating of the probe or tissue immediately surrounding the probe
    • A61B2018/00011—Cooling or heating of the probe or tissue immediately surrounding the probe with fluids
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
    • A61B2018/00053—Mechanical features of the instrument of device
    • A61B2018/00214—Expandable means emitting energy, e.g. by elements carried thereon
    • A61B2018/0022—Balloons
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
    • A61B18/02—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by cooling, e.g. cryogenic techniques
    • A61B2018/0212—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by cooling, e.g. cryogenic techniques using an instrument inserted into a body lumen, e.g. catheter
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61B—DIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B18/00—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body
    • A61B18/02—Surgical instruments, devices or methods for transferring non-mechanical forms of energy to or from the body by cooling, e.g. cryogenic techniques
    • A61B2018/0231—Characteristics of handpieces or probes
    • A61B2018/0262—Characteristics of handpieces or probes using a circulating cryogenic fluid
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M25/00—Catheters; Hollow probes
    • A61M25/10—Balloon catheters
    • A61M2025/1043—Balloon catheters with special features or adapted for special applications
    • A61M2025/1052—Balloon catheters with special features or adapted for special applications for temporarily occluding a vessel for isolating a sector
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M25/00—Catheters; Hollow probes
    • A61M25/10—Balloon catheters
    • A61M2025/1043—Balloon catheters with special features or adapted for special applications
    • A61M2025/1086—Balloon catheters with special features or adapted for special applications having a special balloon surface topography, e.g. pores, protuberances, spikes or grooves

Definitions

  • the present disclosure relates to catheter-based methods, systems, devices for occlusion, and in particular, utilizing measurements of one or more physiological parameters to guide an ablation treatment of cardiac arrhythmias.
  • Catheter based devices are employed in various medical and surgical applications because they are relatively non-invasive and allow for precise treatment of localized tissues that are otherwise inaccessible. Catheters may be easily inserted and navigated through the blood vessels and arteries, allowing non-invasive access to areas of the body with relatively little trauma.
  • catheter-based systems have been developed for implementation in tissue ablation for treatment of cardiac arrhythmias such as atrial fibrillation, supra ventricular tachycardia, atrial tachycardia, ventricular tachycardia, ventricular fibrillation, and the like.
  • One such implementation involves the use of fluids with low operating temperatures, or cryogens, to selectively freeze, or "cold-treat", targeted tissues within the body.
  • the cryogenic treatment involves cooling a portion of the catheter to a very low temperature through the use of the cryogenic fluid flowing through the catheter.
  • a cryogenic device uses the energy transfer derived from thermodynamic changes occurring in the flow of a cryogen therethrough to create a net transfer of heat flow from the target tissue to the device, through conductive and convective heat transfer between the cryogen and target tissue.
  • cooling can be achieved through injection of high-pressure coolant into a lumen of the catheter.
  • the refrigerant undergoes two primary thermodynamic changes: (i) expanding to low pressure and temperature through positive Joule-Thomson throttling, and (ii) undergoing a phase change from liquid to vapor, thereby absorbing heat of vaporization.
  • the resultant flow of low temperature refrigerant through the device acts to absorb heat from the target tissue and thereby cool the tissue to the desired temperature.
  • refrigerant Once refrigerant is injected into the lumen, it may be expanded inside of an expandable chamber, which is positioned proximal to the target tissue.
  • the expandable chamber may also be thermally conductive.
  • Devices with an expandable chamber, such as a balloon may be employed. Such a device is disclosed in U.S. Patent 7,300,433, Lane et al., which is incorporated herein by reference in its entirety.
  • refrigerant is supplied through a catheter lumen into an expandable balloon coupled to such catheter, wherein the refrigerant acts to both: (i) expand the balloon near the target tissue for the purpose of positioning the balloon, and (ii) cool the target tissue proximal to the balloon to cold-treat adjacent tissue.
  • the expandable chamber may also serve a second function; blocking the flow of blood through the desired treatment site (occlusion).
  • the catheter is typically of a relatively small diameter and long body, generally determined, by the diameter and length of the vascular pathways leading to the ablation site.
  • the coolant in the catheter is highly susceptible to conductive warming effects due to the relative proximity of the catheter (and coolant) to the body tissue and blood. Furthermore, the rate of cooling is limited by the ability to circulate a sufficient mass flow of coolant through the catheter. Yet there is a requirement that the coolant itself be at a sufficiently low temperature, in some cases below freezing, at the location of the ablation.
  • Radio frequency (RF) catheter ablation is another common implementation of the catheter-based treatment.
  • Arrays of ablation elements including but not limited to geometrically-adjustable electrode arrays, may be configured in a wide variety of ways and patterns on the catheter as disclosed for example in U.S. Application 2007/083194 by Kunis et al., which is incorporated herein by reference in its entirety. Such elements may be coupled to the expandable chamber or other portions of the catheter.
  • RF catheter ablation includes a preliminary step of conventional electrocardiographic mapping followed by the creation of one or more ablated regions (lesions) in the cardiac tissue using RF energy.
  • RF energy applied by the catheter elevates the temperature of the tissue for therapeutic treatment of an arrhythmia. The effectiveness of the RF energy may be limited by the flow of blood; the rapid blood flow carries away the generated heat and causes cooling of the ablating electrodes and/or tissue.
  • blocking the flow of blood using the expandable chamber allows more effective cooling or heating (depending on the treatment method) which facilitates the treatment process and may reduce the treatment period.
  • Effective contact to achieve occlusion may require moving, positioning, anchoring and other mechanisms for locating and stabilizing the conformation of the expandable chamber of the catheter.
  • slight changes in orientation may greatly alter the characteristics of the catheter, so that even when the changes are predictable or measurable, it may become necessary to provide positioning mechanisms of high stability or accuracy to assure adequate treatment at the designated sites.
  • Known techniques for visualizing the contact between the expandable chamber and the target tissue include the use of radiographically opaque contrast medium to enable radiographic-mapping of the target tissue during application and operation of the catheter. Such an imaging technique may not be desirable due to the use of contrast medium and its interaction with the patient tissue. Additionally, it may be desirable to eliminate or minimize the exposure of both patient and clinician to the radiographic-mapping waves used for imaging.
  • the catheters comprise a tubular body member having a proximal end, a distal end and a lumen extending therebetween.
  • An expandable chamber in fluid communication with the lumen is disposed at the distal end of the tubular body member.
  • the expandable chamber may be adjusted by inflating or deflating it so as to engage cardiac tissue, such as the pulmonary vein ostial tissue.
  • the catheter may be advanced over a guide wire for delivery to the treatment site.
  • the catheter may have a steerable tip that allows precise positioning of the distal portion such as when the distal end of the catheter needs to access a pulmonary vein of the left atrium of the patient's heart.
  • One or more physiologic sensors may be coupled to the catheter for measurement of a physiological parameter.
  • the physiologic sensor coupled to the catheter may comprise first and second pressure sensors.
  • the first pressure sensor may be disposed on the tubular body member at a location distal to the expandable chamber.
  • the second pressure sensor may be disposed on the tubular body member at a location that is proximal to the expandable chamber.
  • First and second pressure sensors may be employed for a differential measure of pressure at locations that are distal and proximal to the expandable chamber.
  • the physiologic sensor may comprise a single pressure sensor.
  • the sensor may be employed for measurement of an absolute value of the pressure at a region that is distal to the expandable chamber.
  • a pressure sensor may be disposed on the tubular body member distal to the expandable chamber.
  • an external sensor may be coupled in fluid communication with a lumen of the catheter for measurement of the pressure at a location that is distal to the expandable chamber, whereby the pressure is mechanically coupled to a fluid in the lumen, transmitted via the fluid and sensed by the external sensor.
  • the catheter may include a temperature sensor as the physiologic sensor.
  • the temperature sensor may be coupled proximal, distal, or directly on the expandable chamber. Temperature measurements of the regions proximate to the temperature sensor may be obtained by the sensor.
  • the catheter includes one or more flow sensors mounted on the tubular body member. At least a first of the one or more flow sensors may be mounted distal to the inflatable balloon assembly.
  • the flow sensor comprises a calorimetric flow sensor having two temperature sensors that are coupled distal to the expandable chamber for calorimetric flow measurement.
  • the present disclosure provides methods for measuring a physiologic parameter at one or more regions separated by an expandable chamber.
  • the catheter may be of the type used for performing intracardiac procedures, typically being percutaneously introduced and advanced from the femoral vein in a patient's leg.
  • the method includes treatment of an arrhythmia with a catheter.
  • the catheter may include an expandable chamber for abutting the catheter to a pulmonary vein to occlude blood flow through the vein.
  • differential pressure measurements of the pressure at locations distal and proximal to the expandable chamber may be obtained.
  • an absolute pressure measurement of pressure at a location distal to the expandable chamber may be obtained.
  • the differential or absolute pressure measurements may be evaluated to guide the placement of the catheter, and in particular, placing the expandable chamber to occlude blood flow in the pulmonary vein.
  • the differential or absolute pressure measurements may be derived continuously during an insertion and treatment procedure to determine appropriate placement of the catheter. Changes in the differential or absolute pressure may be correlated to mechanical occlusion of the pulmonary vein.
  • Systems in accordance with embodiments of the present disclosure may include a console for delivery of energy and circulation of a coolant through a catheter.
  • the systems may or may not also include a processing unit for processing signals sensed by sensors positioned on the catheter.
  • the systems may further include a mapping unit that receives information recorded from one or more mapping electrodes positioned on the ablation catheter.
  • the mapping unit may provide electrical activity information to an operator of the system to identify or confirm the location of target tissue.
  • FIG. 1 illustrates an exemplary ablation catheter of the present disclosure as it would be deployed and used for an ablation procedure.
  • FIG. 2 illustrates an exemplary system for performing an ablation.
  • FIGS. 3A and 3B illustrate cross sectional views of catheter as it would be used within the vascular system of a patient.
  • FIGS. 4 A and 4B illustrate signal waveforms of pressure signals indicative of incomplete and complete mechanical occlusion.
  • FIG. 5 illustrates an ablation system adapted for use in accordance with an alternative embodiment of the present disclosure.
  • FIGS. 6A and 6B illustrate signal waveforms of the pressure distal to the expandable chamber indicative of incomplete and complete mechanical occlusion measured by the single pressure sensing system of FIG. 5.
  • FIG. 7 illustrates an alternative embodiment of a catheter having a temperature sensor mounted thereon.
  • FIG. 8 depicts temperature profiles generated from temperature sensor of FIG. 6.
  • FIG. 9 illustrates an alternative embodiment of a catheter having a flow sensor.
  • FIG. 10 shows a flow diagram illustrating a process of performing an ablation using a catheter in accordance with embodiments of the present disclosure.
  • FIG. 1 shows a cutaway view of the human heart 10, showing the major structures of the heart 10 including the left and right atria, and the pulmonary veins 15 a, 15b.
  • the atrial septum separates the left and right atria.
  • the fossa ovalis 11 is a small depression in the atrial septum that may be used as an access pathway to the left atrium from the right atrium, such as with a transeptal puncture device and transeptal sheath.
  • the fossa ovalis 11 can be punctured, and easily reseals and heals after procedure completion.
  • aberrant electrically conducive tissue may be found in the atrial walls, as well as in the pulmonary veins 15 a, 15b. Ablation of these areas, referred to as arrhythmogenic foci (also referred to as drivers or rotors), is an effective treatment for atrial fibrillation.
  • Systems, devices and methods of the present disclosure provide means of creating lesions, including lesions to surround the pulmonary vein ostia, and are deployed to identify and ablate the driver and rotor tissue.
  • a catheter (FIG. 2) is inserted into the right atrium, preferably through the inferior vena cava or through the superior vena cava.
  • the catheter is sized for advancement through the patient's vasculature.
  • an exemplary catheter may have a shaft having a diameter ranging from 7-9 Fr, with the shaft length ranging from 100-125 cm and the overall length being in the range of 140-160 cm.
  • the catheter may be passed through transeptal sheath, which may or may not be a deflectable sheath since the catheter preferably includes a deflectable distal portion.
  • transeptal sheath When passing into the left atrium, transeptal sheath passes through or penetrates the fossa ovalis 11, such as over guide wire 215 which may have been placed by a transeptal puncture device.
  • the catheter is inserted over guide wire 215 and through transeptal sheath such that its distal end enters the lumen of right superior pulmonary vein 15a, 15b.
  • the catheter carries an ablating element, such as an expandable chamber (FIG. 2) into the left atrium.
  • the expandable chamber is transitioned to expand to a maximal diameter by, for example inflation, such that the expandable chamber is in contact with the walls of the target tissue e.g., pulmonary vein ostia to occlude the vein.
  • An electrical mapping procedure may be performed to identify or confirm the location of the target cardiac tissue.
  • a treatment medium e.g., cooling fluid or RF power
  • a source external to the patient is provided through the catheter into the ablating element to ablate the neighboring tissue and form a lesion.
  • the created lesions may be segmented and localized.
  • the lesions may be linear or curvilinear, circumferential and partial circumferential, and/or continuous or discontinuous.
  • the lesions created by the ablation catheters are suitable for inhibiting the propagation of inappropriate electrical impulses in the heart 10 for prevention of reentrant arrhythmias.
  • the goal of catheter ablation therapy is to disrupt the electrical pathways in cardiac tissue to stop the emission of and/or prevent the propagation of erratic electric impulses.
  • FIG. 2 illustrates an exemplary system 100 for performing an ablation.
  • System 100 shows an ablation catheter 110 as it would be used in an ablation procedure of patient 12.
  • Catheter 110 includes elongate catheter body 115 that may suitably be flexible to permit passage through the vascular system of patient 12.
  • the catheter body 115 has a proximal portion 117 that is coupled to a handle 111.
  • Handle 111 may include one or more control knobs 112 for manipulating the catheter body 115 or other components of catheter 110.
  • Handle 111 may be provided with a port (not shown) for receiving a guide wire (not shown) that is passed into one or more lumens 118 of the catheter body 115.
  • Handle 111 may also include connectors that are coupled directly to an energy source or cryogenic fluid supply/exhaust and control unit or indirectly by way of one or more conduits 113.
  • the energy source/fluid supply and exhaust, as well as various control mechanisms for the system are housed in a console 60.
  • console 60 may employ a plurality of units to implement the functions of console 60, with each providing a separate function.
  • Console 60 circulates and/or recovers cooling fluid through the catheter body 115 to the patient 12.
  • console 60 may provide an exhaust function for the ablation catheter fluid supply.
  • Catheter body 115 includes one or more lumens for releasing coolant into the expandable chamber 130 responsive to console 60 commands and other control input, such as from the control knobs on handle 111.
  • console 60 creates a low-pressure environment in the one or more lumens within the catheter body 115.
  • the low-pressure environment draws coolant into lumen 118, away from expandable chamber 130, and towards proximal portion 117.
  • General principles concerning the construction or operation of an exemplary cryogenic system may be found in U.S.
  • Catheter body 115 includes a distal portion 116.
  • An expandable chamber 130 is coupled proximate to the distal portion 116.
  • Expandable chamber 130 may also be thermally conductive to facilitate conduction of heat to and from the tissue into a medium that may be carried by the chamber 130.
  • expandable chamber 130 is shown as a balloon having a single membrane, it should be understood that any known multi- membrane balloon may suitably be used.
  • catheter 110 operates to treat vascular tissue of a patient 12 that is adjacent to the expandable chamber 130 by freezing or through RF energy that may be delivered through electrodes (not shown) mounted on the distal end of catheter 110.
  • catheter body 115 may be navigated through the vascular system to the desired vascular tissue such as a vessel 30.
  • vessel 30 may include a left pulmonary vein, a right pulmonary vein, ostia, or other blood vessel.
  • expandable chamber 130 may be deflated for ease of steering and passage through the vascular system. Once catheter 110 is adjacent the desired site in vessel 30, expandable chamber 130 may be inflated, as discussed generally in U.S.
  • the occlusion is predicated upon proper positioning of the expandable chamber 130 to abut with the opening of vessel 30.
  • proper positioning presents several challenges to the user. These challenges include the difficulty of navigating catheter 110 within the vascular system and the size and nature of the vascular system.
  • Embodiments of the present disclosure utilize one or more physiologic sensors to ascertain the extent of occlusion (and consequently proper location) of the expandable chamber 130.
  • a first pressure sensor 120a is coupled to catheter 110 at a location that is anterior or distal to the expandable chamber 130.
  • sensor 120a is in fluid communication with vessel 30 and measures the pressure of the blood flowing within vessel 30.
  • a second pressure sensor 120b may be coupled to catheter 110 at a location that is posterior or proximal to the expandable chamber 130.
  • Pressure sensor 120b may preferably be used in conjunction with sensor 120a to obtain the differential pressure across expandable chamber 130; i.e., the difference between the pressure in the region that is distal to expandable chamber 130 and the pressure in the region that is proximal to expandable chamber 130.
  • the construction and integration of sensors 120a and 120b into the catheter 110 may resemble that disclosed in U.S. Patent 7,231,829 to Michael Schugt, which is hereby incorporated by reference in its entirety.
  • Sensor 120b operably measures the blood pressure within a body region 20 that is in fluid communication with vessel 30.
  • region 20 is an atrial chamber adjacent the vessel 30. Accordingly, a computation of the differential pressure in vessel 30 and region 20 can be computed based on the pressure measurements of sensors 120a and 120b. In another embodiment, region 20 may simply be a location that is more distal within vessel 30.
  • sensors 120a and 120b have been disclosed in relation to pressure sensors, other forms of sensors may alternatively be used to measure other physiologic and hemodynamic parameters in either or both of region 20 and vessel 30.
  • sensors such as a temperature sensor (FIG. 7), flow sensor (FIG. 9), an optic sensor, a force sensor, or an electrical sensor or any other suitable sensor known in the art may be substituted.
  • Catheter 110 may also include a strain gauge 121 that may be coupled to the expandable chamber 130.
  • the strain gauge 121 functions to measure the force exerted on the circumference of the expandable chamber 130. As such, signals obtained by strain gauge 121 can provide an indication of whether the expandable chamber 130 has achieved complete circumferential contact with vessel 30 based on the force (contact) between the circumference of the expandable chamber 130 and the vessel 30 wall.
  • System 100 may include an output module 170 that is electrically coupled to first and second pressure sensors 120a, 120b for monitoring information sensed by the first and second pressure sensors 120a, 120b.
  • Output module 170 may include signal processing capability comprising a digital signal processor for receiving input signals from the pressure sensors 120a and 120b. The output module 170 may convert the signals to digital form, process those digital signals, and derive an indication of the differential pressure of the blood pressure in region 20 and vessel 30.
  • the signal processor may correlate the differential pressure computation with a predetermined value.
  • the pressure signal waveform in the vessel 30 converts from the pressure signal waveform of region 20 to that of isolated vessel 30.
  • the predetermined value may be obtained by subtracting the signal waveform of the pressure signal in region 20 from the pressure in vessel 30. Computations of the differential pressure measured in vessel 30 and region 20 may be continuously performed and compared against the predetermined value.
  • the results of differential pressure computation of the pressure in region 20 and vessel 30 may be delivered to a user via display 171. Additionally or alternatively, the raw signals sensed by pressure sensors 120a and 120b may be received by output module 170 and displayed in raw signal waveform on display 171.
  • output module 170 may provide an indication to a user, such as a clinician of whether or not occlusion has been achieved or if changes have arisen based on the sensed signals.
  • output module 170 may include a tactile alarm 173 that is worn by the clinician to provide a vibratory signal to the physician when the signals indicate changes in the level of occlusion.
  • Output module 170 may also activate an audible alarm in response to occlusion changes to alert the clinician to indications of possible changes that may require readjustment of the position of catheter 110 or even termination of the process.
  • light indicators can be used to instruct the physician about the level of occlusion: for example, a green light indicating occlusion, an orange light indicating partial occlusion and a red light indicating no occlusion.
  • Catheter 110 may additionally include one or more sensors 152a, 152b for sensing electrical activity of the tissue adjacent the sensors 152a, 12b. Electrical activity signals sensed by sensors 152a, 152b facilitate mapping of the conduction pathways in the tissue. The sensors 152a, 152b may be coupled to output module 170 that performs the mapping procedure to identify or confirm the location of the tissue exhibiting arrhythmia conditions.
  • FIGS. 3A and 3B illustrate cross sectional views of catheter 110 as it would be used within the vascular system of a patient.
  • FIG. 3 A illustrates catheter 110 with the expandable chamber 130 radially expanded, e.g., by inflation.
  • a guide wire 215 is used for over-the-wire insertion of catheter 110 through the vascular system to vessel 30.
  • the lumen in which the guide wire 215 resides is filled with a fluid such as saline, contrast or body fluid.
  • This configuration allows use of the catheter 110 by insertion through region 20, such as a cardiac chamber to abut vessel 30 exiting the chamber.
  • the expandable chamber 130 is shown positioned to near a desired site at vessel 30. In this orientation, however, expandable chamber 130 will not completely occlude or block the flow of blood from region 20 through vessel 30 because of the interruptions in the circumferential contact with the opening to the interior of vessel 30 at the target site.
  • expandable chamber 130 is shown positioned within vessel 30 in accordance with principles of the present disclosure.
  • Catheter 110 is navigated through the vascular system and with the aid of the measured differential pressure measurements, as discussed in FIG. 2, expandable chamber 130 may be positioned such that its external circumferential surface is in an uninterrupted contact with the opening to the interior of vessel 30.
  • the continuous circumferential contact between the opening of vessel 30 and expandable chamber 130 enables complete occlusion of blood flow within vessel 30.
  • FIGS. 4A and 4B illustrate signal waveforms 310, 312, 314, and 316 of pressure signals indicative of incomplete and complete occlusion.
  • the pressure sensors 120a and 120b may be utilized to measure the blood pressure within vessel 30 and region 20, respectively, to determine whether or not the expandable chamber 130 has achieved complete occlusion.
  • the signal waveforms 310, 312, 314, 316 illustrated in FIGS. 3 A and 3B may be viewed in relation to FIG. 4A and FIG. 4B as described in detail below.
  • the signal waveform 310 corresponds to the pressure of blood flow within region 20 whereas the signal waveform 312 corresponds to the blood flow within vessel 30.
  • FIG. 4B correlates to FIG. 3B where there is a complete occlusion of vessel 30.
  • the signal waveforms 310 and 312 at the proximal and distal location will have identical or substantially identical waveforms for a non-occluded vessel 30.
  • the signal waveforms 314 and 316 at the proximal and distal location will differ when the vessel 30 is occluded.
  • the signal waveforms of the pressure measurement in region 20 and vessel 30 may be processed by output module 170 to provide a visual representation of a composite waveform that aggregates the signal waveforms of both region 20 and vessel 30.
  • output module 170 may perform signal processing of the sensed signals to provide other parameters, including but not limited to text, numerical or graphical representations of the differential pressure.
  • FIG. 5 illustrates a catheter-based ablation system 500 adapted for use in accordance with an alternative embodiment of the present disclosure.
  • An ablation catheter 510 is illustrated as it would be used, in one example, in heart 10 to achieve occlusion of a pulmonary vein 506.
  • a body 515 of the catheter 510 has a proximal portion 517 and a distal portion 516 with a lumen 518 therethrough.
  • An expandable chamber 530 is coupled at the distal portion 516. Expandable chamber 530 may be in fluid communication with lumen 518 to facilitate selective expansion of the expandable chamber 530.
  • the proximal portion 517 includes a handle 511 which may include one or more control knobs and an orifice in communication with the lumen 518.
  • Catheter 510 may be coupled to a console 560 through a tubular connector 509.
  • the connector 509 may be in fluid communication with the lumen 518 to permit pressure wave transmission, via a fluid, from pulmonary vein 506 to connector 509.
  • Console 560 may include control electronics including, but not limited to, a pressure gauge and signal processing circuitry.
  • console 560 processes the mechanical pressure exerted on the distal opening of catheter 510 and transmitted through the fluid in lumen 518.
  • fluid such as saline is supplied into the lumen 518 to substantially fill up the lumen 518.
  • Occlusion of the pulmonary vein 506 by the expandable chamber 530 may be determined based on the mechanical pressure exerted by this blood flow.
  • the blood flow in the pulmonary vein 506 causes a mechanical deflection of the fluid at the distal opening of lumen 518.
  • the mechanical deflection corresponds to the mechanical pressure exerted by the blood flowing adjacent to the distal portion 516.
  • the mechanical deflection of the fluid at the tip of distal portion 516 is transmitted to the proximal portion of catheter 510.
  • This deflection of the fluid in lumen 518 may be sensed and processed by console 560 which is in fluid communication with the lumen 518.
  • a separate pressure gauge/sensor may be coupled to catheter 510 for determination of the mechanical pressure exerted on the distal portion 516.
  • system 500 correlates the mechanical occlusion at a location distal to the expandable chamber 530 to the pressure exerted on the distal portion 516.
  • the mechanical pressure signal corresponding to the pressure exerted on the catheter body 516 may be processed and a result of the processing delivered to the user via display 561.
  • the result displayed may be a graphical, text, numerical, pictorial, or any other suitable indication of the determination of occlusion. Additionally or alternatively, the sensed raw signal waveform may be displayed directly on the display 561.
  • FIGS. 6A, 6B illustrate pressure waveforms of mechanical pressure exerted on the catheter body 515 of FIG. 5. These raw signal waveforms may be provided to the user on display 561.
  • the illustration in FIG. 6A depicts an exemplary pressure waveform 570a of pulmonary vein 506 prior to occlusion by the expandable chamber 530.
  • the pressure in the atrial chamber adjacent the pulmonary vein 506 fluctuates based on the changes in the cardiac phase.
  • the pressure within the first three to five centimeters in the pulmonary vein 506 substantially fluctuates in a similar pattern to the pressure in the adjoining atrial chamber.
  • Pressure waveform 570a includes an atrial A pressure component 571 corresponding to atrial mechanical contraction and a ventricular V pressure component 572.
  • the presence of both the atrial A component 571 and ventricular V component 572 in the pressure waveform 570a monitored in the pulmonary vein 506 indicates that the pulmonary vein 506 is not occluded or at least is only partially occluded.
  • FIG. 6B depicts pressure waveform 570b of a completely occluded pulmonary vein 506.
  • Pressure waveform 570b includes only the ventricular V pressure component 572 with complete disappearance of the atrial A pressure component 571.
  • the conversion of the monitored pressure waveform 570a (FIG. 6A) to the pressure waveform 570b, indicates a complete occlusion by the expandable chamber 530 and hence occlusion of blood flow in the pulmonary vein 506.
  • the absolute pressure monitoring illustrated in the embodiment of FIG. 5 may be inhibited by the flow of the cooling fluid. This is because the cooling fluid flowing in the lumen 518 may be cooled to below a freezing temperature which may prevent the fluid transmission of mechanical deflections indicative of the pressure.
  • a pressure sensor may additionally be coupled to the catheter 510 distal to the expandable chamber 530. It should also be noted that in alternative embodiments, it is contemplated in that one or more of the illustrative embodiments may be combined for use during different phases of an ablation procedure.
  • FIG. 7 illustrates a catheter 610 having a temperature sensor 600 mounted thereon.
  • Temperature sensor 600 includes a conductive element 615 that is coupled to an electrically conductive wire 620 for electrical coupling of the conductive element 615 to electronic circuitry (not shown).
  • the electronic circuitry cooperates with the temperature sensor 600 to sense the temperature of the tissue/environment surrounding temperature sensor 600. The temperature measurements may be used to provide information regarding occlusion. A temperature gradient may be created at the location of the
  • tissue/environment surrounding the temperature sensor 600 by introducing saline through a lumen 625.
  • the saline may be at a higher or lower temperature than the patient's blood/body temperature, provided there is a temperature difference between the surrounding blood and/or tissue/environment and the saline.
  • cold saline at a temperature in the range of about twenty degrees Celsius to thirty-five degrees Celsius may be used.
  • appropriate temperature profiles as measured by the temperature sensor 600 can be obtained for the case of occlusion, partial occlusion or no occlusion. These profiles can be incorporated into the console (not shown) and compared with real-time measurements to determine occlusion.
  • a large temperature change e.g., greater than five degrees Celsius, as measured by the temperature sensor 600 may be associated with complete occlusion whereas a temperature change of two degrees Celsius or less may be associated with no occlusion. Temperature differences between two and five degrees Celsius may be designated as corresponding to partial occlusion.
  • temperature variances noted above are merely illustrative and as a matter of routine use, temperature profiles tailored to specific classes of patients can easily be obtained.
  • conductive element 615 may serve a dual function, i.e., as a sensor and an electrode. As such, conductive element 615 may be used for electrical mapping or may be used to provide information about tip location during navigation.
  • FIG. 8 depicts temperature profiles 700, 710 generated from temperature sensor 600.
  • catheter 610 is advanced into a desired chamber and an expandable chamber 630 is positioned adjacent the target tissue.
  • Saline is injected into lumen 625 of the catheter 610 and exits through a distal opening of catheter 610.
  • the saline may be at a higher or lower temperature than the patient's blood/body temperature. In this example, the saline is at a lower temperature.
  • the illustration of temperature profile 700 indicates an occluded vessel. If the desired vessel is occluded, the saline will displace or mix with the stationary blood, which has a known temperature— typically, about thirty-seven degrees Celsius— creating a decrease in the temperature measured by the temperature sensor 600.
  • temperature profile 710 indicates a vessel that has not been occluded. If the vessel is not occluded, the saline will be entrained by the blood flowing past the expandable chamber 630, resulting in no or insignificant change in the temperature profile around the conductive element 615.
  • FIG. 9 illustrates a catheter 810 having a flow sensor 800.
  • Flow sensor 800 has a proximal conductive element 805a and a distal conductive element 805b.
  • Conductive element 805a is coupled to electrically conductive wire 815a while conductive element 805b is coupled to electrically conductive wire 815b.
  • Each of wires 815a, 815b is electrically coupled to electronic circuitry (not shown) for obtaining output signals from the conductive elements 805a, 805b.
  • flow sensor 800 is a calorimetric flow measuring device such as that disclosed in U.S. 6,539,791 issued to Weber and U.S. 5,390,541 issued to Feller both of which are incorporated herein by reference in their entirety.
  • Catheter 810 also includes an expandable chamber 830 which is constructed in accordance with the description of expandable chamber 130 (FIG. 2). In accordance with an exemplary method of use, catheter 810 is navigated to the desired chamber and expandable chamber 830 placed adjacent the target vessel to occlude blood flow as generally described above.
  • operation of flow sensor 800 is characterized as follows: if there is no flow and the fluid is stationary (as in the case of an occluded vessel), there will be a constant temperature difference between the proximal conductive element 805a and the distal conductive element 805b.
  • the temperature of the distal element 805b will correspond generally to the temperature of the heat source and the temperature of the proximal element 805a will correspond generally to the temperature of the stationary blood.
  • FIG. 10 shows a flow diagram illustrating a process of performing an ablation using the catheters of the present disclosure.
  • the process may be initiated with the placement 400 of any one of the catheters (110, 510, 610, or 810) of the present disclosure into a region 20, such as the left atrium with the corresponding expandable chamber (130, 530, 630, or 830) positioned to abut a vessel 30 such as a pulmonary vein or ostium.
  • the expandable chamber may be expanded to a desired size prior to contact with vessel 30.
  • a physiologic parameter may be measured to guide the positioning of expandable chamber in vessel 30 as described above in reference to the various embodiments of the catheters. In the case of catheter 110, the physiologic parameter measured is the differential pressure.
  • the physiologic parameter measured is the absolute pressure.
  • the physiologic parameter measured is temperature.
  • the physiologic parameter measured is flow.
  • the physiologic parameter is evaluated to confirm whether the signal information is indicative of an appropriate placement of the expandable chamber 130 that denotes that complete occlusion has been achieved.
  • the evaluation may be performed on the raw sensed signal or information derived from processing the sensed signal. In either event, if the sensed signal is not acceptable, the catheter 110 may be manipulated 420 with the aid of the sensed signals to abut the vessel 30 and achieve complete occlusion.
  • the manipulation may include torquing, advancing, retracting, repositioning, inflating, or deflating the expandable chamber 130.
  • the tissue ablation may be initiated at step 430 upon confirmation that the expandable chamber 130 has achieved complete occlusion.
  • a cooling fluid may be circulated through catheter 110 by console 60 into expandable chamber 130.
  • the energy transfer phenomenon is utilized to create a net transfer of heat from the target tissue on vessel 30 into the cooling fluid. Because of the circulation of cooling fluid by console 60, energy is extracted from the target tissue by the cooling fluid.
  • the rate and magnitude of energy transfer can be controlled by the controls on handle 111.
  • a count of a predetermined duration for circulating the cooling fluid may also be initiated.
  • RF energy may be delivered from console 60 via electrodes to form the lesions on the desired tissue.
  • Step 440 denotes an optional process of continual, intermittent or on-demand monitoring of the physiologic parameter to determine the occlusion of the vessel 30.
  • the optional monitoring of the physiologic parameter at step 440 may facilitate the
  • determination of occlusion of vessel 30 during the ablation procedure Determining whether vessel 30 is continuously occluded during the tissue ablation may be useful because blood flow during the procedure may be undesirable. This is because the blood flow may inhibit effective cooling of the target tissue of vessel 30 due to the presence of heat in the flowing blood or in the case of RF energy, the blood may lower the temperature of the delivered energy. If the monitored physiologic parameter at step 440 indicates that vessel 30 is properly occluded, the ablation is continued 460.
  • the process determines whether the predetermined duration for delivery of the cooling fluid has elapsed. If the duration has not elapsed, the system will maintain the monitoring of the physiologic parameter at step 440 to determine whether the vessel 30 is still completely occluded.
  • the monitored physiologic parameter at step 440 may indicate the recurrence of blood flow. Responsive to the indication of recurrence of blood flow at 440, various adjustments 450 may be performed. For instance, the catheter 110 may be repositioned and/or the temperature or flow rate of the cooling fluid may be modified.
  • the physiologic parameter measurement may be utilized in conjunction with an imaging procedure.
  • imaging may be performed through fluoroscopy to verify proper placement and complete occlusion of the blood vessel 30.
  • the physiologic parameter measurements may significantly reduce the imaging time thereby reducing exposure of the patient and clinician to radiation waves of the imaging procedure.
  • the present disclosure may also be used in combination with devices that deliver one or more forms and types of energy for ablation therapy including but not limited to: sound energy such as acoustic energy and ultrasound energy; electromagnetic energy such as electrical, magnetic, microwave and radiofrequency energies; thermal energy such as heat energy; chemical energy such as energy generated by delivery of a drug; laser or light energy such as infrared and visible light energies; mechanical and physical energy;
  • sound energy such as acoustic energy and ultrasound energy
  • electromagnetic energy such as electrical, magnetic, microwave and radiofrequency energies
  • thermal energy such as heat energy
  • chemical energy such as energy generated by delivery of a drug
  • laser or light energy such as infrared and visible light energies
  • mechanical and physical energy including but not limited to: sound energy such as acoustic energy and ultrasound energy; electromagnetic energy such as electrical, magnetic, microwave and radiofrequency energies; thermal energy such as heat energy; chemical energy such as energy generated by delivery of a drug; laser or light energy such as infrared and visible light energies; mechanical and physical energy;
  • the patient's phrenic nerve may be paced prior to measurement of the physiologic parameter.
  • Methods and devices for phrenic nerve stimulation are known in the art and include U.S. Patent 7,225,019, issued to Jahns, et al., which is incorporated herein by reference in its entirety.

Abstract

La présente invention concerne des dispositifs médicaux et des méthodes de dérivation d'une indication d'occlusion d'un vaisseau sanguin à partir d'un ou de plusieurs capteurs physiologiques. Les paramètres physiologiques envisagés pour la mise en œuvre conformément à des modes de réalisation de l'invention peuvent comprendre la pression, le débit, la force, la température ou la tension. Un dispositif donné à titre d'exemple comprend un cathéter doté d'une chambre gonflable reliée à une partie d'extrémité distale de la tige de cathéter. Dans divers modes de réalisation, un ou plusieurs capteurs physiologiques peuvent être disposés sur la tige de cathéter et couplés électriquement à une électronique de commande qui peut être prévue dans une console afin de mesurer un signal physiologique. En variante, un capteur externe peut être disposé en communication fluidique avec une lumière du cathéter pour permettre la dérivation d'un paramètre physiologique, tel que la pression, via un accouplement mécanique de pression, disposé de manière distale par rapport à la chambre gonflante, au fluide dans la lumière. Les paramètres mesurés par le ou les capteurs physiologiques fournissent une mesure des paramètres physiologiques dans au moins une première région. Le paramètre physiologique mesuré dans la première région est évalué pour permettre l'obtention d'une indication d'occlusion distale de la chambre gonflable. Dans d'autres modes de réalisation, des mesures des paramètres physiologiques peuvent être réalisées dans la première région et dans une seconde région, pour dériver des mesures différentielles qui sont évaluées afin de permettre l'obtention d'une indication d'occlusion.
PCT/US2010/059795 2009-12-11 2010-12-10 Dispositifs d'occlusion veineuse et méthodes d'ablation à base de cathéter WO2011072186A1 (fr)

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EP3626168A1 (fr) 2013-05-24 2020-03-25 Medyria AG Agencement de capteur de débit et procédé d'utilisation d'un agencement de capteur de débit
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CA2785814A1 (fr) 2011-06-16
EP2512329B1 (fr) 2017-07-12
EP2512329A1 (fr) 2012-10-24
CA2785814C (fr) 2017-11-07
US20110144637A1 (en) 2011-06-16

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