Integrated heart valve delivery system

Integrated heart valve delivery system

5 COUNTRYSIDE

The present application refers to embodiments of a system for delivering a prosthetic valve to a heart through the patient's vasculature.

10 BACKGROUND

Endovascular carrier catheters are used to implant prosthetic devices, such as a prosthetic valve, in locations inside the body that are not easily accessible by a surgeon or where access without surgery is desirable. The utility of carrier catheters is largely limited by the capacity

fifteen of the catheter to successfully navigate through the small vessels and around the narrow folds of the vasculature, such as around the aortic arch.

Known delivery devices include a balloon catheter having an inflatable balloon that mounts a prosthetic valve in a pressed state and a retractable cover that extends over the valve to protect the interior walls 20 of the vasculature as the valve advances to the site of implantation. Various techniques have been used to adjust the curvature of a section of the delivery apparatus to help "direct" the valve through the folds of the vasculature. The balloon catheter may also include a tapered tip portion mounted distal to the balloon to facilitate travel through the vasculature. However, the tip portion increases the length of the relatively rigid and non-addressable section of the apparatus. Unfortunately, due to the relatively rigid section

25 long, the successful delivery of a prosthetic valve through a tortuous vasculature, such as that required for retrograde delivery of a prosthetic aortic heart valve, has proven difficult.

A known technique for adjusting the curvature of a delivery apparatus employs a traction cable that has a distal end fixedly attached to the steerable section and a proximal end operatively connected to a

30 adjustment knob located outside the body. The rotation of the adjustment applies a tensile force on the traction cable, which in turn causes the airship section to bend. The rotation of the adjustment knob produces a movement of less than 1: 1 of the traction cable; that is, the rotation of the knob does not produce an equivalent movement of the airship section. To facilitate steering, it will be desirable to provide an adjustment mechanism that can substantially produce a 1: 1 movement of the airship section.

35 The use of an introducer to safely insert a delivery device into the patient's vasculature (eg, the femoral artery) is also known. An introducer has an elongated sleeve that is inserted into the vasculature and a seal housing that contains one or more sealing valves that allow a delivery device to be placed in fluid communication with the vasculature with minimal blood loss. An introducer

40 Conventional typically requires a tubular magazine to be inserted through the seals in the introducer housing to provide an unobstructed path through the seal housing for a valve mounted on a balloon catheter. A conventional charger extends from the proximal end of the introducer and, therefore, decreases the available working length of the delivery apparatus that can be inserted through the introducer and into the body.

Four. Five In addition, US 2005/0283231 A1 describes an everted heart valve. The device includes a replacement valve and an expandable anchor configured for endovascular delivery in close proximity to the patient's heart valve. The replacement valve is adapted to wrap around the anchor outward during endovascular deployment. The apparatus additionally includes a balloon catheter that can

fifty advancing with respect to the valve, while the valve is in a partially deployed state at an implantation site in a patient's body, in which the balloon can then be inflated to fully deploy the replacement valve at said implantation site.

Therefore, there is still a need in the art for improved endovascular systems to implant 55 valves and other prosthetic devices.

SUMMARY

The present invention is intended to provide an apparatus for treating a defective heart valve in a patient, comprising a delivery system for a prosthetic heart valve. The present invention relates more specifically to the problem of reducing the maximum external diameter of said delivery system and facilitating the placement of the prosthetic valve inside the body.

5 The underlying problem of the present invention has been solved by the subject matter of independent claim 1. Preferred embodiments are subject to the dependent claims.

Certain embodiments of the present disclosure provide a heart valve delivery apparatus for delivering a prosthetic heart valve to a native valve site through the human vasculature. The apparatus of

10 Delivery is particularly suitable for advancing a prosthetic valve through the aorta (i.e., in a retrograde approach) to replace a native stenotic aortic valve.

The delivery apparatus includes a balloon catheter that has an inflatable balloon that can advance with respect to a pressed valve and is suitable for delivery through the patient's vasculature. The delivery apparatus may include a guide, or flexible catheter, which has an axis extending over the axis of the balloon catheter. The axis of the guide catheter has an airship section, whose curvature can be adjusted by the operator to facilitate navigation of the delivery apparatus around the folds of the vasculature. The delivery apparatus may also include a nose catheter having an axis extending through the axis of the balloon catheter and a nose piece located distally from the valve. The nose piece desirably has a tapered outer surface and is made of a

twenty Flexible material to provide a traumatic path through the arteries and a native stenotic valve. The nose piece desirably has an internal hole that is sized to receive at least a distal end portion of the deflated balloon during delivery of the valve.

By inserting a portion of the balloon into the nose piece, the length of the non-addressable section of the delivery device

25 it can be reduced (for example, from about 1.5 to 2.0 centimeters in some examples), which greatly improves the travel capability of the delivery apparatus through the aortic arch with little or no contact between the end of the apparatus Delivery and internal walls of the aorta. Once the delivery apparatus has advanced to the implantation site, the nose catheter can move distally with respect to the balloon catheter to remove the balloon from the nose piece so as not to interfere with inflation of the balloon.

30 The guide catheter shaft may be provided with a cap at its distal end to cover a portion of the balloon and / or the valve that has not yet been covered by the nose piece. The lid may extend over the remaining portion of the balloon and the valve that is not covered by the nose piece. In this way, the entire outer surface of the valve and the balloon are hidden by the nose piece and the cap. Consequently, an introducer does not need to be used to

35 Insert the delivery device into the patient's vasculature. Unlike an introducer, the lid needs to be in contact only with the femoral and iliac arteries for only a short period of time, and this minimizes the possibility of damaging these vessels. Additionally, by eliminating the introducer, the maximum diameter of the system can be reduced and, therefore, is less occlusive for the femoral artery.

40 In a variation of the delivery apparatus, the nose piece has an internal hole sized to receive the entire valve and substantially the entire balloon during delivery of the valve. Therefore, the cover attached to the end of the guide catheter need not be provided. In another variation, the guide catheter cap extends completely over the valve and the balloon, and the nose catheter is not provided. The lid can be an expandable mesh basket that can contract around the valve and the balloon to provide a uniform travel profile. The basket of

Four. Five Mesh can be expanded by the operator, such as pulling one or more traction cables, which dilates a distal opening in the mesh basket allowing the balloon and valve to advance from the basket for deployment.

As indicated above, the guide catheter desirably has an airship section that can be folded or folded by the operator to assist the delivery apparatus in the travel around the folds of the vasculature. The guide catheter can be provided with a manually operated adjustment mechanism that substantially produces a 1: 1 movement of the airship section. At said ends, the adjustment mechanism may include a rotating lever that is operatively coupled to the addressable section through a traction cable that extends through a lumen in the axis of the guide catheter. The rotation of the lever functions like a pulley, which retracts the traction cable, substantially producing a 1: 1 movement of the airship section. He

55 Turning the lever in the opposite direction releases tension in the traction cable, and the elasticity of the airship section causes the airship section to regain its normal unfolded shape.

In cases where an introducer is used to assist in inserting the delivery apparatus into the patient's vasculature, the introducer may be provided with an integrated loading tube that extends into the seal housing of the introducer. The loading tube is connected to an end piece coupled to the distal end of the seal housing. The final piece can move along the length of the seal housing between a first extended position in which the loading tube is separated from the sealing valves in the seal housing and a second retracted position in which the loading tube is extends through the sealing valves to

5 provide an unobstructed path for a valve mounted on a balloon catheter. Since the loading tube does not extend behind the end piece, the loading tube does not reduce the available working length of the delivery apparatus that can be inserted through the introducer and into the vasculature.

In an example not included in the claims, an apparatus for delivering a prosthetic valve through the

10 A patient's vasculature comprises a balloon catheter, a guide catheter and a nose catheter configured to move longitudinally with respect to each other. The balloon catheter comprises an elongated shaft and a balloon connected to a distal end portion of the shaft, the balloon being adapted to carry the valve to a pressed state and being inflatable to deploy the valve at an implantation site in the patient's body . The guide catheter comprises an elongated shaft extending over the axis of the balloon catheter, comprising the catheter shaft

fifteen Guide an airship section. The guide catheter further comprises an adjustment mechanism operatively coupled to the airship section. The adjustment mechanism is configured to adjust the curvature of the airship section and the shaft portion of the balloon catheter that extends through the airship section. The nose catheter comprises an elongated shaft that extends through the shaft of the balloon catheter and a nose piece connected to a distal end of the nose catheter shaft. The nose piece has an internal hole adapted to receive the

twenty minus a portion of the distal end of the balloon in a deflated state during delivery of the valve.

A method of implanting a prosthetic valve at an implantation site in a patient's body is further described, which comprises placing the valve in an inflatable balloon of a balloon catheter of a delivery apparatus and inserting at least a portion of the distal end of the balloon in a piece of catheter nose

25 nose of the delivery device. Then, the balloon catheter and the nose catheter are inserted into the body and advanced through the patient's vasculature. At or near the implantation site, the nose catheter moves distally with respect to the balloon catheter to discover the portion of the balloon inside the nose piece and, after this, the valve can be deployed at the implantation site inflating in ball.

30 A method of implanting a prosthetic valve at the implantation site in the body of a patient is further described, which comprises placing the valve in a pressed state in the distal end portion of an elongated delivery apparatus and advancing the delivery apparatus. through the vasculature of the patient. After the act of advancing the delivery apparatus, the pressed valve is moved on the inflatable balloon of the distal end portion of the delivery apparatus and then deployed at the implantation site by inflating the balloon.

35 The present invention refers to an apparatus for delivering a prosthetic valve through a patient's vasculature comprising a balloon catheter and a nose catheter. The balloon catheter comprises an elongated shaft, a balloon connected to a distal end portion of the shaft, and a tapered wedge connected to the distal end portion adjacent to the balloon. The nose catheter comprises an elongated shaft that extends to

40 through the axis of the catheter with balloon, the ball and the wedge. The nose catheter additionally includes a nose piece connected to a distal end of the nose catheter shaft. The valve can be mounted in a pressed state between the nose piece and the wedge. The nose piece can be retracted proximally to push the valve over the wedge and over the ball, the wedge partially expanding the valve before it is placed on the ball.

Four. Five In another example, a guide catheter for an endovascular delivery apparatus comprises an elongated shaft having an airship section, a handle comprising a rotating lever and a traction cable. The traction cable has a proximal end portion coupled to the lever and a distal end portion fixedly attached to the addressable section, such that the rotary movement of the lever applies a tensile force on the traction cable for make the airship section fold.

fifty In another example, an endovascular delivery apparatus comprises a balloon catheter comprising an elongated shaft and a balloon connected to a distal end portion of the shaft. A guide catheter comprises an elongated shaft comprising an internal polymeric tubular liner having a lumen with a size that allows the insertion of the balloon and the axis of the balloon catheter through it. The shaft additionally comprises a layer of

55 braided metal that surrounds the tubular lining, and an outer polymeric layer that surrounds the braided metal layer.

In another example, a method for making a catheter comprises making an inner tubular layer of a polymeric material, the inner tubular layer having a lumen with a dimension that allows a balloon of a balloon catheter to pass through it, making a conduit of tubular tensile cable of a polymeric material, place the conduit and the inner tubular layer side by side in a parallel relationship with each other, forming a braided metal layer around the conduit and the inner tubular layer, and forming an external polymeric layer around the braided metal layer.

5 In another example, an introducer comprises an elongated tubular sleeve that has a lumen and is adapted to be inserted into a patient's vasculature, a sealing housing comprising an internal hole in communication with the lumen of the sleeve and one or more sealed sealing valves in the hole, and an end piece coupled to the seal housing opposite the sleeve. The final piece comprises a magazine tube that extends

10 in the hole and can move along a length of the seal housing to move the magazine tube from a first position separated from one or more sealing valves to a second position in which the magazine tube extends through the sealing valves

The foregoing and other features and advantages of the invention will be more apparent from the following detailed description, which proceeds with reference to the attached figures.

BRIEF DESCRIPTION OF THE DRAWINGS

Figure 1 is a side view of an endovascular delivery apparatus for implanting a prosthetic valve.

twenty Figure 2 is a side view of the balloon catheter of the delivery apparatus of Figure 1, partially shown in section.

Figure 2B is an enlarged cross-sectional view of the balloon catheter shown in Figure 2A, taken along the length of the catheter.

Figure 3A is a cross-sectional view of the guide catheter of the delivery apparatus of Figure 1, taken along a plane that extends along the guide catheter.

30 Figure 3B is a cross-sectional view of the guide catheter, taken along a plane that is perpendicular to the plane defining the cross-sectional view shown in Figure 3A.

Figure 4A is a cross-sectional view of the nose catheter of the delivery apparatus shown in Figure 1, taken along the length of the nose catheter. Figure 4B is an enlarged cross-sectional view of the nose catheter.

Figures 5A and 5B are cross-sectional and perspective views, respectively, of a sliding nut used in the handle portion of the guide catheter.

40 Figures 6A and 6B are perspective and side views, respectively, of an inner sleeve used in the handle portion of the guide catheter.

Figure 7A is a cross-sectional view of a guide catheter taken along its length. Figure 7B is a cross-sectional view of the guide catheter shown in Figure 7A.

Figure 7C is an enlarged longitudinal cross-sectional view of the distal end portion of the guide catheter shown in Figure 7A.

fifty Figures 8A-8C are cross-sectional views of the distal end portion of the delivery apparatus of Figure 1, illustrating the operation thereof to implant a prosthetic valve.

Figure 9 is a side view of an endovascular delivery apparatus for implanting a prosthetic valve. Figure 10A is a side view of the introducer of the delivery apparatus shown in Figure 9.

Figure 10B is a side view of the introducer of Figure 10A partially shown in section.

Figure 10C is a view from one end of the introducer of Figure 10A. Figure 11 is a perspective view of a guide catheter.

5 Figure 12 is a top plan view of the guide catheter of Figure 11. Figure 13 is a side plan view of the guide catheter of Figure 11. Figure 14 is an exploded perspective view of the guide catheter of Figure 11.

10 Figure 15 is a partial cross-sectional view of the guide catheter of Figure 11. Figures 16A and 16B are perspective views of a pulley used in the guide catheter of Figure 11.

fifteen Figure 17 is a perspective view of a lever portion used in the guide catheter of Figure 11. Figures 18A and 18B are partial cross-sectional views of the guide catheter of Figure 11 illustrating the operation of an adjustable lever for Adjust the curvature of the guide catheter.

twenty Figure 19A is a perspective view of the distal end portion of a nose catheter. Figures 19B and 19C are cross-sectional views illustrating the operation of the nose catheter shown in Figure 19A.

25 Figure 20A is a side plan view of the distal end portion of a delivery apparatus. Figure 20B is a cross-sectional view of the guide catheter of the delivery apparatus of Figure 20A. Figures 21A-21C are cross-sectional views of a delivery apparatus according to the invention that

30 they illustrate its operation to implant a prosthetic valve. Figures 22A and 22B are cross-sectional views of the distal end portion of a delivery apparatus. Figure 23A shows a cross-sectional view of an introducer and an exemplary delivery apparatus that

35 It can be introduced into a patient's vasculature through the introducer. Figure 23B is a cross-sectional view of the introducer of Figure 23A after insertion of the delivery apparatus into the introducer.

40 Figures 24A-24B are cross-sectional views of a delivery apparatus. Figures 25A-25E schematically illustrate a delivery apparatus. Figures 26A-26E schematically illustrate an introducer.

DETAILED DESCRIPTION

Figure 1 shows a delivery apparatus (10) adapted to deliver a prosthetic heart valve (12) (for example, a prosthetic aortic valve) to a heart. The apparatus (10) generally includes an airship guide catheter

fifty (14) (also called flexible catheter), a balloon catheter (16) that extends through the guide catheter (14), and a nose catheter (18) that extends through the balloon catheter (16) . The guide catheter (14), the balloon catheter (16) and the nose catheter (18) are adapted to slide longitudinally with respect to each other to facilitate delivery and placement of the valve (12) at an implantation site in a patient's body, as described in detail below.

55 The guide catheter (14) includes a handle portion (20) and an elongated guide tube or shaft (22) extending from the handle portion (20). The balloon catheter (16) includes a proximal portion (24) adjacent to the handle portion (20) and an elongated shaft (26) extending from the proximal portion (24) and through the handle portion

(20) and the guide tube (22). An inflatable balloon (28) is mounted on the distal end of the balloon catheter. The valve (12) is shown mounted on the balloon (28) in a pressed state that has a deducted diameter for delivery to the heart through the patient's vasculature.

The nose catheter (18) includes an elongated shaft (30) that extends through the proximal portion (24), the shaft (26) and the balloon (28) of the balloon catheter. The nose catheter (18) additionally includes a nose piece (32) mounted on the distal end of the shaft (30) and adapted to receive a distal end portion of the balloon when the apparatus

(10) is used to advance the valve through the patient's vasculature to the implantation site.

As can be seen in Figures 2A and 2B, the balloon catheter (16) in the illustrated configuration includes

10 additionally an internal axis (34) (Figure 2B) extending from the proximal portion (24) and coaxially through the external axis (26) and the balloon (28). The balloon (28) can be held in a distal end portion of the inner shaft

(34) extending outwardly from the outer shaft (26) with a proximal end portion (36) of the balloon attached to the distal end of the outer shaft (26) (for example, with a suitable adhesive). The outer diameter of the inner shaft (34) is sized so that an annular space is defined between the inner and outer axes along the entire length of the

fifteen external shaft length. The proximal portion (24) of the balloon catheter may be formed with a fluid passage

(38) which can be fluidly connected to a fluid source (for example, a water source) to inflate the balloon. The fluid passage (38) is in fluid communication with the annular space between the inner shaft (34) and the outer shaft (26) such that fluid from the fluid source can flow through the fluid passage (38 ), through the space between the axes, and in the balloon (28) to inflate it and deploy the valve (12).

twenty The proximal portion (24) also defines an internal lumen (40) that is in communication with a lumen (42) of the internal axis (34). The lumens (40, 42) in the illustrated embodiment are sized to receive the shaft (30) of the nose catheter. The balloon catheter (16) may also include a coupler (44) connected to the proximal portion (24) and a tube (46) extending from the coupler. The tube (46) defines an internal passage that communicates fluidly with

25 the lumen (40). The balloon catheter (16) may also include a sliding support (48) connected to the proximal end of the coupler (44). The sliding support (48) supports and cooperates with an adjustment ring (50) (Figures 1 and 4A4B) of the nose catheter (18) to allow the nose catheter to be maintained in selected longitudinal positions with respect to the balloon catheter ( 16), as described in more detail below.

30 As shown in Figure 2A, the outer surface of the outer shaft (26) may include one or more annular grooves

<dl><dt /><dd>or notches (52a, 52b, 52c) separated from each other along the proximal end portion of the shaft (26). The grooves cooperate with a locking mechanism (84) of the guide catheter (14) (Figures 3A-3B) to allow the guide catheter</dd></dl>

<dl><dt>(14)</dt><dd> stay in the selected longitudinal positions with respect to the balloon catheter (16), as described in more detail below. </dd></dl>

35 The inner shaft (34) and outer shaft (26) of the balloon catheter can be made of any various suitable materials, such as nylon, braided stainless steel cables, or a polyether block amide (commercially available as Pebax®). The shafts (26, 34) may have longitudinal sections formed of different materials in order to vary the flexibility of the shafts along their lengths. The inner shaft (34)

40 it can have an internal lining or formed layer of Teflon® to minimize sliding friction with the nose catheter shaft (30).

The guide catheter (14) is shown in more detail in Figures 3A and 3B. As discussed above, the guide catheter (14) includes a handle portion (20) and an elongated guide tube, or shaft, (22) that extends distally

Four. Five from it. The guide tube (22) defines a lumen (54) sized to receive the outer shaft (26) of the balloon catheter and allow the balloon catheter to slide longitudinally with respect to the guide catheter. The distal end portion of the guide tube (22) comprises an airship section (56), whose curvature can be adjusted by the operator to assist in guiding the apparatus through the patient's vasculature, and in particular, the aortic arch.

fifty The guide catheter desirably includes a cap, or cover, (23) attached to the distal end of the guide tube (22). Cover

(23) in particular embodiments it has a size and shape to receive the valve (12) pressed around the balloon and rest on the proximal end surface of the nose piece (32), which is adapted to cover a distal end portion of the balloon (28) (as shown in Figure 8A). Therefore, when the apparatus advances to the deployment site, the valve (12) and the balloon (28) can be completely enclosed within the cover (23) and the workpiece

55 nose (32).

As further shown in Figures 3A and 3B, the handle portion (20) includes a main body, or housing, (58) formed with a central lumen (60) that receives the proximal end portion of the guide tube (22) . The handle portion (20) may include a side arm (62) that defines an internal passage that fluidly communicates with the lumen (60). A stopcock 63 can be mounted on the upper end of the side arm (62).

The handle portion (20) is operatively connected to the airship section (56) and functions as an adjustment to allow the operator to adjust the curvature of the airship section (56) through a manual adjustment of the handle portion . For example, the handle portion (20) includes an inner sleeve (64) surrounding a portion of the guide tube

(22) inside the handle body (58). A threaded sliding nut (68) is arranged in and can slide with respect to the sleeve (64). The sliding nut (68) is formed of external threads that match the internal threads of an adjustment knob (70).

10 As best shown in Figures 5A and 5B, the sliding nut (68) is formed of two grooves (76) formed on the inner surface of the nut and extending the length thereof. As best shown in Figures 6A and 6B, the sleeve (64) is also formed of longitudinally extending grooves (78) that are aligned with the grooves (76) of the sliding nut (68) when the sliding nut is placed in the cuff In each slot (78) there is a respective elongated nut guide (66a, 66b) (Figure 3B), which can be in shape

fifteen of an elongated rod or pin. The nut guides (66a, 66b) extend radially in the respective grooves

(76) on the sliding nut (68) to prevent rotation of the sliding nut (68) with respect to the sleeve (64). Under this arrangement, the rotation of the adjustment knob (70) (clockwise or counterclockwise) causes the sliding nut (68) to move longitudinally with respect to the sleeve (64) in the directions indicated by the double headed arrow (72).

twenty One or more traction cables (74) connect the adjustment knob (70) to the airship section (56) to produce a movement of the airship section after the adjustment knob is rotated. The proximal end portion of the traction cable (74) can extend in and can be fixed to a retaining pin (80) (Figure 3A), such as pressing the pin (80) with respect to the traction cable. The plug (80) has a slot (82) in the sliding nut (68)

25 (as best shown in Figure 5A). The pull cable (74) extends from the plug (80), through a slot (98) in the sliding nut, a slot (100) in the sleeve (64), and in and through a lumen of the cable of traction on the shaft (22) (figure 3A). The distal end portion of the traction cable (74) is fixed to the distal end portion of the airship section (56).

30 The pin (80), which retains the proximal end of the traction cable (74), is clamped in the groove (82) in the sliding nut (68). Therefore, when the adjustment knob (70) is rotated to move the sliding nut (68) in the proximal direction (towards the proximal portion (24) of the balloon catheter), the traction cable (74) also moves in the proximal direction. The traction cable pushes the distal end of the airship section (56) back towards the handle portion, thereby bending the airship section and reducing its radius of curvature. The friction between

35 adjustment knob (70) and the sliding nut (68) is sufficient to keep the tension cable tense, thus retaining the shape of the fold in the airship section if the operator releases the adjustment knob (70). When the adjustment knob (70) is turned in the opposite direction to move the sliding nut (68) in the distal direction, the tension in the tension cable is released. The elasticity of the airship section (56) causes the airship section to recover its normal non-bent shape as tension in the tension cable decreases. Since the traction cable

40 (74) the sliding nut (68) is not fixed, the movement of the sliding nut in the distal direction does not push the end of the traction cable, causing its buckling. Instead, the plug (80) is allowed to float inside the slot

(82) of the sliding nut (68) when the knob 79 is adjusted to reduce tension in the traction cable, avoiding buckling of the traction cable.

Four. Five The airship section (56) in its unfolded form can be slightly curved and in its fully curved position, the airship section can generally be adapted to the shape of the aortic arch. The airship section may be substantially upright in its unfolded position.

The handle portion (20) may also include a locking mechanism (84) that is configured to maintain

fifty the balloon catheter (16) in the longitudinal positions selected with respect to the guide catheter (14). The locking mechanism (84) in the illustrated configuration comprises a button (86) having an opening (88) through which the external axis (26) of the balloon catheter extends. As best shown in Figure 3A, the push button (86) has a distal end portion (90) that is partially received in an internal groove (92). A helical spring (94) disposed in the groove (92) elastically holds and pushes the distal end portion (90)

55 towards the axis (26). The distal end portion (90) can be formed with a small projection (96) that can be placed inside any of the grooves (52a, 52b, 52c) on the shaft (26) (Figure 2A). When one of the grooves is aligned with the projection (96), the spring (94) pushes the projection into the groove to maintain the axis

(26) in the longitudinal position with respect to the guide catheter (as shown in Figure 3A). Since the grooves extend circumferentially completely around the axis (26), the balloon catheter can be rotated with respect to the guide catheter when the longitudinal position of the balloon catheter is locked in place by the button (86). The position of the balloon catheter can be released by pressing the button (86) in front of the deflection of the spring (96) to remove the projection (96) from the corresponding groove in the shaft (26).

5 The handle portion (20) may have other configurations that are adapted to adjust the curvature of the airship section (56). An alternative handle configuration of this type is shown in US Patent Application Pending Processing No. 11 / 152,288 (published as Publication No. US2007 / 0005131). Another handle portion is described below and Figures 11-15 are shown.

10 Figures 7A and 7B show the axis of the guide catheter (22). The shaft (22) comprises an internal tubular liner

(104) made of low friction polymeric material, such as PTFE. The liner (104) is sized to allow a deflated balloon (28) and the shaft of the balloon catheter (26) to be inserted therethrough. A smaller conduit, or sheath, (106), which extends along the outside of the inner sheath (104), defines a lumen through which the traction cable (74) extends. An outer layer (108) surrounds the coatings (104,

fifteen 106) and imparts the desired flexibility and stiffness to the shaft (22).

The outer box (108) comprises a braided layer formed of braided metal cable (110) screwed into the sheath (104) and the conduit (106), and a polymeric material (112) that surrounds and encapsulates the layer of braided metal cable. The shaft can be manufactured by forming the coverings (104, 106), placing the coverings side

twenty side by side in a parallel relationship with each other, winding the metal cable around the liners to form the braided layer, placing a polymeric sleeve over the braided layer, and flowing the sleeve again to form a uniform laminated layer (108) surrounding the coatings The polymeric material (112) may comprise any suitable material, but desirably comprises a thermoplastic elastomer, such as Pebax®. The braided metal layer can be made of stainless steel cable.

25 As best shown in Figure 7A, the shaft (22) desirably comprises a relatively rigid section.

(114) extending from the proximal end (116) of the shaft to the proximal end (118) of the airship section (56). The length of the airship section (56) may comprise approximately ¼ of the total length of the shaft (22). The total length of the shaft (22) can be approximately 45 inches (including the airship section) and the

30 Dirigible section length is approximately 11.7 inches, although the total length of the axle and / or the length of the dirigible section may vary depending on the particular application.

The steerable section (56) of the shaft is desirably formed of a relatively soft durometer material

(112) to allow the airship section to fold after adjusting the adjustment knob (70), as has been

35 previously described. The rigid section (114) is desirably formed of a relatively stiffer polymeric material (112) that resists folding when the tension cable is tensioned by the adjustment knob (70). The rigid section (114) desirably shows sufficient rigidity to allow the operator to push the apparatus (10) through a potentially clogged body vessel. The polymeric material (112) of the airship section may comprise 55D Pebax® and the polymeric material (112) of the remaining section (114) of the shaft comprises 72D Pebax®,

40 which is more rigid than 55D Pebax®.

The metallic braided layer in the airship section (56) can be replaced by a metal coil (for example, a stainless steel coil) disposed in the inner liner (104) to improve the flexibility of the airship section. Therefore, the braided metal layer extends along the rigid section (114) and the metal coil

Four. Five It extends along the airship section (56). The metallic braided layer in the airship section (56) can be replaced by a stainless steel hypotube that is formed by circumferentially laser-cut openings, such as described in US Patent Application Pending Processing No. 11 / 152,288.

fifty As shown in Figure 7C, the distal end of the shaft (22) may include a flared, or elongated, end portion (116). The external diameter D of the final portion (116) is equal to or approximately the same as the external diameter of the pressed valve (12) supported on the balloon (28). Therefore, when the valve (12) advances through an introducer, the final portion (116) pushes the pressed valve (12), instead of the balloon (28). This minimizes accidental movement between the balloon catheter and the valve, which may cause the position

55 of the valve on the ball move. The shaft (22) can have an outer diameter of about 16 F to about 18 F and the final portion (116) has an outer diameter D of about 22 F. The elongated end portion (116) can be made of any of various materials adequate. For example, the final portion

(116) can be molded from Pebax® (for example, 55D Pebax®) and flow back into the final portion of the airship section (56).

As mentioned above, the distal end of the traction cable (74) is fixed at the distal end of the airship section (56). As best shown in Figure 7C, this can be achieved by attaching the distal end portion of the tension cable (74) to a metal ring (118) embedded in the outer layer (108) of the shaft, such as by welding the tension cable to the metal ring.

5 Although not shown in Figures 7A-7C, the guide catheter shaft (22) may include a cap (23) to cover the valve (12) and the balloon (28) (or a portion thereof) during delivery from valvule. As explained below, the use of an introducer may be optional if the valve is covered after insertion into the patient's vasculature.

10 Referring to Figures 4A and 4B, and as previously discussed briefly, the nose catheter

(18) includes an adjustment ring (50) at its proximal end and a nose piece (32) at its distal end, and an elongated shaft (30) extending therebetween. The shaft (30) is desirably formed with a lumen (120) that extends the length of the shaft to receive a guide wire (140) (figure 8A) so that the apparatus (10) can advance over

fifteen the guide wire after it is inserted into the delivery path in the body. As shown in Figures 4A and 4B, the nose piece (32) is desirably formed with an opening or cavity (122) sized and shaped to receive at least a distal end portion of the balloon (28).

As best shown in Figure 4A, the adjusting ring (50) is arranged on and slidable with respect to the support

twenty slide (48) of the balloon catheter, which functions as a locking or retention mechanism to retain the nose catheter in the selective longitudinal positions with respect to the balloon catheter. As explained further, the shaft (30) extends through and is fixedly attached to a shaft support (124) disposed inside the side support (48). The adjusting ring (50) is fixed to the shaft support (124) by screws (126), which extend through the elongated grooves (128a, 128b) in the sliding support (48). The slots (128a,

25 128b) extend longitudinally along the length of the sliding support (48). Therefore, when the adjusting ring (50) slides longitudinally along the length of the sliding support (48) (in the directions indicated by the double headed arrow (130)), the shaft support (124) and the shaft (30) are forced to move in the same direction to adjust the longitudinal position of the nose catheter relative to the balloon catheter.

30 The groove (128a) is formed with circumferentially extending notches (132a-132d) and the groove (128b) is formed with notches that extend circumferentially analogously (134a-134d) opposite the notches (132a-132d). Therefore, for each notch (132a-132d), there is a corresponding diametrically opposite notch (134a-134d) extending from the groove (128b). To maintain the longitudinal position of the

35 nose catheter with respect to the balloon catheter, the adjusting ring (50) is moved to align the screws (126) with a pair of diametrically opposed opposite notches and then rotate slightly until the screws (126) are positioned in the notches. For example, Figure 4A shows the screws (126) located in the notches (132b and 134b). The notches limit the movement of the screws (126) and, therefore, of the shaft support (124) and the shaft (30), in the distal and proximal directions.

40 Each slot (128a, 128b) is formed with four notches. When the screws (126) are placed in the notches (132c, 134c) or in the notches (132d, 134d), the nose piece (32) is held in a position that covers a portion of the distal end of the balloon (28) and that borders the cap (23) of the guide catheter (14) so ​​that the balloon

(28) and the valve (12) are completely closed by the cover (23) and the nose piece (32) (figure 8A). When the

Four. Five screws (126) are located in the notches (132b, 134b), the nose piece (32) is held in a position distally separated from a first distance from the balloon (28) so that the valve can be deployed by inflating the balloon without inference from the nose piece (figure 8C). When the screws are placed in the notches (132a, 134a), the nose piece is held in a position distally separated from a second distance, greater than the first distance, from the balloon (28). In this position, the balloon (28) can be retracted inside the lid (23) (after deployment

fifty of the valve) without interfering with the nose piece.

The valve (12) can take a variety of different forms. Generally, the valve may comprise an expandable stent portion that supports a valve structure. The stent portion desirably has a sufficient radial force to hold the valve at the treatment site and resist the retro-impact of the leaflets of the

55 native stenotic valve. Additional details regarding expandable balloon valves can be found in US Patent Nos. 6,730,118 and 6,893,460, each entitled "IMPLANTABLE PROTESTIC VALVE (IMPLANTABLE PROSTHETIC VALVE)". It will also be appreciated that the delivery system can be used with self-expanding prosthetic valves. For example, when using a self-expanding valve, an impeller can be used to aid in ejection of the self-expanding valve from a delivery sleeve that keeps the valve in its compressed state.

When the valve (12) is used to replace the native aortic valve (or a failed prosthetic aortic valve previously implanted), the valve (12) can be implanted in a retrograde approach in which the valve, mounted

5 in the ball in a pressed state, it is introduced into the body through the femoral artery and advances through the aortic arch to the heart. During use, a guide wire (140) (Figure 8A) can be used to assist in the advancement of the delivery device (10) through the patient's vasculature. The guide wire (140) can be placed in the body vessel through a dilator (not shown), which expands the internal diameter of the body vessel to introduce the delivery device. The dilator diameters vary between, for example, 12 and 22 French.

10 As indicated above, and as shown in Figure 8A, the valve (12) can be placed inside the cover (23) with the nose piece (32) covering the distal end portion of the balloon (28 ) and that borders the distal end of the stage (23). The adjusting ring (50) of the nose catheter can be locked instead of retaining the nose piece (32) against the cap (23) during delivery. In this position, the nose catheter is placed

fifteen Desirably at a slight tension with the nose piece (32) held tightly against the lid (32) to inhibit the separation of the nose piece from the lid while the device travels through the vasculature and during removal of the delivery device from the body .

Advantageously, since the valve (2) is completely covered by the cover (23), it is not necessary to introduce a

twenty introducer to the valve in the body vessel. In an retrograde procedure, an introducer having a diameter of about 22 to 24 French is typically used. In contrast, the cover (23) desirably has an outer diameter that is smaller than the outer diameter of the introducer, and in particular embodiments, the outer diameter of the cover (23) is in the range of about 0.260 inches to about 0.360 inches , a specific example being approximately 0.330 inches. Reducing the overall diameter of the

25 device, is less occlusive for the femoral artery and the patient's leg can remain well perfused during the procedure. Additionally, since the lid (23), which represents the largest diameter of the delivery device, only needs to be in contact with the femoral artery and the iliac artery for a very short period of time, damage to these vessels can be minimized.

30 Although less desirable, the cover (23) may have a shorter length so that less external surface of the valve and the balloon is covered by the cover (23) during delivery. For example, the cover (23) may be sized to extend only over a proximal end portion of the balloon or a proximal end portion of the valve.

35 According to the delivery apparatus (10), it advances along the guide wire (140) and through the aortic arch, the guide catheter (14) is used to "direct" the apparatus away from the internal surface of the aorta. The tapered distal end portion of the nose piece (32) aids in the passage through the femoral and iliac arteries, as well as provides an atraumatic path through the aortic arch and a uniform crossing of the native aortic valve. In the previous delivery system, it is known to fix a nose piece at the distal end of the balloon catheter, which increases the length of

40 the portion of the device that cannot be curved by the handling of a guide catheter. On the contrary, the nose piece

(32) is mounted on a separate nose catheter (18) that can move relative to the valve (12). Therefore, the nose piece (32) can be mounted on the distal end portion of the balloon during delivery in order to minimize the length of the non-addressable section at the distal end of the delivery device. This allows easier travel through the aortic arch with little or no contact between the end of the delivery device and

Four. Five the internal walls of the aorta. The length L (figure 8A) of the non-airship section at the end of the delivery device may be approximately 6 cm or less.

Using conventional fluoroscopy, the operator can traverse the positions of the marker bands (142) (Figures 2A and 2B) on the axis of the guide wire (34) in order to place the valve at the implantation site. After the valve (12) advances to the aortic ring, the nose catheter can move distally with respect to the balloon catheter to advance the nose piece (32) distally away from the balloon (28) (Figure 8B) and The guide catheter can move proximally with respect to the balloon catheter to expose the valve (12) of the cover (23) (Figure 8C). As explained above, the longitudinal positions of the nose catheter and the guide catheter can be fixed with respect to the balloon catheter while the operator adjusts the position of and then deploys

55 the valve (12). Balloon inflation (28) is effective for expanding the valve (12) in order to couple the leaflets of the native valve. Then, the balloon (28) can be deflated and retracted back into the lid (23) and the nose piece (32) can slide back over the distal end portion of the balloon. Then, the entire delivery apparatus can be removed again on the guide wire (140) and removed from the body, after which the guide wire can be removed from the body.

Figure 9 shows an alternative delivery apparatus (10). The guide catheter (1) is not provided with a cover (23) (as previously illustrated in Figures 3A and 3B) and instead an introducer (150) can be used to insert the delivery apparatus into the body. As best shown in Figures 10A and 10B, the introducer (150) includes an introducer housing (152) and an introducer sleeve (154) extending from the housing (152). 5 The housing (152) houses a sealing valve (166). During use, the sleeve (154) is inserted into a body vessel (for example, the femoral artery) while the housing (152) remains outside the body. The delivery apparatus (10) is inserted through a proximal opening (168) in the housing, the sealing valve (166), the sleeve (154) and in the body vessel. The sealing valve (166) is tightly coupled to the outer surface of the guide catheter shaft (22) to minimize blood loss. In certain embodiments, the sleeve (154)

10 It can be coated with a hydrophilic coating and extends in the body vessel approximately 9 inches, just past the iliac bifurcation and in the patient's abdominal aorta.

The sleeve (154) may have a tapered section (156) that is chamfered from a first diameter at a proximal end (158) to a smaller second diameter at a distal end (160). An end portion

fifteen Small diameter distal (162) extends from the tapered portion (156) to the distal end of the sleeve (154). The tapered portion (156) provides a smoother transition between the outer surface of the sleeve (154) and the outer surface of the guide shaft (22) of the guide catheter (14). The tapered portion (156) also allows variable placement of the sleeve (154) in the patient's vasculature to help minimize complete occlusion of the femoral artery.

twenty Figures 11-15 show an alternative handle portion, indicated by the number (200), which can be used in the guide catheter (14) (Figures 1 and 3A), instead of the handle portion (20). The handle portion (200) includes a main housing (202) and an adjustment lever (204) rotatably connected to the housing (202). The lever (204) can be rotated distally and proximally (as indicated by the double headed arrow (206) in the

25 Figure 13) to adjust the curvature of the shaft (22), as will be described further below.

As best shown in Figure 14, the housing (202) may be formed by a first and second housing portions (208, 210) that can be secured together using a suitable adhesive, mechanical clamps, a pressure connection, or other proper techniques. Inside the housing (202) there is a seal housing (212) having a central hole (226) extending therethrough. The distal end portion of the hole (226) may form an elongated portion that receives the proximal end portion (214) of the shaft (22). The shaft (22) extends from the seal housing (212) through the main housing (202) and out of a nose piece (228) connected to the distal end of the main body (202). An end piece (216) can be connected to the proximal end of the seal housing (212) with a seal (218) captured between these two components. As best shown in Figure 15, the final piece (216) may be formed with a stepped hole formed to receive the seal (218) and a final portion of the seal housing (212). The seal (218) may be made of a suitable elastomer, such as silicon. The shaft (26) of the balloon catheter (16) extends through the end piece (216), a central opening in the seal (218), the seal housing (212) and the axis of the guide catheter (22) . The seal housing (212) can be formed with an irrigation port (220) that is in communication

40 fluid with the central hole (226). The irrigation port (220) receives one end of a flexible tube (222). The opposite end of the tube (222) can be connected to a stopcock (224) (figure 11).

As shown in Figure 14, the lever (204) in the configuration illustrated comprises first and second lever portions (230, 232), respectively, mounted on opposite sides of the main housing 45 (202). The internal surface of each lever portion can be formed with an annular groove (274) adapted to receive a respective O-ring (234). The lever portion (230) can be coupled to a pulley (236) mounted in the housing to produce the rotation of the pulley after the rotating movement of the lever portion. For example, the lever portion (230) may be formed with a projection (238) extending through the housing portion (208) and in a complementary shaped concavity (240) (Figure 16A) on the pulley (236 ). fifty The projection (236) can be formed with recesses in its outer surface that couple the corresponding recesses in the concavities (240) to produce the rotation of the pulley when the lever is activated. The pulley (236) can also be formed with a non-circular concavity or opening (242) that is shaped to receive a final portion of an axle (244) (Figure 14). The opposite end of the shaft (244) extends through the second housing portion (210) and into a complementary shaped concavity or opening (246) of the

55 lever portion (232) (figure 17). In the illustrated configuration, the end portions of the shaft (244) and the corresponding openings (242 and 246) are hexagonal to inhibit the relative rotation between the shaft (244), the pulley (236) and the lever portion (232), although several different non-circular shapes can be used. Alternatively, the final portions of the shaft and the openings (242, 246) may be circular if the shaft is otherwise fixed against rotation with respect to the pulley and the lever portion.

Upper and lower crossbars (248, 250), respectively, are connected to and extend between the respective upper and lower eyelets of the first and second lever portions (230, 232). Screws

(252) extending through the eyelets of the lever portions (230, 232) and tightened on the crossbars (248, 250) can be used to fix the components of the lever (204) to the main body (202) . A screw (254) can extend through the lever portion (230), the housing portion (208), and into a threaded opening in the shaft (244). An adjustment knob (266) can be fixedly attached to a screw (268), which can extend through the lever portion (232), the housing portion (210), and into a threaded opening at the opposite end of the shaft (244). The screw (268) can be fixedly attached to the adjustment knob, for example, by means of an adhesive by holding the screw head in a recess (not shown) on the

10 internal surface of the adjustment knob. Accordingly, the adjustment knob (266) can be turned manually to loosen or tighten the screw on the shaft (244) to adjust the rotating friction of the pulley (236).

Referring again to Fig. 15, a pull cable (74) extends through a lumen of pull cable on the shaft (22) and extends from the shaft inside the main housing (202). A flexible tension member 15 (256), such as a piece of cord, is attached or otherwise connected to one of them to the end of the traction cable (74). The tension member (256) extends around a transverse member (258), partially around the outer circumference of the pulley (236), through a radially extending opening (260) in the pulley and is attached or otherwise it is connected to the shaft (244) adjacent to the center of the pulley (236). As shown in Figures 16A and 16B, the pulley (236) can be formed by an annular groove or concavity

twenty (262) adapted to receive the tension member (256).

When explaining the operation of the handle portion (200), Figure 18A shows the adjustment lever (204) in an advanced position. In this position, the airship section (56) of the shaft (22) is in its normal unfolded state (for example, straight, as shown in Figure 1, or slightly curved). When the lever (204) is turned towards

25 Behind, in the direction of the arrow (264), the pulley (236) rotates clockwise, causing the tension member to wrap around the pulley and pull back the traction cable (74) . The traction cable (74), in turn, pulls the distal end of the shaft to adjust the curvature of the airship section (56), in the manner described previously. Figure 18B shows the lever (204) in a delayed position corresponding to the fully curved position of the steerable section of the shaft (22).

30 The rotating friction of the pulley (236) is sufficient to keep the tension cable tense, thus maintaining the shape of the fold in the airship section if the operator releases the adjustment lever (204). When the adjustment lever (204) is turned back to the forward position (figure 18A), the tension in the traction cable is released. The elasticity of the airship section (56) causes the airship section to recover to its unfolded shape

35 normal as the tension in the tension cable is released. Since the tension member (256) does not apply a pushing force to the traction cable, the movement of the lever (204) towards the forward position does not cause buckling of the traction cable. In addition, as indicated above, the adjustment knob (266) can be adjusted by the operator to vary the rotating friction of the pulley (236). Rotational friction is desirably adjusted so that if the catheter is accidentally pulled back while in the patient's vasculature, the pulley can

40 rotate to the forward position with a front pull force of the pull wire (as indicated by the arrow (270) in Figure 18B) to allow the airship section to straighten as it slides through the vasculature, minimizing damage to the walls of the vasculature.

Advantageously, the adjustment lever (204) provides a substantially 1: 1 deflection of the airship section

Four. Five in response to the movement of the lever; that is, the rotation of the lever (204) causes a substantially 1: 1 movement of the traction cable and, therefore, the airship section (56). Thus, the adjustment lever (204) provides the operator with tactile feedback of the curvature of the airship section to facilitate travel through the vasculature. In addition, the lever is ergonomically positioned to maintain the correct orientation of the guide catheter during use. Another advantage of the illustrated handle portion (200) is that the portion

fifty proximal (24) of the balloon catheter (16) (figure 2B) or a portion thereof can fit inside the final piece

(216) to minimize the working length of the balloon catheter.

Figures 19A and 19B illustrate an alternative nose catheter (300) that can be used with the delivery apparatus (10) (figure 1), instead of the nose catheter (18). The nose catheter (300) in the illustrated configuration includes a nose piece 55 or a valve cover (302) connected to an axis of the nose catheter (304). The valve cover (302) is adapted to cover the balloon (28) and a valve (12) mounted on the balloon. Therefore, the guide catheter (14) does not need to have a cover (23) (figure 8A) to cover the valve during delivery. The shaft (304) is fixedly fixed at its distal end to the distal end of the lid (302) and extends through the balloon (28) and the shaft of the balloon catheter (26). The shaft (304) may have a lumen to receive a guide wire (140). The shaft (304) can move

longitudinally with respect to the balloon catheter and the guide catheter, as well as the nose catheter (18) described previously.

As best shown in Figure 19A, the cover (302) has a proximal end portion (306) formed with a

5 plurality of slits defining triangular tongues (308). The tabs (308) can be flexed radially outward from each other to form an opening large enough to allow the passage of the balloon (28) and the valve (12) when it is desired to deploy the valve. The proximal end portion (306) can be chamfered as shown to facilitate retraction of the cap (302) back into an introducer. The tapered shape of the final portion (306) also provides an atraumatic surface to minimize damage to vascular walls

10 when the delivery device is removed from the body. The lid may also have a tapered distal end portion (310) to assist in the passage through the femoral and iliac arteries, as well as providing a non-traumatic path through the aortic arch and a uniform crossing of the native aortic valve.

The cap (302) is desirably made of a flexible material, such as nylon, Pebax®, or PET and may have a

fifteen wall thickness in the range of about 0.0015 inches to about 0.015 inches. By making the cap (302) flexible enough, the only relatively rigid non-flexible section along the portion of the delivery apparatus that advances through the patient's vasculature is the section of the balloon covered by the valve. This greatly improves the ability of the delivery apparatus to follow the path of the guide wire (140) as it progresses through the tortuous body vessels.

twenty During use, the delivery apparatus is advanced on the guide wire (140) until the valve is located at or near the deployment location. Then, the nose catheter (300) is advanced distally with respect to the balloon catheter (16) to discover the balloon and the valve (12), as illustrated in Figure 19C. As the lid (302) advances distally, the balloon and the valve can pass through the proximal opening formed by the tabs

25 (308). Once the valve (12) is exposed, the balloon (28) can be inflated to deploy the valve.

Figure 20A shows a modification of the guide catheter (14) in which the valve cover (23) is replaced by an expandable mesh basket or cover (400) connected to the distal end of the guide catheter shaft (22). The cover (400) is sized and shaped to cover the valve (12) and the balloon (28). Therefore, a catheter of

30 nose (for example, the nose catheter (18)). The cover (400) can have a braided mesh construction formed by metallic cable (for example, Nitinol or stainless steel cables).

One or more ribbon cables (402) are connected to the distal end (404) of the cover (400) and extend through the respective lumens in the axis of the guide catheter (22) along their length (figure 20B). For example, the cables (402) may be 0.003 inch x 0.020 inch Nitinol ribbon cables. The cables

(402) are connected at their proximal ends to a handle portion of the guide catheter that allows the operator to apply pushing and pulling forces to the cables. Pushing the cables forward (402), in the direction of the arrow (406), causes the cover to contract on the balloon (28) and the valve (12) to provide a uniform travel profile. The pullback of the cables (402), in the direction of the arrow (408), causes

40 The lid expands and allows the balloon and valve to move outwardly through an opening in the distal end (404) of the lid (400).

During use, the cap (400) is placed in a contracted state that covers the valve and the balloon during delivery through the patient's vasculature at the deployment site. Then, the cables (402) slide in the direction

Four. Five proximal (as indicated by the arrow (408)) to expand the cover (400). Then, the guide catheter can slide in the proximal direction to advance the balloon and the valve from the distal end of the lid. Alternatively, the balloon catheter (16) can be advanced distally with respect to the guide catheter (14) to advance the balloon and the valve from the lid (400).

fifty Figures 21A-21C show an alternative delivery apparatus according to the present invention, indicated by the number (500). The delivery apparatus (500) allows a valve (12) to be mounted on a balloon (28) of a catheter with a balloon inside a body vessel. The balloon catheter may have a construction similar to the balloon catheter shown in Figures 2A and 2B except that in Figures 21A-21B, the shaft of the balloon catheter (26) has a distal end portion (504) that extends distally from the balloon (28) and an annular wedge is disposed

55 tapered (502) in the distal end portion (504) adjacent to the balloon. The tapered wedge (502) works to expand the valve in order to facilitate its placement on the ball inside the body, as will be described further below. The wedge (502) is desirably made of a low friction material, such as nylon, to allow the valve to slide easily over the wedge and over the ball.

The delivery apparatus includes a nose catheter comprising a shaft (506) and a nose piece (508) connected to the distal end of the shaft (506). The nose catheter shaft (506) can have a guide wire lumen to receive a guide wire (140) so that the apparatus can be advanced over the guide wire by passing the guide wire through the lumen. The delivery apparatus (500) may additionally include a guide catheter comprising a catheter shaft

5 guide (22) and an elongated cover (510) extending from the distal end of the shaft (22). The nose catheter, the balloon catheter and the guide catheter may move longitudinally with respect to each other and may have locking mechanisms at the proximal end of the apparatus for retaining the catheters at the selected longitudinal positions with respect to each other, as He has described in detail above.

10 As shown in Figure 21A, the valve (12) is initially mounted in a pressed state on the nose catheter shaft (506) between the nose piece (508) and the tapered wedge (502), instead of over the balloon before inserting the delivery device into the body. The valve is pressed on the axis of the nose catheter so that the valve can still move along the axis when it is desired to place the valve on the balloon (28). The nose piece (508) can be formed with a stepped hole comprising a first hole portion (512) and a

fifteen second elongated hole portion (514) at the proximal end of the noise piece. The stepped hole may be formed with an annular flange (516) that extends between the first and second hole portions and is adapted to engage the distal end of the valve (12) when the valve is inserted into the second portion (514) . The nose piece (508) may have an outer surface that is chamfered in a direction toward the distal end of the nose piece (508) to provide a non-traumatic path through a vasculature

twenty tortuous The cover (510), which may be optional, is adapted to extend over and cover the balloon (28), the wedge (502), and at least a proximal end portion of the valve (12) when the valve is placed in The axis of the nose catheter during delivery. The distal end of the cap (510) can be positioned to border the proximal end of the nose piece (508) to completely enclose the valve during delivery. In alternative embodiments, the cap (510) may be shorter in length such that less outside surface of the valve or the cover is covered.

25 ball during delivery.

The nose piece (508), when moving proximally with respect to the balloon catheter (in the direction indicated by the arrow (518)), pushes the valve (12) on the wedge (502) and on the balloon (28) . As the valve passes over the wedge, the valve expands slightly to facilitate its placement on the ball. The catheter shaft with 30 balloon (26) may have radiopaque markers (520) (Figure 21A) to assist the operator in aligning the valve in the correct location on the balloon. The nose piece may have an outer layer (522) formed of a relatively soft and flexible material and an inner layer (524) formed of a relatively harder material. The inner layer (524) forms the flange (516) and the inner surface of the first hole portion (512). In this way, the nose piece shows sufficient rigidity to push the valve (12) on the wedge and on the ball and

35 Provides a soft outer surface to minimize damage to body vessels. For example, the outer layer (522) can be made of 55D Pebax® and the inner layer can be made of 72D Pebax®, which is stiffer than 55D Pebax®.

The section of the delivery apparatus that is mounted on the valve typically defines the maximum outside diameter of the

40 device inserted in the body. By mounting the valve (12) on the nose catheter shaft instead of on the balloon before insertion into the body, the valve (12) can be pressed to a smaller diameter than if the valve is mounted on the balloon. Therefore, the maximum external diameter of the delivery apparatus can be reduced during insertion into and through the vasculature. As indicated above, reducing the maximum diameter of the delivery apparatus is less occlusive for the femoral artery and, therefore, the patient's leg may

Four. Five remain well perfused during the procedure. The maximum outer diameter of the cap (510) and the nose piece (508) (at its proximal end) may be approximately 0.223 inches, which is the maximum diameter of the portion of the delivery apparatus that is inserted into the body. The wedge (502) may have a diameter at its proximal end of approximately (120) inches and the axis of the guide catheter (22) may have an external diameter of approximately 184 inches.

Next, in the explanation of the operation of the delivery apparatus (500), the valve (12) is initially mounted on the nose catheter shaft and inserted into the nose piece (508) and the cover (510). After inserting a guide wire (140) into the body, the proximal end of the cable extending from the body can be inserted into the distal end of the lumen of the guide wire and the delivery apparatus (500) can be inserted into a vessel

55 body (for example, the femoral artery) and is advanced through the body (as shown in Figure 21 A). Alternatively, an introducer can first be introduced into the body vessel, for example, if a cap (510) is not provided to cover the valve (12). After insertion of the introducer, the delivery apparatus can be inserted through the introducer and into the body vessel.

When the distal end of the delivery apparatus advances to a location that is suitable for sliding the valve (12) over the balloon, the guide catheter retracts proximally with respect to the balloon catheter to advance the valve and the balloon from the cap ( 510). For example, if by implanting a prosthetic valve into the native aortic valve, the valve and the balloon can advance in the ascending aorta or in the left ventricle where the valve can then move over the balloon. In any case, as shown in Figure 21B, the nose catheter can be retracted proximally to advance the valve over the wedge (502) and over the balloon (28). Markers (520) (Figure 21A) can be used to center the valve on the ball. After mounting the valve on the balloon, the nose catheter may advance distally so as not to interfere with balloon inflation, as shown in Figure 21C. Then, the valve can be placed at the implantation site (for example, within the

10 native aortic valve) and unfolds inflating the balloon.

Figures 22A and 22B show a modification of the delivery apparatus (10) (Figures 1-8). The cap (23) has a generally tubular shape but is provided in a rolled state on the distal end portion of the guide catheter shaft (22). After the valve (12) is mounted on the balloon (28), the cover can be unwound on the

fifteen valve (12) during insertion into and through the patient's vasculature. The operation of the delivery apparatus shown in Figures 22A and 22B is otherwise identical to the operation of the delivery apparatus (10) described above with reference to Figures 8A-8C.

Figures 23A and 23B show an improved introducer, indicated by the number (600), which can be used for

twenty facilitate the insertion of a delivery device into a body vessel. The introducer (600) is particularly suitable for use with a delivery apparatus that is used to implant a prosthetic valve.

The introducer (600) can also be used to introduce other types of delivery apparatus to place various types of intraluminal devices (e.g., stents, grafts with endovascular stent, etc.) in many types of 25 vascular and nonvascular body lumens (for for example, veins, arteries, esophagus, bile tree ducts, intestine, urethra, fallopian tubes, other endocrine or exocrine ducts, etc.). The example illustrated in Figure 23A shows the distal end portion of a delivery apparatus used to implant a prosthetic valve (12). The delivery apparatus comprises a balloon catheter and a guide catheter. The balloon catheter comprises a shaft (26) and a balloon (28) mounted on the distal end portion of the shaft. The guide catheter comprises an axis (22) that is

30 extends over the catheter shaft with balloon (26). The remaining portions of the balloon catheter and the guide catheter can be constructed in accordance with the embodiments shown in Figures 1-8.

A conventional introducer typically requires inserting a tubular magazine through the seals into the introducer housing to provide an unobstructed path for a valve mounted on a balloon catheter.

35 The charger extends from a proximal end of the introducer, thereby increasing its working length, and decreasing the available working length of a delivery apparatus that can be inserted into the body. The introducer (600) includes an integrated magazine tube housed in the introducer housing to reduce the working length of the introducer and, therefore, increase the available working length of a delivery apparatus that can be inserted into the body.

40 For example, the illustrated introducer (600) includes a seal housing (602) and a tubular sleeve (604) that extends distally from the housing. The seal housing (602) houses one or more sealing valves, such as a transverse opening valve (606), a disc valve (608) and a hemostatic valve (610) as shown in the illustrated embodiment. The valves are desirably made of an elastic biocompatible material, such

Four. Five as polysoprene, although similar biocompatible materials can also be used. The valves (606, 608, 610) are additionally shown and described in U.S. Patent No. 6,379,372. A separator (612) can be interposed between the disc valve (608) and the transverse opening valve (606).

Attached to the proximal end of the seal housing is an end piece (614) adapted to move

fifty longitudinally along the length of the seal housing. The final piece has a tubular body formed by internal threads (616) that fit with external threads (618) formed on the outer surface of the seal housing (602). Therefore, the rotation of the final piece (614) moves it in and out with respect to the seal housing. The final piece (614) has a central opening (620) and an elongated magazine tube (622) fixedly attached to the proximal end portion of the final piece and extending distally therefrom. The

55 opening (620) and the loading tube (622) are sized to allow the passage of the valve (12) (or other prostheses) mounted on the delivery apparatus. The final piece (614) also houses a seal (624) that has a central opening aligned with the opening (620). The seal (624) hermetically engages the external surface of the delivery apparatus when inserted into the introducer (600).

As indicated above, the final part (614) can be adjusted in and out with respect to the seal housing (602). Adjusting the end piece (614) from the extended position shown in Figure 23A to the retracted position shown in Figure 23B moves the loading tube (622) through the seals (606, 608, 610) to provide a path not blocked so that the valve (12) passes through the introducer. Since the tube

5 The magazine does not extend behind the end piece, as in a conventional introducer, the magazine tube does not reduce the available working length of the delivery device that can be inserted into the vasculature.

During use, the introducer (600) in the extended position shown in Fig. 23A can be placed in a pre-inserted guide wire (140) and advances through it until the sleeve (604) extends in a body vessel 10 to a desired distance Then, the delivery device can then be inserted through the opening

(620) to place the valve (12) in the magazine tube (622) with the seal (624) forming a tight seal around the axis of the guide catheter (22). Subsequently, the final part (614) is rotated to slide the loading tube (622) through the valves (606, 608, 610) (Figure 23B), thus placing the delivery apparatus in communication with the cuff lumen. (604) and the body vessel in which the cuff is inserted. Advantageously, this approach

fifteen simplifies the loading process and reduces the number of stages and parts necessary to load the valve into the introducer.

In an alternative introducer (600), the seal housing (602) may have internal threads that fit with external threads in an end piece (614). The final piece can be rotated to adjust the position of the magazine tube (622) as

twenty It has been previously described. In addition, the inclination of the threads in the seal housing and the end piece can be varied to vary the amount of rotational movement necessary to extend the magazine through the sealing valves. The final piece (614) can be slidably positioned along the length of the seal housing by pushing and pulling the final piece without turning it.

25 Figures 24A and 24B show another nose catheter, indicated by the number (700), which can be used in the delivery apparatus (10) (figure 1). The nose catheter (700) includes a nose piece (702) and a nose catheter shaft (704). The nose piece (702) has a distal end (706) connected to the axis of the nose catheter (704) and a proximal end connected to the distal end of an axis of the balloon catheter (26). The nose piece (702) comprises a balloon or a similar structure formed of a flexible and fine material, such as nylon or PET, capable of assuming a

30 inverted shape that covers a valve (12) and a balloon (28) or portions thereof when the nose piece (702) drives the balloon (28). For example, the nose piece (702) may have a structure similar to the balloon (28).

The axis of the nose catheter (704) can slide with respect to the axis of the balloon catheter (26), although the proximal end of the nose piece (702) is connected to the axis of the balloon catheter. Therefore, according to the axis of the nose catheter 35 (704) it moves proximally with respect to the axis of the balloon catheter (26) (in the direction of arrow 710) from a first extended position (Figure 24B) towards a second retracted position (figure 24A), the nose piece (702) drives the distal end of the balloon catheter shaft (26), causing the nose piece (702) to assume an inverted position that covers a portion of the outer surface of the balloon (28) and valve (12). Similarly, it can be seen that moving the catheter shaft with the balloon distally with respect to the catheter shaft of

40 The nose from the extended position shown in Figure 24B is also effective in making the nose piece assume an inverted position on the ball and the valve.

During use, the nose piece (702) is initially placed in the inverted position shown in Figure 24A to provide a uniform travel profile during delivery of the valve through the patient's vasculature. Four. Five At or near the implantation site, the axis of the nose catheter (704) moves distally with respect to the axis of the balloon catheter (20) (in the direction of the arrow (712)) to discover the valve (12) and the balloon (28) for subsequent deployment of the valve. Desirably, but not necessarily, the nose piece (702) may be initially inflated so that it can more easily assume the inverted position shown in Figure 24A. In this regard, the lumen of the nose catheter shaft (704) can be fluidly connected to a source of fluid for

fifty partially inflate the nose piece (702), similar to the way the catheter shaft is used to deliver fluid to the balloon (28).

Figure 25A shows the distal end portion of a modification of the delivery apparatus (10). The delivery apparatus includes a stepped balloon (800) mounted on the distal end portion of the catheter shaft with balloon (26) 55 and the inner shaft (34). As shown in Figure 25B, the illustrated balloon (800) includes a first splined portion (802), a first conical portion 804, a main cylindrical portion (806), a second conical portion (808), a second cylindrical portion ( 810), a third conical portion (812) and a second spike portion (814). A valve (12) (Figure 25A) can be mounted in a pressed state in the main cylindrical portion (806). The stepped balloon (800) is further described in detail in US Application No. 11 / 252,657 (the application

'657) (published as United States Patent Application Publication No. 2007/0088431).

As shown in Figure 25A, the delivery apparatus includes a guide catheter comprising an axis of the guide catheter (22) having an elongated end portion (816) that borders the proximal end of the valve (12). The guide catheter 5 additionally includes a retractable cover (818) that extends over and covers the valve (12). The cover (818) can run in a longitudinally sliding manner with respect to the valve and the distal end of the guide catheter shaft (22) to discover the valve during its deployment inside a body vessel. The portions (802, 804) of the balloon (800) extend from the distal end of the cap (818) and can be partially inflated to provide a transition member between the distal end of the balloon catheter and the cap (818), facilitating from

10 this way the route through the vasculature of the patient, as well as the nose piece (32) (figure 1). The end of the balloon extending from the lid (818) can also be used as a dilator to dilate the stenotic leaflets of a native heart valve or other portions of the patient's vasculature before deploying the valve at the desired implantation site, such as It is further described in the application '657.

fifteen As further shown in Figure 25A, the cover (818) has a cylindrical distal end portion (820) that extends over the valve (12) and a plurality of circumferentially separated tongues (822) that extend proximally from the end proximal of the cylindrical distal end portion (820). The proximal end portion of each tongue (822) is connected to a tensile cable (826) that extends through a respective lumen in the axis of the guide catheter (22). As shown in Figure 25C, each pull cable (826) is

twenty extends distally from a respective lumen (828), through an opening (830) in the proximal end portion (824) of a respective tongue (822), and back into the lumen (828). The guide catheter may additionally include a flexible outer cover (838) that extends over the portions of the traction cables (826) that extend from the shaft (22) to prevent the cables from coming into contact with the inner walls of the vasculature The cover (838) can be fixedly attached to the external surface of the shaft (22), as with a

25 suitable adhesive. Alternatively, the cover (838) can be adapted to slide longitudinally with respect to the axis (22).

The cover (818) in the illustrated example has four fingers (822), each of which is connected to a pull cable (826) that extends through a respective lumen (828). As shown in Figure 25D, the

30 Lumens (828) may also be separated around a central lumen (54) of the axis (22). The shaft (22) may also include another lumen to receive a pull cable (74) to adjust the curvature of the guide catheter, as described above. The traction cables (826) extend the axis length of the guide catheter (22) and are operatively connected to an adjustment mechanism at the proximal end of the axis to allow manual adjustment of the traction cables (826) and, therefore, the cover (818).

35 Figure 25E is a schematic illustration of a handle portion (832) connected to the proximal end of the guide catheter shaft. The handle portion (832) may have a construction similar to the handle portion (20) (described above and shown in Figures 3A-3B) except that the former may include an additional adjustment mechanism (834) connected to traction cables (826). The adjustment mechanism (834) can move towards

40 Forward and backward (in the directions of the double headed arrow (836)) by the operator to move the traction cables (826). The traction cables (826) desirably show sufficient rigidity to apply a pushing force to the cover (818) in the distal direction without buckling. The traction cables can be, for example, 0.006 inch x 0.012 inch ribbon cables. In this way, the cover (818) can be retracted in the proximal direction with respect to the valve and, if necessary, move in the distal direction, such as to return the

Four. Five valve on the cover (818), by operating the adjustment mechanism (834). Additional details of an adjustment mechanism that can be used to produce a movement of the traction cables in the distal and proximal directions are described in detail in the application ('657).

When the valve advances to the implantation site inside the body, the cover (818) is retracted by the

fifty operation of the adjustment mechanism to discover the valve. According to the cover (818) is retracted (with respect to the shaft (22) and the outer cover (838)), the distal end of the final portion of the shaft (816) rests on the valve to prevent accidental movement of the position of the valve in the balloon (800). Therefore, the balloon catheter can advance distally with respect to the guide catheter to advance the balloon (800) a sufficient distance from the cover (838) and the final portion of the shaft (816) to allow a full inflation of the balloon during the deployment of the

55 valve (12). The valve (12) can be an expandable balloon valve that is deployed by the balloon, or alternatively, the valve (12) can be a self-expanding valve that expands radially as it advances from the lid (818). In the latter case, the balloon (800) can be used to further expand the valve to ensure close engagement with the orifice of the native valve.

A distal end portion of the alternative shaft (816) can be configured to provide a releasable fixation to the valve (12), as described in detail in the application ('657). In this way, the guide catheter can move forward and backward to adjust the position of the valve in the body vessel as the valve unfolds. Before deployment (or after deployment, or partial expansion of the valve), control can be achieved

5 of the placement of the valve by the operator pushing, pulling or twisting the guide catheter. Once the operator is satisfied with the position of the valve, the valve can be fully deployed and the valve is separated from the distal end of the guide catheter shaft.

Figures 25A-25E illustrate another introducer, indicated by the number (900), which can be used to facilitate the

10 introduction of a delivery device into a blood vessel. The introducer (900) has an elongated and expandable sleeve (902) that can expand radially from a first diameter (figure 25A) to a second larger diameter (figure 25B) to facilitate insertion of the longer portion of the delivery apparatus (the portion in which the valve or other prosthetic device is mounted). The introducer (900) additionally includes a handle portion (904) connected to the proximal end of the sleeve (902). The sleeve (902) includes an inner layer (906) and a layer

fifteen external (908). The inner layer (906) can be a braided polymeric layer made of a suitable material, such as, peek, nylon or polypropylene. The outer layer (908) may be formed of urethane or other suitable material. The outer surface of the outer layer (908) can be provided with a hydrophilic coating. The handle portion (904) can accommodate one or more sealing valves configured to tightly engage the external surface of a delivery apparatus inserted through the introducer, as previously described.

twenty As shown in Figure 25C, the sleeve (902) may be formed of a main lumen (910) sized to allow passage of a delivery apparatus and one or more internal ducts (912) defining separate lateral lumens around the lumen main (910). A respective tension cable (914) extends through each lateral lumen. The proximal end of each traction cable (914) is connected to a

25 adjustment mechanism (916) in the handle portion (904). The distal end of each traction cable (914) is firmly attached to the distal end portion of the sleeve (902). For example, as shown in Figure 25D, each pull cable (914) can extend outwardly from the distal end of a respective lumen and can be welded to the inner layer (906) adjacent to the distal end of the sleeve.

30 The adjusting mechanism (916) is configured to allow manual adjustment of the sleeve diameter (902) between a first diameter (figure 25A) and a second larger diameter (figure 25B). For example, the adjustment mechanism may move longitudinally with respect to the handle portion (904), in the directions indicated by the double headed date (918). The movement of the adjustment mechanism in the proximal direction (away from the sleeve (902)) is effective for sliding the traction cables (914) in the same direction, which makes the sleeve (902)

35 expand radially and the length is shortened. The movement of the adjustment mechanism (914) in the distal direction (towards the sleeve) slight tension on the tension cables (914) to allow the sleeve (902) to contract radially and lengthen in its own resilience. In particular embodiments, the sleeve (902) has an external diameter of approximately 18 F in its contracted state and can be expanded to an external diameter of approximately 28 F.

40 During use, the sleeve (902) can be inserted into a blood vessel as previously described. As a delivery device (for example, the delivery device (10)) is inserted through the sleeve (902), the sleeve

(902) can be expanded radially to allow a prosthetic valve (for example, valve 12) or other prosthetic device mounted in the delivery apparatus to easily pass through the sleeve (902). Once the

Four. Five Prosthetic valve is inserted into the blood vessel, the sleeve (902) can be reduced in diameter to minimize vessel occlusion.

As shown in Figure 25E, the inner layer (906) can be a laser cut tube instead of a braided layer. The tube may be formed of a plurality of cuts or slits that extend

fifty longitudinally (920) that allow the tube to expand and contract radially.

The various embodiments of the delivery apparatus described herein can be used to implant prosthetic devices other than prosthetic heart valves in the body. For example, the delivery apparatus can be used to deliver and deploy various types of intraluminal devices (e.g., stents, grafts with endovascular stent, etc.) in many types of vascular and non-vascular body lumens (e.g., veins, arteries , esophagus bile tree ducts, intestine, urethra, fallopian tubes, other endocrine ducts

or exocrines, etc.). In a specific example, the delivery apparatus can be used to implant an expandable balloon stent into a coronary artery (or other blood vessels) to maintain the permeability of the lumen of the vessels.

In view of the many possible embodiments to which the principles of the invention described can be applied, it should be recognized that the illustrated embodiments are only preferred examples of the invention and should not be taken as limiting the scope of the invention. On the contrary, the scope of the invention is defined by the

5 following claims. Therefore, everything that includes the scope of these claims is claimed as its invention.