Less-invasive devices and methods for cardiac valve surgery

Systems and methods are disclosed for performing less-invasive surgical procedures within the heart. A method for less-invasive repair or replacement of a cardiac valve comprises placing an instrument through an intercostal access port and through a penetration in a wall of a vessel in communication with the heart, advancing the instrument into the heart, and using the instrument to perform a surgical intervention on a cardiac valve in the heart under visualization through an intercostal access port. The surgeons hands are kept outside of the chest during each step. The surgical intervention may comprise replacing the cardiac valve with a prosthetic valve, wherein the native valve is removed using a tissue removal instrument, the native valve annulus is sized with a specialized sizing device, a prosthetic valve is introduced through an intercostal access port and through the penetration in the vessel, and the prosthetic valve is secured at the native valve position, all using instruments positioned through intercostal access ports without placing the hands inside the chest. Systems and devices for performing these procedures are also disclosed.

FIELD OF THE INVENTION 
The present invention relates generally to surgical instruments, and more 
specifically, to surgical instruments for less-invasive surgery of the 
heart and great vessels, especially instruments for repair and replacement 
of heart valves. 
BACKGROUND OF THE INVENTION 
The present invention is directed to devices and techniques for the 
surgical treatment of heart valve disease, and particularly aortic valve 
disease. The aortic valve separates the left ventricle of the heart from 
the aorta, which carries oxygenated blood to the arterial system. 
Normally, when the left ventricle contracts during systole, the aortic 
valve opens to allow blood to flow into the aorta. During diastole, when 
the left ventricle returns to its uncontracted state, the aortic valve 
closes to prevent blood from flowing from the aorta back into the heart. 
In aortic valve disease, the aortic valve is compromised due to 
calcification of the valve leaflets, congenital deformation of the valve, 
or other conditions such that the valve does not completely open or close 
normally. As a result, the valve restricts blood flow out of the heart 
during systole, or the valve allows blood flow back into the heart during 
diastole. If the condition becomes sufficiently severe, surgical treatment 
is frequently required. 
Various surgical techniques have been used to repair aortic valves. In 
conventional "open-chest" approaches, a large opening is formed in the 
chest--known as a sternotomy or thoracotomy--the patient's heart is 
arrested while circulation is supported by a cardiopulmonary bypass 
system, an incision is formed in the aorta, and instruments are then used 
to decalcify the valve, to separate valve leaflets which are fused 
together, or to constrict the annulus of an enlarged valve. Less-invasive 
approaches to valve repair have also been proposed. Balloon valvuloplasty, 
for example, involves the use of a balloon catheter threaded from a 
peripheral artery into the aorta, and expansion of a balloon within the 
calcified aortic valve to separate the valve leaflets while the heart 
remains beating. Unfortunately, aortic valve repair techniques have not 
had long-lasting success in preventing recurrence of the disease, and 
eventual replacement of the valve is frequently required. 
The most widely-accepted surgical technique for the treatment of severe 
aortic valve disease is aortic valve replacement. In aortic valve 
replacement surgery, the diseased aortic valve is replaced with a 
prosthetic valve, homograft, allograft, or other type of replacement 
valve. Conventional aortic valve replacement techniques require a 
sternotomy or thoracotomy to be formed so as to provide access into and 
visualization of the chest cavity. The patient is placed on 
cardiopulmonary bypass, and the heart is stopped using an aortic 
cross-clamp to block blood flow through the aorta while a cardioplegic 
fluid is injected into the aorta upstream of the cross-clamp or into the 
coronary sinus on the venous side of the heart. An incision is then made 
in the ascending aorta near the aortic valve, and the native valve 
leaflets are removed using surgical scissors inserted through the aortic 
incision. Specialized instruments may also be used to debride the valve 
annulus. A replacement valve is then sutured in place at the native valve 
position. 
While aortic valve replacement is frequently effective in treating aortic 
valve disease and can add ten or more years to the life of a patient 
having the disease, the procedure also suffers from significant drawbacks 
surrounding the invasiveness and trauma of the surgery. The large 
thoracotomy required by the procedure is highly invasive, produces a great 
deal of pain, heightens the risk of infection and other complications, 
increases costs, and lengthens hospital stay considerably. 
What is needed, therefore, are devices and techniques for the surgical 
treatment of aortic valve disease, especially for performing aortic valve 
replacement, which do not suffer from the drawbacks of conventional 
open-chest aortic valve surgery. Most desirably, the devices and 
techniques should obviate the need for a sternotomy and minimize the size 
of any necessary thoracic incisions to eliminate the pain, trauma, risks, 
costs, and lengthy recovery time associated with conventional aortic valve 
surgery. At the same time, the devices and techniques should facilitate 
replacement of a diseased aortic valve with the same types of replacement 
valves which currently enjoy wide acceptance for aortic valve replacement, 
including mechanical valves, bioprosthetic valves, homografts, allografts, 
and others. 
SUMMARY OF THE INVENTION 
The invention provides devices and methods for performing heart valve 
surgery which eliminate the need for a median sternotomy or other type of 
thoracotomy. The devices and methods are particularly advantageous in that 
they facilitate surgical repair or replacement of a heart valve in a 
manner analogous to the widely-accepted surgical techniques used in 
open-chest valve repair or replacement, yet without the invasiveness, 
pain, risks, and recovery time of conventional techniques. Advantageously, 
the devices and methods facilitate replacement of a diseased heart valve 
using various types of commercially-available replacement valves with 
proven safety and effectiveness. The devices and methods of the invention 
are perhaps most useful for the repair and replacement of the aortic 
valve, but may be used for the surgical treatment of any of the valves of 
the heart, as well as in other surgical procedures within the heart and 
great vessels of the thorax. 
In one aspect of the invention, a method is provided for accessing an 
internal chamber of a patient's heart through a vessel in fluid 
communication with the chamber. The method includes visualizing the vessel 
through a percutaneous access port between two adjacent ribs. An 
instrument is positioned into an inner lumen of the vessel through a 
penetration in a wall of the vessel. The proximal end of the instrument 
extends out of the patient's chest through a percutaneous access port 
between the ribs, and the proximal end of the instrument is then 
manipulated to position the distal end of the instrument through the 
vessel and into the internal chamber of the heart. With the instrument 
within the internal chamber, various types of inspection, diagnostic and 
interventional procedures may then be performed. All manipulations of the 
instrument are performed with the surgeon's hands outside of the patient's 
chest, and none of the ribs or the sternum are cut or removed during each 
step. Preferably, in fact, none of the ribs or the sternum are 
significantly retracted from their natural undeflected positions during 
the procedure. Visualization is accomplished either by looking directly 
into the chest through an access port between the ribs, by introducing a 
thoracoscope through such an access port and viewing a video image of the 
vessel and heart on a monitor, or by using other available less-invasive 
visualization devices. 
In a preferred embodiment, the vessel is the aorta, the chamber is the left 
ventricle of the heart, and the distal end of the instrument is positioned 
into the aorta, through the aortic valve, and into the left ventricle. The 
instrument may then be used to perform a procedure in the heart or on the 
aortic valve itself. For example, the instrument could be used for 
repairing a diseased aortic valve, and may comprise a debridement device 
for removing calcium from the valve annulus or leaflets, a scissors for 
incising the leaflet commissures to separate the leaflets, a cutting 
device for resecting the valve leaflets, or a needle driver for applying a 
suture to the valve annulus to reduce the diameter of the valve. 
In a particularly preferred embodiment, the instrument is used in the 
replacement of a diseased aortic valve. The instrument may be a scissors, 
rongeur, knife or other cutting instrument for removing the native valve 
leaflets, or a needle driver or other device for applying sutures to the 
native valve annulus which are used to secure a replacement valve at the 
aortic valve position. The instrument could alternatively comprise a valve 
sizing device for measuring the size of the native valve annulus, or a 
valve delivery instrument for positioning a replacement valve at the 
aortic valve position. In any case, the instrument extends from the left 
ventricle out of the chest through a percutaneous access port between two 
ribs, and is manipulated entirely from outside of the chest. 
As another alternative, the instrument may comprise any of a variety of 
devices for performing diagnostic or interventional procedures within the 
heart, such as an angioscope or other endoscopic visualization device, an 
electrophysiological mapping or ablation device, or a laser for 
transmyocardial revascularization. Additionally, the instrument could be 
used to repair or replace other valves of the heart. For example, the 
mitral valve could be repaired or replaced by positioning the instrument 
through the aorta and left ventricle to the mitral position (and through 
the mitral valve into the left atrium if necessary). Or, an instrument 
could be positioned through the superior vena cava or the inferior vena 
cava into the right atrium to perform a procedure on the right side of the 
heart, including repair or replacement of the tricuspid valve between the 
right atrium and right ventricle, or repair or replacement of the 
pulmonary valve between the right ventricle and the pulmonary artery. 
Various other procedures may also be performed according to the method of 
the invention, including pulmonary thrombectomy, the Cox "maze" procedure 
for treatment of atrial fibrillation, and repair of congenital defects 
such as atrial and ventricular septal defects or patent ductus arteriosus. 
In many of the procedures which may be performed using the methods of the 
invention, the patient is placed on cardiopulmonary bypass and the heart 
is arrested. First, general anesthesia is administered. To establish 
cardiopulmonary bypass, an arterial cannula is placed into a peripheral 
artery, usually a femoral artery, and a venous cannula is placed in a 
peripheral vein, usually a femoral vein. The arterial and venous cannulae 
are connected to a cardiopulmonary bypass pump and oxygenator, allowing 
deoxygenated blood to be withdrawn from the venous system through the 
venous cannula, oxygenated, and then pumped back into the patient's 
arterial system through the arterial cannula. 
The heart may then be arrested in any of several ways. In an endovascular 
technique, an aortic catheter is introduced into a peripheral artery 
selected from among the femoral, brachial or subclavian arteries. The 
aortic catheter is advanced transluminally into the ascending aorta, and 
an expandable member such as a balloon is expanded in the ascending aorta 
to block blood flow through the aorta. A cardioplegic fluid is then 
delivered into the ascending aorta upstream of the expandable member so as 
to perfuse the myocardium via the coronary arteries. Alternatively, a 
thoracoscopic aortic occlusion device may be used to arrest the heart. The 
thoracoscopic aortic occlusion device may be an external clamp 
positionable through a percutaneous access port between two ribs and 
around the exterior of the aorta, the clamp being movable between an open 
position and a closed position in which it clamps the aorta to occlude the 
aortic lumen. A cardioplegic fluid is then delivered into the aorta 
upstream of the clamp, either through a cannula penetrating the aortic 
wall and extending out of the chest through an intercostal access port, or 
through an endovascular catheter extending into the ascending aorta from a 
peripheral artery. The thoracoscopic aortic occlusion device may 
alternatively comprise a shaft having an expandable member such as a 
balloon mounted to its distal end which is configured to be introduced 
into the aorta through a small incision or puncture in the aortic wall. 
The expandable member may be expanded within the aorta to occlude the 
aortic lumen, and a cardioplegic fluid then delivered upstream of the 
clamp through either a thoracoscopic cannula or endovascular catheter. 
In many cases, in order to maintain cardioplegic arrest, it will be 
desirable to deliver cardioplegic fluid to the myocardium in a retrograde 
manner via the coronary sinus instead of or in addition to antegrade 
delivery from the ascending aorta. In these cases, an endovascular 
catheter is introduced transluminally into the coronary sinus, which 
drains into the right atrium of the heart, from a peripheral vein such as 
the femoral, subclavian or internal jugular vein. The endovascular 
catheter preferably has a balloon or other occluding member on its distal 
end for occluding the coronary sinus during delivery of cardioplegic 
fluid. Usually, the occluding member is expanded while cardioplegic fluid 
is delivered, then contracted to allow fluid to drain into the right side 
of the heart from the capillary beds feeding the myocardium. 
With the heart arrested and circulation of blood supported by 
cardiopulmonary bypass, the patient is prepared for a surgical procedure 
conducted in accordance with the principles of the invention. One such 
procedure is replacement of the aortic valve. In a method of aortic valve 
replacement according to the invention, a valve prosthesis is positioned 
through a percutaneous access port between two adjacent ribs and through 
an incision in a wall of the aorta using a first instrument. The valve 
prosthesis is then attached at the aortic valve position between the left 
ventricle and the aorta using at least a second instrument. All 
instruments used in the procedure are manipulated only from outside of the 
chest, and neither the ribs nor the sternum are cut or removed during the 
procedure. Visualization of the vessel and heart is accomplished, as 
described above, by direct vision through an access port, or using a 
thoracoscope or other minimally-invasive visualization device. 
In a preferred embodiment, the first instrument comprises a delivery handle 
which is coupled to the valve prosthesis, or to a holder on which the 
valve prosthesis is mounted. The delivery handle is configured to allow 
the valve prosthesis to be introduced into the chest through the 
percutaneous access port and has a length selected to reach the aortic 
valve position from outside of the chest. Usually, the valve prosthesis is 
introduced from the first, second, third, or fourth intercostal space on 
the anterior side of the chest, and the delivery handle is at least about 
20 cm in length. In a specific embodiment, the valve prosthesis is movably 
coupled to the delivery handle such that it may be positioned through the 
access port between the ribs in a first orientation, then re-oriented 
within the chest relative to the delivery handle into a second orientation 
suitable for attachment at the aortic valve position. Preferably, the 
delivery handle has an actuator on its proximal end to allow the valve 
prosthesis to be reoriented by moving the actuator outside of the 
patient's chest. 
The valve prosthesis is preferably coupled to the delivery handle in such a 
way that it may be positioned through an intercostal space without 
removing or retracting the ribs significantly. In a preferred embodiment, 
the valve prosthesis is mounted such that an axis extending axially 
through the middle of the sewing ring of the valve prosthesis is 
approximately perpendicular to the longitudinal axis of the delivery 
handle. In this way, the profile of the valve prosthesis and delivery 
handle in a plane perpendicular to the longitudinal axis of the delivery 
handle is minimized. For some types of replacement valves, however, even 
in this orientation, the profile of the valve and handle will be large 
enough that some minor retraction of the adjacent ribs may be required to 
allow the valve to be introduced into the chest without risking damage to 
the valve. 
The percutaneous access port through which the valve prosthesis is 
positioned may comprise a puncture or incision through the chest wall 
between the ribs which does not involve cutting or removing the ribs or 
the sternum adjacent to the incision. Preferably, no significant 
retraction or displacement of the ribs or sternum will be necessary. In 
most cases, the tissue adjacent to the access port will need to be 
retracted or separated to provide an opening into the chest which will not 
interfere with introduction of the valve prosthesis and through which the 
surgeon may view the chest cavity. For this purpose, the invention 
provides a retraction device particularly well-suited for aortic valve 
replacement. In a preferred embodiment, the retraction device comprises a 
cannula having a distal end suitable for placement between the ribs into 
the chest, a proximal end, and a passage therebetween configured to allow 
the valve prosthesis to be easily passed through it. In a preferred 
configuration, the passage in the cannula has a cross-sectional height 
which is substantially greater than its cross-sectional width, preferably 
at least about 1.5 times the cross-sectional width. In this way, the 
cross-sectional height may be large enough to accommodate the outer 
diameter of the valve prosthesis in the passage, while the cross-sectional 
width is small enough to fit between the ribs without significant 
retraction (yet being large enough to accommodate the height of the valve 
prosthesis when mounted to the delivery handle). 
If a replacement valve having a larger profile is to be used requiring some 
minor retraction of ribs, the retraction device of the invention may be 
adjustable in width to provide a slightly larger passage into the chest 
while the valve is introduced, deflecting the ribs adjacent to the access 
port as needed. Once the replacement valve is within the chest cavity, the 
retraction device may be returned to a smaller width in which the ribs are 
in their natural, undeflected positions for the remainder of the 
procedure. 
The retraction device of the invention may further include a suture 
organizer mounted to it for arranging the sutures used to secure the valve 
prosthesis in the aortic valve position. In a preferred embodiment, the 
suture organizer is mounted to the proximal end of the cannula through 
which the valve prosthesis is positioned, whereby a plurality of sutures 
may be drawn out of the chest cavity through the passage in the cannula 
and placed in spaced-apart locations on the suture organizer. The suture 
organizer may comprise, for example, a ring having a plurality of radial 
slots arranged about its perimeter each of which is configured to receive 
and retain a suture thread. 
Usually, the native valve leaflets are excised from the native annulus and 
any calcium or other debris on the annulus is removed before a replacement 
valve is implanted. To remove the valve leaflets, thoracoscopic scissors 
and forceps may be introduced through a percutaneous access port and used 
to cut the leaflets from the annulus. Specialized thoracoscopic 
debridement devices, such as rongeurs having an inner lumen through which 
suction may be applied, are then used to cut away calcific deposits and 
other undesirable matter from the surface of the valve annulus. During 
this process a filter or trap may be placed through the aortic valve into 
the left ventricle to catch any debris which may be released. 
In most cases, the native valve annulus must be measured to ascertain the 
appropriate size of the valve prosthesis to be used. This is accomplished 
by utilizing a specialized valve sizing device which may be introduced 
through a percutaneous access port and positioned adjacent to or advanced 
through the native annulus. The sizing device preferably includes an 
elongated handle with a sizing disk of a known size at its distal end 
which may be compared to or positioned within the native annulus. The 
sizing disk may be adjustable in diameter to measure a range of sizes, may 
include markings for visual identification of the size of the annulus, or 
may be interchangeable with larger and smaller sizing disks to allow 
multiple sizes to be tried until the proper one is found. The sizing disk 
is mounted to the distal end of the handle in such a way as to be 
positionable into the chest without retracting or removing ribs, and is 
preferably pivotably attached to the handle so as to be movable into a low 
profile orientation for introduction, or is collapsible for introduction 
and then expandable for sizing the valve annulus. 
A variety of different replacement valves may be implanted using the 
devices and methods of the invention, including mechanical prostheses, 
bioprostheses, homografts and allografts. Advantageously, the invention 
facilitates the use of many of the clinically-proven replacement valves 
currently used in open-chest valve replacement without modification of 
these valves and without the need for removal or significant retraction of 
the ribs. 
The replacement valve may be secured at the native valve position in 
various ways, but is preferably secured using sutures. The sutures are 
applied to the aortic valve annulus using elongated thoracoscopic needle 
drivers or other known types of thoracoscopic suture placement devices 
positioned through a percutaneous access port. Usually, a plurality of 
sutures are applied to the annulus, drawn out of the chest cavity, and 
then applied to the sewing ring of the valve prosthesis outside of the 
chest. The valve prosthesis is then slid along the sutures through the 
access port and placed against the native valve annulus using the delivery 
handle or other appropriate thoracoscopic instrument. A knot is formed in 
each suture outside of the chest, and the knot is pushed long the suture 
through the access port and against the sewing ring of the valve 
prosthesis using a thoracoscopic knot pusher. The free ends of the suture 
are then trimmed using thoracoscopic scissors. 
For securing bioprosthetic valves and other types of replacement valves, it 
may be desirable to use a single suture to form a running stitch between 
the sewing ring and the native valve annulus. In these cases, with the 
valve held in place at or near the aortic position using the delivery 
handle, thoracoscopic needle drivers may be positioned through an access 
port and used to drive a needle alternately between the native annulus and 
the sewing ring of the replacement valve. The suture is then tied off and 
trimmed using thoracoscopic instruments. 
Once the replacement valve has been secured at the aortic valve position, 
the aortic incision must be closed. Thoracoscopic needle drivers are 
introduced through a percutaneous access port and used to drive a suture 
back and forth across the incision from end to end in a running stitch. 
The suture is then tied off and trimmed. 
With the aortic incision closed, the patient's heart is restarted by 
removing the aortic occlusion device, whether an external clamp, 
endovascular aortic occlusion catheter, or other means, from the ascending 
aorta. If placed through a puncture in a wall of the aorta, the puncture 
is closed with a purse-string suture or running stitch using thoracoscopic 
needle drivers. Warm oxygenated blood delivered to the arterial system by 
the arterial cannula is thereby allowed to flow into the ascending aorta 
and to perfuse the myocardium via the coronary arteries. Normal heartbeat 
will ordinarily resume spontaneously. If not, electrical defibrillation 
may be administered. Once normal heartbeat has resumed, any retractors, 
trocars, or other devices in the percutaneous access ports are removed, 
and chest incisions are closed with sutures or adhesive strips. The 
patient is gradually weaned from cardiopulmonary bypass, all arterial and 
venous cannulae are removed, and arterial and venous punctures are closed. 
The patient is then recovered from anesthesia. 
A further understanding of the nature and advantages of the invention will 
become apparent from the following detailed description taken in 
conjunction with the drawings.

DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS 
Specific embodiments of the devices and methods of the invention will now 
be described in connection with aortic valve replacement procedures. 
However, it will be understood to those of ordinary skill in the art that 
a wide variety of procedures may be performed on a variety of body 
structures without departing from the scope of the invention. These 
include, in addition to surgery of the aortic valve via the aorta, 
interventions in the coronary arteries, left ventricle, mitral valve, left 
atrium, or pulmonary vein via the aorta, interventions in the right 
atrium, tricuspid valve, right ventricle, pulmonary valve or pulmonary 
artery via the superior vena cava or inferior vena cava, as well as 
interventions in various other organs via vessels in communication with 
those organs. The types of interventions which can be performed include 
not only aortic valve repair and replacement, but catheter interventions 
in the coronaries such as angioplasty, atherectomy, stent placement or 
endoarterectomy, electrophysiological interventions within the heart such 
as mapping and ablation, transmyocardial revascularization using a laser 
placed within the heart, repair of septal defects and patent ductus 
arteriosus using patch placement or other defect closure devices placed in 
the right or left chambers of the heart, repair or replacement of the 
mitral, tricuspid or pulmonary valve including placement of annuloplasty 
rings and prosthetic valves, reattachment of chordae tendonae, 
commissurotomy, and quadrangular resection, incision of the atrial or 
ventricular wall for the performance of a Cox maze procedure in the 
treatment of atrial fibrillation, and other procedures. The principles of 
the invention will apply to the performance of these procedures in much 
the same way as to the performance of aortic valve replacement, which is 
now described with reference to FIGS. 1-36. 
The patient is first prepared for aortic valve surgery by putting the 
patient under general anesthesia, establishing cardiopulmonary bypass 
(CPB) and inducing cardioplegic arrest. General anesthesia is induced in a 
conventional manner. A preferred technique for accomplishing CPB and 
cardioplegic arrest which does not require a sternotomy, thoracotomy, or 
other opening in the patient's chest is illustrated in FIG. 1. Additional 
aspects of the systems and methods for inducing cardioplegic arrest 
described here may be found in patent application Ser. No. 08/282,192, 
filed Jul. 28, 1994, now U.S. Pat. No. 5,584,803, and Ser. No. 08/486,216, 
filed Jun. 7, 1995, now U.S. Pat. No. 5,766,151, the complete disclosures 
of which are hereby incorporated herein by reference. 
A cardiopulmonary bypass system 20 includes a venous cannula 22 which is 
placed in a femoral vein 24 in the groin area or in another peripheral 
vein such as an internal jugular vein or subclavian vein, located in the 
neck. While illustrated in a shorter configuration, the venous cannula may 
be long enough to extend from the femoral vein into the inferior vena 
cava, into the right atrium of the heart or through the right atrium into 
the superior vena cava. The system also includes an arterial return 
cannula 26 placed in a femoral artery 28 or in another peripheral artery 
such as the subclavian or brachial artery in the neck or armpit. The 
arterial return cannula 26 is generally long enough so that it extends 
sufficiently into the femoral artery to avoid backing out of the artery 
but as short as possible to reduce damage to blood delivered through the 
arterial return cannula. Both venous cannula 22 and arterial return 
cannula 26 are configured to be placed into the femoral vein and femoral 
artery, respectively, either by surgical cut-down, or by a percutaneous 
technique such as the Seldinger technique. 
Venous cannula 22 and arterial return cannula 26 are connected to a CPB 
pump and oxygenator 30 of well-known construction. CPB pump and oxygenator 
30 oxygenates the deoxygenated blood withdrawn from the patient's venous 
system through venous cannula 22, and pumps the oxygenated blood back into 
the patient's arterial system via arterial return cannula 26. In this way, 
circulation and re-oxygenation of the patient's blood may be maintained 
while the heart is temporarily arrested. 
Cardioplegic arrest may be induced using any of several techniques. One 
preferred technique is illustrated in FIGS. 1 and 2. In this technique, an 
endoaortic catheter 32 is introduced by surgical cut-down or by a 
percutaneous technique into a peripheral artery, which may be the femoral 
artery 34 as illustrated, or a brachial or subclavian artery. Endoaortic 
catheter 32 is configured to be advanced transluminally, usually over a 
guidewire (not shown), from femoral artery 34 into the aorta until its 
distal end 36 is positioned in the ascending aorta 38 between the coronary 
ostia (not shown) just downstream of the aortic valve and the 
brachiocephalic artery 40. Endoaortic catheter 32 has an expandable member 
42 mounted near its distal end 36 which, as shown in FIG. 2, is configured 
to expand into sealing engagement with the inner wall of the ascending 
aorta 38 to block blood flow through the aorta without occluding either 
brachiocephalic artery 40 or the coronary ostia. In a preferred 
embodiment, expandable member 42 is an elastomeric balloon in 
communication with an inflation lumen 43 extending through endoaortic 
catheter 32 to a delivery device such as syringe 46 for delivering an 
inflation fluid such as saline or radio-opaque contrast solution to expand 
expandable member 42 until completely occluding the aorta. The elastomeric 
balloon preferably is short in the axial direction, being disc-shaped (a 
short cylinder), donut-shaped (toroidal), ellipsoidal, or other shortened 
shape to minimize the amount of the ascending aorta which is occupied by 
the balloon so that the surgeon has the maximum room to work upstream of 
the balloon. In one embodiment, expandable member 42 has an axial length 
between its proximal and distal ends of about 1-40 mm, preferably about 
1-20 mm, and an expanded outer diameter in the radial direction of about 
10 to 60 mm, preferably about 30-40 mm. 
In a particularly preferred embodiment, arterial return cannula 26 includes 
an additional hemostatic port (not shown) at its proximal end that allows 
endoaortic catheter 32 to be slidably positioned through the blood return 
lumen of the arterial return cannula. Arterial return cannulae having such 
a configuration are disclosed in copending application Ser. No. 
08/282,192, filed Jul. 28, 1994, now U.S. Pat. No. 5,584,563, which is 
incorporated herein by reference. 
With expandable member 42 occluding the ascending aorta 38, a cardioplegic 
fluid is delivered from a cardioplegic fluid supply 48 through a delivery 
lumen 44 in endoaortic catheter 32 and a port 51 at its distal end 36 into 
the ascending aorta distal to expandable member 42 so that the 
cardioplegic fluid flows into the coronary arteries to perfuse the 
myocardium. The cardioplegic fluid preferably includes a cardioplegic 
agent such as potassium chloride mixed with blood and cooled to a low 
temperature, e.g. 5-20.degree. C. Upon perfusion of the myocardium with 
cardioplegic fluid, heart contractions will quickly cease. Circulation of 
oxygenated blood to organs and tissues other than the heart is maintained 
by cardiopulmonary bypass system 20. Expandable member 42 prevents the 
oxygenated blood delivered by arterial return cannula 26 from reaching the 
coronary arteries, which would allow the blood to perfuse the myocardium 
and revive the heart. 
Periodically, it may be necessary to remove fluids from the ascending aorta 
38 during the procedure. Such fluids may be withdrawn through delivery 
lumen 44 of endoaortic catheter 32 and diverted through a valve 47 to a 
filter and recovery system 49, which removes impurities from the blood and 
directs the blood to cardiopulmonary bypass system 20 where it is 
delivered back into the arterial system. Alternatively, a separate 
cardiotomy suction probe may be introduced through an access port and 
through the aortic wall to remove such fluids. Endoaortic catheter 32 
preferably also includes a pressure port 53 near its distal end 36 in 
communication with a pressure lumen extending to the proximal end of the 
catheter where it may be connected to a pressure measurement device 50, 
allowing pressures in the ascending aorta distal to expandable member 42 
to be monitored during the procedure. 
In addition to delivery of cardioplegic fluid in the "antegrade" manner via 
endoaortic catheter 32 as just described, it is usually desirable to 
deliver cardioplegic fluid in a "retrograde" manner through the coronary 
sinus during the aortic valve replacement procedure. For this purpose, a 
coronary sinus catheter 52 is placed into a peripheral vein 54, preferably 
the internal jugular vein or subclavian vein in the neck, and advanced 
through the superior vena cava into the right atrium, where it is 
maneuvered into the coronary sinus (not illustrated). Coronary sinus 
catheter 52 has a balloon or other expandable member 58 near its distal 
end 60 which may be expanded by means of a syringe 62 to occlude the 
coronary sinus during fluid delivery. A delivery lumen (not pictured) 
extends through the coronary sinus catheter 52 to a port at its distal end 
60 to allow delivery of a cardioplegic fluid, which will usually be 
similar to that described above used in antegrade delivery. Coronary sinus 
catheter 52 may also include a pressure port near distal end 60 and a 
pressure lumen extending to its proximal end for monitoring pressure 
distal to expandable member 58. Other aspects of coronary sinus catheters 
and retrograde cardioplegia techniques useful in connection with the 
present invention are disclosed in copending application Ser. No. 
08/372,741, filed Jan. 12, 1995, now U.S. Pat. No. 5,558,644, which is 
hereby incorporated herein by reference. 
In a preferred technique, after an initial infusion of cardioplegic fluid 
through endoaortic catheter 32 to induce cardioplegic arrest, most 
subsequent infusions are performed retrograde through coronary sinus 
catheter 52. To maintain cardioplegic arrest, cardioplegic fluid is 
preferably delivered in periodic infusions at, for example, 600 ml volumes 
delivered in about 120 to 180 seconds at 15 minute intervals. Between 
infusions, expandable member 58 of coronary sinus catheter 52 is 
preferably deflated to allow fluid to drain from the coronary sinus. 
In an alternative technique for inducing cardioplegic arrest, devices are 
introduced thoracoscopically through access ports between the ribs to 
occlude the ascending aorta and, optionally, to deliver cardioplegic fluid 
into the ascending aorta upstream of the occluded area. In these 
thoracoscopic techniques, the pericardium is first opened to expose the 
ascending aorta. As illustrated in FIG. 3A, several access ports 71, such 
as trocar sleeves or other tubular cannulae, are placed in intercostal 
spaces I between ribs R. A thoracoscope 73 of conventional construction 
and having a video camera 75 mounted to its proximal end may be placed 
through one of access ports 71 for visualizing the procedure, or the 
surgeon may look directly into the chest through one of access ports 71. 
Thoracoscopic scissors 77 and graspers 79 are introduced through access 
ports 71 and used to create an incision 81 approximately 4-10 cm in length 
in the anterior side of the pericardium 83 overlying the aorta 85 so that 
the ascending aorta 87 and upper anterior side of the heart 89 are 
exposed. Thoracoscopic scissors 77 and graspers 79 may have any of various 
well-known constructions, including those described in copending 
application Ser. No. 08/194,946, filed Feb. 14, 1994, now U.S. Pat. No. 
5,501,698, which is hereby incorporated herein by reference. 
In a first embodiment of a thoracoscopic technique for arresting the heart, 
illustrated in FIGS. 3-4, an expandable member 64 such as an elastomeric 
balloon is positioned in the ascending aorta 66 through a penetration in a 
wall of the aorta. Expandable member 64 will be shaped and dimensioned to 
allow complete occlusion of ascending aorta 66 without blocking blood flow 
into the brachiocephalic artery 78 or the coronary ostia. Additionally, 
expandable member 64 will be as short as possible in the axial direction 
(along the central axis of the aortic lumen) to minimize its space 
requirements in the ascending aorta, preferably having a short 
cylindrical, discoid, ellipsoid, donut or toroidal shape with an axial 
length of about 140 mm, preferably about 1-20 mm. Expandable member 64 is 
attached to a distal end 68 of a shaft 70, which may be a rigid or 
flexible biocompatible metal or polymer. Shaft 70 extends through the 
penetration in the aortic wall and out of the chest through an access port 
72 between the ribs R. Shaft 72 is at least about 6 cm, preferably about 
10-20 cm, in length so that its proximal end 76 is outside of the chest 
when expandable member 64 is in the ascending aorta 66 between the 
brachiocephalic artery 78 and the coronary ostia (not shown). 
Access port 72, as with other access ports referred to in this application, 
is illustrated as a tubular cannula or trocar sleeve, but may 
alternatively comprise a wound retractor with rigid blades or flexible 
adhesive strips for retracting tissue to create a small opening between 
the ribs. Instruments may alternatively be positioned directly through a 
puncture or incision between the ribs without a retractor, cannula or 
trocar, but usually some means of retracting tissue is desirable to 
prevent tissue damage and to facilitate introduction and manipulation of 
instruments. In some cases, it may be necessary to cut or remove one or 
more of the costal cartilages that connect the ribs to the sternum, to 
allow a slightly greater degree of rib retraction. However, in most cases, 
the access ports will be configured to facilitate introduction of surgical 
instruments, visualization devices, valve prostheses, and other devices 
used in the various procedures of the invention without removing the ribs 
R or sternum S, and preferably without retracting or cutting the ribs R 
significantly. Thus, the access ports will have a transverse profile 
suitable for positioning within an intercostal space I between two 
adjacent ribs R, which typically has a width (the distance between 
adjacent ribs R) of about 10-25 mm in normal adult patients, without 
cutting or removing the ribs, and without retracting the ribs more than 
about 1-2 cm from their natural, undeflected positions. In many cases, the 
access ports may be circular in cross-section with an outer diameter of 
less than about 12 mm so as to be easily positionable within an 
intercostal space I. In other cases the access ports may have a 
cross-sectional shape other than circular and may have a slightly larger 
transverse dimension to accommodate specialized instruments or prostheses, 
as described below. 
As shown in FIG. 4, shaft 70 includes a delivery lumen 80 extending from a 
first connector 82 at proximal end 76 to a delivery port 84 at distal end 
68, through which cardioplegic fluid may be delivered into ascending aorta 
66. If expandable member 64 is a balloon, shaft 70 also has an inflation 
lumen 86 extending from a second connector 88 to the interior of 
expandable member 64, through which an inflation fluid such as saline or 
contrast solution may be delivered into the balloon. In addition, shaft 70 
may optionally include an arterial return lumen 90 extending from a third 
connector 92 at proximal end 76 to an arterial return port 94 at distal 
end 68, through which oxygenated blood may be delivered into the aorta 
downstream of expandable member 64. Third connector 92 may be connected 
with tubing to the outlet of cardiopulmonary bypass system 20, allowing 
arterial return lumen 90 to be used in place of or as a supplement to the 
use of separate arterial return cannula 26 of FIG. 1. Shaft 70 may also 
include a pressure lumen (not shown) extending from proximal end 76 to a 
pressure port (not shown) at distal end 68 to allow pressure monitoring in 
ascending aorta 66 upstream of expandable member 64. 
Shaft 70 is dimensioned so as to pass easily through access port 72 between 
ribs R, while having sufficient cross-section that lumens 80, 86 and 90 
are large enough to perform their respective functions. Usually shaft 70 
will have an outer diameter of less than about 12 mm, preferably less than 
about 10 mm. Delivery lumen 80 must be large enough in cross-section to 
allow cardioplegic fluid to be delivered at a sufficient flow rate to 
induce and maintain cardioplegic arrest, preferably allowing cooled 
cardioplegic fluid containing blood, usually having a viscosity of about 
1-4 centipoise, to be delivered at a flow rate of at least about 200 
ml/min at a pressure no more than about 300 mmHg. Thus, delivery lumen 80 
has a cross-sectional area of about 0.5-8 mm.sup.2, preferably about 
0.5-2.0 mm.sup.2. Arterial return lumen 90 is preferably large enough to 
allow blood to be delivered at flow rates adequate to maintain full 
cardiopulmonary bypass with the heart arrested (preferably without the use 
a separate arterial return cannula), having a cross-sectional area of 
about 12-75 mm.sup.2, and preferably about 25-50 mm.sup.2. In addition, 
inflation lumen 86 must be large enough to allow saline or other inflation 
fluid to be delivered at flow rates sufficient to inflate expandable 
member 64 in less than about 30 seconds, preferably less than about 10 
seconds, having a cross-sectional area of about 0.1-5 mm.sup.2, preferably 
about 1-3 mm.sup.2. 
A second embodiment of a thoracoscopic technique for inducing cardioplegic 
arrest is illustrated in FIGS. 5-6. In this technique, an external clamp 
98 is placed around the ascending aorta 100 to occlude the aortic lumen 
102 just upstream of the brachiocephalic artery 104. Clamp 98 is attached 
to a distal end 106 of a shaft 108 which is long enough to extend out of 
the chest through an access port 110 between ribs R, having a length of at 
least about 10 cm, preferably 20-30 cm. An actuator 112 is attached to 
proximal end 114 of shaft 108 to allow clamp 98 to be opened and closed 
from outside of the chest. Actuator 112 includes a pair of movable handles 
116 with finger loops 118, and a locking mechanism 120 which may comprise 
a pair of overlapping fingers 122 with transverse teeth (not shown) which 
interlock with one another. Clamp 98 includes a first jaw 124 fixed to 
shaft 108, and a second jaw 126 fixed to an inner shaft (not shown) 
extending through the interior of shaft 108 and rotatable relative to 
shaft 108. One of handles 116 is fixed to the proximal end of shaft 108, 
while a second of handles 116 is fixed to a proximal end of the inner 
shaft, so that by pivoting handles 116 relative to one another, the inner 
shaft rotates relative to shaft 108, opening or closing jaws 124, 126. 
Other aspects of thoracoscopic clamping devices suitable for use in the 
method of the invention are described in U.S. Pat. No. 5,425,705, which is 
incorporated herein by reference. 
In order to deliver cardioplegic fluid into the ascending aorta, several 
alternative techniques may be used. In one technique, illustrated in FIGS. 
5-6, a delivery cannula 130 may be positioned through an inner lumen of 
shaft 108 so that a needle 132 at the distal end of the delivery cannula 
extends distally of distal end 106 of shaft 108, generally parallel to and 
spaced apart from jaws 124. Jaws 124 may be curved or angled away from 
shaft 108 so that the portions of the jaws that extend around the aorta 
are offset from needle 132 to allow needle 132 to be placed through shaft 
108 and penetrate the aortic wall upstream from jaws 124. Delivery cannula 
130 has an inner lumen extending from its distal end to its proximal end 
which may be connected to a cardioplegic fluid source. In one embodiment, 
a connector 134 is provided near the proximal end of delivery cannula 130 
which connects to a connector on the proximal end of shaft 108 to fix the 
delivery cannula in position relative to clamp 98. In this way, after 
clamp 98 has been closed on ascending aorta 100 to occlude the aortic 
lumen 102, delivery cannula 130 may be positioned through shaft 108 to 
penetrate the aortic wall with needle 132, allowing cardioplegic fluid to 
be delivered upstream of clamp 98. The inner lumen of delivery cannula 130 
will be configured to facilitate delivering cardioplegic fluid containing 
blood at a rate of at least about 200 ml/min and a pressure of no more 
than about 300 mmHg, having a cross-sectional area of at least about 0.5 
mm.sup.2, and preferably 0.5-2.0 mm.sup.2. Delivery cannula 130 may 
alternatively be independent of clamp 98 and shaft 108, and placed through 
a separate access port rather than being placed through shaft 108. 
Alternative techniques of delivering cardioplegic fluid are described in 
U.S. Pat. No. 5,425,705, which has been incorporated herein by reference. 
In one such technique, not illustrated here, an endovascular delivery 
catheter may be placed through a peripheral artery such as a femoral 
artery until its distal end is in the ascending aortic lumen 102 upstream 
of the brachiocephalic artery 104. Clamp 98 may then be actuated to close 
on the aorta around the endovascular delivery catheter, which may be 
reinforced in its distal extremity to prevent collapsing. In this way, 
cardioplegic fluid may be delivered upstream of the external clamp 98 
without requiring a puncture through the aortic wall. Such an endovascular 
delivery catheter may also include a pressure port and pressure lumen for 
monitoring pressure in the ascending aorta during the procedure. 
In a further embodiment of a thoracoscopic aortic occlusion technique, 
illustrated in FIGS. 7-8, an external clamp 136 is placed around the 
ascending aorta 138 by a thoracoscopic clamp applier 140, closed on aorta 
138 to block blood flow through the aortic lumen, then released from clamp 
applier 140, which may then be removed from the chest. Clamp 136 comprises 
a pair of movable jaws 142, 144 pivotably connected to each other by a pin 
152. Jaws 142, 144 have proximal extremities 154, 156 proximal to pin 152 
to which a locking mechanism 148 is mounted, which may comprise a pair of 
deflectable overlapping fingers 150 having transverse teeth 152 which 
interlock with one another to maintain clamp 136 in a closed position. A 
pair of detents 158 are disposed at the proximal ends of jaws 142, 144 and 
are adapted to receive the distal tips 160 of clamp applier jaws 162. 
Clamp 136 is configured to be positionable through an access port 146 or 
incision between ribs R. Access port 146 has a transverse cross-sectional 
width to fit between the ribs without requiring significant deflection or 
removal of the ribs, but may have a longer transverse cross-sectional 
dimension parallel to the ribs to allow clamp 136 to be positioned through 
the access port when held by clamp applier 140. 
Clamp applier 140 has, as shown in FIG. 7, an actuator 164 at its proximal 
end which comprises one or more movable leaves 166 pivotably mounted to a 
shaft 168. Leaves 166 are linked to clamp applier jaws 162 by a linkage 
170, best seen in FIG. 8, which may be a rod or wire slidably disposed in 
a lumen 171 within shaft 168, linked to a scissors mechanism 172 coupled 
to jaws 162. In this way, moving leaves 166 toward shaft 168 causes jaws 
162 to move between an open position for releasing clamp 136 to a closed 
position for grasping and closing clamp 136. Clamp 136 is preferably 
biased into an open configuration by a torsion spring (not shown) around 
pin 152 or a compression spring (not shown) between proximal extremities 
154, 156 of jaws 142, 144. In this way, once locking mechanism 148 is 
released by deflecting fingers 150 away from each other, clamp 136 will be 
urged open as clamp applier jaws 162 are opened. Other aspects and 
alternative configurations of clamp 136 and clamp applier 140 are 
disclosed in commonly-assigned copending application Ser. No. 08/567,966, 
filed Dec. 4, 1995, now U.S. Pat. No. 5,618,307, which is hereby 
incorporated herein by reference. 
With clamp 136 closed on the aorta to occlude blood flow through the aortic 
lumen, cardioplegic fluid may be delivered into the ascending aorta by 
means of a delivery cannula 176 placed into the chest through an access 
port 178 and having a needle 180 at its distal end for penetrating the 
aortic wall. Usually, a purse-string suture 182 will be placed in the 
aortic wall surrounding needle 180 using thoracoscopic needle drivers 
positioned through an intercostal access port. The purse-string suture 182 
is cinched up around delivery cannula 176 to maintain hemostasis around 
the cannula. Alternatively, as discussed above, an endovascular delivery 
catheter (not illustrated) may be used which extends into the ascending 
aortic lumen transluminally from a peripheral artery such as the femoral, 
brachial, or subclavian artery. Clamp 136 is clamped around the aorta 
after the endovascular delivery catheter has been positioned so that the 
inner wall of the aorta seals against the outer wall of the delivery 
catheter. The delivery catheter may be reinforced in its distal extremity 
to resist collapsing under the force of clamp 136. The delivery catheter 
may alternatively have an expandable member such as a balloon near its 
distal end which may be expended in the ascending aorta like endoaortic 
catheter 32 of FIGS. 1-2. Clamp 136 may then be applied to the ascending 
aorta directly around the expandable member to achieve complete occlusion 
without excessive crushing or collapsing of the aorta. Clamp 136 may also 
be placed distally or proximally of the expandable member, or a clamp may 
be placed in either side, to prevent migration of the expandable member as 
well as blocking blood flow. 
In addition, retrograde delivery of cardioplegic fluid via the coronary 
sinus by means of an endovascular catheter introduced through a peripheral 
vein (described above) may be used instead of or in combination with 
antegrade delivery through a thoracoscopic or endovascular delivery 
catheter placed in the aorta. 
It should be noted that, in some cases, it may be appropriate not to induce 
cardioplegic arrest, but instead to place the heart in a state of 
fibrillation. While this is usually not desirable because it is generally 
thought to provide inadequate protection of the myocardium, it may be 
induced using the devices and methods of the present invention. The 
patient is placed on cardiopulmonary bypass as described above (without 
occluding the ascending aorta so as to arrest the heart), and the 
oxygenated blood returned to the arterial system is cooled to a 
sufficiently low temperature to induce fibrillation. An endovascular or 
thoracoscopic catheter may be placed in the ascending aorta as described 
above, and, without occluding the ascending aorta, drugs or blood may be 
delivered to the coronary arteries, and fluids may be removed to vent the 
heart and aorta. Alternatively, one of the above-described aortic 
occlusion devices may be used to periodically induce fibrillation during 
the procedure by occluding the aorta temporarily without delivering the 
cardioplegic fluids that induce cardioplegic arrest, with intermittent 
periods of no occlusion so as to avoid ischemia. 
While the remainder of the aortic valve replacement procedure is described 
with reference to the use of clamp 136 and delivery cannula 176 for 
inducing cardioplegic arrest, it should be understood that any of the 
devices and techniques described above, as well as various other 
techniques not specifically described here, may be used for inducing 
cardioplegic arrest without departing from the scope of the invention. 
Once cardioplegic arrest is induced, the patient is supported on 
cardiopulmonary bypass, and the pericardium has been opened as described 
above, an incision, or aortotomy, 184 is formed in the wall of ascending 
aorta 186 as shown in FIGS. 9-10. At this point, at least one, and usually 
at least three, access ports should be placed in intercostal spaces I 
between ribs R on the right anterior side of the chest. One or two access 
ports 188 with outer diameter less than about 12 mm are placed in the 
first, second, or third intercostal space through which delivery cannula 
176 and thoracoscope 73 (if utilized) are positioned. Another access port 
190 with outer diameter less than about 12 mm is placed in the third, 
fourth or fifth intercostal space through which various instruments used 
in the procedure may be positioned. An additional access port 192, which 
is specially-configured for positioning a replacement valve through its 
central lumen as described more fully below, is placed in the first, 
second, third or fourth intercostal space, depending upon patient size and 
anatomy. As described above, access ports 188, 190, 192 may comprise 
trocar sleeves or other tubular cannulae, or simply incisions in which 
tissue is retracted apart to create a small opening using any of a variety 
of tissue retraction devices. Preferably, however, access ports 188, 190, 
192 will not require cutting or removal of ribs or the sternum, and will 
not require significant retraction of the ribs, preferably requiring less 
than about 2 cm of retraction from the ribs' natural, undeflected 
positions. 
It should be noted that, in the absence of a large thoracic incision for 
access into the chest, some means of illuminating the chest cavity is 
usually necessary. A thoracoscopic light wand or a commercially-available 
thoracoscope or endoscope having a fiber-optic channel which emits light 
from the distal end of the device may be placed through an access port for 
illumination. Alternatively, one or more access ports may have an 
illumination device mounted to it, as described below in connection with 
FIGS. 37-40. 
Aortotomy 184 is created using thoracoscopic angled scissors 194 or a knife 
(not shown) positioned through access port 192, assisted by means of 
thoracoscopic forceps 196 positioned through access port 190. Angled 
scissors 194 and forceps 196 may be commercially-available thoracoscopic 
instruments or may be constructed as described in copending applications 
Ser. No. 08/194,946, now U.S. Pat. No. 5,501,688, and Ser. No. 08/281,962, 
now abandoned which have been incorporated herein by reference. Aortotomy 
184 is approximately 6-8 cm in length, extending distally and slightly 
posteriorly along the anterior side of the aorta from a point at least 
about 10 mm, and preferably about 15 mm, downstream of the right coronary 
ostium. 
Aortotomy 184 is then retracted open as illustrated in FIGS. 11-12. In an 
exemplary embodiment, sutures 200 are placed in the aortic wall along the 
edges of aortotomy 184, preferably with a suture near each end of 
aortotomy 184 on each side of the incision. Each of sutures 200 has a 
needle 202 attached to an end thereof which is driven through aortic wall 
204 using thoracoscopic needle drivers 206 introduced through either 
access port 190 or access port 192. Needle drivers 206 may be 
commercially-available thoracoscopic instruments or may be constructed as 
described in the aforementioned patent applications, Ser. Nos. 08/194,946 
or 08/281,962. Sutures 200 preferably have a length of at least about 20 
cm so that they may be withdrawn from the chest cavity by passing needles 
202 through the chest wall between ribs R or by snaring the sutures with a 
hook introduced through an intercostal space. Sutures 200 are tensioned in 
opposing directions to retract aortotomy 184 open and are then secured 
outside the chest with hemostats 208 or other suitable clamping device of 
conventional construction. Alternatively, sutures 200 may be secured to 
tissue within the chest cavity by passing needles 202 through such tissue 
and tying the sutures off, or by attaching the suture ends to a clip, 
clamp, hook or staple which can be fastened to tissue in the chest. With 
aortotomy 184 retracted open, the aortic valve 210 is fully exposed and 
visible through the inner lumen 212 of access port 192, as illustrated in 
FIG. 12. 
The leaflets 214 of the native aortic valve 210 are then removed using 
thoracoscopic curved or angled scissors 194 or knife (not illustrated), 
and forceps 196 positioned through access ports 190, 192, respectively. 
Leaflets 214 are grasped by forceps 196, retracted away from the valve 
annulus 216, and cut closely to the inner edge of valve annulus 216 
without cutting into the valve annulus or the aortic wall. 
During this process, it may be advantageous to provide a mechanism for 
catching any bits of valve leaflet, calcium or other debris that may fall 
into the left ventricle as the leaflets are excised. As illustrated in 
FIG. 14, a catcher 220 may be placed through aortic valve 210 into the 
left ventricle 222 and positioned so as to catch any debris released in 
the leaflet removal or debridement process. Catcher 220 may comprise a 
flexible, porous mesh, foam, gauze, or screen constructed as a bag or 
pouch with an opening 222 on a top end 224 thereof. Top end 224 is 
configured to be positioned in the left ventricle just below the aortic 
valve, with the sides of catcher 220 engaging the ventricular wall 226. 
Preferably catcher 220 is collapsible into a smaller shape suitable for 
positioning through access port 190 or access port 192, through aortotomy 
184, and through aortic valve 210, and at least top end 224 is resiliently 
biased to return to an expanded configuration in which the outer sides of 
top end 224 engage ventricular wall 226. A flexible and resilient metal or 
elastomeric ring 228 may be mounted to catcher 220 around opening 222 
which may be radially collapsed during positioning, then released to allow 
the ring to expand outwardly to engage the ventricular wall. To facilitate 
positioning, catcher 220 may be collapsed and placed in a tubular sleeve 
or catheter (not shown) during positioning through the aortic valve, then 
ejected from the sleeve within the left ventricle. Alternatively, 
thoracoscopic forceps or graspers positionable through an intercostal 
access port may be used to grasp and collapse catcher 220 and position it 
into the left ventricle. A suture or other flexible tether 230 is 
preferably attached to catcher 220 and extends out of the chest through an 
access port to allow catcher 220 to be retrieved after use. The 
aforementioned tubular sleeve may be guided over tether 230 back into the 
left ventricle and catcher 220 then collapsed and retracted into the 
sleeve to facilitate removing the device from the chest. 
Following removal of the aortic valve leaflets, any calcific deposits and 
any remaining leaflet tissue around the inner surface of valve annulus 216 
are removed using thoracoscopic rongeurs 232. Rongeurs 232 have a 
split-shaft construction, wherein two independent shaft members 234, 236 
are longitudinally slidable relative to one another. A fixed jaw 238 is 
disposed at the end of shaft member 234, and a movable jaw 240 is 
pivotably mounted to the distal end of shaft member 236 by a first pin 242 
and pivotably attached to shaft member 234 by a second pin 244. In this 
way, longitudinal translation of shaft member 236 relative to shaft member 
234 by means of an actuator (not shown) at the proximal end of the device 
pivots movable jaw 240 relative to fixed jaw 238. Fixed jaw 238 and 
movable jaw 240 have hollow or concave inner sides facing each other, and 
cutting edges 246, 248 along the periphery of their inner sides. This 
construction allows cutting edges 246, 248 to be positioned close to or 
against the inner surface of valve annulus 216 to excise any remaining 
leaflet material or calcific deposits along the valve annulus. Any 
material removed is collected within the concave inner sides of jaws 238, 
240. In a preferred embodiment, rongeurs 232 include a suction lumen 
through which a vacuum may be applied from the proximal end of the device 
to evacuate tissue and debris as it is cut from valve annulus 216. In the 
split shaft design of FIG. 15, for example, at least one of shaft members 
234, 236 may be provided with an inner lumen in communication with the 
inner sides of jaws 238, 240 through which a vacuum may be applied to 
evacuate material cut by cutting edges 246, 248. 
In addition, an irrigation lumen may be provided in one of shaft members 
234, 236 to allow an irrigation fluid such as saline to be delivered to 
the inner surfaces of jaws 238, 240 to keep the jaws clean and free of 
debris. In one embodiment, a suction lumen is provided in one shaft member 
234 and an irrigation lumen is provided in the other shaft member 236 to 
provide both irrigation and suction in the space between jaws 238, 240. 
As an alternative to the use of thoracoscopic rongeurs 232, various other 
devices may be used for removal of calcific and fibrous material at the 
native valve position, including high-speed rotating cutters or grinders 
like those used in atherectomy and arthroscopy devices, lasers, and 
ultrasonic scalpels, any of which may be equipped with irrigation or 
suction lumens. 
The valve annulus is then sized to determine the appropriate size for a 
replacement valve. As illustrated in FIG. 16, a valve sizing device 250 is 
introduced through access port 192 into the ascending aorta 186 through 
aortotomy 184. Sizing device 250 includes a shaft 252 having a pivoting 
tongue 254 at its distal end and a handle 256 at its proximal end. A 
sizing disk 258 is releasably attached to tongue 254. An actuator button 
260 is slidably mounted to handle 256 and is connected to tongue 254 by a 
linkage (not shown) such as a slidable rod extending through a passage in 
shaft 252. In this way, sliding actuator button 260 along handle 256 
pivots tongue 254 from a first orientation in which the tongue is 
generally parallel to shaft 252 to a second orientation in which the 
tongue is perpendicular to shaft 252. Thus, for a generally cylindrical 
sizing disk having a central axis, sizing disk 258 is positionable in an 
orientation in which the central axis is perpendicular to the longitudinal 
axis of shaft 252, providing a minimum profile to allow the sizing disk to 
be introduced through lumen 212 of access port 192. Once inside the chest, 
sizing disk 258 may be re-oriented using actuator button 260 so that the 
sizing disk is in an appropriate orientation for sizing valve annulus 216, 
usually with its axis about parallel to the longitudinal axis of shaft 252 
as shown in FIG. 16. A button lock 262 may also be provided on actuator 
button 260 to allow sizing disk 258 to be releasably locked in a suitable 
orientation for sizing valve annulus 216. Other aspects of valve sizing 
devices suitable for use in the method of the invention are described in 
copending applications Ser. No. 08/485,600 and Ser. No. 08/281,962, now 
abandoned, which have been incorporated herein by reference. 
Once positioned inside ascending aorta 186 through aortotomy 184 and 
oriented in an orientation suitable for sizing valve annulus 216, sizing 
disk 258 is positioned within valve annulus 216 to allow a comparison of 
the outer diameter of sizing disk 258 to the inner diameter of valve 
annulus 216. To see the sizing procedure, the surgeon may look directly at 
valve annulus 216 through lumen 212 of access port 192 or a thoracoscope 
may be used for video imaging of the valve annulus. If the sizing disk is 
either larger or smaller than the valve annulus, sizing device 250 is 
removed from the chest and sizing disk 258 is removed from tongue 254 and 
replaced with another sizing disk of a different diameter. The process is 
repeated until the surgeon has identified the appropriate size of 
replacement valve to be implanted. It should be understood that other 
techniques may be used for determining the annulus size, including 
endoscopic video imaging, transesophageal echocardiography, or 
thoracoscopic ultrasonic imaging, as well as using an adjustable valve 
sizer that may be placed within the valve annulus and adjusted in diameter 
until the appropriate size is determined. 
When the size of the valve annulus has been determined, the appropriate 
replacement valve is then identified. A variety of replacement valves may 
be used in the method of the invention, including many of the more 
widely-accepted valves used in conventional open-chest aortic valve 
replacement procedures. These include mechanical valves such as the St. 
Jude Medical Mechanical Heart Valve (St. Jude Medical, Inc., St. Paul, 
Minn.), the Carbomedics Prosthetic Heart Valve (Carbomedics, Inc., Austin, 
Tex.), and the Sorin Monostrut Heart Valve or Sorin Bicarbon Valve (Sorin 
Biomedical, Inc., Irvine, Calif.), as well as bioprosthetic or tissue 
valves, such as the Carpentier-Edwards Pericardial Bioprosthesis or 
Carpentier-Edwards Model 2625 Porcine Bioprosthesis (Baxter, Inc., Edwards 
CVS Division, Irvine, Calif.)., or Medtronic Hancock MO Bioprosthesis or 
Medtronic Hall valve (Medtronic, Anaheim, Calif.). In addition, the method 
of the invention may be used to replace a diseased aortic valve with an 
autologous graft such as the pulmonary valve from the same patient, which 
may be removed thoracoscopically from the patient's pulmonary artery using 
thoracoscopic instruments and visualization devices positioned through 
access ports between the ribs. Allografts, such as an aortic valve removed 
from another donor patient's heart, may also be implanted using the 
methods of the invention. While the aortic valve replacement procedure of 
the invention will be described with reference to a mechanical bileaflet 
valve such as the St. Jude Medical Mechanical Valve, it should be 
understood that the methods described are equally applicable to other 
types of mechanical valves, as well as to bioprosthetic valves, autografts 
and allografts. 
In order to implant most mechanical valve prostheses, a plurality of 
sutures 264 are placed in the native valve annulus to form mattress 
stitches or inverted mattress stitches. As shown in FIGS. 17-18, sutures 
264 are double-armed with arcuate needles 266 on both ends, and are placed 
in valve annulus 216 using a specialized rotational needle driver 268, 
described in detail in copending application Ser. No. 08/594,869, entitled 
"Endoscopic Suturing Devices and Methods", which is hereby incorporated 
herein by reference. Rotational needle driver 268 has a shaft 270 with a 
rotatable carriage 272 at its distal end a handle 274 at its proximal end. 
One of needles 266 is releasably held in carriage 272 such that the 
needle's sharp point 274 is exposed outside of the carriage. Carriage 272 
is rotatable about a pin 276 in shaft 270. An actuator button 278 is 
slidably mounted to handle 274 and is coupled to carriage 272 by a linkage 
(not shown) such as a slidable rod within a passage in shaft 270. In this 
way, sliding actuator button along handle 274 rotates carriage 272 about 
pin 276. Carriage 272 may be configured to drive sharp point 275 of needle 
266 in either a distal or proximal direction, depending upon whether it is 
desired to drive the needle from the ventricle toward the aorta, or from 
the aorta toward the ventricle. In the embodiment illustrated, rotational 
needle driver 268 is set up to drive needle 266 from the left ventricle 
222 toward aorta 186. Carriage 272 holding needle 266 is positioned 
through access port 192, through aortotomy 184 and through valve annulus 
216. Sharp point 275 of needle 266 is then positioned so as to penetrate 
the valve annulus a distance of about 1-5 mm from the inner edge of the 
annulus, as visualized by looking through access port 192 or under 
thoracoscopic visualization. When the needle is properly positioned, 
actuator button 278 is moved along handle 274 to translate needle 266 
through valve annulus 216. Once sharp point 275 emerges from the annulus 
within the aorta, the needle may be picked up with thoracoscopic needle 
drivers 206 positioned through access port 192 (or through a separate 
access port). In an alternative embodiment, a needle pick-up mechanism 
(not shown) is provided on needle driver 268 to allow needle 266 to be 
picked up without the use of a separate instrument, as described in the 
above-mentioned patent application Ser. No. 08/594,869, entitled 
"Endoscopic Suturing Devices and Methods". When needle 266 is picked up, 
it is drawn through valve annulus 216 and withdrawn from the chest through 
lumen 212 of access port 192. A total of 10-20 sutures are placed in valve 
annulus 216 in this way. 
Because of the large number of sutures that are placed in valve annulus 
216, a suture organizing device is provided outside the chest to keep the 
sutures orderly and free of tangles. In a preferred embodiment, a suture 
organizer 279 is disposed on the proximal end of access port 192 itself, 
the suture organizer including a plurality of radial slits 280, usually 
12-24 pairs, arranged around the circumference of a rim 282 on access port 
192. Slits 280 are configured to frictionally engage sutures 264 placed 
into the slits, allowing each suture 264 to be placed in valve annulus 
216, drawn out of the chest and placed in one of slits 280 until all of 
the sutures have been placed. Other aspects of suture organizer 279 are 
described in copending application Ser. No. 08/485,600, which has been 
incorporated herein by reference. 
In the case of certain bioprosthetic valves and other types of replacement 
valves, techniques may be used for securing the valve to the heart which 
do not require a plurality of sutures to be placed in valve annulus 216. 
For example, some tissue valves are secured using a single continuous 
length of suture to make a running stitch around the sewing ring of the 
replacement valve. In other cases, staples, clips or other fastening 
devices may be used to secure the replacement valve to the native annulus 
or adjacent tissue. In such cases, it may be unnecessary to place sutures 
or other fasteners in valve annulus 216 until after the replacement valve 
has been introduced into the chest and positioned at the aortic valve 
position. 
With all of sutures 264 placed in valve annulus 216 and the ends of sutures 
264 organized outside of the chest, each suture is placed through sewing 
ring 286 of prosthetic valve 288, which is held by a delivery handle 290. 
Delivery handle 290 has an elongated shaft 291 and a handle 293 at its 
proximal end, and may be the same handle used in valve sizing device 250 
described above in reference to FIG. 16, with sizing disk 258 removed from 
tongue 254. Prosthetic valve 288 is releasably held on a holder 292 which 
includes a slot or aperture (not shown) configured to receive a tongue on 
delivery handle 290 similar to tongue 254 on valve sizing device 250. 
Various other details concerning the construction of delivery handle 290, 
prosthetic valve 288, and holder 292 are described in copending 
application Ser. No. 08/281,962 and application Ser. No. 08/485,600, which 
have been incorporated herein by reference. A needle driver of 
conventional construction is used to grasp each of needles 266 and drive 
it through sewing ring 286. After each needle is driven through the sewing 
ring, it is secured by means of a hemostat 294 or by placement in a suture 
organizer positioned on or near the patient's chest. 
Delivery handle 290 is configured to allow prosthetic valve 288, mounted to 
holder 292, to be delivered through an intercostal access port with 
minimal retraction of the ribs. If the annular sewing ring 286 has a 
central axis extending through it (generally defining the direction of 
blood flow through the valve), delivery handle 290 preferably holds 
prosthetic valve 288 in an orientation in which the central axis of sewing 
ring 286 is generally perpendicular to the longitudinal axis of shaft 291, 
wherein the prosthetic valve, holder, and delivery handle have a minimum 
profile in a direction perpendicular to the longitudinal axis of shaft 
291. This will allow prosthetic valve 288 to be delivered through an 
intercostal space without removing or cutting the ribs or the sternum, 
and, in most patients, without retracting the ribs. Certain types of 
prosthetic valves, particularly tissue valves, may have a larger profile 
due to the height of the valve commissures. However, even for these 
prosthetic valves, delivery handle 290 is adapted to hold the prosthetic 
valve in an orientation of minimum profile, allowing the prosthetic valve 
to be positioned into the chest with minimal retraction of the ribs, 
usually with less than about 10 mm of retraction of each rib from its 
natural, undeflected position, and preferably less than about 5 mm from 
the rib's natural, undeflected position. 
To facilitate positioning prosthetic valve 288 through an intercostal space 
without interference with the ribs or tissue of the chest wall, the 
prosthetic valve is placed through inner lumen 212 of access port 192, as 
illustrated in FIG. 20. Inner lumen 212 is specially adapted to allow 
prosthetic valve 288 to pass through it in an edge-first orientation. 
Preferably, the prosthetic valve is positioned through lumen 212 such that 
the central axis of sewing ring 286 is generally perpendicular to the 
longitudinal axis of inner lumen 212. At the same time, the overall 
profile of access port 192 is minimized so as to require an incision in 
the chest wall of minimum size. In a preferred embodiment, the 
cross-section of inner lumen 212 in a direction perpendicular to its 
longitudinal axis has a cross-sectional length which is substantially 
greater than its cross-sectional width, with an oval, rectangular, 
racetrack, elliptical, or other shape suitable for passage of prosthetic 
valve 288 in the edge-first orientation illustrated. The cross-sectional 
length will be just larger than the outer diameter of sewing ring 286, 
usually 17-35 mm, and the cross-sectional width will be just larger than 
the height of the valve parallel to the central axis of sewing ring 286, 
ranging from about 5-25 mm for mechanical valves, to about 15-30 mm for 
tissue valves. 
Of course, a variety of other devices may be used to retract the chest wall 
tissue to allow prosthetic valve 288 to be introduced into the chest, 
including a soft tissue retractor designed to atraumatically retract 
tissue adjacent to an intercostal incision to create an opening in the 
chest without retracting the ribs. Alternatively, a conventional retractor 
with a pair of movable parallel rigid blades may be positioned in an 
intercostal incision parallel to the ribs, the distance between the blades 
being adjustable to create an opening in the intercostal space of a 
desired width. Such an adjustable retractor may be desirable where the 
height and outer diameter of the prosthetic valve are both larger than the 
distance between the ribs in the intercostal space through which the 
prosthetic valve is to be positioned, as may be the case with certain 
types of tissue valves. In this way, the ribs may be slightly retracted 
temporarily to allow the prosthetic valve to be positioned into the chest, 
and the retractor then re-adjusted to allow the ribs to return to their 
natural, undeflected positions for the remainder of the procedure, thus 
minimizing the trauma associated with such retraction. 
As prosthetic valve 288 is advanced into the chest, tension is maintained 
on sutures 264 by means of hemostats 294 or an assistant's hands so that 
sewing ring 286 slides along sutures 264 toward aortic valve annulus 216. 
Delivery handle 290 has a length sufficient to allow prosthetic valve 288 
to be positioned at the native aortic valve position in the heart with 
handle 293 remaining outside the chest, shaft 291 preferably having a 
length of at least about 15 cm. Once inside the chest, prosthetic valve 
288 may be reoriented into an orientation suitable for securing the valve 
to valve annulus 216, i.e., an orientation in which sewing ring 286 may be 
positioned parallel to and axially-aligned with valve annulus 216 
(illustrated in FIG. 21). Such reorientation may be accomplished by simply 
removing prosthetic valve 288 from delivery handle 290, but is preferably 
accomplished by pivoting prosthetic valve 288 relative to shaft 291 by 
sliding an actuator button 296 on handle 293. This pivots a tongue at the 
distal end of shaft 291 to which holder 292 and prosthetic valve 288 are 
attached, in a manner like that described above with reference to valve 
sizing device 250 of FIG. 16 (and described in copending application Ser. 
No. 08/485,600, which has been incorporated herein by reference). Usually, 
prosthetic valve 288 is reoriented such that the central axis of sewing 
ring 286 is generally parallel to the longitudinal axis of shaft 291 plus 
or minus about 30.degree., although the exact angular orientation may vary 
according to the location of access port 192 and patient anatomy. 
Prosthetic valve 288 is positioned adjacent to the valve annulus 216 and 
then released from delivery handle 290, which may then be removed from the 
chest, as illustrated in FIG. 21. Prosthetic valve 288 is preferably 
released by cutting a suture (not shown) on holder 292 as frequently 
provided on conventional prosthetic valve holders. This allows a movable 
portion of holder 292 to pivot away from sewing ring 286, releasing the 
prosthetic valve from the holder, as described in greater detail in 
copending application Ser. No. 08/281,962, which has been incorporated 
herein by reference. 
Referring now to FIG. 22, knots 300 are formed in each of sutures 264 
outside of the chest, and a thoracoscopic knot pusher 302 is used to push 
knots 300 along sutures 264 through lumen 212 of access port 192, through 
aortotomy 184 and against sewing ring 286 of prosthetic valve 288. Knot 
pusher 302 preferably has an elongated shaft 303 to which is attached a 
head 304 with a convex curvature on its distal end 306 and a pair of axial 
channels 308, 310 along its lateral sides, as described in copending 
application Ser. No. 08/288,674, filed Aug. 10, 1994, now U.S. Pat. No. 
5,601,576, which is hereby incorporated herein by reference. One end of 
each suture is threaded through channel 308, a knot 300 is formed in the 
suture distally of head 304, and the other end of the suture is positioned 
in channel 310. While holding the ends of suture 264 in tension, knot 
pusher 302 is advanced toward prosthetic valve 288, engaging knot 300 with 
distal end 306 and sliding the knot along suture 264 until it is against 
sewing ring 286. Several knots are formed in each suture in this manner. 
The ends of sutures 264, along with needles 266, are then trimmed off 
above knots 300, using thoracoscopic angled scissors 194 or other suitable 
cutting device. 
With prosthetic valve 288 successfully secured in the aortic valve 
position, the movable leaflets 312 may be tested for proper action by 
inserting a probe (not shown) through an access port and exerting a gentle 
force against the outer edges of the leaflets. The probe may comprise an 
elongated shaft with an atraumatic tip of a soft elastomer suitable for 
contacting the valve leaflets, like that described in copending 
application Ser. No. 08/485,600, which has been incorporated herein by 
reference. Alternatively, the probe may include an inner lumen extending 
to a port at its distal end, the inner lumen being adapted for connection 
to a source of suction outside the chest, whereby suction may be applied 
to the valve leaflets to test for proper opening and closing. 
If leaflets 312 are functioning properly, aortotomy 184 may be closed. This 
may be accomplished, as illustrated in FIG. 23, by suturing the opposing 
edges of the aortic incision together using a conventional running stitch 
applied by means of thoracoscopic needle drivers 206 positioned through 
access ports 188, 190 or 192. Alternatively, an endoscopic stapler may be 
used to apply a series of staples across aortotomy 184. 
While aortotomy 184 is being closed, it will usually be desirable to remove 
any air from within the left ventricle and ascending aorta 186 upstream of 
aortic clamp 136. This is accomplished by first reducing venous drainage 
of the heart via venous cannula 22 to allow blood to flow from the right 
side of the heart into the left ventricle, thereby filling the left 
ventricle with blood. This forces air out of the left ventricle into the 
ascending aorta. Preferably, the patient will be positioned so that the 
superior or anterior aspect of the aortic arch is upward so that any air 
collects at a point where it can be suctioned out through delivery cannula 
176. An irrigation fluid such as saline may also be delivered through 
delivery cannula 176 into the ascending aorta and left ventricle to assist 
in displacing air to the upper part of the ascending aorta near delivery 
cannula 176. Additionally, thoracoscopic instruments may be positioned 
through intercostal access ports to depress and collapse the heart, 
forcing out any air in the left ventricle. Heart manipulation devices may 
also be positioned through an access port to lift and/or rotate the heart 
so that any air tends to flow through the aortic valve into the ascending 
aorta, where it may be suctioned out. Further, small needles may be used 
to aspirate air from the left ventricle and/or aorta. 
In an alternative technique of keeping air out of the heart during the 
procedure, the chest cavity may be flooded with a gas such as carbon 
dioxide at the outset of the procedure to prevent any air from entering 
the chest through the access ports. A gas delivery tube may be introduced 
through an intercostal access port, or a gas delivery lumen may be 
provided in a wall of the one of the access ports themselves through which 
the gas is delivered. To facilitate maintaining the gas within the chest, 
the access ports may be provided with gaseous seals such as those commonly 
used in laparoscopic trocar sleeves which provide a gas-tight seal both 
when an instrument is introduced through the port, as well as when the 
instrument is removed. These and other techniques for removing air from 
the heart and aorta are disclosed in copending application Ser. No. 
08/585,871, filed Jan. 12, 1996, attorney docket No. 14635-23-6, entitled 
"Methods and Apparatus for Preventing Air Embolism When Performing A 
Procedure On A Patient's Cardiovascular System," which is incorporated 
herein by reference. 
With de-airing complete, cardiac function may be allowed to resume. The 
patient's head is temporarily tilted head-down to prevent emboli from 
entering the cerebral circulation. Aortic clamp 136 (or other aortic 
occlusion device) is removed from ascending aorta 186 to allow oxygenated 
blood delivered via arterial return cannula 26 to flow into the ascending 
aorta and into the coronary arteries. To remove clamp 136, clamp applier 
140 (FIGS. 7-8) is reintroduced into the chest via access port 192, and 
proximal extremities 154, 156 are engaged by clamp applier jaws 162 and 
actuated so as to release locking mechanism 148, allowing jaws 142, 144 to 
return to an open position. Clamp 136 is then withdrawn from the chest 
cavity. Oxygenated blood is then permitted to flow through the coronary 
arteries to perfuse the myocardium, whereupon cardiac contractions will 
quickly resume. In the event that cardiac function does not return 
spontaneously, electrical defibrillation may be utilized to restore normal 
heart beat. Defibrillation electrodes may be placed on the heart via 
intercostal access ports, or external paddles of conventional construction 
may be used on the surface of the chest, and an electrical charge may then 
be delivered to stimulate the heart. 
When cardiac contractions have resumed, it may still be desirable to 
maintain suction through delivery cannula 176 so as to remove any air or 
other emboli which may be present in the aorta or left ventricle. When it 
is believed that such emboli are no longer present, delivery cannula 176 
is removed from ascending aorta 186 and purse-string suture 182 (FIG. 8) 
is tightened securely and knotted to close the puncture in the aorta. 
Thoracoscopic needle drivers 206 may be used for this purpose. 
Thoracoscopic scissors are then used to trim the ends of purse-string 
suture 182. 
The patient is then weaned from cardiopulmonary bypass in the conventional 
manner, and venous cannula 22, arterial return cannula 24, coronary sinus 
catheter 52, any other catheters utilized in the procedure, and access 
port 188, 190, 192, are removed from the patient. Chest drainage tubes may 
be placed temporarily through incisions used for access, or through 
additional incisions. All other thoracic and vascular punctures and 
incisions are closed, and the patient is recovered from anesthesia. 
While the invention has been described in the context of aortic valve 
replacement, various other procedures may be performed using the methods 
of the invention, including repair or replacement of the mitral, pulmonary 
or tricuspid valves; repair of atrial and ventricular septal defects and 
patent ductus arteriosus by means of stapling, suturing or patch-applying 
instrument positioned into the heart; transmyocardial revascularization by 
means of a laser introduced into the heart; electrophysiological mapping 
and ablation by means of a mapping and ablation catheter positioned into 
the heart; performance of a Cox maze procedure by means of a cutting or 
ablation device positioned in the heart for transecting the atrial wall to 
correct atrial fibrillation; and pulmonary embolectomy by positioning a 
embolus-removal device into the pulmonary artery. Advantageously, in each 
such procedure, all instruments may be introduced into the heart either 
through intercostal access ports or via blood vessels with the surgeon's 
hands outside the chest, eliminating the need for a median sternotomy or 
other form of gross thoracotomy. 
Another exemplary embodiment of a delivery handle for positioning either a 
sizing disk or a replacement valve through an intercostal access port and 
into the native valve position is illustrated in FIGS. 24-26. In this 
embodiment, delivery handle 320 comprises a shaft 322 having a distal end 
324 and a proximal end 326. A sizing disk or a holder for releasably 
holding a replacement valve, represented schematically by cylindrical 
element 328, is pivotably mounted to distal end 324 by a transverse pin 
330. A pair of finger grips 332 are fixed to shaft 322 near proximal end 
326, and an end cap 334 is slidably received over proximal end 326. 
As shown in FIG. 26, a rod 336 extends through an inner lumen 338 in shaft 
322. Rod 336 has a proximal end 340 fixed to end cap 334, and a distal end 
342 rotatably pinned to element 328 at a point laterally offset from 
transverse pin 330. A spring 344 is disposed within a bore 346 within end 
cap 334 and engages the proximal end of shaft 322 to bias end cap 334 and 
rod 336 in the proximal direction. In this way, element 328 may be pivoted 
relative to shaft 322 by pushing end cap 334 distally with the thumb while 
the fingers are placed against finger grips 332. Element 328 is usually 
rotatable through an angle of at least about 45.degree., and preferably at 
least about 90.degree., relative to shaft 322. In a preferred embodiment, 
delivery handle 320 is configured to position element 328 in an 
orientation suitable for introduction through an intercostal access port 
without removing, cutting, or significantly retracting the ribs. As 
illustrated in FIG. 25, element 328 is preferably movable into an 
orientation in which the central axis AA extending axially through 
cylindrical element 328 is generally perpendicular .+-.20.degree. relative 
to the longitudinal axis LA of shaft 322. In this way, the profile of 
delivery handle 320 together with element 328 as seen from the distal end 
of the device is minimized. Element 328--whether a sizing disk or 
replacement valve--may be introduced through an intercostal access port 
(such as access port 192 of FIGS. 7-24) in the orientation of FIG. 25 by 
maintaining pressure against end cap 334. Once inside the chest, end cap 
334 may be released, allowing element 328 to return to the orientation of 
FIG. 24, wherein the element is in a suitable orientation for alignment 
with the native valve annulus for either sizing the annulus or implanting 
the replacement valve. Usually, element 328 will be oriented such that 
central axis AA is at an angle of between -45.degree. and 45.degree., and 
preferably about 0.degree..+-.20.degree., relative to the longitudinal 
axis LA of shaft 322. 
FIGS. 27-29 illustrate an additional embodiment of an access port for 
retraction of tissue within an intercostal space so as to provide an open 
passageway through which a replacement valve may be positioned into the 
chest. Access port 350 comprises a tubular body 352 having an axial 
passage 354 configured to allow a replacement valve to be positioned 
through it without contacting the inner walls of the axial passage. 
Tubular body 352 is a metal or biocompatible polymer with sufficient 
rigidity to retract intercostal tissue and to retain a shape suitable for 
positioning a replacement valve through the axial passage into the chest. 
Axial passage 354 preferably has a cross-sectional shape suitable for 
introducing a replacement valve or sizing disk through it in the 
edge-first orientation illustrated in FIG. 25, such as oval, elliptical, 
racetrack, rectangular, trapezoidal, or other suitable shape. Axial 
passage 354 will have a cross-sectional width orthogonal to a central axis 
AX of less than about 30 mm, usually about 10 mm-25 mm, and preferably 
about 15 mm-20 mm. The cross-sectional length of axial passage 354 
orthogonal to central axis AX will be larger than the outer diameter of 
the replacement valve utilized, and usually substantially larger than the 
cross-sectional width of the axial passage, usually being about 15 mm-50 
mm, and preferably being about 25 mm-40 mm. Tubular body 352 has an 
exterior shape and dimensions suitable for positioning access port 350 in 
an intercostal space without cutting or removing the ribs, and preferably 
without significant retraction of the ribs from their natural, undeflected 
positions (e.g. less than about 10 mm of retraction). In an exemplary 
configuration, the outer surface of tubular body 352 has a shape 
corresponding to that of axial passage 354 with a wall thickness 
therebetween of about 0.25-2 mm, preferably 0.75-1.25 mm. Of course, the 
exact size and shape of tubular body 352 will be determined by the size 
and shape of the replacement valve to be utilized in the procedure. 
Access port 350 may further include a flange 356 on its proximal end which 
engages the outer surface of the patient's chest. A suture organizer 358 
is preferably mounted to flange 356, and includes an annular wall 360 with 
a plurality of radial slits 362 in spaced-apart locations around its 
circumference. Each slit 362 is configured to receive a suture thread and 
frictionally retain it as described above in connection with FIGS. 18-19. 
Access port 350 additionally includes a retention mechanism 364 mounted to 
a distal extremity of tubular body 352 for retaining the access port in 
the chest wall. As illustrated in FIG. 28, retention mechanism 364 
comprises a sleeve 366 slidably mounted on tubular body 352 and coupled to 
flange 356 by a pair of tension springs 368, which may be elastomeric 
bands or cords. A retention element 370 is mounted near the distal end of 
sleeve 366 and is collapsible for introduction through an intercostal 
space in the chest wall, and then expandable into a configuration in which 
the retention element engages the inner wall of the chest. In the 
exemplary configuration illustrated in the figures, retention element 370 
comprises a continuous flexible band 372 which extends through two pairs 
of slots 374 on opposing sidewalls of sleeve 366 forming two inner loops 
376 in the interior of sleeve 366 and two outer loops 378 exterior to 
sleeve 366. Band 372 is preferably a resilient, flexible metal, plastic or 
elastomer which is biased into a fully expanded oval or circular ring 
shape. By compressing outer loops 378 radially inward toward sleeve 366, a 
portion of band 372 slides through slots 374, enlarging inner loops 376 
and collapsing outer loops 378 into the configuration illustrated in FIG. 
28. To expand outer loops 378, inner loops are pushed outwardly against 
sleeve 366. 
An assembly view of access port 350 is illustrated in FIG. 29. Annular wall 
360 has a plurality of openings 380 formed around its circumference. An 
insert assembly 382 has a support ring 383 with a plurality of elastomeric 
inserts 384 attached thereto and configured to fit into openings 380. A 
lower end of each insert 384 is configured to be received in one of a 
plurality of slots (not shown) in flange 356 aligned with each opening 
380. Each insert 384 has an enlarged lower end 386 which engages the lower 
surface of flange 356 to retain the insert within opening 380. In this 
way, the adjacent surfaces of inserts 384 and wall 360 within openings 380 
form radial slits 362 (FIG. 27). Inserts 384 will preferably have 
sufficient compliance to deflect slightly as a suture thread is drawn into 
slit 362, and sufficient resilience to maintain pressure against the 
thread to retain it in the slit. 
Also attached to support ring 383 are tension springs 368, which may 
comprise resilient elastomeric bands or cords, extending distally through 
a pair of appropriately aligned slots (not shown) in flange 383. Sleeve 
366 has a pair of ears 388 at its proximal end with axial passages through 
which tension springs 368 may extend. Each tension spring 368 has a flange 
or ledge 390 at its distal end which retains the tension spring in ear 
388. 
To facilitate expanding and collapsing retention element 370, the invention 
provides a specialized obturator for use with access port 350, illustrated 
in FIGS. 30-31. Obturator 392 has a shaft 394 shaped to occlude axial 
passage 354 of access port 350. A distal end 396 of shaft 394 is tapered 
to facilitate introduction through a puncture or incision in the chest 
wall. A handle 398 is fixed to the proximal end of shaft 394. A pair of 
hooks 400 are movably coupled to shaft 394 near distal end 396 and form a 
distally-open U-shaped channel 401 configured to receive inner loops 376 
of band 372. As illustrated in FIGS. 31A-31B, hooks 400 are mounted to a 
pair of actuators 402 pivotably mounted to handle 398 by a pin 404 such 
that actuators 402 move in a scissors-like manner. Actuators 402 each have 
an outwardly extending button 406 which extends through an aperture 408 in 
handle 398. Actuators 402 are biased outwardly by a torsion or U-shaped 
spring 410. In this way, pressing buttons 406 inwardly moves hooks 400 
from the outward position illustrated in FIG. 31A to the inward position 
illustrated in FIG. 31B. 
Obturator 392 further includes a locking mechanism 412 comprising a 
pivotable locking button 414 mounted within an opening 416 in handle 398. 
Locking button 414 has a foot 418 extending from a distal surface thereof. 
Each of actuators 402 has a notch 420 on a proximal surface thereof which 
is configured to receive foot 418. A torsion spring 422 biases locking 
button 414 in a clockwise direction. When actuators 402 are pivoted 
inwardly, foot 418 slides along the proximal surfaces of actuators 402 
until notches 420 are aligned. This allows foot 418 to slide into notches 
420, locking actuators 402 in the inward position, as shown in FIG. 31B. 
The locking mechanism is released by pushing on the proximal surface of 
locking button 414 on the side opposite that of foot 418, pivoting locking 
button 414 counterclockwise to remove foot 418 from notches 420. 
In use, obturator 392 is positioned in axial passage 354 of access port 350 
such that hooks 400 extend around inner loops 376 of band 372 to position 
the band in channels 401. Buttons 406 are then pressed inwardly, drawing 
inner loops 376 inwardly and collapsing outer loops 378 against the outer 
surface of sleeve 366. Access port 350 may then be positioned through an 
incision or puncture through the chest wall between two ribs. When band 
372 is inside the chest cavity, locking button 414 is released, allowing 
actuators 402 and hooks 400 to return to the outward position. Outer loops 
378 are thereby deployed into their expanded configuration, and obturator 
392 may be removed from axial passage 354. Tension springs 368 pull sleeve 
366 toward flange 356 on tubular body 352, compressing the chest wall 
between band 372 and flange 356. Access port 350 is thus firmly held in 
position during the procedure. To remove the access port from the chest, 
obturator 392 is re-inserted into axial passage 354 such that hooks 400 
engage inner loops 376, buttons 406 are pressed inwardly to collapse outer 
loops 378, and access port 350 is withdrawn from the intercostal incision. 
Referring now to FIGS. 32-33, a preferred embodiment of a holder for an 
aortic valve prosthesis according to the invention will be described. As 
shown in FIG. 32, holder 430 is attached to the distal end of delivery 
handle 320 in place of element 328, described above in connection with 
FIGS. 24-26. Holder 430 is pivotable relative to shaft 322 from a first 
orientation of minimum profile suitable for introduction through an 
intercostal space, to a second orientation suitable for aligning the 
prosthetic valve with the native valve annulus so that it may be secured 
thereto. Preferably, as described above, in the first orientation, holder 
430 is positioned such that the central axis of the prosthetic valve 
sewing ring is generally perpendicular to the longitudinal axis of shaft 
322, as shown in phantom in FIG. 32. In the second orientation, holder 430 
is preferably positioned so that the central axis of the prosthetic valve 
sewing ring is generally parallel to the longitudinal axis of shaft 322. 
A configuration of holder 430 will be described which is appropriate for 
use with a mechanical bileaflet aortic valve prosthesis such as the St. 
Jude Medical Mechanical Aortic Valve. However, it will be understood to 
those of ordinary skill in the art that holder 430 may be configured to 
accommodate a wide variety of prosthetic valves without departing from the 
scope of the invention. As shown in FIGS. 33A-33B, holder 430 is 
configured to hold prosthetic valve 432 from its downstream side with 
movable valve leaflets 434 in their closed position. In this position, 
valve leaflets 434 form a V-shaped space within the interior of the valve 
surrounded by annular valve body 436 and sewing ring 438. Holder 430 
therefore has a peaked or wedge-shaped distal surface 440 with angled 
faces 441A, 441B forming an angle .alpha. of between about 90.degree. and 
150.degree., which fits within the V-shaped space adjacent valve leaflets 
434. An annular rim or flange 442 is configured to abut annular sewing 
ring 438 of prosthetic valve 432. A handle coupling 444 is attached to the 
proximal surface 446 of holder 430 and is configured to be attached to 
delivery handle 320. Handle coupling 444 has a transverse channel 448 as 
shown in FIG. 33B configured to receive the distal end of shaft 322. A 
pair of holes 450, 452 extend through handle coupling 444 across channel 
448 and may be aligned with holes 454, 456 in delivery handle 320 so that 
pins may be inserted therethrough. In this way, by sliding rod 336, holder 
430 pivots relative to shaft 320. 
Prosthetic valve 432 may be removably attached to holder 430 in various 
ways. In a preferred embodiment, sutures are placed through sewing ring 
438 and through holder 430 and tied in order to secure the prosthetic 
valve to the holder. For this purpose, holder 430 may include holes, 
loops, eyelets or the like proximal to rim 442 through which sutures may 
be placed. Alternatively, holder 430 may be made of a soft elastomeric 
material through which a suture needle may be driven to secure the suture 
to the holder. When it is desired to remove the prosthetic valve from 
holder 430, the sutures are cut with scissors or a knife. 
Certain prosthetic valves are designed to allow the valve body and valve 
leaflets to be rotated relative to the sewing ring of the prosthesis after 
the sewing ring has been secured to the heart. Advantageously, once holder 
430 has been removed from prosthetic valve 432 and the prosthetic valve 
secured in the heart, holder 430 may be used to rotate valve body 436 
along with leaflets 434 by repositioning holder 430 within the V-shaped 
space formed by leaflets 434 and rotating handle 320 about its 
longitudinal axis. A flat 458 is provided along the two sides of holder 
430 which are positioned adjacent to side supports 459 of prosthetic valve 
432, allowing torque to be transmitted to valve body 436 rather than to 
the fragile valve leaflets 434. 
FIGS. 34-36 illustrate an alternative embodiment of a holder according to 
the invention. In this embodiment , holder 460 is configured to hold a 
bi-leaflet mechanical valve from its upstream side for replacement of a 
diseased cardiac valve from the upstream side of the native valve, e.g., 
for replacement of the mitral valve via an incision in the left atrium as 
described in copending application Ser. No. 08/281,962 and Ser. No. 
08/485,600, which have been incorporated herein by reference. As shown in 
FIG. 34, mechanical bileaflet valve 462 has a pair of leaflets 464 movably 
attached to a pair of upwardly extending side supports 465 on an annular 
valve body 466. A sewing ring 468 is attached to valve body 466. Leaflets 
464 are pivotable between an open position wherein the leaflets are nearly 
parallel, to a closed position wherein the inner edges of leaflets 464 
abut one another and the curved outer edges of the leaflets abut the inner 
surface of annular valve body 466. As shown in FIGS. 35-36, holder 460 is 
configured to be positioned on the upstream side of valve 462 with 
leaflets 464 in the open position. Holder 460 has a distal end 470 having 
a pair of crescent-shaped feet 472 for positioning between the outer 
(upstream) surface of each leaflet 464 and the inner surface of valve body 
466. An arcuate channel 474 extends across distal end 470 between feet 472 
which accommodates side supports 465 and the inner ends of leaflets 464. A 
rim 476 extends around the perimeter of distal end 470 which abuts sewing 
ring 468 and/or valve body 466. Holder 460 is adapted for attachment to 
delivery handle 320 by a handle coupling 480 extending laterally from a 
proximal end of the holder. Handle coupling 480 has a pair of holes 482, 
484 which may be attached to delivery handle 320 as described above in 
connection with FIGS. 33A-33B. 
Prosthetic valve 462 may be releasably attached to holder 460 in various 
ways. In a preferred technique, holder 460 is constructed of a soft 
elastomer which allows a suture needle to be driven through it. In this 
way, one or more sutures may be placed through sewing ring 468 and through 
holder 460 and tied to secure the valve to the holder. Alternatively, 
holder 460 may be a more rigid material and holes, eyelets, or loops may 
be mounted to the holder to which sutures may be secured. When valve 462 
is to be released, the sutures are simply cut. 
An additional embodiment of an access port according to the invention is 
illustrated in FIGS. 37-40. In this embodiment, access port 490 comprises 
a tubular cannula 492 having a distal end 494, a proximal end 496, and a 
lumen 498 through which any of the replacement valves, valve holders and 
valve delivery devices described above may be positioned without 
interference. As described above in connection with FIGS. 27-29, lumen 498 
is preferably oval-shaped, but the lumen may be any of a variety of shapes 
suitable for introducing a prosthetic valve into the chest with minimal 
retraction of the ribs. Cannula 492 has a wall 500 constructed of a 
material having sufficient rigidity to retract intercostal tissue so as to 
provide an opening into the chest through which a replacement valve may be 
positioned. A rim 501 is provided at proximal end 496 which is adapted to 
engage the outer surface of the chest. 
An obturator (not shown) removably positionable within lumen 498 may also 
be provided to facilitate introduction through the chest wall. 
As best seen in FIGS. 38-39, a channel 502 extends axially through wall 500 
between proximal end 496 and distal end 494. A plurality of 
axially-extending optical fibers 504 are distributed around channel 502 so 
as to surround lumen 498 and are potted, bonded or other wise fixed within 
channel 502 such that distal ends 506 of the optical fibers are disposed 
near distal end 494 of the cannula and are pointing generally in the 
distal direction. Optical fibers 504 extend proximally through channel 
502, through an annular space 508 within rim 501, and into a flexible 
cable 510 attached to rim 501 that has a protective, opaque jacket 511 
surrounding the optical fibers. An optical coupling 512 is fixed to the 
free end of cable 510 and is configured to be coupled to a conventional 
fiber optic light source of the type used for fiber optic lighting in 
endoscopes and the like, allowing light to be transmitted from the light 
source through optical fibers 504 and emitted from their distal ends 506. 
In use, cannula 492 is positioned within a small incision between two ribs 
such that distal end 494 is within the chest cavity. Coupling 512 is 
connected to a light source so that light is emitted from optical fibers 
504 so as to illuminate the chest cavity. Various surgical procedures may 
then be performed within the chest using instruments positioned through 
lumen 498 or through other access ports under the illumination provided by 
optical fibers 504. For example, the various steps of an aortic valve 
replacement procedure as described above may be performed under 
illumination provided by access port 490. Advantageously, access port 490 
may be positioned in alignment with the aortic valve to provide the 
optimum angle of illumination, while at the same time providing the 
optimum angle of approach to the valve for introduction of instruments, 
valve sizers, and the prosthetic valve itself through lumen 498. The 
provision of optical fibers 504 on access port 490 may thereby eliminate 
the need for a separate light source within the body cavity for much of 
the procedure, reducing the number of access ports that are required. 
Optical fiber 504 may be mounted to access port 490 in various ways. In 
addition to the annular arrangement of FIGS. 37-40, optical fibers 504' 
may also be mounted along one side of lumen 498', in a crescent-shaped 
channel 516 extending through cannula 492', as shown in FIG. 41. Multiple 
channels (not shown) may extend along two or more sides of lumen 498 among 
which optical fibers 504 may be distributed. Alternatively, as shown in 
FIGS. 42A-42B, instead of mounting optical fibers to the access port, an 
open axial channel 518 may extend through cannula 492" through which an 
endoscopic light wand or thoracoscope (not shown) having a light source 
mounted to it may be slidably inserted into the body cavity alongside 
lumen 498". 
The access ports of FIGS. 37-42 may also include any of the features of the 
access ports described above in connection with FIGS. 27-29, including 
having a suture organizer mounted to the proximal end of the access port 
for retaining sutures in an organized manner around lumen 498, or having a 
selectively deployable retention device mounted near the distal end of the 
access port for engaging the inner wall of the chest (or other body 
cavity) to maintain the access port in position. 
While the above is a complete description of the preferred embodiments of 
the invention, various alternatives, substitutions, modifications and 
improvements are possible without departing from the scope hereof, which 
is defined by the following claims.