Abstract:
A conjunctive method of treating coronary artery disease includes a primary treatment where a stent is placed in a coronary artery of a patient at a site of an occlusion. The conjunctive method comprises placing a therapeutic agent at an epicardial surface of a heart of the patient and at the site of the occlusion. The therapeutic agent is selected for abating restenosis at the site.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
       [0001]    This application claims subject matter disclosed in commonly assigned and co-pending U.S. patent application Ser. No. [not yet assigned] filed on even date herewith and in the name of the same inventors as the present application and titled “Cardiac Tissue Therapy”. 
     
    
     BACKGROUND OF THE INVENTION 
       [0002]    1. Field of the Invention 
         [0003]    This invention pertains to treating coronary artery disease. More particularly, this invention pertains to treating such disease with a conjunctive therapy of a coronary stent and an anti-restenosis agent applied at an epicardial surface of a patient&#39;s heart. 
         [0004]    2. Description of the Prior Art
       a. Coronary Artery Disease Treatments       
 
         [0006]    The history of treatment of coronary artery disease includes a progressive development of less-invasive procedures for treating coronary vessel occlusion. Traditional bypass procedures include harvesting a patient&#39;s blood vessel and using the harvested vessel to create a new blood flow path which terminates distal to a coronary occlusion. Historically, such surgical procedures required a highly invasive sternotomy. Less invasive surgical procedures such as thoracotomies have been developed. 
         [0007]    Non-surgical (i.e., percutaneous) options have been developed for treating occluded blood vessels. Angioplasty involves placement of a balloon in a coronary vessel at an occlusion site. The balloon is inflated to improve the patency of the blood vessel. Further, mechanical supports (i.e., stents) have been developed for placement in the blood vessel at the occlusion site. Such stents may be self-expanding or balloon expanded. 
         [0008]    Historically, coronary stents were bare metal stents (e.g., stainless steel, nitinol or other bio-compatible material). More recently, drug-eluting stents have been developed. These stents include an anti-restenosis drug to abate restenosis following placement of the stent. Commonly, the drug is carried in a polymer matrix permitting delayed release of the drug over a period of time following stent placement. 
         [0009]    Drug-eluting stents have exhibited a material improvement in abating restenosis. However, with passage of time, such stents have exhibited an apparent increased likelihood of thrombosis relative to bare metal stents. It is believed the thrombogenic experience is related to the polymer matrix which carries the anti-restenosis drug. Namely, after the anti-restenosis drug is discharged from the matrix, the polymer of the matrix remains on the stent and presents a site for thrombus formation. 
         [0010]    One of several inventions disclosed in this application includes a conjunctive therapy of a stent and an epicardial delivered anti-restenosis agent.
       b. Pericardial Access Procedures       
 
         [0012]    The pericardium is a sack surrounding the exterior surface (i.e., epicardium or epicardial surface) of the heart. Incisions through the pericardium can result in adhesions which may complicate future heart treatments. 
         [0013]    Less invasive procedures have been described for accessing the pericardial space (i.e., the space defined between the pericardium and the epicardial surface). These include surgical and percutaneous procedures. As used herein, “surgical” access means accessing a pericardial space from an exterior side of the pericardium. “Percutaneous” access means accessing the pericardial space without penetrating through the tissue of the pericardium. 
         [0014]    Examples of such less invasive surgical procedures are shown in the following (all of which are incorporated herein by reference as though set forth in full): U.S. Pat. No. 5,634,895 to Igo et al. issued Jun. 3, 1997; U.S. patent application Publication No. US 2006/0074373 to Walsh et al. published Apr. 6, 2006; U.S. patent application Publication No. US 2006/0189840 to Walsh et al. published Aug. 24, 2006; U.S. patent application Publication No. US 2005/0261673 to Bonner et al. published Nov. 24, 2005 (also enumerating various therapeutic agents); U.S. Pat. No. 7,186,214 to Ness issued Mar. 6, 2007; U.S. Pat. No. 6,206,004 to Schmidt et al. issued Mar. 27, 2001; U.S. Pat. No. 6,156,009 to Grabek issued Dec. 5, 2004; U.S. Pat. No. 5,972,013 to Schmidt issued Oct. 26, 1999 and U.S. Pat. No. 5,931,810 to Grabek issued Aug. 3, 1999. 
         [0015]    Examples of such less invasive percutaneous procedures are shown in the following (all of which are incorporated herein by reference as though set forth in full): U.S. Pat. No. 5,269,326 to Verrier issued Dec. 14, 1993; U.S. Pat. No. 6,200,303 to Verrier et al. issued Mar. 13, 2001; U.S. patent application Publication No. US 2001/0039410 to Verrier et al. published Nov. 8, 2001; U.S. Pat. No. 5,968,010 to Waxman et al. issued Oct. 19, 1999; U.S. Pat. No. 6,582,536 to Shimada issued Jun. 24, 2003; U.S. Pat. No. 7,207,988 to Leckrone et al. issued Apr. 24, 2007; U.S. Pat. No. 6,692,458 to Forman et al. issued Feb. 17, 2004; U.S. Pat. No. 4,884,567 to Elliott et al. issued Dec. 5, 1989; U.S. Pat. No. 6,613,062 to Leckrone et al. issued Sep. 2, 2003; U.S. patent application Publication No. US 2006/0247672 to Vidlund et al. published Nov. 2, 2006; U.S. patent application Publication No. US 2007/0010793 to Callas et al. published Jan. 11, 2007; U.S. patent application Publication No. US 2006/0173441 to Gelfand et al. published Aug. 3, 2006; U.S. patent application Publication No. US 2006/0074397 to Shimada published Apr. 6, 2006; and U.S. Pat. No. 5,087,243 to Avitall issued Feb. 11, 1992 (describing myocardial iontophoresis). 
         [0016]    One of several inventions disclosed in this application includes a novel method and apparatus for delivery of a therapeutic agent to the pericardial space.
       c. Therapeutic Agents       
 
         [0018]    The description of the present invention includes placement of a cardiac therapeutic agent at an epicardial surface. Such agents are well-known in the art and form no part of this invention per se. Examples of such are described in the following (all of which are incorporated herein by reference as though set forth in full): U.S. patent application Publication No. US 2003/0060415 to Hung published Mar. 27, 2003 (enumerating a variety of such agents including anti-restenosis agents and agents administered to the epicardial space); U.S. patent application Publication No. US 2005/0261673 to Bonner et al. published Nov. 24, 2005; U.S. Pat. No. 5,634,895 to Igo et al. issued Jun. 3, 1997 (including describing delivery of anti-restenosis agents to the pericardial space); U.S. patent application Publication No. US 2003/0032998 to Altman published Feb. 13, 2003 (including describing a rolled epicardial patch for distributing a drug to an epicardial surface—e.g., paragraph 0084 of the &#39;998 application); U.S. Pat. No. 6,977,080 to Donovan issued Dec. 20, 2005; International Publication No. WO 2006/076342 A2 published Jul. 20, 2006; U.S. patent application Publication No. US 2003/0109442 to Bisgaier et al. published Jun. 12, 2003 (describing restenosis treatment with localized delivery of therapeutic agent); U.S. patent application Publication No. US 2004/0102759 to Altman et al. published May 27, 2004 (including treating of coronary artery disease with therapeutic agents injected into heart wall tissue); U.S. patent application Publication No. US 2006/0084943 to Rosenman et al. published Apr. 20, 2006 (including therapeutic agent delivery carriers implanted into heart wall tissue); U.S. patent application Publication No. US 2006/0292125 to Kellar et al. published Dec. 28, 2006; U.S. patent application Publication No. US 2007/0078620 to Seward et al. published Apr. 5, 2007 (including method and kits for delivering pharmaceutical agents to adventia surrounding a blood vessel); U.S. patent application Publication No. US 2003/0004141 to Brown published Jan. 2, 2003 (including describing polymeric compounds impregnated with a therapeutic agent for delayed delivery); U.S. patent application Publication No. 2003/0009145 to Struijker-Boudier et al. published Jan. 9, 2003 (including describing delivery of drugs from sustained release devices implanted in myocardial tissue or in the pericardial space); U.S. Pat. No. 6,333,347 to Hunter et al. issued Dec. 25, 2001 (describing intrapericardial delivery of agents for treating a variety of cardiac diseases); U.S. Pat. No. 5,482,925 to Keefer et al. issued Jul. 22, 1997 (describing nitric oxide releasing polymers to treat restenosis); U.S. Pat. No. 7,208,011 to Shanley et al. issued Apr. 24, 2007 (describing an implantable medical device with drug filled holes) and U.S. Pat. No. 5,387,419 to Levy et al. issued Feb. 7, 1995 (controlled release, site specific myocardial agents in polymeric matrix at epicardium). 
       SUMMARY OF THE INVENTION 
       [0019]    According to a preferred embodiment of the present invention, a method and kit are disclosed for a conjunctive method of treating coronary artery disease for use in conjunction with a primary treatment. In the primary treatment, a stent is placed in a coronary artery of a patient at a site of an occlusion. The conjunctive method comprises placing a therapeutic agent at an epicardial surface of a heart of the patient and at the site of the occlusion. The therapeutic agent is selected for abating restenosis at the site. 
       BRIEF DESCRIPTION OF THE DRAWINGS 
       [0020]      FIG. 1  is a schematic side-sectional view showing a coronary artery at an epicardial surface of a heart and spaced from a pericardium and showing an occlusion within a coronary artery; 
         [0021]      FIG. 2  is a cross-sectional view of  FIG. 1 ; 
         [0022]      FIG. 3  is the view of  FIG. 1  showing an occlusion treated by a prior art balloon angioplasty; 
         [0023]      FIG. 4  is the view of FIG. I showing the occlusion treated by a prior art placement of a stent within the coronary artery; 
         [0024]      FIG. 5  is the view of  FIG. 1  showing a coronary obstruction treated in combination with a device according to the present invention for use as an adjunctive therapy; 
         [0025]      FIG. 6  is a top plan view of an epicardial surface of the heart showing the device of the present invention overlying a treated area of a coronary artery (shown in phantom lines); 
         [0026]      FIG. 7  is the view of  FIG. 5  showing treatment of the occlusion site with the device delivered through a fat layer; 
         [0027]      FIG. 8  is a schematic, longitudinal cross-sectional view of a distal end of a deployment device with an implant of the present invention shown within the distal end in a first geometry and positioned to be ejected from the delivery device by a push rod; 
         [0028]      FIG. 9  is the view of  FIG. 8  following ejection of the implant from the delivery device and with the implant assuming a second geometry; 
         [0029]      FIG. 10  is a view shown in exploded format of a kit according to the present invention; 
         [0030]      FIG. 11  is a top plan view of an alternative embodiment of the present invention showing an implant at an epicardial surface (not separately shown) over a site of a coronary occlusion treated by a prior art stent and with the coronary artery shown in cross-section to reveal the stent; 
         [0031]      FIGS. 12 through 15  are the view of  FIG. 11  showing further alternative embodiments of the present invention; 
         [0032]      FIG. 15A  is a cross-sectional view of the implant of  FIG. 15 ; 
         [0033]      FIG. 16  is a side-sectional view of a coronary artery in a myocardium and showing (in perspective) an alternative embodiment of the present invention within heart tissue at a site of a coronary artery occlusion treatment; and 
         [0034]      FIGS. 17-22  are the view of  FIG. 16  showing still further embodiments of the present invention. 
     
    
     DESCRIPTION OF THE PREFERRED EMBODIMENT 
       [0035]    Referring now to the several drawing figures in which identical elements are numbered identically throughout, a description of a preferred embodiment of the present invention will now be provided. The present invention is described in a currently preferred embodiment as an adjunctive treatment with prior art coronary artery stents. However, the invention is not intended to be so limited and may include a stand-alone therapy for a wide variety of uses including treatments for ischemia, infarction, vulnerable plaque and other cardiac disorders. 
         [0036]    By way of background,  FIGS. 1 and 2  illustrate, in schematic format, representative human anatomy. A portion of a patient&#39;s heart is shown as the heart wall or myocardium M. A coronary artery CA is shown imbedded within the myocardium M. The coronary artery CA defines a coronary lumen CL. The patient in  FIGS. 1 and 2  suffers from coronary artery disease illustrated by an obstruction  0  contained within the coronary lumen CL which reduces blood flow through the coronary artery CA and which can lead to ischemia or infarction. The outer surface of the heart is the epicardium E. Overlying the epicardium E is the pericardium P. Opposing surfaces of the pericardium P and the epicardium E define the pericardial space PS. 
         [0037]      FIGS. 3 and 4  illustrate prior art therapies for treating a patient with the obstruction  0  of  FIGS. 1 and 2 .  FIG. 3  illustrates a balloon angioplasty procedure where a catheter C is inserted into the lumen of the coronary artery CA. The distal end of the catheter C contains an inflatable balloon B which is positioned at the obstruction  0 . The balloon B is inflated urging the obstruction  0  to compress against the walls of the coronary artery CA to present a reduced obstruction RO. The balloon is deflated and the catheter C and balloon B are removed. With the reduced obstruction RO, improved blood flow is attained through the coronary artery CA.  FIG. 4  illustrates a prior art stenting procedure where a stent S is placed within the coronary artery CA at the site of the obstruction  0 . The stent S is expanded to reduce the obstruction. Unlike balloon angioplasty, the stent S remains in place at the site of the coronary artery disease. Stents come in many sizes and constructions. Stents may be bare metal stents fabricated from bio-compatible material as nitinol or stainless steel or the like. 
         [0038]    With the prior art procedures of  FIGS. 3 and 4 , blood flow through the coronary artery is improved. However, the patient is at risk of restenosis whereby the site of the obstruction may, over time, become obstructed again. To reduce the likelihood of restenosis, stents S may be coated or impregnated with anti-restenosis drugs. These drugs are released from the stent S over time to prevent restenosis. The delayed delivery of a drug following initial placement of a stent S may occur over a period of, for example, 30-45 days. In this period of time, the drug reduces the inflammatory response and/or smooth muscle cell proliferation during a healing period. 
         [0039]    While drug-eluting stents have been very effective in reducing restenosis, long-term (for example, two to four years following stent placement) drug-eluting stents are shown in certain studies to have higher incidences of thrombus formation over bare metal stents. While bare metal stents (i.e. not drug-eluting stents or drug-coated stents) are more likely to experience restenosis during a short-term period (e.g., less than 6 to 12 months), such stents which do not restenose are more likely to have successful endothelial growth relative to drug-eluting stents and less potential for late term thrombosis (e.g., after one year). With such endothelial growth, blood flow to the coronary artery is not exposed directly to the metal of the stent thereby reducing the likelihood of platelet activation or other responses to foreign bodies within the blood flow. It is believed that such thrombus formation is due to the fact that the sites on the stent which release the drug present blood-contact surface which can produce thrombus formation. 
         [0040]    In its most preferred embodiment, the present invention is an adjunct procedure for use with placement of a bare metal stent at an occlusion site within a coronary artery. The invention is illustrated in  FIGS. 5 and 6  as an implant  10  in the form of a implant placed on the epicardial surface E overlying the site of a stent S. In  FIG. 5 , the coronary artery CA is shown imbedded within the myocardium M. It will be appreciated that coronary arteries may be superficial and located just at the epicardial surface E. 
         [0041]    The implant  10  is shown in  FIGS. 5 and 6  as a implant with a width W greater than a width W′ of the coronary artery CA and with a length L greater than a length L′ of the stent S. As a result, the implant  10  presents a surface area greater than the surface area of the stent at the epicardial surface E so that the entire area of the occlusion site is covered by the surface area of the implant  10 . The implant  10  has a thickness T for the implant to reside within the pericardial space PS at the epicardial surface E. 
         [0042]    It will be appreciated that  FIG. 5  shows a simplified version of anatomy. It does not show fat deposits which may reside on the epicardial surface E. Such is shown in  FIG. 7  with a fat layer F shown on the epicardial surface E. The implant  10  is shown imbedded within the fat layer F and partially protruding through the epicardial surface E into the myocardium M. In the present invention, the implant  10  is placed at the epicardial surface with the term “at” meaning on or near the epicardial surface either spaced from the epicardial surface E by a fat layer F, directly on the epicardial surface E or imbedded within the myocardium M through the epicardial surface E. 
         [0043]    The implant  10  is a carrier for a therapeutic agent to treat coronary disease residing beneath the position of the implant  10 . In the embodiments of  FIGS. 5 and 6 , the drug is preferably an anti-restenosis drug such as those described under the heading “Therapeutic Agents” of this application. Such drugs may be surface coatings on the implant  10 , impregnated within the material of the implant  10 , or placed within holes formed within the implant  10  (all of which forms no part of this invention per se and may be as disclosed in the various documents described under “Therapeutic Agents”). 
         [0044]    The implant  10  is delivered to the epicardial surface E through the pericardial space PS. Access to the pericardial space PS may be either surgical or percutaneous through any of the techniques disclosed in the previous section of this application titled “Pericardial Access Procedures”. In percutaneous access, implant  10  is preferably delivered through an atrial appendage into the pericardial space PS. 
         [0045]    In either of the pericardial access procedures, a small diameter catheter  12  ( FIG. 8 ) is admitted to the pericardial space PS for delivery of the implant  10 . For pericardial access, such catheter  12  must be small diameter to permit passage through the patient&#39;s vasculature into the pericardial space PS while minimizing blood loss from the heart into the pericardial space PS. Further, in the less invasive surgical procedures, small diameter catheters are placed in the pericardial space to reduce the amount of incision through the pericardium P. As a consequence, the implant  10  has a first geometry ( FIG. 8 ) for delivery to the pericardial space PS and a second geometry ( FIG. 9 ) following discharge from a delivery device  12  into the pericardial space PS. 
         [0046]    In  FIG. 8 , the implant  10  is shown rolled up in a coiled configuration at a distal end of a catheter  12  with the implant  10  presenting a diameter D to be fully positioned within the catheter  12 . A push rod  14  is positioned within the catheter  12  just proximal to the implant  10 . Relative movement of the catheter  12  and a push rod  14  (i.e., either distal movement of the push rod  14  or proximal movement of the catheter  12 ) ejects the implant  10  from the distal end of the catheter  12  as illustrated in  FIG. 9 . Upon discharge, the implant  10  assumes a planar configuration to overly the treatment area. Following such delivery, the delivery device  12  is removed leaving the implant  10  fully implanted within the patient and with no portion of the implant  10  exposed outside of the pericardial space PS. 
         [0047]    The material of the implant  10  is biocompatible for chronic placement in the pericardial space PS. It may be an elastic material or material which assumes the second geometry by reason of phase change of the material. It will be appreciated that such materials (both plastic and metal) are well known in the art (such as nitinol and polymer materials). The therapeutic agent may be in a polymer coating on the material of the implant. The agent is selected that upon release it penetrates heart tissue to a coronary artery (e.g., capable of tissue penetration up to 5 mm). Such drugs are none in the art are in included in those described in the section “Therapeutic Agents”. 
         [0048]    The implant  10  may contain radiopaque markers to permit visualization by a physician when placing the implant  10  within the pericardial space PS to ensure positioning over the stent S. The implant  10  may be placed during the same procedure at the placement of the stent S or may be placed before or after placement of the stent S. Drugs from the implant  10  are released over time and migrate through the myocardium M to the coronary artery at the site of the stent S to provide the desired therapy of anti-restenosis drugs at the stent site. Implant  10  may include sufficient drugs for full release (e.g., 90% of the original amount of the drug) of the drugs over a time period (for example, 30 to 45 days) to abate restenosis at the site of the stent S. 
         [0049]      FIG. 10  illustrates a kit according to the present invention including a container  16  in the form of a cardboard box having a lid  18  for access to an interior of the container  16 . The catheter  12  of the present invention is contained within a sterile pouch  20 . Preferably, the sterile pouch  20  is a sealed plastic pouch of clear plastic to permit inspection of the catheter  12  through the pouch. The pouch  20  is contained within the container  16 . Also contained within the container  16  are written instructions  22  for use of the catheter  12 . Such instructions include instruction for placement of a distal end of the catheter  12  in the pericardial space PS and ejecting the implant  10  from the distal end to the epicardial surface E at the site of the obstruction  0 . Optionally, a container  16  may include a second sterile sealed pouch  24  containing devices for treatment of the occlusion such as a catheter C with a balloon B at a distal end. 
         [0050]    The previously described embodiment of the present invention is an implant  10  in the form of a implant sized to have a surface area overlying the epicardial surface E to cover the area of a stent S placed within a coronary artery CA beneath the epicardial surface E.  FIGS. 11-15  show alternative embodiments of an implant for placement on the epicardial surface overlying a stent. 
         [0051]    In  FIGS. 11-15 , the epicardial surface and the myocardium are not shown for ease of illustration. Also, the coronary artery CA is shown in longitudinal cross-section to reveal a prior art stent S at an occlusion site. 
         [0052]    In  FIG. 11 , an implant  10   a  is shown in the form of a resilient coil. Within the delivery device  12 , the coil  10   a  is deformed to a linear configuration (i.e., first geometry). The width Wa of the implant  10   a  is smaller than or equal to the diameter D of the catheter lumen. Following ejection of the implant  10   a  from the catheter  12 , the implant  10   a  is biased to assume the coiled shape (i.e., second geometry) of  FIG. 11  with the diameter Da greater than the width W′ of the coronary artery and the length L′ of the stent. An end of the implant  10   a  is provided with a hole  26  or other attachment location for later grabbing the end of the implant  10   a  and pulling it into a catheter for subsequent removal of the implant  10   a  from the epicardial surface. 
         [0053]    In  FIG. 12 , an alternative embodiment is shown where the implant  10   b  may be straight and elongated (first geometry) within a catheter and assume a wavy configuration (second geometry) following discharge of the implant  10   b.  The length and width of the implant  10   b  in its second geometry (LB, WB) are preferably greater than the length and width L′, W′ of the area to be treated. 
         [0054]    In  FIG. 13 , the implant  10   c  is, again, an elongated implant which, following discharge from a catheter  12  assumes a second geometry. In  FIG. 13 , the second geometry is a more random coiling and intertwining of the implant  10   c.  However, it continues to have the further benefit of the second geometry which is greater in overall surface area than the area occupied by the stent so that drugs eluted from the implant  10   c  cover the site to be treated. 
         [0055]    In  FIG. 14 , the implant  10   d  has a construction similar to conventional stent construction in that it is a mesh. Different from cylindrical stents, the mesh of implant  10   d  is planar in configuration when in the second geometry having a length and width LD and WD greater than the length and width L′, W′. Mesh of  10   d  is compressible to fit within the diameter D of the catheter  12 . 
         [0056]    The implant  10   e  of  FIG. 15  is similar to  FIG. 14  in that the implant  10   e  is planar in configuration with a length and width Le, We greater than the length and width L′, W′ and with implant  10   e  compressible to fit within the diameter D of the catheter  12 . The implant  10  has a plurality of holes  28  formed through a first surface  30  of the implant  10   e  and not projecting through the opposite second surface  32  (as best shown in the cross-sectional view of  FIG. 15A . The holes  28  may be filled with the desired therapeutic agent. Such drug delivery is shown in U.S. Pat. No. 7,208,011 to Shanley et al. issued Apr. 24, 2007 (describing an implantable medical device with drug-filled holes). In previously described embodiments, either side of the implant may oppose the epicardial surface with drug delivery eluting from all exposed surfaces of the implants. In the embodiments of  FIGS. 15 and 15A , the drug is delivered from the holes  28  only across the surface  30 . No drugs are eluted across surface  32  into the pericardial space PS. The implant  10   e  is placed on the epicardial surface E with surface  30  opposing the epicardial surface E. 
         [0057]      FIGS. 16-22  show embodiments of the present invention where implants carrying the therapeutic agent are placed wholly or partially into the myocardium M across the epicardial surface E from the pericardial space PS. 
         [0058]    In  FIG. 16 , the implant  10   f  is a conical shaped coil and having a cone tip end  32 f which is sharpened to penetrate into the myocardium M from the epicardial surface E. The base of the cone has an area greater than the area of the occlusion site. 
         [0059]    In  FIG. 17 , the implant  10   g  is a planar mesh construction having a sharp leading end  32   f.  In  FIG. 18 , the implant  10   h  is a cylindrical mesh construction which expands following ejection from the catheter  12 . Within the catheter  12 , the cylindrical implant  10   h  has a diameter less than or equal to diameter D. Following ejection, it expands to a greater diameter. 
         [0060]    In  FIGS. 19 and 20 , the implant  10   i  is shown as a clip having side walls  33   e  which expand to be spaced apart greater than a width W′ of the coronary artery CA. Side walls  33   e  terminate at sharpened edges  32   e  to facilitate penetration from the epicardial surface E into the myocardium M with the coronary artery CA positioned between the side walls  33   e.  The side walls  33   e  are joined at a common handle  34  which may be grasped by any grasping tool passed through the catheter  12  to manipulate the implant  10   i.    
         [0061]    In  FIGS. 21 and 22 , the implant  10   j  is a plurality of rods containing a therapeutic agent for time delay delivery. The rods have sharpened distal ends  32   j  to permit placing a plurality of rods through the epicardial surface ES into the myocardium M with the rods positioned on opposite sides of the coronary artery CA. 
         [0062]    In all of the disclosed embodiments, the implant discharges a therapeutic agent over time. The therapeutic agent migrates through the myocardial tissue to a desired treatment site of the heart. The implant is positioned within the heart at the epicardial surface by delivery from a delivery tool admitted into the pericardial space. Following delivery, the delivery tool is removed leaving the implant  10  completely contained within the heart (i.e., not exposed through the pericardium). 
         [0063]    With the present invention now disclosed in the preferred embodiment, modifications and equivalents of the disclosed concepts may occur to one of ordinary skill in the art. It is intended that such modifications and equivalents be included within the scope of the claims which are appended hereto.