Patent Publication Number: US-2007112390-A1

Title: Cardiac harness for treating congestive heart failure and for defibrillating and/or pacing/sensing

Description:
BACKGROUND OF THE INVENTION  
      The present invention relates to a device for treating heart failure. More specifically, the invention relates to a cardiac harness configured to be fit around at least a portion of a patient&#39;s heart. The cardiac harness includes electrodes attached to a power source for use in defibrillation or pacing.  
      Congestive heart failure (“CHF”) is characterized by the failure of the heart to pump blood at sufficient flow rates to meet the metabolic demand of tissues, especially the demand for oxygen. One characteristic of CHF is remodeling of at least portions of a patient&#39;s heart. Remodeling involves physical change to the size, shape and thickness of the heart wall. For example, a damaged left ventricle may have some localized thinning and stretching of a portion of the myocardium. The thinned portion of the myocardium often is functionally impaired, and other portions of the myocardium attempt to compensate. As a result, the other portions of the myocardium may expand so that the stroke volume of the ventricle is maintained notwithstanding the impaired zone of the myocardium. Such expansion may cause the left ventricle to assume a somewhat spherical shape.  
      Cardiac remodeling often subjects the heart wall to increased wall tension or stress, which further impairs the heart&#39;s functional performance. Often, the heart wall will dilate further in order to compensate for the impairment caused by such increased stress. Thus, a cycle can result, in which dilation leads to further dilation and greater functional impairment.  
      Historically, congestive heart failure has been managed with a variety of drugs. Devices have also been used to improve cardiac output. For example, left ventricular assist pumps help the heart to pump blood. Multi-chamber pacing has also been employed to optimally synchronize the beating of the heart chambers to improve cardiac output. Various skeletal muscles, such as the latissimus dorsi, have been used to assist ventricular pumping. Researchers and cardiac surgeons have also experimented with prosthetic “girdles” disposed around the heart. One such design is a prosthetic “sock” or “jacket” that is wrapped around the heart.  
      Patients suffering from congestive heart failure often are at risk to additional cardiac failures, including cardiac arrhythmias. When such arrhythmias occur, the heart must be shocked to return it to a normal cycle, typically by using a defibrillator. Implantable cardioverter/defibrillators (ICD&#39;s) are well known in the art and typically have a lead from the ICD connected to an electrode implanted in the right ventricle. Such electrodes are capable of delivering a defibrillating electrical shock from the ICD to the heart.  
      Other prior art devices have placed the electrodes on the epicardium at various locations, including on or near the epicardial surface of the right and left heart. These devices also are capable of distributing an electrical current from an implantable cardioverter/defibrillator for purposes of treating ventricular defibrillation or hemodynamically stable or unstable ventricular tachyarrhythmias.  
      Patients suffering from congestive heart failure may also suffer from cardiac failures, including bradycardia and tachycardia. Such disorders typically are treated by both pacemakers and implantable cardioverter/defibrillators. The pacemaker is a device that paces the heart with timed pacing pulses for use in the treatment of bradycardia, where the ventricular rate is too slow, or to treat cardiac rhythms that are too fast, i.e., anti-tachycardia pacing. As used herein, the term “pacemaker” is any cardiac rhythm management device with a pacing functionality, regardless of any other functions it may perform such as the delivery cardioversion or defibrillation shocks to terminate atrial or ventricular fibrillation. Particular forms and uses for pacing/sensing can be found in U.S. Patent Nos. 6,574,506 (Kramer et al.) and U.S. Pat. No. 6,223,079 (Bakels et al.); and U.S. Publication No. 2003/0130702 (Kramer et al.) and U.S. Publication No. 2003/0195575 (Kramer et al.), the entire contents of which are incorporated herein by reference thereto.  
      The present invention solves the problems associated with prior art devices relating to a harness for treating congestive heart failure and placement of electrodes for use in defibrillation, or for use in pacing.  
     SUMMARY OF THE INVENTION  
      In accordance with the present invention, a cardiac harness is configured to fit at least a portion of a patient&#39;s heart and is associated with one or more electrodes capable of providing defibrillation or pacing functions. In one embodiment, rows or strands of undulations are interconnected and associated with coils or defibrillation and/or pacing/sensing leads. In another embodiment, the cardiac harness includes a number of panels separated by coils or electrodes, wherein the panels have rows or strands of undulations interconnected together so that the panels can flex and can expand and retract circumferentially. The panels of the cardiac harness are coated with a dielectric coating to electrically insulate the panels from an electrical shock delivered through the electrodes. Further, the electrodes are at least partially coated with a dielectric material to insulate the electrodes from the cardiac harness. In one embodiment, the strands or rows of undulations are formed from Nitinol and are coated with a dielectric material such as silicone rubber. In this embodiment, the electrodes are at least partially coated with the same dielectric material of silicone rubber. The electrode portion of the leads are not covered by the dielectric material so that as the electrical shock is delivered by the electrodes to the epicardial surface of the heart, the coated panels and the portion of the electrodes that are coated are insulated by the silicone rubber. In other words, the heart received an electrical shock only where the bare metal of the electrodes are in contact with or are adjacent to the epicardial surface of the heart. The dielectric coating also serves to attach the panels to the electrodes.  
      In another embodiment, the electrodes have a first surface and a second surface, the first surface being in contact with the outer surface of the heart, such as the epicardium, and the second surface faces away from the heart. Both the first surface and the second surface do not have a dielectric coating so that an electrical charge can be delivered to the outer surface of the heart for defibrillating or for pacing. In this embodiment, at least a portion of the electrodes are coated with a dielectric coating, such as silicone rubber, Parylene™ or polyurethane. The dielectric coating serves to insulate the bare metal portions of the electrode from the cardiac harness, and also to provide attachment means for attaching the electrodes to the panels of the cardiac harness.  
      The number of electrodes and the number of panels forming the cardiac harness is a matter of choice. For example, in one embodiment the cardiac harness can include two panels separated by two electrodes. The electrodes would be positioned 180° apart, or in some other orientation so that the electrodes could be positioned to provide a optimum electrical shock to the epicardial surface of the heart, preferably adjacent the right ventricle or the left ventricle. In another embodiment, the electrodes can be positioned 180° apart so that the electrical shock carries through the myocardium adjacent the right ventricle thereby providing an optimal electrical shock for defibrillation or periodic shocks for pacing. In another embodiment, three leads are associated with the cardiac harness so that there are three panels separated by the three electrodes.  
      In yet another embodiment, four panels on the cardiac harness are separated by four electrodes. In this embodiment, two electrodes are positioned adjacent the left ventricle on or near the epicardial surface of the heart while the other two electrodes are positioned adjacent the right ventricle on or near the epicardial surface of the heart. As an electrical shock is delivered, it passes through the myocardium between the two sets of electrodes to shock the entire ventricles.  
      In another embodiment, there are more than four panels and more than four electrodes forming the cardiac harness. Placement of the electrodes and the panels is a matter of choice. Further, one or more electrodes may be deactivated.  
      In another embodiment, the cardiac harness includes multiple electrodes separating multiple panels. The embodiment also includes one or more pacing/sensing electrodes (multi-site) for use in sensing heart functions, and delivering pacing stimuli for resynchronization, including biventricular pacing and left ventricle pacing or right ventricular pacing.  
      In each of the embodiments, an electrical shock for defibrillation, or an electrical pacing stimuli for synchronization or pacing is delivered by a pulse generator, which can include an implantable cardioverter/defibrillator (ICD), a cardiac resynchronization therapy defibrillator (CRT-D), and/or a pacemaker. Further, in each of the foregoing embodiments, the cardiac harness can be coupled with multiple pacing/sensing electrodes to provide multi-site pacing to control cardiac function. By incorporating multi-site pacing into the cardiac harness, the system can be used to treat contractile dysfunction while concurrently treating bradycardia and tachycardia. This will improve pumping function by altering heart chamber contraction sequences while maintaining pumping rate and rhythm. In one embodiment, the cardiac harness incorporates pacing/sensing electrodes positioned on the epicardial surface of the heart adjacent to the left and right ventricle for pacing both the left and right ventricles.  
      In another embodiment, the cardiac harness includes multiple electrodes separating multiple panels. In this embodiment, at least some of the electrodes are positioned on or near (proximate) the epicardial surface of the heart for providing an electrical shock for defibrillation, and other of the electrodes are positioned on the epicardial surface of the heart to provide pacing stimuli useful in synchronizing the left and right ventricles, cardiac resynchronization therapy, and biventricular pacing or left ventricular pacing or right ventricular pacing.  
      In another embodiment, the cardiac harness includes multiple electrodes separating multiple panels. At least some of the electrodes provide an electrical shock for defibrillation, and one of the electrodes, a single site electrode, is used for pacing and sensing a single ventricle. For example, the single site electrode is used for left ventricular pacing or right ventricular pacing. The single site electrode also can be positioned near the septum in order to provide bi-ventricular pacing.  
      In yet another embodiment, the cardiac harness includes one or more electrodes associated with the cardiac harness for providing a pacing/sensing function. In this embodiment, a single site electrode is positioned on the epicardial surface of the heart adjacent the left ventricle for left ventricular pacing. Alternatively, a single site electrode is positioned on the surface of the heart adjacent the right ventricle to provide right ventricular pacing. Alternatively, more than one pacing/sensing electrode is positioned on the epicardial surface of the heart to treat synchrony of both ventricles, including bi-ventricular pacing.  
      In another embodiment, the cardiac harness includes coils that separate multiple panels. The coils have a high degree of flexibility, yet are capable of providing column strength so that the cardiac harness can be delivered by minimally invasive access.  
      All embodiments of the cardiac harness, including those with electrodes, are configured for delivery and implantation on the heart using minimally invasive approaches involving cardiac access through, for example, subxiphoid, subcostal, or intercostal incisions, and through the skin by percutaneous delivery using a catheter. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS  
       FIG. 1  depicts a schematic view of a heart with a prior art cardiac harness placed thereon.  
       FIGS. 2A-2B  depict a spring hinge of a prior art cardiac harness in a relaxed position and under tension.  
       FIG. 3  depicts a prior art cardiac harness that has been cut out of a flat sheet of material.  
       FIG. 4  depicts the prior art cardiac harness of  FIG. 3  formed into a shape configured to fit about a heart.  
       FIG. 5A  depicts a flattened view of one embodiment of the cardiac harness of the invention showing two panels connected to two electrodes.  
       FIG. 5B  depicts a cross-sectional view of an electrode.  
       FIG. 5C  depicts a cross-sectional view of an electrode.  
       FIG. 5D  depicts a cross-sectional view of an electrode.  
       FIG. 6A  depicts a cross-sectional view of an undulating strand or ring.  
       FIG. 6B  depicts a cross-sectional view of an undulating strand or ring.  
       FIG. 6C  depicts a cross-sectional view of an undulating strand or ring.  
       FIG. 7A  depicts an enlarged plan view of a cardiac harness showing three electrodes separating three panels, with the far side panel not shown for clarity.  
       FIG. 7B  depicts an enlarged partial plan view of the cardiac harness of  FIG. 7A  showing an electrode partially covered with a dielectric material which also serves to attach the panels to the electrode.  
       FIG. 8A  depicts a transverse cross-sectional view of the heart showing the position of electrodes for defibrillation and/or pacing/sensing functions.  
       FIG. 8B  depicts a transverse cross-sectional view of the heart showing the position of electrodes for defibrillation and/or pacing/sensing functions.  
       FIG. 8C  depicts a transverse cross-sectional view of the heart showing the position of electrodes for defibrillation and/or pacing/sensing functions.  
       FIG. 8D  depicts a transverse cross-sectional view of the heart showing the position of electrodes for defibrillation and/or pacing/sensing functions.  
       FIG. 9  depicts a plan view of one embodiment of a cardiac harness having panels separated by and attached to flexible coils.  
       FIG. 10  depicts a flattened plan view of a cardiac harness similar to that of  FIG. 9  but with fewer panels and coils.  
       FIG. 11  depicts a plan view of one embodiment of a cardiac harness having panels separated by and attached to flexible coils.  
       FIG. 12  depicts a plan view of a cardiac harness similar to that shown in  FIG. 11  mounted on the epicardial surface of the heart.  
       FIG. 13  depicts a perspective view of a cardiac harness similar to that of  FIG. 9  where the harness has been folded to reduce its profile for minimally invasive delivery.  
       FIG. 14  depicts the cardiac harness of  FIG. 13  in a partially bent and folded condition to reduce its profile for minimally invasive delivery.  
       FIG. 15A  depicts an enlarged plan view of a cardiac harness showing continuous undulating strands with electrodes overlaying the strands.  
       FIG. 15B  depicts an enlarged partial plan view of the cardiac harness of  FIG. 15A  showing continuous undulating strands with an electrode overlying the strands.  
       FIG. 15C  depicts a partial cross-sectional view taken along lines  15 C- 15 C showing the electrode and undulating strands.  
       FIG. 15D  depicts a partial cross-sectional view taken along lines  15 D- 15 D showing the undulating strands in notches in the electrode.  
       FIG. 16  depicts a top view of a fixture for winding wire to construct the cardiac harness.  
       FIG. 17  depicts a plan view of a portion of a cardiac harness showing panels separated by electrodes.  
       FIGS. 18A, 18B  and  18 C depict various views of a mold used for injecting a dielectric material around the cardiac harness and the electrodes.  
       FIGS. 19A, 19B  and  19 C depict various views of molds used in injecting a dielectric material around the cardiac harness and the electrodes.  
       FIG. 20  depicts a top view of a portion of an electrode having a metallic coil winding.  
       FIG. 21  depicts a side view of the electrode portion shown in  FIG. 20 .  
       FIG. 22  depicts a cross-sectional view taken along lines  22 - 22  showing lumens extending through the electrode.  
       FIG. 23  depicts a cross-sectional view taken along lines  23 - 23  depicting another embodiment of lumens extending through the electrode.  
       FIG. 24  depicts a top view of a portion of an electrode having multiple coil windings.  
       FIG. 25A  depicts a side view of a portion of a defibrillator electrode combined with a pacing/sensing electrode.  
       FIG. 25B  depicts a top view of the electrode portion of  FIG. 25A .  
       FIGS. 26A-26C  depict various views of a defibrillator electrode combined with a pacing/sensing electrode.  
       FIG. 27  depicts a side view of an introducer for delivering the cardiac harness through minimally invasive procedures.  
       FIG. 28  depicts a perspective end view of a dilator with the cardiac harness releasably positioned therein.  
       FIG. 29  depicts an end view of the introducer with the cardiac harness releasably positioned therein.  
       FIG. 30  depicts a schematic cross-sectional view of a human thorax with the cardiac harness system being delivered by a delivery device inserted through an intercostal space and contacting the heart.  
       FIG. 31  depicts a plan view of the heart with a suction device releasably attached to the apex of the heart.  
       FIG. 32  depicts a plan view of the heart with the suction device attached to the apex and the introducer positioned to deliver the cardiac harness over the heart.  
       FIG. 33  depicts a plan view of the cardiac harness being deployed from the introducer onto the epicardial surface of the heart.  
       FIG. 34  depicts a plan view of the heart with the cardiac harness being deployed from the introducer onto the epicardial surface of the heart.  
       FIG. 35  depicts a plan view of the heart with the cardiac harness having electrodes attached thereto, surrounding a portion of the heart.  
       FIG. 36  depicts a schematic view of the cardiac harness assembly mounted on the human heart together with leads and an ICD for use in defibrillation or pacing.  
       FIG. 37  depicts an exploded a side view of a delivery system with the introducer tube, dilator tube, and ejection tube shown prior to assembly.  
       FIG. 38  depicts a cross-sectional view of the introducer tube taken along lines  38 - 38 .  
       FIG. 39  depicts a cross-sectional view taken along lines  39 - 39  showing the cross-section of the dilator tube.  
       FIG. 40  depicts a cross-sectional view taken along lines  40 - 40  extending through the plate of the ejection tube and showing the various lumens in the plate.  
       FIG. 41  depicts a cross-sectional view taken along lines  41 - 41  of the proximal end of the ejection tube.  
       FIG. 42  depicts a longitudinal cross-sectional view and schematic of the ejection tube with the leads from the electrodes extending through the lumens in the plate and the tubing from the suction cup extending through a lumen in the plate. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS  
      This invention relates to a method and apparatus for treating heart failure. It is anticipated that remodeling of a diseased heart can be resisted or even reversed by alleviating the wall stresses in such a heart. The present invention discloses embodiments and methods for supporting the cardiac wall and for providing defibrillation and/or pacing functions using the same system. Additional embodiments and aspects are also discussed in Applicants&#39; co-pending application entitled “Multi-Panel Cardiac Harness” U.S. Ser. No. 60/458,991 filed Mar. 28, 2003, the entirety of which is hereby expressly incorporated by reference.  
      Prior Art Devices  
       FIG. 1  illustrates a mammalian heart  10  having a prior art cardiac wall stress reduction device in the form of a harness applied to it. The harness surrounds a portion of the heart and covers the right ventricle  11 , the left ventricle  12 , and the apex  13 . For convenience of reference, longitudinal axis  15  goes through the apex and the AV groove  14 . The cardiac harness has a series of hinges or spring elements that circumscribe the heart and, collectively, apply a mild compressive force on the heart to alleviate wall stresses.  
      The term “cardiac harness” as used herein is a broad term that refers to a device fit onto a patient&#39;s heart to apply a compressive force on the heart during at least a portion of the cardiac cycle.  
      The cardiac harness illustrated in  FIG. 1  has at least one undulating strand having a series of spring elements referred to as hinges or spring hinges that are configured to deform as the heart expands during filling. Each hinge provides substantially unidirectional elasticity, in that it acts in one direction and does not provide as much elasticity in the direction perpendicular to that direction. For example,  FIG. 2A  shows a prior art hinge member at rest. The hinge member has a central portion and a pair of arms. As the arms are pulled, as shown in  FIG. 2B , a bending moment is imposed on the central portion. The bending moment urges the hinge member back to its relaxed condition. Note that a typical strand comprises a series of such hinges, and that the hinges are adapted to elastically expand and retract in the direction of the strand.  
      In the harness illustrated in  FIG. 1 , the strands of spring elements are constructed of extruded wire that is deformed to form the spring elements.  
       FIGS. 3 and 4  illustrate another prior art cardiac harness, shown at two points during manufacture of such a harness. The harness is first formed from a relatively thin, flat sheet of material. Any method can be used to form the harness from the flat sheet. For example, in one embodiment, the harness is photochemically etched from the material; in another embodiment, the harness is laser-cut from the thin sheet of material. The harness shown in  FIGS. 3 and 4  has been etched from a thin sheet of Nitinol, which is superelastic material that also exhibits shape memory properties. The flat sheet of material is draped over a form, die or the like, and is formed to generally take on the shape of at least a portion of a heart.  
      With further reference to  FIGS. 1 and 4 , the cardiac harnesses have a base portion which is sized and configured to generally engage and fit onto a base region of a patient&#39;s heart, an apex portion which is sized and shaped so as to generally engage and fit on an apex region of a patient&#39;s heart, and a medial portion between the base and apex portions.  
      In the harness shown in  FIGS. 3 and 4 , the harness has strands or rows of undulating wire. As discussed above, the undulations have hinge/spring elements which are elastically bendable in a desired direction. Some of the strands are connected to each other by interconnecting elements. The interconnecting elements help maintain the position of the strands relative to one another. Preferably the interconnecting elements allow some relative movement between adjacent strands.  
      The undulating spring elements exert a force in resistance to expansion of the heart. Collectively, the force exerted by the spring elements tends toward compressing the heart, thus alleviating wall stresses in the heart as the heart expands. Accordingly, the harness helps to decrease the workload of the heart, enabling the heart to more effectively pump blood through the patient&#39;s body and enabling the heart an opportunity to heal itself. It should be understood that several arrangements and configurations of spring members can be used to create a mildly compressive force on the heart to reduce wall stresses. For example, spring members can be disposed over only a portion of the circumference of the heart or the spring members can cover a substantial portion of the heart.  
      As the heart expands and contracts during diastole and systole, the contractile cells of the myocardium expand and contract. In a diseased heart, the myocardium may expand such that the cells are distressed and lose at least some contractility. Distressed cells are less able to deal with the stresses of expansion and contraction. As such, the effectiveness of heart pumping decreases. Each series of spring hinges of the above cardiac harness embodiments is configured so that as the heart expands during diastole the spring hinges correspondingly will expand, thus storing expansion forces as bending energy in the spring. As such, the stress load on the myocardium is partially relieved by the harness. This reduction in stress helps the myocardium cells to remain healthy and/or regain health. As the heart contracts during systole, the disclosed prior art cardiac harnesses apply a moderate compressive force as the hinge or spring elements release the bending energy developed during expansion allowing the cardiac harness to follow the heart as it contracts and to apply contractile force as well.  
      Other structural configurations for cardiac harnesses exist, however, but all have drawbacks and do not function optimally to treat CHF and other related diseases or failures. The present invention cardiac harness provides a novel approach to treat CHF and provides electrodes associated with the harness to deliver an electrical shock for defibrillation or a pacing stimulus for resynchronization, or for biventricular pacing/sensing.  
     The Present Invention Embodiments  
      The present invention is directed to a cardiac harness system for treating the peart. The cardiac harness system of the present invention couples a cardiac harness for treating the heart coupled with a cardiac rhythm management device. More particularly, the cardiac harness includes rows or undulating strands of spring elements that provide a compressive force on the heart during diastole and systole in order to relieve wall stress pressure on the heart. Associated with the cardiac harness is a cardiac rhythm management device for treating any number of irregularities in heart beat due to, among other reasons, congestive heart failure. Thus, the cardiac rhythm management device associated with the cardiac harness can include one or more of the following: an implantable cardioverter/defibrillator with associated leads and electrodes; a cardiac pacemaker including leads and electrodes used for sensing cardiac function and providing pacing stimuli to treat synchrony of both vessels; and a combined implantable cardioverter/defibrillator and pacemaker, with associated leads and electrodes to provide a defibrillation shock and/or pacing/sensing functions.  
      The cardiac harness system includes various configurations of panels connected together to at least partially surround the heart and assist the heart during diastole and systole. The cardiac harness system also includes one or more leads having electrodes associated with the cardiac harness and a source of electrical energy supplied to the electrodes for delivering a defibrillating shock or pacing stimuli.  
      In one embodiment of the invention, as shown in a flattened configuration in  FIG. 5 , a cardiac harness  20  includes two panels  21  of generally continuous undulating strands  22 . A panel includes rows or undulating strands of hinges or spring elements that are connected together and that are positioned between a pair of electrodes, the rows or undulations being highly elastic in the circumferential direction and, to a lesser extent, in the longitudinal direction. In this embodiment, the undulating strands have U-shaped hinges or spring elements  23  capable of expanding and contracting circumferentially along directional line  24 . The cardiac harness has a base or upper end  25  and an apex or lower end  26 . The undulating strands are highly elastic in the circumferential direction when placed around the heart  10 , and to a lesser degree in a direction parallel to the longitudinal axis  15  of the heart. Similar hinges or spring elements are disclosed in co-pending and co-assigned U.S. Ser. No. 60/458,991 filed Mar. 28, 2003, the entire contents of which are incorporated herein by reference. While the  FIG. 5  embodiment appears flat for ease of reference, in use it is substantially cylindrical (or tapered) to conform to the heart and the right and left side panels would actually be one panel and there would be no discontinuity in the undulating strands.  
      The undulating strands  22  provide a compressive force on the epicardial surface of the heart thereby relieving wall stress. In particular, the spring elements  23  expand and contract circumferentially as the heart expands and contracts during the diastolic and systolic functions. As the heart expands, the spring elements expand and resist expansion as they continue to open and store expansion forces. During systole, as the heart  10  contracts, the spring elements will contract circumferentially by releasing the stored bending forces thereby assisting in both the diastolic and systolic function.  
      As just discussed, bending stresses are absorbed by the spring elements  23  during diastole and are stored in the elements as bending energy. During systole, when the heart pumps, the heart muscles contract and the heart becomes smaller. Simultaneously, bending energy stored within the spring elements  23  is at least partially released, thereby providing an assist to the heart during systole. In a preferred embodiment, the compressive force exerted on the heart by the spring elements of the harness comprises about 10% to 15% of the mechanical work done as the heart contracts during systole. Although the harness is not intended to replace ventricular pumping, the harness does substantially assist the heart during systole.  
      The undulating strands  22  can have varying numbers of spring element  23  depending upon the amplitude and pitch of the spring elements. For example, by varying the amplitude of the pitch of the spring elements, the number of undulations per panel will vary as well. It may be desired to increase the amount of compressive force the cardiac harness  20  imparts on the epicardial surface of the heart, therefore the present invention provides for panels that have spring elements with lower amplitudes and a shorter pitch, thereby increasing the expansion force imparted by the spring element. In other words, all other factors being constant, a spring element having a relatively lower amplitude will be more rigid and resist opening, thereby storing more bending forces during diastole. Further, if the pitch is smaller, there will be more spring elements per unit of length along the undulating strand, thereby increasing the overall bending force stored during diastole, and released during systole. Other factors that will affect the compressive force imparted by the cardiac harness onto the epicardial surface of the heart include the shape of the spring elements, the diameter and shape of the wire forming the undulating strands, and the material comprising the strands.  
      As shown in  FIG. 5 , the undulating strands  22  are connected to each other by grip pads  27 . In the embodiments shown in  FIG. 5 , adjacent undulating strands are connected by one or more grip pads attached at the apex  28  of the spring elements  23 . The number of grip pads between adjacent undulating strands is a matter of choice and can range from one grip pad between adjacent undulating strands, to one grip pad for every apex on the undulating strand. Importantly, the grip pads should be positioned in order to maintain flexibility of the cardiac harness  20  without sacrificing the objectives of maintaining the spacing between adjacent undulating strands to prevent overlap and to enhance the frictional engagement between the grip pads and the epicardial surface of the heart. Further, while it is desirable to have the grip pads attached at the apex of the spring elements, the invention is not so limited. The grip pads  27  can be attached anywhere along the length of the spring elements, including the sides  29 . Further, the shape of the grip pads  27 , as shown in  FIG. 5 , can vary to suit a particular purpose. For example, grip pad  27  can be attached to the apex  28  of one undulating strand  22 , and be attached to two apices on an adjacent undulating strand (see  FIG. 7 ). As shown in  FIG. 5 , all of the apices point toward each other, and are said to be “out-of-phase.” If the apices of the undulations were aligned, they would be “in-phase.” The apices are all out-of-phase since the number of spring elements in each undulating strand is the same, however, the invention contemplates that the number of spring elements in each undulating strand may vary since the heart is tapered from its base near the top to its apex  13  at the bottom. Thus, there would be more spring elements and a longer undulating strand per panel at the top or base of the cardiac harness than at the bottom of the cardiac harness near the apex of the heart. Accordingly, the cardiac harness would be tapered from the relatively wide base to a relatively narrow bottom toward the apex of the heart, and this would affect the alignment of the apices of the spring elements, and hence the ability of the grip pads  27  to align perfectly and attach to adjacent apices of the spring elements. A further disclosure and embodiments relating to the undulating strands and the attachment means in the form of grip pads is found in co-pending and co-assigned U.S. Ser. No. 60/486,062 filed Jul. 10, 2003, the entire contents of which are incorporated herein by reference. While the connections between adjacent undulating strands  22  is preferably grip pads  27 , in an alternative embodiment (not shown) the undulating strands are connected by interconnecting elements made of the same material as the strands. The interconnecting elements can be straight or curved as shown in  FIGS. 8A-8B  of commonly owned U.S. Pat. No. 6,612,979 B2, the entire contents of which is incorporated by reference herein.  
      It is preferred that the undulating strands  22  be continuous as shown in  FIG. 5 . For example, every pair of adjacent undulating strands are connected by bar arm  30 . It. is preferred that the bar arms form part of a continuous wire that is bent to form the undulating strands, and then welded at its ends along the bar arm. The weld is not shown in  FIG. 5 , but can be by any conventional method such as laser welding, fusion bonding, or conventional welding. The type of wire used to form the undulating strands may have a bearing on the method of attaching the ends of the wire used to form the undulating strand. For example, it is preferred that the undulating strands be made out of a nickel-titanium alloy, such as Nitinol, which may lose some of its superelastic or shape memory properties if exposed to high heat during conventional welding.  
      Associated with the cardiac harness of the present invention is a cardiac rhythm management device as previously disclosed. Thus, associated with the cardiac harness as shown in  FIG. 5 , are one or more electrodes for use in providing defibrillating shock. As can be seen immediately below, any number of factors associated with congestive heart failure can lead to fibrillation, acquiring immediate action to save the patient&#39;s life.  
      Diseased hearts often have several maladies. One malady that is not uncommon is irregularity in heartbeat caused by irregularities in the electrical stimulation system of the heart. For example, damage from a cardiac infarction can interrupt the electrical signal of the heart. In some instances, implantable devices, such as pacemakers, help to regulate cardiac rhythm and stimulate heart pumping. A problem with the heart&#39;s electrical system can sometimes cause the heart to fibrillate. During fibrillation, the heart does not beat normally, and sometimes does not pump adequately. A cardiac defibrillator can be used to restore the heart to normal beating. An external defibrillator typically includes a pair of electrode paddles applied to the patient&#39;s chest. The defibrillator generates an electric field between electrodes. An electric current passes through the patient&#39;s heart and stimulates the heart&#39;s electrical system to help restore the heart to regular pumping.  
      Sometimes a patient&#39;s heart begins fibrillating during heart surgery or other open-chest surgeries. In such instances, a special type of defibrillating device is used. An open-chest defibrillator includes special electrode paddles that are configured to be applied to the heart on opposite sides of the heart. A strong electric field is created between the paddles, and an electric current passes through the heart to defibrillate the heart and restore the heart to regular pumping.  
      In some patients that are especially vulnerable to fibrillation, an implantable heart defibrillation device may be used. Typically, an implantable heart defibrillation device includes an implantable cardioverter defibrillator (ICD) or a cardiac resynchronization therapy device (CRT-D) which usually has only one electrode positioned in the right ventricle, and the return electrode is the defibrillator housing itself, typically implanted in the pectoral region. Alternatively, an implantable device includes two or more electrodes mounted directly on, in or adjacent the heart wall. If the patient&#39;s heart begins fibrillating, these electrodes will generate an electric field therebetween in a manner similar to the other defibrillators discussed above.  
      Testing has indicated that when defibrillating electrodes are applied external to a heart that is surrounded by a device made of electrically conductive material, at least some of the electrical current disbursed by the electrodes is conducted around the heart by the conductive material, rather than through the heart. Thus, the efficacy of defibrillation is reduced. Accordingly, the present invention includes several cardiac harness embodiments that enable defibrillation of the heart and other embodiments disclose means for defibrillating, resynchronization, left ventricular pacing, right ventricular pacing, and biventricular pacing/sensing.  
      In further keeping with the invention, the cardiac harness  20  includes a pair of leads  31  having conductive electrode portions  32  that are spaced apart and which separate panels  21 . As shown in  FIG. 5 , the electrodes are formed of a conductive coil wire  33  that is wrapped around a non-conductive member  34 , preferably in a helical manner. A conductive wire  35  is attached to the coil wire and to a power source  36 . As used herein, the power source  36  can include any of the following, depending upon the particular application of the electrode: a pulse generator; an implantable cardioverter/defibrillator; a pacemaker; and an implantable cardioverter/defibrillator coupled with a pacemaker. In the embodiment shown in  FIG. 5 , the electrodes are configured to deliver an electrical shock, via the conductive wire and the power source, to the epicardial surface of the heart so that the electrical shock passes through the myocardium. Even though the electrodes are spaced so that they would be about 180° apart around the circumference of the heart in the embodiment shown, they are not so limited. In other words, the electrodes can be spaced so that they are about 45° apart, 60° apart, 90° apart, 120° apart, or any arbitrary arc length spacing, or, for that matter, essentially any arc length apart around the circumference of the heart in order to deliver an appropriate electrical shock. As previously described, it may become necessary to defibrillate the heart and the electrodes  32  are configured to deliver an appropriate electrical shock to defibrillate the heart.  
      Still referring to  FIG. 5 , the electrodes  32  are attached to the cardiac harness  20 , and more particularly to the undulating strands  22 , by a dielectric material  37 . The dielectric material insulates the electrodes from the cardiac harness so that electrical current does not pass from the electrode to the harness thereby undesirably shunting current away from the heart for defibrillation. Preferrably, the dielectric material covers the undulating strands  22  and covers at least a portion of the electrodes  32 . In the  FIG. 5  embodiment, the middle panel undulating strands are covered with the dielectric material while the right and left side panels are bare metal, While it is preferred that all of the undulating strands of the panels be coated with the dielectric material, thereby insulating the harness from the electric shock delivered by the electrodes, some or all of the undulating strands can be bare metal used to deliver the electrical shock to the epicardial surface of the heart for defibrillation or for pacing.  
      As will be described in more detail, the electrodes  32  have a conductive discharge first surface  38  that is intended to be proximate to or in direct contact with the epicardial surface of the heart, and a conductive discharge second surface  39  that is opposite to the first surface and faces away from the heart surface. As used herein, the term “proximate” is intended to mean that the electrode is positioned near or in direct contact with the outer surface of the heart, such as the epicardial surface of the heart. The first surface and second surface typically will not be covered with the dielectric material  37  so that the bare metal conductive coil can transmit the electrical current from the power source (pulse generator), such as an implantable cardioverter/defibrillator (ICD or CRT-D)  36 , to the epicardial surface of the heart. In an alternative embodiment, either the first or the second surface may be covered with dielectric material in order to preferentially direct the current through only one surface. Further details of the construction and use of the leads  31  and electrodes  33  of the present invention, in conjunction with the cardiac harness, will be described more fully herein.  
      Importantly, the dielectric material  37  used to attach the electrodes  32  to the undulating strands  22  insulates the undulating strands from any electrical current discharged through the conductive metal coils  33  of the electrodes. Further, the dielectric material in this embodiment is flexible so that the electrodes can serve as a seam or hinge to fold the cardiac harness  20  into a lower profile for minimally invasive delivery. Thus, as will be described in more detail (see  FIGS. 13 and 14 ), the cardiac harness can be folded along its length, along the length of the electrodes, in order to reduce the profile for intercostal delivery, for example through the rib cage or other area typically used for minimally invasive surgery for accessing the heart. Minimally invasive approaches involving the heart typically are made through subxiphoid, subcostal or intercostal incisions. When the cardiac harness is folded, it can be reduced into a circular or a more or less oval shape, both of which promote minimally invasive procedures.  
      In further keeping with the invention, cross sectional views of the leads  31  and the electrode portion  32  are shown in  FIGS. 5B, 5C , and  5 D. As shown in  FIG. 5B , the electrode  32  has the coil wire  33  wrapped around the non-conducting member  34  in a helical pattern. The dielectric material  37  provides a spaced connection between the electrode and the bar arms  30  at the ends of the undulating strands  22 . The electrodes do not touch or overlap with the bar arms or any portion of the undulating strands. Instead, the dielectric material provides the attachment means between the electrodes and the bar arms of the undulating strands. Thus, the dielectric material  37  not only acts as an insulating non-conductive material, but also provides attachment means between the undulating strands and the electrodes. Because the dielectric material  37  is relatively thin at the attachment points, it is highly flexible and permits the electrodes to be flexible along with the cardiac harness panels  21 , which will expand and contract as the heart beats as previously described.  
      Referring to  FIG. 5C , the non-conductive member  34  extends beyond the coil wire  33  for a distance. The non-conductive member preferably is made from the same material as the dielectric material  37 , typically a silicone rubber or similar material. While it is preferred that the dielectric material be made from silicone rubber, or a similar material, it also can be made from Parylenem™ (Union Carbide), polyurethanes, PTFE, TFE, and ePTFE. As can be seen, the non-conductive member provides support for the dielectric material to attach the bar arms  30  of the undulating strands  22  in order to connect the strands to the electrode  32 . A conductive wire  35  extends through the non-conducting member and attaches to the proximal end of the coil wire  33  so that when an electrical current is delivered from the power source  36  through conductive wire  35 , the electrode coil  33  will be energized. The conductive wire  35  is also covered by non-conducting material  34 . Referring to  FIG. 5D , it can be seen that the non-conductive member  34  continues to extend beyond the bottom (apex) of the cardiac harness and that conductive wire  35  continues to extend out of the non-conductive member and into the power source  36 . In the embodiment shown in  FIGS. 5B-5D , the cardiac harness is insulated from the electrodes by the dielectric material  37  so that there is no shunting of electrical currents by the cardiac harness  20  from the electrical shock delivered by the electrodes during defibrillation or pacing functions.  
      While it is preferred that the cardiac harness  20  be comprised of undulating strands  22  made from a solid wire member, such as a superelastic or shape memory material such as Nitinol, and be insulated from the electrodes  32 , it is possible to use some or all of the undulating strands to deliver the electrical shock to the epicardial surface of the heart. For example, as shown in  FIG. 6A , a composite wire  45  can be used to form the undulating strands  22  and, importantly, to effectively transmit current to deliver an electrical shock to the epicardial surface of the heart. The composite wire  45  includes a current conducting wire  47  made from, for example silver (Ag), and which is covered by a Nitinol tube  46 . In order to improve the surface conductivity of the outer Nitinol tube  46 , a highly conductive coating is placed on the Nitinol tube. For example, the Nitinol tube can be covered with a deposition layer of platinum (Pt) or platinum-iridium (Pt—Ir), or an equivalent material including iridium oxide (IROX). The composite wire, so constructed, will have superior mechanical performance to expand and contract due to the Nitinol tubing, and also will have improved electrical properties resulting from the current conducting wire  47  and improved electrolytic/electrochemical properties via the surface layer of platinum-iridium. Thus, if some portion or all of the undulating strands  22  are made from a composite wire  45 , the cardiac harness  20  will be capable of delivering a defibrillating shock on selected portions of the heart via the undulating strands and will also function to impart compressive forces as previously described.  
      In contrast to the current conducting undulating strands of  FIG. 6A , are the non-conducting insulated undulating strands  22  as shown by cross sectional view  FIG. 6B . As previously described, some or all of the undulating strands  22  can be covered with dielectric material  37  in order to insulate the strands from the electrical current delivered through the electrodes while delivering shock on the epicardial surface of the heart. Thus, as shown in  FIG. 6B , the undulating strands  22  are covered by dielectric material  37  to provide insulation from the electrical shock delivered by the electrodes  32 , yet maintain the flexibility and the expansive properties of the undulating strands.  
      An important aspect of the invention is to provide a cardiac harness  20  that can be implanted minimally invasively and be attached to the epicardial surface of the heart, without requiring sutures, clips, screws, glue or other attachment means. Importantly, the undulating strands  22  may provide relatively high frictional engagement with the epicardial surface, depending on the cross-sectional shape of the strands. For example, in the embodiment disclosed in  FIG. 6C , the cross-sectional shape of the undulating strands  22  can be circular, rectangular, triangular or for that matter, any shape that increases the frictional engagement between the undulating strands and the epicardial surface of the heart. As shown in  FIG. 6C , the middle cross-section view having a flat rectangular surface (wider than tall) not only has a low profile for enhancing minimally invasive delivery of the cardiac harness, but it also has rectangular edges that may have a tendency to engage and dig into the epicardium to increase the frictional engagement with the epicardial surface of the heart. With the proper cross-sectional shape for the undulating strands, coupled with the grip pads  27  having a high frictional engagement feature, the necessity for suturing, clipping, or further attachment means to attach the cardiac harness to the epicardial surface of the heart becomes unnecessary.  
      In another embodiment as shown in  FIGS. 7A and 7B , a different configuration for cardiac harness  20  and the electrodes  32  are shown, as compared to the  FIG. 5  embodiments. In  FIGS. 7A and 7B , three electrodes are shown separating the three panels  21  with undulating strands  22  extending between the electrodes. As with previous embodiments, springs  23  are formed by the undulating strands so that the undulating strands can expand and contract during the diastolic and systolic functions, and apply a compressive force during both functions. The far side panel of  FIG. 7A  is not shown for clarity purposes. The position of the electrodes around the circumference of the heart is a matter of choice, and in the embodiment of  FIG. 7A , the electrodes can be spaced an equal distance apart at about 120°. Alternatively, it may be important to deliver the electrical shock more through the right ventricle requiring the positioning of the electrodes closer to the right ventricle than to the left ventricle. Similarly, it may be more important to deliver an electrical shock to the left ventricle as opposed to the right ventricle. Thus, positioning of electrodes, as with other embodiments, is a matter of choice.  
      Still referring to  FIGS. 7A and 7B , in this embodiment electrodes  32  extend beyond the bottom or apex portion of the cardiac harness  20  in order to insure that the electrical shock delivered by the electrodes is delivered to the epicardial surface of the heart and including the lower portion of the heart closer to the apex  13 . Thus, the electrodes  22  have a distal end  50  and a proximal end  51  where the proximal end is positioned closer to the apex  13  of the heart and the distal end is positioned closer to the base or upper portion of the heart. As used herein, distal is intended to mean further into the body and away from the attending physician, and proximal is meant to be closer to the outside of the body and closer to the attending physician. The proximal ends of the electrodes are positioned closer to the apex of the heart and provide several functions, including the ability to deliver an electrical shock closer to the apex of the heart. The electrode proximal ends also function to provide support for the cardiac harness  20  and the panels  21 , and lend support not only during delivery (as will be further described herein) but in separating the panels and in gripping the epicardial surface of the heart to retain the harness on the heart without slipping.  
      While the  FIGS. 7A and 7B  embodiments show electrodes  32  separating three panels  21  of the cardiac panel  20 , more or fewer electrodes and panels can be provided to suit a particular application. For example, in one preferred embodiment, four electrodes  32  separate four panels  21 , so that two of the electrodes can be positioned on opposite sides of the left ventricle and two of the electrodes can be positioned on opposite sides of the right ventricle. In this embodiment, preferably all four electrodes would be used, with a first set of two electrodes on opposite sides of the right ventricle acting as one (common) electrode and a second set of two electrodes on opposite sides of the left ventricle acting as the opposite (common) electrode. Alternatively, two of the electrodes can be activated while the other two electrodes act as dummy electrodes in that they would not be activated unless necessary.  
      At present, commercially available implantable cardioverter/defibrillators (ICD&#39;s) are capable of delivering approximately thirty to forty joules in order to defibrillate the heart. With respect to the present invention, it is preferred that the electrodes  22  of the cardiac harness  20  of the present invention deliver defibrillating shocks having less than thirty to forty joules. The commercially available ICD&#39;s can be modified to provide lower power levels to suit the present invention cardiac harness system with electrodes delivering less than thirty to forty joules of power. As a general rule, one objective of the electrode configuration is to create a uniform current density distribution throughout the myocardium. Therefore, in addition to the number of electrodes used, their size, shape, and relative positions will also all have an impact on the induced current density distribution. Thus, while one to four electrodes are preferred embodiments of the invention, five to eight electrodes also are envisioned.  
      In keeping with the present invention, the cardiac harness and the associated cardiac rhythm management device can be used not only for providing a defibrillating shock, but also can be used as a pacing/sensing device for treating the synchrony of both ventricles, for resynchronization, for biventricular pacing and for left ventricular pacing or right ventricular pacing. As shown in  FIGS. 8A-8D , the heart  10  is shown in cross-section exposing the right ventricle  11  and the left ventricle  12 . The cardiac harness  20  is mounted around the outer surface of the heart, preferably on the epicardial surface of the heart, and multiple electrodes are associated with the cardiac harness. More specifically, electrodes  32  are attached to the cardiac harness and positioned around the circumference of the heart on opposite sides of the right and left ventricles. In the event that fibrillation should occur, the electrodes will provide an electrical shock through the myocardium and the left and right ventricles in order to defibrillate the heart. Also mounted on the cardiac harness, is a pacing/sensing lead  40  that functions to monitor the heart and provide data to a pacemaker. If required, the pacemaker will provide pacing stimuli to synchronize the ventricles, and/or provide left ventricular pacing, right ventricular pacing or biventricular pacing. Thus, for example, in  FIG. 8C , pairs of pacing/sensing leads  40  are positioned adjacent the left and right ventricle free walls and can be used to provide pacing stimuli to synchronize the ventricles, or provide left ventricular pacing, right ventricular pacing or biventriculator pacing. The use of proximal Y connectors can simplify the transition to a post-generator such as Oscor&#39;s, iLink-B 15 - 10 . The iLink-B 15 - 10  can be used to link the right and left ventricular free-wall pace/sense leads  40 , as shown in  8 D.  
      In another embodiment of the invention, as shown in  FIGS. 9-14 , cardiac harness  60  is similar to previously described cardiac harness  20 . With respect to cardiac harness  60 , it also includes panels  61  consisting of undulating strands  62 . In the disclosed embodiments, the undulating strands are continuous and extend through coils as will be described. The undulating strands act as spring elements  63  as with prior embodiments that will expand and contract along directional line  64 . The cardiac harness  60  includes a base or upper end  65  and an apex or lower end  66 . In order to add stability to the cardiac harness  60 , and to assist in maintaining the spacing between the undulating strands  62 , grip pads  67  are connected to adjacent strands, preferably at the apex  68  of the springs. Alternatively, the grip pads  67  could be attached from the apex of one spring element to the side  69  of a spring element, or the grip pad could be attached from the side of one spring to the side of an adjacent spring on an adjacent undulating strand. In further keeping with the invention as shown in the  FIGS. 9-14 , in order to add stability and some mechanical stiffness to the cardiac harness  60 , coils  62  are interwoven with the undulating strands, which together define the panels  61 . The coils typically are formed of a coil of wire such as Nitinol or similar material (stainless steel, MP35N), and are highly flexible along their longitudinal length. The coils  72  have a coil apex  73  and a coil base  74  to coincide with the harness base  65  and the harness apex  66 . The coils can be injected with a non-conducting material so that the undulating strands extend through gaps in the coils and through the non-conducting material. The non-conducting material also fills in the gaps which will prevent the undulating strands from touching the coils so there is no metal-to-metal touching between the undulating strands and the coils. Preferably, the non-conducting material is a dielectric material  77  that is formed of silicone rubber or equivalent material as previously described. Further, a dielectric material  78  also covers the undulating strands in the event a defibrillating shock or pacing stimuli is delivered to the heart via an external defibrillator (e.g., transthoracic) or other means.  
      Importantly, coils  72  not only perform the function of being highly flexible and provide the attachment means between the coils and the undulating strands, but they also provide structural columns or spines that assist in deploying the harness  60  over the epicardial surface of the heart. Thus, as shown for example in  FIG. 12 , the cardiac harness  60  has been positioned over the heart and delivered by minimally invasive means, as will be described more fully herein. The coils  72 , although highly flexible along their longitudinal length, have sufficient column strength in order to push on the apex  73  of the coils so that the base portion  74  of the coils and of the harness  65  slide over the apex of the heart and along the epicardial surface of the heart until the cardiac harness  60  is positioned over the heart, substantially as shown in  FIG. 12 .  
      Referring to the embodiments shown in  FIGS. 9 and 11 , the cardiac harness  60  has multiple panels  61  and multiple coils  72 . More or fewer panels and coils can be used in order to achieve a desired result. For example, eight coils are shown in  FIGS. 9 and 11 , while fewer coils may provide a harness with greater flexibility since the undulating strands  62  would be longer in the space between each coil. Further, the diameter of the coils can be varied in order to increase or decrease flexibility and/or column strength in order to assist in the delivery of the harness over the heart. The coils preferably have a round cross-sectional wire in the form of a tightly wound spiral or helix so that the cross-section of the coil is circular. However, the cross-sectional shape of the coil need not be circular, but may be more advantageous if it were oval, rectangular, or another shape. Thus, if coils  72  had an oval shape, where the longer axis of the oval was parallel to the circumference of the heart, the coil would flex along its longitudinal axis and still provide substantial column strength to assist in delivery of the cardiac harness  60 . Further, an oval-shaped coil would provide a lower profile for minimally invasive delivery. The wire cross-section also need not be round/circular, but can consist of a flat ribbon having a rectangular shape for low profile delivery. The coils also can have different shapes, for example they can be closed coils, open coils, laser-cut coils, wire-wound coils, multi-filar coils, or the coil strands themselves can be coiled (i.e., coiled coils). The electrode need not have a coil of wire, rather the electrode could be formed by a zig-zag-shaped wire (not shown) extending along the electrode. Such a design would be highly flexible and fatigue resistant yet still be capable of providing a defibrillating shock.  
      The cardiac harness embodiments  60  shown in  FIGS. 9-12 , can be folded as shown in  FIGS. 13 and 14  and yet remain highly flexible for minimally invasive delivery. The coils  72  act as hinges or spines so that the cardiac harness can be folded along the longitudinal axis of the coils. The grip pads typically connecting adjacent undulating strands  62  have been omitted for clarity in these embodiments, however, they would be used as previously described.  
      In an alternative embodiment, similar to the embodiment shown in  FIGS. 9-12 , the cardiac harness  60  includes both coils  72  and electrodes  32 . In this embodiment, as with the previously described embodiments, a series of undulating strands  22  extend between the coils and the electrodes to form panels  21 . In this embodiment, for example, the coils and electrodes form hinge regions so that the panels can be folded along the longitudinal axis of the coils and electrodes for minimally invasive delivery. Further, in this embodiment, there are two coils and four electrodes, with two of the electrodes positioned adjacent the right ventricle, with the remaining two electrodes being positioned adjacent the left ventricle. The coils not only act as a hinge, but provide column strength as previously described so that the cardiac harness can be delivered minimally invasively by delivery through, for example, the intercostal space between the ribs and then pushing the harness over the heart. Likewise, the electrodes provide column strength as well, yet remain flexible along their longitudinal axis, as do the coils.  
      Referring to  FIGS. 15A-15D , the electrodes  32  or the coils  72  can be mounted on the inner surface (touching the heart) or outer surface (away from the heart) of the cardiac harness. Thus, the cardiac harness  20  includes continuous undulating strands  22  that extend circumferentially around the heart without any interruptions. The undulating strands are interconnected by any interconnecting means, including grip pads  27 , as previously described. In this embodiment, electrodes  32  or coils  72 , or both, are mounted on an inner surface  80  or an outer surface  81  of the cardiac harness  20 . A dielectric material  82  is molded around the electrodes or coils and around the undulating strands in order to connect the electrodes and coils to the cardiac harness. Alternatively, as shown in  FIG. 15D , the electrodes  32  or coils  72  can be formed into a fastening means by forming notches  83  into the electrode (or coil) and which are configured to receive portions of the undulating strand  22 . The undulating strands  22  are spaced from the coils or electrodes so that there is no overlapping/touching of metal. The notches  83  are filled with a dielectric material, preferably silicone rubber, or similar material that insulates the undulating strands of the cardiac harness from the electrodes yet provides a secure attachment means so that the electrodes or coils remain firmly attached to the undulating strands of the cardiac harness. Importantly, the electrodes  32  do not have to be in contact with the epicardial surface of the heart in order to deliver a defibrillating shock. Thus, the electrodes  32  can be mounted on the outer surface  81  of the cardiac harness, and not be in physical contact with the epicardial surface of the heart, yet still deliver a defibrillating shock as previously described.  
      It is to be understood that several embodiments of cardiac harnesses can be constructed and that such embodiments may have varying configurations, sizes, flexibilities, etc. Such cardiac harnesses can be constructed from many suitable materials including various metals, fabrics, plastics and braided filaments. Suitable materials also include superelastic materials and materials that exhibit shape memory properties. For example, a preferred embodiment cardiac harness is constructed of Nitinol. Shape memory dielectric materials can also be employed. Such shape memory dielectric materials can include shape memory polyurethanes or other dielectric materials such as those containing oligo(e-caprolactone) dimethacrylate and/or poly(e-caprolactone), which are available from mnemoScience.  
      In keeping with the invention, as shown in  FIG. 16 , the undulating strands  22  and  62  can be formed in many ways, including by a fixture  90 . The fixture  90  has a number of stems  91  that are arranged in a pre-selected pattern that will define the shape of the undulating strands  22  and  62 . The position of the stems will define the shape of the undulating strands, and determine whether the previously disclosed apex of the springs is either in-phase or out-of-phase. The shape of stems  91  will define the shape of the springs in terms of radius of curvature, or other shape, such as a keyhole shape, a U-shape, and the like. The spacing between the stems will determine the pitch and the amplitude of the undulating strands which is a matter of choice. Preferably, in one exemplary embodiment, a Nitinol wire  92  or other superelastic or shape memory wire having a 0.012 inch diameter, is woven between stems  91  in order to form the undulating strands. Other wire diameters can be used to suit a particular need and can range from about 0.007 inch to about 0.020 inch diameter. Other wire cross-section shapes are envisioned to be used with fixture  90 , particularly a flat rectangular-shaped wire and an oval-shaped wire. The Nitinol wire is then heat set to impart the shape memory feature. Any free ends can be connected together by laser bonding, laser welding, or other type of similar connection consistent with the use of Nitinol, or the ends may remain free and be encapsulated in a dielectric material to keep them atraumatic, depending upon the design.  
      Again referring to  FIG. 16 , after the Nitinol wire is heat set to impart the shape memory feature, the wire is jacketed with NuSil silicone tubing (Helix Medical) having 0.029 inch outside diameter by 0.012 inch inside diameter. Thereafter, the jacketed Nitinol wire is placed in molds for transfer of liquid silicone rubber which will insulate the Nitinol wire from any electrical shock from any electrodes associated with the cardiac harness, or any other device providing a defibrillating shock to the heart. The dimensions of the silicone tubing will of course vary for different wire dimensions.  
      In another embodiment of the invention, shown in  FIG. 17 , cardiac harness  100  includes multiple panels  101  similar to those previously described. Further, undulating strands  102  form the panels and have multiple spring elements  103  that expand and contract along directional line  104 , also as previously described for other embodiments. In the cardiac harness  100  shown in  FIG. 17 , the amplitude of the spring elements is relatively smaller than in other embodiments, and the pitch is higher, meaning there are more spring elements per unit of length relative to other embodiments. Thus, the cardiac harness  100  should generate higher bending forces as the heart expands and contracts during the diastolic and systolic cycles. In other words, the spring elements  103  of cardiac harness  100  will resist expansion, thereby imparting higher compressive forces on the wall of the heart during the diastolic function and will release these higher bending forces during the systolic function as the heart contracts. It may be important to provide undulating strands  102  that alternate in amplitude and pitch within a panel, starting at the base of the harness and extending toward the apex. For example, the pitch and amplitude of an undulating strand closer to the base or the harness may be configured to impart higher compressive forces on the epicardial surface of the heart than the undulating strands closer to the apex or the lower part of the harness. It also may be desirable to alternate the amplitude and pitch of the spring elements from one undulating strand to the next. Further, where multiple panels are provided, it may be advantageous to provide one amplitude and pitch of the spring elements of the undulating strands of one panel, and a different amplitude and pitch of the spring elements of the undulating strands of an adjacent panel. The  FIG. 17  embodiment can be configured with electrodes as previously described in other embodiments, or with coils, both of which assist with the delivery of the cardiac harness by providing column support to the harness.  
      The cardiac harness of the present invention, having either electrodes or coils, can be formed using injection molding techniques as shown in  FIGS. 18A-18C  and  19 A- 19 C. The molds in  FIGS. 18A-18C  are substantially the same as the molds shown in  FIGS. 19A-19C , with the exception of the undulating pattern grooves that receive the undulating strands previously described. In referring to  FIG. 18A , bottom mold  110  includes a pattern for receiving the cardiac harness and a coil or an electrode. For illustration purposes,  FIG. 18B  shows top mold  111  and  FIG. 18C  shows end view mold  112 . The top mold mates with the bottom mold. As can be seen, the cardiac harness undulating strands will fit in undulating strand groove  113 , which extend into coil groove  114 . The previously described electrodes or coils fit into coil grooves  114 . Injection port  115  is positioned midway along the mold fixtures, however, more than one injection port can be used to insure that the flow of polymer is uniform and consistent. Preferably, silicone rubber is injected into the molds so that the silicone rubber flows over the undulating strands and the electrodes or the coils. When the cardiac harness assembly is taken out of the mold, the undulating strands will be attached to the electrodes or the coils by the silicone rubber according to the pattern shown. Other patterns may be desired and the molds are easily altered to provide any pattern that ensures a secure attachment between the undulating strands and the electrodes or the coils. Importantly, the molds of  FIGS. 18 and 19  can be used to inject the dielectric material or silicone rubber inside the coils and, if necessary, between the gaps in the coils in order to insure that the coils and the undulating strands are insulated from each other. The silicone rubber fills the inside of the coils, extrudes through the gaps in the coils, and forms a skin on the inner and outer surface of the coil. This skin is selectively removed (as will be described) to expose portions of the electrode coils so that they can conduct current as described. Further, it is desired that the coils and the undulating strands do not overlap or touch in order to reduce any frictional engagement between the metallic coils and the metallic undulating strands. In order to increase the frictional engagement between the cardiac harness and the epicardial surface of the heart, small projections (not shown) can be molded along the surface of the coils that will contact the epicardial surface. As previously described with respect to the grip pads, these small projections, preferably formed of silicone rubber, will engage the epicardial surface of the heart and increase the frictional engagement between the coils and the surface of the heart in order to secure the harness to the heart without the use of sutures, clips, or other mechanical attachment means.  
      In further keeping with the invention, as shown in  FIGS. 20-23 , a portion of a lead having an electrode  120  is shown in the form of a conductive coil  121 . The coil can be formed of any suitable wire that is conductive so that an electrical shock can be transmitted through the electrode and through the myocardium of the heart. In this embodiment, the coil wire is wrapped around a dielectric material  122  in a helical configuration, however, a spiral wrap or other configuration is possible as long as the coil has superior fatigue resistance and longitudinal flexibility. Importantly, conductive coils  121  have high fatigue resistance which is necessary since the coil is on or near the surface of the beating heart so that the coil is constantly flexing along its longitudinal length in response to heart expansion and contraction. The cross-section of the wire preferably is round or circular, however, it also can be oval shaped or flat (rectangular) in order to reduce the profile of the electrode for minimally invasive delivery. A circular, oval or flat wire will have a relatively high fatigue resistance as well as a relatively low profile for delivery purposes. Also, a flat wire coil is highly flexible along the longitudinal axis and it has a relatively high surface area for delivering an electrical shock. The electrode  120  has a first surface  123  and a second surface  124 . The first surface  123  will be proximate the epicardial surface of the heart, or other portions of the heart, while the second surface will be opposite the first surface and away from the epicardial surface of the heart. A conductive wire (not shown) extends through the dielectric material  122  and attaches to the coil wire  121  at one or more locations along the coil or coils, and the conductive wire is connected to a power source (e.g., an ICD) at its other end. As shown in  FIG. 22 , the cross-section of the electrode  120  can be circular, or as shown in  FIG. 23 , can be oval for reduced profile for minimally invasive delivery. Other cross-sectional shapes for electrode  120  are available depending upon the particular need. All of these cross-sectional shapes will have relatively high fatigue resistance. As shown in  FIGS. 22 and 23 , multiple lumens  125  can be provided to carry one or more conductive wires from the electrode to the power source (pulse generator, ICD, CRT-D, pacemaker, etc.). The lumens also can carry sensing wires that transmit data from a sensor on or in the heart to a pacemaker so that the heart can be monitored. Further, the lumens  125  can be used for other purposes such as drug delivery (therapeutic drugs, steroids, etc.), dye area that is exposed and that will deliver a shock. The amount of surface area per electrode can vary greatly depending upon a particular application, however, surface areas in the range from about 50 mm 2  to about 600 mm 2  are typical. While it is possible to remove the silicone rubber from only the second surface (facing away from the heart), and leaving the first surface coated with silicone rubber, an electrical shock can still be delivered from the bare metal second surface, however, the electrical shock delivered may not be as efficient as with other embodiments. While the dimensions of the electrodes can vary widely due to the variations in the size of the heart to be treated in conjunction with the size of the cardiac harness, generally the length of the electrode ranges from about 2 cm to about 16 cm. The coil  121  has a length in the range of about 1 cm to about 12 cm. Commercially available leads having one or more electrodes are available from several sources and may be used with the cardiac harness of the present invention. Commercially available leads with one or more electrodes is available from Guidant Corporation (St. Paul, Minn.), St. Jude Medical (Minneapolis, Minn.) and Medtronic Corporation (Minneapolis, Minn.). Further examples of commercially available cardiac rhythm management devices, including defibrillation and pacing systems available for use in combination with the cardiac harness of the present invention (possibly with some modification) include, the CONTAK CD®, the INSIGNIA® Plus pacemaker and FLEXTREND® leads, and the VITALITY™ AVT® ICD and ENDOTAK RELIANCE® defibrillation leads, all available from Guidant Corporation (St. Paul, Minn.), and the InSync System available from Medtronic Corporation (Minneapolis, Minn.).  
      In an alternative embodiment, as shown in  FIG. 24 , the conductive coils  121  need not be continuous along the length of the electrode  120 , but can be spatially isolated or staggered along the electrode. For example, multiple coil sections  127 , similar to the coil  121  shown in  FIG. 20 , can be spaced along the electrode with each coil section being attached to the conductive wire so it receives electrical current from the power source. The coil sections can be from about0.5 cm to about 2.0 cm long and be spaced from about 0.5 cm to about 4 cm apart along the  
      In keeping with the invention, a pacemaker and a pacing/sensing electrode are incorporated into the design of the cardiac harness. As shown in  FIGS. 25A and 25B , a lead (not shown) having a defibrillator electrode  130  at its distal end, shown in partial section, not only incorporates wire coils  131  used to deliver a defibrillating electrical shock to the epicardial surface of the heart, but also incorporates a pacing/sensing electrode  132 . The defibrillator electrode  130  can be attached to any cardiac harness embodiment previously described herein. In this embodiment, a non-penetrating pacing/sensing electrode  132  is combined with the defibrillating electrode  130  in order to provide data relating to heart function. More specifically, the pacing/sensing electrode  132  does not penetrate the myocardium in this embodiment, however, it may be beneficial in other embodiments for the pacing or sensing electrode to penetrate the myocardium. One advantage of a non-penetrating pacing/sensing electrode is that there is no danger of puncturing a coronary artery or causing further trauma to the epicardium or myocardium. It is also easier to design since there is no requirement of a penetration mechanism (barb or screw) on the pacing/sensing electrode. The pacing/sensing electrode  132  is in direct contact with the epicardial surface of the heart and will provide data via lead wire  133  to the pulse generator (pacemaker), which will interpret the data and provide any pacing function necessary to achieve, for example, ventricular resynchronization therapy, left ventricular pacing, right ventricular pacing, synchrony of both ventricles, and/or biventricular pacing. As shown in  FIG. 25B , the pacing/sensing electrode  132  is incorporated into a portion of a cardiac harness  134 , and more particularly the undulating strands  135  are attached by dielectric material  136  to the pacing/sensing electrode. As can be seen in  FIGS. 25A and 25B , the wire coils  131  of the defibrillating electrode  130  are wrapped around the dielectric material  136 , and the dielectric material insulates the pacing/sensing electrode  132  from both the wire coils  131  and from the undulating strands  135  of the cardiac harness. Multiple pacing/sensing electrodes  132  can be incorporated along defibrillating electrode  130 , and multiple pacing and sensing electrodes can be incorporated on other electrodes associated with the cardiac harness.  
      In one of the preferred embodiments, multi-site pacing (as previously shown in  FIGS. 8A-8D ) using pacing/sensing electrodes  132  enables resynchronization therapy in order to treat the synchrony of both ventricles. Multi-site pacing allows the positioning of the pacing/sensing electrodes to provide bi-ventricular pacing or right ventricular pacing, left ventricular pacing, depending upon the patient&#39;s needs.  
      In another embodiment, shown in  FIGS. 26A-26C , a defibrillating electrode is combined with pacing/sensing electrodes, for attachment to any of the cardiac harness embodiments disclosed herein. In this embodiment, the defibrillating electrode  130  is formed of wire coils  131  wrapped in a helical manner. The helical wire can be a wound wire having a single strand or a quadrafilar wire having four wires bundled together to form the coil. The wire coils  131  are wrapped around dielectric material  136  in a manner similar to that described for the embodiments in  FIGS. 25A and 25B . In this embodiment, the pacing/sensing electrode  132  is in the form of a single ring for unipolar operation, and two rings for bi-polar operation. The pacing/sensing electrode rings  132  are mounted coaxially with the defibrillating electrode wire coils  131 , and the conducting wires from the wire coils and the pacing/sensing ring electrode are shown extending through the dielectric material  136  and being insulated from each other. The conducting wires from the defibrillating electrode  130  and from the pacing/sensing ring electrodes  132  can be bundled into a common lead wire  133  which extends to the pulse generator (an ICD, CRT-D, and/or a pacemaker). As can be seen in  FIGS. 26A-26C , the pacing/sensing electrode rings  132  have a diameter that is somewhat larger than the defibrillator electrode coils  131  in order to insure preferential contact by the electrode rings against the epicardial surface of the heart. Preferably, several pairs of pacing/sensing electrode rings (bipolar) would be positioned on the cardiac harness and be positioned to come into contact with, for example, the left ventricle free wall. Multi-site pacing allows the pacing/sensing electrode rings  132  to be used for both pacing and resynchronization concurrently. Further, the pacing/sensing electrode rings  132  also can be used in the absence of defibrillating electrodes  130 . The prior disclosure relating to molding of the cardiac harness to the defibrillator electrode applies equally as well to the pacing/sensing electrode rings. The wire coil  131  and the pacing/sensing electrode rings  32  can be fabricated in several ways including by laser cutting stainless steel tubing or using highly conductive materials in wire form, such as biocompatible platinum wire. As previously disclosed, the wire coils  131  can be quadrafilar wire (platinum) for improved flexibility and conformability to the epicardial surface of the heart and be biocompatible. The surface of the pacing/sensing electrodes can vary greatly depending upon the application. As an example, in one embodiment, the surface area of the pacing/sensing electrodes are in the range from about 2 mm 2  to about 12 mm 2 , however, this range can vary substantially. While the disclosed embodiments show the pacing/sensing electrodes combined with the defibrillating electrodes, the pacing/sensing electrodes can be formed separately and mounted on the cardiac harness with or without defibrillating electrodes.  
      The defibrillating electrode  130  as disclosed herein, can be used with commercially available pacing/sensing electrodes and leads. For example, Oscor (Model HT 52PB) endocardial/passive fixation leads can be integrated with the defibrillator electrode  130  by molding the leads into the fibrillator electrode using the same molds previously disclosed herein.  
      The foregoing disclosed invention incorporating cardiac rhythm management devices into the cardiac harness combines several treatment modalities that are particularly beneficial to patients suffering from congestive heart failure. The cardiac harness provides a compressive force on the heart thereby relieving wall stress, and improving cardiac function. The defibrillating and pacing/sensing electrodes associated with the cardiac harness, along with ICD&#39;s and pacemakers, provide numerous treatment options to correct for any number of maladies associated with congestive heart failure. In addition to the defibiillation function previously described, the cardiac rhythm devices can provide electrical pacing stimulation to one or more of the heart chambers to improve the coordination of atrial and/or ventricular contractions, which is referred to as resynchronization therapy. Cardiac resynchronization therapy is pacing stimulation applied to one or more heart chambers, typically the ventricles, in a manner that restores or maintains synchronized bilateral contractions of the atria and/or ventricles thereby improving pumping efficiency. Resynchronization pacing may involve pacing both ventricles in accordance with a synchronized pacing mode. For example, pacing at more than one site (multi-site pacing) at various sites on the epicardial surface of the heart to desynchronize the contraction sequence of a ventricle (or ventricles) may be therapeutic in patients with hypertrophic obstructive cardiomyopathy, where creating asynchronous contractions with multi-site pacing reduces the abnormal hyper-contractile function of the ventricle. Further, resynchronization therapy may be implemented by adding synchronized pacing to the bradycardia pacing mode where paces are delivered to one or more synchronized pacing sites in a defined time relation to one or more sensing and pacing events. An example of synchronized chamber-only pacing is left ventricle only synchronized pacing where the rate in synchronized chambers are the right and left ventricles respectively. Left-ventricle-only pacing may be advantageous where the conduction velocities within the ventricles are such that pacing only the left ventricle results in a more coordinated contraction by the ventricles than by conventional right ventricle pacing or by ventricular pacing. Further, synchronized pacing may be applied to multiple sites of a single chamber, such as the left ventricle, the right ventricle, or both ventricles. The pacemakers associated with the present invention are typically implanted subcutaneously on a patient&#39;s chest and have leads threaded to the pacing/electrodes as previously described in order to connect the pacemaker to the electrodes for sensing and pacing. The pacemakers sense intrinsic cardiac electrical activity through the electrodes disposed on the surface of the heart. Pacemakers are well known in the art and any commercially available pacemaker or combination defibrillator/pacemaker can be used in accordance with the present invention.  
      The cardiac harness and the associated cardiac rhythm management device system of the present invention can be designed to provide left ventricular pacing. In left heart pacing, there is an initial detection of a spontaneous signal, and upon sensing the mechanical contraction of the right and left ventricles. In a heart with normal right heart function, the right mechanical atrio-ventricular delay is monitored to provide the timing between the initial sensing of right atrial activation (known as the P-wave) and right ventricular mechanical contraction. The left heart is controlled to provide pacing which results in left ventricular mechanical contraction in a desired time relation to the right mechanical contraction, e.g., either simultaneous or just preceding the right mechanical contraction. Cardiac output is monitored by impedence measurements and left ventricular pacing is timed to maximize cardiac output. The proper positioning of the pacing/sensing electrodes disclosed herein provides the necessary sensing functions and the resulting pacing therapy associated with left ventricular pacing.  
      An important feature of the present invention is the minimally invasive delivery of the cardiac harness and the cardiac rhythm management device system which will be described immediately below.  
      Delivery of the cardiac harness  20 , 60 , and  100  and associated electrodes and leads can be accomplished through conventional cardio-thoracic surgical techniques such as through a median sternotomy. In such a procedure, an incision is made in the pericardial sac and the cardiac harness can be advanced over the apex of the heart and along the epicardial surface of the heart simply by pushing it on by hand. The intact pericardium is over the harness and helps to hold it in place. The previously described grip pads and the compressive force of the cardiac harness on the heart provide sufficient attachment means of the cardiac harness to the epicardial surface so that sutures, clips or staples are unnecessary. Other procedures to gain access to the epicardial surface of the heart include making a slit in the pericardium and leaving it open, making a slit and later closing it, or making a small incision in the pericardium.  
      Preferably, however, the cardiac harness and associated electrodes and leads may be delivered through minimally invasive surgical access to the thoracic cavity, as illustrated in  FIGS. 27-36 , and more specifically as shown in  FIG. 30 . A delivery device  140  may be delivered into the thoracic cavity  141  between the patient&#39;s ribs to gain direct access to the heart  10 . Preferably, such a minimally invasive procedure is accomplished on a beating heart, without the use of cardio-pulmonary bypass. Access to the heart can be created with conventional surgical approaches. For example, the pericardium may be opened completely or a small incision can be made in the pericardium (pericardiotomy) to allow the delivery system  140  access to the heart. The delivery system of the disclosed embodiments comprises several components as shown in  FIGS. 27-36 . As shown in  FIG. 27 , an introducer tube  142  is configured for low profile access through a patient&#39;s ribs. A number of fingers  143  are flexible and have a delivery diameter  144  as shown in  FIG. 27 , and an expanded diameter  145  as shown in  FIG. 29 . The delivery diameter is smaller than the expanded diameter. An elastic band  146  expands around the distal end  147  of the fingers and prevents the fingers from overexpanding during delivery of the cardiac harness. The distal end of the fingers is the part of the delivery device  140  that is inserted through the patient&#39;s ribs to gain direct access to the heart.  
      The delivery device  140  also includes a dilator tube  150  that has a distal end  151  and a proximal end  152 . The cardiac harness  20 , 60 , 100  is collapsed to a low profile configuration and inserted into the distal end of the dilator tube, as shown in  FIG. 28 . The dilator tube has an outside diameter that is slightly smaller than the inside diameter of the introducer tube  142 . As will be discussed more fully herein, the distal end  151  of the dilator tube is inserted into the proximal end  147  of the introducer tube in close sliding engagement and in a slight frictional engagement. The slidable engagement between the dilator tube and the introducer tube should be with some mild resistance, however, there should be unrestricted slidable movement between the two tubes. The distal end  151  of the dilator tube will expand the fingers  143  of the introducer tube  142  as the dilator tube is pushed distally into the introducer tube as shown in  FIG. 29 . In the embodiments shown in  FIGS. 27-36 , the cardiac harness  20 , 60 , 100  is equipped with leads (previously described) having electrodes for use in defibrillation or pacing functions.  
      As shown in  FIG. 31 , the delivery system  140  also includes a releasable suction device, such as suction cup  156  at the distal end of the delivery device. The negative pressure suction cup  156  is used to hold the apex of the heart  10 . Negative pressure can be applied to the suction cup using a syringe or other vacuum device commonly known in the art. A negative pressure lock can be achieved by a one-way valve stop-cock or a tubing clamp, also known in the art. The suction cup  156  is formed of a biocompatible material and is preferably stiff enough to prevent any negative pressure loss through the heart while manipulating the heart and sliding the cardiac harness  20 , 60 , 100  onto the heart. Further, the suction cup  156  can be used to lift and maneuver the heart  10  to facilitate advancement of the harness or to allow visualization and surgical manipulation of the posterior side of the heart. The suction cup has enough negative pressure to allow a slight pulling in the proximal direction away from the apex of the heart to somewhat elongate the heart (e.g., into a bullet shape) during delivery to facilitate advancing the cardiac harness over the apex and onto the base portion of the heart. After the suction cup  156  is attached to the apex of the heart and a negative pressure is drawn, the cardiac harness, which has been releasably mounted in the distal end  151  of the dilator tube  150 , can be advanced distally over the heart, as will be described more fully herein.  
      As shown in  FIG. 30 , the delivery device  140 , and more specifically introducer tube  142 , has been advanced through the intercostal space between the patient&#39;s ribs during insertion of the introducer tube, the fingers  143  are in their delivery diameter  144 , which is a low profile for ease of access through the small port made through the patient&#39;s ribs. Thereafter, the dilator tube  150 , with the cardiac harness  20 , 60 , 100  mounted therein, is advanced distally through the introducer tube so that the fingers  143  are expanded until they achieve their expanded diameter  145 . The suction cup  156  can be attached to the apex  13  of the heart  10  either before or after the dilator tube is advanced to spread the fingers  143  of the introducer tube  142 . Preferably, the dilator tube has already expanded the fingers on the introducer tube so that there is a larger opening for the suction cup as it is advanced through the inside of a dilator tube, out of the distal end of the introducer tube, and placed in contact with the apex of the heart. Thereafter, a negative pressure is drawn allowing the suction cup to securely attach to the apex of the heart. Visualizing equipment that is commonly known in the art may be used to assist in positioning the suction cup to the apex. For example, fluoroscopy, magnetic resonance imaging (MRI), dye injection to enhance fluoroscopy, and echocardiography, and intracardiac, transesophageal, or transthoracic echo, all can be used to enhance positioning and in attaching the suction cup to the apex of the heart. After negative pressure is drawn and the suction cup is securely attached (releasably) to the apex of the heart, the heart can then be maneuvered somewhat by pulling on the tubing  157  attached to the suction cup, or by manipulating the introducer tube  142 , the dilator tube  150 , both in conjunction with the suction cup. As previously described, it may be advantageous to pull on the tubing  157  to allow the suction cup to pull on the apex of the heart and elongate the heart somewhat in order to facilitate sliding the harness over the epicardium.  
      As more clearly shown in  FIGS. 32-36 , the cardiac harness  20 , 60 , 100  is advanced distally out of the dilator tube and over the suction cup  156 . The suction cup is tapered so that the distal end of the harness slides over the narrow portion of the taper (the proximal end of the suction cup  158 ). The suction cup becomes wider at its distal end where it is attached to the apex of the heart, and the cardiac harness continues to slide and expand over the suction cup as it is advanced distally. As the cardiac harness continues to be advanced distally, it slides over the apex of the heart and continues to expand as it is pushed out of the dilator tube and along the epicardial surface of the heart. Since the harness and the electrodes  32 , 120 , 130  are coated with the previously described dielectric material, preferably silicone rubber, the cardiac harness should slide easily over the epicardial surface of the heart. The silicone rubber offers little resistance and the epicardial surface of the heart has sufficient fluid to allow the harness to easily slide over the wet surface of the heart. The pericardium previously has been cut so that the cardiac harness is sliding over the epicardial surface of the heart with the pericardium over the cardiac harness to help hold it onto the surface of the heart. As shown in  FIGS. 35 and 36 , the cardiac harness  20 , 60 , 100  has been completely advanced out of the dilator tube so that the harness covers at least a portion of the heart  10 . The suction cup  156  has been withdrawn, and the introducer tube  142  and dilator tube  150  also have been withdrawn proximally from the patient. Prior to removing the introducer tube, a power source  170  (such as an ICD, CRT-D, and/or pacemaker) can be implanted by conventional means. The electrodes will be attached to the pulse generator to provide a defibrillating shock or pacing functions as previously described.  
      In the embodiments shown in  FIGS. 27-36 , the cardiac harness  20 , 60 , 100  was advanced through the dilator tube by pushing on the proximal end of the electrodes  32 , 120 , 130 , on the lead wires  31 , 133 , and on the proximal end (apex  26 ) of the cardiac harness. Even though the electrodes are designed to be atraumatic and longitudinally flexible, the electrodes have sufficient column strength so that pushing on the proximal ends of the electrodes assists in pushing the cardiac harness out of the dilator tube and over the epicardial surface of the heart. In one embodiment, advancement of the cardiac harness is accomplished by hand, by the physician simply pushing on the electrodes and the leads to advance the cardiac harness out of the dilator tube to slide onto the epicardial surface of the heart.  
      As shown in the embodiments of  FIGS. 27-36 , the delivery device  140 , and more specifically introducer tube  142  and dilator tube  150 , have a circular cross-section. It may be preferable, however, to chose other cross-sectional shapes, such as an oval cross-sectional shape for the delivery device. An oval delivery device may be more easily inserted through the intercostal space between the patient&#39;s ribs for a low profile delivery. Further, as the cardiac harness  20 , 60 , 100  is advanced out of a delivery device  140  having an oval cross-section, the harness distal end will quickly form into a more circular shape in order to assume the configuration of the epicardial surface of the heart as it is advanced distally over the heart.  
      In the embodiments shown in  FIGS. 35 and 36 , the cardiac harness  20 , 60 , 100  remains firmly attached to the epicardial surface of the heart without the need for any further attachment means, such as sutures, clips, adhesives, or staples. Further, the pericardial sac helps to enclose the harness to prevent it from shifting or sliding on the epicardial surface of the heart.  
      Importantly, during delivery of the cardiac harness  20 , 60 , 100 , the harness itself, the electrodes  32 , 120 , 130 , as well as leads  31  and  132  have sufficient column strength in order for the physician to push from the proximal end of the harness to advance it distally through the dilator tube  150 . While the entire cardiac harness assembly is flexible, there is sufficient column strength, especially in the electrodes, to easily slide the cardiac harness over the epicardial surface of the heart in the manner described.  
      In an alternative embodiment, if the cardiac harness  20 , 60 , 100  includes coils  72 , as opposed to the electrodes and leads, the harness can be delivered in the same manner as previously described with respect to  FIGS. 27-36 . The coils have sufficient column strength to permit the physician to push on the proximal end of the coils to advance the cardiac harness distally to slide over the apex of the heart and onto the epicardial surface.  
      In another embodiment, delivery of the cardiac harness  20 , 60 , 100  can be by mechanical means as opposed to the hand delivery previously described. As shown in  FIGS. 37-42 , delivery system  180  includes an introducer tube  181  that functions the same as introducer tube  142 . Also, a dilator tube  182 , which is sized for slidable movement within the introducer tube, also functions the same as the previously described dilator tube  150 . An ejection tube  183  is sized for slidable movement within the dilator tube, that is, the outer diameter of the ejection tube is slightly smaller than the inner diameter of the dilator tube. As shown in  FIGS. 40 and 41 , the ejection tube has a distal end  184  and a proximal end  185 , wherein the distal end of the ejection tube has a plate that fills the entire inner diameter of the ejection tube. The plate has a number of lumens  187  for receiving leads  31 , 132  and for receiving the suction cup  156  and associated tubing  157 . Thus, lumens  188  are sized for receiving leads  31 , 132  therethrough, while lumen  189  is sized for receiving suction cup  156  and the associated tubing  157 . The number of lumens  188  in plate  186  will be defined by the number of leads  31 , 132  associated with the cardiac harness  20 , 60 , 100 . Thus, as shown in  FIG. 40 , there are four lumens  188  for receiving four leads therethrough, and one lumen  189  for receiving the suction cup  156  and tubing  157  therethrough. The leads and the tubing  157  extend proximally out the proximal end  185  of the ejection tube. As shown in  FIG. 42 , the suction cup and cardiac harness are on the left side of the schematic, and the ejection tube  183  is on the right hand side of the schematic. For clarity, the dilator tube and the introducer tube have been omitted, however, in practice the cardiac harness would be mounted in the dilator tube, and the dilator tube would extend into the introducer tube, while the ejection tube would extend into the dilator tube. As can be seen in  FIG. 42 , the leads  31 , 132  extend through lumens  188 , while the tubing  157  associated with the suction cup extends through lumen  189 . The tubing and the leads extend proximally out of the proximal end of the ejection tube, and extend out of the patient during delivery of the harness. As previously described, after the introducer is positioned through the rib cage, and the apex of the heart is acquired by the suction cup, the harness can be advanced out of the dilator by advancing the ejection tube  183  in a distal direction toward the apex of the heart. The leads, the cardiac harness and electrodes all provide sufficient column strength to allow the plate  186  to impart a pushing force against the cardiac harness to advance it distally over the heart as previously described. After the cardiac harness is pushed over the epicardial surface of the heart, the ejection tube can be withdrawn proximally so that the tubing  157  and the leads  31 , 132  slide through lumens  189 , 188  respectively. The ejection tube  183  continues to be withdrawn proximally so that the proximal end of the leads and the proximal end of tubing  157  are pulled through the distal end  184  of the ejection tube so that the ejection tube is clear of the leads and the tubing.  
      As with the previous embodiment, suitable materials for the delivery system  140 , 180  can include the class of polymers typically used and approved for biocompatible use within the body. Preferably, the tubing associated with delivery systems  140  and  180  are rigid, however, they can be formed of a more flexible material. Further, the delivery systems  140 , 180  can be curved rather than straight, or can have a flexible joint in order to more appropriately maneuver the cardiac harness  20 , 60 , 100  over the epicardial surface of the heart during delivery. Further, the tubing associated with delivery systems  140 , 180  can be coated with a lubricious material to facilitate relative movement between the tubes. Lubricious materials commonly known in the art such as Teflon™ can be used to enhance slidable movement between the tubes.  
      Delivery and implantation of an ICD, CRT-D, pacemaker, leads, and any other device associated with the cardiac rhythm management devices can be performed by means well known in the art. Preferably, the ICD/CRT-D/pacemaker, are delivered through the same minimally invasive access site as the cardiac harness, electrodes, and leads. The leads are then connected to the ICD/CRT-D/pacemaker in a known manner. In one embodiment of the invention, the ICD or CRT-D or pacemaker (or combination device) is implanted in a known manner in the abdominal area and then the leads are connected. Since the leads extend from the apical ends of the electrodes (on the cardiac harness) the leads are well positioned to attach to the power source in the abdominal area.  
      It may be desired to reduce the likelihood of the development of fibrotic tissue over the cardiac harness so that the elastic properties of the harness are not compromised. Also, as fibrotic tissue forms over the cardiac harness and electrodes over time, it may become necessary to increase the power of the pacing stimuli. As fibrotic tissue increases, the right and left ventricular thresholds may increase, commonly referred to as “exit block.” When exit block is detected, the pacing therapy may have to be adjusted. Certain drugs such as steriods, have been found to inhibit cell growth leading to scar tissue or fibrotic tissue growth. Examples of therapeutic drugs or pharmacologic compounds that may be loaded onto the cardiac harness or into a polymeric coating on the harness, on a polymeric sleeve, on individual undulating strands on the harness, or infused through the lumens in the electrodes and delivered to the epicardial surface of the heart include steroids, taxol, aspirin, prostaglandins, and the like. Various therapeutic agents such as antithrombogenic or antiproliferative drugs are used to further control scar tissue forrnation. Examples of therapeutic agents or drugs that are suitable for use in accordance with the present invention include 17-beta estradiol, sirolimus, everolimus, actinomycin D (ActD), taxol, paclitaxel, or derivatives and analogs thereof. Examples of agents include other antiproliferative substances as well as antineoplastic, antiinflammatory, antiplatelet, anticoagulant, antifibrin, antithrombin, antimitotic, antibiotic, and antioxidant substances. Examples of antineoplastics include taxol (paclitaxel and docetaxel). Further examples of therapeutic drugs or agents include antiplatelets, anticoagulants, antifibrins, antiinflammatories, antithrombins, and antiproliferatives. Examples of antiplatelets, anticoagulants, antifibrins, and antithrombins include, but are not limited to, sodium heparin, low molecular weight heparin, hirudin, argatroban, forskolin, vapiprost, prostacyclin and prostacyclin analogs, dextran, D-phe-pro-arg-chloromethylketone (synthetic antithrombin), dipyridamole, glycoprotein IIb/IlIa platelet membrane receptor antagonist, recombinant hirudin, thrombin inhibitor (available from Biogen located in Cambridge, Mass.), and  7 E- 3 B® (an antiplatelet drug from Centocor located in Malvern, Pa.). Examples of antimitotic agents include methotrexate, azathioprine, vincristine, vinblastine, fluorouracil, adriamycin, and mutamycin. Examples of cytostatic or antiproliferative agents include angiopeptin (a somatostatin analog from Ibsen located in the United Kingdom), angiotensin converting enzyme inhibitors such as Captopril® (available from Squibb located in New York, N.Y.), Cilazapril® (available from Hoffman-LaRoche located in Basel, Switzerland), or Lisinopril® (available from Merck located in Whitehouse Station, N.J.); calcium channel blockers (such as Nifedipine), colchicine, fibroblast growth factor (FGF) antagonists, fish oil (omega 3-fatty acid), histamine antagonists, Lovastatin® (an inhibitor of HMG-CoA reductase, a cholesterol lowering drug from Merck), methotrexate, monoclonal antibodies (such as PDGF receptors), nitroprusside, phosphodiesterase inhibitors, prostaglandin inhibitor (available from GlaxoSmithKline located in United Kingdom), Seramin (a PDGF antagonist), serotonin blockers, steroids, thioprotease inhibitors, triazolopyrimidine (a PDGF antagonist), and nitric oxide. Other therapeutic drugs or agents which may be appropriate include alpha-interferon, genetically engineered epithelial cells, and dexamethasone.  
      Although the present invention has been described in terms of certain preferred embodiments, other embodiments that are apparent to those of ordinary skill in the art are also within the scope of the invention. Accordingly, the scope of the invention is intended to be defined only by reference to the appended claims. While the dimensions, types of materials and coatings described herein are intended to define the parameters of the invention, they are by no means limiting and are exemplary embodiments.