Source: https://patents.google.com/patent/EP2170458A1/en
Timestamp: 2018-09-22 01:48:18
Document Index: 580348264

Matched Legal Cases: ['Application No. 60', 'art 10', 'art 10', 'art 10', 'art 10', 'art 1', 'art 1200', 'art 1300', 'art 1300', 'art 2000', 'art 2100', 'art 2200']

EP2170458A1 - Implantable devices and methods for stimulation of cardiac or other tissues - Google Patents
Implantable devices and methods for stimulation of cardiac or other tissues
EP2170458A1
EP2170458A1 EP20080756387 EP08756387A EP2170458A1 EP 2170458 A1 EP2170458 A1 EP 2170458A1 EP 20080756387 EP20080756387 EP 20080756387 EP 08756387 A EP08756387 A EP 08756387A EP 2170458 A1 EP2170458 A1 EP 2170458A1
EP20080756387
E- Pacing Inc
PACING Inc E
E- Pacing, Inc.
An implantable system is provided for stimulation of the heart, phrenic nerve, or other tissue structures accessible via a patient's airway. The stimulation system includes an implantable controller housing which includes a pulse generator, at least one electrical lead attachable to said pulse generator; and at least one electrode carried by the at least one electrical lead, wherein the at least one electrode is positionable and fixable at a selected position within an airway of a patient. The controller housing may be adaptable for implantation subcutaneous, or alternatively, at a selected position within the patient's trachea or bronchus, wherein the controller housing is proportioned to substantially permit airflow through the patient's airway about housing.
CROSS-REFERENCE TO RELATED APPLICATIONS Priority is claimed to U.S. Provisional Application No. 60/943,593, filed June 13, 2007, which is incorporated herein by reference.
Certain cardiac deficiencies, such as cardiac arrhythmias including bradycardia and tachycardia are typically treated by pacemakers or implantable cardioverter-defibrillators. A pacemaker is an electronic device that may pace or regulate the beating of a patient's heart by delivering precisely timed electrical stimulation to certain areas of the heart, depending upon the condition being treated. For example, bradycardia, where the heart rate is too slow, or tachycardia, where heart rate is too fast, may be treated by performing cardiac pacing. As used herein, the term "pacemaker" may refer to any cardiac rhythm management device that is operable to perform pacing functionality, regardless of any other functions it may perform. Other cardiac stimulation devices may include implantable cardioverter-defibrillators, which may also be referred to herein as "cardioverters," "defibrillators," or "ICD." Implantable cardioverter-defibrillators perform functions similar to pacemakers by delivering electrical pulses, though they are most-often used to treat sudden cardiac arrhythmias such as atrial or ventricular fibrillation or ventricular tachycardia. Most ICDs operate by monitoring the rate and/or rhythm of the heart and deliver electrical pulses and/or electrical shocks when abnormalities are detected. For example, some ICDs may only deliver electrical shocks, while other ICDs may first deliver lower power electrical pulse to pace the heart prior to delivering electrical shocks.
In order to electrically stimulate the heart, electrodes are typically positioned and fixed close to the required stimulation site. In certain conventional cardiac stimulation techniques, a transvenous electrode is delivered by transvenous catheterization to the right atrium, the right ventricle, or both for performing dual chambers pacing. Other conventional cardiac stimulation devices include epicardial electrodes delivered to the epicardium at various locations. ϊn addition to generating and delivering electrical stimulation to a patient's heart, cardiac treatment devices often measure various physiological parameters to aid in detecting and treating cardiac deficiencies. For example, observing the heart's electrical activity allows for detecting many heart deficiencies, including, but not limited to, bradycardia, tachycardia, atrial fibrillation, and myocardial infraction. Additionally, the synchronization may be detected between relative heart chambers, including the delay between right atrium and right ventricle (AV delay) and the delay between the right and left ventricles (V-V)3 which may assist in detecting and treating heart deficiencies. Furthermore, certain conventional cardiac devices measure electrical impedance around the heart to detect fluid congestion in the lungs, which may be indicative of congestive heart failure. Conventional cardiac devices may further include additional sensors, such as accelerometers, flow monitors, oxygen sensors, for example, for measuring other conditions related to a patient's cardiac performance.
An implantable system is provided for stimulation of the heart, phrenic nerve, or other tissue structures accessible via a patient's airway. The stimulation system includes an implantable controller housing which includes a pulse generator; at least one electrical lead attachable to said pulse generator; and at least one electrode carried by the at least one electrical lead, wherein the at least one electrode is positionable and fixable at a selected position within an airway of a patient. The controller housing may be adaptable for implantation subcutaneously, or alternatively, at a selected position within the patient's trachea or bronchus, wherein the controller housing is proportioned to substantially permit airflow through the patient's airway about housing. The pulse generator may be operable to deliver one or more electrical pulses effective in cardiac pacing, cardiac defibrillation, cardioversion, cardiac resynchronization therapy, or a combination thereof In one embodiment, the system may further include a cannula adaptable for passage of the at least one electrical lead through a wall of the trachea or bronchus. In another embodiment, the system may further include a tissue interface for wirelessly communicating an electrical signal through a wall of the trachea or bronchus. In another aspect, a method is provided for implanting a stimulation system in a patient in need thereof. The method may include implanting in the patient a controller housing comprising a pulse generator; and positioning at least one electrode, which is carried by at least one electrical lead (which is attached to the pulse generator) at a selected position within the trachea, the bronchus, the bronchioles, or a branch thereof, of the patient's airway.
FIGS. IA- IB illustrate a human cardiovasculature system and a human pulmonary system.
FIG. 4 is a schematic diagram of an example controller housing according to one embodiment of the invention. FlG, 5 is a functional diagram of an example electronic controller according to one embodiment of the invention.
FIGS. 8A-8K are diagrams of example electrodes and electrical leads according to some embodiments of the invention.
FIGS. 9A-9D are diagrams of example cardiac device placements according to some embodiments of the invention. FIG, 10 is a flowchart of an example method of implanting a cardiac device according to one embodiment of the invention.
FIG. 12 is a flowchart of an example method of implanting a controller housing according to one embodiment of the invention. FIG. 13 is a flowchart of an example method of testing an implanted electrode according to one embodiment of the invention.
FlG. 14 is a diagram of an example cardiac device placement according to one embodiment of the invention. FIGS. 15A-15B are diagrams of example cannulae according to some embodiments of the invention.
FIG. 19 is a flowchart of an example method of implanting a cardiac device according to one embodiment of the invention. FlG. 20 is a flowchart of an example method of implanting a cardiac device according to one embodiment of the invention.
FΪG. 22 is a flowchart of an example method of electrically stimulating a heart according to one embodiment of the invention.
Implantable medical devices and methods are provided for stimulation of cardiac or other tissues via electrodes implanted within a patient's airway. The human anatomy beneficially provides access to electrode implantation sites within the patient's airway that are in close proximity to areas of the heart, and thus allows for alternative implantation devices and methods for electrically stimulating the heart and for sensing cardiac activity. The stimulation electrodes beneficially can be implanted using minimally or non-invasive techniques, thus avoiding the complex, higher-risk procedures associated with traditional implantation and stimulation techniques. In certain embodiments, the pulse generator also can be implanted within a patient's airway using minimally or non-invasive techniques
In one aspect, an implantable cardiac stimulation system is provided that may include one or more electrodes carried by one or more electrical leads, implantable within a patient's airway. The electrical leads may be attachable to an implantable pulse generator for generating and delivering electrical stimulation signal to the electrodes, and optionally for receiving electrical signals from one or more electrodes representing sensed parameters. The pulse generator may be housed in a control housing, which may be implanted within the patient's airway, for example in the patient's trachea or bronchus. In some embodiments, the pulse generator may be implanted subcutaneous Iy, for example in the patient's pectoral region. The electrical stimulation signal generated by the implantable cardiac stimulation system may be effective for performing atrial cardiac pacing, ventricular cardiac pacing, dual chamber cardiac pacing, cardiac defibrillation, cardioversion, cardiac resynchronization therapy, or a combination thereof. As used herein, the terms "electrical stimulation signal," "electrical signal," and "signal" are used interchangeably and may generally refer to any transmittable electrical current, and are not limited to a transmission containing information or data. Also, as used herein, the terms "electrical puise" or "pulse" are used interchangeably and may generally refer to one or more intermittent transmissions of an electrical current, such as is used during cardiac synchronization therapy. In addition, the implantable cardiac stimulation system may be operable to sense cardiac electrical activity, other cardiac activity, or other physiological parameters, and to generate and deliver electrical stimulation pulses in response thereto.
Accordingly, the devices and methods described herein may be employed to treat various cardiac symptoms such as asystole, bradycardia resulting from, for example, bilateral bundle branch block, bifascicular block, and first, second, and third degree atrioventricular block, tachyarrhythmia, tachycardia, and congestive heart failure. The devices and methods described herein may further be employed to support surgical anesthesia procedures and cardiac procedures. In certain embodiments, the devices may be operated in cooperation with additional conventionally implanted electrodes, for example, transvenous electrodes, epicardial electrodes, or epidermally placeable electrodes.
In another aspect, implantable system and devices are provided for stimulation of essentially any tissue structure accessible via a patient's airway. That is, the airway may be used to position one or more electrodes for stimulating tissue structures other than the heart. For example, the phrenic nerve may be stimulated to activate the diaphragm or the diaphragm may be directly stimulated, to provide therapy to patient's suffering from respiratory paralysis. As used herein, the terms "comprise," "comprising," "include," and "including" are intended to be open, non-limiting terms, unless the contrary is expressly indicated. Like numbers refer to like elements throughout the following description.
I, Description of Anatomy
FIG. IA illustrates an anatomical view of a human pulmonary system and cardiovascular system, representing the relative position of the heart 10, the right lung 12 and left lung 14, the aorta 16, the pulmonary artery 18, and the trachea 20, The heart includes the left ventricle 22 and right ventricle 24 and the left atrium 26 and right atrium 28. The heart 10 is positioned substantially between and in close proximity to the right lung 12 and the left lung 14, allowing electrodes positioned at selected positions within the pulmonary system to be in proximity to certain areas of the heart 10.
The human pulmonary system includes the trachea and bronchial tree, which includes the bronchi and bronchioles. Each time one of these airways branches (e.g., splits into two or three), it forms a new generation of airway. FIG. IB illustrates an anatomical view of a pulmonary system that includes the trachea 20 (0 generation airway), and the right lung 12 and the left lung 14. The trachea 20 branches into the right primary bronchus 30 and left primary bronchus 32 (first generation airways), which in turn branch into the lobar bronchi (second generation airways). The lobar bronchi include three right secondary bronchi 34 and two left secondary bronchi 36. The secondary bronchi 34, 36 branch into the bronchopulmonary (third generation airways), which includes, as shown in the Figure, the right tertiary bronchi 38 and left tertiary bronchi 40. Although not shown in FlG. IB, the tertiary bronchi 38, 40 branch into primary bronchioles (fourth generation airways) and ultimately into terminal bronchioles which are associated with alveoli for facilitating gas exchange in the lungs. The diameter of the bronchi is typically approximately 7 to 1 1 mm at the primary bronchi, and progressively decreases down the segmental bronchi to a diameter of less than about 1 millimeter at the bronchioles. It is appreciated that herein the terms "bronchus," "bronchi," and "bronchial tree" as used herein may refer to any of the individual components of the bronchi, including the primary bronchi 30, 32, the secondary bronchi 34, 36, the tertiary bronchi 38, 40, and/or the bronchioles branching therefrom. It is also appreciated that herein the term "airway" as used herein may refer to the bronchi and/or the trachea 20. FlG. IB demonstrates that the bronchi reach a substantial portion of the left and right lungs 12, 14, enabling access through at least one branch to be in proximity to various areas of the heart 10.
Since the heart and lungs are separated by the very thin cavities of the pericardium and lung pleura, an electrode positioned in the bronchi operates in a manner similar to an epicardiai electrode placed on the heart. Accordingly, positioning an electrode and/or a pulse generator in a patient's airway in proximity to the heart provides a minimally or non-invasive technique for implanting cardiac stimulation and/or sensing devices, and avoids the complexity and inherent risks of traditional techniques requiring complex, invasive procedures for implantation. Furthermore, because the lungs move during breathing at a much lower rate than the beating heart (e.g., approximately 12 breaths per minute compared to approximately 70 heart beats per minute), an electrical lead and electrode Implanted within the airway suffers much less physical stress than a transvenous or epicardial lead, and thus is less prone to mechanical failure.
O. Implantable Electrodes and Electrical Leads Attachable to a Pulse Generator Implantable in an Airway
FIG. 2 illustrates one embodiment of an implantable cardiac stimulation system according to one embodiment of the invention. A controller housing 50 including a pulse generator 51 may be adaptable for implantation at a selected housing position within the trachea 20, the bronchus, such as the right or left primary bronchus 30, 32, or a branch thereof. In some embodiments, the controller housing 50 is retained by one or more anchor devices 60, as is more fully described herein.
It is appreciated that as used herein the term "controller housing" generally refers to the structure or casing that houses the pulse generator and any other electronic circuitry, hardware, software, and for performing electrical stimulation and sensing as described herein. As used herein, the term "pulse generator" generally refers to any device operable of generating electrical stimulation signals, such as an electrical current; though, in some embodiments, a "pulse generator" may also be operable for receiving electrical signals representing sensed or measured parameters from one or more sensing electrodes or other sensors. Accordingly, a "pulse generator" as referred to herein may generate electrical signals or electrical pulses, such as when performing cardiac therapy, receive electrical signals, such as when performing sensing functions, or both. Furthermore, when referencing the "controller housing," it is appreciated that the "pulse generator" is included therein.
The pulse generator 51 may be electrically coupled to at least one electrical lead 52. At least one electrode is affixed to, integrated within, or carried by an electrical lead 52. As used herein, the term "carried" when referring to an electrical lead carrying an electrode includes electrodes, temporarily or permanently affixed to the electrical lead, electrodes integrated within the electrical lead such that they are a single component, or otherwise. In another embodiment, the pulse generator may communicate wirelessly with one or more electrodes or other sensors, and thus an electrical lead is not required. In the embodiment illustrated in FIG. 2, six electrodes 54, 55, 56, 57, 58, 59, each carried by an individual electrical lead 52 are attachable to the pulse generator 51. The electrode may be positioned at or near the distal end of the electrical lead 52, as illustrated in FIG. 2. However, in other embodiments, an electrode may be positioned proximal to the distal end of the electrical lead 52, for example, in embodiments including a single electrical lead 52 that carries more than one electrode, such as one at or near the distal portion of the lead and one or more electrodes on the same electrical lead 52 proximal to the distal electrode.
The implantable cardiac stimulation system may include one or more electrodes, depending on the type of stimulation or sensing to be performed. The electrodes can be positioned and fixed at different areas within the airway to electrically stimulate various cardiac components, including, but not limited to, the sinoatrial node, the vagus nerve, the right atrium, the right ventricle, the left atrium, and the left ventricle. Additionally, employing multiple electrodes in combination may optimize the path of electrical current, thus improving treatment and minimizing current or voltage requirements to achieve the intended therapy. The embodiment in FlG. 2 illustrates six electrodes 54 positionable and fixable at six selected positions within the bronchi, each connected to a different electrical lead 52. As illustrated, three electrodes 54, 57, 58 are positioned and fixed within the right tertiary bronchi 38, two electrodes 55, 59 are positioned and fixed within left tertiary bronchi 40, and one electrode 56 is positioned and fixed within the left secondary bronchi 36. In this embodiment, each electrode 54, 55, 56, 57, 58, 59 is carried by a separate electrical lead 52 that is electrically coupled to the pulse generator 51. In other embodiments, however, a single lead 52 may be coupled to the pulse generator 51 and split into multiple leads 52 each carrying a single electrode to its implantation site. The embodiment illustrated in FIG. 2 is provided for exemplary purposes and other electrode and pulse generator positioning and configurations are possible, as further described herein.
The controller housing 50 may be implantable within a patient's trachea 20, as illustrated in FIG. 2, within the right or left primary bronchus 30, 32, or a branch thereof. In one embodiment, the controller housing 50 may be dimensioned to be implanted further down the airway, such as the secondary or tertiary bronchi. As described above, the pulse generator 51 may be operable to generate and deliver electrical stimulation signals to the one or more electrodes 54, 55, 56, 57, 58, 59 via the electrical leads 52 effective in performing cardiac pacing, cardiac defibrillation, cardioversion, cardiac resynchronization therapy, or a combination thereof. In one embodiment, the pulse generator 51 may be operable to measure physiological conditions via one or more of the electrodes 54, 55, 56, 57, 58, 59, such as measuring electrical cardiac activity like electrical impedance across two points, or other cardiac activity. In another embodiment, the pulse generator 51 may be operable to control and receive measurements representing other physiological parameters from additional sensors implanted within the patient's body, such as an acceierometer, a strain gauge, a pressure transducer, or a temperature sensor. Although various embodiments described herein include a single controller housing and pulse generator performing all of the cardiac stimulation and sensing functions, other embodiments may include more than one controller housing and pulse generator, with each pufse generator performing separate functions and/or providing redundant functioning for reliability and safety purposes.
A controller housing 50 implantable in an airway is proportioned to substantially permit airflow through the respective airway past the controller housing and to avoid substantial discomfort to the patient. For example, for one embodiment in which the controller housing 50 is implantable in the trachea 20, a trachea may have an inner diameter of approximately 15 to 25 mm and a length of approximately 10 to 16 cm; thus, the controller housing 50 may be proportioned to be smaller in diameter than approximately 15 to 25 mm and have a length less than approximately 10 to 16 cm. For example, in one embodiment the controller housing 50 is an elongated cylinder with a diameter of approximately 4 to 10 mm, and a length of approximately 4 to 1 1 cm. In another embodiment, the controller housing 50 has a diameter less than approximately 7 mm and a length of less than approximately 6 cm. In certain embodiments, the cross section of the controller housing 50 may be substantially curvilinear, such as circular or elliptical; though in other embodiments, the cross section may be substantially square, rectangular, triangular, or the like. The controller housing 50 may further be proportioned such that at least part of the controller housing 50 will substantially contact the inner wall of the airway at the selected implantation site. Thus, in embodiments in which the controller housing 50 has a curvilinear cross section, the radius of curvature may approximate that of the inner wall of the trachea 20 or bronchus.
In addition, any of the example controller housing embodiments described herein may further optionally include radiopaque materia! to aid in delivery procedures using imaging techniques, biocompatible coating, medicinal or therapeutic coating, such as antiproliferative agents, steroids, antibiotic agents, or any combination thereof.
FIGS. 3A-3E illustrate several exemplary devices for anchoring the controller housing containing the pulse generator within the trachea or bronchus, according to certain embodiments of the invention. The embodiments described herein are representative: however, other means for positioning and anchoring the controller housing within an airway may be employed. Although at least some of the embodiments of the anchor device may be described as being implantable within the trachea, the anchor device designs equally apply to controller housing implantable within the bronchus. FIG. 3A illustrates an extensible member, such as a radially expandable member 62 for anchoring the controller housing containing the pulse generator 51 to the inner wall of the trachea 20, for example to the epithelial tissue. The expandable member 62 may be configured in a tubular shape similar to a stent, such that it includes at least one circumferential ring extending from the controller housing 50 and proportioned to interface with the inner wall of the trachea 20. For example, a stent-like expandable member 62 may have a interwoven, zigzag, wave-like, mesh, z-shaped, helical, or otherwise radially expandable and contractible or collapsible shape as is known, and may extend from one side of the controller housing 50. In its expanded or extended position, the expandable member 62 may be have a radius of curvature substantially similar to the inner wall of the trachea 20 so as to promote retention of the controller housing 50. Furthermore, an expandable member 62 configured similar to a stent, having a hollow lumen or path existing along its axis, is advantageously proportioned to permit airflow through the trachea 20 and around the controller housing 50 at the selected housing implantation site or position. The expandable member 62 may be formed from metals, such as nickel-titanium alloys, stainless steels, tantalum, titanium, gold, cobalt chromium alloys, cobalt chromium nickel alloys (e.g., Nitinol™, Elgiloy™) or from polymers, such as silicone, polyurethane, polyester, or any combination thereof. In other embodiments, the anchor device may be formed as a substantially solid tubular member, and may include a separate expansion means for extending from the controller housing 50 and exerting force against the tubular member, causing the tubular member to substantially engage the inner wall of the trachea 20. Each embodiment of the expandable member 62 as described provides sufficient force against the trachea 20 for retaining the controller housing 50 in place, though should not apply too much force so as to avoid damaging the trachea 20 or causing discomfort to the patient. Expansion of these expandable member 62 embodiments may be performed mechanically, such as by stent- like designs, springs, balloons, or the like, or may be caused by the characteristics of the members, such as shape memory alloys, or any combination thereof. Optionally, any of the described expandable members 62 may additionally include one or more barbs, hooks, suture, and the like for securing the member 62 to the inner wall of the trachea 20.
During implantation of the controller housing 50, the stent-like expandable member 62 may be contracted or collapsed against or within close proximity to the controller housing 50 to minimize the profile during delivery, for example when delivered using a delivery device 64, such as a catheter or other elongated lumen for delivery, as is illustrated in FIG 3B. Upon positioning the controller housing 50 at the implantation site and releasing it from the delivery device 64, the expandable member 62 expands and substantially engages the inner wall of the trachea. The controller housing 50 may optionally include a recess or have a substantially flat surface on the side from which the expandable member 62 extends, such that the recess or flat surface receives at least part of the expandable member 62 when in compressed form, further reducing the profile to aid in delivery by a delivery device.
FlG. 3C illustrates another embodiment of an extensible member including one or more expandable connectors 65 connecting at least two separated controller housing sub-components 66, 68. In this embodiment, the one or more expandable connectors 65 create opposing forces against the two separated controller housing sub-components 66, 68, biasing each against the inner wail of the trachea 20 at opposing areas, and thus anchoring the controller housing subcomponents 66, 68 in place. The expandable connectors 65 may be configured similar to the expandable member 62 described with reference to FIGS. 3A-3B. In some embodiments, the expandable connectors 65 may be formed as a metallic or polymeric spring, from a shape memory alloy, as mechanically adjustable rigid members, or as telescoping members. In one embodiment, the two separate sub-components 66, 68 may be electrically coupled by one or more isolated electrical leads 70 to facilitate power transfer and/or electrical communication between the pulse generator circuitry existing within the controller housing sub-components 66, 68 and/or with one or more electrical leads carrying electrodes. Although the embodiment illustrated by FIG. 3C includes only two separated controller housing sub-components 66, 68, the controller housing may be formed as any number of controller housing sub-components, each being radially biased toward the inner wall of the trachea 20. Similar to the embodiment illustrated in FIGS. 3A and 3B, the two or more separated controller housing sub-components 66, 68 connected by one or more expandable connectors 65 may be compressed to a reduced profile during placement, for example, when delivering using a delivery device 64, as illustrated in FIG. 3D. In this embodiment, two separated controller housing sub-components 66, 68 each have a substantially semi-circular cross section and are complementary in shape to each other.
FIG. 3F illustrates an embodiment of an anchor device which may be employed to prevent distal migration of the controller housing 50. According to this embodiment, the bifurcation between the trachea 20 and the right and left primary bronchus 30, 32 support the controller housing 50. An arched member 76 is attached to the distal end of the controller housing 50, includes an arm extending into each primary bronchus 30. 32, and is substantially supported by the bifurcation. The arched member 76 may be secured using an extensible member, such as any described with reference to FIGS. 3A-3E, or by any other anchoring means, such as a balloon, suture, staples, barbs, hooks, studs, adhesive, shape memory alloy members, or any combination thereof. In one embodiment, the arched member 76 may be shaped before or during implantation to more specifically follow the curvature of the bifurcation, further facilitating retention of the controller housing 50 within the airway. In this embodiment, an additional anchor device 60 is affixed to the controller housing 50, such as those described herein, ϊn other embodiments, anchor members may not be employed on either the controller housing, the arched member, or both.
Other embodiments of the anchor device for retaining the controller housing 50 at a desired position within the trachea, though not illustrated, may be employed. For example, the controller housing may be held against the trachea by suture, adhesive, or a combination thereof, as is known. In another embodiment, the anchor device may be a reversibly inflatable balloon, formed as a sleeve, having an opening passing axiatly therethrough, and expanding radially. In this example, the balloon may be deflated during placement and then inflated to expand radially by methods known, causing a biasing force against the trachea. Further, the external surface of the balloon sleeve may be include texturing, texturing, suture, barbs, hooks, studs, adhesive, or any combination thereof, to further facilitate retaining the sleeve against the trachea wall. In yet another embodiment, the anchor device may be formed as one or more radially extending rigid members, which may be extensible, collapsible, telescoping, inflatable, formed from shape memory alloy, or the like, causing a radially biasing force against the inner wall of the trachea. In addition, any of the anchor devices described herein optionally may include a radiopaque material to aid in delivery procedures. The radiopaque material may be used in part or al! of device. The radiopaque material may be useful to facilitate device or component placement using known imaging techniques. The anchor devices described herein optionally may include a biocompatible coating. The coating may include one or more prophylactic or therapeutic agents, such as anti-proliferative agents, steroids, antibiotic agents, or any combination thereof.
Putse Generator
FIG. 4 illustrates an embodiment of a pulse generator 51 and many of the features that may be included as components of the pulse generator 51. Example features which may be included in a typical pulse generator 51 include a power source 82, a capacitor circuit 84, which may be used to charge and discharge during defibrillation, an electronic controller 86. which may be implemented by a microprocessor, an integrated circuit, a field programmable gate array ("FPGA"), or other electronic circuitry as is known, a communication module 88, one or more electrical lead sockets 90, and a controller housing 50 encapsulating components contained within the pulse generator 51 and forming the external structure thereof, As described herein, the pulse generator 51 and its associated elements may be operable to generate and deliver an electrical stimulation signal or pulse, which may be effective for performing cardiac pacing, cardiac defibrillation, cardioversion, cardiac resynchronization therapy, or a combination thereof. The pulse generator 51 may optionally include electronic circuitry, hardware, and software to measure and sense electrical cardiac activity, other cardiac activity, other physiological parameters, or any combination thereof. Accordingly, the power source 82 in combination with the electronic controller 86 may include hardware and/or software suitable for delivering electrical stimulation signals, and optionally for receiving electrical sensing signals, via one or more electrical leads 52 electrically coupled to the lead sockets 90 and carrying one or more electrodes, as is described more fully herein.
Because the pulse generator 51 is implantable within a trachea or bronchus, or in some embodiments subcutaneously, the controller housing 50 may be constructed so as to withstand humidity, gasses, and biological fluids. The controller housing 50 may be hermetically sealed and constructed to withstand the environment of the airway and protect the circuitry, power source, and other elements contained therein. An example controller housing 50 implantable in either the trachea or the bronchus generally will not be continually immersed in a liquid environment, which in contrast to a subcutaneous implant, enables one to use polymeric materials of construction. (In contrast, a subcutaneous implant often requires metallic materials of construction and laser or electron beam welded seams.) Accordingly, in embodiments implanted in the airway, the controller housing 50 may be entirely or partially constructed from polymeric material, such as but not limited to, epoxy, polypropylene, polyethylene, polyamide, poiyamide, polyxylene, polyvinyl chloride ("PVC"), polyurethane, polyetheretherketone ("PEEK"), polyethylene terephthalate ("PET"), liquid crystal polymer ("LCP"), and the like. In other embodiments, however, the controller housing 50 may be constructed from entirely or partially metallic materials, such as, but not limited to, nickel, titanium, stainless steel, tantalum, titanium, gold, cobalt chromium alloy, or any combination thereof. In yet other embodiments, the controller housing 50 may be constructed from a combination of one or more of these polymeric or metallic materials. Other materials known in the art to be suitable for fabricating or encasing implantable medical devices also may be used to construct the controller housing 50. All or partial polymeric construction of the controller housing 50 may be advantageous as compared to completely metallic construction, avoiding the Faraday cage effect that may be caused by a complete metallic casing. A Faraday cage effect may limit the use of electromagnetic fields to communicate or otherwise interface with the pulse generator 51. Accordingly, a non-conductive controller housing 50, such as one constructed from polymeric materials as described herein, allows electromagnetic fields for communicating with, controlling, and otherwise interfacing with the pulse generator 51. For example, electromagnetic fields may be used for recharging battery power sources associated with the pulse generator 51, without removing the pulse generator 51 and/or the battery power source. In another embodiment, the controller housing 50 may be constructed partially from metallic materials, for example at the points interfacing with the trachea and/or bronchus, and partially from polymeric materials. A controller housing 50 constructed in such a manner also avoids the Faraday cage effect by not being completely surrounded by an electrical conducting metal.
Some or all of the external components of the pulse generator 51, including the controller housing 50 and the anchor device as described with reference to FIGS. 3A-3F, may be entirely or partially coated to aid or improve hermetidty, electrical conductivity, electrical isolation, thermal insulation, biocompatibility, healing, or any combination thereof, as is desired. Representative coatings include metals, polymers, ultra-nanocrystalline diamond, ceramic films (e.g., alumina or zirconia), medicinal agents, or combinations thereof. For example, the controller housing 50 may be coated by a polyxylene polymer to further electrically isolate the electrical circuitry, power source, and other elements from the patient's body. In another example, the controller housing 50 and/or the anchor device, particularly at the points interfacing with the trachea or bronchus, may be at least partially coated with a biocompatible coating, medicinal or therapeutic coating, such as anti-proliferative agents, steroids, antibiotic agents, or any combination thereof, to promote healing of trauma caused during implantation and/or to avoid infection.
FIG. 5 depicts a schematic diagram of one example of an electronic controller 88 that may be utilized according to various embodiments of the invention in order to generate, deliver, receive, and/or process electrical stimulation and sensing signals to perform cardiac treatment. As used herein, the terms "electronic controller," "electronic circuitry," and "electrical circuitry" may be utilized interchangeably. The electronic controller 88 may include a memory 90 that stores programmed logic 92 (for example, software). The memory 91 may also include data 94 utilized in the operation of the invention and an operating system 96 in some embodiments. For example, a processor 98 may utilize the operating system 96 to execute the programmed logic 92, and in doing so, may also utilize the data 94, which may either be stored data or data obtained through measurements or external inputs. A data bus 100 may provide communication between the memory 91 and the processor 98. Users may interface with the electronic controller 88 via one or more user interface device(s) 102, such as a keyboard, mouse, control panel, or any other devices suitable for communicating digital data to the electronic controller 88. The user interface device(s) 102 may communicate through wired communication, which may be removably coupled to the pulse generator during implantation or during servicing, or may communicate wirelessly, such as through radio frequency, magnetic, or acoustic telemetry, for example. The electronic controller 88 and the programmed logic implemented thereby may comprise software, hardware, firmware, or any combination thereof.
The elements of the pulse generator, for example the electronic controller 88, may be discrete components, or some or all elements may be based on VLSI technology, having many components embedded within a single semiconductor. In one embodiment, the electronic controller 88 is integrated with a flexible printed circuit board constructed from, for example, a polyimide film, e.g., Kapton™, (E. I. du Pont de Nemours & Co. (Wilmington, Delaware)). A suitable electronic controller 88 may include more or less than all of the elements described herein. Although the electronic controller 88 illustrated in FIG. 5 is described as including each individual component internally within a single controller, multiple electronic controllers 88 may be employed, for example, each performing individual functions and/or each performing redundant functions of the other. Some of the components illustrated in FIG. 5 may exist externa! to the controller housing 50 and the patient, for example, within a separate processing unit, such as a personal computer or the like, in communication with the controller housing 50. The power source 82 illustrated in FIG. 4 may be a battery of any known chemistry, for example a battery having high voltage, high capacity, low self-discharge, long durability, and that is non-toxic. Example battery chemistries may include lithium iodine, lithium thionyl chloride, lithium carbon monoflouride, lithium manganese oxide, and lithium/silver-vanadiurn- oxide. In another embodiment, the power source 82 may include one or more rechargeable batteries. Example rechargeable battery chemistries may include, but are not limited to, lithium ion, LΪPON, nickel-cadmium, and nickel-metal hydride. The power source 82 may comprise more than one battery, for example a primary battery and a back-up battery, or in another example, certain pulse generator 51 elements may be powered by a first battery and certain other elements may be powered by a second battery.
Because the pulse generator 51 is implantable within the trachea or the primary bronchus, and thus relatively close to the patient's surface, a rechargeable power source 82 may be charged using electromagnetic charging, as is known. Other wireless charging methods may be used, for example, magnetic induction, radio frequency charging, or light energy charging. Embodiments including a rechargeable power source 82 may further be charged by direct charging, such as may be delivered by a catheter, through an endotracheal tube, or during bronchoscopy, for example, to a charging receptacle 108, feedthrough, or other interface optionally included in the controller housing 50 and in electrical communication with the power source 82. The charging frequency and the charging duration of the power source 82 depends on its capacity and the device usage,
In another embodiment, the power source 82 may be replaceable, and the controller housing 50 may be adapted for simple, safe access to the power source, memory, processor, electrical circuitry, or other pulse generator elements, while implanted within the airway. For example, the embodiment illustrated in FIG. 4 optionally includes a reattachable detachable portion of the controller housing 50. In one embodiment, the detachable portion may be a replaceable removable cap 104 adaptable for removably connecting to the controller housing 50 of the controller housing 50. The removable cap 104 may create a hermetic seal between the main body of the controller housing 50 and the cap 104 using a flexible o-ring 106, for example. In some embodiments, the o-ring may be constructed from elastomeric polymers, such as perfluoroeiastomer, silicone, acryloniirile butadiene copolymers, butadiene rubber, butyl rubber, chlorosulfonated polyethylene, epichiorohydrin, ethylene propylene diene monomer, ethylene propylene monomer, or fluoroelastomers, or from soft metals, such as copper, gold, silver, tin, or indium. The removable cap 104 may be secured to the main body of the controller housing 50 by any fastener suitable for releasably securing two items, such as threads and threaded receiver, bolt, clamp, pin and slot, or adhesive, for example. In one embodiment, the removable cap 104 may be removably secured to the proximal end of the controller housing 50, providing easier access to the components contained therein. In another embodiment, the controller housing 50 may be adapted to include one or more removable caps 104 at other portions of the controller housing 50. The controller housing 50, may further include one or more recesses or protruding members to facilitate gripping the controller housing 50 during access and removal of the cap 104.
The removable cap 104 may also include means for forming an electrical contact with the power source 82, such as a standard spring, flat spring, or conical spring, such that when the cap 104 is removed the electrical contact is broken and no power is delivered to the pulse generator 51 from the power source 82. Accordingly, a controller housing 50 adapted to include a replaceable power source 82 allows for removing the cap 104, removing the power source 82, replacing the power source 82, re-securing the cap in a non-invasive, incisioniess procedure, such as with the use of an endotracheal tube, a catheter, or during a bronchoscopy, for example. In one embodiment, the controller housing 50 may have a substantially elongated cylindrical shape and is dimensioned to allow commercially available batteries such as one or more "AAA- size,"1 "AAAA-size," or button eel! batteries having any of the battery chemistries described herein.
In another embodiment, the reattachably detachable portion may be a sub-casing of the controller housing 50 that similarly provides access to one or more elements within the pulse generator. The sub-casing may be reattachably secured to the controller housing in a manner similar to that described with reference to the removable cap 104. For example, the sub-casing may provide an additional, sealed compartment, which may be in electrical communication with the remainder of the pulse generator 51. For example, the sub-casing creates a hermetic seal between the main body of the controller housing 50 and the sub-casing. The sub-casing may be secured to the main body of the controller housing 50 by any fastener suitable for releasably securing two items, such as threads and threaded receiver, bolt, clamp, pin and slot, or adhesive, for example. In one embodiment, the sub-casing may be removably secured to the proximal end of the controller housing 50, providing easier access to the components contained therein. With reference to FIG. 4, the removable cap 104 may be replaced by the detachable portion, such that instead of a cap, the detachable portion provides an additional, sealed compartment, which may be in electrical communication with the remainder of the pulse generator 51.
The one or more electrical lead sockets 90 illustrated in FIG. 4 may be an insulated, or otherwise electrically isolated, junction or feedthrough, enabling electrical communication between the one or more leads 52 and elements of the pulse generator 51, such as the electronic controller 86. As compared to conventional pulse generators implanted subcutaneous Iy, typically requiring strict hermetic sealing, a tracheal or bronchial implanted controller housings may be less demanding. For example, the lead socket or sockets 90 therefore may simply consist of polymeric or eϊastomeric seals. However, it is also appreciated that more robust sealing mechanisms, such as a glass to metal sealed or a ceramic sealed feedthrough, may be used, such as for embodiments implantable subcutaneously. Any conventional fasteners may be used to secure (e.g., removably secure) an electrical lead 52 to a lead socket 90. Removably securing the electrical leads 52 to the controller housing 50 allows flexible implantation techniques. In other pulse generator 51 embodiments, however, the one or more electrical leads 52 may be permanently integrated with the controller housing 50, and thus may not be removable. The pulse generator 51 and controller housing 50 may further include one or more sensors for monitoring conditions external to the patient's body. Being implantable within the trachea or primary bronchus, the pulse generator 51 is substantially exposed to inspired air and may sense, measure, or record parameters substantially representative of the environment external to the patient's body. Example sensors include a pressure sensor for monitoring the air pressure within the trachea and for evaluating the barometric pressure, or a temperature sensor for estimating temperature external to the patient's body. The measured air pressure in the trachea may also be used for observing and/or recording parameters related to the patient's breathing, including, for example, respiration rate and airway pressure in the inspirium and expirium stages. Measurements related to breathing may help a physician detect, diagnose, and treat various chronic lung problems, such as asthma, bronchitis, emphysema, or chronic obstructive pulmonary disease, for example. These sensor devices and measured parameters are exemplary; other sensor devices may be operably associated with and/or mechanically connected to the pulse generator 51 and controller housing 50, for measuring other parameters, Representative examples of the pulse generator 51 may also include electronic circuitry and hardware for performing audio-based communication and audio-driven commands to and from the pulse generator 51. A pulse generator 51 implanted within the airway makes it possible to use transmit such audio-driven commands, for example, voice or digitally generated audio streams, which otherwise would be substantially attenuated in conventional devices surrounded by tissues and/or fluid, to a receiver (not shown). For example, the receiver may be a microphone or other transducer. The receiver may be integrated within the pulse generator 51 and may be in communication with the electronic controller 86 for executing logic within the controller 86 and causing a response in the pulse generator 51 functioning.
Exemplary embodiments of the pulse generator 51 may optionally include one or more stimulation and/or sensing electrodes (not shown) positioned on or near the controller housing 50 for substantially communicating with the inner wall of the trachea or bronchus when implanted. The housing electrode may be formed from an electrically conductive member, such as a metallic member, and in electrical communication with the electronic controller 86 within the controller housing 50, directly or by way of one or more electrical leads passing along the external surface of the casing to the one or more electrical lead sockets 90. In another example, one or more electrodes may be affixed to an anchor device and positioned to substantially communicate with the inner wall of the trachea or bronchus upon implantation of the pulse generator 51. A housing electrode integrated with the controller housing 50 or an electrode affixed to an anchor device may perform any or all of the electrical stimulation and/or sensing functions described herein. In one example, the casing electrode may serve as a reference electrode when measuring electrical impedance in the cardiac region, In another example, a housing electrode affixed to a pulse generator 51 implanted within a primary bronchus may be used to electrically stimulate at least one of the right or left atrium.
Being insertible through either the oral or nasal cavity, example controller housing 50 embodiments may be at least partially flexible to ease insertion. A flexible controller housing 50 may be constructed at least partially of elastomeric materials, for example, elastomeric polymers or polyurethane. In other embodiments, a metallic controller housing 50 may include one or more areas along its axis that may bend, flex, or otherwise be malleable, FIGS. 6A and 6B illustrate two possible embodiments of a flexible controller housing 50. The controller housing 50 illustrated by FIG. 6A includes one or more corrugated areas 110, allowing the controller housing 50 to flex or bend at the corrugated areas 110. Though not illustrated, the pulse generator 51 illustrated in FIG. 6A further includes one or more of the pulse generator elements described with reference to FIG. 4, though these elements may be designed and positioned so as to not restrict or interfere with the flexion of the controller housing 50. FlG. 6B illustrates another example controller housing 50 configuration that also aids in longitudinal casing flexibility. This controller housing 50 embodiment includes at least two subcases 112, 1 14, each housing some of the components as described with reference to FlG. 4, and connected by one or more flexible connectors 116. Thus, the controller housing 50 may bend or otherwise flex around the flexible connectors 116, and be electrically connected by a non-rigid electrical conductor 117. The flexible connectors 1 16 may be constructed from metallic materials, polymeric materials, or any combination thereof, and may be formed so as to limit longitudinal (or axial) movement, but permit lateral flexion at the connectors 116. In one embodiment, the flexible connectors 1 16 may be formed as a spring-like structure; though other configurations suitable to provide the desired flex may be used. The non-rigid electrical conductor 117 may be an insulated, or otherwise electrically isolated lead, and may provide electrical communications between components within each sub-case 1 12, 1 14. In one example, each sub-case 1 12, 1 14 may include a hermetically sealed electrical junction 120, such as a feedthrough, operable to receive an end of the non-rigid electrical conductor 117. One or more of the sub-cases 1 12, 114 may be separated from the controller housing 50, for example, for servicing, programming, calibration, or data abstraction. For example, in one embodiment, the proximal sub-case 114 (that opposite the case including lead sockets 90) may house a power source, which may be removable for charging or replacement, without requiring removal of the entire pulse generator 51 from the implantation site, thus avoiding disengaging leads, anchor devices, and the like. FIG, 7 illustrates another possible embodiment of a controller housing 50 having a tracheal component 1 18 and a bronchial component 119. The controller housing 50 of this embodiment may be anchored at least partially within the trachea 20 and one of the right or left primary bronchus 30, 32 as illustrated. A controller housing 50 configured in this manner can be larger in size than an embodiment implanted solely within the trachea 20 or implanted solely within the primary bronchus 30, 32. Accordingly, the diameter of trachea! component 1 18 may be substantially larger than the diameter of the bronchial component 119, optimizing the controller housing 50 volume while minimizing any interference to airflow through the airway. In another embodiment, the controller housing 50 may be implantable within the trachea 20 and both primary bronchi 30, 32. A controller housing 50 implantable within both bronchi 30, 32, and the trachea 20 may be configured in an inverse "Y" shape (not shown), and may at least partially rest at or near the bronchial bifurcation. The controller housing 50 of these embodiments may be anchored to the trachea 20, the primary bronchus 30, 32, or to both, by an anchor device, such as described herein.
The electrodes and leads may be guided to and positioned at the desired implantation site using delivery devices, such as a catheter, a guidewire, a combination thereof, or other known means for guiding elongate devices within a body iumen.
The electrodes may be fixable at one or more selected implantation positions within the airway to prevent electrode migration from the selected position and to promote electrical coupling with the epithelial tissue lining the airway. Various anchoring devices may fix the electrode at the selected implantation site. For example, these anchoring devices may include. but not are not limited to, one or more barbs, one or more hooks, suture, one or more extensible members, one or more stent-like expandable members, a balloon, an adhesive, or any combination thereof, as described more fully herein. Barbs or hooks may be in a fixed relationship with the electrode, or may be selectably retractable by way of mechanical, electrical, chemical means, or the like. Extensible members may include, for example, members made of self expandable metals (e.g., nickel-titanium, cobalt alloy, stainless steel, shape memory alloys), members made of self expandable polymeric materials (e.g., silicone), or mechanically extensible members, such as those stent-like expandable members described with reference to FIGS. 3A-3E for use in conjunction with the controller housing 50. Alternatively, the one or more electrodes may be proportioned to have a diameter slightly larger or approximately the same size as the inner bronchi at the selected implantation site, causing the electrode to lodge within the airway. Though, electrode embodiments proportioned to lodge within the airway as a result of its diameter may optionally include a lumen or passageway formed axially through the body of the electrode and in parallel with the airway lumen to permit airflow through the passageway or lumen, thus avoiding interference with respiratory activities occurring at or downstream of the implantation site.
In certain embodiments, the electrode or electrodes may be at least partially coated with an insulating material. Examples of suitable materials may include a polymer insulator (such as silicone, polyurethane, polytetrafluoroethylene (e.g., Teflon™), or other fluoropolymers), a ceramic insulator, or a glass insulator. An insulative coating may enable the control, direction, and focus of the stimulation signal sent by the pulse generator. An insulative coating may also allow one to divide the electrode into multiple electrode stimulation regions for optimizing the stimulation location and/or for operating in a multi-electrode configuration, such as a bipolar or tripolar electrode. FIGS. 8A-8G illustrate several exemplary embodiments of electrode configurations that aid in fixation and retention within the airway, improve electrical coupling, and may or may not permit airflow by pass by the implanted electrode, i.e., past the implantation site. Example electrode configurations and anchor devices are similar in design and function to those described with reference to the controller housing anchor devices. Accordingly, any of the example anchor device embodiments described with reference to the controller housing herein may be applied as anchor devices for an electrode, and any anchor device embodiments described with reference to the electrodes herein may be applied as anchor devices for the controller housing.
FIG. SA illustrates an electrode 122 positioned at the distal tip of an electrical lead 52 and implantable within the airway of a patient, for example, within the trachea, primary, secondary, or tertiary bronchus, bronchioles, or any branch thereof. The diameter of the electrode 122 is substantially similar or slightly larger than the inner diameter of the airway at the selected implantation site. For example, an electrode 122 proportioned for placement at an implantation site in the tertiary bronchus may have a diameter of approximately 5 mm to approximately 8 mm if the inner diameter of the tertiary bronchus is approximately 5 mm. Accordingly, in some embodiments, the diameter of an electrode 122 may be 0 mm to approximately 8 mm greater than the inner diameter of the airway at the implantation site. The inner diameter of a patient's airway varies depending upon the location within the airway and upon the patient; thus, the diameter of an electrode 122 in accordance with the embodiment illustrated in FlG. 8A also will vary depending upon the intended implantation site dimensions. An electrode 122 having a diameter substantially similar or slightly greater than airway lumen in which it is implanted will aid electrode 122 retention at the implantation site and promote electrical coupling for more effective stimulation or sensing. Additional anchor devices, such as texturing, suture, barbs, hooks, studs, adhesive, shape memory alloy members, or any combination thereof, may optionally be included to enhance electrode 122 retention in the airway. Accordingly, for certain electrode embodiments also including additional anchor devices, the electrode diameter need not be the same or slightly larger as the airway, but may optionally be a slightly smaller diameter than the airway.
The embodiment illustrated in FIG. 8A, without further design enhancements, may inhibit airflow downstream from the implantation site. Accordingly, this embodiment may be generally suited for implantation sites located in the periphery of the bronchi, having relatively smaller diameters such that the restricted airflow passage may be clinically insignificant, for example, within smaller branches of the tertiary bronchi or within the bronchioles,
FIG. 8C illustrates a cross-section of the electrode 122 embodiment illustrated in FIG, SB. Accordingly, this embodiment may include a lumen 124 passing through the electrode 122 body and multiple protrusions 126 extending from the body. As illustrated in FIG. 8C, the protrusions 126 may have a hook shape, though other shapes may be employed, such as pointed, barbed, rounded, and the like. The protrusions 126 illustrated in FIGS. 8B and SC are equally applicable to other electrode embodiments described herein.
FIG. SD illustrates another electrode 122 embodiment including an anchor device 128 similar to those described with reference to FIGS. 3A-3E for use with the controller housing. In this embodiment, the anchor device 128 may be an extensible anchor device, such as a stent-like expandable member, as further described herein. Other example anchor devices 128 may include one or more radially expandable circumferential rings, balloon sleeves, radially extensible rigid members, tubular members, texturing, suture, barbs, hooks, studs, adhesive, shape memory alloy members, or any combination thereof. In one embodiment, the anchor device 128 may be formed from electrically conductive material and serve as part of the electrically conductive electrode 122 function, so as to further promote electrical stimulation or sensing effectiveness.
FIGS. 8E and 8F illustrate another embodiment of electrode 122 which includes at least two electrode sub-components 130, 132 configured similar to the controller housing configuration described with reference to FIGS. 3C and 3D. The at least two electrode subcomponents 130, 132 may be connected by one or more expandable connectors 134 which create opposing forces against the two electrode sub-cornponents 130, 132, radially biasing each against the inner wall of the airway at opposite areas. The expandable connector 134 and electrode subcomponents 130, 132 fix the electrode 122 at the implantation site while leaving a passageway between the electrode sub-components 130, 132 through which airflow may pass. The expandable connector 134 may be configured similar to any of the expandable members described herein with reference to example electrode and/or controller housing embodiments. In various embodiments, the expandable connectors 134 may be formed as a metallic or polymeric spring, from a shape memory alloy, as mechanically adjustable rigid members, as telescoping members, or the like. In one embodiment, the two electrode sub-components 130, 132 may further be electrically coupled by one or more isolated electrical connector 136, to facilitate electrical communication between each electrode sub-components 130, 132. In another embodiment, the one or more expandable connectors 134 may double as an isolated electrical connector, eliminating the need for an additional isolated electrical connector. As illustrated in FIG. 8F, the two or more electrode sub-components 130, 132 connected by one or more expandable connectors 134 may be compressed to a reduced profile during delivery and positioning, for example using a delivery device 138, such as a catheter. In one embodiment, the two electrode sub-components 130, 132 each have a substantially semi-circular cross section, each being complementary in shape to the other, and having an external radius of curvature substantially similar to the inner wall of the airway in which it may be implanted. Although the embodiment illustrated by FIGS. 8E and 8F may include only two electrode subcomponents, the electrode 122 may be formed from any number of electrode sub-components, each being biased radially against the inner wall of the airway implantation site. In another embodiment, only one of the electrode sub-components 130, 132 may be electrically conductive and serve the electrode function.
FIG. 8G illustrates another suitable electrode and electrical lead embodiment including at least one electrode and at least one pre-shaped electrical lead. The distal end of the pre-shaped electrical lead 135 may be pre-shaped, such that the shape will substantially lodge or wedge within the lumen of the airway in which it may be implanted. As illustrated in FIG. 8G, the pre- shaped electrical lead may be shaped substantially waved shape, such as an "S" shape, such that the wave amplitude may be substantially similar or slightly larger than the inner diameter of the airway lumen in which it may be implanted. In other embodiments, the pre-shaped electrical lead 135 may be formed in other shapes, such as a spiral, circular, elliptical, or hooked, for example. The pre-shaped electrical lead 135 may carry one or more electrodes 122. The embodiment illustrated in FIG. 8G includes three electrodes 122, positioned at or near the distal portion, and then along the pre-shaped portion of the electrical lead 135. Positioning the one or more electrodes 122 at or near a maximum or minimum of the pre-shaped form causes the electrode or electrodes 122 to be biased against the inner wall of the airway lumen, thus increasing the electrical coupling therewith. The pre-shaped portion of the electrical lead 135 may include a less pliable, less flexible and more shape resilient material than the remaining proximal portion of the lead 135. In one example, the pre-shaped portion of the electrical lead may be coated or otherwise constructed at least partially with poiyurethane whereas the remaining proximal portion may be coated or constructed at least partially with silicone. In another example, a shape memory alloy, such as nickel titanium alloy, may be integrated with the pre-shaped portion of the electrical lead 135, such that upon application of energy, the electrical lead 135 may transition from substantially straight shape to assume any pre-defined shape, for example an "S" shape as illustrated.
A pre-shaped electrical lead 135 carrying one or more electrodes 122 may be delivered using a delivery device, such as a catheter, sheath, stylet, or guϊdewire. Accordingly, when contained within a lumen of the delivery device, the pre-shaped electrical lead 135 may be substantially straightened for delivery and positioning at or near the implantation site. Upon removing the delivery device, the pre-shaped portion of the electrical lead 135 may reform to it's pre-shaped form, causing it to apply a force against the wall of the airway lumen and substantially affix the electrode 122 and electrical lead 135 in place. FIGS. 8H-8K illustrate some embodiments of electrical leads 52 that include at least one lead securing member 137 for substantially retaining the electrical lead 52 at a certain position within the airway, such as the trachea or bronchus. Because the electrical lead 52 is a foreign object to the airway tissues, irritation may occur, causing discomfort and/or other undesirable conditions, such as chronic coughing, itching, or tissue granulation. In one embodiment, as illustrated in FlG. 8H, at least two lead securing members 137 may be formed as a pin, arm, rod, or other member extending radially from the electrical lead 52 in approximately opposite directions and substantially affixing to or exerting pressure against the inner wall of the airway in which the electrical lead 52 may be positioned, and the electrical lead 52 is suspended therebetween. In another embodiment, as illustrated in FIG. 81, the lead securing member 137 may be formed as a coil or other radially extending elliptical member, such that the lead securing member is in at least partial contact around the circumference of the inner wall of the airway and the electrical lead 52 is suspended therebetween. The lead securing members 137 illustrated in FIGS. 8H and 81 allow the electrical lead 52 to be suspended within the interior lumen of the airway, and avoid substantial contact with the inner wall. FIGS. 8J and 8K illustrate still other embodiments of lead securing member 139 which biases the electrical lead 52 toward the inner wall of the airway, such as the trachea or bronchus. In this way, the electrical lead 52 may be at least partially or totally encapsulated by the epithelial tissue of the airway inner wall, so as to allow the body's natural mechanisms to protect against and combat contamination, such as bacteria or infection resulting therefrom. In one embodiment, as illustrated in FIG. 8J, the lead securing member 139 may be an expandable member, similar to those described with reference to FIGS. 3A or 8D, that radially exerts a biasing force against the inner wall of the airway and causes the electrical lead 52 to interface with the inner wall opposite the lead securing mechanism 139. In this example, the lead securing member 139 may be configured as an expandable member, such as a stεnt-like member, an inflatable balloon sleeve, a spring, or a coil. In another embodiment, as illustrated in FIG, 8K, the lead securing member 139 may be configured as a pin, arm, rod. or other member extending radially from the electrical lead 52 in an approximately opposite direction and substantially affixing to or exerting pressure against the inner wall of the airway opposite the electrical lead 52, creating a biasing force which causes the electrical lead 52 to interface with the inner wall opposite the lead securing member 139. In still another embodiment, the lead securing member 139 may be like one of the electrode anchor devices or controller housing anchor devices described herein and illustrated in FIGS. 3A, 3B, 3 E, 3F, or 8D. The lead securing members 137, 139, as described herein, may be formed of a biocompatible elastomeric material or shape memory material. Examples of these materials include elastomeric polymers (such as silicone, polyurethane), flexible metals, and shape memory alloys (e.g., Nitinol™).
The electrical leads may also optionally include a radiopaque coating or a radiopaque material to aid in delivery when using imaging techniques, such as x-ray, computed tomography, or fluoroscopy, for example. Furthermore, example electrical leads may be capable of eluting and/or delivering medicinal agents to reduce rejection of the lead and electrode by the surrounding tissue, therefrom. For example, the electrical leads may be coated with steroids, anti -inflammatory agents, anti -bacteria! agents, antibiotics, or any combination thereof, as are known. In other embodiments, the electrical lead may include a lumen existing therethrough for selectively delivery of such rnedicina! agents, for example, during electrode delivery as administered by the physician, or while implanted as released from the pulse generator or other source.
FIGS. 9A-9D illustrate additional embodiments of the implantable cardiac stimulation system having one or more electrodes positioned and fixed at various positions within a human airway according to embodiments of the invention. FIG. 9A illustrates one embodiment of a implantable cardiac stimulation system including a single electrode 57 carried by an electrical lead 52 implanted within the right tertiary bronchus or substantially near the bronchus branch and in proximity to the right atrium and the sinoatrial node ("SA node") of a heart. In another embodiment, the electrode 57 may be positioned within the airway to be in proximity to the heart atrioventricular node ("AV node"). In this embodiment, the system may be operable for monitoring cardiac electrical activity and for identifying heart deficiencies, including, but not limited to, bradycardia and atrial fibrillation. The single electrode 57 may also be used for pacing the heart right atrium by delivering appropriately timed electrical pulses from the pulse generator 51 in a manner similar to that as performed by conventional right atrial pacemakers. The single implanted electrode 57 may be used to treat atrial fibrillation by delivering a low voltage, high pacing rate electrical pulse from the pulse generator, similar to anti-tachycardia pacing ("ATP''), or by delivering a high voltage excitation signal from the pulse generator 51. Though not illustrated, the implantable cardiac stimulation system may include positioning a single electrode at other positions within the bronchi to be in proximity to other areas of the cardiac system. For example, in another embodiment, the electrode may be placed within the left tertiary bronchus or substantially near the bronchus branch and in proximity to the left atrium, in a manner similar but opposite to that illustrated in FIG. 9 A, for electrically stimulating the left atrium.
FΪG. 9B illustrates another embodiment of an implantable cardiac stimulation system including two electrodes 57, 54 carried by electrical leads 52, each implanted at different sites within the right tertiary bronchus. The first electrode 57 is implanted proximal to the second electrode 54, in proximity to the right atrium. The second electrode 54 Js implanted distally from the first electrode 57, in proximity to the right ventricle. This embodiment may be operable to perform cardiac pacing of the right atrium and the right ventricle with an appropriate delay (A-V delay) between them, which may be generally be referred to as dual-chamber pacing. The embodiment illustrated in FΪG. 9B may be operable to perform any conventional dual-chamber pacing, such as DDDR pacing, for example. The distally placed electrode 54 may be operable for detecting ventricular tachycardia. Furthermore, in embodiments in which the controller housing or the anchor device includes an additional electrode, as described herein, the system illustrated in FIG. 9B may be operable to perform cardiac defibrillation, such that the controller housing electrode (not shown) may serve as the counter electrode to the distally placed electrode 54. Though not illustrated, the cardiac device may include positioning two electrodes at other relative positions within the bronchi to be in proximity to multiple other areas of the cardiac system. FIG. 9C illustrates another embodiment of an implantable cardiac stimulation system including three electrodes 57, 54, 55 carried by electrical leads 52 in electrical communication with a pulse generator 51, each implanted at different sites within the right and the left bronchus. This embodiment may include the additional electrode 55 implanted distally within the left bronchus, such as the lower lobe bronchial branch, to the two electrodes 57, 54 illustrated in FIG. 9B. The additional electrode 55 is positioned in proximity to the left side of the heart, for example, in proximity to the left ventricle. Accordingly, this embodiment including an electrode 57 in proximity to the right atrium, an electrode 54 in proximity to the right ventricle, and an electrode 55 in proximity to the left ventricle may be operable to perform cardiac ^synchronization therapy by synchronizing the contraction between the left and right ventricles with the delivery of electrical pulses, as is known.
The three-electrode embodiment illustrated in FIG. 9C may also be operable to perform cardiac ^synchronization therapy defibrillation ("CRT-D"), in which defibrillation signals are added to the dual-chamber pacing functions. Furthermore, in embodiments in which the controller housing or the anchor device includes an additional electrode, as described herein, the device illustrated in FlG. 9C may be used to perform cardiac defibrillation, such that the pulse generator electrode (not shown) may serve as the counter electrode to either the distally placed electrode 54 in proximity to the right ventricle or the electrode 55 in proximity to the left ventricle. It may be advantageous to perform defibrillation between the pulse generator (or anchor device) and the electrode 55 in proximity to the left ventricle because it may provide a better conducting path and may increase the changes for cardioversion, while possibly reducing the electrical energy threshold for treatment.
Furthermore, the three-electrode embodiment may simply perform cardioversion/defibrillation therapy (such as that performed by conventional implantable cardioverter-defibrillators), and may optionally perform cardiac pacing therapy. The two distaliy positioned electrodes 54, 55 may perform the defibrillation functions. The proximally placed electrode 57 near the right atrium may only be necessary if additional cardiac pacing therapy is provided. Though, the third electrode 57 may alternatively be operable to perform sensing functions, such as sensing cardiac electrical activity, and/or to reduce the electrical energy required for defibrillation by supplementing the stimulation signal delivered. Though not illustrated, it is appreciated that use of the cardiac device may include positioning three electrodes at other relative positions within the bronchi to be in proximity to multiple other areas of the cardiac system.
In another example of the three-electrode embodiment configured to perform cardioversion/defibrillation therapy, the three electrodes may be positionable within a patient's airway such that at least two electrical shock vectors may be created for simultaneous cardioversion of the two ventricles. For example, in one embodiment, electrode 55 is positioned substantially near the left ventricle, electrode 57 is placed substantially near the right atrium, and electrode 54 is positioned substantially near the right ventricle. Accordingly, two shock vectors - between electrode 54 and electrode 57 and between electrode 54 and electrode 55 are created. In another embodiment, the two shock vectors may be between electrode 55 and electrode 54 and between electrode 55 and electrode 57. In embodiments configured for performing cardioversion/defibrϋlation therapy, the electrodes placed substantially near the atrium, such as electrode 57, may be carried on the same electrical lead 52 as an electrode placed substantially near the ventricle, such as electrode 54, on the same side, because the electrode positioning near the atrium is less critical than the ventricle positioning. Accordingly, the positioning of electrodes near the atrium may be adjusted depending upon other factors, such as pacing requirements or battery constraints, for example.
FlG. 9D illustrates another embodiment of an implantable cardiac stimulation system including two electrodes 53, 55 carried by a single electrical lead 52. One electrode 55 is implanted in the left tertiary bronchus in proximity to the left ventricle and the other electrode 53 is implanted proximaliy at a position within the left bronchus. In this embodiment, the second proxirnally positioned electrode 52 is implanted within the left primary bronchus 32, This embodiment may be operable to perform cardiac pacing, such as dual pacing or single ventricular pacing performed by electrode 55 and sensing performed by electrode 53. This embodiment may further be operable to provide atrial fibrillation therapy, such as by anti- tachycardia pacing therapy to the left atrium and an optional defibrillation pulse signal to treat (i.e., stop) atrial fibrillation. In certain embodiments, proximaliy positioned electrode 53 may serve as the reference electrode when delivering the defibrillation signal. In alternative embodiments, an electrode associated with the pulse generator 51 or the anchor device be employed instead of the electrode 53 positioned within the right primary bronchus.
The electrode configurations illustrated in FIGS. 2 and 9A-9D are exemplary, and other electrode placements within the bronchi or trachea, or any combinations of those described herein, may also be employed to perform cardiac stimulation and/or sensing. Moreover, in other embodiments, electrodes posrtϊonable in a patient's airway may be used in combination with conventionally implanted electrodes, such as transvenous electrodes, epicardial electrodes, or epidermaliy placeable electrodes. In one embodiment (not shown), conventional transvenous leads may be used to perform sensing, right or left side pacing, and/or defibrillation, while airway implanted leads may be use to perform ventricular pacing of the opposite side. Sensing Function
As described with reference to various embodiments, the implantable cardiac stimulation system may be operable to perform sensing functions as well as electrical stimulation. Physiologic electrical activity, such as electrical potential, impedance, or other physiological parameters of the heart and/or lungs for example, may be measured by the implantable cardiac stimulation system. In one embodiment, one or more electrodes and the pulse generator may be operable to perform the physiological electrical activity sensing, in addition to or instead of electrical stimulation described herein. In another embodiment, the system may include one or more sensors operable for performing mechanical measurements, such as flow, pressure, temperature, acceleration, or strain, for performing optical measurements, such as imaging, absorption, or fluorescence, or for performing ultrasonic imaging, or any combination thereof. Furthermore, one electrode may be operable to perform both sensing and electrical stimulation functions, thus reducing the number of electrodes and electrical leads implanted within the airway. As described herein, with reference to FIGS. 2 and 9A-9D for example, in one embodiment of the invention, at least one electrode operable for sensing may be positioned away from the heart to serve as a counter electrode for measuring cardiac electrical activity, such as electrical impedance, between one or more other electrodes implanted in various positions within the airway. In another embodiment, ventricular tachycardia may be detected by monitoring electrical activity of the left ventricle or alternatively the right ventricle,
In addition to monitoring cardiac electrical activity, one or more other sensors may be carried by an electrical lead for sensing mechanical activity of the heart or the lungs. For example, one or more sensors, such as an accelerometer, a strain gauge, a pressure transducer, or other sensors suitable for measuring position or movement, located within the bronchi in close proximity to the heart, may sense movements resulting from various sources, including lung movement during breathing, peritoneal diaphragm movement, and cardiac contractility. Because the lungs are mechanically coupled to the heart, cardiac movement, such as cardiac contractility, may be measured by sensing lung movement. Lung movement caused by breathing is characterized by relative slow acceleration compared to cardiac contraction and may be filtered out of the measurements through signal processing, such as filtering, to isolate cardiac movement. The signal processing may be performed by the pulse generator or other electrical circuitry existing within the controller housing or external to the patient. Measuring cardiac movement may be useful for detection of atrial fibrillation, ventricular fibrillation, bradycardia, or myocardial infraction, for example. Furthermore, measuring cardiac movement can help detect uncoordinated motion of the heart chambers (e.g., the ventricles) during pacing or other electrical stimulation therapy. In some embodiments, a feedback loop may be applied by the pulse generator between the sensed signal received by the controller that represents mechanical movement and the generation of electrical stimulation signal to the same or other electrodes implanted within the airway. A feedback loop may provide increased control over cardiac contractility synchronization by the implantable cardiac stimulation system. For example, certain operating parameters may further control synchronization, such as the delay between the left and right side contraction of the heart, the delay between atrial and ventricular contraction, synchronization of a ventricle by applying more than one electrical stimulation to more than one area on the ventricle, optimizing the stimulation signal, such as the amplitude, width, or shape, or selecting excitation and counter electrode configurations and positions. By delivering electrical leads through the airway, access and proximity is provided to other systems, such as the aorta, the pulmonary vein, the pulmonary artery, the diaphragm, or the phrenic nerve, which are otherwise primarily accessible only through complex, invasive procedures like subcutaneous or intravascular delivery. Accordingly, other physiological parameters, such as cardiac output, blood flow, or blood pressure, for example, may be sensed, or other therapy may be provided, such as respiratory paralysis, using electrical leads delivered through the patient's airway as generally described herein.
In one embodiment, an electrical lead carrying an ultrasonic sensor may be acoustically coupled to one or more of the aorta, pulmonary vein, or pulmonary artery by positioning within the bronchi in close proximity thereto. In another embodiment, a sensor may be carried by an electrical lead delivered through the airway, but may further be invasively implanted within the lung tissue, a cavity of the lung pleura, a cavity of pericardium, the heart epicardium, the cardiac muscle, or the heart chambers, for example, by penetrating the wall of the airway and physically implanting the sensor within the tissue. In one embodiment, the distal tip of the electrical lead or sensor may include a needle or probe to pierce the airway wall and secure the sensor in the tissue. However, in other embodiments, the electrical lead may be secured at least partially in the airway by anchoring means as described herein while the needle or probe pierces the airway wall and extends into the tissue. As described in reference to other embodiments, the electrical lead and sensor may be guided to the implantation site using imaging techniques, such as fluoroscopy, computed tomography, magnetic resonance imaging, x-ray, ultrasound, position emission tomography, as are known. In some embodiments, the needle or probe tip may include one or more sensors for sensing parameters, such as cardiac electrical activity, cardiac contractility, blood pressure, blood flow, cardiac motion, oxygen, or the like. A needle or probe tip may further or alternatively include an electrical stimulation electrode operable for providing electrical stimulation therapy as described herein. In one embodiment, the needle or probe tip for piercing the airway may have a relatively small diameter, such as approximately 0.1 mm to approximately 4 mm, and in some embodiments less than approximately 2.5 mm, to reduce the risks of pneumothorax, which may result from air or gas accumulating in the pleural cavity. In another embodiment, the airway may be used to position one or more electrodes for stimulating systems or organs such as the diaphragm or the phrenic nerve. For example, the phrenic nerve may be stimulated to activate the diaphragm or the diaphragm may be directly stimulated, to provide therapy to patient's suffering from respiratory paralysis (for example due to a lesion in the central nervous system or in the phrenic nerve). Because the phrenic nerve runs from the neck to the diaphragm, and is in substantially close proximity to the lungs, implanting electrodes within the airway provides close access thereto. Furthermore, electrodes implantable within the lower branches of the bronchus also provides close access to the diaphragm. Accordingly, a system including one or more electrodes implantable within the airway and in close proximity to the phrenic nerve and/or the diaphragm may be operable to deliver electrical stimulation to perform diaphragm pacing. As further described herein, the one or more electrodes for diaphragm pacing may be in electrical communication with an implantable pulse generator, or may be in electrical communication with pulse generator positioned external to the patient.
III. Method of Implanting a Pulse Generator in an Airway In exemplary' embodiments, the method of use of the stimulation systems described herein may include at least one electrode implantable within a patient's airway, for example the trachea, the primary, secondary, or tertiary bronchus, the bronchioles, or any branch thereof, and a pulse generator implanted within the trachea, the primary bronchus, or both. Various techniques may be performed to implant the electrode or the pulse generator within an airway. For example, techniques similar to those used to perform a bronchoscopy, laryngoscopy, tracheal intubation, or percutaneous catheterization may be performed to position and implant the electrodes or the pulse generator.
The method begins at block 1010. At block 1010, the controller housing containing the pulse generator is implanted in the patient within the trachea or a bronchus, such as the right or left primary bronchus. The controller housing may be inserted through the patient's oral or nasal cavity and delivered to the trachea or the right or left primary bronchus. In one embodiment, such as described herein with reference to FIG. 7, the controller housing may be positioned partially within the trachea and partially within one or both of the primary bronchi at the bronchial bifurcation. The controller housing may be any controller housing operable to perform electrical stimulation or sensing of cardiac, pulmonary, or any other physiologic functions, such as those described herein with reference to FIGS. 3A-3F, 4, and 6A-6B. The controller housing may be implanted using similar procedures as those which may be used to deliver and position an electrode, as described herein. The controller housing may be delivered and positioned using procedures similar to those performed for tracheal intubation. The controller housing is anchored within the airway to retain the housing at the selected position. The controller housing may further include one or more sensing or stimulation electrodes associated with the casing or the anchor device. Accordingly, anchoring may further serve to improve electrical coupling of any controller housing or anchor electrodes. The control ler housing may be fixed within the airway by an anchor device, such as those described herein with reference to FIGS. 3A-3F.
Following block 1010 is block 1012, in which at least one electrode carried by at least one lead is positioned at a selected position (also referred to as an "implantation site") within the trachea, the primary, secondary, or tertiary bronchus, the bronchioles, or any branch thereof. The electrode may be inserted through the patient's oral or nasal cavity, and delivered through the trachea and bronchi to the selected implantation site. The electrode may be any suitable design, such as those described herein with reference to FIGS. 8A-8G.
Each electrode positioned within the airway may be fixed within the airway to retain the electrode at its selected position site and to improve electrical coupling. The electrode or electrodes may be fixed within the airway by an anchor device, such as the embodiments described herein with reference to FIGS. 8A-8G. Each electrical lead carrying an electrode is attachable to the pulse generator to enable electrical communication therebetween. The electrical lead may be attached prior to implantation, during implantation, or after implantation of the electrodes and/or controller housing (e.g., the pulse generator). Furthermore, in one embodiment, the electrical lead may be permanently integrated within the controller housing, and thus permanently attached. The electrical lead or leads optionally may be fixed within the airway by a lead securing member, such as the embodiments described herein with reference to FIGS. 8H-8K.
Although FIG. 10 describes an example method of implanting a putse generator within the airway, the pulse generator may be implantable subcutaneousiy rather than within the airway as described herein, for example with reference to FIGS. 19-21.
FlG. 11 illustrates a flowchart 1 100 describing one method for implanting at least one electrode of an implantable cardiac stimulation system within the airway of a patient, for example trachea, the primary, secondary, or tertiary bronchus, the bronchioles, or any branch thereof, according to certain embodiments, such as those described herein with reference to FIGS. 2, 8A-8K, and 9A-9D.
The method begins at block 11 10. At block 1110, access is provided to a patient's trachea for subsequent insertion of one or more delivery devices and one or more electrical leads each carrying at least one electrode or other sensor. Access may be provided by inserting an access lumen, for example, an endotracheal tube, such as those used when intubating a patient, an endoscope, such as those used when performing bronchoscopies or laryngoscopies.
Moreover, the access lumen may be inserted orally or nasally. This method may be performed while the patient is under general anesthesia, regional anesthesia, or local anesthesia. In some embodiments, the access lumen may serve multiple functions, for example, to aid in providing mechanical ventilation and to provide an access path to one or more desired implantation sites within the airway.
Following block 1112 is block 1114, in which the delivery device is guided to and positioned substantially near the selected position for implantation. As described herein, the selected implantation site may be at any path within the patient's airway, such as the trachea, primary, secondary, or tertiary bronchus, or the bronchioles. In exemplary embodiments, the optimal implantation site for performing electrical stimulation may not be the optima! site for performing sensing. In this situation, a compromise implantation site may be selected, the site correlating to the most important function (e.g., the optimal stimulation site) may be selected, or separate stimulation and sensing electrodes may be implanted. As described herein, the two electrodes may be carried by the same electrical lead or may be carried by individual electrical leads.
One or more imaging techniques may be used to assist guiding the delivery device to the implantation site. Representative examples of suitable imaging techniques include bronchoscopy, bronchography, fluoroscopy, computed tomography, magnetic resonance imaging, x-ray, ultrasound, or position emission tomography. The delivery device optionally may include a radiopaque coating or a radiopaque component, as known in the art, to increase visibility and aid in delivery using certain imaging techniques. Other navigation techniques may also be used to aid in delivery. One technique may include the delivery technology developed by superDimension, Ltd. (Herzelia, Israel) known as the inReach System™, which includes a catheter with a magnetic tracking device calibrated with a computed tomography scan of the patient, allowing for the computed tomography data to assist in guiding the catheter to the implantation site. Another example technique may include the location technique developed by MediGuide, Ltd. (Haifa, Israel) known as the Medical Positioning System™, which includes a catheter or other delivery device having a miniaturized sensor and enables three-dimensional tracking of the device's position. Yet another example guiding technique may include a mapping electrode within the delivery device, such that the mapping electrode may be used to aid in selection of the implantation site. For example, electrical coupling of an electrode, electrical impedance over a wide range of frequencies, and electrical coupling at multiple positions within the airway may be mapped to identify optimal implantation sites. In one embodiment, one of the electrodes intended to be used for ultimate stimulation and/or sensing may also be used as the mapping electrode, leaving the electrode in place. In another embodiment, an additional mapping electrode may be used with the delivery device and removed prior to positioning and fixing the system electrode or electrodes. For example, a mapping electrode or other sensor may detect one or more intrinsic signals generated by the heart, such as electrical activity or acoustic signals. The mapping electrode may be integrated with the implantable electrical lead or with the delivery device. Additional guiding techniques, such as measuring the electrical threshold for stimulating the heart or a specific portion thereof. For embodiments that measure the electrical threshold, an algorithm may determine the stimulation gradient, for example by calculating the derivative of the measured threshold along its path. Block 1 1 16 follows block 1 114, in which the electrical lead carrying the one or more electrodes is inserted through the delivery device after the delivery device has been positioned at or near the desired implantation site. As previously described, the delivery device may have a lumen through which the electrical lead may be inserted, such as a catheter. As previously described, the delivery device may be integrated with the electrical lead and electrode, such that delivery and positioning of the delivery device also delivers the electrical lead and electrode. For example, a delivery device may include a first catheter delivered through the airway to the implantation site, and a second catheter housing the electrical lead and electrode therein, which is delivered through the first catheter. Accordingly, the delivery device, in some embodiments, may be integrated with the electrical lead and electrode, and all or some of the steps described at blocks 1 1 14-1 1 18 may be performed concurrently.
At block 1 1 18, following block 1 116, the electrical lead may be advanced through the delivery device to or substantially near the selected implantation site. As described with reference to insertion/positioning of the delivery device, the method optionally may include imaging techniques or other guiding technologies to assist in delivery of the lead to identify the location of the electrode and its proximity to the selected implantation position.
Block 1 120 follows block 1 118, in which the electrode may be anchored within the airway lumen at the selected implantation position. Any of the described anchor devices may be used to assist anchoring and retaining the electrode at or near the implantation site, such as those described with reference to FIGS. 8A-8G. For example, an electrode embodiment as described with reference to FIGS. 8E and 8F delivered through a catheter or other lumen will have the two or more electrode sub-components compressed within the lumen and the expandable connector under tension during delivery through the delivery device. Upon positioning the electrode at or near the implantation site, the delivery device is removed, which releases the tension on the expandable connector and causes the electrode sub-components to expand radially in contact with the inner walls of the airway at the selected implantation site. In other electrode embodiments, the anchor devices may require additional action, such as mechanically extending rigid radially extensible members, inflating a balloon or a balloon sleeve, applying heat, radio frequency, electrical, or other energy to change a shape memory alloy-based anchor device, suturing, or stapling, for example. In yet other embodiments, the electrode anchor device may by design anchor without additional action, such as anchor devices configured as hooks, barbs, studs, or adhesive, or anchor devices having a diameter the same as or slightly larger than the inner wall of the airway that lodge within the airway. Optionally, one or more lead securing members may be used to assist retaining the electrical lead within the airway, such as is described with reference to FIGS. 8H-8K.
Blocks 1 122 and 1124 follow block 1120, in which the delivery device and the access lumen are removed upon positioning and fixing the electrode or electrodes. However, in some embodiments, the access lumen and/or the delivery device may be used during implantation of the controller housing (if not implanted prior); thus, the removal steps occurring at blocks 1 122 and 1 124 may occur subsequent to delivery and implantation of the controller housing.
As described herein, the electrical leads may be attached to the controller housing prior to delivery of the electrical leads, or they may be free from the controller housing and attached subsequent to delivery of the electrical leads either before or after delivery of the controller housing. Accordingly, in some embodiments, upon removing the delivery device and the access lumen, the electrical leads may temporarily extend out of the patient's oral or nasal cavity until subsequent attachment to and implantation of the controller housing. Though, in some embodiments, the electrical leads may be retained entirely within the patient's airway, such as when the controller housing is implanted prior to the electrical leads or otherwise. FIG. 12 illustrates a flowchart 1200 describing one method for implanting a controller housing containing a pulse generator of a cardiac device within the airway of a patient, for example the trachea or the left or right primary bronchus, such as described herein with reference to FIGS. 2, 3A-3F, and 9A-9D. This method may include steps similar to those described with reference to FIG. 1 1 for implanting one or more electrodes. The example method begins at block 1210. At block 1210 access is provided to a patient's trachea for subsequent insertion of one or more delivery devices and the controller housing. Access may be provided by inserting an access lumen, for example, an endotracheal tube, such as those used when intubating a patient, an endoscope, such as those used when performing bronchoscopies or laryngoscopies. Moreover, the access lumen may be inserted orally or nasally. This example method may be performed while the patient is under general anesthesia, regional anesthesia, local anesthesia, or performed without anesthesia.
Block 1212 follows block 1210, in which a delivery device may be inserted through the access lumen. The delivery device may be any device suitable for providing access of a medical device into a lumen of the body, such as those described with reference to FIG. 1 1. In one embodiment of the method, the delivery device may be a series of catheter systems, by which a first catheter aids in the placement of a second catheter that may carry the controller housing, for example, In another embodiment, however, the delivery device may include a guidewire or other supporting device first inserted through the access lumen and a second catheter or other device carrying the controller housing that slides over the guidewire. In yet another embodiment, the delivery device may be a single catheter carrying the controller housing directly to the implantation site without the use of a guidewire or additional catheter. This embodiment may best be used when the implantation site is within the patient's trachea because the site is relatively close to the patient's oral or nasal cavity, larger in diameter, and may be visible during implantation, Following block 1212 is block 1214. in which the delivery device is guided to and positioned substantially near the desired implantation site. The implantation site may be at any point within the patient's airway, such as the trachea or the right or left primary bronchus. In one embodiment, in which the pulse generator includes one or more electrodes on the housing or anchor device, the electrode may optionally be used to identify desired implantation site based at least in part on stimulation or sensing functioning as described above. Furthermore, one or more imaging techniques, for example those described with reference to FIG. 1 1, may optionally be used to assist guiding the delivery device to the implantation site.
Block 1220 follows block 1218, in which the controller housing is fixed within the airway lumen at the selected implantation position. Any of the anchor devices described herein may be used to assist fixing and retaining the controller housing at or near the implantation site. such as those described with reference to FIGS. 3A-3F or those described with reference to FIG. 11 for implanting an electrode.
Upon positioning and implantation at least one or more electrodes within the patient's airway, the functionality, position, and/or electrical coupling of each electrode may be tested. FIG. 13 illustrates a flowchart 1300 describing one method for testing at least one of the positioning, functionality, or electrical coupling of each electrode subsequent to implantation. The method begins at block 1310. At block 1310, the electrode testing procedures for testing at least one of the positioning of the electrode, the functionality of the electrode, or the electrical coupling of the electrode begin subsequent to implanting the electrode within a patient's airway. This step may include attaching the proximal end of the electrical lead carrying the implanted electrode to external testing electrical circuitry, software, and/or hardware. In other embodiments, the electrical lead may be attached to the controller housing prior to its implantation and the pulse generator may be used at least partially during the testing procedures. While the flowchart 1300 illustrates performing the testing procedures subsequent to implantation of each electrode, the testing procedures may be performed after all electrodes have been implanted, after the controller housing has been implanted, or at any other suitable stage in the implantation methods subsequent to implanting the electrode being tested.
At decision block 1312, it is determined whether the electrode is properly positioned. This determination may be performed using any of the imaging techniques, guiding techniques, or electrical signal monitoring described herein. If it is determined that the electrode is not positioned properly, then block 1314 follows, in which the electrode may be repositioned according to any of the electrode placement methods described herein, such as those described with reference to FIG. 11. Alternatively, if it is determined that the electrode is positioned properly, then block 1316 follows. At decision block 1316, it is determined whether the electrode is properly functioning. This determination may be performed using externally located testing circuitry, electronic controllers, software, hardware, or the like, as is suitable for performing electrode testing. Electrode functions, such as conductivity, electrical stimulation functioning, or sensing functioning, may be tested by this procedure. For example, whether the electrode stimulation is within a pre-defined acceptable range, or whether the electrode stimulation threshold is stable. Further, safe operation may be tested at this stage as well. If it is determined that the electrode is not functioning properly, then block 1318 follows, in which the electrode may be adjusted, repaired, or replaced. Alternatively, if it is determined that the electrode is functioning properly, then block 1320 follows.
At decision block 1320, it is determined whether the electrode is sufficiently electrically coupled with the tissue at the selected implantation site. Similar to testing the functionality, external hardware, software, and/or the pulse generator may be used to perform the electrical coupling testing. In one example, the electrical impedance is measured between the implanted electrode and another electrode operating as a reference electrode, and using electronic circuitry, such as a resistance-capacitance- inductance meter, as known in the art. If it is determined that the electrode is not properly coupled, then block 1322 follows, in which the electrode may be re- anchored, repositioned, repaired, or replaced. Alternatively, if it is determined that the electrode is coupling properly, then block 1324 follows. At block 1324 the testing procedures are completed and subsequent implantation steps may be performed as necessary, such as implanting additional electrodes, the controller housing, or attaching the electrical leads to the housing, as is described herein with reference to FIGS. 10- 12, for example.
In another embodiment, a controller housing including a pulse generator may be implantable at a subcutaneous location within the patient, and at least one electrical lead carrying at least one electrode fixable within the trachea or bronchi, may pass through, or communicate wirelessly at, an area of the patient's trachea or a primary bronchus. FlG. 14 illustrates one embodiment of an implantable cardiac stimulation system having a controller housing 140 including a pulse generator 141 implantable subcutaneously and at least one electrode implantable within the bronchi. Thus, the cardiac device of this embodiment minimizes the components implanted within the airway, but does require an invasive surgical procedure for implantation of the controller housing 140. For example, the controller housing 140 may be surgically implanted approximately in a patient's pectoral region and a subcutaneous tunnel formed from the controller housing 140 to the patient's trachea or primary bronchus. In other variations of this embodiment, another subcutaneous location may be selected as the implantation site for the controller housing.
The pulse generator 141 of this embodiment may be operable to perform some or all of the same functions described herein, such as those with reference to FlG. 2 describing a pulse generator implanted within an airway. For example, the pulse generator 141 may perform electrical stimulation through the one or more attachable electrical leads and electrodes, such as is used to perform atrial cardiac pacing, ventricular cardiac pacing, dual chamber cardiac pacing, cardiac ^synchronization therapy, cardioversion, and/or defibrillation. The pulse generator 141 may be operable to sense or measure cardiac electrical activity, other cardiac activity, and/or other physiological parameters. As used with this embodiment, the pulse generator 141 may be a conventional implantable pulse generator suitable for subcutaneous implantation, as is commercially available; which may also commonly be referred to as an "implantable pulse generator" or an "implantable cardioverter-defibrillator." However, the electrical circuitry, software, and hardware of the pulse generator 141 may be altered or adapted for operation with electrodes implantable within the airway, as compared to conventional implantable pulse generators used with electrodes in direct contact with the heart. The controller housing 140 may be proportioned to have a substantially flat shape to ease placement subcutaneously and avoid discomfort to the patient. The controller housing 140 may be hermetically sealed, electrically isolated, biocompatible, in order to operate safely and to withstand the biological environment within which it may be implanted.
The pulse generator 141 is electrically coupled to at least one electrical lead 52, carrying at least one electrode. The electrode or electrodes may be positioned at or near the distal end of the electrical leads 52, as illustrated in FlG. 14, However, in other embodiments, an electrode may be positioned at another point distanced from the lead's distal end. The device illustrated in FIG. 14 may include six electrodes 54, 55, 56, 57, 58, 59 implantable within the bronchi, each connected to a different electricai lead 52, in a similar manner as is described with reference to FlG. 2. In another embodiment, the pulse generator 141 may be operated in combination with one or more airway implanted electrodes and with one or more conventionally implanted electrodes, such as transvenous electrodes, epicardial electrodes, or epidermally placeable electrodes.
A subcutaneous tunne!, through which the one or more electrical leads 52 may pass, may be surgically formed between the controller housing 140 implantation site, for example near the pectoral region, and a junction 142 at the trachea or the left or right bronchus. As illustrated, the electrical lead or leads 52 may pass through one or more apertures formed in the trachea 20 or the left or right primary bronchus 30, 32 at the junction 142 and into one or more locations within the airway. Alternatively, rather than passing through an aperture, the electrical lead may communicate wirelessly across the junction 142. In the embodiment illustrated in FIG 14, a single lead 52 may be coupled to the pulse generator 141 and split into multiple leads carrying each electrode 54, 55, 56, 57, 58, 59 to respective selected implantation positions within the airway, In other embodiments, however, each electrode may be carried by individual leads, which may be optionally bundled to ease the passage through an aperture, or simplify wireless communication, at the junction 142. The electrical leads 52 used in these embodiments may be substantially similar to other electrical leads described herein. The embodiment illustrated in FIG. 14 is provided for exemplary purposes; other electrode and controller housing positioning and configurations are envisioned. For example, the electrodes may be positioned at any selected electrode position, as illustrated in FIGS. 9A-9D,
In one embodiment, the trachea or the left or right primary bronchus may be penetrated and one or more apertures may be formed therethrough for passing at least one electrical lead carrying at least one electrode from the subcutaneously implanted controller housing and into the bronchi. In one embodiment including multiple implantable electrical leads, an aperture for each electrical lead may be formed in the trachea or the left or right primary bronchus, to reduce the aperture sizes and to reduce the friction caused within each aperture to minimize stresses caused on the electrical lead or on the airway wall, A cannula may optionally be implanted in the wall of the trachea or bronchus to aid in sealing the thoracic cavity from the airway, exclude the passage of air, biological contaminants, or biological fluids therebetween, provide structural integrity to the aperture in the airway wall, house the electrical leads to ease movement therethrough, and reduce irritation, inflammation, or infection where the electrical leads may otherwise contact the trachea or bronchus wall. In some embodiments, however, the cannula may not be implanted in the trachea or bronchus wall, but may be affixed to the inner or exterior wait of the trachea or bronchus and around the aperture formed therein. The cannula may be formed in any shape suitable to be implanted in the trachea or bronchus and to permit one or more electrical leads to pass therethrough, such as tubular, sleeve-like, disk-like, or elliptical, for example. The cannula may be constructed from any biocompatible materials suitable for subcutaneous implantation and to provide at least partial rigidity and structural support in the passage, such as metals, polymers, or any combination thereof. Furthermore, in an embodiment having multiple apertures formed in the airway wall, cannulae may be dimensioned to position an individual cannula in each aperture. FIG. 15A illustrates one example of a cannula useful with the systems and methods described herein. The cannula 144 may be formed as a sleeve or conduit, having an outer surface 146 and an inner surface (not shown) existing within the cannula 144, and defining an orifice 148 extending therethrough. In one embodiment, the inner diameter of the cannula 144 may range from about 1 mm to about 4 mm, to allow for passing one or more electrodes therethrough. In another embodiment, the cannula 144 may have multiple orifices for passing individual leads therethrough, such that each individual orifice may have a diameter of about 1 mm to about 4 mm. In one embodiment, the length of the cannula 144 may range from approximately 0.5 mm to about 3 mm, which may generally depend upon the configuration of the cannula 144 and the actual trachea or bronchus wall thickness, although the cannula 144 dimensions may depend upon the size of the passage, which may ultimately depend, for example, upon its position, the size of the patient, or the number of electrical leads to pass therethrough. The cannula 144 may optionally include a first flange 150 and a second flange 152 extending radially from opposite ends of the cannula. The first and second flanges 150, 152 are positionable positioned against the inner wall and the outer wall of the airway to aid in retaining the cannula 144 implanted in the passage and to aid in sealing the thoracic cavity from the airway environment. The first and second flanges 150, 152 may further have a preformed curvature approximating that of the curved surfaces of the inner trachea and outer trachea, respectively, to aid in sealing, retention, and/or comfort.
In various embodiments, the cannula 144 may further include an inner membrane 154 extending between at least one of the flanges 150, 152 and across the orifice 148, having one or more slots or apertures 156 formed therethrough. The aperture 156 may be dimensioned to have approximately the same or slightly smaller diameter as the electrical lead or leads intended to pass therethrough, such that the aperture 156 forms at least a partial seal around the electrical lead or leads. The inner membrane 154 allows passage of the electrical leads and provides further isolation between the environments. The inner membrane 154 may be formed from any biocompatible elastomeric materia! suitable for subcutaneous implantation, such as elastomeric polymers, for example. Though not shown, two inner membranes 154 may be included, one on each end of the cannula and extending between each flange 150, 152.
FIG. 15B illustrates another embodiment of a cannula useful in the systems and methods described herein. Cannula 121 may be configured in a manner similar to that illustrated by FIG. 15A but including two interconnecting sleeves (or interconnecting flanges), an inner sleeve 123 adapted for implantation in the trachea or bronchus from the interior and an exterior sleeve 125 adapted for implantation from the exterior of the trachea or bronchus. In one example, the inner sleeve 123 may have an exterior diameter substantially the same or slightly smaller than the inner diameter of the exterior sleeve 125 to allow for slidably connecting them. Each of the inner sleeve 123 and exterior sleeve 125 may have flanges extending radially therefrom, one or more orifices extending therethrough, and/or one or more membranes or sealing rings, as described with reference to FIG. 15 A. Slideably connectable sleeves 123, 125 forming a cannula may adjustably compensate for trachea or bronchus wall thickness, thus improving the seal formed by the cannula 121. A cannula 121 configured in this manner may be implanted in the aperture in manners similar to those described herein with reference to FIGS. 16A-16C or 17A- 17B. FIGS. 16A-16C illustrate a cross section of one embodiment of cannula 144 that may optionally be implanted within the wall of the trachea or primary bronchus at a junction 142, and represent exemplary stages in one method for implanting the cannula 144, FIG. 16A illustrates an initial stage during the implantation of the cannula 144 within the airway. The cannula 144 may be implanted during, or subsequent to, forming an aperture or passage in the trachea 20, such as by using a tunneling device, needle, or wire 158. In some embodiments, the aperture may be formed with the tunneling device 158 through the wall and between the cartilage rings 160 of the trachea 20. If necessary or desired, the diameter of the aperture may be increased using a fenestrator, catheter tip, blade, tunneling device 158, or other suitable device for forming and/or opening an aperture in a human lumen. Subsequent to opening the aperture to the desired size, a cannula delivery device 162, such as a catheter or other elongated lumen for delivery, may be inserted through the aperture and advanced into the airway of the trachea 20. The catheter may be inserted through the aperture over the tunneling device 158, or the tunneling device 158 may be removed prior to insertion of the cannula delivery device 162.
FIG. 16B illustrates a cross section of the cannula 144 during another stage of the implantation method. In this embodiment, the cannula 144 may formed from pliable materials and compressed within the delivery device 162 for delivery to the trachea 20. FIG. 16B illustrates the cannula 144 partially disposed within the distal tip of the delivery device 162 and partially released such that the first flange 150 is expanded radially within the airway of the trachea 20 and the second flange 152 remains compressed within the delivery device 162. FIG. 16C illustrates a cross section of the cannula 144 implanted in the trachea 20 wall after removing the delivery device 162. Properly implanted, the first flange 150 is positioned substantially against the inner wall of the trachea 20 and the second flange 152 is positioned substantially against the exterior wall of the trachea 20. Accordingly, the first and second flanges 150. 152 serve to retain the cannula 144 in the trachea wall, as well as provide an additional barrier between the two environments (e.g., one sterile, one non-sterile), ϊn one embodiment, the cannula 144 may include an anchor device for retaining the cannula 144 in place, similar to certain devices described herein with reference to certain controller housing or electrode embodiments, such as one or more hooks, barbs, studs, suture, staples, or adhesive.
FIGS. 17A-17B illustrate a cross section of one embodiment of a cannula that may optionally be affixed to the inner or exterior wall of the trachea or bronchus around an aperture formed therein, and represent exemplary stages in a method for implanting the cannula. FIG. 17A illustrates a cannula 164 integrated with an electrical lead 52, such that the electrical lead 52 passes through the cannula 164. This cannula 164 may be formed in a disk-like shape having an orifice extending therethrough. The cannula 164 may serve as a flange for mounting or affixing to the inner wall of the trachea 20 around the aperture. Similar to the cannula described with reference to FIG. 15, an inner membrane may also extend across the orifice for retaining the electrical lead or leads and to provide an additional seal. The electrical lead 52 may sϋde within the cannula 164 to allow for adjustment and freedom of movement during positioning and implantation of the electrode, the controller housing, and the cannula. The cannula 164 may further include one or more anchor devices 166, similar or identical to other anchor devices described herein.
FIG. 17B illustrates the cannula 164 anchored to the inner wall of the trachea 20 by anchor devices 166. As is shown, the electrical lead passes from within the airway, through the cannula 164, and to a subcutaneous Iy implanted controller housing. In another embodiment, the cannula 164 may be affixed to the exterior wall of the trachea, and the electrical lead 52 and electrode may be implanted by passing the delivery device 162 through the cannula 164 and into the airway, and passing the electrical lead 52 therethrough to the selected implantation position within the bronchi.
While the embodiments described in FIGS. 16A-16C and 17A-17B include implanting a cannula in the trachea, in other embodiments, a cannula may be implanted at a point in the bronchus, for example the left primary bronchus or the right primary bronchus, using similar methods. Cannula designs and methods other than those described herein may be employed to aid in the retention of electrical leads and sealing the thoracic cavity from the airway. For example, certain embodiments may not include a cannula, but may allow the one or more electrical leads to pass directly through the aperture formed in the trachea or bronchus wall. Furthermore, in other embodiments, other means for sealing the aperture may be used, such as an adhesive, a membrane, suturing, or stapling, for example. In some embodiments in which one or more devices are passed from within the airway to a subcutaneous position within the body, contamination from within the airway may be prevented and/or treated to promote a more sterile environment. For example, in some embodiments, the electrode, electrical lead, cannula, or other device may be covered with a sterile sleeve prior to subcutaneous insertion from the trachea. In other embodiments, the electrode, electrical lead, cannula, or other device may be treated (e.g., coated) with an antimicrobial material, such as antiseptic and/or antibiotic agent. Furthermore, the patient may be treated with antibiotics, steroids, or other pharmaceutical agents systemically or by inhalation, prior to and/or after the implantation procedure. Devices, such as electrodes, leads, or a controller housing implantable within the airway may be similarly coated or treated to prevent infection and scarring within the airway.
As described, one embodiment may include a tissue interface adaptable for wirelessly communicating one or more electrical signals between the pulse generator and the electrodes implanted within the bronchi, rather than forming an aperture in the trachea or bronchus, FIG. 18 illustrates a cross section of an example tissue interface 170 operable for wireless communication, according to one embodiment of the invention. In one example, the tissue interface 170 may be formed as two components - an exterior interface 172 and an interior interface 174. The exterior interface 172 is adaptable to couple with one or more subcutaneous lead portions 176 attachable to a subcutaneous iy implantable controller housing. The subcutaneous lead portion 176 may be implantable within a subcutaneous tunnel formed between the implantation site of the controller housing, for example near the pectoral region, and a junction 142 at a point on the trachea 20 or bronchus 30, 32 for wirelessly communicating electrical signals to and from one or more airway lead portions 178 positioned within the airway. Accordingly, the airway lead portion 178 is adaptable to couple to the interior interface 174 at its proximal end. In another embodiment, the exterior interface 172 and the interior interface 174 may be integrated with the distal end of the subcutaneous lead portion 176 and the proximal end of the airway lead portion 178, respectively. The lead portions 176, 178 and the tissue interface 170 may be implanted by any implantation methods described herein.
Electrical signals may be wirelessly communicated across the tissue interface by electromagnetic induction, for example. However, other wireless means for transmitting electrical signals may be employed, such as radio frequency, ultrasonic, infrared, or other electromagnetic waves. For example, the exterior interface 172 and the interior interface 174 may each have a wireless transmitter and receiver operable to communicate wirelessly through protocol, such as radio frequency, microwave, infrared, for example. Further, in this embodiment, the interior interface 174 may include electronic circuitry, a power source, hardware, and/or software for receiving and transmitting wireless communications from and to the pulse generator, and for generating electrical stimulation pulses or performing sensing functions. Thus, in this embodiment, electrical stimulation or sensing functions may be divided, with at least some of the electrical stimulation signals being generated within the airway, for example within the interior interface 174 and at least some of the logic for determining timing, delay, magnitude, and the tike of signals occurring within the subcutaneously implanted pulse generator. Furthermore, at least part of the sensing functions may be performed within the airway and communicated wirelessly to through the tissue interface 170 to the controller housing.
In other embodiments, the electronic circuitry for performing stimulation and/or sensing may be integrated within or near the electrode carried by the airway lead 174, In yet other embodiments, at least one or both of the subcutaneous lead 176 or the airway lead 174 may be unnecessary. Instead, wireless communications may be sent directly from the pulse generator implanted subcutaneously (or implanted within the trachea or bronchus) to one or more electrodes implanted within the airway that includes electronic circuitry, a power source, hardware, and/or software for receiving and transmitting wireless communications and for generating electrical stimulation pulses and/or performing sensing functions.
V. Method of Implanting a Pulse Generator Subcutaneously In one aspect of the invention, the system may include at least one electrode implantable within a patient's airway, for example the primary, secondary, or tertiary bronchus, or the bronchioles, and a controlier housing containing a pulse generator implantable subcutaneously and external to the patient's airway. Various techniques may be performed to implant an electrode within the airway or to implant the controller housing subcutaneously. For example, techniques similar to those described herein with reference to FIGS. 10 and 11 may be performed to position and implant the one or more electrodes. Additional methods are described for implanting a controller housing subcutaneously, external to the patient's airway.
The method begins at block 1910. At block 1910 the controller housing is implanted subcutaneously. An incision may be made and the controller housing may be implanted in a manner similar to methods used for commercially available implantable controller housings, as are known. The controller housing may be any example controller housing operable to perform electrical stimulation or sensing of cardiac, pulmonary, or any other physiologic functions, such as the embodiment described with reference to FlG. 14.
Each electrode positioned within the airway is fixed within the airway to retain the electrode at the desired implantation site and to improve electrical coupling. The electrode or electrodes may be fixed within the airway in any manner described herein, such as with reference to FIG. 1 1.
Each electrical lead carrying an electrode may be coupled to the pulse generator to enable electrical communication therebetween. Accordingly, in one embodiment, an electrical lead delivered by way of a delivery device passing through the catheter may already pass through a subcutaneous tunnel created from the controller housing to the aperture in the trachea or bronchus, and may simply be attached to the controller housing if not already coupled, In another embodiment, however, the electrical lead may have been inserted orally or nasally into the airway. For this embodiment, the lead may be snared or otherwise pulled through the aperture formed in the trachea, through the subcutaneous tunnel, and attached to the subcutaneously implanted controller housing. This step is optional, and may not be required for certain embodiments. For example, in some embodiments, the electrical lead or leads may be permanently affixed to the controller housing. In other embodiments, wireless communication is used instead of electrical leads.
FlG. 20 illustrates a flowchart 2000 describing one method for implanting a controller housing of a cardiac device subcutaneously, for example at or near the pectoral region, according to another embodiment, such as described with reference to FIGS. 14-17.
Block 2012 follows block 201O5 in which a subcutaneous tunnel may be formed between the controller housing implantation site and a point on either the trachea or the bronchus, for example the left or right primary bronchus, using a tunneling device and procedure as known in the art. The subcutaneous tunnel allows one or more electrical leads to pass subcutaneously from the controller housing to the trachea or bronchus. Accordingly, the subcutaneous tunnel may have a diameter large enough at least for the electrical lead or leads to exist therein, and optionally large enough for an electrode delivery device, such as a catheter, to pass therethrough. The size of the subcutaneous tunnel may be adjusted by adjusting the size of the tunneiing device or by subsequent enlarging procedures using the tunneling device, for example.
At block 2018, following block 2016, a delivery device may be guided to and positioned substantially near the selected electrode implantation position within the patient's airway. In one embodiment, the delivery device is guided from the subcutaneous tunnel, through the aperture (and optionally the cannula), and into the airway to the implantation site. In another embodiment, however, the delivery device may be inserted orally or nasally. The delivery device may be guided and positioned substantially near the selected implantation site using methods similar to those described with reference to FIG. 11 describing electrode implantation. As described with reference to FlG. 113 the delivery device may optionally be positioned using imaging techniques or other guiding technologies.
Block 2020 follows block 2018, in which the electrical lead carrying the one or more electrodes is inserted through the delivery device, delivered to the implantation site, and the electrode is fixed therein. Upon positioning the delivery device at the implantation site, the electrical lead and electrodes may be fixed in the same manner as described with reference to FlG. 1 1. Upon implantation of the one or more electrodes, the delivery device may be removed, pulled through the trachea or bronchus aperture and subcutaneous tunnel or through the oral or nasal cavity, depending upon initial insertion method. Block 2022 follows block 2020, in which each electrical lead carrying an electrode is coupled to the pulse generator to enable electrical communication therebetween. The electrical leads may be coupled to the controller housing in the same manner as is described with reference to FlG. 19. This step is optional and may not be required for certain embodiments. For example, in some embodiments, the electrical lead or leads may be permanently affixed to the controller housing. In other embodiments, wireless communication may be used instead of electrical leads. At block 2024, following block 2022, the electrode testing procedures for testing at least one of the positioning of the electrode, the functionality of the electrode, or the electrical coupling of the electrode may be performed in the same manner as is described with reference to FlG. 13. Furthermore, if the embodiment includes an aperture formed in the trachea or bronchus and a cannula implanted therein, the positioning, stability, and seal of the cannula may be optionally tested at this step.
These steps need not be performed in the exact order as presented. For example, in some implantation methods, the electrodes may be positioned and anchored prior to implanting the controller housing. In another method, the electrical leads may be attached to the controller housing prior to implanting the controller housing, the electrodes, or both. In yet another method, the testing procedures may be performed after implanting each electrode or after implanting a cannula, for example. FIG. 21 illustrates a flowchart 2100 describing another suitable method for implanting a controller housing subcutaneously, for example, at or near the pectoral region, and pulling one or more electrical leads from within the trachea or bronchus, according to various embodiments, such as those described with reference to FIGS. 14-17.
The method may begin at block 2110. The steps performed at blocks 2110-21 17 may be performed in a substantially similar manner as the steps described with reference to blocks 2010- 2017 of FIG. 20. However, for the implantation method described with reference to FIG. 21 , the electrical leads may be implanted through an oral or nasal cavity, in a substantially similar manner as is described with reference to FIG. 11. Upon implantation, the electrical leads remain within the airway. Block 2118 follows block 21 17, in which a retrieval lumen, such as a catheter, and/or a retrieval tool may grasp the proximal end of the electrical lead within the airway and pull the lead through the aperture to attach to the subcutaneously implanted controller housing, such as is described with reference to FIGS. 17A-17B. An endoscope, such as a bronchoscope or laryngoscope, or other visualization, imaging, or guiding techniques, may aid in grasping and retrieving the electrical lead by the retrieval tool. As described above with reference to FIG. 20, in one embodiment, the trachea or bronchus may be penetrated from within the airway to form the aperture, rather than from within the subcutaneous tunnel. In another embodiment, the proximal end of the electrode or electrodes may remain external to the patient, for example passing out of the patient's oral or nasal cavity. The retrieval tool may be passed through the aperture from the subcutaneous tunnel and out of the same orifice, allowing the grasping or temporary coupling of the electrical lead to be performed externally. Upon grasping, the retrieval tool may be pulled through the aperture and the subcutaneous tunnel, for attachment of the electrical lead with the controller housing. In another embodiment, the retrieval tool may be initially inserted through the patient's airway, such as through the oral or nasal cavity, and then through the aperture into the subcutaneous tunnel for delivering the and attaching the electrical lead to the controller housing. In one embodiment including a cannula, such as the cannula described with reference to FIGS. 17A-17B, the cannula may be affixed to the inner or exterior wall of the trachea or bronchus when the electrical lead is pulled, as described more completely with reference to FIGS. 17A-17B. The steps performed at blocks 2120-2124 may be performed in a substantially similar manner as the steps described with reference to blocks 2022-2026 of FIG. 20.
Vl. Method of Electrically Stimulating a Heart
FIG. 22 illustrates a flowchart 2200 describing one method for stimulating a patient's heart using example implantable cardiac stimulation system as described herein, such as those described with reference to FIGS. 2, 9A-9D, and 14.
The method begins at block 2210. At block 2210, at least one electrode is positioned and fixed at a selected position within the patient's trachea, primary, secondary, or tertiary bronchus, bronchioles, or any branch thereof within a patient's airway. The one or more electrodes may be carried by one or more electrical leads, respectively, which are attached to a controller housing including a pulse generator implanted within the patient. The electrode and electrical lead may be positioned and fixed by example methods and devices described herein, such as those described with reference to FIGS, 8A-8K, 10, and 1 1.
1. An implantable system for stimulation of cardiac or other tissue, comprising: a controller housing comprising a pulse generator, said controller housing being adaptable for implantation subcutaneously or at a selected housing position within the trachea or the bronchus of a patient's airway; at least one electrical lead attachable to said pulse generator; and at least one electrode, which is carried by said at least one electrical lead, said at least one electrode positionable and fixable at a first selected position within the trachea, the bronchus, the bronchioles, or a branch thereof, of a patient's airway.
2. The system of claim 1, wherein said controller housing is adaptable for implantation subcutaneously, and further comprising a cannula adaptable for passage of said at least one electrical lead through a wall of the trachea or bronchus.
4. The system of claim 1, wherein said controller housing is adaptable for implantation subcutaneously, and further comprising a tissue interface for wirelessly communicating an electrical signal through a wall of the trachea or bronchus.
5. The system of claim 4, wherein said at least one electrical lead comprises a subcutaneous lead portion attachable to said pulse generator and adaptable to electrically communicate with said tissue interface external to said trachea or bronchus, and an airway lead portion carrying said at least one electrode and adaptable to electrically communicate with said tissue interface within said trachea or bronchus,
6. The system of claim 1, wherein said controller housing is adaptable for implantation at said selected housing position within the trachea or the bronchus, and wherein said controller housing is proportioned to substantially permit airflow through said airway about the selected housing position.
7. The system of claim 6, further comprising at least one anchor for fixing the controller housing at said selected housing position within said trachea or bronchus.
8. The system of claim 6, wherein said controller housing comprises at least two substantially rigid sub-cases and at least one flexible connector between each rigid subcase.
9. The system of claim 6, wherein said controller housing comprises an at least partially flexible casing.
10. The system of claim 6, wherein said controller housing comprises a reattachabiy detachable portion comprising a power source, a memory, a processor, electrical circuitry, or a combination thereof.
1 1. The system of claim 6, wherein said controller housing further comprises at least one electrode.
12. The system of any one of claims 1 to 1 1, wherein said pulse generator is operable to deliver one or more electrical pulses effective in cardiac pacing, cardiac defibrillation, cardioversion, cardiac resynchronization therapy, or a combination thereof.
13. The system of any one of claims 1 to 11, wherein said at least one electrode is further operable for sensing electrical cardiac activity.
14. The system of any one of claims 1 to 11, wherein said at least one electrical lead further carries at least one sensor operable to detect cardiac movement.
15. The system of any one of claims 1 to 11, further comprising a second electrode which is carried by a second electrical lead, said second electrode being positionable and fixable at a second selected position within the trachea, the bronchus, the bronchioles, or a branch thereof, of the patient's airway.
16. The system of any one of claims 1 to 1 1 , further comprising an anchor for securing said at least one electrode within said trachea, bronchus, bronchioles, or a branch thereof.
17. An endotracheal device comprising: a controller housing proportioned for implantation at a selected housing position within the trachea, the bronchus, or a combination thereof, of a patient's airway, and proportioned to substantially permit airflow through said airway about said selected housing position; and electrical circuitry operable to transmit an electrical signal to at least one electrode.
18. The device of claim 17, further comprising at least one electrical lead attachable to said controller housing, which carries said at least one electrode, said at Jeast one electrode implantable at a selected electrode position in said trachea, said bronchus, the bronchioles, or a branch thereof, of the patient's airway.
19. The device of claim 17, wherein said controller housing further comprises an anchor for fixing said controller housing at said selected controller position.
20. The device of any one of claims 17 to 19, wherein said electrical circuitry is operable to deliver to said at least one electrode one or more electrical pulses effective in cardiac pacing, cardiac defibrillation, cardioversion, cardiac resynchronization therapy, or a combination thereof.
EP20080756387 2007-06-13 2008-05-28 Implantable devices and methods for stimulation of cardiac or other tissues Withdrawn EP2170458A1 (en)
US94359307 true 2007-06-13 2007-06-13
PCT/US2008/064998 WO2008156982A1 (en) 2007-06-13 2008-05-28 Implantable devices and methods for stimulation of cardiac or other tissues
EP2170458A1 true true EP2170458A1 (en) 2010-04-07
ID=39642614
EP20080756387 Withdrawn EP2170458A1 (en) 2007-06-13 2008-05-28 Implantable devices and methods for stimulation of cardiac or other tissues
US (1) US20080312725A1 (en)
EP (1) EP2170458A1 (en)
WO (1) WO2008156982A1 (en)
See references of WO2008156982A1 *
US20080312725A1 (en) 2008-12-18 application
WO2008156982A1 (en) 2008-12-24 application