Patent Document

This application is a continuation of application Ser. No. 09/496,450 filed Feb. 2, 2000 (now abandoned), the disclosure of which is fully incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention generally relates to heart valve repair and replacement techniques and apparatus. More specifically, the invention relates to the repair of heart valves having various malformations and dysfunctions. 
     BACKGROUND OF THE INVENTION 
     The mitral valve depends on adequate apposition or alignment between the anterior and posterior leaflets along a relatively long surface area under high pressure conditions. Typically, the contact surface is about 12 mm in a direction perpendicular to the anterior-posterior direction and this provides little margin of safety. The leaflet margins are attached to numerous fine chords suspended from attachment points along the inner surface of the left ventricle. Although these attachments are often referred to as papillary muscles, there is often a very diffuse arc-shaped attachment for each of the groups of chords to the endocardial surface. Unfortunately, this anchor point (i.e., the inner wall of the left ventricle) must move with each heartbeat and so the distance between the attachment of the leaflet edges is constantly changing. The chordal lengths may also change—typically increasing with age and degeneration and the chords frequently do not lengthen in a symmetrical fashion. This leads to variations in their lengths at all-important points of coaptation. Chords may also rupture. In addition, the mitral annulus changes diameter with each heartbeat such that it surface area changes by about 40% with each systole. As the heart enlarges, the annulus of the mitral valve can enlarge as well. In short, there are many variables affecting proper functioning of the mitral valve. The anatomy, such as the leaflet length, the chordal length and the annular length/diameter can change. The attachment points can change as the ventricle changes shape. More importantly, all of these aspects can change simultaneously. For example, a patient may have ischemic mitral regurgitation which pulls the posterolateral valve attachments away from their natural coaptation points and leads to an opening in this area of the mitral valve. This can be further affected if the chordal lengths are changed by even minor degrees of degenerative disease. 
     Mitral valve pathology has changed remarkably since the origin of open heart surgery one generation ago. Initially, the most common pathology or condition was rheumatic mitral valve disease. This produced thickened, impliable leaflets with grossly deformed chords, or chordae tendinae, often combined with fusion of the two leaflets. This valve was not suitable for any type of plastic procedure and, accordingly, numerous valve prostheses were developed to replace the entire valve, i.e., the annulus, leaflets and chords. Now, except in centers with high rates of immigration from third world countries, rheumatic mitral valve disease is a relatively uncommon indication for surgery. Various forms of degeneration ranging from gross billowing of leaflets to relatively minor chordal lengthening as well as ischemic mitral valve pathology are most commonly encountered. Recently, it has become apparent that combinations of these two problems are relatively common. In both of these situations, the mitral valve leaflets are soft, pliable and can be retained over the long-term in various repair procedures. Unfortunately, despite the fact that the leaflet tissue is suitable for retention, mitral repair is performed for less than half of the cases where mitral regurgitation is the problem. In surgical centers where mitral repair is not practiced, valves are often discarded and replaced. 
     One main problem is that mitral valve repair technology has not kept pace with the change in mitral valve pathology. Mitral valve repair is more an art than a science and requires a constant interaction between visual inspection and post operative results, as evidenced by transesophageal echocardiography (TEE). Few surgeons or surgical centers are equipped for or capable of performing this type of work on a routine basis. Many surgeons only perform mitral annuloplasty with rings that reduce the diameter of the annulus. These rings may appear to be a solution for a variety of problems but are not ideal for many ischemic and degenerative disease conditions. 
     Despite many attempts, the homograft mitral valve replacement is not an operation which can be performed reliably. It could have potential advantages in third world countries or in cases of infection. Failures occur because of the unreliability of attachment of the chords to the left ventricle. It is not difficult to anchor the valve in the annulus. However, it is virtually impossible to ensure that the chords are correctly spaced inside the ventricle to produce a competent valve. Again, the inner surface of the ventricle is a moving surface and it is almost impossible to guarantee that a chord extending from a leaflet edge will be fixed in such a way that the anterior and posterior leaflets are reliably aligned during valve operation. 
     Various other repair procedures are performed, but these are limited to the removal of leaflet tissue which is poorly supported and to chordal shortening and replacement. Many valves simply remain unrepaired due to the shortage of acceptable techniques and apparatus. The sophisticated procedures are acquired art forms that many surgeons either cannot master or do not have the time and opportunity to master. 
     Thirty years of valve surgery have indicated that the native leaflet tissue is the most reliable valve material. Despite numerous attempts to produce durable leaflet replacements, none have been found. The cost of demonstrating the value of a new material is extremely high. However, chordal replacement with polytetrofluorethylene is durable and highly satisfactory. Therefore, this at least provides a proven, reliable material to suspend leaflet tissue. 
     It is also clear that annuloplasty rings are durable, well-tolerated and do not require long-term anticoagulation. They fix the annular dimensions and reliably reduce one of the most important variables (i.e., the mitral annulus diameter) in mitral valve competence. 
     Regulatory issues in this field are the single most expensive factor. Next generation valve prosthesis designs are therefore most desirably based on the numerous available annuloplasty devices. 
     To properly and consistently repair the mitral valve, these variables must be fixed—the annular diameter, the leaflet length, the chordal length and the attachment point of the chords. Fortunately, the leaflet length is relatively constant. The annulus diameter can be fixed by the annuloplasty ring. The chords can be replaced by polytetrofluorethylene suture to fix their length. The missing variable is the attachment of the chords to the left ventricle. To date, this remains a troublesome variable to the valve repair. 
     Ischemic mitral regurgitation occurs when there is ventricular dysfunction which causes the posterolateral attachments of the mitral valve to be drawn away from the annulus in systole. This pulls the two leaflet edges apart at their point of coaptation and produces an asymmetrical regurgitant jet or, in other words, blood flow in the wrong direction through the valve. In its pure form, the leaflets, the chords and the attachment points are all anatomically normal. Sometimes there is a relative discrepancy between the distance the anterior leaflet is drawn inward relative to the posterior leaflet so they are not just separated from edge-to-edge but also there is a step deformity of the junction point. The patient may also have some underlying mild degree of degenerative deformity which may initially cause a mild, but well-tolerated degree of mitral regurgitation. However, the regurgitation often becomes severe after left ventricular ischemia occurs. 
     Some repair techniques apply tight annuloplasty rings which serve to buckle the leaflets and draw them together. This often leaves a degree of mitral regurgitation and mitral stenosis results. Annuloplasty can be accompanied by a modification of the Alfieri edge-to-edge repair, more recently referred to as the bowtie repair. With this technique, the surgeon merely sews the anterior leaflet to the posterior leaflet at the point of maximal distraction. This produces a two orifice valve with more stenosis. 
     Devices and methods are necessary that preserve the leaflet tissue but provides for virtually guaranteed coaptation of the leaflets by fixing some of the variables responsible for regurgitation. Other devices and methods are necessary that do not simply reduce the diameter of a heart valve annulus, but allow more specialized treatment tailored to patient needs. 
     SUMMARY OF THE INVENTION 
     Degenerative disease generally involves a relatively normal leaflet which is poorly supported by lengthened or ruptured chords. By attaching the poorly supported leaflet to replacement or native chords connected with a post in the left ventricle, a guaranteed point of coaptation can be produced. In this regard, one general form of the invention provides a device for supporting a heart valve in a patient with the heart valve including an annulus generally lying in a plane and a plurality of leaflets connected therewith and adapted to open and close to selectively allow and prevent blood flow. The device comprises a support member configured for attachment to the heart valve and the above-mentioned post extending from the support member and configured to extend away from the plane of the annulus. A connector is coupled with the post and configured for attachment to at least one of the leaflets. The post can support the posterior leaflet (extending from the posterior part of the support member), the anterior leaflet (extending from the anterior part of the support member) or both leaflets. For example, this would require a relatively simple modification of the currently available annuloplasty rings or other support members, for example, which may be ring segments. The connector may be one or more flexible tensile members, such as replacement chords passing from the leaflet(s), through or along the post and up to the support member. These flexible tensile members may be precisely length adjusted to bring the unsupported leaflet edge to the precise depth. This could replace the current posterior leaflet resection. It would also be a solution for the anterior leaflet repair which has produced only marginal results in most hands. The invention is also applicable to replacement heart valves formed of biologic or artificial materials. Various aspects of the invention are applicable to the repair of native valves, while other aspects apply to replacement valves of artificial biocompatible material, animal valve tissue or human valve tissue. 
     A device constructed in accordance with the invention would preferably fix the annular diameter, the chordal length and the point of chordal fixation in the ventricle. In this way, the invention provides a more reliable and permanent solution to the problems associated with the valve repair. Furthermore, it would be easy to perform by most surgeons. A small incision could be made in the annular attachment of the poorly supported anterior leaflet and the post passed through this incision. The support member would then be attached to the native annulus. Flexible tensile members, such as artificial or natural chords would then be attached from the post to the unsupported edge of the leaflet and adjusted by pulling them to length and fixing them. In the case of replacement chords, they are preferably fixed at the level of the support member. Devices could include posterior posts, anterior posts or both. A variety of possibilities exist for modified structures, including multi-forked posts or surgeon-created posts. It would also be preferable to provide chordal patterns to attach the posts to the leaflets and to develop a quick connect system for attachment of the chords to the leaflet edges. Adjustability of the system will be important in many cases for fine tuning. 
     Another form of the invention comprises a support member, which may be an annuloplasty ring or other support structure, and at least one post. A first chord gripping member is coupled with the post and configured to grip at least one of the chords and thereby fix the length of the chord between the first gripping member and the leaflets to support and align the leaflets for coaptation during operation of the valve. In the case of mitral valve repair, the post extends into the left ventricle taking origin from the posterolateral commisure. In a preferred embodiment, one gripping member traps the chords to the anterior leaflet in such a way that their distance from the leaflet edge is precisely fixed. A second post and gripping member can do the same for the posterior leaflet. The surgeon would then confirm that the gripping members had captured the chords precisely so that the leaflets meet exactly in systole. If there would be any doubt about this coaptation or should there be a fear of late failure due to chordal rupture, the native chords could be augmented or replaced by an array of replacement chords suspended from the posts and attaching to the leaflet edge. One may also postulate improved left ventricular function from the device since the bulging of the posterior wall of the heart will be prevented by the tethering of the chords which are trapped in the device. 
     The various devices of this invention are formed of biocompatible materials including, but not limited to, exposed biocompatible metals, fabric covered metal or polymer, exposed polymer, or any other biocompatible artificial or biologic material. The various devices of this invention may also be incorporated into a full replacement heart valve structure again formed from any biocompatible material for cases necessitating full replacement of the valve. In these cases, the replacement valve is fully supported in a position ensuring accurate coaptation of the valve leaflets and less stressful interaction of the valve leaflets with each other as well as with the valve commisures. 
     Another aspect of the invention provides a device for supporting a heart valve in a patient comprising a support structure configured for attachment to the heart valve annulus and a post connected to opposite sides of the support structure and configured to extend from one side of the annulus to another side thereof. This modifies the shape of the annulus, for example, to correct for ischemic condition. The post may be contained substantially in the same plane as the support structure and valve annulus or may extend substantially out of the plane containing the support structure and valve annulus. If extending substantially in the same plane, the post prevents outward bellowing of the valve leaflets, while if extending substantially out of the plane, the post simply functions to connect and modify the shape of opposite sides of the annulus. The post may be length adjustable to allow variable modification of the annulus and may include additional posts of adjustable length or fixed length. As with other embodiments of the invention, the support structure may comprise a ring-shaped member or one or more discrete support segments. 
     As another manner of correcting an ischemic condition, for example, a ring-shaped support member is provided having an asymmetric-shape about two perpendicular axes. Stated more generally, one side of the ring-shaped support member may be of narrower width than an opposite side of the ring-shaped support member. This may or may not be coupled with a slight angling downward of one side of the ring-shaped support member with respect to the opposite side of the ring-shaped support member. These modifications help to close a gap created between the valve leaflets due to conditions such as an ischemic condition. 
     In another aspect of the invention, a device is provided for adjusting the distance between a papillary muscle and an annulus of a heart valve. This device comprises a support member configured to be affixed to the annulus of the heart valve and an elongate flexible tensile member having first and second ends with the first end adapted to be fixed to the papillary muscle. A connector is configured to connect with the elongate flexible member and with the support member in a manner allowing adjustment in the length between the papillary muscle and the support member and fixation of the elongate flexible member at a desired length between the papillary muscle and the support member. Generally, this device is useful for setting the critical distance between the papillary muscle and the valve annulus and may be used in preparation for the various valve replacement and repair techniques and devices disclosed herein. 
     In another aspect of the invention, a device is provided for supporting a heart valve in a patient and generally comprising a support member adapted to be affixed to the annulus and having at least one selectively adjustable portion allowing one section of the support member to be moved with respect to another section thereof and locked in place in order to maintain one or both of the annulus and the leaflets in a desired configuration. The support member may be ring-shaped, for example, and may be selectively adjustable such that one section, lying in a single plane, may be adjusted and angled away from a plane containing another section of the ring-shaped support member. Alternatively, or in addition, the ring-shaped support member may be adjustable to allow one section to be narrowed in width with respect to another section. This feature is also advantageous for correcting ischemic conditions. 
     In one general method of supporting a heart valve in accordance with the invention, a support structure is first connected to the heart valve annulus. A post is then fixed to the support structure, or the support structure may already have a post extending therefrom. The post is then connected to one of the valve leaflets to support the leaflets during opening and closing thereof. In accordance with the various aspects of this invention, the post may be connected to the leaflet with a flexible tensile member, such as a natural or artificial chord, or may be more directly connected to the leaflet. One direct connection includes extending a wire coil from the post into two adjacent leaflets to connect central portions of leaflets together. Other possible connections include the artificial or natural chord connections mentioned above. 
     Various objectives, features and advantages of the invention will become more readily apparent to those of ordinary skill in the art upon review of the following detailed description taken in conjunction with the the accompanying drawings. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     FIG. 1 is a perspective view of a first embodiment of the present invention being applied to a heart shown in partial cross section. 
     FIG. 2 is a perspective, partially sectioned view similar to FIG. 1 but enlarged and showing the device of this invention affixed to the mitral valve. 
     FIG. 3 is a perspective, partially sectioned view of the device shown in FIGS. 1 and 2 with the mitral valve shown in cross section. 
     FIG. 4 is a partially fragmented, perspective view of the device shown in FIGS. 1-3. 
     FIG. 5 is a cross sectional view taken along line  5 — 5  of FIG.  4 . 
     FIG. 6 is a fragmented perspective view of a device similar to that shown in FIG. 4, but illustrating additional flexible tensile members or artificial chords. 
     FIG. 7 is a perspective view of a second embodiment of the invention shown affixed to a mitral valve. 
     FIG. 7A is an alternative embodiment similar to the embodiment shown in FIG.  7 . 
     FIGS. 8-14 illustrate various alternative mechanisms for grasping a patient&#39;s native or artificial chords and useable in conjunction with the embodiment of FIGS. 7 and 7A. 
     FIG. 15 is another alternative embodiment of a support device shown affixed to a heart valve. 
     FIG. 16 is another alternative embodiment of a support device for a heart valve. 
     FIG. 17 is a perspective view of another alternative embodiment of a support device shown affixed to a heart valve. 
     FIG. 18 is a perspective view of another alternative support device for a heart valve. 
     FIGS. 19 and 20 are perspective views of alternative devices used to establish a distance between a heart valve support ring and the papillary muscles of a patient. 
     FIG. 21 is a fragmented view showing a heart valve with a malformation caused by an ischemic heart muscle. 
     FIG. 22 is an elevational view of a support ring having an adjustability feature in accordance with the invention. 
     FIG. 22A is a perspective view showing a portion of the ring of FIG.  22  and an adjustability feature thereof. 
     FIG. 23 is an elevational view showing the ring of FIG. 22 applied to correct the malformation shown in FIG.  21 . 
     FIG. 24 is a partially sectioned view showing an adjustable ring or heart valve support member connected to a heart valve and used in conjunction with a post of the present invention. 
     FIG. 25 is a perspective view of an alternative heart valve and heart valve support. 
     FIG. 26 is a partially sectioned view of the device shown in FIG. 25 with a catheter inserted through the heart valve. 
     FIG. 27 is a perspective, partially sectioned view of a device for establishing the distance between the heart valve and the papillary muscles of a patient. 
     FIG. 28 is a perspective view of an alternative heart valve support device of the present invention. 
     FIG. 29 is a fragmented, partially sectioned view showing an adjustability feature between the post and the heart valve support member of this invention. 
     FIG. 30 is a perspective view of an alternative heart valve support device shown affixed to a heart valve. 
     FIG. 31 is another alternative heart valve support device shown affixed to a heart valve. 
     FIG. 32 is a perspective view of another alternative heart valve support device. 
     FIG. 33 is a perspective, partially sectioned view of another heart valve support device. 
     FIG. 33A is a perspective, partially sectioned view of another alternative heart valve support device. 
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     Referring first to FIG. 1, a device  10  for supporting a heart valve in a patient is shown. In the illustrated example, the left ventricle  12  of a patient&#39;s heart is shown in cross section with a mitral valve  14  for supplying blood into the ventricle  12 . Mitral valve  14  includes an annulus  16  generally lying in a plane and a plurality of native chordae tendonae or chords  18 ,  20  respectively connected with a pair of valve leaflets  22   a ,  22   b  at one end and papillary muscles  24 ,  26  at an opposite end. In a normally functioning heart, chords  18 ,  20  support the valve leaflets  22   a ,  22   b  between open and closed positions to selectively allow and prevent blood flow into and out of left ventricle  12 . Blood enters left ventricle  12  through mitral valve  14  and is expelled during the subsequent contraction of the heart muscle through aortic valve  28 . It will be appreciated that the present invention is applicable to heart valves other than the mitral valve in various of its aspects to be described below. 
     Device  10  more particularly includes a support member  30  configured for attachment to the heart valve annulus  16  and a post  32  extending from support member  30  and configured to extend away from the plane of annulus  16 . A connector which, in this embodiment, is in the form of at least one flexible tensile member, is coupled with post  32  and configured for attachment to at least one of the leaflets  22   a ,  22   b . In this embodiment of the invention, post  32  is a hollow, J-shaped member having a longer section  32   a  and a shorter curved section  32   b . Also, post  32  may be hollow as shown with flexible tensile members  34  extending through the post and exiting at shorter section  32   b . Flexible tensile members  34  may include suture needles for affixing the tensile members to the edges of the valve leaflets  22   a ,  22   b  as described below. Other connectors suitable for directly or indirectly coupling post  32  or a post of different configuration to valve leaflets  22   a ,  22   b  may be utilized as well and some variations are described herein below. 
     As shown in FIG. 2, flexible tensile members  34  may completely substitute for one set of chordae tendonae  18  (FIG. 1) or, as an alternative, one or more defective chords, such as a lengthened chord  18   a  (FIG.  1 ), may be replaced with an artificial chord or flexible tensile member in accordance with the invention. As shown in FIG. 2, all of the native chords  18  of the patient have been removed and device  10  has been affixed by suturing ring-shaped support  30  to valve annulus  16  using stitches (not shown) and by affixing flexible tensile members or artificial chords  34  to leaflets  22   a ,  22   b . Flexible tensile members  34  may be affixed to mating edges of valve leaflets  22   a ,  22   b  by being stitched thereto as shown in FIG. 3 using suitable pads or suture supports  40 ,  42 . It will be appreciated that the remaining native chords and other artificial chords have been omitted in FIG. 3 for clarity. A crimp member  44  is also shown in FIG. 3 for fixing flexible tensile members  34  at the desired length. That is, after chords  34  have been affixed to valve leaflets  22   a ,  22   b  as shown in FIG. 3, the distance between the lower edges of leaflets  22   a ,  22   b  and section  32   b  of post  32  may be adjusted to ensure effective coaptation or mating of the valve leaflets  22   a ,  22   b . When this is achieved, crimp member  44  is crimped onto flexible tensile members  34  to retain flexible tensile members  34  at this distance and maintain the effective coaptation. Ring-shaped support member  30  may be comprised of two integrated sections with one being a curved section  30   a  and one being a straight section  30   b  as is the case with certain conventional annuloplasty rings. FIGS. 4,  5  and  6  illustrate the hollow nature of the support post and the use of a number of flexible tensile members or artificial chords  34 , depending on the patient&#39;s needs. 
     FIGS. 7 illustrates a device  50  constructed in accordance with one alternative embodiment. in this embodiment, a valve annulus support member  52  is again shown as a ring-shaped member and a post  54  extends away from ring-shaped support member  52 . Post  54  includes at least one chord gripping member  56  comprised of a pair of jaws  56   a ,  56   b . In this embodiment, a second chord gripping member  58  is shown also comprising a pair of jaws  58   a ,  58   b . Gripping member  56  is shown as gripping anterior native chords of the patient, while gripping member  58  is shown to grip posterior native chords of the patient. The purpose of device  10  is to retain the use of the patient&#39;s native chords  18 , but to more fully restore their function. In cases in which a patient&#39;s heart is ischemic, there may be stretched or lengthened chords, such as chord  18   a  shown in FIG.  1 . In this case, device  50  and, more particularly, gripping members  56 ,  58  may be used to capture chords  18  and place them under suitable tension mimicking their natural, normal condition to provide full support to valve leaflets  22   a ,  22   b . FIG. 7A illustrates an alternative embodiment similar to FIG. 7, but having a annulus support portion  52 ′ which is not ring-shaped, but neverthel ss provides suitable support when attached to a valve annulus for supporting post  54 . It will be appreciated that, while this embodiment is especially suitable for use on a patient&#39;s native chords, similar chord gripping members may be used to capture artificial chords, such as sutures or GOR-TEX (expanded polytetrafluoroethylene) fibers, connected with the valve leaflet edges as previously described. Jaws  56   a ,  56   b  and  58   a ,  58   b  may be formed in any suitable manner and may operate between open and closed positions also in any suitable manner. 
     FIGS. 8-14 illustrate several different illustrative examples of mechanisms for opening and closing the jaws of a gripping member suitable for use in the embodiments of FIGS. 7 and 7A. FIG. 8 illustrates a gripping member  70  comprised of jaws  72 ,  74  connected with a post  76  by respective shape memory rods  78 ,  80 . When electric current or heat is applied to rods  78 ,  80 , jaws  72 ,  74  move together into a clamped or closed position. 
     In FIG. 9, gripping structure  90  is shown as comprising a pair of hinged jaws  92 ,  94  operable by a cam member  96  and an actuating wire  98  contained within a post  100 . When wire  98  is pulled and fixed, cam member  96  will cam jaws  92 ,  94  into closed or clamped positions on the patient&#39;s native or artificial chords. 
     FIG. 10 illustrates a chord gripping member  110  comprised of first and second jaws  112 ,  114  pivotally connected together by a series of links  116  and operable between open and closed positions by a wire  118  contained within a post  120 . When wire  118  is pulled in the direction of arrow  122 , and fixed, links  116  will move jaws  112 ,  114  to the closed position. 
     FIG. 11 illustrates a chord gripping member  130  comprising a pair of jaws  132 ,  134  hingedly connected together and contained within an actuating member  136  fixed within a post  138 . When wire  140  is pulled in the direction of arrow  142 , jaws  132 ,  134  will be forced by actuating member  136  into their closed and clamped position. Wire  140  may then be fixed in this position by any suitable means. 
     FIG. 12 illustrates another alternative gripping member  150  comprised of first and second jaws  152 ,  154  hingedly connected together and pivotally secured to a hollow post  156 . A wire  158  is connected to the ends of jaws  152 ,  154  and when pulled in the direction of arrow  160  jaws  152 ,  154  will be actuated to their closed and clamped positions. Again, wire  158  may be fixed in any suitable manner once gripping member  150  is in the closed and clamped position. 
     FIG. 13 illustrates a gripping member  170  comprised of a movable jaw  172  hingedly or flexibly connected with a post  174  and operable by a wire or movable actuating member  176 . An outer end of jaw  172  is retained against a cam surface  178  of actuating member  176 . When actuating member  176  is pulled in the direction of arrow  180 , jaw  172  will be forced to close against member  176  and clamp the native or artificial chords therebetween. Actuating member  176  may be fixed in any suitable manner at this position. 
     FIG. 14 illustrates another alternative clamping member  190  comprised of a movable jaw  192  hingedly or flexibly connected with a post  194  and operable between open and closed positions by an actuating member or wire  196  which slides with respect to a stationary jaw  198 . Movable jaw  192  has one end retained against a cam surface  200 . When actuating member or wire  196  is pulled in the direction of arrow  202 , jaw  192  will be forced to a closed and clamped position against jaw  198  by way of the camming action of surface  200 . Wire or actuating member  196  may be fixed at this position by any suitable means. 
     FIG. 15 illustrates another alternative valve support  210  constructed in accordance with the invention. In this embodiment, valve support  210  may be used as a support for a replacement heart valve  212 , which may be formed from artificial or biological material. Valve support device  210  more specifically comprises a pair of ring-shaped support members  214 ,  216  with ring support member  214  being connected with the annulus of valve  212 . Ring-shaped support member  216  is connected to support member  214  in spaced relation by a series of posts  218 ,  220 ,  222 ,  224 . This structure supports a series of flexible tensile members, or artificial chords  226 ,  228 ,  230 ,  232  connected to the edges of valve leaflets  234 ,  236  in a suitable manner, such as in the manner described with respect to the first embodiment. 
     FIG. 16 illustrates another alternative valve support device  250  including a ring-shaped support member  252  configured to be connected with the annulus of a heart valve  254  and including a post  256  connected therewith. In this embodiment, post  256  includes a section  258  extending inwardly toward the center of heart valve  254 . This spaces post  256  away from any potentially harmful contact with the inner wall of the heart muscle. A series of flexible tensile members or artificial chords  260 ,  262 ,  264 ,  266  extend outwardly from post  258  and include respective grippers  268 ,  270 ,  272 ,  274 . Grippers  268 ,  270 ,  272 ,  274  may be used as alternatives to directly stitching these artificial chords to the valve leaflets. Instead, these grippers may simply be clamped onto the edges of the valve leaflets to provide the same function as the attachment shown and described with respect to FIG. 3, for example. 
     FIG. 17 illustrates another alternative valve support device  280  comprised of a ring-shaped support member  282  fixed to a heart valve  284  in any suitable manner and including a post  286 . Post  286  is preferably rigidly secured to ring-shaped support member  282  and extends through the center thereof so as to be configured to extend between the valve leaflets  288 ,  290 . Post  286  is connected with or integrally includes a chord supporting portion  292  at an opposite end and, as with the other embodiments, flexible tensile members or artificial chords  294 ,  296  are connected between support portion  292  and valve leaflets  288 ,  290 . 
     FIG. 18 illustrates an alternative valve support device  300  comprised of a ring-shaped support member  302  and preferably a pair of posts  304 ,  306 . Ring-shaped support member  302  is configured to be affixed to the annulus of a heart valve, as with various other embodiments of this invention, while posts  304 ,  306  are configured to prevent outward billowing of the heart valve leaflets. For this purpose, posts  304 ,  306  may be slightly curved, as shown, in an outward direction with respect to the heart valve beneath. 
     FIG. 19 illustrates a device for setting the distance between the annulus of the mitral heart valve and the patient&#39;s papillary muscles. In particular, device  300  comprises a ring-shaped support member  302  configured to be sutured or otherwise affixed to the annulus of the heart valve and a pair of flexible tensile members  304 ,  306 , which may be sutures, connected between the respective papillary muscles  308 ,  310  of the patient and the ring-shaped support member  302 . In this embodiment, to facilitate connection with ring-shaped support member  302 , tensile members  304 ,  306  are slidably retained on crimp members  312 ,  314  while the length or distance between papillary muscles  308 ,  310  and ring-shaped support member  302  is set. Crimp members  312 ,  314  may then be forced into respective holes  316 ,  318  and thereby crimped to tensile members  304 ,  306  to simultaneously affix crimp members  312 ,  314  to ring-shaped support member  302  and to the corresponding tensile member  304 ,  306 . 
     FIG. 20 illustrates an alternative device  300 ′ for setting the distance between a ring-shaped support member  302 ′ and the respective papillary muscles  308 ,  310 . In FIG. 20, reference numerals with prime (′) marks indicate subject matter similar to the corresponding reference numerals in FIG. 19, while like numerals indicate like elements between these figures. Device  300 ′ includes a ring-shaped support member  302 ′ configured to be connected to a heart valve annulus and including two connectors  320 ,  322  that affix tensile members  304 ,  306  to ring-shaped support members  302 ′ after ring-shaped support member  302 ′ has been affixed to a heart valve annulus, a surgeon stitches flexible tensile members  304 ,  306  to papillary muscles  308 ,  310  and after adjusting the distance properly between papillary muscles  308 ,  310  and ring-shaped support member  302 ′, affixes tensile members  304 ,  306  to connectors  320 ,  322 . These connectors  320 ,  322  may include slots  320   a ,  322   a  which allow flexible tensile members  304 ,  306  to become wedged and retained therein. 
     FIG. 21 illustrates a heart valve  330  comprised of first and second leaflets  322 ,  334  that engage one another at an area of coaptation  336  defining a selectively opened and closed portion of the valve. Valve  330  has a malformation, however, in the form of a gap  338  that is typically the result of an ischemic condition which pulls one portion or leaflet of the valve away from the other. 
     FIGS. 22,  22 A and  23  illustrate a valve support device  350  for correcting valve malformations such as that shown in FIG.  21 . These devices are especially useful for treating ischemic conditions in which one side of the valve pulls away from another side resulting in imperfect coaptation of the valve leaflets. Specifically, device  350  is in the form of a ring-shaped support member  352  having a selectively adjustable and lockable portion  354 . As shown best in FIG. 22, ring-shaped support member  352  may be reformed into the shape shown in phantom and retained in that shape. Alternatively, device  350  may be formed with a permanent asymmetric shape about both axes x,y. As shown in FIG. 23, the ability to squeeze portion  354  of ring-shaped support member  352  together and retain portion  354  in that position will bring valve leaflets  332 ,  334  together to close gap  338 . FIG. 22A illustrates one manner of allowing selectively adjustable and lockable positioning of ring-shaped support member  352 . In this regard, respective socket segments  354   a ,  354   b ,  354   c  receive balls  356  therebetween and further receive a wire  358  which may be tensioned and locked in place with a set screw  360  by use of a tool  362 . When wire  358  and socketed segments  354   a-d  and balls  356  are loosened, adjustability of section  354  is possible. Once the adjustment in position is made, wire  358  is tensioned to bring the balls and sockets together and then lock in place using tool  362 . This retains the adjusted shape. 
     FIG. 24 illustrates another alternative device  370  for supporting a heart valve  372 . Device  370  again comprises a valve support member  374  adapted to be connected with the valve annulus  376 , such as by suturing or other mechanical fastening means. A post  378  and flexible tensile members  380  are connected with support member  374  as described generally above to support valve leaflets  382 ,  384 . In this embodiment, one portion  374   a  of valve support member  374  may be bent out of the plane containing another portion  374   b  and retained in that position to fix the valve in a desired position. Any suitable manner of retaining the adjusted shape may be used, including the manner described with respect to FIG.  22 A. Alternatively, device  370  may be permanently formed with a nonplanar shape, such as the shape shown in FIG.  24 . The modified shape shown in phantom in FIG. 22 may also, be combined with the modified shape shown in FIG. 24 for ring-shaped support member  374 . 
     FIG. 25 illustrates another alternative valve support device  390  incorporating a replacement heart valve  392  with the support structure including a post  394  and a plurality of flexible tensile members or sutures  396  extending from an end  394   a  of post  394  and edges of three leaflets  398 ,  400 ,  402  associated with valve  392 . Flexible tensile members  396  are preferably distributed evenly along the edges of leaflets  398 ,  400 ,  402  to support the leaflets during operation with proper coaptation or mating of the adjacent leaflet surfaces. Flexible tensile members  396  also reduce stress on commisures  393 . 
     FIG. 26 illustrates a cross sectional view of a somewhat modified form  390 ′ of support device  390  having a catheter inserted between the valve leaflets  398 ,  400 ,  402 . In this embodiment, flexible tensile members  396  prevent leaflets  398 ,  400 ,  402  from opening and closing against catheter  410  with excessive force. This is in addition to stress reduction on commisures  393 . Such force may be harmful to valve  392 . Catheter  410  may be support within valve  392  by suitable struts or other support members  412 ,  414 . 
     FIG. 27 illustrates another alternative device in the form of a ring-shaped valve support member  422  configured to be affixed to the annulus  424  of a heart valve. Device  420  is used to set the distance between the ring-shaped support member  422  and the papillary muscles  425 ,  427  of the patient. A pair of posts  426 ,  428  extend generally in a radially inward direction from ring-shaped support member  422  and are directed through the center of the valve between leaflets  429 ,  431  and down along the patient&#39;s native chords  433 ,  435 . Posts  426 ,  428  are affixed to the patient&#39;s papillary muscles  425 ,  427  at the desired location. This suitable fixes the location of chords  433 ,  435  and allows the surgeon to use any of the other valve support devices contemplated by this invention to facilitate supporting the leaflets  429 ,  431  for proper coaptation. Once the appropriate valve support device or devices are in place to properly support leaflets  429 ,  431 , device  420 , or at least posts  426 ,  428 , may be removed. 
     FIG. 28 illustrates another alternative valve support device  440  comprised of a ring-shaped support member  442  configured for attachment to the annulus of a heart valve and a post  444  connected to support member  442  and including an annular or loop-shaped end  446 . As with previous embodiments of the invention, one or more flexible tensile members or artificial chords may be affixed to end portion  446  and connected at an opposite end to one or more valve leaflets (not shown). Post  444 , and especially loop-shaped end portion  446 , provides a resilient structure for bearing against the internal wall of the heart muscle. At least end portion  446  can flex in a resilient fashion toward ring-shaped support member  442  as the heart muscle contracts and moves. This reduces the likelihood of injury to the heart muscle and provides an artificial chord support that more naturally mimics the operation of a papillary muscle. 
     FIG. 29 illustrates an alternative valve support device  440 ′, which may be configured similarly to valve support device  440 , except that post  444  is connected to ring-shaped support member  442  by an adjustable and lockable connection  450 . This allows adjustment in the direction or arrows  452 ,  454 . After the appropriate adjustment is made, post  444  may be locked in the desired position with a set screw  456  tightened against ring-shaped support member  442 . A slot  450   a  also allows post  444  to be completely removed from support member  442 . 
     FIG. 30 illustrates a valve support device  460  similar to device  440 , but having a support member  462  which is not ring-shaped and having a post  464  with first and second loop-shaped end portions  466 ,  468 . One or more flexible tensile members  470 ,  472  may be retained on post  464  and loop-shaped end portions  466 ,  468  by suitable rings  474 ,  476  allowing length adjustment of flexible tensile members  470 ,  472 . Flexible tensile members  470 ,  472  may extend upwardly past support member  462  and may be tied thereto after length adjustment is made. 
     FIG. 31 illustrates a valve support device  480  comprising separate support members  482 ,  484  affixed to opposite sides of a heart valve annulus  486 . A post  488  connects support members  482 ,  484  together thereby affixing the position of these opposite portions of heart valve annulus  486  with respect to one another. This may be used to pull two valve leaflets  490 ,  492  together. Also, device  480  may be used to remodel the shape of annulus  486 . 
     FIG. 32 is a valve support device  500  constructed in a similar manner to support device  480 , but allowing further adjustability. Specifically, first and second valve annulus support members  502 ,  504  are respectively connected to opposite sides of a heart valve annulus  506 . At least one and preferably two telescopically adjustable posts  508 ,  510  connect support members  502 ,  504  together. In the configuration shown, one or both posts  508 ,  510  may be adjusted in length depending on the particular malformation or abnormality of leaflets  512 ,  514 . Once adjusted to the appropriate length by the surgeon, telescopic posts  508 ,  510  may be fixed at the desired length by any suitable means. 
     FIG. 33 illustrates another alternative valve support device  520  comprised of a ring-shaped support member  522  configured to be connected with a heart valve annulus  524  and a post  526  generally constructed with a J-shape as in certain previous embodiments. In this embodiment, however, post  526  connects directly with valve leaflets  528 ,  530  by way one or more spiral coil connectors  532 ,  534  extending outwardly from post  526 . As the surgeon pushes these wires  532 ,  534  from post  526 , they will form the coiled shape shown in the figure and simultaneously be directed through leaflets  528 ,  530  to connect these leaflets at a central location. 
     FIG. 33A illustrates another valve support device  540  similar to device  520  but utilizing separate valve support members  542 ,  544  in place of a ring-shaped support member and further including a centralized post structure  546  comprised of post members  546   a  and  546   b . Again, the surgeon will install this device by affixing support members  542 ,  544  to the heart valve annulus  524  and then as coiled wire connectors  548 ,  550  are pushed through post portion  546   b , they will simultaneously be coiled and directed through valve leaflets  552 ,  554  to connect central portions thereof together. 
     While the present invention has been illustrated by a description of preferred embodiments and while these embodiments have been described in some detail, it is not the intention of the Applicants to restrict or in any way limit the scope of the appended claims to such detail. Additional advantages and modifications will readily appear to those skilled in the art. The various features and concepts of the invention may be used alone or in numerous combinations depending on the needs and preferences of the user. This has been a description of the present invention, along with the preferred methods of practicing the present invention as currently known. However, the invention itself should only be defined by the appended claims, wherein we claim:

Technology Category: 1