CA1183655A - Low profile prosthetic xenograft heart valve - Google Patents

Abstract

LOW PROFILE PROSTHETIC XENOGRAFT
HEART VALVE
Abstract Prosthetic heart valves having a low profile are disclosed which comprise an annular, right cylindrical, metal stent covered with fabric around which a glutaraldehyde-stabilized pericardial valving element is attached. The valving element is formed of three leaflets, each having a plateau on a truncated triangle extending higher at the center than at the edges, and formed as a cylinder having a diameter substantial-equal to the diameter of the stent.

Description

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P.C. 6349 - Canada LOW PROFILE PROSTHETIC XENOGRAFT
HEART VALVE
The early development of prosthetic heart valves is well documented in papers given at symposia in 1960 and in 1968, published in PROSTHETIC HEART VALVES, Lyman A. Brewer III, Ed., Charles C. Thomas Publishing Co., Springfiled, Illinois (1969), Second National Conference on Prosthetic Heart Valves; PROSTHETIC
VALVES FOR CARDIAC SURGERY, K. Alvin Merendino, Ed., Charles C. Thomas Publishing Co~, Springfield, Illinois (1961).
Lefrak and Starr recently surveyed the develop-ment of cardiac valve prostheses, E.A. Lefrak and A. Starr, CA~DIAC VALVE PROSTHESES, Appleton-Century-Krofts, New York, 1979 and the development of tissue heart valves has been comprehensively reviewed by Ionescu, Marian I., TISSUE HEART VALVES~ Butterworths, Boston, 1'379.
Grea1 efforts have been expended in the develop-ment of tissue heart valve prostheses and in the development of supportive structures, or stents, for tissue va:Lves. Representative of effots to develop stents for tissue valves are the disclosures in the following United States patents: Patent 3,570,014, W. D. Hancock, March 16, 1971; Patent 3,714,671, William Sterling Edwards et al, February 6, 1973;
Patent 3,755,823, W. D. Hancock, September 4, 1973;
Patent 3,983,581, William W. Angell, Ockober 5, 1976;
Patent 4,035,849l William W. Angell et al, July 19~
1977; Patent 4,079,468, Domingo Santo Liotta, March 21, .

1~33~5~

1978; Patent 4,084,268, Marian I. Ionescu et al~, April 18, 1978; Patent 4,106,129, Alain F~ Carpentier et al, August 15, 1978; Patent 4,172,295, Richard J.
Batten, October 30, 1979 and Patent 4,192,020, Richard B. Davis et al, March 11, 1980. Other structures are also reported in the aforementioned treatises on heart valve developments.
A number of specific tissue valves are described in the following publica~ions:
W. Sterling Edwards et al, MITRAL AND AORTIC VALVE
REPLACEMENT WITH FASCIA LATA ON A FRAME, Journal of Thoracic & Cardiovascular Surgery, Volume 58, No. 6, December 1969, Pages 854-858; Ionescu, M.I. e-t al, HEART VALVE REPLACEMENT WITH IONESCU-SHILEY PERICARDIAL
XENOGRAFT, Cardiolo~y Di~est, June 1977, Page 45;
Ionescu, M.I. et al, HEART VALVE REPLACEMENT WITH THE
IONESCU-SHILEY PERICARDIAL XENOGRAFT, The Journal of Thoracic and Cardiovascular Surgery, Volume 73, Pages 31 - 42, 1977; Tandon, A. P. et al, LONG-TERM
HAEMODYNAMIC E~ALUATION OF AORTIC PERICARDIAL XENOGRAFT, British Heart Journal, Volume 40, Pages 602-607, 1978;
Ionescu, M.I. et al, LONG-TERM CLINICAL AND HAEMODYNAMIC
EVALUATION OF THE IONESCU-SHILEY PERICARDIAL XENOGRAFT
HEART VALVE, Thora~chirugie, Volume 26, Pages 250-258, 25 1978; Ionescu, M. I. et al, LONG-TE~M SEQUENTIAL
HEMODYNAMIC EVAL~ATION OF RIGHT VENTRICULAR OUTFLOW
TRACT RECONSTRUCTION USING A VALVE MECHANISM, The Annals of Thoracic Surgery, Volume 27, No. 5, May 1979;
Ros5, D. N., FLEXIBLE BIOPROSTHETIC PERICARDIAL HEART
VALVE, Thoracic & Cardiovascular Surgery, Volume 28, -Pages 150-152, 1980.
Particular techniques for preparing, handling and storing tissue valves are disclosed in U.S. Patents Nos.

s ~3--3,966,401, Hancock et al, Ju~e 29, 1976, and 4,182,446, Penny, January 1980.
Some of the earliest heart valve prostheses were flexible two-or three-cusp valves in which the cusps were constructed of various types of fabric. Some of these flexible leaflet valves had good flow characteristics but most failed early.
The leaflets tore, separated from the annulus, or become rigid due to fibrous ~issue ingrowth. From about 1960 into the 1970's the trend was to mechanical valves. These ranged from the mecahnically quite simple Starr-Edwards valve to the xelatively sophisticated Bjork-Shiley valve and included a number of disc poppet valves. These mechanical val~es generally dominated the market and are still very satisfactory for many applications. Tissue valves are however the preferred treatment where anticoagulation therapy is not tolerated by the patient.
In 1962, Donald Ross and Sir Brian Barratt-Boyes, working independently, were performing implanatations of homograft tissue valves, some of which were free graft implants and some of which were mounted on supporting stents. Fully clothed covered rigid stents were used in some of these homograEt valves.
In 1965, Drs. Binet and Carpentier, and their associates, implanted a specially prepared porcine aortic valve xenograft. These porcine valves were sterilized and treated, e.g. with formaldehyde, and were commonly attached to a metal stent~ Experience showed that these valves were of shor-t life, largely because formaldehyde was used as the cross-linking agent. Formaldehyde was found to create reversible cross links in the tissue, thereby allowing early breakdown of the tissue. ~r. Car~entier, in about 1968, established the concept of the bioprosthesis by substantially eliminating antigenicity of the tissue, principally by changing the preservative from formaldehyde to glutaraldehyde. Glutaraldehyde has been shown to create cross links of a more permanent nature than those created by formaldehyde.
A number of porcine bioprostheses and specially designed stents for supporting these prostheses resulted from the efforts of Warren Hancock et al.
Generally, pig aortic valves are procured under clean conditions, placed in a cold, balanced electrolyte solution, excess tissue is trimmed and the xenografts are immersed in 0.2% glutaraldehyde. The lea~lets are held in their normal valving position under pressure during the tanning process and each valve is sutured to a cloth covered stent by sutures~ A
number o~ designs and stent constructions for the Hancock type valve are exemplified in the aforementioned United States Patents Nos. 3,570,014 and 3,755,823.
Stents for porcine valves were developed by a number of other workers also, see, e.gO, U.S. Patents Nos.
3,983,581; 4,035,849; 4,079,468 and 4,106,129.
Stents for supporting cusp valves of other tissue memberst e.g. ~ascia lata and pericardium, have been developed by a number of workers, see, e.g., U.S. Patent 3,714,671, and Edwards et al, MITRAL AND AORTIC VALVE REPLACEMENT WITH FASCIA
LATA ON A FRAME, supra7 Much of the pioneering work in this area of valve development was done by Dr. Martin I. Ionescu and his associates, see, e.g., Bartek et al, FRAME-MOUNTED TISSUE HEART VALVES:
TECHNIQUE OF CONSTRUCTION, Thorax, Volume 29, Pages 51-55, 1974; Ionescu et al, HEART VALVE REPLACEMENT
WITE IONESCU-SHILEY PERICARDIAL XENOGRAFT, Cardiology -5~

Digest, June 1977; Ionescu et al, HEART VALVE
REPLACEMENT WITH IONESCU-SHII,EY PERICARDIAL XENOGRAFT, The Journal of_Thoracic and_Cardiovascular Surge.ry, Volume 73, Pages 31-42, 1~77; Tandon et al, LONG~TERM
HAEMODYNAMIC EVALUATION OF AORTIC PERICARDIAL XENOGRAFT, Brit~sh Heart Journal, Volume 40, Pages 602~607, 1978;
Ionescu et al, LONG-TERM CLINICAL AND HAEMODYNAMIC
EVALUATION OF THE IONESCU-SHILEY PERICARDIAL XENO&RAFT
HEART VALVE, Thoraxchiru~ie, Volume 26, Pages 250-258, 1978; Ionescu, et al~ LONG-TERM S~QUENTIAL
HEMODYNAMIC EVALUATION OF RIGHT VENTRICULAR OUTFLOW
TRACT RECONSTRVCTION USI~G A VALVE MECHANISM, The Annals of Thoracic Sur~y, _ , 425-434, 1979; and Ionescu, Editor, TISSUE HEART VALVES, Butterworths, 1979.
A number of improvements in the basic Ionescu tissue hea:rt valve have been made. For example, a tissue heart valve has been developed which has a cloth-cove.red stent of special construction, in which the outflow annulus diameter of the valve is defined and limited by the positioning of a coaptation stitch on the ins:ide of the supporting legs of the stent, as has been the prac-tice since the early development of the Ionescu type tissue heart valve. Another improvemen-t in the method for aligning the -tissue of the cusps of the Ionescu type heart valve is described i.n U.S. Patenk No. 4,172,295, which also discloses the coaptation stitch inside the stent legs.
It has been the practice, in order to achieve a maximum flow orifice in valves of implantation diameters less than or equal to 23 mm, to splay the stent legs outwardly in an effort to achieve a full-flow orifice inside the coaptation stitches.

While these various modifications and improvements in -the basic Ionescu valve over the years have solved some of the problems, there remains a number of problems which have not been solved. Among these problems are the limitations on the size of the flow annulus which can be obtained, with consequent increased pressure gradient across the valve. Per-haps the most important disadvantage of the three-cusp tissue valves of the prior art is the fact that in each cusp there are two points of stress due to three-dimensional flexure at about ~ o'clock and at about 8 o'clock in the lower arc of the cusp, i.e. in the lower right hand portion and the lower left hand por-tion of the closed cusp as viewed laterally, head-on, from the outside. A similar phenomena is created by creases whichtend to concentrate stress in the areas of the crease.
The tissue valves of the prior art generally have relied upon a face-to-face meeting of the cusps in the closed position and, consequently, have required relatively high stent legs and, in general, the tissue valves of the prior art have trimmed the tissue around the outflow end so as to form a generally round regular cylindrical configuration. This app-roach has resulted in the concentration of stresses in fold areas or in the lower riyht and left hand portions of the cusps .
The problems described above are largely or entirely solved by the present invention.
According to the present invention, there is provided -7~
a prosthetic heartvalve ^omprising: a stent comprising an annu-lar base integrally formed with three upwardly extending legs, the space between the legs configured to form generally ellip-tically shaped scallops having a depth U measured from the top of the legs to the bottom of the scallop, the stent circum-ferentially forming a substantially right cylinder having an interior diameter D with the legs extending parallel -to the axis of the cylinder, the lower edge of the base forming scal-lops corresponding generally -to the arc of the scallops between the legs, the scallops of the lower edge of the base and the scallops between the legs vertically defining three generally elliptically shaped one-third portions of the base between the respective upright legs; a fabric covering encompassing and following the configuration of the stent; an annular sew-ing ring attached to the fabric covering and extending outwar-dly from the base; a tissue valve element formed of three tissue leaflets joined to form a generally cylindrical three-cups valving element, each leaflet having a top edge forming a raised truncated triangular form with a central plateau and two sides diverging from each side of the plateau to corners at their junctures with the sides oE the le~aElet; ~neclns attach-ing the tissue valve element around the Eabric covered stent;
and a plurality of coaptation stitches through the tissue leaf-le-ts adjacent the upper edges thereof disposed directlyabove the tops of the fabric covered stent legs fixing the leaflets to form three cusps; with said plateaus extending upwardly ~, midway between the legs in the open position of the valve, the upper edges of the cusps meeting in the closed position of the valve with the plateaus adjacent each other, and in the open position of the valve the tissue valve element forming a cylinder having an inside diameter at the top of the valve substantially equal to the inside diameter of the fabric covered stent.
For convenience, in describing the valve, the outflow end of the valve is depicted at the top of the drawings and the valve is described in this configuration; thus, the upward or top portion of the valve would correspond to the outflow portion oE the valve and the bottom would correspond to the inflow end of the valve.
In the prosthetic valve of this invention, the scallop depth U of the stent is between 50% and 65% of the stent inner diameter D. Optimally, the stent scallop depth U is from about 55% to about 62% of the diameter D. ThisU/Dratio is very important in providing a low profile tissue valve prosthesis which has optimum flexure and coaptation of the leaflets using tissue fixed in the unstressed state, and resultant maximum valve life.
The outflowend oE the three cusps oE the valving mem--ber are, in the closed position, adjacent in the center and in face-to-face contact with each other alony radii defined by the legs. The upper ~9~

or outflow ends of the valving element lie in sub-stantially face-to-face contact between the interior faces of the cusps of the valving element by from O
to 1 or 2 mm in the center and from 3 to 7 mm in~er-mediate the center and the legs, along the radialcontact lines.
FIGURE 1 is a perspective view of a completed valve of this invention.
FIGURE 2 is an exploded view of the cloth covered stent and the valving element formed of three leaflets prior to attachment -to the stent.
FIGVRE 3 is a perspective view of the preferred stent configuration.
FIGURE 4 iS a sectional view of the curvature of tissue around the covered stent leg taken along line 4-4 in FIGURE 2.
FIGURE 5 is a -top view of the stent shown in perspective in FIGURE 3.
FIGURE 6 is a sectional view taken along section line 6-6 in FIGURE 5.
FIGURE 7 is a partial perspective view of the coaptation of the tissue leaflets with the stent leg and coaptation stitch.
FIGURE 8 is another partial perspective view showing the view of FIGURE 7 in a later stage of manufacture.

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FIGURE 9 is a top plan view, viewed from the outflow end, of the completed valve in the fully open position.
FIGURE 10 is a sectional view of the curvature of tissue around the stent taken along section line 10-10 in FIGURE 2.
FIGVRE ll is a detailed view of an embodiment of the coaptation stitching.
FIGURE 12 is a detailed view of the preferred embodiment of the coaptation sti-tching.
FIGURE 13 is a detailed view of a typical tab and stent leg tip showing the relative widths of each.
FIGURE 14 is a detailed view of another embodi-ment of a typical tab and stent leg tip showing the relative widths of each.
FIGURE 15 is a top view and a sectional view, taken along the section line in the top view, of a prior art stent utilized in one of the improvements of the basic Ionescu valve, with the measurements thereof shown for purposes of comparison with the present inven-tion.
FIGURE 16 is a flat plan view of the outline of one of the leaflets used in the present valving element, before the sewing of three such leaflets together to form a cylindrical valving member.
FIGURE 17 is a top plan ~iew, viewed ~rom the outflow end, of the completed valve in the fully closed position.
FIGURE 18 is a partial cross-section taken along line 18-18 in FIGURE 8 showing the closed cusps of the valve leaflets along the closure line.

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FIGVRE 1 shows a low profile pericardial xenograft heart valve 10 which comprises a valving element 20, a stent assembly 102 and a suture or sewing ring assembly 200. The coaptation stitches 130, 132 and 134 cause coaptation or joining of the edges of the tissue leaflets of valving element 20 in ~he vicinity of the tips of the ~tent legs thereby forming radial coaptation lines 133 in FIGURE 2 depicts an exploded view o~ the tissue valving element 20 prior to attachment of the stent 102, and generally shows the three stitch seams 22, 24 and 26 which join the three tissue leaflets 30, 50 and 70 into a right cylindrical valving element.
This valving element is then sewn to the cloth-covered stent 102.
FIGURE 16 depicts one of the leaflets, leaflet 30, of the valving element 20, as exemplary of all of the leaflets 30, 50 and 70, all of which are sub-stantially identical. The leaflet 30 is a generally flat layer or sheet of pericardium tissue, treated as will be described and discussed in more detail hereinafter, and includes a curved bottom 32 and curved sides 34 and 36 with a top, or outflow edge generally indicated at 40. The top 40, howe~er, comprises three distinct portions. Edges 42 and 44 converge upwardly li~.e symmetrical sides o~ a triangle to a central plateau 46 at the top and form obtuse corners with the sides 34 and 36, respectively, on the bottom. ~ach of the leaflets 50 and 70 are to be understood as including corresponding elements, includin~ the top or outflow edges 60 and 80, as shown in FIGURE 2, for e~ample, and plateaus 66 and 86 corresponding to plateau 46. The three leaflets 30, 50 and 70 are in all essen~ial respects identical, although there will be some minor variation in the exact shape and size of these leaflets because the~ are made from naturally occurring tissue and considerahle manual dex-terity and skill is required in production. Minor variations, so long as the function is no~ impaired, are readily tolerated in the present valve construction.
The shape of the leaflets 30, 50 and 70 is very important to the proper functioning of the valve, although precise dimensions are not critical because minor deviations and dimensions can be compensated for in the final joinder of the leaflets into the valving element and in fitting the valving element over the stent. One portion of the con-figuration of the leaflets is of vital importance to th~ optimum functioning of the present invention, although the invention will function in an improved manner over the prior art even if ver~ minor devia-tions are permitted. This important portion of the configuration is the truncated triangular top edge con~erging to the plateau 46 in FIGURE 16 and to plateaus 66 and 86 in the leaflets 50 and 70. The base of the triangle iæ, of course, an imaginary line joining the lower corners of the top edge.
Plateau 46 is centrally located between the juncture of the outflow edge portion 42 with side 34 and out-flow edge portion 44 with side 36. The best definition of the shape of -this obtuse truncated triangle defined by the plateau 46 and the juncture of the top edges 42 and 4~ with the sides of the lea~let, is that this -13~

~runcated triangle is so configured and dimensioned that when the three leaflets are sewn together at their respective edges to form a cylinder, and fitted over a stent, with a coaptation stitch posi-~ioned directly over the end of the stent when thevalve is closed, the plateau 46 of the leaflet 30 touches, or substantially touches, the corresponding plateaus 66 and 86 of the leaflets 50 and 70, wi-th no more than about 1 mm of face-to-face contact, in the center of the flow path of the val~e with substantial face-to-face contact, i.e~ from about

2 mm to about 6 or 7 mm, between the interior surfaces of the edges intermediate the center and the outer diameter of the valve. ~xactitude is not perfectly required, but it i5 required that the plateaus 46t 66 and 86 be in touching or substantially in ~ouching relationship when the valve is closed, and that there be substantial surface~to-surface contact along the central portion of the radial coaptation lines of cusp contact. This relationship is shown in FIGURE 18 which depicts the valve of E'IGURE 1 cut perpendicular the radius defined by the cusp coaptation line 133, the area of contact being shown at 90~ The maximum face-to-face contact is about halfway between the center and the legs and would be at least 2 or 3 mm but not more than 9 or 10 mm, optimally from 3 to 7 mrn depending on valve size.
It is neither necessary nor possi.ble to give exact shape and dimensional definitions to the lea~lets exemplified by leaflet 30, but the configura-tion may be described, realizing that the truly -14~

critical relationship is the interrelationship of the three obtuse truncated triangular portions.
The maximum width of the leaflet lies about midheight thereof. The height o~ the. leaflet is, of course, of no criticality whatever, and so this is merely a general relationship. Thus, the sum o Sa, Sb and Sc (see FIGURE 16) is approximately equal to one-half of the total vertical height of the leaflet, Sa representing the mean altitude of the obtuse truncated triangle formed by plateau 46, converging edg~ portions 42 and 44 and the base defined by the junctures of top edge 40 with side 34 and side 36, respectively, Sb plus Sa being equal to about 35% plus or minus 3 to 5% of the total vertical height, and the sum of Sa, Sb and Sc being about 50% plus or minus around 10% of the total vextical height. The width of the leaflet, Wa, measured Sa down from the plateau 46 is about 85%
plus or mlnus 10% of the maximum width, Wc, of the leaflet, Sa being around 12 to 17% of the total vertical height. The width ~ measured at Sa plus Sb from the plateau 46 is about 95% plus or minus about 5% of the maximum width. The ex.act width and height ratios depend generally upon the overall size of the valve and will usually fall within the ranges indicated, a].though the ~irst de~inition by ~unction is the best and most meaningful description presently comprehended. In a specific embodiment, the valving member ~or the size 23 valve is a scction of pexicardium 0.012 inch thick, with a maximum height of 21 millimeters and a maximum width Wc of 26.5 millimeters at about 52% of total height. The P5~

width l~a of the obtuse triangle is 22.5 millimaters measured at Sa down about 1~% of the total height from the top, the intermediate width Wb being 25.5 millimeters at Sb, 35% from the top. Again, this is merely one example of one si~e of a valve and the dimensions are not the critical factor; it is the interrelationship of the top edges of the leaflet that is critical.
Clutaraldehyde has been used effectively to stabilize connective tissue for clinical heart valve substitutes for several years. The tissue leaflets of the present invention are cut from pericardium tissue, although other tissues may be used. The use of formaldehyde and glutaraldehyde tanning in preservation of tissue is descriked by E. Aubrey Woodruff, The Chemistry and Biology of Aldehyde Treated Tissue Heart ~alve Xenografts, in Ionescu, TISSUE
HEART VALVES, Butterworths, 1979. Woodruff and other contributors to TISSUE HEART VALVES discuss in detail the glutaraldehyde tanning and preservation of connective tissue. In the preferred embodiment of the present invention, pericardium treated with .5% glutaraldehyde at pH 7.4 without fixing the tissue in a prestressed condition is preferred; however, it is to be understood that the invention dis-closed and claimed here relates to the configuration of the valvin~
leaflets and element and the supporting stent, and any suitably preserved tissue may be utilized in thc present invention.

~ 15 ~

~16-The stent assembly re~ers generally to the entire sten-t assembly which includes a biologically compatible metal or plas~ic stent 102. The stent 102 defines the configuration of the stent assembly~
The stent 102 may be considered as three one-third protions of a stent integrally formed of one piece of material although, of course, the method of ~ormation or the number of pieces is of no consequence provided the completed stent is as described hereinO
The stent 102 comprises an annular base or ring 10~
which extends around and defines the flow orifice of the valve. Coupled to the ring or integrally formed therewith are a plurality of stent legs extending upwardly a distance H toward the outflow end of the valve from the lowermost portion of the base. There are three substantially identical legs 106, 108 and 110~ each s~parated from its neighboring legs by scallops 112 as best shown in FIGURE 3. The bottom or inflow edge of the stent 102 is also scalloped to conform ~enerally to the arc of the scallops between the legs. These bottom scallops generally follow the configuration of the scallops 112 of the outflow edge so as to generally form parallel edges defining ring or base 104. The scallops of the lower or inflow edge o~ the b~se and the scallops of the outflow edge between the legs vertically define three generally ellipti.cal shaped one~third portions of the base between the centerlines of the respective upright legs which together circumferentially form a right cylinder of constant diameter having an inside diameter D with the legs extending parallel to the axis o~ the cylinder as shown in FIGURE 5.

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The stent assembly, in the pre-ferred embodiment, also includes a fabric covering which totally or at least substantially encloses the stent 102. It is not essential to the functioning of the present valve that the stent be cloth-covered, but it has been long recognized that there are structural and biological advantages to the use of fully cloth-covered stents for supporting tissue valves. This concept predates the present invention and constitutes no part thereof but is simply adopted as part of the best mode in carrying out the present invention. The fabric covering described in detail by Ionescu et al in United States Patent 4,084,268 has been generally adopted, and the same techni-ques are applied in the present invention as are taught in United States Patent 4,084,2G8 except for the improvements dis-closed herein. Reference is made to United States Patent 4,084,268 for specific details of the fabrics, knots, sewing and techniques. It is sufficient here to describe the stent assem bly as including a cloth covering which encloses or substantially encloses and conforms to the stent.
FIGUR~ 7 is a partial cross-section depicting a fabric 120 enclosing the outside of the stent, a fabric 122 which encloses the inside of the stent, with a suitable seam area 124 joining the fabrics along the top or out~low edge of the stent.
A fabric 126 is joined along the lower edge of the stent and extends outwardly forming part of and attaching a sewing or suture ring generally indicated at 200 which may be of any of the forms used in the prior art.

LB3~SS5 Generally, such suture rings comprise a plurality of layers of fabric and padding, 202, 204 and 206, enclosed in layer 126, soft enough to permi-t the suturing needle to be readily inser-ted through it and yet rigid and strong enough to provide ~irm mounting o the prosthesis in the heart valve area.
The suture ring 200 of this invention differs from the prior art su~ure rings only in that it curves and conforms to the scalloped contour of the valve ring or base defined by the portion 104 o the stent 102.
The tissue lea~lets, after being sewn to form a cylinder as shown in FIGURE 2, may be sewn to the stent assembly in any conventional manner, as, for example, by running stitches shown in 210 in FIGURE 7.
FIG~RE 7 depicts the valve in a partially completed configuration with the tissue leaflets 30 and 70 joined by seam 22, the upper edges 80 and 40 substan~ially touching or just touching, without a large or significant surface-to-surface contact of the tw~ leaflets. Coaptation stitch 130 is disposed directly over the tip 109 of the stent leg 108 and passes through a hole 121 in the tab 123 to form the radial coaptation line 133.
FIGURE 8 shows another stage in the construction of the valve shown in FIGURE 7 by the addition of the pledget and covex 220~ This cover is sewn by stitches 222 to the stent leg through the tissue as described by Ionescu et al in ~.S. Patent 4,084,268, or it can be connected in any other con~enient mannerO The abric covering, the pledget, and the sewing, all as disclosed -19~

with great particularity by Ionescu et al, supra, are utilized in carrying out the invention in its preferred embodiment, but they are not part of the invention per se.
Coaptation of the tissue leaflets is caused by the action of coaptation stiches 134, 130 and 132 shown in FIGURE 1. The present inven-tion departs from the prior art in a very important and significant manner in the way in which the coaptation of the edges 40 and 60, the edges 40 and 80, as best shown in FIG~RE 18, and the edges 60 and 80 abut in touching relationship. This coaptation is defined generally by the placement of the coaptation stitches 134, 130 and 132 directly above the respective stent legs 106, 108 and 110, the placement of the coaptation sti-tch 130 being depicted as exemplary in FIGURES 7 and 8.
In prior art valves such as the one disclosed in U.S.
Patent 4,084,268, the coaptation stitch had been placed inside the circumference of the circle dPfined by the tips of the stent legs. Placement of the coapta-tion stitch dixectly above the tips of the stent legs tends to allow the orifice diameter of the fully open valve to equal the inside diameter of the covered stent. FIGURE 9 illustrates a tissue valve in the fully open position.
Another extremely significant departure from the prior art is the relative height H of the stent 102, the depth U of the scallops between the legs of the stent 102, and the inside diameter D of the stent.
In the prior art it was considered necessary, or at least very important, that in smaller valve sizes, e.g. 23 mm or less, the legs be splayed out-wardly from the base. Thus, referring to FIGURE 15, -20~

in the prior art stent 102', the input dia~eter Din was smaller than the outflow diameter DoUt, DoUt being the diameter of the circle in which the legs at the outflow end of the valve lie. The coaptation stitches of the prior art were formed ins.ide the legs, and the diameter of the circle on which these coaptation stitches were made to lie was made, or attempted to be made, approximately equal to Din.
Thus, the stent, viewed circum~erentially, e.g.
from the end, was not a right cylinder, but was generally frustoconical because o~ the splaying.
Sometimes, of course, the splaying of the legs was accomplished by bending the legs out from another ~ide cylindrical base, but the result was substantially the same as a frustocon.ical imaginary figu.re derived from the d.iameter of the inflow and the outflow ends o~ the valve.
In contrast to the prior art; the stent 102 o~
the present invention is, viewed circumferentially, a right cy:Linder, with the axis of the cylinder lying in the center of the ~low path and the legs extending from the inflow end toward the outflow end (the top as viewed :in the figures) of the valve parallel to the axis of the right cylinder. Thus, Din becomes equal to DoUt.
~ lso of great s.ignificance is the ratio U/~, D being equal, of course, to the inner diameter of the stent. As compared with what is regarded as the closest and most pertinent prior art, the Ionescu type valve described by Ionescu et al in U.S. Patent 4,084,268~ vari~us features of which are also described in U.S. Patent No. 4,172,295 to Batten, the scallop depth U measured from the scallop bottom on the out~low edgP of the stent base 104 to the upper or outflow end of the stent legs (see FIGURE 6 ), iS very much less, for a given valve diameter, than the corresponding distance V' in the prior art stent depicted in FIGURE 15. In particular, the ratio of U/D in the present valve is between about .50 and about .65, and optimally from about .55 to .62.
It is important, of course, to obtain and main-tain as low a profile valve as can be made to operate;
but that alone is not the only significance of the aforesaid ratio of U/D. This result, long sought for but heretofore unattainable, is obtained by reason of -the unique combination of elements, con-figurations, relationships, and dimensional ratios, which, acting together in a unique way, make it possi-ble to provide a heart valve prosthesis, in l~hich the valving element is a generally cylindrical tissue element, which has a profile of less than two-thirds the profile of prior a.rt valves, which closes more rapidly than prior art valves of related construction, and in which the stresses in the cusps of related prior art valves have been wholly or substantially avoided. This new result comes about by reason o~
the interaction and cooperative act.ion and function of the U/D ratio o~ the stent, the positioning o the coaptation stitch above the end o~ the stent leg, and the unique con~iguration of the cusp lea~lets o~
the valving element.

-22~

As wil 1 be seen in FIGURE 9, when the valve i5 in the fully open position, the flow path is substantially a right cylinder through the valve, with the coaptation stiches being placed directly 5 above the legs. This has two functions. The first is of significance but, comparatively, of lesser significance than the other. The first result of this placement of the coaptation stitches is that a larger flow orifice is obtained without the necessity for splaying the legs of the valve. More importantly, the stresses of the prior art tissue valves at four o'clock and at eight o'clock, i~e. at the lower right and the lower left-hand portions of the cusp, when viewing the cusp straight on laterally, have been avoided without fluttering, rolling and floating of the edges of the tissue at the outflow end of the valve. This is a new and e~tremely desirable result which follows from the combination of configuxations describedO This result is accomplished by reason of the unique configuration of the leaflets in which the valve element comprises three tissue leaflets joined to form a generally cylindrical valve element having three points which extend centrally of each of the cusps respectively toward the outflow end of the valve and centrally between the ends of the legs, the valve element forming in the open position a cylinder having three points on the outflow end thereof and, in the closed position, forming three cusps which arc inwardly between the legs with the outflow end of the leaflets touching with the three points adjacent each other in the center of the outflow end of the valve. It will be apparent from a consideration of the structure -23~ 3~

o~ the leaflets that, while in the pre~erred embodiment they are ~ormed of three separate pieces, they may very well be formed o~ a single integral piece of tissue with appropriate cu-tting and stitching such that the end result, the valving element, has the proper configuration. Thus, while it is convenient to start with three pieces o~ tissue, the same invention may be pxacticed with only one piece in which the three lea~lets are integrally joined~
The shortening of the implant depth, to less khan about two-thirds of the prior art stent heights of corresponding valves, and the adoption of the coaptation stitch directly above the ends o~
the legs, permit the use of the above described valving element while providing a substantial area of face-to-face overlapping contact along the radial contact lines o~ the cusps and obviating the tendency of the out~low ends o~ the leaflets to roll, flutter, and otherwise to delay in closing or to twist and deform by minimizing the coaptation, at the cen~er o~ the valve, of the plateaus 46, 66 and 86.
A preferred stent design ~or tissue heart valves is depicted in detail in FIGURES 3, 5 and 6.
FIGURE ~ shows the improved stent in perspective.
FIGURE 5 shows a top view o~ the stent, and FIGURE 6 is a sectional view of ~he stent taken alony section line 6-6 in FIGURE 5. It is advantageous to use this pre~erred stent design in conjunction with the valving element 20 described above. Such a combina-tion is a pre~erred method o~ valve construction in the present invention. However, the valving element 20 may be used with other stents.

-24~ S ~

The width Wt of the stent legs 106, 108 and 110 at their tips 107, 109 and 111~ as viewed in FIGURE
5, is substantially less than the width of -the tips of prior art stent legs. As shown in FIGURE 4, which is a detailed sectional view of the tip 107 of stent leg 106, the width Wt is equal to the diameter of the half circle defining the tip if the tip is rounded.
In other embodiments where the tip is not rounded, Wt is measured between the points near the tip where the edges of the s-tent leg first start to curve in toward the center line of the stent leg~
In the preferred embodiment of the stent design, the stent legs are rounded at their tips. The width of the stent legs at the tips thereof has been reduced from approximately 2.032 millimeters in prior stents to a substantially narrower range of widths from about 0.76 mm to about 1.14 mm. This reduced width of the stent legs at their tips has the effect of in-creasing the radius of curvature of the tissue inside the stent leg and tip. This curvature is caused by the action of the coaptation stitches 13~, 130 and 132 in FI~URE 1 and by closure of the valve which causes collapse o~ the cusps 30, 50 and 70 toward the center of the valve under restriction o~ the coaptation stitches. That is, the tissue leaflets 30, 50 and 70 curve less sharply together at the tips 107, 109 and 111 of the stent legs when the tips of the legs are narrower. This increased radius of curvature translates into reduced stress in the tissue of the cusps and a longer service life for the valve.

~3~

However, -this reduced width of the tips of the stent legs 106, 108 and 110 in FIGURE 3 leaves less material in the stent legs to carry the structural loading of the closed leaflets caused by the impulse pressure in the flow of blood caused by intermittent pumping action of the heart. To compensate for the reduced width in the leg tips, tabs 120, 123 and 125 ~see FIGURES 3 and 5) are add~d at the outflow end or tip of each of the stent legs to add structural strenth to the legs. These tabs preferably project inwardly toward the center of th~ stent and are integrally formed with the stent legs and preferably conform to the width WT at the tips of the stent legs as seen in FIGURE 5. The tabs extend both vertically down the stent leg for a distance Htl, FIGURE 6, and toward the center of the aperture defined by the stent ring for a distance Tt.
The exact dimensions of the tabs, Wt, Htl, Ht2 and Tt in FIGURES 5 and 6, are, within the parameters of this aspect of the invention, matters of design choice.
The strength of material used in constructing the s-tent will affect the choice. Typical dimensions in the preferred embodiment of the stent design are given in Table I below.
The tabs 120, 123 and 125 have apertures 121 formed therein through which the coaptation stitches pass. It is preferred that the coaptation stiches be passed through the holes 121 in the kabs since this registers the position of the coaptation stitch at a positive, repeatable location. The diameter of the holes 121 in the preferred embodiment is 0.813 mm, and the dimension Tt in FIGURE 6 is chosen to give sufficient strength. The ~26~

use of holes 121 in the tabs located as described above insures good repeatability of manufacture because different assembly workers cannot change the orifice diameter or induce stresses in the tissue by inadvertent mislocation of the coaptation stitch too far ~oward or away from the center of the aperture.
The tabs 120, 123 and 125 are included in the preferred embodil~ent because they have been found to be highly desirable and necessary, in many instances, for sufficient strength; however, the tabs are not always necessary. With refined manufacturing techniques and adaptation of stronger materials, the tabs are expected to be eliminated or reduced in size. The fundamental concept disclosed herein is extension of the service life of the valve by reducing stress levels in the tissue by, among other things, utilizing narrower, rounded stent leg tips 107, 109 and 111 as shown in FIGURES 3 and 4. Ideally, a substantially zero tip width would be desirable, but structurally this is impossible at present:. The width of the stent leg at its tip is made more narrow than heretofore known; however, the stated width of the tips of the stent legs in the preferred embodiment should not be understood as limiting the invention in any way.
A general guideline ~or the narrowness of the stent leg tip is that the tip should be sufficiently narrow so that the quotient of the radius of curvature of tissue together inside the stent leg tip divided by the thickness of the tissue is greater than or equal to five. The radius of curvature Rc of the tissue inside a typical stent leg tip is illustrated in FIGURE 4O This curvature is caused by the coaptation of the leaflets under pressure and tends to concentrate shear stresses in the tissue at points 135 and 137 -27- ~3~5~

where curvature is yreatest. In the preferred embodiment, this ratio should be a minimum of approximately five. That is, if the radius of curvature of the tissue around the tip of the stent leg is less than approximately five times the thick-ness T of the tissue, then the tips of the stent ~egs are too wide. This general guideline has been shown to increase the service life of the valve; but the foregoing statement should not be understood as limiting the invention to a ratio of five.
It is critical that the stent dimensions be selected such that touching between the tissue and the stent is substantially eliminated or minimized, and the radius of curvature of the tissue around the stent is not smaller than a predetermined value~ That is, touching between the tissue and the stent is substantially eliminated or minimized, and the radius of curvature of the tissue a,round the stent measured at the point of greatest curvature divided by ~he thickness of the tissue should be greater than or equal to five~ This curvature at two o~ the various places on the stent where it occurs is illustrated in FIGURES 4 and 10. FIGURE
4 is a sectional view taken along section line 4-4 in FIGURE 2 looking down on the top of the stent leg.
The center of the stent is toward t,he top of FIGURE
4. The radius lines ~c illustrate the radius of curvature of the tissue 21 together inside the stent leg tip 107 and the fabric covering 113 surrounding the tip. The coaptation stitch 134 is seen to pass through the hole 121 in the stent leg tip and is approximately centered above the tip of the leg.
.

-28- ~3~3~q5 The points of maximum curvature 135 and 137 are seen to be in the tissue at a point just inside of the centermost extremity of the cloth covering 1130 The thickness of the tissue is designated as T. The ratio of RC/T should be greater than or equal to five for extended durability.
FIGURE 10 is another sectional view of a place of curvature of the tissue around the stent taken along section line 10-10 in FIG~RE 2. Again, Rc indicates the radius of curvature of the tissue 21 over the top of the cloth covering 124 surrounding the base ring 104 of the stent. T indicates the thickness of the tissue and, for extended durability, the ratio RC/T should be greater than or equal to five.
The reason for the above stated criteria of tip narrowness is that most curvature of the tissue around the stent leg occurs at the tips 107, lOg and 111 of the stent legs where the coaptation stitches 134, 130 and 132 in FIGURE 1 pull the cusps together. Thus, stress in the tissue is concentrated where the radius of curvature is smallest as can be visualized in examining FIGURES 7 and 4. Because the tissue formed around the legs and inside of the coaptation stitches is mobile, a large radius through which the tissue can flex helps to reduce the risk of fatigue failures.
Referring to FIGURE 11, there is shown another embodiment of a coaptation stitch arrangement typical for all three stent legs. This embodiment includes a separate coaptation stitch 134 passing through the tissue leaflets 50 and 70, through the top hole 121a in the tab 120, and up and over the tip 107 of the stent G~

leg 106~ Coap-tation stitch 13~ could be a group of stitches. Another coaptation stitch 135, or group of stitches, passes through the tissue leaflets 50 and 70, through the bottom hole 12lb in the tab 120, and out and around the outside edge 138 of the stent leg 106.
Thus, the top coaptation stitch 134 lies in a plane parallel to the long axis of the stent leg 106. The top stitch 134 or group of stitches is tied off above the tip 107 of the stent leg. The bottom coaptation stitch 135 lies in a plane generally perpendicular to the plane of the top stitch or stitches 134 and is tied off at the outside edge 138 of the stent leg 106. These stitches are placed so that they do not interfere with the normal operation of the val~e in the open position.
Because the thread is smaller in diameter than the holes 121, the thread of coaptation stitches 134 and 135 will pull to the side of the holes 121 closest to the stitch knot when the thread is pulled tight. At times during manufacture, the thread may b~ passed through the tissue leaflets along an axis not parallel to the a~is of the bottom hole 121b. Thus, when the thread is pulled tight the tissue leaflet on one side of the hole is moved farther toward the knot at the outside edge 13~ of the stent leg 106 than is the tissue leaflet on the other side. Thus uneven pulling can cause wrinkling of the tissue lea~lets.
An improvemen-t of the coaptation stitching of FIGURE 11 is illustrated in FIGURE 12 which shows the preferred embodiment of the coaptation stitching arrangement. FIG~RE 12 shows a coaptation stitch or stitches 140 residing generally in a plane parallel to the long axis of the stent leg 106 and passing through both the top and bottom holes 121a and 121b and through -30~ 3~

the tissue leaflets 50 and 70. The stitch can be either a single figure eight stitch as shown in FIGURE 12 ox it can be two separate stitches, each passing through both -tissue leaflets and through one of the holes 121a or 121b~ Each stitch ]40 is tied together above the tip 107 of the stent leg 106. The figure ei~ht stitch shown in FIGURE 12 iS the preferred embodiment, however, because it is simpler and faster to implement than two separate stitches both in a vertical plane. The figure eight stitch is simpler because only one knot need be tied.
The coaptation stitch illustra~ed in FIGURE 12 tends to eliminate the tendency for variations in stitch placement during manufacturing which can cause wrinkling of the tissue leaflets.
Referrin~ again to FIGURE 12, it has been found experimentally that the width, WT, of the tab and the amount of inward projection or protuberance, P, of the tab from the inside edge of the hole toward the center Gf the flow aperture o~ the valve is important in preventing abrasion of the tissue leaflets on the inside edges of the tab. When the tissue leaflets coapt together during the closing action of the valve, if the tabs 12 0, 123 and 12~ protrude too far in toward the center of the flow aperture, abrasion can occur in the area generally marked 142 in FIGURE 8.
To prevent this abrasion, the dimension P shown in FIGURES 5 and 12 is, in the preferred embodiment, restricted to a maximum of for-ty thousandths of an inch (0.040 inches or 1.016 millimeters). However, any embodiment will be satisfactory wherein the distance which the tab extends toward the center of -31 ~3~

the aperture is restricted to a distance which sub-stantially eliminates touching between the tissue leaflets and the bottom surfaces or lower 20% of the tab under maximum backpressure conditions. The bottom of the tab surfaces refers generally to those portions of the tab surfaces below the midway point in the height of the tab designated HT2 in FIGURES
~, 13 and 14.
The area of coaptation of the tissue leaflets, designated generally as 144 in FIGURE 8, tends to grow larger during higher backpressure conditions.
This phenomenon can be ~isualized in placing the fingertips on each hand to~ether fingerprint to fingerprint with the fingertips on the other hand to form a roof shaped arrangementO The fingerprint area of contact represents the area of coaptation 144 in FIGURE 8. As the hands are pressed together keeping the fingers stiff, the fingers tend to flex toward each other such that the opposing first and second knuckle areas tend to come closer together.
This represents the situation when higher backpressure exists on the tissue leaflets during closing.
As the tissue leaflets come closer together under increased backpressure, the area of contact between the leaflets tends to increase by expanding in the downward direction, i.e. toward the stent ring 104 in FIGURE 7. If the tabs 120, 123 and 125 extend too far in toward khe center, abrasion between the mobile areas of the tissue leaflets just inside the kabs and the bottom portions of the tabs can occur. Restriction of the distance which the tabs protrude into the flow aperture tends to eliminate the aforestated abrasion.

-32~ 3~5~

The same reasoning applies to restriction of the relative widths, WT, of the tabs 120, 123 and 125 throughout their height I~T2 as compared to the relatiYe width of the stent legs 106, 108 and 110 as the stent legs descend from tips 107, 109 and 111.
Referring to FIGURE 13, there is shown a detail view of the preferred embodiment for the tabs and stent leg tips. As seen in FIGU~E 13, the width, WT, of the tab 120 remains constant throughout its height, HT2, regardless of the width of the stent leg 106. It is seen in FIGURE 13 that the width o~ the stent leg 106 is increasing at points farther away from the tip 107.
FIGURE 14 shows another embodiment for the tabs wherein the width, WT, o~ the tab 120 decreases at lS points farther down from the tip 107 irrespective of the width of said stent leg.
The purpose of maintaining a constant or de-creasing width for the tabs 120, 123 and 125 is to minimize the possibility of abrasion of the tissue leaflets on the tabs during closure of the valve and coaptation of the tissue leaflets just inside the tabs.
The increasing width of the stent legs 106, 108 and 110 tend to give shape and support to the tissue leaflets to f~rm the cusps of the valve. The incLeasing width of the stent legs versus the constant or dec~easing width of the tabs tends to keep the tissue leaflets away from the lower sur~aces o~ the tabs during coaptation thereby minimizing abrasion. Any shape or form for the tabs which accomplishes the purpose of minimizing or eliminating this abrasion will be satisfactory and is intended to be included within the scope of the claims appended thereto.

-33~

~ s exemplary only and not in any limiting sense, optimum stent dimensions for the stent depicted in F~GURES 5 and 6 are given in Table I.
In FIGUP~ES 5 and 6, D refers to the inside diameter of the stent ring and Do refers to the outside diameter thereof. V refers to the depth of scallop 112 and W refers to the width of stent ring 104.
Ri refers to the inside radius of the scallop 112 and Ro refers to the outside radius of the scallop forming the bottom of stent rin~ 1040 Finally HT2 refers to the total height of the tabs.
It will be apparent that the foregoing description, given in considerable detail as to the method o~
carrying out the bes-t mode of the invention as contemplated by the inventor, is given to e~emplify the concepts and principles of the invention and not to limit it. The stent may be made of titanium, Delrin (TM), polyacetal, polypropylene or Elgiloy with the fabric covering of Dacron or Teflon but the invention is not limited to these materials nor is it limited to any particular covered stent; indeed, the present invention can be carried out without a covered stent. Similarly, the structures and elements of the invention have been descrihed, in their best mode embodiments, as integral, in the case of the stent, and separate, in the case of the le~flets. Elowever, whether formed of one or many pieces, if the structure which results functions in the manner as described herein, it is the same invention. Thus, it is contemplated that the scope of the invention will be as defined in the following claims read in light oP the principles of the invention as disclosed herein and not limited by the best mode.

~3~5S

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-35~

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Claims (4)

1. A prosthetic heart valve comprising:
a stent comprising an annular base integrally formed with three upwardly extending legs, the space between the legs configured to form generally elliptically shaped scallops having a depth U measured from the top of the legs to the bottom of the scallop, the stent circumferentially forming a substantially right cylinder having an interior diameter D with the legs extending parallel to the axis of the cylinder, the lower edge of the base forming scallops corresponding generally to the arc of the scallops between the legs, the scallops of the lower edge of the base and the scallops between the legs vertically defining three generally elliptically shaped one-third portions of the base between the respective upright legs;
a fabric covering encompassing and following the configuration of the stent;
an annular sewing ring attached to -the fabric covering and extending outwardly from the base;
a tissue valve element formed of three tissue leaflets joined to form a generally cylindrical three-cusp valving element, each leaflet having a top edge forming a raised truncated triangular form with a central plateau and two sides diverging from each side of the plateau to corners at their junctures with the sides of the leaflet;

means attaching the tissue valve element around the fabric covered stent; and a plurality of coaptation stitches through the tissue leaflets adjacent the upper edges thereof disposed directly above the tops of the fabric covered stent legs fixing the leaflets to form three cusps, with said plateaus extending upwardly midway between the legs in the open position of the valve, the upper edges of the cusps meeting in the closed position of the valve with the plateaus adjacent each other, and in the open position of the valve the tissue valve element forming a cylinder having an inside diameter at the top of the valve sub-stantially equal to the inside diameter of the fabric covered stent.

2. The prosthetic heart valve of Claim 1 wherein the ratio U/D is from about 0.50 to about 0.65.

3. The prosthetic heart valve of Claim 1 wherein the width of the area of contact of the cusps in the closed position of the valve is about 0 to 2 mm in the center of the valve and from about 3 to about 7 mm halfway between the center of the valve and the legs of the stent.

4. The prosthetic heart valve of Claim 1 wherein the sewing ring extends outwardly circumferentially forming an annulus vertically following the scalloped curvcature of the base of the stent.