Device for monitoring valve expansion

Abstract

Embodiments of a prosthetic valve delivery device are disclosed. The delivery device may include an indicator arm that is changeable between a first configuration and a second configuration. The second configuration differs from the first configuration by a different position or shape of the indicator arm. The indicator arm can be configured to remain in the first configuration when the diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size.

Description

[Technical field]

[0001] [CROSS REFERENCE TO RELATED APPLICATIONS] This application claims the benefit of priority to U.S. Provisional Application No. 62 / 978,193, filed February 18, 2020, which is incorporated herein by reference.

[0002] The present invention relates to embodiments of systems and methods for monitoring the radial expansion of a prosthetic valve. [Background technology]

[0003] The human heart can suffer from a variety of valvular diseases. These valvular diseases can result in significant dysfunction of the heart, eventually requiring repair of the native valve or replacement of the native valve with an artificial valve. There are several known repair devices (e.g., stents) and artificial valves, as well as several known methods for implanting these devices and valves in humans. Due to the drawbacks associated with traditional open-heart surgery, percutaneous and minimally invasive surgical approaches have been of interest. In one technique, the artificial device is configured to be implanted in a minimally invasive procedure using a catheter. For example, a collapsible percutaneous prosthetic heart valve can be collapsed to a compressed state, introduced percutaneously in the compressed state by a catheter, and expanded to a size operable at a desired location. Despite recent advances in percutaneous valve technology, there remains a need for improved percutaneous heart valves and improved delivery devices for such valves. [Prior art documents] [Patent documents]

[0004] [Patent Document 1] U.S. Patent No. 6,730,118 [Patent Document 2] U.S. Patent No. 7,393,360 [Patent Document 3] U.S. Patent No. 7,510,575 [Patent Document 4] U.S. Pat. No. 7,993,394 [Patent Document 5] U.S. Patent No. 8,252,202 [Patent Document 6] U.S. Patent Application Publication No. 62 / 614,299 [Patent Document 7] US Patent Application Publication No. 2018 / 0153689 [Patent Document 8] US Patent Application Publication No. 2018 / 0344456 [Patent Document 9] US Patent Application Publication No. 2015 / 0135506 [Patent Document 10] US Patent Application Publication No. 2014 / 0296962 [Patent Document 11] U.S. Patent Application No. 16105353 [Patent Document 12] U.S. Provisional Application No. 62 / 776,348 [Patent Document 13] WO 2019 / 64373 [Patent Document 14] U.S. Provisional Application No. 62 / 928291 [Patent Document 15] U.S. Provisional Application No. 62 / 950005 Summary of the Invention [Problem to be solved by the invention]

[0005] The present invention is directed to methods and devices relating to monitoring the radial expansion, and therefore the size, of a prosthetic valve within a patient. The present invention is also directed to methods and devices relating to locking a prosthetic valve at a desired expanded diameter. [Means for solving the problem]

[0006] Some embodiments of the invention relate to a delivery device configured to provide visual feedback of radial expansion of a prosthetic valve. In one exemplary embodiment, the delivery device includes a first portion and a second portion. The first portion is configured to maintain a fixed spatial relationship with a first end of the prosthetic valve during radial expansion of the prosthetic valve, and the second portion is configured to maintain a fixed spatial relationship with a second end of the prosthetic valve. The first portion can include one or more reference radiopaque markers, and the second portion can include an indicator radiopaque marker. The position of the indicator radiopaque marker relative to the one or more reference radiopaque markers allows for a measurement of the axial distance between the first and second ends of the prosthetic valve, which indicates a corresponding diameter of the prosthetic valve when the prosthetic valve is radially expanded from a radially compressed state to a radially expanded state.

[0007] Some embodiments of the present invention also relate to a prosthetic valve delivery assembly. The assembly may include a prosthetic valve having an inflow end and an outflow end, and a delivery device having a first portion and a second portion. The second portion may be configured to move axially relative to the first portion as the prosthetic valve is radially expanded from a radially compressed state to a radially expanded state. The first portion may include one or more reference radiopaque markers, and the second portion may include an indicator radiopaque marker. The position of the indicator radiopaque marker relative to the one or more reference radiopaque markers may provide a measurement of the axial length of the prosthetic valve, which is indicative of a corresponding diameter of the prosthetic valve.

[0008] Some embodiments of the present invention further relate to a method for implanting a prosthetic valve, which may include positioning the prosthetic valve at a target site within a patient using a delivery device, radially expanding the prosthetic valve from a radially compressed state to a radially expanded state, and monitoring under fluoroscopy a diameter of the prosthetic valve based on a change in position of an indicator radiopaque marker relative to one or more reference radiopaque markers. The indicator radiopaque marker and the reference radiopaque marker may be disposed on the delivery device.

[0009] Some embodiments of the invention relate to a delivery device configured to provide visual feedback of radial expansion of a prosthetic valve. The delivery device can include an indicator arm changeable between a first configuration and a second configuration, the second configuration differing from the first configuration in location or shape of the indicator arm. The indicator arm can be configured to remain in the first configuration when the diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size.

[0010] Some embodiments of the invention also relate to medical assemblies including a prosthetic valve and a delivery device configured to radially expand and compress the prosthetic valve. The delivery device may include an indicator arm changeable between a first configuration and a second configuration. The indicator arm in the second configuration may differ in location or shape from the first configuration. The indicator arm may be configured to remain in the first configuration when the diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size.

[0011] Some embodiments of the invention also relate to a method of implanting a prosthetic valve. The method may include positioning the prosthetic valve at a target site within a patient using a delivery device. The delivery device may include an indicator arm held in a first configuration. The method may further include radially expanding the prosthetic valve from a radially compressed state to a radially expanded state, and determining that the diameter of the prosthetic valve has reached a predetermined size when the indicator arm changes to a second configuration. The indicator arm in the second configuration may be in a different position or shape than the first configuration.

[0012] Some embodiments of the invention also relate to a delivery device configured to provide visual feedback of radial expansion of a prosthetic valve. The delivery device may include an indicator arm movable between a biased position and an unbiased position. The indicator arm may be configured to remain in the biased position when the diameter of the prosthetic valve is less than a first predetermined size and to move to the unbiased position when the diameter of the prosthetic valve is expanded to the first predetermined size.

[0013] Some embodiments of the invention further relate to a medical assembly comprising a prosthetic valve and a delivery device. The delivery device may include a drive member and an indicator arm attached to the drive member. The drive member may be removably attached to an expansion mechanism of the prosthetic valve. The expansion mechanism may be configured to radially expand and compress the prosthetic valve. The indicator arm may be changeable between a first configuration and a second configuration. The indicator arm in the second configuration may differ in location or shape from the first configuration. The indicator arm may be configured to remain in the first configuration when the diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size.

[0014] Some embodiments of the present invention further relate to a method of providing visual feedback that a prosthetic valve has radially expanded. The method may include connecting a drive member to an expansion mechanism of the prosthetic valve. The drive member may include an indicator arm held in a first configuration. The method may further include actuating the expansion mechanism with the drive member to radially expand the prosthetic valve from a radially compressed state to a radially expanded state, and determining that the diameter of the prosthetic valve has reached a predetermined size when the indicator arm changes to a second configuration. The indicator arm in the second configuration may differ in location or shape from the first configuration.

[0015] The above and other objects, features, and advantages of the disclosed technology will become more apparent from the following detailed description which proceeds with reference to the accompanying drawings. [Brief description of the drawings]

[0016] [Figure 1] FIG. 1 is a side elevation view of one embodiment of a prosthetic valve delivery assembly. [Figure 2A] FIG. 13 is a side perspective view of an inner member of a valve expansion mechanism according to one embodiment. [Figure 2B] FIG. 13 is a side perspective view of the valve expansion mechanism. [Figure 2C] FIG. 2C is a side perspective view of one embodiment of a prosthetic valve including multiple expansion mechanisms of the type shown in FIG. 2B. [Diagram 3] 2C is a cross-sectional view of one of the valve expansion mechanisms and components of a delivery device of FIG. 2B. [Figure 4] FIG. 2C is a perspective view of one of the valve expansion mechanisms of FIG. 2B and components of a delivery device. [Diagram 5] FIG. 1 illustrates a prosthetic valve in a radially compressed configuration. [Figure 6] FIG. 6 illustrates the prosthetic valve of FIG. 5 in a radially expanded configuration with an unlocked radial diameter. [Figure 7] 6 shows the prosthetic valve of FIG. 5 after the locking mechanism has been activated to lock the prosthetic valve in the expanded state. [Figure 8]13A-13C show an alternative embodiment of a portion of a delivery device having a plurality of indicator radiopaque markers and a plurality of reference radiopaque markers. [Figure 9A] FIG. 2 illustrates a portion of a delivery device with an indicator arm held in a first configuration, according to a first embodiment. [Figure 9B] FIG. 9B illustrates the portion of the delivery device of FIG. 9A with the indicator arm changed to a second configuration. [Figure 10] 13A shows a portion of a delivery device having an indicator arm according to a second embodiment. [Figure 11] 13A-13D show a portion of a delivery device having an indicator arm according to a third embodiment. [Figure 12] FIG. 13 shows a portion of a delivery device having an indicator arm according to a fourth embodiment. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0017] Described herein are examples of prosthetic implant delivery assemblies and components thereof that can enhance a physician's ability to monitor and / or control the size of a mechanically expandable prosthetic implant, such as a prosthetic valve (e.g., a prosthetic heart valve or venous valve), stent, or graft, and to lock the size of the prosthetic implant during an implantation procedure. The prosthetic heart valves disclosed herein can be implanted within any of the heart's native valves (aortic, mitral, tricuspid, and pulmonary valves).

[0018] The prosthetic valves disclosed herein can be radially compressible and expandable between a radially compressed state and a radially expanded state, such that the prosthetic valve can be contracted or held in a radially compressed state by an implant delivery device during delivery, and then expanded to a radially expanded state once the prosthetic valve reaches the implantation site.

[0019] 1 illustrates an example of a prosthetic implant delivery assembly 10 according to one embodiment of the present invention. The delivery assembly 10 may include two major components: a prosthetic valve 200 and a delivery device 100. The prosthetic valve 200 may be releasably coupled to the delivery device 100 via one or more retention and actuator assemblies 110, as described further below. It should be understood that the delivery device 100, and other delivery devices disclosed herein, may be used to implant prosthetic devices other than prosthetic valves, such as stents or grafts.

[0020] The delivery device 100 may include a handle 102 at its proximal end. The delivery device 100 may include one or more shafts 104 coupled to the handle 102. During delivery of the prosthetic valve 200, the handle 102 may be manipulated by a surgeon to advance and retract the delivery device 100 through the patient's vasculature. In some embodiments, the handle 102 may include multiple knobs or other actuation mechanisms that control separate components of the delivery device 100 to expand and / or position the prosthetic valve 200. For example, the handle 102 may include one or more knobs or other actuation mechanisms, each configured to operate a respective retention and actuator assembly 110 of the delivery device 100 to interact with a corresponding valve expansion mechanism 300 (also referred to as a "valve actuator") to expand or compress the prosthetic valve 200 and / or lock the prosthetic valve 200 at a desired diameter, as described further below.

[0021] 2C is a perspective view of the prosthetic valve 200. In certain embodiments, the prosthetic valve 200 can be implanted in the native aortic annulus, but can also be implanted elsewhere in the heart, including in the native mitral, pulmonary, and tricuspid valves. The prosthetic valve 200 can include an annular stent or frame 204 having a proximal end 206 and a distal end 208. In some embodiments, the proximal end 206 can be the outflow end and the distal end 208 can be the inflow end. In other embodiments, the proximal end 206 can be the inflow end and the distal end 208 can be the outflow end. For example, in a retrograde transfemoral approach to implanting the prosthetic valve, the proximal end 206 can be the outflow end and the distal end 208 can be the inflow end. In another example, in an antegrade transseptal route to implanting the prosthetic valve, the proximal end 206 can be the inflow end and the distal end 208 can be the outflow end.

[0022] The prosthetic valve 200 may also include a valve structure 202, which is attached to a frame 204 and configured to regulate the flow of blood through the prosthetic valve 200 from the inflow end to the outflow end. For example, the valve structure may include a leaflet assembly with one or more leaflets made of a flexible material. The leaflets of the leaflet assembly may be made in whole or in part from a biological material, a biocompatible synthetic material, or other such material. Suitable biological materials may include, for example, bovine pericardium (or pericardium from other sources). Further details regarding transcatheter prosthetic heart valves, including the manner in which the valve structure may be attached to the prosthetic valve frame, may be found, for example, in U.S. Patent Nos. 5,233,633, 5,233,633, 5,233,633, 5,233,633, and 5,371,363, all of which are incorporated herein by reference in their entirety.

[0023] Although not shown, the prosthetic valve 200 may also include one or more skirts or sealing members. For example, the prosthetic valve 200 may include an inner skirt attached to an inner surface of the frame. The inner skirt may function as a sealing member to prevent or reduce paravalvular leakage, to secure the leaflets to the frame, and / or to protect the leaflets from damage caused by contact with the frame during retraction and during the operating cycle of the prosthetic valve. The prosthetic valve 200 may also include an outer skirt attached to an outer surface of the frame 204. The outer skirt may function as a sealing member of the prosthetic valve by sealing against the tissue of the native annulus and by helping to reduce paravalvular leakage through the prosthetic valve. The inner and outer skirts may be made from any of a variety of suitable biocompatible materials, including any of a variety of synthetic materials (e.g., PET) or natural tissue (e.g., pericardial tissue).

[0024] The frame 204 may be made of any of a variety of suitable materials, such as stainless steel, a cobalt-chromium alloy (e.g., MP35N alloy), or a nickel-titanium alloy ("NiTi"), e.g., Nitinol. As shown, the frame 204 may include a plurality of interconnected struts 210 arranged in a lattice-type pattern. The struts 210 are shown as being disposed diagonally or offset at an angle to a longitudinal axis 214 of the prosthetic valve 200 when the prosthetic valve 200 is in an expanded configuration, and radially offset from the longitudinal axis. In other embodiments, the struts 210 may be offset by a different amount than depicted in FIG. 2C, or some or all of the struts 210 may be disposed parallel to the longitudinal axis of the prosthetic valve 200.

[0025] In the illustrated embodiment, the struts 210 are pivotally coupled to one another at one or more pivot joints along the length of each strut. For example, each of the struts 210 may be formed with openings 212 at opposite ends of the strut and spaced apart along the length of the strut. Each hinge may be formed with a rivet extending through the opening. 2. The struts 210 can be formed at an overlapping position with fasteners such as pins 216 (see, e.g., FIG. 3) or hinges such as pins 216. The hinges can allow the struts 210 to pivot relative to one another when the frame 204 is radially expanded or compressed, such as during assembly, preparation, or implantation of the prosthetic valve 200.

[0026] In some embodiments, the frame 204 can be constructed by creating individual components (e.g., frame struts and stops) and then mechanically assembling and connecting the individual components. In other embodiments, the struts 210 are not connected to one another at their respective hinges, but are otherwise pivotable or bendable relative to one another to allow radial expansion and contraction of the frame 204. For example, the frame 204 can be formed (e.g., by laser cutting, electroforming, or physical vapor deposition) from a single piece of material (e.g., a metal tube). Further details regarding the construction of frames and prosthetic valves that can be used with the delivery devices disclosed herein are described in U.S. Patent Nos. 5,233,633; 5,233,633; 5,233,633; 5,233,633; and 5,233,633, all of which are incorporated herein by reference.

[0027] As alluded to above, the prosthetic valve 200 may further include one or more valve expansion mechanisms 300. As shown in FIG. 1, each of the expansion mechanisms 300 may be configured to form a releasable connection with a respective retention and actuator assembly 110 of the delivery device 100. In some embodiments, the valve expansion mechanisms 300 may be mounted and evenly spaced around the inner surface of the frame 204. For example, FIG. 2C shows three valve expansion mechanisms 300 evenly spaced around the inner surface of the frame 204. It should be understood that the prosthetic valve 200 may have any number of valve expansion mechanisms, which may be mounted to the outer surface of the frame or unevenly spaced around the frame.

[0028] As described below, the valve expansion mechanism 300 can be used to radially expand or compress the prosthetic valve 200. In some embodiments, the valve expansion mechanism 300 can also be used to lock the prosthetic valve 200 in a radially expanded state.

[0029] 2A-2C, the valve expansion mechanism 300 of the illustrated embodiment can include an inner member or actuator screw 302 (which in the illustrated embodiment functions as a linear actuator or push-pull member) with a relatively long upper or distal portion 304 and a relatively short lower or proximal portion 306 at the proximal end of the actuator screw 302, the proximal portion 306 being smaller in diameter than the upper portion 304. Both the distal portion 304 and the proximal portion 306 of the actuator screw 302 can have male threaded surfaces.

[0030] The actuator screw 302 may have a distal attachment piece 308 with a radially extending distal valve connector 310 attached to its distal end. The distal attachment piece 308 may be fixed (e.g., welded together or manufactured as one piece) to the actuator screw 302. The distal valve connector 310 may extend through an opening at or near the distal end of the frame 204 formed at a location on the frame where two or more struts intersect as shown in FIG. 2C. The distal valve connector 310 may be fixed (e.g., welded) to the frame 204. Due to the geometry of the struts, the distal end of the frame 204 consists of a series of alternating distal joints 250 and distal tips 252. In the illustrated example, the distal valve connectors 310 of the three valve expansion mechanisms 300 are connected to the frame 204 by passing through the distal joints 250. In other examples, one or more distal valve connectors 310 may connect to the frame 204 through the distal tip 252. In other embodiments, the distal valve connectors 310 may connect to a junction closer to the proximal end 206 of the frame 204.

[0031] The valve expansion mechanism 300 may further include an outer member or sleeve 312. The sleeve 312 may be annularly disposed about the distal portion 304 of the actuator screw 302 and may include axial openings at proximal and distal ends of the sleeve through which the actuator screw 302 may extend. The axial opening and lumen of the sleeve 312 may have a diameter greater than the diameter of the distal portion 304 of the actuator screw 302 such that the screw is free to move within the sleeve (the actuator screw 302 may move proximally and distally relative to the sleeve 312). Because the actuator screw 302 is free to move within the sleeve, it may be used to radially expand and / or contract the frame 204, as disclosed in further detail below.

[0032] The sleeve 312 may have a proximal valve connector 314 extending radially from its outer surface. The proximal valve connector 314 may be fixed (e.g., welded) to the sleeve 312. The proximal valve connector 314 may be axially spaced from the distal valve connector 310 such that the proximal valve connector may extend through an opening at or near the proximal end of the frame 204. The proximal end of the frame 204 is comprised of an alternating series of proximal joints 260 and proximal tips 262. In the illustrated example, the proximal valve connectors 314 of the three valve expansion mechanisms 300 are connected to the frame 204 through the proximal joints 260. In other examples, one or more of the proximal valve connectors 314 may be connected to the frame 204 through the proximal tips 262. In other embodiments, the proximal valve connectors 314 may be connected to a joint closer to the distal end of the frame 204.

[0033] It should be understood that the distal connector 310 and the proximal connector 314 do not have to be connected to opposite ends of the frame 204. The valve expansion mechanism 300 can be used to expand and compress the frame 204, so long as the distal and proximal connectors are connected to respective joints on the frame that are axially spaced apart from one another.

[0034] A locking nut 316 may be disposed inside the sleeve 312 and may have an internally threaded surface that is engageable with the externally threaded surface of the actuator screw 302. The locking nut 316 may have a notched portion 318 at its proximal end, the purpose of which will be described below. The locking nut may be used to lock the frame 204, particularly in a radially expanded state, as will be described below.

[0035] 3-4 show one valve expansion mechanism 300 in communication with components of a retention and actuator assembly 110 of a delivery device 100. As shown, the retention and actuator assembly 110 includes a support tube 120, an actuator member 122, and a locking tool 124. The proximal end of the support tube 120 may be connected to a handle or other control device (not shown) that a physician or operator of the delivery assembly may utilize to operate the valve expansion mechanism 300 described herein. Similarly, the proximal ends of the actuator member 122 and the locking tool 124 may be connected to a handle.

[0036] The support tube 120 annularly surrounds a proximal portion of the locking tool 124 such that the locking tool 124 extends through a lumen of the support tube 120. The support tube 120 and sleeve 312 are sized such that the distal end of the support tube 120 can abut or engage the proximal end 330 of the sleeve 312 such that the support tube 120 cannot move distally beyond the sleeve 312.

[0037] The actuator member 122 can extend through a lumen of the locking tool 124. The actuator member 122 can be, for example, a shaft, rod, cable, or wire. A distal end portion of the actuator member 122 can be releasably connected to a proximal portion 306 of the actuator screw 302. For example, the distal end portion of the actuator screw 302 can have an internally threaded surface that can engage with the external threads of the proximal portion 306 of the actuator screw 302. Alternatively, the actuator member can have external threads that engage with the internally threaded portion of the screw. Other releasable connection mechanisms (e.g., hook-and-loop fasteners, buckles, clips, magnets, etc.) can also be used. Thus, when the actuator member 122 is threaded onto the actuator screw 302, axial movement of the actuator member 122 can cause axial movement of the actuator screw 302.

[0038] A distal portion of the locking tool 124 annularly surrounds the actuator screw 302 and can extend through a lumen of the sleeve 312, and a proximal portion of the locking tool 124 annularly surrounds the actuator member 122 and can extend through a lumen of the support tube 120 to the handle 102 of the delivery device 100. The locking tool 124 can have an internally threaded surface that can engage with an externally threaded surface of the actuator screw 302 such that clockwise or counterclockwise rotation of the locking tool 124 advances the locking tool 124 distally or proximally along the actuator screw 302, respectively.

[0039] The distal end of the locking tool 124 may include a notched portion 326, as best seen in FIG. 4. The notched portion 326 of the locking tool 124 may have an engagement surface 327 configured to engage a correspondingly shaped engagement surface 319 of the notched portion 318 of the locking nut 316, such that rotation of the locking tool (e.g., clockwise) causes the locking nut 316 to rotate in the same direction (e.g., clockwise) and advance distally along the actuator screw 302. The notched portions 318, 326 of the illustrated embodiment are configured such that rotation of the locking tool 124 in the opposite direction (e.g., counterclockwise) causes the notched portion 326 of the locking tool 124 to disengage the notched portion 318 of the locking nut 316. That is, rotation of the locking tool 124 in a direction that moves the locking tool 124 proximally does not result in a corresponding rotation of the locking nut 316.

[0040] In alternative embodiments, the distal end portion of the locking tool 124 may have a variety of other configurations adapted to engage and cause rotation of the locking nut 316 by rotation of the locking tool 124 to move the nut distally, such as any of the tool configurations described herein. In some embodiments, the distal end portion of the locking tool 124 may be adapted to cause rotation of the locking nut 316 in both directions to move the locking nut 316 distally and proximally along the actuator screw 302.

[0041] In operation, prior to implantation, the actuator member 122 can be threaded onto the proximal portion 306 of the actuator screw 302 and the locking nut 316 can be rotated so that it is disposed on the proximal end of the actuator screw 302. The frame 204 can then be placed in a radially collapsed state and the delivery assembly 200 can be inserted into the patient. Once the prosthetic valve is at the desired implantation site, the frame 204 can be radially expanded as described herein.

[0042] To radially expand the frame 204, the support tube 120 can be held rigidly against the sleeve 312. The actuator member 122 can then be pulled proximally through the support tube 120, such as by pulling on the proximal end of the actuator member 122 or by moving a control knob on a handle which causes proximal movement of the actuator member 122. The support tube 120 is held against the sleeve 312, which is connected to the proximal end of the frame 204 by the proximal valve connector 314, so that the proximal end of the frame 204 is prevented from moving relative to the support tube 120. Thus, proximal movement of the actuator member 122 can cause the actuator screw 302 to move proximally (because the actuator member 122 is threaded into the actuator screw 302), thereby allowing the frame 204 to contract axially and expand radially. Alternatively, the frame 204 can be expanded by moving the support tube 120 distally while keeping the actuator member 122 fixed, or by moving the support tube 120 distally while moving the actuator member 122 proximally.

[0043] After the frame 204 has been expanded to a desired radially expanded size, the frame 204 may be locked in this radially expanded size as described herein. Locking the frame 204 may be accomplished by rotating the locking tool 124 in one direction (e.g., clockwise) to engage the notched portion 326 of the locking tool with the notched portion 318 of the locking nut 316, thereby advancing the locking nut 316 distally along the actuator screw 302. The locking tool 124 may be so rotated until the locking nut 316 abuts an internal shoulder on the distal end of the sleeve 312 such that the locking nut 316 cannot be advanced distally any further (see, e.g., FIG. 4). This prevents the actuator screw 302 from advancing distally relative to the sleeve 312 and radially compressing the frame 204. However, in the illustrated embodiment, the locking nut 316 and actuator screw 302 can still be moved proximally through the sleeve 312, thereby allowing additional expansion of the frame 204 during implantation or later during a valve-in-valve procedure as described in U.S. Patent No. 5,313,633, which is incorporated herein by reference.

[0044] Once the frame 204 is locked in the radially expanded state, the locking tool 124 can be rotated in a direction that moves the locking tool 124 proximally (e.g., counterclockwise) to separate the notched portion 326 from the notched portion 318 of the locking nut 316 and remove the locking tool 124 from the actuator screw 304. Additionally, the actuator member 122 can be rotated in a direction that removes it from the proximal portion 306 of the actuator screw 302 (e.g., the actuator member 122 can be configured to disengage from the actuator screw 302 when rotated counterclockwise). Once the locking tool 124 and actuator member 122 are removed from the actuator screw 304, they can be removed from the patient along with the support tube 120, leaving the actuator screw 302 and sleeve 312 connected to the frame 204 and locking the frame 204 in a particular radially expanded state, as shown in FIG.

[0045] In an alternative embodiment, the locking tool 124 can be formed without female threads that engage with the male threads of the actuator screw 302 such that the locking tool 124 can be slid distally and proximally along the actuator screw 302 through the sleeve 312 to engage and disengage the locking nut 316.

[0046] In yet another embodiment, instead of using the locking nut 316 and actuator screw 304 described above, the frame can be locked in the extended size using a different locking mechanism, such as the ratchet mechanism described in U.S. Patent Nos. 5,993,333 and 5,993,323, both of which are incorporated herein by reference.

[0047] Any of the delivery assemblies disclosed herein can have a variety of handle configurations with one or more actuators or controls configured to produce movement of the components of the assembly that expand and compress the prosthetic valve (or another type of implant). In some embodiments, the handle can have an actuator that can be operated by a user by manually rotating and / or manually pushing / pulling the actuator in the handle. In other embodiments, the actuator in the handle and / or other components of the assembly can be electrically, pneumatically, and / or hydraulically controlled.

[0048] For example, in some embodiments, the handle 102 may house one or more electric motors that are actuated by a user to produce movement of components of the delivery assembly, such as one or more electric motors operable to produce linear movement of the actuator screw 302 and one or more electric motors operable to produce rotational movement of the locking tools 124 (to rotate the locking nuts 316). In one particular implementation, one electric motor is used to produce all linear movement of the actuator screws 302 attached to the prosthetic valve, and one electric motor is used to produce all rotational movement of the locking tools 124 included in the assembly. In another implementation, one electric motor may be provided for each actuator screw and each locking tool 124. Further details regarding handle configurations including electric motors for controlling the delivery assembly components are disclosed in U.S. Patent Application Publication No. 2005 / 0139994, which is incorporated herein by reference.

[0049] Additionally, any of the delivery assemblies disclosed herein may include software and / or hardware operable to control the expansion of the prosthetic valve, as further disclosed in U.S. Patent No. 6,399,693. In certain embodiments, the delivery assembly may include a programmable controller (such as housed in the handle) operable to radially expand the prosthetic valve according to a particular algorithm. For example, the delivery assembly may include one or more motors (e.g., electric motors) controlled by an electronic controller to radially expand the prosthetic valve according to a particular algorithm. In some implementations, the controller may be programmed to produce a pulsatile radial expansion of the prosthetic valve, as further disclosed in U.S. Patent No. 6,399,693.

[0050] As described below, the delivery device 100 can be configured to provide real-time visual feedback for radially expanding the prosthetic valve 200. In some embodiments, the delivery device 100 can also be configured to provide visual confirmation that the prosthetic valve 200 is locked into a desired radial expansion size.

[0051] In one embodiment, one or more reference radiopaque markers 140 can be positioned on an outer surface of the support tube 120 of the holding and actuator assembly 110, and at least one indicator radiopaque marker 142 can be positioned on an outer surface of the locking tool 124 of the same holding and actuator assembly 110.

[0052] Each of the indicator radiopaque marker 140 and the reference radiopaque marker 142 may comprise a radiopaque material, such as gold, platinum, tungsten, platinum-iridium alloy, palladium, etc., so that they are visible under fluoroscopy when the prosthetic valve is delivered into the patient's body by the delivery device. The markers may be formed using any of a variety of techniques known in the art. In some embodiments, the radiopaque markers 140 and 142 may be formed using radiopaque inks and adhesives and may be applied to the delivery device components in several ways, such as screen printing, high speed roller printing, coating, dipping, etc. In other embodiments, the markers may be separately formed components (e.g., in the form of an annular ring or C-shaped band that is attached to the delivery device component). Except for the reference radiopaque marker 140, the distal end portion of the support tube 120 may comprise a radiopaque material or have a cut-out window, which allows the indicator radiopaque marker 142 on the locking tool 124 to be visible under fluoroscopy.

[0053] In some embodiments, the reference radiopaque marker 140 is configured to be visually distinguishable under fluoroscopy from the indicator radiopaque marker 142. For example, the reference radiopaque marker 140 may have a different width and / or circumference than the indicator radiopaque marker 142.

[0054] As described above, to radially expand the frame 204, the distal end of the support tube 120 can be held rigidly against the sleeve 312 such that the proximal end of the frame 204 does not move relative to the support tube 120. Thus, the support tube 120 and the fiducial radiopaque markers 140 disposed therein maintain a fixed spatial relationship relative to the proximal end 206 of the frame 204 during radial expansion of the prosthetic valve.

[0055] Further, as described above, pulling the actuator member 122 proximally through the support tube 120 may move the actuator screw 302 (or the ratchet rack, if a ratchet mechanism as described in U.S. Patent No. 5,993,331 or U.S. Patent No. 5,993,331 is used) proximally, thereby causing the frame 204 to contract axially and expand radially. Because the locking tool 124 is threadably coupled to the actuator screw 302, the locking tool 124 and the indicator radiopaque marker 142 disposed therein maintain a fixed spatial relationship relative to the distal end 208 of the frame 204 during radial expansion of the prosthetic valve.

[0056] Thus, the position of the indicator radiopaque marker 142 relative to one or more reference radiopaque markers 140 allows for the measurement of an axial length of the frame 204 (i.e., the distance between the proximal end 206 and the distal end 208) that is indicative of a corresponding diameter of the prosthetic valve when the prosthetic valve is radially expanded from a radially compressed state to a radially expanded state. In other words, the reference radiopaque marker 140 can effectively function as a "scale" and the indicator radiopaque marker 142 can effectively function as a "dial" or "pointer," such that the position of the "dial" relative to the "scale" can indicate a corresponding diameter of the prosthetic valve.

[0057] Thus, as the operator radially expands the prosthetic valve by actuating the valve expansion mechanism 300, the operator can monitor and / or measure the diameter of the prosthetic valve in real time under fluoroscopy based on the matching of the indicator radiopaque marker 142 with any one of the reference radiopaque markers 140.

[0058] The indicator radiopaque marker 142 is desirably configured to be disposed on the exterior of the frame 204 to ensure that the indicator radiopaque marker 142 is always visible under fluoroscopy during radial expansion of the prosthetic valve. For example, in some embodiments, the indicator radiopaque marker 142 can be disposed along a proximal portion of the locking tool 124 between the proximal end 206 of the frame 204 and the proximal end 330 of the sleeve 312. In other embodiments, the indicator radiopaque marker 142 can be disposed along a proximal portion of the locking tool 124 near the proximal end 330 of the sleeve 312.

[0059] As described above, the support tube 120 may include multiple reference radiopaque markers 140. For example, while FIGS. 5-7 show three reference radiopaque markers 140a, 140b, 140c, it is understood that any number of reference radiopaque markers 140 may be used. Each reference radiopaque marker 140 may correspond to a particular diameter of the prosthetic valve. For example, while the prosthetic valve is radially expanded from a radially compressed state, the indicator radiopaque marker 142 may align with the distal-most reference radiopaque marker 140a to indicate a first expanded diameter of the prosthetic valve, the indicator radiopaque marker 142 may align with the intermediate reference radiopaque marker 140b to indicate a second expanded diameter of the prosthetic valve, the second diameter being greater than the first diameter, and the indicator radiopaque marker 142 may align with the proximal-most reference radiopaque marker 140c to indicate a third expanded diameter of the prosthetic valve, the third diameter being greater than the second diameter.

[0060] In the depicted example, the more distally located reference radiopaque markers indicate a smaller diameter of the prosthetic valve than the more proximally located reference radiopaque markers. For example, the prosthetic valve may be expanded to a diameter within an operating range defined by a minimum diameter Dmin and a maximum diameter Dmax. Thus, reference radiopaque marker 140a may indicate a minimum diameter Dmin, reference radiopaque marker 140c may indicate a maximum diameter Dmax, and reference radiopaque marker 140b may indicate a median diameter Dmed. In an exemplary embodiment, reference radiopaque markers 140a, 140b, and 140c may indicate a prosthetic valve expanded to a diameter of 27 mm, 28 mm, and 29 mm, respectively.

[0061] It should be appreciated that the support tube 120 may have any number of reference radiopaque markers. For example, the number of reference radiopaque markers 140 may be only one or two, or may be three or more.

[0062] In some embodiments, the plurality of reference radiopaque markers 140 disposed on the support tube 120 are evenly spaced with equal spacing between any two adjacent reference radiopaque markers. In other embodiments, the plurality of reference radiopaque markers 140 can be unequally spaced.

[0063] While the embodiment depicted in Figures 5-7 shows only one expansion mechanism 300 coupled to the retention and actuator assembly 110, it should be understood that each of the expansion mechanisms can be connected to a corresponding retention and actuator assembly, as shown in Figure 1. In some embodiments, only one, or selected, of the retention and actuator assemblies 110 can have a corresponding set of indicator and reference radiopaque markers. In other embodiments, each of the retention and actuator assemblies can include a respective indicator radiopaque marker and reference radiopaque marker to facilitate the operator's viewing of the radiopaque markers regardless of the angular position of the prosthetic valve.

[0064] Although the embodiment depicted in Figures 5-7 shows only one type of expansion and locking mechanism 300 coupled to the retention and actuator assembly 110, it should be understood that the same concept of using radiopaque markers to indicate the radial diameter of the prosthetic valve and / or lock confirmation of the frame can be applied when other expansion and locking mechanisms are used, such as the ratchet mechanisms described in U.S. Patent No. 5,399,623 or U.S. Patent No. 5,499,623.

[0065] As discussed above and further shown in Figures 6-7, the frame 204 can be locked into its radially expanded size by rotating the locking tool 124 to advance the locking nut 316 to the distal end of the sleeve 312. According to one embodiment, at least one radiopaque marker can be used to visually confirm under fluoroscopy that the locking nut 316 has been moved to the desired position to lock the frame 204.

[0066] For example, the indicator radiopaque marker 142 can be configured to mate or be adjacent to the proximal end portion 332 of the sleeve 312 when the locking tool 124 advances the locking nut 316 to the distal end of the sleeve 312. In one embodiment, the proximal end portion 332 of the sleeve 312 can include a radiopaque marker such that it is visible under fluoroscopy. In other embodiments, the proximal end portion 332 of the sleeve 312 does not include a radiopaque marker. Instead, the proximal end portion 332 of the sleeve 312 can be sized and / or shaped to be visually distinguishable from surrounding structures under fluoroscopy. For example, the proximal end portion 332 can have a larger diameter than the distal end support tube 120. Thus, locking of the frame 204 can be confirmed by verifying that the indicator radiopaque marker 142 mates with the proximal end portion 332 of the sleeve 312. By way of example, FIG. 6 shows the indicator radiopaque marker 142 in an “unlocked” position spaced proximally from the frame 204, while FIG. 7 shows the indicator radiopaque marker 142 in a “locked” position aligned with or adjacent to the proximal end portion 332 of the sleeve 312.

[0067] In some embodiments, delivery device 100 includes only one set of radiopaque markers (e.g., markers 140 and 142) that are used to provide both visual feedback of the radial diameter of the prosthetic valve and visual confirmation of frame locking. In other embodiments, the delivery device may include one set of radiopaque markers that are used only for visual feedback of the radial diameter of the prosthetic valve and / or one or more different radiopaque markers that are used for visual confirmation of frame locking. Alternative Embodiments for Monitoring Valve Expansion and Verifying Framelock

[0068] Although the systems and methods for monitoring valve expansion and verifying framelock have been described with reference to the specific embodiments shown in FIGS. 1-7, it should be understood that the disclosed embodiments are non-limiting examples and that the general concepts disclosed herein may be implemented in alternative embodiments.

[0069] For example, in some embodiments, the indicator radiopaque markers can be located on the actuator member 122 rather than on the locking tool 124. Because valve expansion occurs by pulling the actuator member 122 proximally relative to the support tube 120, the position of the indicator radiopaque markers on the actuator member 122 relative to the reference radiopaque markers on the support tube 120 can also indicate the diameter of the prosthetic valve during radial expansion.

[0070] In other embodiments, the relative locations of the indicator radiopaque markers and the reference radiopaque markers can be swapped. For example, one or more reference radiopaque markers can be located on an outer surface of the locking tool 124 and at least one indicator radiopaque marker can be located on an outer surface of the support tube 120. Thus, the indicator radiopaque markers remain stationary and the reference radiopaque markers move axially relative to the indicator radiopaque markers during valve expansion. Similarly, the matching of the indicator radiopaque markers with one or more of the reference radiopaque markers can indicate a corresponding expansion diameter of the prosthetic valve.

[0071] Although the valve expansion mechanism 300 described above comprises a moving inner member (actuator screw 302) and a fixed outer member (sleeve 312), it should be understood that the valve expansion mechanism can be configured differently so long as it allows for a first end of the prosthetic valve to be pushed towards a second end, or vice versa. In some embodiments, the first end is an inflow end and the second end is an outflow end. In other embodiments, the first end is an outflow end and the second end is an inflow end.

[0072] For example, in the embodiment described above with respect to Figures 5-6, the prosthetic valve can be expanded by pulling the inner member proximally relative to the outer member while holding the proximal end of the prosthetic valve stationary. In other embodiments, the prosthetic valve can be expanded by pushing the inner member distally relative to the outer member while holding the distal end of the prosthetic valve stationary. In yet other embodiments, the prosthetic valve can be expanded by pushing the proximal end distally while pulling the distal end proximally.

[0073] Alternatively, the valve expansion mechanism can be configured to have a fixed inner member and a movable outer member annularly surrounding the inner member. To expand the prosthetic valve, the outer member can be configured to hold the inflow end (or outflow end) of the prosthetic valve stationary, and the inner member can be configured to pull (or push) the outflow end (or inflow end) towards the inflow end (or outflow end) of the prosthetic valve.

[0074] More generally, the valve expansion mechanism can be configured to have two members that can be moved axially relative to one another. In some embodiments, the two members can be arranged side-by-side rather than coaxially. To expand the prosthetic valve, one member can be configured to hold the inflow end (or outflow end) of the prosthetic valve stationary, and the other member can be configured to pull (or push) the outflow end (or inflow end) towards the inflow end (or outflow end) of the prosthetic valve.

[0075] Regardless of how the valve expansion mechanism is configured, monitoring the diameter of the expanded prosthetic valve can be accomplished by applying the same concepts described above. For example, a delivery device can include a first portion releasably connected to a first member of the valve expansion mechanism and a second portion releasably connected to a second member of the valve expansion mechanism, the first and second members being configured to be axially movable relative to one another. One or more reference radiopaque markers can be disposed on the first portion (or the second portion) and an indicator radiopaque marker can be disposed on the second portion (or the first portion). Axial movement of the second portion relative to the first portion can result in corresponding axial movement between the first and second members, thereby resulting in axial compression and radial expansion of the prosthetic valve. Thus, matching of the indicator radiopaque markers with the one or more reference radiopaque markers can indicate the diameter of the expanded prosthetic valve.

[0076] Although the prosthetic valve has been described as having a mechanically expandable frame, it should be understood that the same concepts disclosed herein can also be applied to other types of prosthetic valves, such as balloon expandable prosthetic valves and self-expandable prosthetic valves. For example, the delivery device may include a first portion releasably connected to the inflow end (or outflow end) of the prosthetic valve and a second portion releasably connected to the outflow end (or inflow end) of the prosthetic valve. One or more reference radiopaque markers may be disposed on the first portion (or the second portion) and an indicator radiopaque marker may be disposed on the second portion (or the first portion). When the prosthetic valve is radially expanded by the self-expansion mechanism or by inflating the inflatable balloon, the distance between the inflow end and the outflow end of the prosthetic valve is shortened. As a result, the second portion moves axially relative to the first portion. Thus, the matching of the indicator radiopaque marker and the one or more reference radiopaque markers may indicate the diameter of the expanded prosthetic valve.

[0077] In yet another embodiment, two or more indicator radiopaque markers can be used in combination with one or more reference radiopaque markers. For example, FIG. 8 shows an embodiment of the retainer and actuator assembly 110 having three reference radiopaque markers 440a, 440b, 440c equally spaced apart at a distance d1, and two indicator radiopaque markers 442a, 442b spaced apart by a distance d2, which can be, for example, one-half of d1. The diameter of the prosthetic valve is indicated as D1, D2, or D3 when the proximal-most indicator radiopaque marker 442b matches the reference radiopaque marker 440a, 440b, or 440c, respectively. On the other hand, if the proximal-most indicator radiopaque marker 442b is located between the reference radiopaque markers 440a and 440b (or between 440b and 440c) and the distal-most indicator radiopaque marker 442a is aligned with the reference radiopaque marker 440a (or 440b), then the diameter of the prosthetic valve may be indicated as an intermediate value between D1 and D2 (or between D2 and D3), e.g., as the average of D1 and D2 (or the average of D2 and D3). Thus, using multiple indicator radiopaque markers spaced differently from the reference radiopaque markers can provide different measurement resolutions of the valve diameter.

[0078] It should be appreciated that the retention and actuator assembly can be configured to have any number of indicator radiopaque markers and any number of reference radiopaque markers. The marker spacing between the indicator radiopaque markers can be greater or less than the marker spacing between the reference radiopaque markers. Additionally, the marker spacing between the indicator radiopaque markers and / or the marker spacing between the reference radiopaque markers can be equal or uneven. Embodiments using indicator arms to monitor valve expansion

[0079] Some embodiments of the invention also relate to the use of indicator arms to monitor the radial expansion of a prosthetic valve, as described below. The indicator arms described below can be implemented in a delivery device, such as delivery device 100, with or without the radiopaque markers described above.

[0080] 9A-9B show a distal portion of a delivery device's retention and actuator assembly 510, according to one embodiment. The retention and actuator assembly 510 includes a support tube 520 (also referred to as the "first actuating element") and an actuator member 522 (also referred to as the "second actuating element"). The support tube 520 has an outer surface 524 and an inner surface 526. The inner surface 526 defines a lumen 528 into which the actuator member 522 extends. The actuator member 522 is axially movable within the lumen 528 relative to the support tube 520.

[0081] 1-7 and as described above, the retention and actuator assembly 510 can be configured to couple with a valve expansion mechanism 300 of a prosthetic valve 200. For example, a distal end of the support tube 520 can abut or engage a proximal end of the sleeve 312 of the valve expansion mechanism 300, and a distal end portion of the actuator member 522 can be releasably connected to a proximal portion 306 of the actuator screw 302 of the valve expansion mechanism 300.

[0082] For simplicity, Figures 9A-9B, as well as Figures 10-12 described below, show only the proximal portion 306 of the actuator screw 302, and omit other detailed structures of the valve expansion mechanism 300 and the prosthetic valve 200.

[0083] Similar to the operation of the retention and actuator assembly 110, the valve expansion mechanism can be actuated to radially expand or compress the prosthetic valve by axially moving the actuator member 522 relative to the support tube 520. For example, the prosthetic valve can be expanded by pulling the actuator member 522 (which can be connected to the actuator screw 302) proximally while keeping the support tube 520 (which can abut the sleeve 312) stationary. Alternatively, the prosthetic valve can be expanded by pushing the support tube 520 distally while keeping the actuator member 522 stationary, or by pushing the support tube 520 distally while pulling the actuator member 522 proximally.

[0084] The support tube 520 can have an indicator arm 550 that is changeable or movable between a first configuration (see, e.g., FIG. 9A) and a second configuration (see, e.g., FIG. 9B). As described more fully below, the indicator arm 550 can be configured to remain in the first configuration when the diameter of the prosthetic valve is less than a predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the predetermined size.

[0085] In some embodiments, the indicator arm 550 may include a resilient material such that the indicator arm 550 in a first configuration is in a biased state and the indicator arm 550 in a second configuration is in an unbiased state. Upon release from the first configuration, the indicator arm may self-expand or transition to the second configuration under the natural restoring force of the resilient material. Thus, the first configuration may be referred to as the "biased position" and the second configuration may be referred to as the "unbiased position." The resilient material may be a metal, alloy, plastic, or any other suitable material known in the art. In certain embodiments, the indicator arm 550 may be made from Nitinol.

[0086] In the biased position, the indicator arm 550 can be oriented generally along the axis of the support tube 520 and the prosthetic valve connected thereto (not shown). In the unbiased position, the indicator arm 550 can be oriented at an oblique angle (α) relative to the axis of the support tube 520 (and the prosthetic valve connected thereto).

[0087] In some embodiments, angle α can be between about 10 degrees and about 170 degrees. In some embodiments, angle α can be between about 30 degrees and about 150 degrees. In some embodiments, angle α can be between about 60 degrees and about 120 degrees. In some embodiments, angle α can be between about 45 degrees and about 90 degrees. In some embodiments, angle α can be about 90 degrees.

[0088] In some embodiments, the indicator arm 550 can be slightly arched or curved in the biased position (see, e.g., FIG. 9A). In some embodiments, the indicator arm 550 can be substantially straight in the unbiased position (see, e.g., FIG. 9B). In some embodiments, the indicator arm 550 can be substantially straight in both the biased and unbiased positions.

[0089] In the illustrated embodiment, the indicator arm 550 has a first end 552 and a second end 554. The first end 552 may be fixedly attached to the outer surface 524 of the support tube 520 by, for example, thermal bonding, adhesive, welding, mechanical fasteners, or any other suitable technique. Alternatively, the indicator arm 550 may be integrally formed with the support tube 520 (e.g., laser cutting the support tube to form the indicator arm and then shaping the indicator arm to be biased into the second configuration shown in FIG. 9B). The second end 554 of the indicator arm 550 is configured to be removably attached to the support tube 520.

[0090] For example, when the indicator arm 550 is in the biased position (see, e.g., FIG. 9A), the second end 554 can be removably attached to the support tube 520 such that an imaginary line extending through the first and second ends 552, 554 is generally parallel to the axis of the support tube 520.

[0091] 9A, the support tube 520 can have an opening 530 located distal to a first end 552 of an indicator arm 550 and proximal to the prosthetic valve (not shown). When the indicator arm 550 is in the biased position, a second end 554 of the indicator arm 550 can extend through the opening 530 and into the lumen 528. Further, the second end 554 can frictionally engage an edge 532 of the opening 530 and / or an inner surface 526 of the support tube 520 adjacent the opening 530 to hold the indicator arm 550 in the biased position.

[0092] In some embodiments, when the prosthetic valve is radially expanded, a portion of the prosthetic valve may proximally engage and push the second end 554 of the indicator arm 550 to help release the second end 554 from the support tube 520, thereby allowing the indicator arm 550 to return to its unbiased position (see, e.g., FIG. 9B ).

[0093] For example, the proximal portion 306 of the actuator screw may have a larger diameter than the actuator member 522. Thus, when the distal end of the actuator member 522 is connected to the proximal end of the proximal portion 306, at least the peripheral portion 307 of the proximal end of the proximal portion 306 may expand radially outwardly of the actuator member 522. In the illustrated embodiment, the proximal end of the proximal portion 306 has a frusto-conical shape. Thus, the peripheral portion 307 has an inclined surface relative to the actuator member 522. In other embodiments, the proximal end of the proximal portion 306 may have a cylindrical shape. Thus, the uncovered peripheral portion 307 may be perpendicular to the actuator member 522.

[0094] As described above, moving the actuator member 522 proximally relative to the support tube 520 causes the actuator screw to move proximally relative to the sleeve, thereby radially expanding the prosthetic valve. In some embodiments, as the actuator screw moves proximally, the peripheral portion 307 of the actuator screw can contact the second end 554 of the indicator arm 550 in the biased position. Further movement of the actuator screw proximally can exert a force against the second end 554 sufficient to urge the second end 554 proximally away from the edge 532 of the opening 530 and / or the inner surface 526 of the support tube 520. As a result, the second end 554 can pass through the opening 530 and out of the lumen 528 (i.e., released from the opening 530) and the indicator arm 550 can return to its unbiased position shown in FIG. 9B.

[0095] In some embodiments, the indicator arm 550 may have a radiopaque marker 556 such that a change in the indicator arm 550 from the biased position to the unbiased position is visible under fluoroscopy, for example, by observing a change in the position of the radiopaque marker 556. In some embodiments, the radiopaque marker 556 may be located adjacent the second end 554. In some embodiments, the radiopaque marker 556 may be located at an intermediate portion of the indicator arm 550. In alternative embodiments, the entire arm 550 may be formed of a radiopaque material that is visible under fluoroscopy.

[0096] In the illustrated embodiment, the opening 530 can be positioned in the support tube 520 such that the diameter of the prosthetic valve expands to a predetermined size when the peripheral portion 307 of the actuator screw engages the second end 554 of the indicator arm 550 and releases the second end 554 from the opening 530. Thus, once the indicator arm 550 is observed (e.g., under fluoroscopy) to change from the biased position to the unbiased position, it can be determined that the prosthetic valve has expanded to a predetermined size.

[0097] Although not shown, it should be understood that another portion of the prosthetic valve other than the peripheral portion 307 of the actuator screw, or even a portion of the retention and actuator assembly 510 itself, may be configured to engage and release the second end 554 of the indicator arm 550 from the opening 530. For example, a distal end portion of the actuator member 522 may have a shoulder (not shown) that projects radially outwardly of the actuator member 522, such shoulder being configured to contact the second end 554 when the actuator member 522 is moved proximally to push it out of the lumen 528 through the opening 530. The same principles described herein apply as long as the second end 554 of the indicator arm 550 can be released from the opening 530 by any portion of the prosthetic valve or delivery device when the prosthetic valve is expanded to a predetermined size.

[0098] 10 illustrates another embodiment of a retention and actuator assembly 512 that is similar to the retention and actuator assembly 510 described above, except that the support tube 520 may have multiple openings 530a, 530b, 530c, 530d (four in the illustrated example) located distal to the first end 552 of the indicator arm 550 and proximal to the prosthetic valve (not shown). Although four openings are shown in FIG. 10, it should be understood that the number of openings may be two, three, or five or more.

[0099] The indicator arm 550 can be held in the biased position when the second end 554 of the indicator arm 550 extends through any of the openings 530a, 530b, 530c, 530d into the lumen 528 and frictionally engages the edge of the corresponding opening or the inner surface 526 of the support tube 520 adjacent the corresponding opening.

[0100] Similarly, when the actuator screw is moved proximally (e.g., by moving the actuator member 522 proximally relative to the support tube 520), the peripheral portion 307 of the actuator screw can contact the second end 554 of the indicator arm 550 that is held in the biased position, regardless of which opening (530a, 530b, 530c, or 530d) the second end 554 extends through. Further proximal movement of the actuator screw can push the second end 554 out of the lumen 528 through the corresponding opening (530a, 530b, 530c, or 530d) so that the indicator arm 550 can return to its unbiased position.

[0101] In some embodiments, the openings 530a, 530b, 530c, 530d can be spaced apart from one another such that each opening corresponds to a different predetermined expansion diameter of the prosthetic valve. Prior to inserting the prosthetic valve into a patient, a user can insert the second end of the indicator arm 550 into the opening that corresponds to the desired expansion diameter for that particular patient. Thus, upon expansion of the prosthetic valve, when the second end 554 of the indicator arm 550 is released from its opening, the indicator arm 550 can move to its unbiased state to visually indicate that the prosthetic valve has been expanded to a selected diameter.

[0102] For example, the four openings 530a, 530b, 530c, 530d may correspond to four predetermined diameters Da, Db, Dc, Dd, respectively, of the prosthetic valve. In some embodiments, the closer an opening is to the first end 552 of the indicator arm 550, the larger the corresponding predetermined diameter. For example, in the example depicted in FIG. 10, the predetermined diameters corresponding to the openings 530a, 530b, 530c, 530d are progressively larger, i.e., Da, Db, Dc, Dd, respectively. <Db<Dc<Ddとすることができる。

[0103] In an alternative embodiment, the retention and actuator assembly 512 can have multiple indicator arms (not shown), each of which is similar to the indicator arm 550 described above. Each of the indicator arms can have a first end fixedly connected to the support tube 520 and a second end removably attached to the support tube 520. For example, the retention and actuator assembly 512 can have four indicator arms. The first ends of each of the four indicator arms can be fixedly coupled to the proximal portion of the support tube 520 (each of the first ends can be fixed to the same location on the proximal portion of the support tube 520 or spaced apart from one another). The second ends of the four indicator arms can each extend through the four openings 530a, 530b, 530c, 530d into the lumen 528 to retain the four indicator arms in their respective biased positions. Thus, successive proximal movements of the actuator screw can sequentially push the four second ends out of the lumen 528 through the corresponding openings (530a, 530b, 530c, or 530d) so that the corresponding indicator arms can return to their respective unbiased positions. The four openings can thus function as scales so that an operator can monitor to what diameter the prosthetic valve has expanded by noting which indicator arm has changed from its biased position to its unbiased position. In some embodiments, the retention and actuator assembly 512 can have any number of indicator arms (e.g., two, three, five or more) with a corresponding number of openings.

[0104] 11 illustrates another embodiment of a retention and actuator assembly 514, which is similar to the retention and actuator assembly 510 described above, except for the shape of the indicator arm 560. Specifically, the indicator arm 560 has a first end 562 fixedly attached to the outer surface 524 of the support tube 520 and a second end 564 configured to be removably attached to the support tube 520 at a location distal to the first end 562. The second end 564 has a hook 565 extending transversely relative to the indicator arm 560. The indicator arm 560 can be retained in the biased position when the hook 565 extends through the opening 530 and into the lumen 528 to frictionally engage the edge 532 of the opening 530 and / or the inner surface 526 of the support tube 520 adjacent the opening 530.

[0105] Similarly, during valve expansion, peripheral portion 307 of actuator screw (or another portion of the prosthetic valve or a portion of the delivery device, as discussed above) can engage hook 565 inside lumen 528 and push it out of lumen 528 through opening 530. Thus, second end 564 can be released from opening 530 and indicator arm 560 can return to its unbiased position.

[0106] Similarly, indicator arm 560 may have a radiopaque marker 566 such that the change of indicator arm 560 from the biased position to the unbiased position is visible under fluoroscopy. In some embodiments, radiopaque marker 566 may be located adjacent second end 564. In some embodiments, radiopaque marker 566 may be located on hook 565. In some embodiments, radiopaque marker 566 may be located on an intermediate portion of indicator arm 560. In alternative embodiments, the entire arm 560 may be formed of a radiopaque material that is visible under fluoroscopy.

[0107] 12 illustrates yet another embodiment of a retention and actuator assembly 516, which is similar to the retention and actuator assembly 510 described above, except that an indicator arm 570 is disposed inside the lumen 528 when it is in the biased position. Specifically, a first end 572 of the indicator arm 570 can be fixedly attached to the inner surface 526 of the support tube 520 at a location proximate the opening 530. A second end 574 of the indicator arm 570 can be configured to be removably attached to the support tube 520 at a location distal to the first end 572. For example, the indicator arm 570 can be retained in the biased position when the second end 574 is pressed against the inner surface 526 of the support tube 520 at a location slightly distal from the opening 530.

[0108] Similarly, during valve expansion, the peripheral portion 307 of the actuator screw (or another portion of the prosthetic valve or a portion of the delivery device, as described above) can engage the second end 574 inside the lumen 528. A distal portion 575 of the indicator arm 570 adjacent the second end 574 can be made of a flexible material such that it can curve radially outward when the second end 574 is pushed proximally. The opening 530 can be sized to allow the curved distal portion 575 to extend out of the opening 530 and out of the lumen 528. Further pushing of the second end 574 proximally can cause the second end 574 to "pop" out of the opening 530 and out of the lumen 528, allowing the indicator arm 570 to return to its unbiased position.

[0109] Similarly, indicator arm 570 may have a radiopaque marker 576 such that the change of indicator arm 570 from the biased position to the unbiased position is visible under fluoroscopy. In some embodiments, radiopaque marker 576 may be located adjacent second end 574. In some embodiments, radiopaque marker 576 may be located at an intermediate portion of indicator arm 570. In alternative embodiments, the entire arm 570 may be formed of a radiopaque material that is visible under fluoroscopy.

[0110] More generally, after placing the prosthetic valve at a target site within a patient using the delivery device, an operator can radially expand the prosthetic valve from a radially compressed state to a radially expanded state. The operator can determine that the diameter of the prosthetic valve has reached a predetermined size when the indicator arms change from a first configuration (e.g., a biased position) to a second configuration (e.g., an unbiased position), and such change can be confirmed based on differences in position and / or shape between the first and second configurations. As noted above, such confirmation can be facilitated by radiopaque markers disposed on the indicator arms.

[0111] 9-12, the indicator arm can be biased to the second configuration by a separate biasing element, such as a spring (e.g., a torsion spring) connected to the indicator arm and to the support tube 520. For example, the indicator arm can be made of a non-resilient material and a biasing element (e.g., a spring) can be connected to the indicator arm to bias the indicator arm to the second configuration when the second end of the indicator arm is released from the support tube.

[0112] Additionally, in an alternative embodiment, the first end of the indicator arm (of any of the above-described embodiments) can be connected to the support tube by a hinge, which can include a pin that extends through the first end of the indicator arm and through corresponding openings in the support tube. The hinged indicator arm can be self-expanding or can include a separate biasing element.

[0113] It should further be appreciated that a delivery device, such as delivery device 100, may include one or more indicator arms, such as those disclosed in FIGS. 9-12, on one or more of the retention and actuator assemblies of the delivery device. In some embodiments, each retention and actuator assembly of the delivery device has at least one indicator arm, such as those disclosed in any of FIGS. 9-12. In some embodiments, each retention and actuator assembly has the same type of indicator (e.g., each retention and actuator assembly has a respective indicator arm 550). In other embodiments, each retention and actuator assembly has a different indicator arm (e.g., one retention and actuator assembly has an indicator arm 550 and another retention and indicator arm has an indicator arm 570). In some embodiments, each indicator arm of each different retention and actuator assembly can be configured to indicate a different expansion size of the prosthetic valve. For example, the indicator arms may be configured such that when a first indicator arm of a first retaining and actuator assembly changes from its biased position to its unbiased position, the prosthetic valve expands to a first predetermined size, and when a second indicator arm of a second retaining and actuator assembly changes from its biased position to its unbiased position, the prosthetic valve expands to a second predetermined size, etc.

[0114] It should be understood that the same concept of using an indicator arm to determine when the diameter of the prosthetic valve has been expanded to a predetermined size can also be applied when other expansion mechanisms are used, such as one or more ratchet mechanisms described in U.S. Patent No. 5,393,633, U.S. Patent No. 5,393,633, U.S. Patent No. 5,393,633, or U.S. Patent No. 5,393,633 (as long as actuation of the expansion mechanism can change the indicator arm from one configuration to another configuration that is visible to the operator).

[0115] General Considerations It should be understood that the disclosed embodiments can be adapted to deliver and implant the prosthetic device into any of the heart's native annulus (e.g., the pulmonary, mitral, and tricuspid annulus) and can be used using any of a variety of delivery approaches (e.g., retrograde, antegrade, transseptal, transventricular, transatrial, etc.).

[0116] For purposes of this specification, certain aspects, advantages, and novel features of the embodiments of the present invention are described herein. The disclosed methods, devices, and systems should not be construed as limiting in any way. Instead, the present invention is directed to all novel and non-obvious features and aspects of the various disclosed embodiments, alone and in various combinations and subcombinations with each other. The methods, devices, and systems are not limited to any particular aspect or feature, or combination thereof, nor do the disclosed embodiments require that any particular advantage or advantages be present or problems be solved. The technology of any example can be combined with the technology described in any one or more of the other examples. In view of the many possible embodiments to which the principles of the disclosed technology may be applied, it is to be understood that the described embodiments are merely preferred examples and should not be construed as limiting the scope of the disclosed technology.

[0117] Although some operations of the disclosed embodiments are described in a particular order for convenience of presentation, it should be understood that this description encompasses rearrangements unless specific language set forth below requires a particular ordering. For example, operations described sequentially may be rearranged or performed simultaneously in some cases. Moreover, for simplicity of illustration, the accompanying figures may not show various means by which the disclosed methods may be used in combination with other methods. Furthermore, terms such as "provide" or "achieve" may be used in some cases to describe the disclosed methods. These terms are high-level abstractions of the actual operations that are performed. The actual operations that correspond to these terms may vary depending on the particular implementation, but are readily discernible by one of ordinary skill in the art.

[0118] As used herein, with reference to prosthetic valves, delivery devices, and other components of a delivery assembly, "proximal" refers to a location, direction, or portion of the device that is closer to the handle of the delivery assembly outside the patient's body, and "distal" refers to a location, direction, or portion of the device that is further from the handle. The terms "longitudinal" and "axial" refer to axes extending in the proximal and distal directions, unless expressly defined otherwise.

[0119] In this application and claims, the singular forms "a," "an," and "the" include the plural forms unless the context clearly dictates otherwise. In addition, the term "includes" means "comprises." Furthermore, the terms "coupled" and "connected" generally mean electrically, electromagnetically, and / or physically (e.g., mechanically or chemically) coupled or connected and do not exclude the presence of intermediate elements between what is coupled or connected, unless specifically stated to the contrary.

[0120] Directions and other relative relationships (e.g., inside, outside, upper, lower, etc.) may be used to facilitate discussion of the figures and principles herein, but are not limiting. For example, several terms such as "inside," "outside," "upper," "lower," "internal," "external," etc. may be used. Such terms are used specifically with respect to the described embodiments to provide some clarity of description when dealing with relative relationships, where applicable. However, such terms do not imply absolute relationships, positions, and / or directions. For example, with respect to an object, an "upper" part may become a "lower" part by simply turning the object over. The part is still the same part and the object remains the same. As used herein, "and / or" means "and" or "or," as well as "and" and "or."

[0121] Additional Examples of Disclosed Technologies In view of the above-mentioned embodiments of the disclosed subject matter, the present application discloses additional examples, which are listed below. It should be noted that any feature of the examples alone or multiple features of the examples taken in combination, and optionally multiple features of the examples taken in combination with one or more features of one or more additional examples, are further examples that also fall within the scope of the disclosure of the present application. EXAMPLES

[0122] 1. A delivery device configured to provide visual feedback that a prosthetic valve has been radially expanded, the delivery device comprising an indicator arm changeable between a first configuration and a second configuration, the second configuration differing from the first configuration in a position or shape of the indicator arm, the indicator arm being configured to remain in the first configuration when a diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve has been expanded to the first predetermined size. EXAMPLES

[0123] The delivery device of any embodiment herein, particularly embodiment 1, wherein the indicator arm comprises a radiopaque marker such that a change of the indicator arm from the first configuration to the second configuration is visible under fluoroscopy. EXAMPLES

[0124] A delivery device described in any of the embodiments herein, particularly any one of embodiments 1 to 2, wherein the indicator arm comprises a resilient material such that the indicator arm in the first configuration is in a biased state and the indicator arm in the second configuration is in a non-biased state. EXAMPLES

[0125] A delivery device described in any of the embodiments herein, particularly any one of embodiments 1 to 3, wherein the indicator arm of the first configuration is oriented generally along the axis of the prosthetic valve and the indicator arm of the second configuration is oriented at an oblique angle relative to the axis of the prosthetic valve. EXAMPLES

[0126] The delivery device described in any of the embodiments herein, particularly any one of embodiments 1 to 4, further comprising a first operating element and a second operating element configured to couple with an expansion mechanism of the prosthetic valve, such that axial movement of the second operating element in a first direction relative to the first operating element expands the prosthetic valve from a radially compressed state to a radially expanded state, and axial movement of the second operating element in a second direction opposite to the first direction compresses the prosthetic valve from the radially expanded state to the radially compressed state. EXAMPLES

[0127] The delivery device of any embodiment herein, particularly embodiment 5, wherein the second operative element extends through a lumen of the first operative element. EXAMPLES

[0128] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 5 to 6, wherein a first end of the indicator arm is fixedly attached to a first position of the first operating element and a second end of the indicator arm is configured to be removably attached to a second position of the first operating element when the indicator arm is in the first configuration. EXAMPLES

[0129] The delivery device of any of the embodiments herein, particularly embodiment 7, wherein the second end of the indicator arm is configured to engage with a portion of an expansion mechanism of the prosthetic valve when the second operating element is axially moved in a first direction relative to the first operating element, thereby enabling the second end of the indicator arm to be released from the second position of the first operating element when engaged with the portion of the expansion mechanism. EXAMPLES

[0130] The delivery device of any of the embodiments herein, particularly embodiment 8, wherein the second position of the first actuating element is determined such that when the expansion mechanism portion of the prosthetic valve engages with the second end of the indicator arm, the diameter of the prosthetic valve is expanded to a first predetermined size. EXAMPLES

[0131] A delivery device described in any of the embodiments herein, particularly any one of embodiments 7 to 9, wherein the second position is closer to the prosthetic valve before expanding the prosthetic valve to the first predetermined size, and the first position is closer to the second position. EXAMPLES

[0132] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 7 to 10, wherein the first actuation element has an opening at the second position, the opening being dimensioned to allow the second end of the indicator arm to extend therethrough. EXAMPLES

[0133] The delivery device described in any of the embodiments herein, particularly embodiment 11, wherein the first position is on an outer surface of the first operating element and the second end of the indicator arm is configured to frictionally engage an edge of the opening or an inner surface of the first operating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0134] The delivery device described in any of the embodiments herein, particularly embodiment 11, wherein the first position is on an outer surface of the first operating element and the second end of the indicator arm comprises a hook configured to engage an edge of the opening and an inner surface of the first operating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0135] The delivery device of any of the embodiments herein, particularly embodiment 11, wherein the first position is on an inner surface of the first actuating element, and the second end of the indicator arm is configured to press against an inner surface of the first actuating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0136] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 7 to 14, wherein the second end of the indicator arm is configured to be removably attached to at least a third position of the first actuation element when the indicator arm is in the first configuration, the third position being spaced apart from the second position. EXAMPLES

[0137] The delivery device of any of the embodiments herein, particularly embodiment 15, wherein the second end of the indicator arm is configured to be released by the prosthetic valve from a third position of the first actuating element when the second actuating element is axially moved in a first direction relative to the first actuating element, the third position being set such that when the second end of the indicator arm is released by the prosthetic valve from the third position, the diameter of the prosthetic valve is expanded to a second predetermined size different from the first predetermined size. EXAMPLES

[0138] 1. A medical assembly comprising: a prosthetic valve; and a delivery device configured to radially expand and compress the prosthetic valve, the delivery device comprising an indicator arm changeable between a first configuration and a second configuration, the indicator arm in the second configuration differing in position or shape from the first configuration, the indicator arm configured to remain in the first configuration when a diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size. EXAMPLES

[0139] The assembly of any of the embodiments herein, particularly embodiment 17, wherein the indicator arm comprises a resilient material such that the indicator arm in the first configuration is in a biased state and the indicator arm in the second configuration is in a non-biased state. EXAMPLES

[0140] An assembly described in any of the embodiments herein, particularly any one of embodiments 17 to 18, wherein the delivery device comprises a first actuating element and a second actuating element, the drive components being configured to couple with an expansion mechanism of the prosthetic valve, such that axial movement of the second actuating element relative to the first actuating element radially expands or compresses the prosthetic valve. EXAMPLES

[0141] The assembly of any embodiment herein, particularly embodiment 19, wherein the second operative element extends through a lumen of the first operative element. EXAMPLES

[0142] An assembly described in any of the embodiments herein, particularly any one of embodiments 19 to 20, wherein a first end of the indicator arm is configured to be fixedly attached to a first position of the first operating element and a second end of the indicator arm is configured to be removably attached to a second position of the first operating element when the indicator arm is in the first configuration. EXAMPLES

[0143] The assembly of any embodiment herein, particularly any one of embodiments 19 to 21, wherein the indicator arm of the second configuration is oriented at an oblique angle relative to the axis of the first actuation element. EXAMPLES

[0144] The assembly of any of the embodiments herein, particularly any one of embodiments 21-22, wherein the indicator arm comprises a radiopaque marker disposed adjacent the second end. EXAMPLES

[0145] An assembly described in any of the embodiments herein, particularly any one of embodiments 21 to 23, wherein the second end of the indicator arm is configured to engage with a portion of the artificial valve when the second operating element is moved axially relative to the first operating element, thereby enabling the second end of the indicator arm to be released from the second position of the first operating element when engaged with the portion of the artificial valve. EXAMPLES

[0146] The assembly of any of the embodiments herein, particularly embodiment 24, wherein the second position of the first actuating element is determined such that when a portion of the prosthetic valve engages with the second end of the indicator arm, a diameter of the prosthetic valve is expanded to a first predetermined size. EXAMPLES

[0147] The assembly described in any of the embodiments herein, particularly any one of embodiments 21 to 25, wherein the second position is closer to the prosthetic valve before expanding the prosthetic valve to the first predetermined size, and the first position is closer to the second position. EXAMPLES

[0148] The assembly of any one of the embodiments herein, particularly any one of embodiments 21 to 26, wherein the first actuating element has an opening at the second position, the opening being dimensioned to allow the second end of the indicator arm to extend therethrough. EXAMPLES

[0149] A delivery device assembly as described in any of the embodiments herein, particularly embodiment 27, wherein the first position is on an outer surface of the first operating element and the second end of the indicator arm is configured to frictionally engage an edge of the opening or an inner surface of the first operating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0150] The assembly of any of the embodiments herein, particularly embodiment 27, wherein the first position is on an outer surface of the first actuating element, and the second end of the indicator arm comprises a hook configured to engage an edge of the opening and an inner surface of the first actuating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0151] The assembly of any of the embodiments herein, particularly embodiment 27, wherein the first position is on an inner surface of the first actuating element, and the second end of the indicator arm is configured to press against an inner surface of the first actuating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0152] The assembly described in any embodiment herein, particularly any one of embodiments 21 to 30, wherein the second end of the indicator arm is configured to be removably attached to at least a third position of the first actuation element when the indicator arm is in the first configuration, the third position being spaced apart from the second position. EXAMPLES

[0153] The assembly of any of the embodiments herein, particularly embodiment 31, wherein the second end of the indicator arm is configured to be released by the prosthetic valve from a third position of the first operating element when the second operating element is moved axially in a proximal direction relative to the first operating element, the third position being set such that when the second end of the indicator arm is released by the prosthetic valve from the third position, the diameter of the prosthetic valve is expanded to a second predetermined size different from the first predetermined size. EXAMPLES

[0154] 1. A method of implanting a prosthetic valve, the method comprising: positioning the prosthetic valve at a target site within a patient's body using a delivery device having an indicator arm maintained in a first configuration; radially expanding the prosthetic valve from a radially compressed state to a radially expanded state; and determining that a diameter of the prosthetic valve has reached a predetermined size when the indicator arm changes to a second configuration, the indicator arm in the second configuration being in a different position or shape than the first configuration. EXAMPLES

[0155] The method of any of the embodiments herein, particularly embodiment 33, wherein the indicator arm comprises a resilient material such that the indicator arm in the first configuration is in a biased state and the indicator arm in the second configuration is in a non-biased state. EXAMPLES

[0156] The method of any one of the embodiments herein, particularly any one of embodiments 33 to 34, wherein expanding the prosthetic valve comprises actuating first and second actuating elements of a delivery device coupled to an expansion mechanism of the prosthetic valve, and actuating the first and second actuating elements is effective to actuate the expansion mechanism to expand the prosthetic valve. EXAMPLES

[0157] The method of any of the embodiments herein, particularly embodiment 35, wherein actuating the first and second actuating elements comprises axially moving the second actuating element relative to the first actuating element to axially move the inner member of the expansion mechanism relative to the outer member of the expansion mechanism. EXAMPLES

[0158] The method according to any of the embodiments herein, particularly any one of embodiments 33 to 36, wherein in a first configuration, a first end of the indicator arm is fixedly attached to a first position of the first operating element and a second end of the indicator arm is removably attached to a second position of the first operating element. EXAMPLES

[0159] The method of any of the embodiments herein, particularly embodiment 37, wherein actuating the expansion mechanism includes releasing the second end of the indicator arm from the second location of the first actuation element such that the indicator arm changes to the second configuration. EXAMPLES

[0160] The method of any of the embodiments herein, particularly embodiment 38, wherein releasing the second end of the indicator arm comprises pressing a portion of the prosthetic valve against the second end. EXAMPLES

[0161] The method of any one of the embodiments herein, particularly any one of embodiments 33 to 39, wherein the indicator arm comprises a radiopaque marker such that the change of the indicator arm from the first configuration to the second configuration can be visualized under fluoroscopy. EXAMPLES

[0162] 1. A delivery device configured to provide visual feedback that a prosthetic valve has been radially expanded, the delivery device comprising an indicator arm movable between a biased position and an unbiased position, the indicator arm configured to remain in the biased position when a diameter of the prosthetic valve is less than a first predetermined size and to move to the unbiased position when the diameter of the prosthetic valve has expanded to the first predetermined size. EXAMPLES

[0163] The delivery device of any embodiment herein, particularly embodiment 41, wherein the indicator arm comprises a radiopaque marker such that movement of the indicator arm from the biased position to the unbiased position is visible under fluoroscopy. EXAMPLES

[0164] A delivery device described in any of the embodiments herein, particularly any one of embodiments 41 to 42, further comprising a first operating element and a second operating element configured to couple with an expansion mechanism of the prosthetic valve, whereby axial movement of the second operating element relative to the first operating element radially expands or compresses the prosthetic valve. EXAMPLES

[0165] The delivery device of any embodiment herein, particularly embodiment 43, wherein the second operative element extends through a lumen of the first operative element. EXAMPLES

[0166] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 41 to 44, wherein a first end of the indicator arm is fixedly attached to a first position of the first operating element and a second end of the indicator arm is configured to be removably attached to a second position of the first operating element when the indicator arm is in the biased position. EXAMPLES

[0167] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 43 to 45, wherein the indicator arm in the unactuated position is oriented at an oblique angle relative to the axis of the first actuation element. EXAMPLES

[0168] A delivery device described in any of the embodiments herein, particularly any one of embodiments 45 to 46, wherein the indicator arm comprises a radiopaque marker disposed adjacent the second end. EXAMPLES

[0169] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 45 to 47, wherein the second end of the indicator arm is configured to engage with a portion of the artificial valve when the second operating element is moved axially relative to the first operating element, thereby enabling the second end of the indicator arm to be released from the second position of the first operating element when engaged with the portion of the artificial valve. EXAMPLES

[0170] The delivery device described in any of the embodiments herein, particularly embodiment 48, wherein the second position of the first actuating element is determined such that when a portion of the prosthetic valve engages with the second end of the indicator arm, the diameter of the prosthetic valve is expanded to a predetermined size. EXAMPLES

[0171] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 45 to 49, wherein the second position is close to the prosthetic valve before expanding the prosthetic valve to the first predetermined size, and the first position is close to the second position. EXAMPLES

[0172] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 45 to 50, wherein the first actuating element has an opening at the second position, the opening being dimensioned to allow the second end of the indicator arm to extend therethrough. EXAMPLES

[0173] A delivery device described in any of the embodiments herein, particularly embodiment 51, wherein the first position is on an outer surface of the first operating element and the second end of the indicator arm is configured to frictionally engage an edge of the opening or an inner surface of the first operating element adjacent the opening when the indicator arm is in the biased position. EXAMPLES

[0174] A delivery device as described in any of the embodiments herein, particularly embodiment 51, wherein the first position is on an outer surface of the first actuation element and the second end of the indicator arm comprises a hook configured to engage an edge of the opening when the indicator arm is in the biased position. EXAMPLES

[0175] The delivery device described in any of the embodiments herein, particularly embodiment 51, wherein the first position is on an inner surface of the first actuating element, and the second end of the indicator arm is configured to press against an inner surface of the first actuating element adjacent the opening when the indicator arm is in the biased position. EXAMPLES

[0176] A delivery device described in any one of the embodiments herein, particularly any one of embodiments 45 to 54, wherein the second end of the indicator arm is configured to be removably attached to at least a third position of the first actuation element when the indicator arm is in the biased position, the third position being spaced apart from the second position. EXAMPLES

[0177] A delivery device as described in any of the embodiments herein, particularly embodiment 55, wherein the second end of the indicator arm is configured to be released by the prosthetic valve from a third position of the first operating element when the second operating element is moved axially relative to the first operating element, and the third position is set such that when the second end of the indicator arm is released by the prosthetic valve from the third position, the diameter of the prosthetic valve is expanded to a second predetermined size different from the first predetermined size. EXAMPLES

[0178] 1. A medical assembly comprising a prosthetic valve and a delivery device, the delivery device comprising a drive member and an indicator arm attached to the drive member, the drive member being removably attached to an expansion mechanism of the prosthetic valve, the expansion mechanism being configured to radially expand and compress the prosthetic valve, the indicator arm being changeable between a first configuration and a second configuration, the indicator arm in the second configuration differing in position or shape from the first configuration, the indicator arm being configured to remain in the first configuration when a diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size. EXAMPLES

[0179] The assembly of any of the embodiments herein, particularly embodiment 57, wherein the indicator arm comprises a resilient material such that the indicator arm in the first configuration is in a biased state and the indicator arm in the second configuration is in a non-biased state. EXAMPLES

[0180] An assembly described in any of the embodiments herein, particularly any one of embodiments 57 to 58, wherein the drive member comprises a first actuating element and a second actuating element, which drive components are configured to couple with an expansion mechanism of the prosthetic valve, such that axial movement of the second actuating element relative to the first actuating element radially expands or compresses the prosthetic valve. EXAMPLES

[0181] The assembly of any embodiment herein, particularly embodiment 59, wherein the second operative element extends through a lumen of the first operative element. EXAMPLES

[0182] An assembly described in any of the embodiments herein, particularly any one of embodiments 59 to 60, wherein a first end of the indicator arm is configured to be fixedly attached to a first position of the first operating element and a second end of the indicator arm is configured to be removably attached to a second position of the first operating element when the indicator arm is in the first configuration. EXAMPLES

[0183] The assembly of any embodiment herein, particularly any one of embodiments 59 to 61, wherein the indicator arm of the second configuration is oriented at an oblique angle relative to the axis of the first actuation element. EXAMPLES

[0184] The assembly described in any of the embodiments herein, particularly any one of embodiments 61 to 62, wherein the indicator arm comprises a radiopaque marker disposed adjacent the second end. EXAMPLES

[0185] An assembly described in any of the embodiments herein, particularly any one of embodiments 61 to 63, wherein the second end of the indicator arm is configured to engage with a portion of the artificial valve when the second operating element is moved axially relative to the first operating element, thereby enabling the second end of the indicator arm to be released from the second position of the first operating element when engaged with the portion of the artificial valve. EXAMPLES

[0186] The assembly described in any of the embodiments herein, particularly embodiment 64, wherein the second position of the first actuating element is determined such that when a portion of the prosthetic valve engages with the second end of the indicator arm, a diameter of the prosthetic valve is expanded to a first predetermined size. EXAMPLES

[0187] The assembly described in any one of the embodiments herein, particularly any one of embodiments 61 to 65, wherein the second position is closer to the prosthetic valve before expanding the prosthetic valve to the first predetermined size, and the first position is closer to the second position. EXAMPLES

[0188] An assembly described in any one of the embodiments herein, particularly any one of embodiments 61 to 66, wherein the first actuating element has an opening at the second position, the opening being dimensioned to allow the second end of the indicator arm to extend therethrough. EXAMPLES

[0189] A delivery device assembly as described in any of the embodiments herein, particularly embodiment 67, wherein the first position is on an outer surface of the first operating element and the second end of the indicator arm is configured to frictionally engage an edge of the opening or an inner surface of the first operating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0190] The assembly described in any of the embodiments herein, particularly embodiment 67, wherein the first position is on an outer surface of the first actuation element, and the second end of the indicator arm comprises a hook configured to engage with an edge of the opening when the indicator arm is in the first configuration. EXAMPLES

[0191] The assembly of any of the embodiments herein, particularly embodiment 67, wherein the first position is on an inner surface of the first actuating element, and the second end of the indicator arm is configured to press against an inner surface of the first actuating element adjacent the opening when the indicator arm is in the first configuration. EXAMPLES

[0192] The assembly described in any embodiment herein, particularly any one of embodiments 61 to 70, wherein the second end of the indicator arm is configured to be removably attached to at least a third position of the first actuation element when the indicator arm is in the first configuration, the third position being spaced apart from the second position. EXAMPLES

[0193] The assembly of any of the embodiments herein, particularly embodiment 71, wherein the second end of the indicator arm is configured to be released by the prosthetic valve from a third position of the first operating element when the second operating element is moved axially in a proximal direction relative to the first operating element, the third position being set such that when the second end of the indicator arm is released by the prosthetic valve from the third position, the diameter of the prosthetic valve is expanded to a second predetermined size different from the first predetermined size. EXAMPLES

[0194] 1. A method for providing visual feedback that an artificial valve has been radially expanded, the method comprising: connecting a drive member having an indicator arm maintained in a first configuration to an expansion mechanism of the artificial valve; actuating the expansion mechanism with the drive member to radially expand the artificial valve from a radially compressed state to a radially expanded state; and determining that the diameter of the artificial valve has reached a predetermined size when the indicator arm changes to a second configuration, the indicator arm in the second configuration being in a different position or shape than the first configuration. EXAMPLES

[0195] The method of any of the embodiments herein, particularly embodiment 73, wherein the indicator arm comprises a resilient material such that the indicator arm in the first configuration is in a biased state and the indicator arm in the second configuration is in a non-biased state. EXAMPLES

[0196] The method of any one of the embodiments herein, particularly any one of embodiments 73 to 74, wherein the drive member comprises a first actuating element and a second actuating element, the second actuating element extending through an inner lumen of the first actuating element. EXAMPLES

[0197] The method of any of the embodiments herein, particularly embodiment 75, wherein actuating the expansion mechanism comprises axially moving a second actuating element relative to the first actuating element to axially move an inner member of the expansion mechanism relative to an outer member of the expansion mechanism. EXAMPLES

[0198] The method of any one of the embodiments herein, particularly any one of embodiments 73 to 76, wherein in a first configuration, a first end of the indicator arm is fixedly attached to a first position of the first operating element and a second end of the indicator arm is removably attached to a second position of the first operating element. EXAMPLES

[0199] The method of any of the embodiments herein, particularly embodiment 77, wherein actuating the expansion mechanism includes releasing the second end of the indicator arm from the second location of the first actuating element such that the indicator arm changes to the second configuration. EXAMPLES

[0200] The method of any of the embodiments herein, particularly embodiment 78, wherein releasing the second end of the indicator arm includes pressing a portion of the prosthetic valve against the second end. EXAMPLES

[0201] The method of any one of the embodiments herein, particularly any one of embodiments 73 to 79, wherein the indicator arm comprises a radiopaque marker such that the change of the indicator arm from the first configuration to the second configuration can be visualized under fluoroscopy.

[0202] Exemplary Alternatives In view of the many possible implementations to which the principles of the disclosed technology can be applied, it should be understood that the described examples are merely preferred examples of the technology and should not be construed as limiting the scope of the invention. Rather, the scope of the claimed subject matter is defined by the appended claims and their equivalents. [Explanation of symbols]

[0203] 10. Artificial implant delivery assembly, delivery assembly 100 Delivery device 102 Handle 104 Axis 110 Retaining actuator assembly 120 Support tube 122 Actuator member 124 Rock Tools 140 Fiducial Radiopaque Marker 140a Most distal fiducial radiopaque marker 140b Intermediate fiducial radiopaque marker 140c Most proximal fiducial opaque marker 142 Indicator radiopaque marker 200 Artificial Valves 202 Valve structure 204 Frames 206 Proximal end of frame 208 Distal end of frame 210 Interconnecting struts, struts 212 Opening 214 Longitudinal axis of artificial valve 216 Rivets or pins 250 Distal Junction 252 Distal tip 260 Proximal Junction 262 Proximal tip 300 Valve expansion mechanism 302 Actuator screw 304 Distal part of actuator screw 306 Proximal part of actuator screw 307 Peripheral part of the proximal end of the proximal part 308 Distal attachment piece 310 Distal Valve Connector 312 Outer member, sleeve 314 Proximal Valve Connector 316 Lock nut 318 Lock nut notch, notch 319 Engagement surface 326 Lock tool notch, notch 327 Engagement surface 330 Proximal end of sleeve 332 proximal end portion of sleeve 312, proximal end portion 440a fiducial radiopaque marker 440b fiducial radiopaque marker 440c fiducial radiopaque marker 442a Most distal indicator radiopaque marker 442b Proximal-most indicator radiopaque marker 510 Retaining Actuator Assembly 512 Retaining Actuator Assembly 514 Retaining Actuator Assembly 516 Retaining Actuator Assembly 520 Support tube 522 Actuator member 524 Exterior 526 Inside 528 Lumen 530 Opening 530a opening 530b opening 530c opening 530d opening 532 Edge of opening 550 indicator arm 552 indicator arm first end, first end 554 indicator arm second end, second end 556 Radiopaque Marker 560 indicator arm 562 First End 564 Second End 565 Hook 566 Radiopaque Marker 570 indicator arm 572 first end of indicator arm 574 Second End 575 curved distal portion 576 Radiopaque Markers d1 Distance d2 distance D1 Diameter of prosthetic valve D2 Diameter of prosthetic valve D3 Diameter of prosthetic valve

Claims

1. 1. A delivery device configured to provide visual feedback of radial expansion of a prosthetic valve, comprising: the delivery device comprising an indicator arm changeable between a first configuration and a second configuration, the second configuration differing from the first configuration in terms of a position or shape of the indicator arm; the indicator arm is configured to maintain the first configuration when a diameter of the prosthetic valve is less than a first predetermined size and to change to the second configuration when the diameter of the prosthetic valve is expanded to the first predetermined size.

2. 10. The delivery device of claim 1, wherein the indicator arm comprises a radiopaque marker such that a change of the indicator arm from the first configuration to the second configuration is visible under fluoroscopy.

3. 10. The delivery device of claim 1, wherein the indicator arm comprises a resilient material such that in the first configuration the indicator arm is in a biased state and in the second configuration the indicator arm is in an unbiased state.

4. 2. The delivery device of claim 1, wherein in the first configuration, the indicator arm is oriented along an axis of the prosthetic valve, and in the second configuration, the indicator arm is oriented at an angle to the axis of the prosthetic valve.

5. the delivery device comprising a first actuating element and a second actuating element configured to couple with an expansion mechanism of the prosthetic valve; 2. The delivery device of claim 1, whereby the prosthetic valve is expanded from a radially compressed state to a radially expanded state by axially moving the second actuating element relative to the first actuating element in a first direction, and the prosthetic valve is compressed from the radially expanded state to the radially compressed state by axially moving the second actuating element relative to the first actuating element in a second direction opposite the first direction.

6. The delivery device of claim 5 , wherein the second working element extends through a lumen of the first working element.

7. 6. The delivery device of claim 5, wherein a first end of the indicator arm is configured to be fixedly attached to a first position of the first actuating element and a second end of the indicator arm is configured to be removably attached to a second position of the first actuating element when the indicator arm is in the first configuration.

8. 8. The delivery device of claim 7, wherein the second end of the indicator arm is configured to engage a portion of the expansion mechanism of the prosthetic valve when the second operating element is axially moved relative to the first operating element in the first direction, such that the second end of the indicator arm is released from the second position of the first operating element when the second end of the indicator arm engages a portion of the expansion mechanism.

9. 9. The delivery device of claim 8, wherein the second position of the first actuating element is positioned such that when the portion of the expansion mechanism of the prosthetic valve engages the second end of the indicator arm, a diameter of the prosthetic valve expands to the first predetermined size.

10. 8. The delivery device of claim 7, wherein the second position is proximal to the prosthetic valve prior to expanding the prosthetic valve to the first predetermined size, and the first position is proximal to the second position.

11. the first actuation element having an opening at the second location; The delivery device of claim 7 , wherein the opening is sized to allow the second end of the indicator arm to extend through the opening.

12. the first location is disposed on an exterior surface of the first actuation element; 12. The delivery device of claim 11, wherein the second end of the indicator arm is configured to frictionally engage an edge of the opening or an inner surface of the first actuating element adjacent the opening when the indicator arm is in the first configuration.

13. the first location is disposed on an exterior surface of the first actuation element; 12. The delivery device of claim 11, wherein the second end of the indicator arm comprises a hook configured to engage an edge of the opening and an inner surface of the first actuation element adjacent the opening when the indicator arm is in the first configuration.

14. the first location is disposed on an inner surface of the first actuation element; 12. The delivery device of claim 11, wherein the second end of the indicator arm is configured to press against an inner surface of the first actuation element adjacent the opening when the indicator arm is in the first configuration.

15. the second end of the indicator arm is configured to be removably attached to at least a third location of the first actuation element when the indicator arm is in the first configuration; The delivery device of claim 7 , wherein the third location is spaced apart from the second location.

16. the second end of the indicator arm is configured to be released from the third position of the first operating element by the prosthetic valve when the second operating element is axially moved relative to the first operating element in the first direction; 16. The delivery device of claim 15, wherein the third position is determined such that when the second end of the indicator arm is released by the prosthetic valve from the third position, the diameter of the prosthetic valve expands to a second predetermined size that is different from the first predetermined size.

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