Medical Implant Delivery Systems

Abstract

Embodiments of the present disclosure are directed to delivery systems, devices, and / or methods of use for delivering and / or controllably positioning an implant in the form of a prosthesis, such as, but not limited to, a replacement heart valve, to a desired location within the body. In some embodiments, replacement heart valves and methods for delivering replacement heart valves to a native heart valve, such as the mitral valve, are provided. Features of the delivery system and echogenic markers for the delivery system are disclosed.

Description

[Technical field]

[0001] Certain embodiments disclosed herein relate generally to delivery systems for implants. In particular, in some embodiments, the delivery systems and implants relate to replacement heart valves, such as replacement mitral or other heart valves. [Background technology]

[0002] Human heart valves, including aortic, pulmonary, mitral, and tricuspid valves, essentially function as one-way valves that operate in sync with the beating heart. These valves allow blood to flow downstream but prevent blood from flowing upstream. Diseased heart valves exhibit defects that impede the valve's ability to control blood flow, such as valve stenosis or regurgitation. Such defects reduce the heart's efficiency in circulating blood and can lead to debilitating and life-threatening conditions. For example, valve failure can lead to conditions such as cardiac hypertrophy and ventricular dilation. Thus, great efforts have been made to develop methods and devices to repair or replace defective heart valves.

[0003] To solve the problems associated with defective heart valves, there are artificial implants. For example, mechanical and tissue-based heart valve prostheses can be used to replace defective natural heart valves. More recently, there has been a great deal of effort in developing replacement heart valves, especially tissue-based replacement heart valves, which can be delivered with less trauma to the patient than by open-heart surgery. Replacement valves are designed to be delivered by minimally invasive procedures, even percutaneous procedures. Such replacement valves often include a tissue-based valve body, which is connected to an expandable frame that is delivered to the natural valve annulus.

[0004] The development of prosthetic implants, including but not limited to replacement heart valves, that can be miniaturized for delivery and then controllably expanded for controlled placement has proven particularly challenging. A further challenge concerns the ability to atraumatically fix these prostheses relative to intraluminal tissue, such as tissue within any body cavity or lumen.

[0005] It can also be difficult to deliver an implant to a desired location in the human body, for example, to deliver a replacement heart valve to the mitral valve. To be able to perform a procedure in the heart or other anatomical locations, it may be necessary to deliver the device percutaneously through a tortuous vascular system, or by an open or semi-open procedure. It can also be difficult to be able to control the placement of the prosthesis in the desired location.

[0006] It can also be difficult to adequately visualize or locate the implant delivery system, including using ultrasound imaging. [Prior art documents] [Patent documents]

[0007] [Patent Document 1] U.S. Patent No. 6,622,367 [Patent Document 2] US Patent Application Publication No. 2015 / 0328000A1 Summary of the Invention [Means for solving the problem]

[0008] Embodiments of the present disclosure are directed to delivery systems, devices, and / or methods of use for delivering and / or controllably positioning an implant in the form of a prosthesis, such as, but not limited to, a replacement heart valve, to a desired location within the body. In some embodiments, replacement heart valves and methods for delivering replacement heart valves to a native heart valve, such as the mitral valve, are provided.

[0009] In some embodiments, a delivery system and method are provided for delivering a replacement heart valve to the location of the native mitral valve. The delivery system and method may utilize a transseptal approach. In some embodiments, components of the delivery system facilitate flexing of the delivery system to steer the prosthesis from the septum to a location within the native mitral valve. In some embodiments, a capsule is provided to house the prosthesis for delivery to the location of the native mitral valve. In other embodiments, the delivery system and method may be adapted for delivery of an implant to a location other than the native mitral valve.

[0010] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding area configured to hold the implant, and a capsule including a hypotube having one or more incisions forming a plurality of rings configured to surround the implant holding area.

[0011] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the delivery system including an implant holding region configured to hold the implant, and a capsule including a hypotube having one or more notches configured to surround the implant holding region that bias the flexibility of the hypotube in a certain direction.

[0012] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding region configured to hold the implant, and a capsule including a hypotube having one or more cuts forming a spiral configured to surround the implant holding region.

[0013] Embodiments herein include a method including the steps of: disposing an elongate shaft at a location within a patient's body, the elongate shaft including a capsule surrounding an implant holding region that holds an implant to be implanted within the patient's body, the capsule including a hypotube having one or more incisions forming a plurality of rings; moving the capsule proximally to expose a portion of the implant within the patient's body; and moving the capsule distally to retrieve the portion of the implant within the patient's body.

[0014] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding area configured to hold the implant, a capsule configured to surround the implant holding area, a shaft portion proximal to the capsule, and a coupler configured to couple the capsule to the shaft portion and allow the capsule to rotate relative to the shaft portion.

[0015] Embodiments herein include a method including the steps of: disposing an elongate shaft at a position within a patient's body, the elongate shaft including a capsule, a shaft portion proximal to the capsule, and a coupler coupling the capsule to the shaft portion, configured to allow the capsule to rotate relative to the shaft portion, the capsule surrounding an implant holding region that holds an implant to be implanted within the patient's body; and moving the capsule proximally to expose a portion of the implant within the patient's body while the capsule rotates relative to the shaft portion.

[0016] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding region configured to hold the implant, a sheath having an internal lumen, an inner shaft positioned within the internal lumen, and an expandable body positioned between the inner shaft and the sheath, the expandable body configured to expand to support the sheath.

[0017] Embodiments herein include methods including the steps of: disposing an elongate shaft at a location within a patient's body, the elongate shaft including a sheath, an inner shaft positioned within a lumen of the sheath, and an implant holding region that holds an implant to be implanted within the patient's body; moving the sheath proximally to expose a portion of the implant within the patient's body; expanding an expandable body between the sheath and the inner shaft; and moving the sheath distally to retrieve a portion of the implant within the patient's body while the expandable body expands between the sheath and the inner shaft to support the sheath.

[0018] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft having an implant holding region configured to hold the implant, and a wall of the elongate shaft including an outer jacket layer, an inner liner layer, a braided layer positioned between the outer jacket layer and the inner liner layer, and a metal layer positioned between the braided layer and the inner liner layer.

[0019] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongated shaft having proximal and distal ends including an implant holding region configured to hold the implant, a sheath configured to bend in at least one plane, a cable having a first end portion, a second end portion, and an intermediate portion extending between the first end portion and the second end portion, the first end portion being coupled to a first side of the sheath and the second end portion being coupled to a second side of the sheath opposite the first side, a cable router that engages the intermediate portion of the cable and allows the cable to move along the cable router when the sheath is bent in at least one plane, and a control mechanism that retracts the cable router and the sheath relative to the implant holding region.

[0020] Embodiments herein include a method including the steps of: disposing an elongate shaft at a position within a patient's body, the elongate shaft including an implant holding region that holds an implant for implantation within the patient's body, a sheath, and a cable having a first end portion, a second end portion, and an intermediate portion extending between the first end portion and the second end portion, the first end portion coupled to a first side of the sheath and the second end portion coupled to a second side of the sheath opposite the first side, the intermediate portion engaging a cable router; bending the sheath in a plane such that a length of the cable between the cable router and the first end portion increases and a length of the cable between the cable router and the second end portion decreases; and retracting the cable router and the sheath relative to the implant holding region.

[0021] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding region configured to hold the implant, a sheath having an inner lumen and a capsule configured to surround the implant holding region, an inner shaft located within the inner lumen, and a stopper located on the inner shaft configured to prevent proximal movement of the capsule relative to the inner shaft.

[0022] Embodiments herein include methods that include the steps of: disposing an elongate shaft at a location within a patient's body, the elongate shaft including a sheath having an inner lumen and a capsule that holds an implant to be implanted within the patient's body, the sheath including an inner shaft and a stopper located on the inner shaft; moving the capsule proximally until the sheath contacts the stopper to expose a first portion of the implant within the patient's body; and moving the capsule proximally over the stopper to expose a second portion of the implant within the patient's body proximal to the first portion of the implant.

[0023] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body comprising: an elongate shaft having a proximal end and a distal end, an implant holding area and an assembly configured to hold at least a portion of the implant within the implant holding area, and a handle including a control knob coupled to the proximal end of the elongate shaft and configured, when rotated, to move the assembly to release at least a portion of the implant from the implant holding area, the control knob including an exposed outer grip surface to be grasped around the entire circumference of the control knob.

[0024] Embodiments herein include a method including the steps of: disposing a delivery device at a location within a patient's body, the delivery device including an elongate shaft and a handle coupled to a proximal end of the elongate shaft, the elongate shaft including an implant holding region for holding an implant to be implanted within the patient's body and an assembly configured to hold at least a portion of the implant within the implant holding region, the handle including a control knob configured to move the assembly, when rotated, to release at least a portion of the implant from the implant holding region, the control knob including an exposed outer grip surface to be gripped around an entire circumference of the control knob; gripping the grip surface of the control knob; and rotating the control knob to move the assembly to release at least a portion of the implant from the implant holding region.

[0025] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the delivery system including an implant holding region configured to hold the implant and a marker configured to enhance echogenicity of the elongate shaft that defines the location of a portion of the elongate shaft when viewed using ultrasound imaging.

[0026] Embodiments herein include methods that include a step of disposing an elongate shaft at a position within a patient's body, the elongate shaft including an implant holding region that holds an implant to be implanted within the patient's body, and a marker that enhances the echogenicity of the elongate shaft to define the position of a portion of the elongate shaft when viewed using ultrasound imaging.

[0027] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding region configured to hold the implant, and a capsule including a distal end configured to extend radially outwardly, configured to surround the implant holding region.

[0028] Embodiments herein include methods including the steps of: disposing an elongate shaft at a location within a patient's body, the elongate shaft including a capsule surrounding an implant holding region that holds an implant to be implanted within the patient's body; moving the capsule proximally to expose a portion of the implant within the patient's body; and moving the capsule distally to retrieve a portion of the implant within the patient's body and passing a distal end of the capsule radially outwardly expanded over the retrieved portion of the implant.

[0029] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding region configured to hold the implant, and a pull tether coupled to a portion of the elongate shaft at or distal to the implant holding region and configured to deflect the distal end of the elongate shaft.

[0030] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising an elongate shaft having a proximal end and a distal end, the elongate shaft including an implant holding region configured to hold the implant, a nosecone located at the distal end of the elongate shaft, and a pull tether coupled to the nosecone and configured to deflect the nosecone.

[0031] Embodiments herein include methods that include disposing an elongate shaft at a location within a patient's body, the elongate shaft including a proximal end, a distal end, and an implant holding region that holds an implant to be implanted within the patient's body, and deflecting the distal end of the elongate shaft using a pull tether coupled to a portion of the elongate shaft at or distal to the implant holding region.

[0032] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body comprising: a steerable first elongated shaft having proximal and distal ends and extending along a first axis; a second elongated shaft having proximal and distal ends and extending along a second axis including an implant holding region configured to hold the implant; and a coupler configured to couple the second elongated shaft to the first elongated shaft such that the second axis is offset from the first axis and the second elongated shaft can slide relative to the first elongated shaft.

[0033] Embodiments herein include methods that include disposing a first elongate shaft at a location within a patient's body, the first elongate shaft extending along a first axis and being steerable; and sliding a second elongate shaft along the first elongate shaft to a location within the patient's body, the second elongate shaft being coupled to the first elongate shaft, extending along a second axis offset from the first axis, and including an implant holding region that holds an implant therein.

[0034] Embodiments herein include a delivery system for delivering an implant to a location within a patient's body, the delivery system comprising: an elongate shaft having a proximal end and a distal end and including an implant holding region configured to hold the implant; and a coating layer on the elongate shaft including reinforcing fibers or beads.

[0035] Embodiments herein include a delivery system that includes a step of disposing an elongate shaft at a location within a patient's body, the elongate shaft including an implant holding region that holds an implant to be implanted within the patient's body, and a covering layer including reinforcing fibers or beads.

[0036] Embodiments herein include methods that include providing a mixture of polytetrafluoroethylene (PTFE) and reinforcing fibers or beads, and providing an elongate shaft of a delivery system for delivering an implant to a location within a patient's body, the elongate shaft including the mixture of polytetrafluoroethylene (PTFE) and reinforcing fibers or beads as a coating layer on the elongate shaft. [Brief description of the drawings]

[0037] [Figure 1] FIG. 1 illustrates an embodiment of a delivery system. [Figure 2A] 2A is a partial cross-sectional view of the distal end of the delivery system of FIG. 1 loaded with the valve prosthesis of FIG. 3A. [Figure 2B] 2B is a partial cross-sectional view of the distal end of the delivery system of FIG. 1 without the valve prosthesis of FIG. 3A. [Figure 2C] FIG. 2C is a partial cross-sectional view of the distal end of the delivery system of FIG. 1 with a particular shaft assembly translated along a rail assembly. [Figure 3A] FIG. 3A is a side view illustrating an embodiment of a valve prosthesis that can be delivered using the delivery systems described herein. [Figure 3B] FIG. 3A is a side view illustrating an embodiment of an aortic valve prosthesis that can be delivered using the delivery systems described herein. [Figure 4] FIG. 4 is a perspective view of the distal end of the delivery system of FIG. [Diagram 5] FIG. 5 illustrates the components of the delivery system of FIG. 4 with the outer sheath assembly moved proximally out of view. [Figure 6A] FIG. 6A illustrates the components of the delivery system of FIG. 5 with the central shaft assembly moved proximally out of view. [Figure 6B] FIG. 6B is a cross-sectional view showing the rail assembly. [Figure 7] FIG. 7 illustrates the components of the delivery system of FIG. 6A with the rail assembly moved proximally out of view. [Figure 8] FIG. 8 illustrates the components of the delivery system of FIG. 7 with the inner assembly moved proximally out of view. [Figure 9A] FIG. 9A illustrates an embodiment of a guidewire shield. [Figure 9B] FIG. 9B illustrates an embodiment of a guidewire shield. [Figure 10] FIG. 10 illustrates an embodiment of an outer hypotube. [Figure 11] FIG. 11 illustrates an embodiment of a central shaft hypotube. [Figure 12A] FIG. 12A illustrates the central shaft hypotube embodiment of FIG. 11 as a flattened pattern. [Figure 12B] FIG. 12B illustrates an embodiment of an outer retaining ring. [Figure 13] FIG. 13 illustrates an embodiment of a rail assembly. [Figure 14] FIG. 14 illustrates an embodiment of the inner assembly. [Figure 15]FIG. 15 is a diagram showing a cross section of a capsule. [Figure 16] FIG. 16 illustrates an embodiment of the hypotube of the outer sheath assembly as a flat pattern. [Figure 17] FIG. 17 illustrates an embodiment of the hypotube of the outer sheath assembly as a flat pattern. [Figure 18] FIG. 18 illustrates an embodiment of the hypotube of the outer sheath assembly as a flattened pattern. [Figure 19] FIG. 19 illustrates an embodiment of the hypotube of the outer sheath assembly as a flattened pattern. [Figure 20] FIG. 20 illustrates an embodiment of the hypotube of the outer sheath assembly as a flattened pattern. [Figure 21] FIG. 21 illustrates an embodiment of the hypotube of the outer sheath assembly in a flat pattern. [Figure 22] FIG. 22 is a cross-sectional view showing a distal portion of an elongate shaft of a delivery system including a coupler that couples the capsule to the shaft. [Diagram 23] FIG. 23 is a perspective view of a distal portion of an elongate shaft of a delivery system including a coupler that couples the capsule to the shaft. [Figure 24] FIG. 24 is a cross-sectional view showing a distal portion of an elongate shaft of a delivery system including a coupler that couples the capsule to the shaft. [Diagram 25] FIG. 25 is a perspective view showing a distal portion of an elongate shaft of a delivery system including a coupler that couples the capsule to the shaft. [Figure 26] FIG. 26 is a cross-sectional view showing a distal portion of an elongate shaft of a delivery system including an expandable body positioned between an outer sheath and an inner shaft. [Figure 27] FIG. 27 is a cross-sectional view of the distal portion of the elongate shaft shown in FIG. 26 with the distal end bent and the expandable body expanded. [Figure 28] FIG. 28 is a side view of an embodiment of a braided layer. [Figure 29] FIG. 29 is a schematic cross-sectional view showing the structure of the wall of the elongated shaft. [Diagram 30] FIG. 30 is a schematic cross-sectional view showing components of an elongate shaft, including a sheath, a cable, and a cable router. [Diagram 31] FIG. 31 is a schematic cross-sectional view showing the sheath shown in FIG. 30 in a bent state. [Figure 32A] FIG. 32A is a cross-sectional view showing the stopper of the capsule. [Figure 32B] FIG. 32B is a cross-sectional view showing the stopper of the capsule. [Figure 32C] FIG. 32C is a cross-sectional view showing the stopper of the capsule. [Figure 33A] FIG. 33A is a cross-sectional view showing the stopper of the capsule. [Figure 33B] FIG. 33B is a cross-sectional view showing the stopper of the capsule. [Figure 33C] FIG. 33C is a cross-sectional view showing the stopper of the capsule. [Figure 34A] FIG. 34A is a perspective view showing the stopper of the capsule. [Figure 34B] FIG. 34B is a perspective view showing the stopper of the capsule. [Figure 34C] FIG. 34C is a perspective view showing the stopper of the capsule. [Diagram 35] FIG. 35 illustrates an embodiment of a handle for a delivery system. [Diagram 36] FIG. 36 shows a cross-section of the handle of the delivery system of FIG. [Figure 37] FIG. 37 is a perspective view of an embodiment of a handle of a delivery system. [Figure 38] 38 is a bottom view of the handle of the delivery system of FIG. 37. FIG. [Figure 39] 39 is a center cross-sectional view of the handle of the delivery system of FIG. 37 from the bottom view of FIG. [Diagram 40] 40 is a front perspective view of the handle of the delivery system of FIG. [Diagram 41] 41 is a perspective cross-sectional view of the handle of the delivery system of FIG. 37 taken along line AA of FIG. [Diagram 42] 42 is a perspective cross-sectional view of the handle of the delivery system of FIG. 37 taken along line BB of FIG. [Diagram 43] 43 is a perspective cross-sectional view of the handle of the delivery system of FIG. 37 taken along line CC of FIG. [Diagram 44] 44 is a perspective cross-sectional view of the handle of the delivery system of FIG. 37 taken along line DD of FIG. [Diagram 45] 45 is a perspective cross-sectional view of the handle of the delivery system of FIG. 37 taken along line EE of FIG. [Figure 46] FIG. 46 is a side view of an embodiment of a nosecone. [Figure 47] 47 is a cross-sectional view of the nosecone of FIG. 46 taken along line AA of FIG. [Figure 48] FIG. 48 is a side view of an embodiment of a nosecone including markers. [Figure 49] FIG. 49 shows an echocardiogram. [Figure 50] FIG. 50 is a side view of an embodiment of a nosecone including markers. [Figure 51] FIG. 51 is a perspective view of an embodiment of a nosecone including markers. [Figure 52] FIG. 52 is a perspective view of an embodiment of a nosecone including markers. [Diagram 53] FIG. 53 is a perspective view of an embodiment of a nosecone including markers. [Figure 54] FIG. 54 is a cross-sectional view showing an embodiment of a nosecone including markers. [Figure 55] FIG. 55 is a perspective view, partially in phantom, of an embodiment of a nosecone including markers. [Figure 56] FIG. 56 is a perspective view of the nosecone of FIG. 55. [Figure 57] FIG. 57 is a perspective view of an embodiment of a nosecone including markers. [Figure 58] FIG. 58 is a cross-sectional view illustrating an embodiment of an outer sheath including a marker. [Figure 59] FIG. 59 is a cross-sectional view showing the marker of FIG. [Figure 60] FIG. 60 shows an echocardiogram. [Figure 61] FIG. 61 is a schematic diagram showing a transseptal delivery approach. [Figure 62] FIG. 62 is a schematic diagram showing a valve prosthesis positioned within the native mitral valve. [Figure 63] FIG. 63 illustrates a valve prosthesis frame positioned within the heart. [Figure 64] FIG. 64 illustrates steps of a method for delivering a valvular prosthesis to an anatomical location. [Figure 65] FIG. 65 illustrates steps of a method for delivering a valvular prosthesis to an anatomical location. [Figure 66] FIG. 66 illustrates steps of a method for delivering a valvular prosthesis to an anatomical location. [Figure 67A] FIG. 67A illustrates a method of rail delivery system. [Figure 67B] FIG. 67B illustrates a method of rail delivery system. [Figure 68] FIG. 68 is a side view showing an embodiment of an implant in the form of a valve prosthesis that can be delivered using the delivery systems described herein. [Figure 69] FIG. 69 illustrates an embodiment of an implant in the form of a valve prosthesis that can be delivered using the delivery systems described herein. [Figure 70] FIG. 70 is a cross-sectional view showing the arms of the implant extending from the capsule. [Figure 71] FIG. 71 is a cross-sectional view showing the distal end of the capsule extending radially outward. [Figure 72]FIG. 72 is a cross-sectional view showing a capsule having a distal end configured to extend radially outward. [Figure 73] FIG. 73 is a cross-sectional view of the capsule shown in FIG. [Fig. 74A] FIG. 74A is a side view showing a capsule with a pull tether connected to a nose cone. [Fig. 74B] FIG. 74B is a side view showing the capsule shown in FIG. 74A bent from the position shown in FIG. 74A. [Fig. 75A] FIG. 75A is a side view showing the capsule and nose cone of the delivery system. [Fig. 75B] FIG. 75B is a side view of the capsule and nose cone of the delivery system shown in FIG. 75A. [Figure 76A] FIG. 76A is a perspective view showing a capsule of the delivery system. [Figure 76B] FIG. 76B is a perspective view of a capsule of the delivery system shown in FIG. 76A. [Figure 77A] FIG. 77A is a perspective view showing a capsule of the delivery system. [Fig. 77B] FIG. 77B is a perspective view of a capsule of the delivery system shown in FIG. 77A. [Fig. 78A] FIG. 78A is a perspective view showing a capsule of the delivery system. [Fig. 78B] FIG. 78B is a perspective view of a capsule of the delivery system shown in FIG. 78A. [Figure 79] FIG. 79 is a side view showing a steerable elongate shaft. [Figure 80] 80 is a side view of an elongate shaft including an implant sliding along the steerable elongate shaft shown in FIG. [Figure 81] 81 is a side view of an elongate shaft including an implant that slides along the steerable elongate shaft shown in FIG. DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

[0038] The present specification and drawings provide aspects and features of the disclosure of the delivery system and method in the context of several embodiments. The delivery system and method may be configured for use within a patient's vasculature, such as for replacing a patient's native heart valve. The embodiments may be described in the context of replacing a particular valve, such as the aortic, tricuspid, or mitral valve of the patient. However, it should be understood that the features and concepts described herein may be applied to products other than heart valve implants. For example, the delivery system and method may also be applied to medical implants, such as other types of expandable prostheses, for use elsewhere in the body, such as in arteries, veins, or other body cavities or locations. Furthermore, specific features, such as valves and delivery systems, should not be construed as limiting, and features of any one embodiment described herein may be combined with features of other embodiments, as desired and appropriate. Although some of the embodiments described herein are described in the context of a transfemoral delivery approach, it should be understood that the embodiments may also be used in other delivery approaches, such as a transapical approach or a transjugular approach. Moreover, it should be understood that some of the features described in connection with some embodiments, including those described in connection with various delivery techniques, can be incorporated in other embodiments.

[0039] FIG. 1 illustrates an embodiment of a delivery system 10 according to an embodiment of the present disclosure. The delivery system 10 may be used to place an implant, such as a prosthetic replacement heart valve, within the body. In some embodiments, the delivery system 10 may use a dual plane deflection approach to properly deliver the implant. The replacement heart valve may be delivered to the patient's mitral heart annulus or other heart valve location in a variety of ways, such as open surgery, minimally invasive surgery, and percutaneous or transcatheter delivery through the patient's vasculature. Although the delivery system 10 may be described in certain embodiments with respect to a percutaneous delivery approach, and more particularly a transfemoral delivery approach, it should be understood that the features of the delivery system 10 may also be applied to other delivery systems, such as a transapical delivery approach delivery system.

[0040] The delivery system 10 can be used to place an implant in the body, such as a replacement heart valve described elsewhere herein. The delivery system 10 can receive and / or cover a portion of an implant, such as a first end 301 and a second end 303 of an implant 70 or prosthesis shown in FIG. 3. For example, the delivery system 10 can also be used to deliver an expandable implant 70, where the implant 70 includes a first end 301 and a second end 303, and the second end 303 is configured to be placed or expanded before the first end 301.

[0041] FIG. 2A further illustrates an example of an implant 70 that can be inserted into a portion of the delivery system 10, specifically the implant holding area 16. For ease of understanding, the implant is shown in FIG. 2A with only a bare metal frame illustrated. The implant 70 or prosthesis can take any number of different forms. A particular example of an implant frame is shown in FIG. 3A, although other designs may be utilized in other embodiments. The implant 70 may include one or more sets of anchors, such as a distal (or ventricular) anchor 80 that extends proximally when the implant frame is in an expanded configuration, and a proximal (or atrial) anchor 82 (shown in FIG. 3A) that extends distally when the implant frame is in an expanded configuration. The implant may further include struts 72 that may terminate in mushroom-shaped tabs 74 at a first end 301 (shown in FIG. 3A).

[0042] In some embodiments, delivery system 10 may be used with a replacement aortic valve, such as that shown in Figure 3B. In some embodiments, delivery system 10 may be modified to support and deliver a replacement aortic valve, although the procedures and structures described below may be used for replacement mitral and aortic valves, as well as other replacement heart valves and other implants as well.

[0043] With reference to FIG. 1 , the delivery system 10 may include an elongated shaft 12 that may comprise a shaft assembly. The elongated shaft 12 may include a proximal end 11 and a distal end 13, with a housing in the form of a handle 14 coupled to the proximal end of the elongated shaft 12. The elongated shaft 12 may be used to hold and advance the implant through the vasculature to a treatment location. The elongated shaft 12 may further include a relatively rigid live-on (or integral) sheath 51 surrounding an inner portion of the shaft 12 that may reduce undesired movement of the inner portion of the shaft 12. The rib-on sheath 51 may be attached to the proximal end of the shaft 12 near the handle 14, such as a sheath hub.

[0044] The elongate shaft 12 and a housing in the form of a handle 14 may form a delivery device configured to deliver the implant 70 to an internal body location.

[0045] 2A and 2B, the elongate shaft 12 may include an implant holding region 16 (shown in FIGS. 2A-2B, where FIG. 2A shows an implant 70 and FIG. 2B shows the implant 70 removed) at its distal end. In some embodiments, the elongate shaft 12 may hold an expandable implant in a compressed state at the implant holding region 16 for advancing the implant 70 within the body. The shaft 12 may then be used to allow controlled expansion of the implant 70 at the treatment location. In some embodiments, the shaft 12 may be used to allow sequential controlled expansion of the implant 70 as described in more detail below. The implant holding region 16 is shown at the distal end of the delivery system 10 in FIGS. 2A-2B, but may be at other locations. In some embodiments, the implant 70 may be rotated at the implant holding region 16, such as by rotation of the inner shaft assembly 18 as described herein.

[0046] As shown in the cross-sectional views of Figures 2A-2B, the distal end of the delivery system 10 can include one or more assemblies, such as an outer sheath assembly 22, a central shaft assembly 21, a rail assembly 20, an inner shaft assembly 18, and a nosecone assembly 31, which are described in more detail below. In some embodiments, the delivery system 10 may not include all of the assemblies disclosed herein. For example, in some embodiments, the central shaft assembly may not be fully assembled into the delivery system 10. In some embodiments, these assemblies may be in a different radial order than described.

[0047] The disclosed embodiments of the delivery system 10 may utilize steerable rails in a rail assembly 20 to steer the distal end of the elongated shaft 12 to allow the implant to be properly positioned within the patient's body. As described in more detail below, the steerable rail may be, for example, a rail shaft that extends through the elongated shaft 12 from the handle 14 to approximately the distal end of the elongated shaft 12. In some embodiments, the steerable rail has a distal end that terminates proximal to the implant holding area 16. A user may manipulate the bend of the distal end of the rail to bend the rail in a particular direction. In a preferred embodiment, the rail has multiple bends along its length to achieve multiple bending directions. The rail may allow the elongated shaft 12 to flex in at least two planes. As the rail bends, it pushes against other assemblies to bend them as well, so that the other assemblies of the elongated shaft 12 may be configured to be steered with the rail as a single cooperating unit to achieve full steerability of the distal end of the elongated shaft 12.

[0048] Once the rail is steered into a particular location within the patient's body, the implant 70 can be advanced along or relative to the rail by moving the other sheaths / shafts relative to the rail to release the implant 70 into the body. For example, the rail can be bent into a desired location within the body to direct the implant 70 toward the native mitral valve. The other assemblies (e.g., outer sheath assembly 22, central shaft assembly 21, inner assembly 18, and nosecone assembly 31) can passively follow the bend of the rail. Additionally, the other assemblies (e.g., outer sheath assembly 22, central shaft assembly 21, inner assembly 18, and nosecone assembly 31) can be advanced together (e.g., somewhat together, sequentially, simultaneously, nearly simultaneously, together, nearly together) relative to the rail while maintaining the implant 70 in a compressed position without releasing or expanding the implant 70 (e.g., within the implant holding region 16). The other assemblies (e.g., outer sheath assembly 22, central shaft assembly 21, inner assembly 18, and nosecone assembly 31) may be advanced together in a distal or proximal direction relative to the rail. In some embodiments, only the outer sheath assembly 22, central shaft assembly 21, and inner assembly 18 are advanced together on the rail. In this manner, the nosecone assembly 31 may remain in the same position. To release the implant 70 from the implant holding area 16, the assemblies may be translated relative to the inner assembly 18 individually, sequentially, or simultaneously.

[0049] 2C illustrates the sheath assemblies, specifically the outer sheath assembly 22, the central shaft assembly 21, the inner shaft assembly 18, and the nosecone assembly 31, translated together in a distal direction along the rail assembly 20. In some embodiments, the outer sheath assembly 22, the central shaft assembly 21, the inner shaft assembly 18, and the nosecone assembly 31 translate together (to some extent together, sequentially by one actuator, simultaneously, nearly simultaneously, together, nearly together). This distal translation can occur while the implant 70 remains in a compressed configuration within the implant retaining region 16.

[0050] As shown in Figures 2A-2C and further as shown in Figures 4-8, starting from the outermost assembly, the delivery system may include an outer sheath assembly 22 that constitutes a radially outer covering or sheath surrounding the implant holding area 16 to prevent the implant from expanding radially. Specifically, the outer sheath assembly 22 may prevent the distal end of the implant from expanding radially. Moving radially inward, and referring to Figure 5, the central shaft assembly 21 may be comprised of a central shaft hypotube 43 whose distal end is attached to an outer retaining member 42 or outer retaining ring for radially retaining a portion of the implant, such as the proximal end of the implant 70, in a compressed configuration. The central shaft assembly 21 may be located within the lumen of the outer sheath assembly 22. Moving further inward, and referring to Figure 6A, the rail assembly 20 may be configured to be steerable, as described above and further below. The rail assembly 20 may be located within the lumen of the central shaft assembly 21. 7, the inner shaft assembly 18 may be comprised of an inner shaft attached at its distal end to an inner retaining member or inner retaining ring 40 (e.g., a PEEK ring) for axially retaining an implant, e.g., the proximal end of the implant. The inner shaft assembly 18 may be located within the lumen of the rail assembly 20. Further, referring to FIG. 8, the radially innermost assembly may be a nosecone assembly 31 including a nosecone shaft 27 connected at its distal end to a nosecone 28. The nosecone 28 may have a tapered tip and forms the tip of the elongated shaft 12. The nosecone assembly 31 is preferably located within the lumen of the inner shaft assembly 18. The nosecone assembly 31 may include a lumen for passing a guidewire.

[0051] The elongated shaft 12 and its assemblies, more particularly the nosecone assembly 31, inner assembly 18, rail assembly 20, central shaft assembly 21, and outer sheath assembly 22, can be collectively configured to deliver an implant 70 located within the implant holding area 16 (shown in FIG. 2A) to a treatment location. One or more of the assemblies can then be moved to allow the implant 70 to be released at the treatment location. For example, one or more of the assemblies can be movable relative to one or more of the other assemblies. The implant 70 can be controllably loaded into the delivery system 10 and subsequently disposed within the body. Additionally, the handle 14 can provide steering to the rail assembly 20 to allow bending / flexion / steering of the distal end of the elongated shaft 12.

[0052] 2A-2C, the inner retaining member 40, the outer retaining member 42, and the outer sheath assembly 22 can cooperate to hold the implant 70 in a compressed configuration. In FIG. 2A, the inner retaining member 40 is shown engaging with struts 72 (numbered in FIG. 3A) on the proximal end 301 of the implant 70. For example, slots located between radially extending teeth on the inner retaining member 40 can receive and engage with struts 72 (numbered in FIG. 3A), which may terminate in mushroom-shaped tabs 74 on the proximal end of the implant 70. The central shaft assembly 21 can be positioned over the inner retaining member 40 such that the first end 301 (numbered in FIG. 3A) of the implant 70 is captured between the inner retaining member 40 and the outer retaining member 42, thereby securely attaching the implant 70 to the delivery system 10 between the central shaft assembly 21 and the inner retaining member 40. The outer sheath assembly 22 can be positioned over a second end 303 (numbered in FIG. 3A) of the implant 70 .

[0053] The outer retaining member 42 can be attached to a distal end of the central shaft hypotube 43, which can be attached at a proximal end to a proximal tube 44 (numbering shown in FIG. 5), which can be attached at a proximal end to the handle 14. The outer retaining member 42 can provide additional stability to the implant 70 when in a compressed state. The outer retaining member 42 can be positioned over the inner retaining member 40 such that the proximal end of the implant 70 is captured between them, thereby providing a secure attachment to the delivery system 10. The outer retaining member 42 can prevent the implant 70 from expanding by encircling a portion of the implant 70, particularly the first end 301. Additionally, the central shaft assembly 21 can be translated proximally relative to the inner assembly 18 into the outer sheath assembly 22 to expose the first end 301 of the implant 70 held within the outer retaining member 42. In this manner, the outer retention member 42 may be used to secure the implant 70 to the delivery system 10 or to aid in the release of the implant 70 from the delivery system 10. The outer retention member 42 may have a cylindrical or elongated tubular shape and may also be referred to as an outer retention ring, but is not limited to a particular shape.

[0054] The central shaft hypotube 43 itself (numbered in FIG. 5 ) may be constructed of, for example, high density polyethylene (HDPE), as well as other suitable materials as described herein. The central shaft hypotube 43 may be constructed of a longitudinally pre-compressed HDPE tube, which may provide certain advantages. For example, the pre-compressed HDPE tube may apply a distal force to the outer retention member 42 to prevent unintended, inadvertent, and / or premature release of the implant 70. In particular, the distal force from the central shaft hypotube 43 may maintain the distal end of the outer retention member 42 distal to the inner retention member 40, thereby preventing the outer retention member 42 from moving proximal to the inner retention member 40 before a user desires to release the implant 70. This is also true when the elongate shaft 12 is deflected at an acute angle.

[0055] As shown in FIG. 2A, the distal anchor 80 (numbering shown in FIG. 3A) can be positioned in a delivery configuration in which the distal anchor 80 points generally in a distal direction (pointing axially away from the main body of the implant frame and the handle of the delivery system as shown). The distal anchor 80 can be constrained in this delivery configuration by the outer sheath assembly 22. Thus, when the outer sheath 22 is retracted proximally, the distal anchor 80 can flip (e.g., bend approximately 180 degrees) to the deployment configuration (e.g., pointing generally in a proximal direction). FIG. 2A also shows a proximal anchor 82 extending distally within the outer sheath assembly 22 in the delivery configuration. In other embodiments, the distal anchor 80 can be held pointing generally in a proximal direction in the delivery configuration and pressed against the body of the implant frame.

[0056] The delivery system 10 may be provided to the user with the implant 70 pre-installed. In other embodiments, the implant 70 may be loaded into the delivery system 10, such as by a doctor or nurse, shortly prior to use.

[0057] 4-8 show additional views of delivery system 10 with various assemblies translated proximally, as will be described in more detail.

[0058] Starting with the outermost assembly shown in FIG. 4, the outer sheath assembly 22 may include an outer proximal shaft 102 attached directly to the handle 14 at its proximal end and an outer hypotube 104 attached at its distal end. A capsule 106 may then be attached to approximately the distal end of the outer hypotube 104. In some embodiments, the capsule 106 may be sized to be 28 French or smaller. These components of the outer sheath assembly 22 may form a lumen for passing other subassemblies therethrough.

[0059] The outer proximal shaft 102 may be a tube and is preferably constructed of plastic, but may be a metal hypotube or other material. The outer hypotube 104 may be a metal hypotube that may be notched or slotted in some embodiments as described in more detail below. The outer hypotube 104 may be coated or encapsulated with a layer of ePTFE, PTFE, or other polymer / material such that the outer surface of the outer hypotube 104 is generally smooth.

[0060] The capsule 106 can be located at the distal end of the outer hypotube 104. The capsule 106 can be a tube constructed of a plastic or metal material. In some embodiments, the capsule 106 is constructed of ePTFE or PTFE. In some embodiments, the capsule 106 is relatively thick to prevent tearing and to help maintain the self-expanding implant in a compressed configuration. In some embodiments, the material of the capsule 106 is the same material as the coating of the outer hypotube 104. As shown, the capsule 106 can have a larger diameter than the outer hypotube 104, but in some embodiments, the capsule 106 can have a similar diameter as the hypotube 104. In some embodiments, the capsule 106 can include a larger diameter distal portion and a smaller diameter proximal portion. In some embodiments, there can be a step or taper between the two portions. The capsule 106 can be configured to hold the implant 70 in a compressed position within the capsule 106. Further construction details of the capsule 106 according to various embodiments are discussed below.

[0061] The outer sheath assembly 22 is configured to be individually slidable relative to the other assemblies. Additionally, the outer sheath assembly 22, along with the central shaft assembly 21, the inner assembly 18, and the nosecone assembly 31, can slide distally and proximally relative to the rail assembly 2.

[0062] In embodiments, a hydrophilic layer may be applied to the elongate shaft of the delivery system 10, and in particular to the outer sheath assembly 22. The outer surface of the outer sheath assembly 22 may include a hydrophilic layer, which may reduce friction of the outer sheath assembly 22 as the elongate shaft is threaded through a patient's vasculature. The hydrophilic layer may cover the entire outer surface of the outer sheath assembly 22, may cover only the outer surface of the capsule 106, or may cover other components of the delivery system 10 in some embodiments.

[0063] In an embodiment, the hydrophilic layer may be applied to a surface of the outer sheath assembly 22 that includes expanded polytetrafluoroethylene (ePTFE). The ePTFE surface may form the outer surface of the outer sheath assembly 22, which is then covered with a hydrophilic layer, which then becomes the outer surface of the outer sheath assembly 22. A process may be utilized in which the hydrophilic layer bonds to the ePTFE surface, with the plasma layer acting as an intermediate or tie layer between the ePTFE surface and the hydrophilic layer. Thus, in an embodiment, an ePTFE outer surface may be provided, and then a plasma layer may be applied to the ePTFE outer surface. A hydrophilic layer may then be applied to the plasma layer (with the plasma layer acting as an intermediate layer).

[0064] In embodiments, other intermediate or tie layers may be utilized, for example, in embodiments, chemical etches or methods may be utilized as intermediate or tie layers.

[0065] In embodiments, the hydrophilic layer may be comprised of the PhotoLink® family of reagents, such as Photo-Polyvinylpyrrolidone (PV), Photo-Polyacrylamide (PA), and Photo-Crosslinker (PR), as well as Kollidon® non-photo polymer povidone reagents. In other embodiments, other formulations of hydrophilic layers may be utilized. In embodiments, the plasma layer may include a plasma hydroxyl treatment coating, which may be comprised of carbon, hydrogen, and oxygen species. In other embodiments, other forms of plasma layers may be utilized. The hydrophilic layers and / or intermediate or tie layers disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0066] Continuing radially inward, the next assembly is the central shaft assembly 21. Figure 5 is a view similar to Figure 4, but with the outer sheath assembly 22 removed to expose the central shaft assembly 21.

[0067] The central shaft assembly 21 can include a central shaft hypotube 43 that is generally attached at its proximal end to a central shaft proximal tube 44 that can be attached at its proximal end to the handle 14, and an outer retaining ring 42 located at the distal end of the central shaft hypotube 43. Thus, the outer retaining ring 42 can be attached to the generally distal end of the central shaft hypotube 43. These components of the central shaft assembly 21 can form a lumen for passing other subassemblies therethrough.

[0068] As with the other assemblies, the central shaft hypotube 43 and / or the central shaft proximal tube 44 may include tubes such as subcutaneous tubes or hypotubes (not shown). These tubes may be constructed from any one of a number of different materials, such as Nitinol, stainless steel, and medical grade plastics. These tubes may be single piece tubes or may have multiple pieces connected together. Using multiple piece tubes allows the tube to have properties such as different stiffness and flexibility in different sections. The central shaft hypotube 43 may be a metallic hypotube, which in some embodiments may be slit or slotted as described in more detail below. The central shaft hypotube 43 may be coated or encapsulated with a layer of ePTFE, PTFE, or other material such that the outer surface of the central shaft hypotube 43 is generally smooth.

[0069] The outer retaining ring 42 can be configured as a prosthesis retention feature that can be used to engage the implant 70, as described with reference to FIG. 2A. For example, the outer retaining ring 42 can be a ring or covering configured to radially cover the struts 72 on the implant 70. The outer retaining ring 42 can also be considered part of the implant retaining area 16 and can be at a proximal end of the implant retaining area 16. With the struts or other portions of the implant 70 engaged with the inner retaining member 40, described below, the outer retaining ring 42 can cover both the implant 70 and the inner retaining member 40 to secure the implant 70 on the delivery system 10. Thus, the implant 70 can be sandwiched between the inner retaining member 40 of the inner shaft assembly 18 and the outer retaining ring 42 of the central shaft assembly 21.

[0070] The central shaft assembly 21 is arranged to be individually slidable relative to the other assemblies, and further, the central shaft assembly 21, along with the outer sheath assembly 22, the inner shaft assembly 18, and the nosecone assembly 31, can slide distally and proximally relative to the rail assembly 20.

[0071] Next, radially inward of the central shaft assembly 21 is the rail assembly 2. FIG. 6A is a view similar to FIG. 5, but with the central shaft assembly 21 removed to expose the rail assembly 20. FIG. 6B further illustrates a cross-section of the rail assembly 20 to reveal the pull wires. The rail assembly 20 may include a rail shaft 132 (or rail) that is generally attached at its proximal end to the handle 14. The rail shaft 132 may include a rail proximal shaft 134 that is attached directly to the handle at its proximal end, and a rail hypotube 136 that is attached to the distal end of the rail proximal shaft 134. The rail hypotube 136 may further include an atraumatic rail tip at its distal end. Additionally, the distal end of the rail hypotube 136 may abut against the proximal end of the inner retaining member 40, as shown in FIG. 6. In some embodiments, the distal end of the rail hypotube 136 may be spaced apart from the inner retaining member 40. These components of the rail shaft assembly 20 may define internal lumens for the passage of other subassemblies.

[0072] 6B, one or more pull wires are attached to the inner surface of the rail hypotube 136 that can be used to apply a force to the rail hypotube 136 to steer the rail assembly 20. The pull wires can extend distally from a knob in the handle 14, described below, to the rail hypotube 136. In some embodiments, the pull wires can be attached at different longitudinal locations on the rail hypotube 136 to provide multiple bend positions on the rail hypotube 136 to allow for multi-dimensional steering.

[0073] In some embodiments, the distal pull wire 138 can extend to the distal section of the rail hypotube 136 and two proximal pull wires 140 can extend to the proximal section of the rail hypotube 136, although other numbers of pull wires can be used and this particular number of pull wires is not limiting. For example, two pull wires can extend to a distal location and one pull wire can extend to a proximal location. In some embodiments, ring-like structures attached to the interior of the rail hypotube 136, called pull wire connectors, such as the proximal ring 137 and the distal ring 135, can be used as attachment locations for the pull wires. In some embodiments, the rail assembly 20 can include the distal ring 135, which can include a distal pull wire connector, and the proximal ring 137 can include a proximal pull wire connector. In some embodiments, the pull wires can be directly connected to the inner surface of the rail hypotube 136.

[0074] The distal pull wire 138 can be connected (by itself or via a connector 135) to a generally distal end of the rail hypotube 136. The proximal pull wire 140 can be connected (by itself or via a connector 137) to a location approximately one-quarter, one-third, or one-half of the length of the rail hypotube 136 from the proximal end. In some embodiments, the distal pull wire 138 can be threaded through a small diameter pull wire lumen 139 (e.g., tube, hypotube, cylinder) attached to the inside of the rail hypotube 136. This can prevent the wire 138 from pulling on the rail hypotube 136 at a location proximal to the distal connection. Additionally, the lumen 139 can act as a compression coil to stiffen the proximal portion of the rail hypotube 136 and prevent undesired bending. Thus, in some embodiments, the lumen 139 is located only in the proximal half of the rail hypotube 136. In some embodiments, multiple lumens 139, such as longitudinally spaced or adjacent, can be used per distal wire 138. In some embodiments, a single lumen 139 is used per distal wire 138. In some embodiments, the lumen 139 can also extend into the distal half of the rail hypotube 136. In some embodiments, the lumen 139 is attached to the outer surface of the rail hypotube 136. In some embodiments, no lumen 139 is used.

[0075] For the pair of proximal pull wires 140, the wires can be spaced approximately 180 degrees apart from each other to allow for steering in both directions. Similarly, if a pair of distal pull wires 138 is used, the wires can also be spaced approximately 180 degrees apart from each other to allow for steering in both directions. In some embodiments, the pair of distal pull wires 138 and the pair of proximal pull wires 140 can be spaced approximately 90 degrees apart from each other. In some embodiments, the pair of distal pull wires 138 and the pair of proximal pull wires 140 can be spaced approximately 0 degrees apart from each other. However, other positions of the pull wires can be used and the particular position of the pull wires is not limiting. In some embodiments, the distal pull wires 138 can be routed through a lumen 139 attached within the lumen of the rail hypotube 136. This can prevent axial forces on the distal pull wires 138 from causing bending of the proximal section of the rail hypotube 136.

[0076] The rail assembly 20 is slidably positioned over the inner shaft assembly 18 and the nosecone assembly 31. In some embodiments, the outer sheath assembly 22, the central shaft assembly 21, the inner shaft assembly 18, and the nosecone assembly 31 can be configured to slide proximally and distally along or relative to the rail assembly 20, for example, with or without bending the rail assembly 20. In some embodiments, the outer sheath assembly 22, the central shaft assembly 21, the inner shaft assembly 18, and the nosecone assembly 31 can be configured to hold the implant 70 in a compressed position when they simultaneously slide along or relative to the rail assembly 20.

[0077] Continuing radially inward, the next assembly is the inner shaft assembly 18. Figure 7 is similar to Figure 6A, but with the rail assembly 20 removed to expose the inner shaft assembly 18.

[0078] The inner shaft assembly 18 may include an inner shaft 122 that is generally attached at its proximal end to the handle 14, and an inner retaining ring 40 located at the distal end of the inner shaft 122. The inner shaft 122 may itself be comprised of an inner proximal shaft 124 that is directly attached at its proximal end to the handle 14, and a distal section 126 that is attached to the distal end of the inner proximal shaft 124. Thus, the inner retaining ring 40 may generally be attached to the distal end of the distal section 126. These components of the inner shaft assembly 18 may form a lumen for passing other subassemblies therethrough.

[0079] As with the other assemblies, the inner proximal shaft 124 may include a tube, such as a hypotube or hypotube (not shown). The tube may be constructed of any one of a number of different materials, such as nitinol, cobalt chrome, stainless steel, and medical grade plastic. The tube may be a single piece tube or may have multiple pieces connected together. A tube with multiple pieces may provide properties such as different stiffness and flexibility in different sections. The distal section 126 may be a metallic hypotube, which in some embodiments may be slit or slotted as described in more detail below. The distal section 126 may be coated or encapsulated with a layer of ePTFE, PTFE, or other material such that the outer surface of the distal section 126 is generally smooth.

[0080] The inner retention member 40 can be configured as an implant retention mechanism that can be used to engage the implant 70, as described with reference to FIG. 2A. For example, the inner retention member 40 can be a ring and can include a number of slots configured to engage with struts 72 on the implant 70. The inner retention member 40 can also be considered part of the implant retention area 16 and can be at a proximal end of the implant retention area 16. With the struts or other portions of the implant 70 engaged with the inner retention member 40, the outer retention ring 42 can cover both the prosthesis and the inner retention member 40 to secure the prosthesis on the delivery system 10. Thus, the implant 70 can be sandwiched between the inner retention member 40 of the inner shaft assembly 18 and the outer retention ring 42 of the central shaft assembly 21.

[0081] The inner shaft assembly 18 is arranged to be individually slidable relative to the other assemblies, and further, the inner assembly 18, along with the outer sheath assembly 22, the central shaft assembly 21, and the nosecone assembly 31, can slide distally and proximally relative to the rail assembly 20.

[0082] Next, moving further radially inward from the inner shaft assembly 18, is the nosecone assembly 31, also shown in Figure 8. This may be a nosecone shaft 27, which in some embodiments may have a nosecone 28 at its distal end. The nosecone 28 may be constructed of polyurethane for atraumatic insertion and to minimize damage to the venous vasculature. The nosecone 28 may also be radiopaque to provide visualization under fluoroscopy.

[0083] The nosecone shaft 27 may include an inner lumen sized and configured to slidably accommodate a guidewire so that the delivery system 10 can be advanced over the guidewire within the vasculature. However, embodiments of the system 10 described herein may not require the use of a guidewire, and thus the nosecone shaft 27 may be solid. The nosecone shaft 27 may be connected from the nosecone 28 to a handle, or may be composed of different segments, such as other assemblies. Additionally, the nosecone shaft 27 may be composed of different materials, such as plastics or metals, as discussed in detail above.

[0084] In some embodiments, the nosecone shaft 27 includes a guidewire shield 1200 located over a portion of the nosecone shaft 27. Examples of such guidewire shields can be seen in FIGS. 9A-9B. In some embodiments, the guidewire shield 1200 can be proximal to the nosecone 28. In some embodiments, the guidewire shield 1200 can be translatable along the nosecone shaft 27. In some embodiments, the guidewire shield 1200 can be locked in place along the nosecone shaft 27. In some embodiments, the guidewire shield 1200 can also be located at least partially within the nosecone 28.

[0085] Advantageously, the guidewire shield 1200 can allow for smooth movement of the guidewire loaded with the implant 70 and can provide a large diameter axial landing zone at the distal end of the implant 70 so that the distal end of the implant 70 can properly expand and be positioned in a uniform radial configuration. This uniformity allows for proper expansion. Additionally, the guidewire shield 1200 can prevent kinking or breaking of the nosecone shaft 27 during compression / crimping of the implant 70, which can apply large compressive forces to the nosecone shaft 27. The guidewire shield 1200 can provide a protective surface since the implant 70 can be crimped to the guidewire shield 1200 instead of directly to the nosecone shaft 27.

[0086] As shown in FIG. 9A, the guidewire shield 1200 can include a lumen 1202 configured to surround the nosecone shaft 27. The guidewire shield 1200 can include a distal end 1204 with a larger diameter and a proximal end 1206 with a smaller diameter. In some embodiments, the change in dimension between the two ends can be tapered or can be a step 1208 as shown in FIG. 9A. The distal end 1204 can include a number of recesses 1210 to aid in a user grip, although these may not be included in all embodiments. Both the proximal end 1206 and the distal end 1204 can be generally cylindrical, although the particular shape of the guidewire shield 1200 is not limiting.

[0087] The distal end of the implant 70 can be crimped into radial contact with the proximal end 1206 of the guidewire shield 1200. This allows the implant 70 to expand appropriately around the circumference of the proximal end 1206 of the guidewire shield 1200. In some embodiments, the distal end of the implant 70 can abut longitudinally against the proximal end of the distal end 1204 (e.g., at a step 1208), thereby providing a longitudinal stop.

[0088] 9B illustrates an alternative embodiment of the guidewire shield 1200' having a more tapered configuration. As shown, the proximal end 1206' of the guidewire shield 1200' can have a single radially outward taper 1208' to the distal end 1204' of the guidewire shield 1200', which can be generally cylindrical. The guidewire shield 1200' can also include an inner lumen 1202' for receiving the nosecone shaft 27.

[0089] The nosecone assembly 31 is arranged to be individually slidable relative to the other assemblies, and further, the nosecone assembly 31, along with the outer sheath assembly 22, the central shaft assembly 21, and the inner assembly 18, can slide distally and proximally relative to the rail assembly 20.

[0090] In some embodiments, the nosecone shaft 27 may be constructed of a Nitinol material. This material may allow for flexibility of the nosecone shaft 27 while making the nosecone shaft 27 resilient and capable of returning to an undeflected state without kinking or breaking the shaft 27. Additionally, this material is relatively strong and may allow the delivery system 10 to flex and to withstand forces applied to the shaft 27 by the delivery system 10 during deployment or, in some cases, retrieval of the implant from the delivery system 10. In some embodiments, the nosecone shaft 27 may include a hypotube that includes a cut pattern that may increase the flexibility of the shaft 27 and reduce the likelihood of the shaft 27 deforming.

[0091] In embodiments, if the nosecone shaft 27 is constructed from a Nitinol material, the guidewire shield 1200, 1200' may not be required. For example, a Nitinol nosecone shaft 27 may be able to withstand the compressive / crimping forces of the implant 70 on the shaft 27, and therefore may not require a guidewire shield 1200, 1200'. However, in embodiments, a guidewire shield 1200, 1200' may be utilized in conjunction with a nosecone shaft 27 constructed from a Nitinol material. The Nitinol nosecone shafts described herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0092] In some embodiments, one or more spacer sleeves (not shown) can be used between different assemblies of the delivery system 10. For example, a spacer sleeve can be concentrically located between the central shaft assembly and the rail assembly 20, typically between the central shaft hypotube 43 and the rail hypotube 136. In some embodiments, a spacer sleeve can be substantially embedded in the hypotube 43 of the central shaft assembly 21, such as on the inner surface of the central shaft assembly 21. In some embodiments, a spacer sleeve can be concentrically located between the rail assembly 20 and the inner assembly 18, typically within the rail hypotube 136. In some embodiments, a spacer sleeve can be used between the outer sheath assembly 22 and the central shaft assembly 21. In some embodiments, a spacer sleeve can be used between the inner assembly 18 and the nosecone assembly 31. In some embodiments, four, three, two, or one of the spacer sleeves described above can be used. A spacer sleeve can be used in any of the above locations.

[0093] The spacer sleeve may be constructed of a polymeric material such as braided Pebax® and may be lined on the inner diameter with, for example, PTFE, although this particular material is not limiting. The spacer sleeve is advantageous because it may reduce friction between the steerable rail assembly 20 and its surrounding assemblies. Thus, the spacer sleeve may act as a buffer between the rail assembly 20 and the inner assembly 18 / nose cone assembly 31. Additionally, the spacer sleeve may absorb any gaps that occur radially between the assemblies to prevent compression or snaking of the assemblies during steering. In some embodiments, the spacer sleeve may include cuts or slots to facilitate bending of the spacer sleeve. In some embodiments, the spacer sleeve may not include any slots and may be a smooth cylindrical feature.

[0094] The spacer sleeve is not physically attached to any of the other components since it can be mechanically accommodated by the other lumens and components, which allows the spacer sleeve to "float" in the area. The floating aspect of the spacer sleeve allows it to move where needed during deflection to provide support and / or one or more lubricious bearing surfaces. This floating aspect therefore allows the delivery system 10 to sustain the deflection forces. However, in some embodiments, the spacer sleeve can also be connected to other components.

[0095] The outer sheath assembly 22, the central shaft assembly 21, the inner assembly 18, and the nosecone assembly 31 each include a shaft. The outer sheath assembly 22, the central shaft assembly 21, and the inner assembly 18 each include a sheath having a lumen. The nosecone assembly 31 includes a sheath having a lumen in embodiments in which the nosecone assembly 31 includes a lumen along which a guidewire extends.

[0096] As discussed above, the outer sheath assembly 22, central shaft assembly 21, inner assembly 18, and rail assembly 20 can house the outer hypotube 104, central shaft hypotube 43, distal section 126, and rail hypotube 136, respectively. Each of these hypotubes / sections / shafts can be laser cut to include a number of slots to create a tortuous path for the delivery system to follow. Various slot assemblies are described below, however it will be understood that any of these hypotubes can have any of the slot configurations described below. Figures 10-14 show the various hypotubes in isolated form.

[0097] The outer hypotube 104, as shown in FIG. 10, may generally be comprised of one or more metal coils. In some embodiments, the outer hypotube 104 may be comprised of a proximal metal coil 107 and a distal metal coil 108. The proximal metal coil 107 and the distal metal coil 108 may be separated longitudinally by a tube portion 110, as shown in FIG. 10. However, in some embodiments, the proximal metal coil 107 and the distal metal coil 108 are connected. To form the complete outer hypotube 104, the proximal metal coil 107 and the distal metal coil 108 may be connected to the outer surface of the tube portion 110, for example, at the distal end of the proximal metal coil 107 and the proximal end of the distal metal coil 108. In some embodiments, the proximal metal coil 107 and the distal metal coil 108 are substantially the same. In some embodiments, the proximal metal coil 107 and the distal metal coil 108 may differ, for example, in the spacing between the coils, the curvature, the diameter, etc. In some embodiments, the distal metal coil 108 has a larger diameter than the proximal metal coil 107, such as when the distal metal coil 108 forms the larger diameter of the capsule 106. In some embodiments, they have the same diameter. In some embodiments, one or both of the metal coils 108 / 107 can form the capsule 106. These coils can be coated with a polymer layer, as described in more detail below in connection with the capsule structure. This coil structure can allow the outer hypotube 104 to follow a rail in any desired direction.

[0098] Going radially inward, Figures 11-12B show that the central shaft hypotube 43 can be a metallic laser cut hypotube, such as a laser cut Nitinol hypotube. Figure 12A shows the flat pattern of Figure 11. As shown in these figures, the hypotube 43 can have several cuts that form slots / openings in the hypotube. In some embodiments, the cut pattern can be the same throughout. In some embodiments, the central shaft hypotube 43 can have different sections with different cut patterns.

[0099] For example, the proximal end of the central shaft hypotube 43 may be a first section 211 having a number of circumferentially extending cut pairs 213 spaced along its length. Generally, two slots are cut around each circumferential location, approximately halfway around the circumference. Thus, between these cuts 213, two backbones or spines 215 are formed that extend the entire length of the first section 211. The cut pairs 213 may be comprised of a first narrow cut 217. The second cut 221 of each cut pair 213 may be thicker than the first cut 217, such as 1, 2, 3, 4, or 5 times thicker. In some embodiments, the second cut 217 may be approximately the same longitudinal thickness throughout the cut. Each cut of a cut pair 213 may also terminate in a drop shape 219 in some embodiments to facilitate bending.

[0100] Continuing distally, the central shaft hypotube 43 may include a second section 220 having several cut pairs 222. Similar to the first section 211, the second section 220 may have a number of circumferentially extending cuts spaced longitudinally along the second section 220. Generally, two cuts (e.g., a pair of cut pairs 222) are cut around each circumferential location, approximately halfway around the circumference. Thus, a "spine" 224 may be formed between the cuts, extending the entire length of the second section 220. Each cut pair 222 may include a first cut 226 that is generally thin and has no particular shape (i.e., may have the same appearance as the cut 213 of the first section 211) and a second cut 228 that is significantly thicker longitudinally than the first cut 226. The second cuts 228 can be curved cuts by being thinner at their ends and thicker longitudinally in their middle. As one progresses longitudinally along the second section 220, each cut pair 222 can be offset approximately 45 degrees or 90 degrees from its longitudinally adjacent cut pair 222. In some embodiments, the second cut pair 222 can be offset 90 degrees from the adjacent first cut pair 222, and a third cut pair 222 adjacent to the second cut pair 222 can have the same configuration as the first cut pair 222. This repeating pattern can extend along the length of the second section 220 to provide a particular bending direction provided by the second cut 228 of these cut pairs 222. Thus, the "backbone" or spine 224 changes circumferential position due to the offset of adjacent slot pairs 222 that change position. Each notch in a notch pair 222 may also terminate in a drop shape 229 in some embodiments to facilitate bending.

[0101] Continuing distally, the central shaft hypotube 43 can have a third section 230 with several cuts. An outer retaining ring 240 can be attached to the distal end of the third section 230. The third section 230 can have a pair of cuts 232 extending circumferentially, with each cut of the pair extending approximately halfway around the circumference to form two backbones or spines 234. The pair of cuts 232 can be comprised of a first narrow cut 236 similar to the cut 213 described in the first section 211. The second cut 238 of each pair of cuts 232 can be thicker than the first cut 236, such as 1, 2, 3, 4, or 5 times thicker. In some embodiments, the second cuts 238 can be of approximately the same longitudinal thickness throughout the entire cut, unlike the second cuts 228 of the second section 220. The first cuts 236 and the second cuts 238 may be circumferentially aligned along the length of the third section 230 such that all of the first cuts 236 are at the same circumferential location and all of the second cuts 238 are at the same circumferential location. The second cuts 238 may be aligned with one of the circumferential locations of the second cuts 228 of the second section 220. Each cut in the cut pair 232 may also terminate in a drop shape 239 in some embodiments to facilitate bending.

[0102] In some embodiments, the outer retaining ring reinforcement 240, which may partially or completely surround the inner retaining member 40 in the circumferential direction, may also have several cuts / slots / holes / openings, as shown in Figs. 11-12. This may allow the outer retaining ring reinforcement to bend along curves, especially tight curves. In some embodiments, the distal end of the reinforcement 240 includes several approximately circular / elliptical holes 242. This may continue for about half the entire length of the reinforcement 240. In the proximal half, the circumferential half of the reinforcement 240 may include repeating thin cuts 244 spaced apart by elongated oval holes 246. For example, two circumferentially spaced elongated oval holes 246 may be between each thin cut 244. Each cut 244 may terminate in a drop shape 219 to facilitate bending. In the other circumferential half of the proximal section, the reinforcement 240 may include several larger cuts 248, such as one, two, three, four, or five longitudinally spaced large cuts 248. The large cuts 248 may be larger in the center and taper toward each circumferential end. The large cuts 248 may also include end extensions 247 to promote flexibility.

[0103] Additionally, the outer retaining ring stiffener 240 can provide strength to reduce deployment forces, can protect the implant 70 from any metal layers, and can provide additional strength. In some embodiments, the stiffener 240 is a polymer, such as PTFE, although the type of polymer or material is not limiting. In some embodiments, the stiffener 240 can be metallic. In some embodiments, the stiffener 240 can further include an outer polymer layer / jacket, such as a Pebax® jacket. This prevents the stiffener 240 from catching on the outer sheath assembly 22.

[0104] In certain embodiments, the outer retaining ring 42 may further include an inner liner to glide smoothly over the implant 70. The inner liner may be PTFE or etched PTFE, although this particular material is not limiting and other friction reducing polymers may be used. As shown in FIG. 12B, the liner 251 may not be flush to the distal end of the outer retaining ring 42 to prevent delamination during loading of the implant 70. Instead, the liner 251 may be extended and inverted at the distal end to cover the distal end of the outer retaining ring 42. In some embodiments, the liner 251 may also cover the outer surface of the stiffener 240. This may create a seamless, rounded, reinforced tip of the liner 251. The liner 251 can completely or partially cover the outer surface of the outer retaining ring 42, for example, 1 / 4, 1 / 3, 1 / 2, 2 / 3, 3 / 4 (or more than 1 / 4, 1 / 3, 1 / 2, 3 / 4), or even the entirety of the outer retaining ring 42. This solution has advantages over previously known methods, such as that disclosed in U.S. Pat. No. 6,622,367, which is incorporated by reference in its entirety, in which the PTFE-lined coating does not adhere as well to the reinforcement component or outer jacket. By inverting the liner 251 and fusing it to the outer retaining ring 42 and / or the reinforcement 240 and / or the outer polymeric jacket over the reinforcement 240 / outer retaining ring 42, a seamless reinforced tip can be created that can mitigate delamination. Delamination is a serious concern because a delaminated liner can tear and jam during deployment and because delaminated layers can make loading and deployment forces extremely high. Lumen translation problems can also occur because the delaminated layer can clog the shaft, thereby increasing the force requirements for translation.

[0105] Now, going radially inward again, FIG. 13 shows an embodiment of a rail hypotube 136 (distal end on the right). The rail hypotube 136 may also include several circumferential cuts in the form of slots. The rail hypotube 136 may generally be divided into several different sections. At the most proximal end is an uncut (or unslotted) hypotube section 231. Going distally, the next section is the proximal slotted hypotube section 233. This section includes several circumferential slots cut into the rail hypotube 136. Generally, two slots are cut around each circumferential location making up approximately half the circumference. Thus, between these cuts 213, two backbones or spines are formed that run the entire length of the hypotube 136. This section is the section that may be guided by the proximal pull wire 140. Going further distally, there is a location 237 where the proximal pull wire 140 may connect and therefore avoid the cuts. This section is immediately distal to the proximal slotted section.

[0106] 13. Continuing distally, after this proximal pull wire connection region is the distal slotted hypotube section 235. This section is similar to the proximal slotted hypotube section 233, but with significantly more slots cut into it over the same length. Thus, the distal slotted hypotube section 235 can bend more easily than the proximal slotted hypotube section 233. In some embodiments, the proximal slotted section 233 can be configured to bend approximately 90 degrees with a half inch radius, whereas the distal slotted hypotube section 235 can bend approximately 180 degrees within a half inch. Additionally, as shown in FIG. 13, the spine of the distal slotted hypotube section 235 is offset from the spine of the proximal slotted hypotube section 233. Thus, the two sections provide different bending patterns and allow for three dimensional steering of the rail assembly 20. In some embodiments, the spine can be offset 30 degrees, 45 degrees, or 90 degrees, although this particular offset is not limiting. In some embodiments, the proximal slotted hypotube section 233 can include a compression coil, which allows the proximal slotted hypotube section 233 to remain rigid for a particular bend in the distal slotted hypotube section 235.

[0107] At the distal most end of the distal slotted hypotube section 235 is a distal pullwire connection region 241 , which is again a non-slotted section of the rail hypotube 136 .

[0108] 14 , the inner assembly 18 is generally comprised of two sections. The proximal section is a hypotube 129, which may or may not be slotted. The distal section 126 overlaps at least partially with the outer surface of the proximal hypotube 129 and may be designed to be particularly flexible. For example, the distal section 126 may be more flexible than any of the other shafts described herein. In some embodiments, the distal section 126 may be more flexible than any of the shafts described herein other than the nosecone shaft 27. In some embodiments, the distal section 126 may be a flexible tube or hypotube. In some embodiments, the distal section 126 may be a cable, such as a flexible cable. For example, the cable may include several strands of metal, plastic, polymer, ceramic, etc., wrapped around each other to form a rope or cable. Because the cable is very flexible, it may bend more easily with the rail assembly 20. Additionally, the cables may be smooth, thereby eliminating the need for any inner liner on the rail assembly 20 since the rail assembly 20 may run over a smooth surface.

[0109] With reference to FIG. 15, the capsule 106 may be constructed of one or more materials, such as PTFE, ePTFE, polyether block amide (Pebax®), polyetherimide (Ultem®), PEEK, urethane, nitinol, stainless steel, and / or any other biocompatible material. The capsule is preferably compliant and flexible while maintaining a sufficient degree of radial strength to maintain the replacement valve within the capsule 106 without substantial radial deformation that may increase friction between the capsule 106 and the replacement valve or implant 70 contained therein. The capsule 106 also preferably has sufficient column strength to resist capsule buckling and sufficient tear resistance to reduce or eliminate the possibility of tearing of the replacement valve and / or breakage of the capsule 106. The flexibility of the capsule 106 may be advantageous, particularly in transseptal approaches. For example, when retracted along a curved member, e.g., when traveling over a rail assembly as described herein, capsule 106 may flex to follow the curved member without applying significant forces to the curved member that may reduce the radius of the curved member. More specifically, capsule 106 may bend and / or twist when retracted along such a curved member such that the radius of the curved member is not substantially affected.

[0110] FIG. 15 illustrates an embodiment of a capsule 106 that can be used with embodiments of the delivery system 10. The capsule 106 can include any of the materials and properties described above. Multiple implant capsules are typically used to balance compression resistance and flexibility, as increased flexibility can lead to decreased compression resistance. Thus, a choice tends to be made between compression resistance and flexibility. However, disclosed are embodiments of a capsule 106 that can achieve both high compression resistance and high flexibility. Specifically, the capsule 106 can bend in multiple directions.

[0111] In particular, metallic hypotubes can provide radial strength and compression resistance, and specific cuts, such as slots, made in the hypotubes can allow the capsule 106 to be flexible. In some embodiments, a thin liner and jacket, such as a polymeric layer, can surround the capsule 106 to prevent any negative interaction between the implant 70 and the capsule 106.

[0112] In some embodiments, the capsule 106 can have a particular structure that allows it to achieve advantageous properties, as shown in Figure 15. The capsule 106 can be composed of several different layers to achieve such properties.

[0113] In some embodiments, the capsule 106 may be comprised of a metal layer 404 to which the capsule 106 gives its structure. This metal layer may include a coil as described with reference to Figure 10, or may be one or more hypotubes. The outer surface of the capsule 106 is then coated with a polymer layer and the inner surface is coated with a liner. All of these features are described in more detail below.

[0114] As mentioned, the metal layer 404 can be, for example, a metal hypotube or a laser cut hypotube. In some embodiments, the metal layer 404 can be a metal coil or spiral, as described in detail above with reference to FIG. 10. Without being limited thereto, the metal layer 404 can have a thickness of 0.007 inches (or about 0.007 inches).

[0115] When using metal coils such as those shown in FIG. 10, the dimensions of the coils may be the same along the entire length of the metal layer 404. However, in some embodiments, the dimensions of the coils may vary along the length of the metal layer 404. For example, the coils may vary between a coil having a gap of 0.014 inches and a pitch of 0.021 inches (e.g., a small coil), a coil having a gap of 0.020 inches and a pitch of 0.02 inches (e.g., a large coil), and a coil having a gap of 0.020 inches and a pitch of 0.027 inches (e.g., spaced large coils). However, these particular dimensions are merely examples and other designs may be used.

[0116] The most distal end of the metal layer 404 may consist of a small coil. Going proximally, the metal layer 404 may then transition to a section of a large coil, followed again by a section of a small coil, and finally, the most proximal section may be a spaced apart large coil. As a non-limiting example set of lengths, the most distal small coil section may have a length of 10 mm (or about 10 mm). Going proximally, the adjacent large coil section may extend over a length of 40 mm (or about 40 mm) to 60 mm (or about 60 mm). These two sections are seen in the distal metal coil 108 shown in FIG. 10. Going towards the proximal metal coil 107 shown in FIG. 10, the small coil section may have a length of 10 mm (or about 10 mm). The remainder of the proximal metal coil 107 may be a spaced apart large coil section. The spaced apart major coil sections may have a length of 40 mm (or about 40 mm) to 60 mm (or about 60 mm).

[0117] As mentioned, the metal layer 404 (either the coil or the hypotube) can be covered with an outer polymeric layer or jacket 402. In some embodiments, the outer polymeric layer 402 is an elastomer, although this particular material is not limiting. In some embodiments, the outer polymeric layer 402 can include polytetrafluoroethylene (PTFE) or expanded polytetrafluoroethylene (ePTFE). ePTFE can have very different mechanical properties than PTFE. For example, ePTFE can be much more flexible while maintaining good tensile / elongation properties. In some embodiments, the outer polymeric layer 402 can include a thermoplastic elastomer such as PEBAX®. In some embodiments, the outer polymeric layer 402 can be axially prestressed prior to application to the capsule. The thickness of the outer polymeric layer 402 can be about 0.006 inches to 0.008 inches, although this particular thickness is not limiting.

[0118] The outer polymeric layer 402 may be applied to the metal layer 404, such as by reflowing the polymer, to form an outer jacket. In some embodiments, the outer polymeric layer 402 may be applied directly to the metal layer 404. In some embodiments, an adhesive layer 406 may be disposed between the metal layer 404 and the outer polymeric layer 402 to facilitate attachment of the outer polymeric layer to the metal layer. For example, a fluoropolymer or other soft durometer fluoroelastomer may be applied between the metal layer 404 and the outer layer 402 to adhere them together and prevent delamination. In some embodiments, an adhesive layer 406 is not used.

[0119] In some embodiments, other materials can be included between the metal layer 404 and the outer polymeric layer 402 to improve properties. For example, a fluorinated ethylene propylene (FEP) section 408 can improve radial strength, especially when the implant is in compression. Although FEP layer 408 is mentioned as a particular material, other high strength polymers, metals, or ceramics can also be used, and this particular material is not limiting. FEP layer 408 can also act as an adhesive in some cases.

[0120] FEP sections 408 may be included at the distal and proximal ends of capsule 106. FEP sections 408 may also overlap adhesive layer 406. Thus, FEP sections 408 may be located between adhesive layer 406 and metal layer 404 or between adhesive layer 406 and outer polymeric layer 402. In some embodiments, FEP sections 408 may be located in sections of capsule 106 that do not include adhesive layer 406.

[0121] The FEP section 408 located at the distal end of the capsule 106 can have a length of 10 mm (or about 10 mm), although this particular length is not limiting. In some embodiments, the thickness of the FEP section 408 is about 0.003 inches, although the thickness may vary and is not limited by this disclosure. In some embodiments, different FEP sections 408 (e.g., the proximal and distal sections) can have different thicknesses. In some embodiments, all of the FEP layers 408 have the same thickness. Exemplary thicknesses include 0.006 inches or 0.003 inches.

[0122] Moving inwardly from the metal layer 404, a liner 410 may be included on its radially inner surface. The liner 410 may be constructed of a low friction and / or high lubricity material that allows the capsule 106 to translate over the implant 70 without catching on or damaging portions of the implant 70. In some embodiments, the liner 410 may be PTFE, which can withstand radial expansion and provide low friction with the implant 70.

[0123] In some embodiments, the liner 410 is made of ePTFE. However, it may be difficult to reflow a standard ePTFE liner 410 onto the inner layer of the capsule 106. Therefore, the ePTFE liner layer 410 may be pre-compressed before being applied onto the inner layer of the capsule 106. In some embodiments, a portion of the outer polymeric layer 402 and the liner 410 may contact each other. Thus, the ePTFE liner 410 and / or the outer polymeric layer 402 may be axially compressed before the two layers are joined. The layers may then be joined by a reflow technique during manufacturing. For example, the ePTFE liner 410 may be compressed into an axial mortar by a mandrel or the like, and the outer polymeric layer 402 may be placed on top of it. The two layers may then be reflowed (e.g., melted under pressure) to connect. The joined layers may then be slid into and / or around the metal layer 404 described herein and melted again under pressure to form the final capsule 106. This technique may allow the capsule 106 to remain flexible and prevent breakage / tear.

[0124] As mentioned above, the inner liner 410 can be ePTFE in some embodiments. The surface friction of ePTFE can be about 15% lower than standard PTFE and about 40% lower than standard extruded thermoplastics used in the art.

[0125] In certain embodiments, the liner layer 410 may extend only along the inner surface of the capsule 106 and terminate at the distal end. However, to prevent delamination during loading of the implant 70, the liner 410 may not be flush to the distal end of the capsule 106. Instead, the liner 410 may be extended and everted at the distal end to cover the outer diameter of the distal end of the capsule 106 and a portion of the outer polymeric layer 402. This may create a seamless, rounded, reinforced tip of the liner 410. This solution is advantageous over previously known methods, such as that disclosed in U.S. Pat. No. 6,622,367, which is incorporated by reference in its entirety, where the PTFE-lined coating does not adhere as well to the reinforcement component or outer jacket. By everting the liner 410 and fusing it to the outer polymeric layer 402, a seamless, reinforced tip may be created that may mitigate delamination. Delamination is a serious concern because the delaminated liner can tear and clog during deployment and the delaminated layers can make the loading and deployment forces too high. Delaminated layers can also create lumen translation problems by clogging the shaft, thereby increasing the translation force requirements.

[0126] In some embodiments, another FEP section 412 may be included between the liner 410 and the metal layer 404. This FEP section 412 may be located on the distal metal coil 108 as well as on the tube 110 at the transition between the distal metal coil 108 and the proximal metal coil 107. In some embodiments, the FEP section 412 may continue partially or completely into the proximal metal coil 107.

[0127] In some embodiments, the FEP section 412 can be included in the proximal-most portion of the proximal metal coil 107. The length of this FEP section 412 is about 0.5 inches. In some embodiments, there is a longitudinal gap between the proximal-most FEP section 412 and the FEP section 412 that extends over the distal metal coil 108. In some embodiments, the FEP section 412 described above is contiguous.

[0128] 15, the metal layer 404 may terminate proximal to the edges of the outer polymeric layer 402, the liner 410, and the FEP section 412. In that case, a portion of the adhesive layer 409 at the distal end of the metal layer 404 may be thickened to match the distal ends of the other layers, although this section may be removed during manufacture so that the distal end of the metal layer 404 becomes the distal end of the capsule 106 and can be covered by the liner 410. In some embodiments, these extended sections distal to the metal layer 404 are not used.

[0129] In an embodiment, a coating layer, which may include reinforcing fibers or beads, may be applied to the capsule 106. Thus, the delivery system may include an elongate shaft having a proximal end and a distal end including an implant holding region configured to hold an implant. The coating layer may be on the elongate shaft and may include reinforcing fibers or beads. The coating layer may form an inner liner of the elongate shaft. The coating layer may include the inner liner 410 of the capsule 106, or a liner of another capsule disclosed herein, or may be a liner of another portion of the delivery system 10. For example, the coating layer may include a liner that extends from the capsule 106 along the interior of the outer sheath assembly 22 to the handle of the delivery system 10, thus constituting an inner liner of the outer sheath. In an embodiment, the coating layer may be applied to other components of the delivery system 10, such as the central shaft assembly or the inner shaft assembly, among others. In an embodiment, the coating layer may be applied as an outer layer of one or more of these components.

[0130] The coating layer may include reinforcing fibers or beads that provide strength to the coating layer. For example, the coating layer may include a material such as polytetrafluoroethylene (PTFE) mixed with reinforcing fibers or beads. PTFE may provide a lubricious surface that is reinforced with reinforcing fibers or beads for strength. For example, the tensile strength of the coating layer may be improved by using reinforcing fibers or beads. Additionally, in the embodiments shown in Figures 16-21 that utilize hypotubes that include a cut pattern in the capsule, the reinforcing fibers or beads may serve to protect the implant from the cut pattern of the hypotube. The reinforcing fibers or beads may include glass, and in embodiments, may include silicate fibers or beads, or carbon (e.g., graphite) fibers or beads.

[0131] The cover layer may further provide toughness and durability to protect any of the hypotube cut patterns (e.g., laser cut members) from bending during relative translation, such as reducing the likelihood of the capsule notched hypotubes binding during relative translation when retracting or advancing the capsule notched hypotubes relative to the central assembly notched hypotubes.

[0132] The coating layer may be comprised of a mixture of a base material (e.g., PTFE) and reinforcing fibers or beads. For example, PTFE pellets may be mixed with the reinforcing fibers or beads in a desired ratio. This mixture may be heated and then extruded to form the coating layer. The remaining portions of the delivery system 10, such as the capsule 106 and other portions of the outer sheath assembly 22, may also be formed with the coating layer. For example, the coating layer may be applied as an inner liner of the capsule 106.

[0133] The ratio of substrate (e.g. PTFE) to reinforcing fibers or beads can be set to any desired ratio. In an embodiment, this ratio can be a mixture of substrate (e.g. PTFE) and reinforcing fibers and beads with 1% to 10% reinforcing fibers or beads. In an embodiment, this ratio can be a mixture of substrate (e.g. PTFE) and reinforcing fibers and beads with 0.5% to 25% reinforcing fibers or beads. In an embodiment, this ratio can be a mixture of substrate (e.g. PTFE) and reinforcing fibers and beads with 0.1% to 30% reinforcing fibers or beads. In an embodiment, this ratio can be a mixture of substrate (e.g. PTFE) and reinforcing fibers and beads with 25% or 30% reinforcing fibers or beads.

[0134] The method may include disposing an elongate shaft at a location within a patient, the elongate shaft including an implant holding region for holding an implant for implantation within the patient, and a coating layer including reinforcing fibers or beads. The method may include retracting a capsule surrounding the implant holding region, the coating layer forming an inner liner of the capsule. The method may include sliding an inner liner over the implant, which may reduce friction with the implant 70 and may provide a tougher and more durable inner liner.

[0135] The method may include providing an elongate shaft and providing a coating layer including reinforcing fibers or beads. The method may include providing a mixture of PTFE and reinforcing fibers or beads, or another substrate. The mixture may be extruded with the PTFE including the reinforcing fibers or beads. The extrusion may comprise the remainder of the elongate shaft, or may include another portion of the liner or outer sheath of the elongate shaft, such as an inner liner of a capsule. The coating layers disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0136] FIG. 16 illustrates an embodiment of a hypotube 500 in a flattened configuration that may be utilized with the assemblies of the present disclosure. The hypotube 500 may be utilized as a metal layer or metal portion of one or more of the assemblies disclosed herein, and may include a portion of the capsule 106, as shown in FIG. 4 in particular. The hypotube 500 may be utilized with the capsule 106 configured to surround the implant holding area 16 of the elongate shaft 12. The hypotube 500 may be utilized as the metal layer 404 of the capsule, as shown in FIG. 15, or may be utilized in other portions of the assemblies that utilize the hypotube, or in other portions of these assemblies. The hypotube 500 may be located between the outer jacket and liner layers disclosed herein, among other components disclosed in the embodiments herein. Although shown in a flattened configuration in FIG. 16, the hypotube 500 has outer portions 512, 514 that, when connected, form the cylindrical shape of the hypotube 500, similar to the hypotube shown in FIG. 11.

[0137] The hypotube 500 may have one or more notches 502a-502h that form multiple rings 504a-504d in the hypotube 500. The notches 502a-502h may be in the shape of a slot, as shown in FIG. 16, or may have any other shape desired. The multiple rings 504a-504d may be longitudinally spaced apart from one another and extend circumferentially around the hypotube 500.

[0138] The hypotube 500 may include a first section 506, which may be a distal portion of the hypotube 500. The distal portion of the hypotube 500 may form a distal portion of the capsule 106 or a distal portion of an assembly utilized with the hypotube 500. The first section 506 may include a pair of cuts (502a and 502b in one pair and 502c and 502d in another pair). The cuts 502a and 502c may be aligned longitudinally at the same circumferential location and the cuts 502b and 502d may be aligned longitudinally at the same circumferential location such that the spines 508, 510 are located between the circumferentially spaced cuts 502a and 502b. The spines 508, 510 may extend longitudinally along the hypotube 500.

[0139] 16 in a flattened configuration, such that when the outer portions 512, 514 of the hypotube 500 are connected and the hypotube 500 forms a cylinder, the first section 506 includes a set of circumferentially extending notches 502a, 502c on one side of the hypotube 500 and a set of circumferentially extending notches 502b, 502d on the opposite side of the hypotube 500. Each of the notches disclosed herein may terminate in a drop shape to facilitate bending.

[0140] Each cut in the pair 502a, 502b may extend circumferentially approximately halfway around the circumference of the hypotube 500, and similarly each cut in the pair 502c, 502d may extend circumferentially approximately halfway around the circumference of the hypotube 500. One cut 502a, 502c in the pair may be circumferentially spaced from the other cut and may have a greater longitudinal size or thickness than the other cut 502b, 502d in the pair. The thickness of the cuts 502a, 502c may be one, two, three, four, or five times the thickness of the other cut 502b, 502d in the pair, among others. By having the incisions 502a, 502c have a larger longitudinal extent or width than the other incisions 502b, 502d, the section 506 has a bias for bending in a direction away from the incisions 502b, 502d and toward the incisions 502a, 502c. Thus, when the first section 506 bends, the spines 508, 510 may extend along a neutral axis of bending.

[0141] Thus, the first section 506 may include a section of the hypotube 500 that is biased to flex in a single direction.

[0142] The hypotube 500 may include a second section 516. The second section 516 may be located proximal to the first section 506 and may include a proximal portion of the capsule 106 or other proximal portion of an assembly utilized with the hypotube 500.

[0143] The second section 516 may include longitudinally spaced rows of notches 502e-502h that are longitudinally spaced from one another and form rings 504c-504d of the hypotube 500 extending circumferentially around the hypotube 500.

[0144] The cuts 502e-502h may form a pair of cuts 502e and 502f and a pair of cuts 502g and 502h. Each cut in the pair 502e, 502f may extend circumferentially approximately halfway around the circumference of the hypotube 500, and similarly, each cut in the pair 502g, 502h may extend circumferentially approximately halfway around the circumference of the hypotube 500.

[0145] One cut 502e, 502h in a pair may have a greater longitudinal size or thickness than the other cut 502f, 502g in the pair. The thickness of cuts 502e, 502h may be 1, 2, 3, 4, or 5 times the longitudinal thickness of the other circumferentially spaced cut 502f, 502g in the pair. The pair of cuts 502e, 502f and the pair of cuts 502g, 502h may be circumferentially offset from one another, and may be offset from one another by approximately 90 degrees as shown in FIG. 16, or by another desired offset. Thus, the pair of cuts 502e, 502f and the pair of cuts 502g, 502h may form two pairs of spine pairs 518, 520 and 522, 524, with the spines 518, 520 longitudinally aligned with the spines 508, 510 of the first section 506. The pair of spines 518, 520 may be offset from the pair of spines 522, 524 by approximately 90 degrees as shown in FIG. 16 or by another desired offset. The spines within each pair may be located 180 degrees apart from each other. Such a configuration may be formed by a repeating pattern of staggered cuts including the pair of cuts 502e, 502f and the pair of cuts 502g, 502h that are offset from each other along the length of the hypotube 500. The location of spines 518, 520, and 522, 524, and the increased longitudinal extent or width of incisions 502e, 502h, result in section 516 having a bias for bending in two directions (a first direction and a second direction), toward incision 520e and toward incision 502h. Thus, spines 518, 520, and 522, 524, respectively, may extend along a neutral axis of bending when second section 516 is bent. More bending directions (e.g., at least two bending directions) may be provided if desired.

[0146] The hypotube 500 can provide support for assembly of the delivery system 10 and can provide support for the capsule 106. The multiple cuts shown in Figure 16 can provide flexibility for the capsule 106, particularly in the direction of deflection provided by the cut pattern.

[0147] The multiple rings 504a-504d of the hypotube 500 can provide support for the capsule 106. Additionally, the multiple rings 504a-504d can allow a force to be applied by the capsule 106 in a distal direction. Such a force may be applied in embodiments utilizing the capsule 106 for retrieval of an implant that may have been incompletely deployed from the implant holding area 16 (as shown in FIG. 2C). For example, when the capsule 106 is retracted to detach the implant from the implant holding area 16, it may be desirable to retrieve the incompletely deployed implant. In this case, the capsule 106 can be pushed distally to retrieve the incompletely deployed implant and optionally return it to the implant holding area 16. The structural strength provided by the hypotube 500 can allow this distal force to be applied to retrieve the incompletely deployed implant. The multiple rings 504a-504d of the hypotube 500 can compress against one another to allow for the application of this distal force.

[0148] Additionally, the biased flexibility provided by the multiple cuts can allow the hypotube 500, and thus the capsule 106, to flex to accommodate bending of the capsule 106, which may include bending caused by translation along a bent rail assembly. The first section 506 can be biased to bend in a single direction corresponding to this bending direction of the rail assembly. The second section 516 can be biased to bend in two directions (or at least two directions) corresponding to the two bending directions (or at least two bending directions).

[0149] This configuration of the hypotube 500, including the use of multiple rings 504a-504d, may allow for improved application of distal force by the capsule 106 or another portion of an assembly utilizing the hypotube 500. The multiple rings 504a-504d may contact and press against one another to allow for application of distal force, but notably, the direction of bending of the first section 506 and second section 516 must be aligned with the direction of bending of the rail assembly or other bending of the elongate shaft 12 to allow for the desired bending of the hypotube 500. Thus, it may be advantageous to create a hypotube configuration that does not have a bias for bending in one direction.

[0150] FIG. 17 illustrates one embodiment of a hypotube 600 shown in a flat configuration that may be utilized with the assemblies of the present disclosure. The hypotube 600 may be utilized as one or more metal layers or portions of the assemblies disclosed herein, and in particular may comprise a portion of the capsule 106 shown in FIG. 4. The hypotube 600 may be utilized with the capsule 106 configured to surround the implant holding area 16 of the elongate shaft 12. The hypotube 600 may be utilized as a metal layer 404 for the capsule as shown in FIG. 15, or may be utilized in other portions of the assembly or other portions of the assembly that utilize the hypotube. The hypotube 600 may be located between the outer jacket and liner layers disclosed herein, among other components disclosed in the embodiments herein. The hypotube 600 is shown in a flat configuration in FIG. 17, but has outer portions 608, 610 that, when connected, form the cylindrical shape of the hypotube 600 similar to the hypotube shown in FIG. 11.

[0151] The hypotube 600 has one or more cuts 602a-c that form multiple rings 604a-b of the hypotube 600. The multiple rings 604a-b may be longitudinally spaced from one another to form a pattern of rings that extend circumferentially across the length of the hypotube 600. The one or more cuts, represented as 602a-c shown in FIG. 17, are cut in a spiral that extends circumferentially around the hypotube 600 across the length of the hypotube 600. The cuts may be separated by spines 606a, 606b, 606c that extend longitudinally along the hypotube 600 and connect the multiple rings 604a-b. The spines may be circumferentially offset from one another. The spines 606a, 606b, 606c may be positioned such that a single cut in the cut pattern extends more than 360 degrees around the hypotube 600.

[0152] The helical configuration of the hypotube 600 may allow the hypotube 600 to lack bias towards a bending direction. Thus, the hypotube 600 may be configured to bend in multiple directions without a particular bias towards one direction and may have equal flexibility in all radial directions. Such a feature may allow the hypotube 600 to have a greater variety of orientations relative to the bending direction of the rail assembly since the hypotube 600 lacks a particular bias towards one direction of bending of the rail assembly. The helical configuration may allow the hypotube 600 to remain flexible and bend in a variety of bending directions as needed.

[0153] Additionally, the helical configuration of the hypotube 600 may allow the multiple rings 604a-b to more strongly contact and compress one another to transmit distal forces, such as for implant retrieval. The gaps formed by the incisions 602a-c may be reduced in size as the hypotube 600 is compressed distally, such that a rigid rod structure is formed for implant retrieval. The lack of bias in the hypotube 600 may also reduce the likelihood that the hypotube 600 will deflect in a certain direction due to a flex bias in the hypotube 600.

[0154] FIG. 18 illustrates one embodiment of a hypotube 700 shown in a flat configuration that may be utilized with the assemblies of the present disclosure. The hypotube 700 may be utilized as one or more metal layers or portions of the assemblies disclosed herein, and in particular may comprise a portion of the capsule 106 shown in FIG. 4. The hypotube 700 may be utilized with the capsule 106 configured to surround the implant holding region 16 of the elongate shaft 12. The hypotube 700 may be utilized as a metal layer 404 for the capsule as shown in FIG. 15, or may be utilized in other portions of the assembly or other portions of the assembly that utilize the hypotube. The hypotube 700 may be disposed between the outer jacket and liner layers disclosed herein, among other components disclosed in the embodiments herein. The hypotube 700 is shown in a flat configuration in FIG. 18, but has outer portions 712, 714 that, when connected, form the cylindrical shape of the hypotube 700 similar to the hypotube shown in FIG. 11.

[0155] The hypotube 700 has one or more cuts 702a-d that form multiple rings 704a-b in the hypotube 700. The multiple rings 704a-b may be longitudinally spaced from one another to form a pattern of rings that extend circumferentially across the length of the hypotube 700.

[0156] The one or more cuts 702a-d shown in FIG. 18 are cut in offset pairs (cuts 702a and 702b form a pair, and cuts 702c and 702d form a pair). The cuts 702a-d may have equal longitudinal widths and may have equal circumferential lengths. The one or more cuts 702a-d may form a repeating pattern of staggered cuts having equal sizes. The cuts may be separated by pairs of spines (706 and 708 form a pair, 710 and 712 form a pair), offset from one another and each extending longitudinally along the hypotube 700. Each spine of the pair may be offset 180 degrees from the other spine of the pair. The offset of the spine pairs may be 90 degrees as shown in FIG. 18, or another amount as desired.

[0157] The offset configuration of the cuts 702a-d in the hypotube 700 may allow the hypotube 700 to lack bias towards a bending direction. Thus, the hypotube 700 may be configured to bend in multiple directions without a particular bias towards one direction and may have equal flexibility in all radial directions. Such a feature may allow the hypotube 700 to have a greater variety of orientations relative to the bending direction of the rail assembly since the hypotube 700 lacks a particular bias towards one direction of bending of the rail assembly. Additionally, in FIG. 18, the circumferential lengths and longitudinal widths of the cuts 702a-d are equal and the offset of the cuts in the repeating rows of the cuts is equal.

[0158] Additionally, the small width of the notches 702a-d in the hypotube 700 may allow multiple rings 704a-b to contact and compress against one another to transmit distal forces, such as for implant retrieval. The gaps formed by the notches 702a-d may be reduced in size as the hypotube 700 is compressed distally, such that a rigid rod structure is formed for implant retrieval. The lack of bias in the hypotube 700 may also reduce the likelihood that the hypotube 700 will deflect in a certain direction due to deflection bias in the hypotube 700.

[0159] FIG. 19 illustrates one embodiment of a hypotube 800 shown in a flat configuration that may be utilized with the assemblies of the present disclosure. The hypotube 800 may be utilized as one or more metal layers or portions of the assemblies disclosed herein, and in particular may comprise a portion of the capsule 106 shown in FIG. 4. The hypotube 800 may be utilized with the capsule 106 configured to surround the implant holding area 16 of the elongate shaft 12. The hypotube 800 may be utilized as a metal layer 404 for the capsule, as shown in FIG. 15, or may be utilized in other portions of the assembly or other portions of the assembly that utilize the hypotube. The hypotube 800 may be located between an outer jacket and a liner layer, among other components disclosed in the embodiments herein. The hypotube 800 is shown in a flat configuration in FIG. 19, but has outer portions 804, 806 that, when connected, form the cylindrical shape of the hypotube 800 as shown in FIG. 19.

[0160] The hypotube 800 is configured similarly to the hypotube 700 shown in FIG. 18, but the size of one or more incisions 802a-d that form the hypotube's multiple rings 806a-b has been increased. However, the length and width of the incisions 802a-d remain equal. The increased size of the incisions 802a-d may allow for greater flexibility of the hypotube 800. The size of the incisions 802a-d may be reduced as the hypotube 800 is compressed distally, such that a rigid rod structure is formed for retrieval of the implant. The lack of bias in the hypotube 800 may also reduce the likelihood that the hypotube 800 will deflect in a certain direction due to the deflection bias of the hypotube 800.

[0161] In some embodiments, hypotubes may be utilized that include a combination of cut patterns that have a bias to bend in one direction and cut patterns that lack a bias to bend in another direction. Figure 20 illustrates such a pattern, where a hypotube 900 includes a first section 902 with a cut pattern 908 configured as the cut pattern of the hypotube 800 shown in Figure 19. The hypotube 900 includes a second section 904 with a cut pattern 906 configured as the cut pattern of the section 506 of the hypotube 500 shown in Figure 16. The first section 902 may be located proximally and the second section 904 may be located distally.

[0162] The hypotube 900 is shown in a flat configuration that may be utilized with the assemblies of the present disclosure. The hypotube 900 may be utilized as one or more metal layers or portions of the assemblies disclosed herein, and in particular may comprise a portion of the capsule 106 shown in FIG. 4. The hypotube 900 may be utilized with the capsule 106 configured to surround the implant holding region 16 of the elongate shaft 12. The hypotube 900 may be utilized as a metal layer 404 for the capsule, as shown in FIG. 15, or may be utilized in other portions of the assembly or other portions of the assembly that utilize the hypotube. The hypotube 900 may be disposed between an outer jacket and a liner layer, among other components disclosed in the embodiments herein. The hypotube 900 is shown in a flat configuration in FIG. 20, but has outer portions 910, 912 that, when connected, form the cylindrical shape of the hypotube 900, as shown in FIG. 20.

[0163] 20 may advantageously lack bias toward the direction of bending, but may provide flexibility in multiple bending directions. The hypotubes 600, 700, and 800 and the cutting pattern 908 may also provide a compressive force that allows the hypotubes 600, 700, and 800 and the cutting pattern 908 to be utilized for implant retrieval, if desired.

[0164] FIG. 21 illustrates one embodiment of a hypotube 1000 shown in a flat configuration that may be utilized with the assemblies of the present disclosure. The hypotube 1000 may be utilized as one or more metal layers or portions of the assemblies disclosed herein, and in particular may comprise a portion of the capsule 106 shown in FIG. 4. The hypotube 1000 may be utilized with the capsule 106 configured to surround the implant holding area 16 of the elongate shaft 12. The hypotube 1000 may be utilized as a metal layer 404 for the capsule, as shown in FIG. 15, or may be utilized in other portions of the assembly or other portions of the assembly that utilize the hypotube. The hypotube 1000 may be located between an outer jacket and a liner layer, among other components disclosed in the embodiments herein. The hypotube 1000 is shown in a flat configuration in FIG. 21, but has outer portions 1010, 1012 that, when connected, form the cylindrical shape of the hypotube 1000 as shown in FIG. 21.

[0165] The pairs of incisions (one pair including incisions 1002a,b and another pair including incisions 1002c,d) may be circumferentially offset from one another such that the spines 1006, 1008 form an angle with respect to the longitudinal direction. Thus, the incisions 1002a,b and 1002c,d may form an angled or swept pattern in which the hypotube 1000 has a bias to bend in a direction with the spines 1006, 1008 extending along the neutral axis of bending. Thus, the direction of the bending bias may vary along the length of the hypotube 1000. The gaps formed by the incisions 1002a,b and 1002c,d may be reduced in size when the hypotube 1000 is compressed distally such that a rigid rod structure is formed for retrieval of the implant.

[0166] In particular, the bias direction of the bend of the hypotube 1000 should be aligned with the direction of bend of the rail assembly. Thus, it may be beneficial to rotate a portion of a delivery system that includes a hypotube with a biased bend direction to align the bias direction with the bend direction of the rail assembly or another structure that forms the bend in the delivery system. The hypotube embodiments disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0167] 22-25 illustrate an embodiment in which the delivery system 10 may be configured to allow the capsule 106 to rotate. Rotation of the capsule 106 may allow the hypotube contained therein to rotate such that the bias direction of the hypotube cut pattern is aligned with the direction of bending of the rail assembly. The capsule 106 may be configured to surround the implant holding area 16. Thus, in embodiments of hypotubes 500, 900, 1000 that include a direction of deflection bias, the capsule 106 may be capable of rotating to align the direction of deflection bias with the direction of bending of the rail assembly. Such a feature may be useful to reduce the likelihood that a hypotube that includes a direction of deflection bias will not be aligned with the direction of bending of the rail assembly and have reduced maneuverability.

[0168] 22 shows a distal portion of the delivery system including a coupler 1900 configured to couple the capsule 106 to a shaft portion 1902 of the elongate shaft 12 located proximally of the capsule 106. The shaft portion 1902 may comprise a portion of the outer shaft assembly, which may include the outer hypotube 104, or the shaft 102, or another portion of the outer shaft assembly, as desired.

[0169] The coupler 1900 may allow the capsule 106 to rotate about the axis of the elongate shaft 12. The coupler 1900 may take a variety of forms and may include a protrusion 1904 located within the channel 1906. The protrusion 1904 may be configured to rotate relative to the channel 1906 to allow the capsule 106 to rotate. As shown in FIG. 22, the protrusion 1904 may comprise a flexible material within the channel 1906. For example, the protrusion 1904 may be crimped within the channel 1906 and thus be able to rotate relative to the channel 1906. The protrusion 1904 may be coupled to the capsule 106, such as a proximal portion of the capsule 106, and the channel 1906 may be coupled to a distal portion of the shaft portion 1902. In other embodiments, the protrusion 1904 may be coupled to the shaft portion 1902 and the channel 1906 may be coupled to the capsule 106. The protrusions 1904 and channels 1906 may be located elsewhere on either the capsule 106 or the shaft portion 1902, as desired.

[0170] 23 shows a side perspective view of the exterior of the elongate shaft 12 including the coupler 1900. The capsule 106 may be configured to rotate about the axis of the elongate shaft 12 relative to the shaft portion 1902, as indicated by the arrow shown in FIG.

[0171] FIG. 24 shows one embodiment of a coupler 2000 comprising a protrusion 2002 that may be configured to rotate relative to a channel 2004 to allow the capsule 106 to rotate. As shown in FIG. 24, the protrusion 2002 may comprise a pin. The channel 2004 may comprise a window. The pin may be configured to slide along the window to allow the capsule 106 to rotate. The window may be coupled to the capsule 106, such as a proximal portion of the capsule 106, and the pin may be coupled to a distal portion of the shaft portion 1902. In other embodiments, the window may be coupled to the shaft portion 1902, and the pin may be coupled to the capsule 106. The protrusion 2002 and the channel 2004 may be located elsewhere on either the capsule 106 or the shaft portion 1902, as desired.

[0172] 25 shows a side perspective view of the exterior of elongate shaft 12 including coupler 2000. Capsule 106 may be configured to rotate about the axis of elongate shaft 12 relative to shaft portion 1902, as indicated by the arrow shown in FIG.

[0173] The couplers 1900, 2000 shown in Figures 22-25 may take a variety of other forms and may vary from the projection and channel configurations shown in Figures 22-25, as desired. Although the perspective views shown in Figures 23 and 25 show the couplers located on the exterior surface of the elongate shaft 12, in other embodiments the couplers may be covered by an outer jacket or another structure, as desired.

[0174] The couplers 1900, 2000 may advantageously allow the capsule 106 to rotate. Rotation of the capsule 106 may allow the hypotube contained therein to rotate such that the bias direction of the hypotube cut pattern is aligned with the direction of bending of the rail assembly. Thus, in embodiments of hypotubes 500, 900, 1000 that include a deflection bias direction, the capsule 106 may be capable of rotating to align the deflection bias direction with the direction of bending of the rail assembly.

[0175] The hypotubes 500, 900, 1000 may be configured to passively rotate to align the direction of flexure bias with the direction of bend of the rail assembly. Thus, as the hypotubes 500, 900, 1000 pass through a bend in the rail assembly, the reduced resistance to bending caused by aligning the direction of flexure bias with the direction of bend of the rail assembly may allow the hypotubes 500, 900, 1000 to passively rotate.

[0176] Although the couplers 1900, 2000 are shown in relation to the capsule 106, in other embodiments, other portions of the elongate shaft 12 may be configured to rotate through the use of couplers 1900, 2000. Such portions may include a mid-shaft assembly, which may include an outer retaining ring 42, which may be configured to rotate similarly to the capsule 106. The mid-shaft assembly may include a hypotube, and the couplers may enable the outer retaining ring 42 to rotate such that the direction of bias of the hypotube cut pattern is aligned with the bending direction of the rail assembly. Other portions of the elongate shaft 12 may utilize couplers for rotation as needed.

[0177] Rotation of the portion of the elongate shaft 12 that may include the capsule 106 may allow for rotation during proximal retraction or distal advancement of the portion of the elongate shaft 12. For example, the capsule 106 may rotate via one of the couplers 1900, 2000 when the capsule is retracting in a proximal direction, or may rotate via one of the couplers 1900, 2000 when the capsule is advancing in a distal direction. In particular, during distal advancement of the capsule 106, compressive forces may be applied to the capsule 106 proximally due to compression of the expandable implant, and distally due to forces applied to the capsule 106 by the handle of the delivery system. It should be noted that such forces may result in structural damage, such as the crushing of the capsule 106, if such forces are strong enough. The coupler and capsule embodiments disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0178] 26 shows a distal portion of a delivery system including an expandable body 2100. The expandable body 2100 may be configured to expand to support the sheath. Expansion of the expandable body 2100 may serve to reduce the possibility of structural damage to the sheath and may strengthen the sheath during distal movement, such as implant retrieval.

[0179] As shown in FIG. 26, the sheath may comprise an outer sheath, which may include the capsule 106 and other portions, such as the outer hypotube 104 (shown in FIG. 4) and the shaft 102. The expandable body 2100 may be configured to expand to support the outer shaft as it expands distally. For example, when the capsule 106 expands distally for retrieval of an expandable implant, the expandable body 2100 may be expanded to provide support for the capsule 106 and other portions of the sheath. The support may reduce the possibility of structural damage to the capsule 106 because structural strength is provided to the capsule 106.

[0180] 26, the expandable body 2100 may be located within the lumen of the sheath. The expandable body 2100 may be located on an inner shaft, which may be located within the lumen of the sheath. The expandable body 2100 may be located between the inner shaft and the sheath and configured to expand to support the sheath. The inner shaft may comprise a central shaft (middle shaft) of the elongate shaft 12 as shown, or in other embodiments, may comprise another shaft within the elongate shaft 12. The expandable body 2100 may be located on the shaft adjacent to the sheath such that expansion of the expandable body 2100 causes contact with the inner surface of the sheath.

[0181] The conduit 2102 may be coupled to the expandable body 2100 and configured to provide fluid to inflate the expandable body 2100. The conduit 2102 may extend along the length of the elongate shaft 12 and may be located within the outer lumen of the outer shaft. A proximal end of the conduit 2102 may be coupled to an inflation port or the like for inflating the expandable body 2100. The conduit 2102 may extend between the outer sheath and the middle sheath, as shown in FIG. 26. In other embodiments, the conduit 2102 may be located in other locations as desired.

[0182] The expandable body 2100 may include one or more balloons, which may be pleated or have another configuration. In other embodiments, the expandable body 2100 may have other configurations. The expandable body 2100 may be configured to exert sufficient force against the inner surface of the sheath such that the sheath is supported as the expandable body 2100 expands and contacts the inner surface of the sheath. Such support may occur as the sheath is advanced distally and may occur as the sheath is bent around the rail assembly 20.

[0183] FIG. 27 shows the expandable body 2100 expanding and supporting a sheath (shown as capsule 106 of the outer sheath) at the bend of the outer shaft. The capsule 106 is advanced in a distal direction, which may be for retrieval of an expandable implant (although the implant is not visible in FIG. 27). A force in a direction 2104, shown by the dashed arrow in FIG. 27, may be applied to the capsule 106. In the absence of the expandable body 2100, the force in the direction 2104 may damage the capsule 106. However, the expandable body 2100 may expand to contact the inner surface of the capsule 106 and fill the space between the capsule 106 and the midshaft. The expandable body 2100 may then be deflated at a desired time.

[0184] Although the outer sheath is shown as a capsule 106 in FIG. 27, an expandable body may be utilized in any embodiment of the sheath. For example, the midshaft may include a sheath extending around the inner shaft, the inner shaft being located within the midshaft outer sheath. The expandable body may be located between the inner shaft and the midshaft sheath to support the midshaft as it advances proximally, such as for retrieval of an implant. The expandable body may be utilized in other locations as desired. The expandable body and shaft embodiments disclosed herein may be utilized alone or with any of the other devices, systems, or methods disclosed herein.

[0185] In some embodiments, the elongate shaft 12 of the delivery system may include a wall having a tensile layer that provides strength to the elongate shaft 12 when pulled in a proximal direction. Figure 28 shows, for example, one embodiment of a tensile layer in the form of a braided layer 2200 that may be utilized to provide strength to the elongate shaft 12 when pulled in a proximal direction.

[0186] The braided layer 2200 may comprise a weave of overlapping metal wires or other forms of fibers forming a sheath, as shown in Figure 28. In other embodiments, other materials may be utilized to form the braided layer 2200, as desired.

[0187] Figure 29 shows a cross-sectional view of the wall of the elongate shaft sheath including the braided layer of Figure 28. The wall 2203 extends circumferentially around the lumen 2201 to form the body of the sheath. The structure of the wall 2203 of the sheath is visible, including the braided layer 2200 surrounding the metal layer 2202. An inner liner layer 2204 is visible surrounded by the metal layer 2202. An outer jacket layer 2206 is visible extending around the braided layer 2200. The lumen 2201 is surrounded by the sheath.

[0188] The metal layer 2202 may be configured similarly to the metal layers disclosed within the present application, including the coil or hypotube embodiments disclosed herein, including the hypotubes shown in Figures 16-21. The braided layer 2200 may surround the metal layer 2202 such that when an axial force 2210 providing tension is applied to the braided layer 2200, the braided layer 2200 compresses the metal layer 2202. The compression is represented by arrows 2212. The metal layer 2202 resists compression of the braided layer 2200 onto the metal layer 2202, thus allowing the braided layer 2200 to exhibit high tensile strength. Thus, the braided layer 2200 may be utilized to strengthen the sheath of the elongate shaft, allowing a greater retraction force to be applied by the sheath of the elongate shaft.

[0189] A buffer layer 2214 may be located between the outer jacket layer 2206 and the braided layer 2200. The buffer layer 2214 may fill the interstices of the braided layer 2200 with material to prevent the outer jacket layer 2206 from flowing between the weaves of the braided layer 2200, thus reducing the effectiveness of the braided layer 2200. The buffer layer 2214 may be constructed of a polymer and may include expanded polytetrafluoroethylene (ePTFE), or in other embodiments, may include other materials. The outer jacket layer 2206 may include PEBAX or another form of polymer.

[0190] The elongate shaft sheath wall configuration shown in Figure 29, including the use of braided layer 2200, may be utilized with various assemblies of a delivery system. For example, the outer sheath capsule 106 may be configured to include the configuration shown in Figure 29. In other embodiments, other assemblies, including the outer sheath, intermediate sheath, or any portion of the inner assembly, may utilize the elongate shaft configuration shown in Figure 29. The sheath wall configurations disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0191] Other devices may improve the retraction force of a portion of the elongate sheath, alone or in combination with the braided layer. FIG. 30 illustrates one embodiment of a delivery system utilizing a cable router 2300. The delivery system may utilize a cable 2302 having two ends 2304, 2306. The ends 2304, 2306 may be coupled to a sheath that may include a capsule 106 as shown in FIG. 30, but in other embodiments may include other sheaths or portions of the delivery system, including an elongate shaft. The cable 2302 may include a middle portion 2308 that may extend between the ends 2304, 2306. The ends 2304, 2306 may be coupled to opposite sides of the sheath. For example, the end 2304 may be coupled to an inner surface of the sheath and the end 2306 may be coupled to an inner surface of the sheath on the opposite side of the sheath. The ends 2304, 2306 may be separated by a lumen of the sheath. Ends 2304, 2306 may be attached to portions of the sheath that lie on either side of the neutral axis of the sheath in the same bending plane. For example, end 2304 may be attached to a portion of the sheath that forms the inner curve of the sheath when the sheath is bent, and end 2306 may be attached to a portion of the sheath that forms the outer curve of the sheath when the sheath is bent. If the sheath is bent in the opposite direction, end 2304 may be attached to a portion of the sheath that forms the outer curve of the sheath, and end 2306 may be attached to a portion of the sheath that forms the inner curve of the sheath when the sheath is bent in the opposite direction.

[0192] The cable 2302 may be configured to slide along the length of the sheath and may extend within the lumen of the sheath. The cable 2302 may extend along the length of the sheath to engage the cable router 2300.

[0193] The cable router 2300 can take a variety of forms and can include a pulley wheel, as shown in Figure 30. The cable router 2300 can include channels that allow the cables 2302 to bend around the cable router 2300. The channels can include, for example, flex tubes that redirect the cables 2302. Other forms of cable router 2300 can be utilized as desired.

[0194] The cable router 2300 may be configured to engage an intermediate portion 2308 of the cable 2302 such that the cable 2302 may move along the cable router 2300 as the cable 2302 is slid through the bending of a sheath, such as the capsule 106 shown in FIG. 30. For example, in one embodiment in which the cable router 2300 is a pulley wheel, the pulley wheel may rotate to allow the cable 2302 to move along the cable router 2300. In one embodiment in which the cable router 2300 is a channel, the channel may allow the cable 2302 to slide along the channel.

[0195] The delivery system may include a control mechanism 2310. The control mechanism 2310 may comprise a body configured to move the cable router 2300 by applying tension to the cable router 2300 to retract the cable router 2300 proximally. The control mechanism 2310 may be configured to retract the sheath as well. The control mechanism 2310 may include threads or the like to allow the control mechanism 2310 to be manipulated by a mechanism in the handle or other part of the delivery system. The cable router 2300 and control mechanism 2310 may be located in the handle of the delivery system or at another location, as desired.

[0196] During operation, the cable 2302 may be configured to passively change its length between the end 2304 and the cable router 2300, and between the end 2306 and the cable router 2300, due to flexing of the sheath. For example, FIG. 31 illustrates the operation of the cable 2302 and the cable router 2300. The sheath, shown as capsule 106, may flex for a variety of reasons, which may include flexing of the rail assembly. The flexing of the sheath causes the end 2304 of the cable 2302 to move proximally and the end 2306 of the cable 2302 to move distally. The amount of proximal movement (change in length) of the end 2304 of the cable 2302 may be equal to the amount of distal movement (change in length) of the end 2306 of the cable 2302, and the changes in length may occur simultaneously. The cable router 2300 can function to allow an intermediate portion 2308 of the cable 2302 to move along the cable router 2300 to transfer a length of the cable 2302 from end 2304 to end 2306. Alternatively, the sheath can be flexed in the opposite direction, with end 2304 extending distally and end 2306 extending proximally.

[0197] A length of the cable 2302 may be routed between the ends 2304 and 2306 to allow the cable 2302 to remain taut between the ends 2304 and 2306 without slack during bending of the sheath. The control mechanism 2310 may retract the cable router 2300 to allow the cable 2302 to pull the sheath, increasing the tensile strength of the sheath when the sheath is retracted. Such a feature may be utilized with the capsule 106, which may retract to allow an expandable implant to be deployed. Such a feature may be utilized with any other portion of the elongate sheath that retracts, such as the intermediate sheath that retracts to retract the outer retaining ring 42. A sheath coupled to a nose cone of the elongate shaft may also be retracted during other use positions. The cable router disclosed herein may be utilized alone or with any of the other devices, systems, or methods disclosed herein.

[0198] 32-34 show a distal portion of a delivery system including a stopper located on an inner shaft of the delivery system and configured to prevent proximal movement of the capsule 106. FIG 32A shows a side cross-sectional view of the distal portion of the delivery system. Although the capsule 106 is shown in FIG 32A as extending over an inner sheath assembly, in other embodiments, the capsule 106 may extend over other inner shafts, such as a mid-shaft assembly.

[0199] The inner shaft, shown as the distal section 126 of the inner shaft assembly, may include a stopper 2400 located thereon. The stopper 2400 may comprise a protrusion extending radially outward from the inner shaft. The stopper 2400 may be configured such that the stopper 2400 applies a force to the proximal body 2402 of the capsule 106 that prevents proximal movement of the capsule 106. For example, FIG. 32B shows the capsule 106 being withdrawn with the proximal body 2402 contacting the stopper 2400. Thus, the position of the capsule 106 may be maintained until additional force is applied to the capsule 106 to overcome the protrusion of the stopper 2400 and allow the capsule 106 to move further proximally to dispose the expandable implant from the implant holding region 16. For example, FIG. 32C shows the capsule 106 being pulled proximally past the stopper 2400.

[0200] The stopper may have a variety of other configurations as desired. For example, in Figures 33A-33C, the stopper 2404 may have the form of threads on the inner shaft. The capsule may include a threaded portion 2406 that may allow the capsule 106 to rotate relative to the threads on the inner shaft to allow the capsule 106 to move proximally past the stopper 2404. For example, Figure 33C shows the capsule 106 pulled proximally past the stopper 2404.

[0201] 34A-34C, the stopper 2408 may have a keyed configuration on the inner shaft. The capsule 106 may include a complementary keyed configuration on the proximal body 2410 into which the stopper 2408 fits to allow the capsule 106 to move proximally past the stopper. The capsule 106 may rotate relative to threads on the inner shaft to allow the capsule 106 to move proximally past the stopper 2408. For example, FIG. 34C shows the capsule 106 pulled proximally past the stopper 2408.

[0202] The stoppers shown in FIGS. 32-34 may be configured to provide a two-stage disposition of the implant retained within the implant retaining region 16. The stoppers may be located on the inner shaft and allow the capsule 106 to retract a prescribed distance, allowing a prescribed amount of partial release, or partial exposure, or partial expansion of the implant when the stoppers are contacted. For example, as shown in FIG. 33B, the capsule 106 may retract a prescribed distance until the stoppers 2400 are contacted. The prescribed distance may be a stopping point for a user of the delivery system to confirm that the implant is partially disposed at this point in the desired location. The stoppers 2400 may prevent the user from fully retracting the capsule 106 without first stopping to confirm that the expandable implant is partially disposed at the desired location. Once the user has made such confirmation, the capsule 106 may continue to retract past the stoppers 2400 to allow the expansion and disposition of the expandable implant to continue. Thus, the stopper 2400 may function as tactile feedback of the desired stop position to the user, to confirm at this point that the expandable implant is partially disposed in the desired location. The stoppers 2404, 2408 may serve a similar function to the stopper 2400. The stoppers may be located proximate the capsule 106 to allow for tactile feedback that is located proximate the capsule 106, which may allow the user to more fully manipulate the delivery system. After the stopper is overcome, full release, or exposure, or expansion of the implant may occur.

[0203] The stoppers may have a variety of configurations and locations beyond those shown in Figures 32-34, as appropriate. The stoppers may be located on an internal shaft, such as a central shaft (midshaft) or inner shaft, as appropriate, among other locations. The stoppers disclosed herein may be utilized alone or with any of the other devices, systems, or methods disclosed herein.

[0204] With reference to Figure 35, the handle 14 is located at the proximal end of the delivery system 10. A cross section of the handle 14 is shown in Figure 36. The handle 14 may include a number of actuators, such as rotatable knobs, that may manipulate various components of the delivery system 10. Although operation of the handle 14 is described with respect to delivery of a replacement mitral valve implant 70, the handle 14 and delivery system 10 may also be used to deliver other devices.

[0205] The handle 14 is generally composed of two housings, a rail housing 202 and a delivery housing 204, where the rail housing 202 is positioned circumferentially around the delivery housing 204. An inner surface of the rail housing 202 may include a threadable portion configured to mate with an outer surface of the delivery housing 204. The delivery housing 204 is thus configured to slide (e.g., thread) within the rail housing 202, as described in more detail below. The rail housing 202 generally surrounds approximately half the length of the delivery housing 204, such that the delivery housing 204 extends both proximally and distally outside of the rail housing 202.

[0206] The rail housing 202 may include two rotatable knobs, a distal pullwire knob 206 and a proximal pullwire knob 208. However, the number of rotatable knobs on the rail housing 202 may vary depending on the number of pullwires used. Rotation of the distal pullwire knob 206 may provide a proximal force, thereby providing axial tension on the distal pullwire 138, bending the distal grooved portion 235 of the rail hypotube 136. The distal pullwire knob 206 may rotate in either direction, allowing bending in either direction and controlling the front to back angle. Rotation of the proximal pullwire knob 208 may provide a proximal force, and therefore axial tension, on the proximal pullwire 140, thereby bending the proximal grooved portion 233 of the rail hypotube 136, controlling the inward and outward angles. The proximal pullwire knob 208 may rotate in either direction, allowing bending in either direction. Thus, when both knobs are actuated, there are two bends in the rail hypotube 136, which may allow for three-dimensional steering of the rail shaft 132 and thus the distal end of the delivery system 10. Additionally, the proximal end of the rail shaft 132 is connected to the inner surface of the rail housing 202.

[0207] Flexion of the rail shaft 132 can be used to position the system, particularly the distal end, at a desired patient location, such as at the native mitral valve. In some embodiments, rotation of the pullwire knobs 206 / 208 can help steer the distal end of the delivery system 10 through the septum and left atrium and into the left ventricle so that the implant 70 is at the location of the native mitral valve.

[0208] Turning to the delivery housing 204, the proximal ends of the inner shaft assembly 18, the outer sheath assembly 22, the mid shaft assembly 21, and the nosecone shaft assembly 31 may be connected to an inner surface of the delivery housing 204 of the handle 14. Thus, they can move axially relative to the rail assembly 20 and the rail housing 202.

[0209] A rotatable outer sheath knob 210 can be disposed on the distal end of the delivery housing 204, distal to the rail housing 202. Rotation of the outer sheath knob 210 pulls the outer sheath assembly 22 axially in a proximal direction, thus pulling the capsule 106 away from the implant 70 and releasing the distal end 303 of the implant 70. The outer sheath assembly 22 thus translates separately relative to the other shafts in the delivery system 10. The distal end 303 of the implant 70 can be released first, while the proximal end 301 of the implant 70 can remain radially compressed between the inner retention member 40 and the outer retention member 42.

[0210] A rotatable mid-shaft knob 214 is located on the delivery housing 204 and in some embodiments may be proximal to the rotatable outer sheath knob 210 and distal to the rail housing 202. Rotation of the mid-shaft knob 214 pulls the mid-shaft assembly 21 axially in a proximal direction, thus pulling the outer retaining ring 42 away from the implant 70, exposing the inner retaining member 40 and the proximal end 301 of the implant 70, thereby releasing the implant 70. Thus, the mid-shaft assembly 21 translates separately relative to the other shafts in the delivery system 10.

[0211] The rotatable depth knob 212 may be located at the proximal end of the delivery housing 204 and thus proximal to the rail housing 202. As the depth knob 212 rotates, the entire delivery housing 204 moves distally or proximally relative to the rail housing 202, which remains in the same position. Thus, at the distal end of the delivery system 10, the inner shaft assembly 18, the outer sheath assembly 22, the mid shaft assembly 21, and the nosecone shaft assembly 31 move together (e.g., simultaneously) proximally or distally relative to the rail assembly 20, while the implant 70 remains in a compressed configuration. In some embodiments, manipulation of the depth knob 212 can move the inner shaft assembly 18, the outer sheath assembly 22, the mid shaft assembly 21, and the nosecone shaft assembly 31 sequentially relative to the rail assembly 20. In some embodiments, manipulation of the depth knob 212 can move the inner shaft assembly 18, the outer sheath assembly 22, and the mid shaft assembly 21 together relative to the rail assembly 20. Thus, the rail shaft 132 can be aligned in a particular direction and the other assemblies can be moved distally or proximally relative to the rail shaft 132 for final positioning without releasing the implant 70. The components can be advanced approximately 1, 2, 3, 5, 6, 7, 8, 9, or 10 cm along the rail shaft 132. The components can be advanced more than approximately 1, 2, 3, 5, 6, 7, 8, 9, or 10 cm along the rail shaft 132. An example of this is shown in FIG. 2C. The capsule 106 and outer retaining ring 42 can then be withdrawn separately relative to the inner assembly 18, as described above, releasing the implant 70, in some embodiments sequentially. The assemblies other than the rail assembly 20 can then be withdrawn back onto the rail shaft 132 by rotating the depth knob 212 in the opposite direction.

[0212] The handle 14 may further include a mechanism (knob, button, handle) 216 for moving the nosecone shaft 27 and thus the nosecone 28. For example, the knob 216 may be part of the nosecone assembly 31 that extends from the proximal end of the handle 14. Thus, a user may pull or push the knob 216 to translate the nosecone shaft 27 distally or proximally separately relative to the other shaft. This may be advantageous to translate the nosecone 28 proximally into the outer sheath assembly 22 / capsule 106, thus facilitating withdrawal of the delivery system 10 from the patient.

[0213] In some embodiments, the handle 14 can provide a lock 218, such as a spring lock, to prevent translational movement of the nosecone shaft 27 by the knob 216 described above. In some embodiments, the lock 218 can be always active, so that the nosecone shaft 27 will not move unless the user disengages the lock 218. The lock can be, for example, a spring lock that is always engaged until a button 218 on the handle 14 is pressed, thereby releasing the spring lock and allowing the nosecone shaft 27 to translate in the proximal / distal direction. In some embodiments, the spring lock 218 allows movement of the nosecone shaft 27 in one direction, either proximal or distal, but prevents movement in the opposite direction.

[0214] The handle 14 may further include communicating flush ports for flushing the various lumens of the delivery system 10. In some embodiments, a single flush port on the handle 14 may provide a fluid connection to multiple assemblies. In some embodiments, the flush port may provide a fluid connection to the outer sheath assembly 22. In some embodiments, the flush port may provide a fluid connection to the outer sheath assembly 22 and the mid shaft assembly 21. In some embodiments, the flush port may provide a fluid connection to the outer sheath assembly 22, the mid shaft assembly 21, and the rail assembly 20. In some embodiments, the flush port may provide a fluid connection to the outer sheath assembly 22, the mid shaft assembly 21, the rail assembly 20, and the inner assembly 18. Thus, in some embodiments, the rail shaft 132, the outer retaining ring 42, and the capsule 106 may all be flushed by a single flush port.

[0215] 37-45 show one embodiment of a handle 14' that includes control knobs 210', 214', 2500, each having an exposed outer gripping surface for gripping around the entire circumference of the respective control knob 210', 214', 2500. This contrasts with the control knobs 210, 214 shown in, for example, FIG. 35, where a portion of the outer gripping surface of the control knobs 210, 214 is covered by a bridge portion of the handle 14 that extends over the control knobs 210, 214.

[0216] The handle 14' shown in FIG. 37 does not include a bridge on the respective control knob 210', 214', 2500, and thus each control knob 210', 214', 2500 has an outer grip surface exposed for gripping around the entire circumference of the respective control knob 210', 214', 2500. Such a feature may advantageously allow a greater gripping force to be applied to the respective control knob 210', 214', 2500 and more fully enable a user to rotate the knob and move the respective portion of the delivery system to which the respective control knob 210', 214', 2500 is coupled. The absence of the bridge portion of the handle 14 on the control knob 210', 214', 2500 improves the ergonomics of the handle 14' and allows a greater gripping force to be applied to the control knob 210', 214', 2500 by the user.

[0217] Handle 14' may include a rail housing 202 that is configured similarly to rail housing 202 shown in FIG. 35 and that is coupled to delivery housing 204' in a manner similar to how rail housing 202 is coupled to delivery housing 204. Pullwire knobs 206, 208 are not shown in FIGS. 37-45 for clarity, and depth knob 212 is not shown for clarity, although pullwire knobs 206, 208 and depth knob 212 operate with handle 14' in the same manner as handle 14.

[0218] FIG. 37 shows a side perspective view of the handle 14' and FIG. 38 shows a bottom view of the handle 14'. FIG. 39 shows a central cross-sectional view of the handle 14' from the bottom view of FIG. 38. The internal structure of the handle 14' is shown in FIG. 39. The distal-most control knob 210' is located at the distal end of the handle 14' and is configured to control the operation of the outer sheath assembly. A distal face 2502 (visible in FIG. 40) forms the distal face of the handle 14' and connects both sides of the gripping surface of the control knob 210'. The middle control knob 214' is located on the delivery housing 204' and is configured to control the operation of the middle shaft assembly. The proximal control knob 2500 is located at the proximal end of the handle 14' and is configured to control the operation of the nosecone assembly. The distal-most control knob 210' and the middle control knob 214' can each be configured to rotate to move their respective assemblies to release a portion of the implant from the implant holding area 16.

[0219] The delivery housing 204' may include an internal cavity that houses a respective slider 2504, 2506, 2508, each coupled to the outer sheath assembly, the mid shaft assembly, and the nosecone assembly, respectively. The sliders may be configured to slide along the respective cavities that house them to enable the sliders 2504, 2506, 2508 to translate the respective assemblies.

[0220] The control knob 210', 214', 2500 may be coupled to a body 2501, 2503, 2505 having threads that engage with threads of the slider 2504, 2506, 2508 to allow rotational movement of the control knob 210', 214', 2500 to effect axial or linear sliding of the respective slider 2504, 2506, 2508. One or more beams 2510, 2512 may be provided that may function to prevent rotation of the slider 2504, 2506, 2508 when the respective control knob 210', 214', 2500 is rotated. Each beam 2510, 2512 may include a channel shaped to match the shape of the respective slider 2504, 2506, 2508 to prevent rotation of the slider 2504, 2506, 2508 upon rotation of the control knob 210', 214', 2500. Because a portion of the body threads is covered by the respective beam, only a portion (e.g., half) of the body threads may engage the slider to effect movement of the slider. Each slider 2504, 2506, 2508 sits within the channel of the beam and slides along the channel to effect movement of the assembly to which the slider 2504, 2506, 2508 is coupled.

[0221] The beams 2510, 2512 may include walls located on either side of the recess to form respective channels in the beams 2510, 2512. Thus, the beams 2510, 2512 may have a "u" shape as shown in Figures 41-45. Such a shape provides enhanced structural support for the handle 14' and resists torque applied to the beams 2510, 2512 upon rotation of the control knobs 210', 214', 2500.

[0222] The beams 2510, 2512 may each extend into a cavity that houses the slider 2504, 2506, 2508 and may depend within the cavity such that the threads of the control knob 210', 214', 2500 do not engage or rotate the beams 2510, 2512. The beams 2510, 2512 may be supported by the delivery housing 204' at supports 2514, 2516, 2518, 2520, 2522. The delivery housing 204' may also include walls 2524, 2526, 2528 that separate the cavities of the delivery housing 204' and function to hold the beams 2510, 2512 from rotating with their respective cavities of the delivery housing 204'.

[0223] 40 shows a front perspective view of the handle 14', without the elongated shaft being visible. The distal face 2502 includes a central opening that allows the elongated shaft to pass therethrough.

[0224] Figure 41 shows a cross-sectional view along line AA of Figure 39. The "u" shape of the beam 2510 is visible, as is the key shape of the slider 2504.

[0225] Figure 42 shows a cross-sectional view along line BB of Figure 39. The support 2516 is shown as a protrusion that enters a portion of the beam 2510. A support wall 2524 abuts the beam 2510 to prevent rotation of the beam 2510 within the handle 14'.

[0226] Figure 43 shows a cross-sectional view taken along line CC of Figure 39. A support wall 2526 abuts the beam 2510 to prevent rotation of the beam 2510 within the handle 14'.

[0227] Figure 44 shows a cross-sectional view taken along line DD in Figure 39. The support 2520 is shown as a protrusion that enters a portion of the beam 2512. A support wall 2528 abuts the beam 2512 to prevent rotation of the beam 2512 within the handle 14'.

[0228] Figure 45 shows a cross-sectional view along line EE of Figure 39. The control knob 2500 is shown to include an unthreaded portion 2530 that acts as a stop to prevent the slider 2508 from passing past the proximal end of the handle 14'.

[0229] The handle 14' may be configured to control the length of the path of travel of the respective sliders 2504, 2506, 2508 in a variety of ways. For example, the threads of the control knob may be interrupted at a point to prevent movement of the respective sliders 2504, 2506, 2508. The size of the cavity through which the sliders 2504, 2506, 2508 travel may be reduced as needed. In some embodiments, a stop in the form of a protrusion may be located along the beams 2510, 2512 or otherwise within the path of travel to control the length of the path of travel of the respective sliders 2504, 2506, 2508. In FIG. 39, the control knob 210' functions as a distal stop to prevent distal axial movement of the slider 2504. The handle 14' may be utilized with any of the embodiments of the delivery system disclosed herein. The handle 14' disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0230] Embodiments of the delivery systems disclosed herein may include markers configured to enhance the echogenicity of the elongate shaft of the delivery system to clarify the location of a portion of the elongate shaft when viewed under ultrasound imaging. Such markers may be located at various locations on the elongate shaft and may be located on a portion of the elongate shaft that is advantageously identified under ultrasound imaging to improve delivery of the expandable implant. Ultrasound imaging may include echocardiography, among other forms of ultrasound imaging.

[0231] Figure 46 shows a side view of the nose cone 28 of the delivery system. The nose cone 28 has a smooth tapered outer surface that does not readily show up in ultrasound imaging. Additionally, Figure 47 shows a cross-sectional view of the nose cone 28 shown in Figure 46. The nose cone 28 is shown to include a homogenous structure made of a single type of material, which is preferably soft and pliable, such as a flexible polymer.

[0232] FIG. 48 illustrates a side view of a portion of the nosecone shown in FIG. 46 as nosecone 28', which includes a marker configured to enhance the echogenicity of the elongate shaft (specifically the nosecone 28') to clarify the location of the portion of the elongate shaft (the nosecone 28') when viewed under ultrasound imaging. The marker shown in FIG. 48 has the shape of a particular shaped portion of the nosecone 28' forming an edge 2600 of the nosecone 28'. The edge 2600 extends around the circumference of the nosecone 28' and forms a planar surface 2602 that extends around the circumference of the nosecone 28'. The planar surface 2602 faces in a distal direction. The edge 2600 forms an abrupt transition in the acoustic impedance of the nosecone 28', which enhances the echogenicity of the nosecone 28'. Additionally, the shape of the edge 2600 extending around the circumference of the nosecone 28' enhances acoustic reflections for various directions of the incident ultrasound waves, thus enhancing the echogenicity of the nosecone 28'.

[0233] Figure 49 shows two echocardiographic images of the nosecone 28' including the edge 2600 shown in Figure 48. The edge 2600 appears brighter in the two echocardiographic images, as indicated by locations 2700 and 2702, which may allow a user to more easily identify the location of the nosecone 28' within the images.

[0234] 50 illustrates an embodiment of a nose cone 2800 including a marker including multiple edges 2802, 2804, 2806 that enhance the echogenicity of the elongate shaft (specifically the nose cone 2800) to clarify the location of a portion of the elongate shaft (the nose cone 2800) when viewed under ultrasound imaging. The multiple edges 2802, 2804, 2806 may function similarly to the edge 2600 illustrated in FIG. 48 and each may extend around the circumference of the nose cone 2800 and form a respective distally facing planar surface that extends around the circumference of the nose cone 2800. Multiple shelves may be formed by the multiple edges 2802, 2804, 2806.

[0235] 51 illustrates an embodiment of a nose cone 2900 including markers including edges 2902 that enhance the echogenicity of the elongate shaft (particularly the nose cone 2900) to clarify the location of a portion of the elongate shaft (the nose cone 2900) when viewed under ultrasound imaging. The edges 2902 may function similarly to the edges 2600 illustrated in FIG. 48 and each may extend around the circumference of the nose cone 2900 and form a distally facing planar surface that extends around the circumference of the nose cone 2900. The edges 2902 may spiral around the nose cone 2900 to form a helical pattern around the nose cone 2900.

[0236] 52 illustrates an embodiment of a nose cone 3000 including a marker that includes multiple edges 3002 that enhance the echogenicity of the elongate shaft (specifically the nose cone 3000) to clarify the location of a portion of the elongate shaft (the nose cone 3000) when viewed under ultrasound imaging. The edges 3002 may function similarly to the edges 2600 illustrated in FIG. 48 and may form a distally facing pattern on the nose cone 3000. The pattern may include multiple recesses in the form of dimples on the nose cone 3000.

[0237] 53 illustrates an embodiment of a nose cone 3100 including a marker that includes multiple edges 3102 that enhance the echogenicity of the elongate shaft (particularly the nose cone 3100) to clarify the location of a portion of the elongate shaft (the nose cone 3100) when viewed under ultrasound imaging. The edges 3102 may function similarly to the edges 2600 illustrated in FIG. 48 and may form a distally facing pattern on the nose cone 3100. The pattern may include multiple recesses in the form of grooves on the nose cone 3100.

[0238] The surfaces shown in Figures 48 and 50-53 may comprise the exterior surface of each nosecone, or in other embodiments, the markers may be encapsulated in a material. The encapsulating material may include a material that has a different acoustic impedance than the markers, making the markers more echogenic. The encapsulating material may allow the nosecone to retain a smooth tapered surface.

[0239] Figure 54 shows a side cross-sectional view of a nose cone 3200 that includes two materials with different acoustic impedances. One material forms the marker 3202 shown in Figure 54, and the other material, which has a different acoustic impedance than the material of the marker 3202, forms an adjacent encapsulating material that forms the exterior surface of the nose cone 3200. The marker 3202 may be encapsulated such that the nose cone 3200 retains a smooth tapered surface.

[0240] FIG. 55 shows a perspective view of a nose cone 3200 including a marker 3202. The marker may include multiple edges and may include multiple planar surfaces oriented along the axial plane of the nose cone 3200 and planar surfaces oriented along the radial plane. The edges may create an abrupt transition in the acoustic impedance of the nose cone 3200, which enhances the echogenicity of the nose cone 3200. Additionally, the edges and orientation of the planar surfaces enhance acoustic reflections for various directions of incident ultrasound waves, thus also enhancing the echogenicity of the nose cone 3200. The marker 3202 includes multiple fins that extend radially outward.

[0241] Figure 56 shows a perspective view of a nose cone 3200 including markers 3202 at a larger angle than shown in Figure 55. The orientation of multiple fins is visible.

[0242] FIG. 57 shows a perspective view of a nose cone 3300 including a marker 3302 configured similarly to marker 3202, but having a greater number of fins than that shown in FIG.

[0243] The markers disclosed herein may be made from materials having a relatively high acoustic impedance, including metals, etc. The acoustic impedance may be greater than the impedance of adjacent materials to allow for enhanced echogenicity resulting from the use of the marker.

[0244] The markers disclosed herein may be utilized at various locations on the elongate shaft, not just on the nosecone that comprises the tip of the elongate shaft. For example, the capsule, the outer retaining ring of the midshaft, and other locations on the outer sheath assembly, midshaft assembly, and inner shaft assembly may include markers, as desired.

[0245] 58 shows a side cross-sectional view of the capsule 106 including a marker 3400 at the distal end of the capsule 106. The marker 3400 may include multiple edges that increase the echogenicity of the elongate shaft (particularly the distal end of the capsule 106) to clarify the location of a portion of the elongate shaft (the distal end of the capsule 106) when viewed under ultrasound imaging.

[0246] FIG. 59 shows an enlarged perspective view of the marker 3400. The marker may include multiple edges 3402 that bound the apertures 3404 of the marker 3400. The multiple apertures 3404 may be circumferentially spaced around the marker 3400. The apertures 3404 may allow for a transition in acoustic impedance between the body of the marker 3400 and the apertures 3404, which may be filled with a material having a different acoustic impedance than the body of the marker 3400. The apertures 3404 may each have an oval shape with adjacent apertures 3404 overlapping each other, such that a vertical scan slice taken from the marker along the vertical direction represented by the line 3406 passes through the apertures 3404, allowing for a transition in acoustic impedance caused by the apertures 3404. Additionally, the angled profile of the apertures 3404 may enhance acoustic reflectivity for various directions of incident ultrasound waves. The marker 3400 in the form of a ring extends about the longitudinal axis of the elongate shaft, with a plurality of apertures positioned circumferentially about the longitudinal axis.

[0247] The location of the aperture 3404 in the vertical direction on the body of the marker 3400 also increases the likelihood that an acoustic slice will pass through the aperture 3404 when extending laterally, as represented by the plane 3408 in FIG.

[0248] The markers 3400 may comprise bands of material having a different acoustic impedance than adjacent materials and may be located as desired. The markers 3400 may be located, for example, on the outer retaining ring of the midshaft, and on the nosecone or tip. Other locations on the outer sheath assembly, midshaft assembly, and inner shaft assembly may include markers as desired.

[0249] 60 shows two echocardiographic images of a capsule including a marker 3400. The marker 3400 appears brighter in the two echocardiographic images, as indicated by locations 3500 and 3502, which may allow a user to more easily identify the location of the capsule within the images. The marker may be coupled to the tip of the elongate shaft, or any other location, and may appear to appear brighter than the remainder of the tip or the remainder of the elongate shaft using ultrasound imaging, such as echocardiography.

[0250] The marker may be configured to be activated in embodiments herein. The marker may be configured to have greater echogenicity when activated. An activation mechanism or another system may be utilized to activate the marker as disclosed herein. FIG. 75A, for example, illustrates one embodiment of a marker 3800 configured to be activated. A distal end of a delivery system including a nose cone 3802 and a capsule 3804 is illustrated in FIG. 75A. The exterior surface of the nose cone 3802 and the exterior surface of the capsule 3804 may comprise smooth surfaces that form a smooth outer contour in the configuration illustrated in FIG. 75A. In such a configuration, for example, the delivery system may pass through a patient's body with a smooth outer contour that reduces the possibility of damaging the surface of the patient's body.

[0251] The capsule 3804 may be configured to retract to activate the marker 3800 and allow the marker 3800 to increase echogenicity of the elongate shaft of the delivery system. Thus, the activation mechanism may include the capsule 3804 and an indicator 3806, which may be located on a proximal portion of the elongate shaft. The indicator 3806 may be configured as a stopper, as shown in FIG. 75A, or in embodiments, may be configured as a tactile indicator, an audible indicator, or other form of indicator.

[0252] When a user desires to activate the marker 3800, a first portion of the elongate shaft may move relative to a second portion of the elongate shaft to activate the marker 3800. For example, the capsule 3804 may be retracted a length 3810 (shown in FIGS. 75A and 75B) to form a gap 3812 (shown in FIG. 75B) between two portions of the delivery system (e.g., the capsule 3804 and the nosecone 3802). FIG. 75B, for example, shows the capsule 3804 retracted a length 3810. The capsule 3804 moves axially relative to the nosecone 3802.

[0253] 75B, the gap 3812 formed by the movement of the capsule 3804 may expose the edges 3814, 3816 of the capsule 3804 and the nosecone 3802, respectively, thus activating the marker 3800. In such a configuration, a user may be able to identify the marker 3800 using ultrasound imaging. The marker 3800 includes contoured portions that form the edges 3814, 3816 of the elongate shaft. The planar surface formed by the edge 3814 may face in a distal direction, and the planar surface formed by the edge 3816 may face in a proximal direction.

[0254] In embodiments, the indicator 3806 may indicate to the user to retract the capsule 3804 a relatively short distance to maintain the proximity between the edges 3814, 3816. The proximity of the edges 3814, 3816 may increase the echogenicity of the marker 3800. When the user desires to further retract the capsule 3804 (e.g., to deploy an implant), the indicator 3806 may be overcome, for example, by riding over a stop or otherwise continuing movement past the indicator 3806. For example, the indicator 3806 may be moved (e.g., pushed or slid) to allow the capsule 3804 to continue to retract.

[0255] In such a configuration, the portion of the delivery system including the marker 3800 may have a smooth outer contour, with the edges 3814, 3816 only exposed at the desired time by the user manipulating the activation mechanism. Thus, the potential for damage to the patient's body caused by a non-uniform outer contour may be reduced until the desired time of activation of the marker 3800.

[0256] Other configurations of activatable markers may be utilized in embodiments. FIG. 76A, for example, illustrates an embodiment in which a first portion of an elongate shaft (e.g., a strip of material 3818) forms an exterior surface of a delivery system (e.g., an exterior surface of a capsule 3820). The portion illustrated may comprise the capsule or another portion of the elongate shaft, as desired. The strip of material 3818 may move relative to a second portion of the elongate shaft (e.g., an adjacent portion of the elongate shaft) to form a gap 3822 between the portions. A user may manipulate an activation mechanism, for example, as disclosed herein. The gap 3822 may expose an edge 3824 of a marker 3826 (shown in FIG. 76B). The material 3818 may slide axially.

[0257] FIG. 77A shows an embodiment in which a first portion of the elongate shaft (e.g., a strip of material 3828) forms an exterior surface of the delivery system (e.g., an exterior surface of the capsule 3830). The strip of material 3828 may move to form a gap 3832 (as shown in FIG. 77B) and expose an edge 3834 of the marker 3836. The material 3828 may rotate relative to a second portion of the elongate shaft (e.g., an adjacent portion of the elongate shaft) to activate the marker 3836. A user may, for example, manipulate an activation mechanism disclosed herein to rotate the strip of material 3828.

[0258] In an embodiment, multiple markers may be located on the delivery system. The markers may be spaced apart from one another at a distance so that a user viewing the markers on ultrasound imaging can identify their relative locations on the delivery system. FIG. 78A, for example, shows an embodiment in which multiple markers 3840 have stepped spacing arranged on the delivery system. The markers 3840 may form a spiral pattern. Thus, when the markers 3840 (shown in FIG. 78B) are activated, multiple locations on the delivery system are indicated. The user may manipulate an activation mechanism, for example, as disclosed herein. The strips of material forming the outer surface of the delivery system may each move to form a gap and expose an edge of the marker 3840. The user may be able to match the locations of the markers 3840 to their respective locations on the delivery system. Additionally, the user may be able to determine the relative scaling on the imaging system based on the imaged distance between the markers 3840. For example, if a user perceives that each marker is 3 millimeters apart, that scaling can be used to determine the distance at which they appear on the imaging system.

[0259] Use of the markers disclosed herein may more easily allow a user to locate a portion of the elongate shaft under ultrasound imaging, which may include echocardiography. A user may be able to more easily determine the placement location of the expandable implant, which may include the depth of the expandable implant and the relationship of the expandable implant to structures in the patient's heart, including the papillary muscles and any valve septum, including the mitral valve septum. A user may advantageously visualize the location of a portion of the elongate shaft without relying solely on fluoroscopy for visualization. The markers disclosed herein may be utilized on catheters, intravenous or digestive systems, or any portion of an implant, or any other device for insertion into the human body where a specific location needs to be identified by ultrasound imaging or echocardiography. The markers disclosed herein may be utilized alone or in conjunction with any of the other devices, systems, or methods disclosed herein.

[0260] Methods of using the delivery system 10 in connection with a replacement mitral valve will now be described. In particular, the delivery system 10 may be used in methods for percutaneous delivery of a replacement mitral valve to treat patients with moderate to severe mitral regurgitation. The following methods are merely examples of how the delivery system may be used. It will be understood that the delivery systems described herein may be used as part of other methods as well. The embodiments shown in Figures 16-60 may be incorporated and utilized as needed.

[0261] As shown in FIG. 61 , in one embodiment, the delivery system 10 can be positioned in the ipsilateral femoral vein 1074 and advanced toward the right atrium 1076. A transseptal puncture using known techniques can then be performed to gain access to the left atrium 1078. The delivery system 10 can then be advanced into the left atrium 1078 and then into the left ventricle 1080. FIG. 61 shows the delivery system 10 extending from the ipsilateral femoral vein 1074 to the left atrium 1078. In embodiments of the present disclosure, a guidewire is not required to position the delivery system 10 in the appropriate location, although in other embodiments, one or more guidewires may be used.

[0262] It may therefore be advantageous for a user to be able to steer the delivery system 10 through complex regions of the heart to position the replacement mitral valve along with the native mitral valve. This task may be performed with or without the use of a guidewire with the systems disclosed above. The distal end of the delivery system may be advanced into the left atrium 1078. The user may then manipulate the rail assembly 20 to direct the distal end of the delivery system 10 to the appropriate region. The user may then continue to thread the bent delivery system 10 into the left atrium 1078 via a transseptal puncture. The user may then further manipulate the delivery system 10 to create an even greater bend in the rail assembly 20. Additionally, the user may apply torque to the entire delivery system 10 to further manipulate and control the position of the delivery system 10. In the fully bent configuration, the user may then place the replacement mitral valve in the appropriate position. This may advantageously enable delivery of the replacement valve to an in situ implantation site, such as the native mitral valve, via a wider variety of approaches, such as a transseptal approach.

[0263] The rail assembly 20 may be particularly advantageous for entering the native mitral valve. As described above, the rail assembly 20 may form two bends, both of which may be positioned within the left atrium 1078. The bends of the rail assembly 20 may position the implant 70, positioned within the implant holding area 16, so as to be coaxial with the native mitral valve. Once the implant 70 is coaxial, the outer sheath assembly 22, midshaft assembly 21, inner assembly 18, and nosecone assembly 31 may be advanced distally together relative to the rail assembly 20 (e.g., using the depth knob 212 of the handle 14). These assemblies advance linearly from the rail assembly 20, thus advancing the assemblies coaxially with the native mitral valve while maintaining the implant 70 in a compressed configuration, as described below, until the implant 70 is released. Thus, the rail assembly 20 provides the user with the ability to lock the angular position in place, so that the user does not need to make any angle changes and only needs to advance the other assemblies longitudinally on the rail assembly 20, greatly simplifying the procedure. The rail assembly 20 functions as an independent steering assembly, and all assemblies are provided with steering and no additional prosthesis release function. Furthermore, the structure of the rail assembly 20 described above is sufficiently rigid such that when the rail assembly is actuated into its bent shape, the rail assembly 20 maintains its shape despite the movement of the other components, e.g., the outer sheath assembly 22, the midshaft assembly 21, the inner assembly 18, and / or the nosecone assembly 31. Thus, the rail assembly 20 can remain in a desired bent position while the other assemblies slide relative to the rail assembly 20, and the rail assembly 20 can help guide the other assemblies to their final position. The proximal / distal translational movement of the other assemblies on the rail assembly 20 allows for ventricular-atrial movement.Additionally, once the distal anchor 80 of the implant 70 is released within the left ventricle 1080, the other assembly can be retracted proximally over the rail assembly 20 to capture any leaflets or chordae tendineae prior to full release.

[0264] Reference is now made to FIG. 62, which shows a schematic diagram of a portion of one embodiment of a replacement heart valve (implant 70) positioned within the native mitral valve of the heart 83. Further details regarding how the implant 70 may be positioned within the native mitral valve are described in U.S. Patent Application Publication No. 2015 / 0328000A1, which is incorporated herein by reference in its entirety, including, but not limited to, FIGS. 13A-15 and paragraphs

[0036] -

[0045] . A portion of the native mitral valve is shown diagrammatically, depicting typical anatomical structures including a left atrium 1078 located above the valve annulus 1106 and a left ventricle 1080 located below the valve annulus 1106. The left atrium 1078 and the left ventricle 1080 communicate with each other via the mitral valve annulus 1106. The native mitral valve leaflets 1108 are also shown diagrammatically in FIG. 62 with chordae tendineae 1110 connecting their downstream ends to the papillary muscles of the left ventricle 1080. A portion of the implant 70 disposed upstream of the annulus 1106 (towards the left atrium 1078) may be referred to as being supranulnarly positioned. A portion approximately within the annulus 1106 is referred to as being intraannularly positioned. A portion downstream of the annulus 1106 is referred to as being subannularly positioned (towards the left ventricle 1080).

[0265] As shown in FIG. 62, a replacement heart valve (e.g., implant 70) may be positioned such that the mitral valve annulus 1106 is located between the distal anchor 80 and the proximal anchor 82. In some circumstances, the implant 70 may be positioned such that an end or tip of the distal anchor 80 contacts the annulus 1106, for example, as shown in FIG. 62. In some circumstances, the implant 70 may be positioned such that an end or tip of the distal anchor 80 does not contact the annulus 1106. In some circumstances, the implant 70 may be positioned such that the distal anchor 80 does not extend around the valve leaflets 1108.

[0266] As shown in FIG. 62, the implant 70 in the form of a prosthesis, specifically a replacement heart valve, may be positioned such that an end or tip of the distal anchor 80 is on the ventricular side of the mitral valve annulus 1106 and an end or tip of the proximal anchor 82 is on the atrial side of the mitral valve annulus 1106. The distal anchor 80 may be positioned such that an end or tip of the distal anchor 80 is on the ventricular side of the native leaflet, beyond where the chordae tendineae 1110 connect to the free ends of the native leaflet. The distal anchor 80 may extend between at least a portion of the chordae tendineae 1110 and, in some circumstances, such as those shown in FIG. 62, may contact or engage the ventricular side of the annulus 1106. It is also contemplated that in some circumstances, the distal anchor 80 may not contact the annulus 1106, but the distal anchor 80 may still contact the native leaflet 1108. In some circumstances, the distal anchor 80 may contact tissue of the left ventricle 1080 beyond the ventricular side of the annulus 1106 and / or leaflets.

[0267] During delivery, the distal anchor 80 (along with the frame) can be moved toward the ventricular side of the annulus 1106, such as by translating the other assemblies (e.g., outer sheath assembly 22, midshaft assembly 21, inner assembly 18, and nosecone assembly 31) proximally relative to the rail assembly 20, such that the distal anchor 80 extends between at least a portion of the chordae tendineae 1110 and places tension on the chordae tendineae 1110. The degree of tension placed on the chordae tendineae 1110 can vary. For example, there may be little or no tension in the chordae tendineae 1110 whose leaflets 1108 are shorter than or similarly sized to the distal anchor 80. A greater degree of tension may be present in the chordae tendineae 1110, where the leaflets 1108 are longer than the distal anchor 80 and therefore assume a compressed configuration and are pulled proximally. If the leaflets 1108 were longer relative to the distal anchor 80, a greater degree of tension could exist in the chordae tendineae 1110. The leaflets 1108 could be long enough so that the distal anchor 80 does not contact the annulus 1106.

[0268] The proximal anchor 82, if present, may be positioned such that an end or tip of the proximal anchor 82 is adjacent to tissue on the atrial side of the annulus 1106 and / or beyond the annulus 1106 in the left atrium 1078. In some circumstances, some or all of the proximal anchor 82 may only occasionally contact or engage tissue on the atrial side of the annulus 1106 and / or beyond the annulus 1106 in the left atrium 1078. For example, as shown in FIG. 62, the proximal anchor 82 may be spaced from tissue on the atrial side of the annulus 1106 and / or beyond the annulus 1106 in the left atrium 1078. The proximal anchor 82 may provide axial stability to the implant 70. It is also contemplated that some or all of the proximal anchor 82 may contact tissue on the atrial side of the annulus 1106 and / or beyond the annulus 1106 in the left atrium 1078. 63 shows the implant 70 implanted in the heart. While the illustrated replacement heart valve includes both proximal and distal anchors, it will be appreciated that proximal and distal anchors are not required in all cases. For example, a replacement heart valve having only a distal anchor may be able to securely maintain the replacement heart valve within the annulus. This is because the greatest forces on the replacement heart valve are directed toward the left atrium during systole. Thus, the distal anchor is paramount to secure the replacement heart valve within the annulus and prevent migration.

[0269] 64-66 show the release mechanism of the delivery system 10. During initial insertion of the implant 70 and delivery system 10 into the body, the implant 70 may be positioned within the system 10 similar to that shown in FIG. 2A. The distal end 303 of the implant 70, specifically the distal anchor 80, is restrained within the capsule 106 of the outer sheath assembly 22, thus preventing expansion of the implant 70. Similar to that shown in FIG. 2A, the distal anchor 80 may extend distally once positioned within the capsule. The proximal end 301 of the implant 70 is restrained within the capsule 106 and within a portion of the inner retention member 40, thus generally restrained between the capsule 106 and the inner retention member 40.

[0270] The system 10 can be initially positioned at a particular location within the patient's body, such as at the native mitral valve, through the use of the steering mechanisms or other techniques discussed herein.

[0271] Once the implant 70 is loaded into the delivery system 10, the user can thread a guidewire to a desired location within the patient. The guidewire passes through a lumen of the nosecone assembly 31, so that the delivery system 10 can be advanced through the patient's body, generally following the guidewire. The delivery system 10 can be advanced by the user manually moving the handle 14 axially. In some embodiments, the delivery system 10 can be placed in a stand while manipulating the controls of the handle 14.

[0272] Once entirely within the heart, the user can begin to steer the rail assembly 20 using the distal pullwire knob 206 and / or the proximal pullwire knob 208. By rotating either of the knobs, the user can provide a bend / flexion of the rail assembly 20 (either the distal or proximal end), and thus bend the distal end of the delivery system 10 into a desired configuration at one, two, or more locations. As discussed above, the user can provide multiple bends in the rail assembly 20 to orient the delivery system 10 toward the mitral valve. In particular, the bends in the rail assembly 20 can orient the distal end of the delivery system 10, and therefore the capsule 106, along a central axis that passes through the native mitral valve. Thus, as the outer sheath assembly 22, midshaft assembly 21, inner assembly 18, and nosecone assembly 31 advance together over the rail assembly 20 with the compressed implant 70, the capsule 106 advances directly along the axis to properly release the implant 70.

[0273] The user may also rotate and / or move the handle 14 itself within the stand for further fine adjustment of the distal end of the delivery system 10. The user may continuously rotate the proximal and / or distal pullwire knobs 208 / 206 and move the handle 14 itself to orient the delivery system 10 for release of the implant 70 within the body. The user may also move other assemblies further relative to the rail assembly 20, such as in a proximal or distal direction.

[0274] In the next step, the user may rotate the depth knob 212. As described above, when these knobs 212 are rotated together, the inner shaft assembly 18, the mid shaft assembly 21, the outer sheath assembly 22, and the nosecone assembly 31 advance over / through the rail assembly 20 while the implant 70 remains in a compressed configuration within the implant holding area 16. For example, the stiffness of any of the inner shaft assembly 18, the mid shaft assembly 21, and / or the outer sheath assembly 22 will cause these assemblies to advance straight forward in the direction aligned by the rail assembly 20.

[0275] Once in the release position, the user can rotate the outer sheath knob 210, which separately translates the outer sheath assembly 22 (and thus the capsule 106) in a proximal direction toward the handle 14 relative to the other assemblies, particularly the inner assembly 18, as shown in FIG. 64. By doing so, the distal end 303 of the implant 70 is exposed within the body, allowing expansion to begin. At this point, the distal anchor 80 can be flipped proximally, and the distal end 303 begins to expand radially outward. For example, if the system 10 is delivered to the native mitral valve position via a transseptal approach, the nosecone is positioned within the left ventricle, preferably aligning the implant 70 so that it is approximately perpendicular to the plane of the mitral annulus. The distal anchor 80 expands radially outward within the left ventricle. The distal anchor 80 can be positioned above the heads of the papillary muscles, but below the mitral annulus and mitral valve leaflets. In some embodiments, the distal anchor 80 may contact and / or extend between the chordae in the left ventricle and contact the leaflets as the distal anchor 80 expands radially. In some embodiments, the distal anchor 80 may not contact and / or extend between the chordae or contact the leaflets. Depending on the location of the implant 70, the distal end of the distal anchor 80 may be at or below where the chordae connect to the free edges of the native leaflets.

[0276] As shown in the illustrated embodiment, the distal end 303 of the implant 70 is expanded outward. Note that the proximal end 301 of the implant 70 may remain covered by an outer retaining ring during this step so that the proximal end 301 remains in a radially compressed state. At this point, the system 10 may be pulled proximally so that the distal anchors 80 capture and engage the leaflets of the mitral valve, or may be moved proximally to reposition the implant 70. For example, these assemblies may be moved proximally relative to the rail assembly 20. Additionally, the system 10 may be torqued so that the distal anchors 80 tension the chordae tendineae through which at least some of the distal anchors may extend. However, in some embodiments, the distal anchors 80 may not tension the chordae tendineae. In some embodiments, the distal anchors 80 may capture the native leaflets and be between the chordae tendineae without further movement of the system 10 after retraction of the outer sheath assembly 22.

[0277] During this step, the system 10 may be moved proximally or distally to cause the distal or ventricular anchor 80 to properly capture the leaflets of the native mitral valve. This may be done by moving the outer sheath assembly 22, the midshaft assembly 21, the inner assembly 18, and the nosecone assembly 31 relative to the rail assembly 20. In particular, the tip of the ventricular anchor 80 may be moved proximally to engage the ventricular side of the native annulus, such that the native leaflets are positioned between the anchor 80 and the body of the implant 70. When the implant 70 is in its final position, there may or may not be tension on the chordae tendineae, but the distal anchor 80 may be disposed between at least some of the chordae tendineae.

[0278] The proximal end 301 of the implant 70 remains within the outer retaining ring 42 after retraction of the capsule 106. As shown in FIG. 65, once the distal end 303 of the implant 70 is fully expanded (or as fully expanded as possible at this point), the outer retaining ring 42 can be pulled separately in a proximal direction relative to the other assemblies, particularly the inner assembly 18, to expose the inner retaining member 40 and thus initiate expansion of the proximal end 301 of the implant 70. For example, in a mitral valve replacement procedure, the proximal end 301 of the implant 70 may be expanded within the left atrium after the distal or ventricular anchor 80 is positioned between at least some of the chordae tendineae and / or engages the native mitral valve annulus.

[0279] The outer retaining ring 42 can be moved proximally to allow the proximal end 310 of the implant 70 to expand radially to its fully expanded form, as shown in FIG. 66. After expansion and release of the implant 70, the inner assembly 18, the nosecone assembly 31, the midshaft assembly 21, and the outer sheath assembly 22 can be simultaneously pulled back to their original positions along or proximally relative to the rail assembly 20. In some embodiments, they are not pulled relative to the rail assembly 20 and remain in the expanded position. Additionally, the nosecone 28 can be retracted into the outer sheath assembly 22 through the center of the expanded implant 70, such as by translating the knob 216 proximally. The system 10 can then be removed from the patient.

[0280] 67A-B show the progression of the various assemblies on the rail assembly 20. Fig. 67A shows the assembly in its proximal-most position on the rail assembly 20. Fig. 67B shows the assembly in its distal-most position compared to the rail assembly 20 shown in Fig. 2C, etc. Thus, the assemblies snake along the rail assembly 20, extending away from each other in the distal direction.

[0281] In some embodiments, the implant 70 may be delivered under fluoroscopy so that the user can see specific reference points for proper positioning of the implant 70. Additionally, echocardiography may be used for proper positioning of the implant 70.

[0282] The following is a description of another implantation method for delivering a replacement mitral valve to the mitral valve position. The following elements can be incorporated into the above description and vice versa. The access site to the patient can be dilated prior to inserting the delivery system 10. Additionally, the dilator can be flushed, for example with heparinized saline, prior to use. The delivery system 10 can then be inserted over a guidewire. In some embodiments, any flush port on the delivery system 10 can be oriented vertically. Additionally, if an introducer tube is used, integrated, or otherwise applied, this can be stabilized. The delivery system 10 can be advanced through the septum until the distal end of the delivery system 10 is positioned across the septum and within the left atrium 1078. Thus, the distal end of the delivery system 10 can be positioned within the left atrium 1078. In some embodiments, the delivery system 10 can be rotated to a desired position, such as under fluoroscopy. The rail can be bent to direct the distal end of the delivery system 10 toward the septum and mitral valve. The position of the delivery system 10 and the implant 70 therein may be confirmed using echocardiographic and fluoroscopic guidance.

[0283] In some embodiments, the implant 70 may be positioned above, along, or below the mitral annulus 1106 prior to release. In some embodiments, the implant 70 may be positioned completely above, along, just below, or completely below the mitral annulus 1106 prior to dilation. In some embodiments, the implant 70 may be positioned partially above, along, or partially below the mitral annulus 1106 prior to dilation. In some embodiments, a pigtail catheter may be introduced into the heart to perform a ventriculogram for proper viewing.

[0284] In some embodiments, the location of the mitral valve plane and any papillary muscle height on the fluoroscopy monitor may be marked to indicate exemplary target landing zones. If desired, the delivery system 10 may be unbent, reduced rotation, and retracted to reduce tension on the delivery system 10 and reduce contact with the left ventricular wall, left atrial wall, and / or mitral valve annulus 1106.

[0285] Additionally, the delivery system 10 may be positioned to be coaxial with the mitral annulus 1106, or at least as coaxial as possible, while still reducing contact with the left ventricular wall, left atrial wall, and / or mitral annulus 1106 and reducing tension on the delivery system. The echo probe may be positioned to view the anterior mitral valve leaflet (AML), posterior mitral valve leaflet (PML) (leaflets 1108), mitral annulus 1106, and outflow tract. Using fluoroscopy and echo imaging, the implant 70 may be confirmed to be positioned coaxially with the mitral annulus 1106 at a particular depth.

[0286] The outer sheath assembly 22 may then be retracted to expose the ventricular anchor 80, thereby releasing the ventricular anchor 80. In some embodiments, once exposed, the outer sheath assembly 22 may be reversed in a direction that releases the tension on the outer sheath assembly 22. In some embodiments, the reversal of direction may also serve to partially or completely capture the implant 70.

[0287] The distal anchors 80 can be released within the left atrium 1078. Additionally, the proximal anchors 82, if included in the implant 70, have not yet been exposed. Additionally, the body of the implant 70 has not undergone any expansion at this point. However, in some embodiments, one or more of the distal anchors 80 can be released within the left atrium 1078 (e.g., supranulnar release), or released entirely along the mitral annulus 1106 (e.g., intraannular release), or released just below the mitral annulus 1106 (e.g., subannular release). In some embodiments, all of the distal anchors 80 can be released together. In other embodiments, a subset of the distal anchors 80 can be released while in the first position, and another subset of the distal anchors 80 can be released while in the second position. For example, some of the distal anchors 80 may be released within the left atrium 1078 and some of the distal anchors 80 may be released while generally along or just below the mitral valve annulus 1106.

[0288] If the distal anchor 80 is released "just below" the mitral valve annulus 1106, the distal anchor 80 may be released 1 inch, 3 / 4 inch, 1 / 2 inch, 1 / 4 inch, 1 / 8 inch, 1 / 10 inch, or 1 / 20 inch below the mitral valve annulus 1106. In some embodiments, the distal anchor 80 may be released less than 1 inch, 3 / 4 inch, 1 / 2 inch, 1 / 4 inch, 1 / 8 inch, 1 / 10 inch, or 1 / 20 inch below the mitral valve annulus 1106. This may cause the distal anchor 80 to snake through the chordae tendineae as it is released. This may advantageously cause the implant 70 to contract slightly as it is turned sharply downward toward the mitral valve. In some embodiments, this may eliminate the need for a guidewire to aid in crossing the mitral valve. In some embodiments, the guidewire may be retracted into the delivery system 10 before or after the release of the distal anchor 80.

[0289] In some embodiments, the distal anchor 80 can be released immediately after crossing the septum, and then the final trajectory of the delivery system 10 can be determined. Thus, the delivery system 10 can cross the septum, release the ventricular anchor 80, establish a trajectory, and move into the left ventricle to capture the valve leaflets.

[0290] As described in detail above, the distal anchors 80 can be flipped from a distally extending state to a proximally extending state upon release from the delivery system 10. This flip can be about 180 degrees. Thus, in some embodiments, the distal anchors 80 can be flipped within the left atrium 1078 (e.g., supranulnar flip), or flipped entirely along the mitral annulus 1106 (e.g., intraannular flip), or flipped just below the mitral annulus 1106 (e.g., subannular flip). The proximal anchors 82, if any, can remain within the delivery system 10. In some embodiments, all of the distal anchors 80 can be flipped together. In other embodiments, a subset of the distal anchors 80 can be flipped while in a first position, and another subset of the distal anchors 80 can be released while in a second position. For example, some of the distal anchors 80 can be inverted within the left atrium 1078 and some of the distal anchors 80 can be inverted while generally along or just below the mitral valve annulus 1106.

[0291] In some embodiments, the distal anchor 80 may be positioned along or just below the annulus 1106 in a non-inverted position. In some embodiments, the distal anchor 80 may be positioned along or just below the annulus 1106 in an inverted position. In some embodiments, the distal-most portion of the implant 70 may be positioned in or just below the mitral annulus 1106, such as just below the mitral annulus 1106, prior to inversion. However, inverting the anchor may move the distal-most portion of the implant 70 / anchor 80 upward and into the left atrium 1078 or move it along the mitral annulus 1106 without any other movement of the delivery system 10. Thus, in some embodiments, the distal anchor 80 may begin to invert at the annulus 1106, but upon inversion, is completely within the left atrium 1078. In some embodiments, the distal anchor 80 can begin to invert below the annulus 1106 but, upon inversion, is completely within the annulus 1106 .

[0292] In some embodiments, the distal anchor 80 may be proximal to the free end of the mitral valve leaflet 1108 (e.g., toward the left atrium 1078) upon release and inversion. In some embodiments, the distal anchor 80 may be along the free end of the mitral valve leaflet 1108 (e.g., toward the left atrium 1078) upon release and inversion. In some embodiments, the distal anchor 80 may be proximal to the free end of the mitral valve annulus 1106 (e.g., toward the left atrium 1078) upon release and inversion. In some embodiments, the distal anchor 80 may be along the free end of the mitral valve annulus 1106 (e.g., toward the left atrium 1078) upon release and inversion.

[0293] Thus, in some embodiments, the distal anchor 80 may be released / inverted above where the chordae tendineae 1110 attach to the free end of the native leaflet 1108. In some embodiments, the distal anchor 80 may be released / inverted above where some of the chordae tendineae 1110 attach to the free end of the native leaflet 1108. In some embodiments, the distal anchor 80 may be released / inverted above where all of the chordae tendineae 1110 attach to the free end of the native leaflet 1108. In some embodiments, the distal anchor 80 may be released / inverted above the mitral valve annulus 1106. In some embodiments, the distal anchor 80 may be released / inverted above the mitral valve leaflet 1108. In some embodiments, the distal anchor 80 may be released / inverted generally along the mitral valve annulus 1106. In some embodiments, the distal anchor 80 may be released / inverted generally along the mitral valve leaflet 1108. In some embodiments, the tip of the distal anchor 80 may be released / inverted generally along the mitral valve annulus 1106. In some embodiments, the tip of the distal anchor 80 may be released / inverted generally along the mitral valve leaflets 1108. In some embodiments, the distal anchor 80 may be released / inverted below where some of the chordae tendineae 1110 attach to the free ends of the native valve leaflets 1108. In some embodiments, the distal anchor 80 may be released / inverted below where all of the chordae tendineae 1110 attach to the free ends of the native valve leaflets 1108. In some embodiments, the distal anchor 80 may be released / inverted below the mitral valve annulus 1106. In some embodiments, the distal anchor 80 may be released / inverted below the mitral valve leaflets 1108.

[0294] Once the distal anchor 80 is released and inverted, the delivery system 10 can be translated through the mitral valve annulus 1106 toward the left ventricle 1080 such that the distal anchor 80 enters the left ventricle 1080. In some embodiments, the distal anchor 80 can be compressed as it passes through the mitral valve annulus 1106. In some embodiments, the implant 70 can be compressed as it passes through the mitral valve annulus 1106. In some embodiments, the implant 70 does not compress as it passes through the mitral valve annulus 1106. The distal anchor 80 can be delivered to any location within the left ventricle 1080 between the leaflets 1108 and the heads of the papillary muscles.

[0295] In some embodiments, the distal anchor 80 is fully expanded before passing through the mitral valve annulus 1106. In some embodiments, the distal anchor 80 is partially expanded before passing through the mitral valve annulus 1106, and continued movement of the delivery system 10 can fully expand the distal anchor 80 within the left ventricle 1080.

[0296] As the distal anchor 80 enters the left ventricle 1080, the distal anchor 80 can pass through the chordae tendineae 1110 and move behind the mitral valve leaflets 1108, thereby capturing the leaflets 1108. In some embodiments, the distal anchor 80 and / or other portions of the implant 70 can push the chordae tendineae 1110 and / or the mitral valve leaflets 1108 outward.

[0297] Thus, after release of the distal anchor 80, the delivery system 10 can then be repositioned, if necessary, so that the end of the left distal anchor 80 is at the same level as the free ends of the native mitral valve leaflets 1108. The delivery system 10 can also be positioned to be coaxial with the mitral valve annulus 1106, if possible, while still reducing contact with the left ventricular wall, left atrial wall, and / or annulus 1106.

[0298] In some embodiments, only the distal anchor 80 is released within the left atrium 1078 before the implant 70 moves into position at or below the annulus. In some alternative embodiments, the distal end of the implant 70 may be further expanded within the left atrium 1078. Thus, instead of the distal anchor 80 everting and not expanding any portion of the body of the implant 70, a portion of the implant 70 may be exposed and expanded within the left atrium 1078. This partially exposed implant 70 may then pass through the annulus 1106 and into the left ventricle 1080. Additionally, the proximal anchor, if any, may be exposed. In some embodiments, the entire implant 70 may be expanded within the left atrium 1078.

[0299] To facilitate passage through the annulus 1106, the delivery system 10 can include a leader element (not shown) that passes through the annulus 1106 before the implant 70 passes through the annulus 1106. For example, the leader element can include an expandable member, such as an expandable balloon, that can maintain the shape of the annulus 1106 or help expand the annulus 1106. The leader element can have a tapered or rounded shape (e.g., conical, frustoconical, hemispherical) to facilitate positioning and expansion of the annulus 1106. In some embodiments, the delivery system 10 can include an engagement element (not shown) that can apply a force to the implant 70 to pass the implant 70 through the annulus 1106. For example, the engagement element can include an expandable member, such as an expandable balloon, that is located within or above the implant 70.

[0300] In some embodiments, to facilitate passage through the annulus 1106, a user can reorient the implant 70 before passing the implant 70 through the annulus 1106. For example, a user can reorient the implant 70 so that the implant 70 passes sideways through the annulus 1106.

[0301] However, if only the distal anchor 80 is everted and no other expansion occurs, the prosthesis may be partially expanded within the ventricle 1080. Thus, when the implant 70 is in place, the distal end may be allowed to expand to capture the leaflets 1108. If the distal end is already expanded, no further expansion occurs, or the distal end may be allowed to expand further.

[0302] Additionally, the PML and AML 1106 may be captured by, for example, adjusting the depth and angle of the implant 70. If a larger prosthesis diameter is required to capture the leaflets 1108, the outer sheath assembly 22 can be retracted until the desired diameter of the implant 70 is achieved. Capture of the leaflets 1108 can be confirmed by echo imaging. In some embodiments, the user can verify that the implant 70 is still at the proper depth and has not advanced into the left ventricle 1080. Its position can be adjusted as needed.

[0303] In some embodiments, once the distal anchor 80 enters the left ventricle 1080, the system 10 can be pulled posteriorly (e.g., toward the left atrium 1078) to fully capture the leaflets 1108. In some embodiments, the system 10 does not need to be pulled posteriorly to capture the leaflets 1108. In some embodiments, the systolic pressure can push the leaflets 1108 upward to be captured by the distal anchor 80. In some embodiments, after the leaflets 1108 are captured and the implant 70 is fully or partially released, the systolic pressure can push the entire implant 70 up toward the mitral annulus 1106. In some embodiments, the user can rotate the delivery system 10 and / or the implant 70 before and / or while pulling the delivery system 10 posteriorly. In some cases, this can beneficially engage a greater number of chordae tendineae.

[0304] The outer sheath assembly 22 may be further retracted to allow the prosthesis to fully expand. Once the implant 70 is fully exposed, the delivery system 10 may be steered to be coaxial and flush with the mitral valve annulus 1106, such as by bending, translating, or rotating the delivery system 10. If desired, the implant 70 may be repositioned to capture the free ends of the leaflets 1108 of the native mitral valve. Once full engagement of the leaflets 1108 has been confirmed, the implant 70 may be placed perpendicular (or nearly perpendicular) to the mitral valve annulus plane.

[0305] The mid-shaft assembly 21 can then be pulled. The mid-shaft assembly 21 can then be reversed in direction to release any tension on the delivery system 10.

[0306] Although a description of the proximal anchor 82 is provided below, some embodiments of the implant 70 may not include the proximal anchor 82. In some embodiments, the proximal anchor 82 may not be released from the system 10 until the distal anchor 80 captures the leaflet 1108. In some embodiments, the proximal anchor 82 may be released from the system 10 before the distal anchor 80 captures the leaflet 1108. In some embodiments, the proximal anchor 82 can be released when the distal anchor 80 is on or within the annulus, and the expanded implant 70 (partially or fully expanded) can be translated through the mitral annulus 1106. In some embodiments, the proximal anchor 82 can be released when the distal anchor 80 is below the annulus, and the entire implant 70 can be pulled up into the left atrium 1078 such that the proximal anchor 82 is on the annulus prior to release. In some embodiments, the proximal anchor 82 may be within the annulus prior to release, and systolic pressure may push the implant 70 into the atrium such that the proximal anchor 82 ends up on the annulus.

[0307] Leaflet capture and positioning of the implant 70 can then be confirmed, along with its perpendicular position relative to the mitral annular plane. In some embodiments, the nosecone 28 can then be pulled until it is within the implant 70. The midshaft assembly 21 can be further retracted until the implant 70 is released from the delivery system 10. Proper positioning of the implant 70 can be confirmed using TEE and fluoroscopic imaging.

[0308] The delivery system 10 may then be centered within the implant 70. The nosecone 28 and delivery system 10 may then be retracted into the left atrium 1078 and removed.

[0309] This intra- and supranular release can have several advantages. For example, it allows the distal anchor 80 to be properly aligned when contacting the chordae tendineae 1110. If the distal anchor 80 were released within the left ventricle 1080, this could cause dislocation or damage to cardiac tissue, such as the leaflets 1108 or chordae tendineae 1110.

[0310] In an alternative delivery approach, the delivery system 10 can be translated into the left ventricle 1080 prior to release of the implant 70. Thus, the distal end of the implant 70, and thus the distal anchor 80, can be released and partially or fully inverted within the left ventricle 1080. Thus, in some embodiments, the anchor 82 can be released / inverted below the mitral annulus 1106, directly below the mitral annulus 1106, and / or below the free ends of the leaflets 1108. Additionally, the anchor 82 can be released above the heads of the papillary muscles. A similar method to that described above can then be used to properly position the implant 70 and remove the delivery system 10 to deliver the implant 70. Additionally, in some embodiments, the distal anchor 80 can be released without first expanding the prosthesis within the ventricle 1080.

[0311] While many of the systems and methods disclosed herein have been described with respect to implantation of a prosthetic mitral valve implant, it is understood that these systems and methods may be utilized to deliver a variety of implants, including implants for heart valve repair. For example, other types of heart valve implants that may be utilized, among other types of implants (e.g., aortic valve implants and other repair implants), are illustrated in Figures 68-69.

[0312] The methods and systems disclosed herein may in some embodiments not be limited to delivery of implants, but may extend to any medical intervention or insertion into a patient's body, which may include performing a medical procedure within the body. The methods and systems disclosed herein may be utilized in general use of catheters, as appropriate. For example, the handles shown in Figures 35 and 37 and the components disclosed therein may comprise a general catheter handle in some embodiments. Additionally, in other embodiments, the configuration of the delivery device may be altered. For example, in an aortic valve delivery device, the configuration of the implant holding area and other features of the delivery device may be altered.

[0313] 68-69, an alternative embodiment of an implant 1600 is shown in an expanded configuration. The implant 1600 can include an inner frame 1620, an outer frame 1640, a valve body 1660, and one or more skirts, such as an outer skirt 1680 and an inner skirt 1690.

[0314] Referring first to the outer frame 1640 shown in Figures 68-69, the outer frame 1640 can be attached to the inner frame 1620 using any known fasteners and / or techniques. Although the outer frame 1640 is shown as a separate component from the inner frame 1620, it should be understood that the frames 1620, 1640 can be unitarily or integrally formed.

[0315] As shown in the illustrated embodiment, the outer frame 1640 can include an outer frame body 1642. The outer frame body 1642 can have an upper region 1642a, a middle region 1642b, and a lower region 1642c. At least a portion of the upper region 1642a of the outer frame body 1642 can be sized and / or shaped to generally match the size and / or shape of the upper region 1622a of the inner frame 1620. As shown in the illustrated embodiment, the upper region 1642a of the outer frame body 1642 can include one or more struts that generally match the size and / or shape of the struts of the inner frame 1620. This can locally reinforce a portion of the implant 1600 by effectively increasing the wall thickness of the combined struts.

[0316] When in an expanded configuration, such as a fully expanded configuration, the middle region 1642b and the lower region 1642c can have a diameter greater than a diameter of the upper region 1642a. The upper region 1642a of the outer frame body 1642 can have a diameter that decreases from a lower end to an upper end such that the upper region 1642a slopes or curves radially inward toward the longitudinal axis of the implant 1600. Although the outer frame body 1642 has been described and illustrated as being cylindrical or having a circular cross-section, it should be understood that all or a portion of the outer frame body 1642 can have a non-circular cross-section, such as, but not limited to, a D-shaped, oval, or otherwise oval cross-sectional shape.

[0317] 68-69, the outer frame body 1642 can include a plurality of struts with at least some of the struts forming cells 1646a-c. Any number of strut configurations can be used, such as rings of wavy struts shown to form oval, elliptical, rounded polygonal, and teardrop shapes, as well as chevrons, diamonds, curved lines, and a variety of other shapes.

[0318] The upper row of cells 1646a can have an irregular octagonal shape, such as a "heart" shape. This additional space can advantageously allow the outer frame 1640 to retain a smaller profile when pleated. The cells 1646a can be formed through a combination of struts. As shown in the illustrated embodiment, the upper portion of the cells 1646a can be formed from a set of circumferentially expandable struts 1648a having a zigzag or wavy shape that forms a repeating "V" shape. The struts 1648a can extend radially outward from an upper end to a lower end. These struts can approximately match the size and / or shape of the struts of the inner frame 1620.

[0319] An intermediate portion of the cells 1646a may be formed from a set of struts 1648b extending downwardly from the bottom end of each of the "V" shapes. The struts 1648b may extend radially outward from the top to the bottom end. The portion of the cells 1646a extending upwardly from the bottom ends of the struts 1648b may be considered to be a substantially less short portion of the outer frame 1640 than appears in the figure.

[0320] The lower portion of the cell 1646a can be formed from a set of circumferentially expandable struts 1648c having a zigzag or wavy shape forming a repeating "V" shape. As shown in the illustrated embodiment, the struts 1648c can include curves in which the lower ends of the struts 1648c run more parallel to the longitudinal axis than the upper ends of the struts 1648c. One or more of the upper ends or tips of the circumferentially expandable struts 1648c can be "free" vertices that are not connected to a strut. For example, as shown in the illustrated embodiment, every other upper end or tip of the circumferentially expandable struts 1648b is a free vertex. However, it should be understood that other configurations can be used. For example, every upper vertex along the upper end can be connected to a strut.

[0321] The middle and / or lower row of cells 1646b-c can have a different shape than the first row of cells 1646a. The middle row of cells 1646b and the lower row of cells 1646c can have a diamond or approximately diamond shape. The diamond or approximately diamond shape can be formed by an arrangement of struts.

[0322] An upper portion of cell 1646b can be formed from a set of circumferentially expandable struts 1648c such that cell 1646b shares struts with cell 1646a. A lower portion of cell 1646b can be formed from a set of circumferentially expandable struts 1648d. As shown in the illustrated embodiment, one or more of the circumferentially expandable struts 1648d can extend generally in a downward direction generally parallel to the longitudinal axis of the outer frame 1640.

[0323] An upper portion of cell 1646c can be formed from a set of circumferentially expandable struts 1648d such that cell 1646c shares a strut with cell 1646b. A lower portion of cell 1646c can be formed from a set of circumferentially expandable struts 1648e. The circumferentially expandable struts 1648e can extend generally in a downward direction.

[0324] As shown in the illustrated embodiment, there may be nine columns of cells 1646a and eighteen columns of cells 1646b-c. Although each of the cells 1646a-c is shown to have the same shape as the other cells 1646a-c in the same column, it should be understood that the shapes of the cells 1646a-c within a column may vary. Additionally, it should be understood that any number of columns of cells may be used and any number of cells may be included in the columns.

[0325] As shown in the illustrated embodiment, the outer frame 1640 can include a set of eyelets 1650. An upper set of eyelets 1650 can extend from an upper region 1642a of the outer frame body 1642. As shown, the upper set of eyelets 1650 can extend from an upper portion of the cell 1646a, such as an upper apex of the cell 1646a. The upper set of eyelets 1650 can be used to attach the outer frame 1640 to the inner frame 1620. For example, in some embodiments, the inner frame 1620 can include one or more eyelets corresponding to the eyelets 1650. In such embodiments, the inner frame 1620 and the outer frame 1640 can be attached to one another via the eyelets 1650 and corresponding eyelets on the inner frame 1620. For example, the inner frame 1620 and the outer frame 1640 can be sewn to one another through the eyelets or attached via other means, such as mechanical fasteners (e.g., screws, rivets, etc.).

[0326] As shown, the set of eyelets 1650 may include two eyelets extending in series from each "V" shaped post. This may reduce the likelihood of the outer frame 1640 twisting along the axis of the eyelets. However, it should be understood that some "V" shaped posts may not include eyelets. Additionally, it should be understood that a fewer or greater number of eyelets may extend from the "V" shaped post.

[0327] The outer frame 1640 may include a set of locking tabs 1652 extending from or near the top end of the upper region 1642a. As shown, the locking tabs 1652 may extend upwardly from a set of eyelets 1650. The outer frame 1640 may include twelve locking tabs 1652, although it should be understood that a greater or lesser number of locking tabs may be used. The locking tabs 1652 may include a longitudinally extending post 1652a. At the upper end of the post 1652a, the locking tab 1652 may include an enlarged head 1652b. As shown, the enlarged head 1652b may have a semicircular or semi-elliptical shape that forms a "mushroom" shape with the post 1652a. The locking tab 1652 may include an eyelet 1652c that may be positioned through the enlarged head 1652b. It should be understood that the locking tab 1652 may include eyelets in other locations or may include more than one eyelet.

[0328] The locking tabs 1652 may be advantageously used with multiple types of delivery systems. For example, the shape of the posts 1652a and enlarged heads 1652b may be used to secure the outer frame 1640 to a "channel" based delivery system, such as the inner retention member 40 described above. The eyelets 1652c and / or eyelets 1650 may be used to secure the outer frame 1640 to a "tether" based delivery system, such as those that utilize sutures, wires, or fingers to control the delivery of the outer frame 1640 and implant 1600. This may advantageously facilitate in situ retrieval and replacement of the outer frame 1640 and implant 1600.

[0329] The outer frame 1640, such as the outer frame body 1642, may be used to attach or secure the implant 1600 to a native valve, such as a native mitral valve. For example, the intermediate region 1642b of the outer frame body 1642 and / or the outer fixation feature 1644 may be positioned to contact or engage the native valve annulus, tissue beyond the native valve annulus, the native valve leaflets, and / or other tissue at or around the implantation location during one or more phases of the cardiac cycle, such as systole and / or diastole. As another example, the outer frame body 1642 may be sized and positioned relative to the inner frame fixation feature 1624 such that tissue of the body cavity located between the outer frame body 1642 and the inner frame fixation feature 1624, such as the native valve leaflets and / or the native valve annulus, may be engaged or pinched to further secure the implant 1600 to the tissue. As illustrated, the inner frame fixation feature 1624 includes nine anchors, although it should be understood that a fewer or greater number of anchors may be used. In some embodiments, the number of individual anchors may be selected as a multiple of the number of commissures of the valve disc 1660. For example, the valve disc 1660 may have three commissures and the inner frame fixation feature 1624 may have three individual anchors (1:1 ratio), six individual anchors (2:1 ratio), nine individual anchors (3:1 ratio), twelve individual anchors (4:1 ratio), fifteen individual anchors (5:1 ratio), or any other multiple of three. In some embodiments, the number of individual anchors does not correspond to the number of commissures of the valve disc 1660.

[0330] 68-69, the valve disc 1660 is attached to the inner frame 1620 on the inside of the inner frame body 1620. The valve disc 1660 functions as a one-way valve, allowing blood flow in a first direction through the valve disc 1660 and preventing blood flow in a second direction through the valve disc 1660.

[0331] The disc 1660 can include multiple leaflets 1662, e.g., three leaflets 1662, joined at commissures. The disc 1660 can include one or more intermediate components 1664. The intermediate components 1664 can be positioned between a portion or all of the leaflets 1662 and the inner frame 1620 such that at least a portion of the leaflets 1662 are coupled to the frame 1620 via the intermediate components 1664. In this manner, the portions of the leaflets 1662 at the commissures and / or a portion or all of the arcuate edges of the leaflets 1662 are not directly coupled or attached to the inner frame 1620, but are indirectly coupled or "floating" within the inner frame 1620.

[0332] Referring now to the outer skirt 1680 shown in FIGS. 68-69, the outer skirt 1680 can be attached to the inner frame 1620 and / or the outer frame 1640. As shown, the outer skirt 1680 can be positioned around and secured to a portion or all of the exterior of the outer frame 1640. The inner skirt 1690 can be attached to the valve disc 1660 and the outer skirt 1680. As shown in FIG. 69, a first end of the inner skirt 1690 can be coupled to the valve disc 1660 along a portion of the valve disc 1660 proximate the inner frame 1620. A second end of the inner skirt 1690 can be attached to an under region of the outer skirt 1680. In doing so, a smooth surface can be formed along the underside of each of the leaflets. This can advantageously improve hemodynamics by allowing blood to circulate more freely and reducing stagnant areas.

[0333] Although the implant 1600 has been described as including an inner frame 1620, an outer frame 1640, a valve body 1660, and skirts 1680, 1690, it should be understood that the implant 1600 need not include all of the components. For example, in some embodiments, the implant 1600 can include the inner frame 1620, the outer frame 1640, and the valve body 1660 while omitting the skirt 1680. Additionally, while the components of the implant 1600 have been described and illustrated as separate components, it should be understood that one or more components of the implant 1600 can be integrally or monolithically formed. For example, in some embodiments, the inner frame 1620 and the outer frame 1640 can be integrally or monolithically formed as a single component.

[0334] The systems, devices, and methods disclosed herein may be utilized in retrieval of a fully or partially deployed implant. For example, in the methods disclosed with respect to Figures 61-67B, the capsule 106 may be configured to slide distally for retrieval of a partially or possibly fully deployed implant 70. Thus, the capsule 106 may move distally and pull all or a portion of the implant 70 back into the capsule 106 to retrieve the implant 70.

[0335] 64, for example, implant 70 is shown partially disposed from capsule 106. Arms of implant 70 in the form of distal anchors 80 extend outwardly from capsule 106 and are bent proximally relative to their orientation when located within capsule 106 (e.g., as shown in FIG. 2A). Notably, in this configuration, distal anchors 80 may extend between chordae tendineae 1110, as shown, for example, in FIG.

[0336] 70 shows a cross-sectional view of capsule 106 in a plane transverse to the axis of capsule 106. Distal anchor 80 is shown extending radially outward from the outer surface of capsule 106, for example, as shown in the perspective view of FIG 64. Tip 3610 of distal anchor 80 extends in a proximal direction, for example, as shown in the perspective view of FIG 64.

[0337] 70 , the chordae 1110 may be located within the narrow space 3612 between adjacent distal anchors 80. After full or partial placement of the implant 70, when the capsule 106 advances distally to retrieve the implant 70, the distal anchor 80 may pinch one or more of the chordae 1110 located within the narrow space 3612. As the distal anchor 80 is retracted into the capsule 106, the chordae 1110 may compress the capsule 106 at a radial distance causing the chordae 1110 to be pinched within the narrow space 3612. This possible complex relationship may result in damage to the chordae 1110, including potentially severing one or more of the chordae 1110.

[0338] 71 shows a side cross-sectional view of one embodiment of a capsule 3614 having a distal end 3616 configured to expand radially outward. The capsule 3614 may be otherwise configured similarly to the capsule 106 or any other embodiment of a capsule disclosed herein. For example, the capsule 3614 may be configured to surround an implant-retaining area.

[0339] The distal end 3616 can be configured to bend radially outward. The distal end 3616 shown in FIG. 71 can be configured to bend radially outward relative to a proximal portion 3618 of the capsule 3614. The distal end 3616 can include an opening 3620 in which the implant 70 is disposed.

[0340] The distal end 3616 may be configured to flare outward relative to the proximal portion 3618 of the capsule 3614. The distal end 3616 may include a contact surface 3622 configured to contact and apply a force to the chordae 1110 to wipe any chordae 1110 off the anchor 80 as the anchor 80 is being pulled back into the capsule 3614 during retrieval. The flare of the distal end 3616 may allow the contact surface 3622 to contact the chordae 1110 at a greater radial position than the position of the chordae 1110 shown in FIG. 70, and thus the chordae 1110 may be less likely to become pinched in the narrow space 3612 between the anchors 80. Thus, the likelihood of damage to the chordae 1110 during retrieval of the implant 70 may be reduced.

[0341] The distal end 3616 may be configured to passively flare outward, which may be caused by an outward force of the anchors 80 against an inner surface of the distal end 3616. In other embodiments, the distal end 3616 may be configured to be controlled to flare the distal end 3616 in a desired manner.

[0342] The distal end 3616 may be constructed of a flexible material, which may include an elastomer or another form of flexible material. The distal end 3616 may be configured to be pliable and therefore may form a large contact surface area against the anchors 80 to wipe the chordae 1110 off the anchors 80. The distal end 3616 may be pliable to pass within the spaces between the anchors 80. The distal end 3616 may be resilient to return to its initial shape upon retrieval of the implant 70 and to resist permanent deformation while the distal end 3616 is expanding. Other configurations of the distal end 3616 may be utilized as desired.

[0343] 72 shows a side cross-sectional view of one embodiment of a capsule 3624 having a distal end 3626 configured to expand radially outward. The capsule 3624 may be otherwise configured similarly to the capsule 106 or any other embodiment of a capsule disclosed herein. For example, the capsule 3624 may be configured to surround an implant holding area. The distal end 3626 of the capsule 3624 may be configured to expand radially outward by expanding radially outward.

[0344] The distal end 3626 may include an expandable body 3628 configured to expand. The expandable body 3628 may include a balloon or other form of expandable body configured to expand and spread the distal end 3626 radially outward. The distal end 3626 may include a contact surface 3630 (shown in FIG. 73 ) that functions similarly to the contact surface 3622 shown in FIG. 71 . Thus, the contact surface 3630 of the distal end 3626 may be configured to contact and wipe any chordae 1110 away from the anchor 80 as it is being pulled back into the capsule 3624 during retrieval. The spread of the distal end 3626 may allow the contact surface 3630 to contact the chordae 1110 at a greater radial position than the position of the chordae 1110 shown in FIG. 70 , and thus the chordae 1110 may be less likely to become pinched in the narrow space 3612 between the anchors 80. Thus, the likelihood of damage to the chordae tendineae 1110 may be reduced during retrieval of the implant 70. The expandable body 3628 may be adapted such that a portion of the expandable body 3628 may be positioned between the anchors 80.

[0345] The distal end 3626 may be configured to vary in size. FIG. 72 shows the distal end 3626 in a non-expanded, non-inflated, or undeployed configuration, and FIG. 73 shows the distal end 3626 in an expanded, inflated, or deployed configuration. The distal end 3626 in an expanded, inflated, or deployed configuration has a larger size and a larger radial extent than the non-expanded, non-inflated, or undeployed configuration. At least one inflation conduit 3632 may extend along the elongate shaft of the delivery system and be configured to inflate the expandable body 3628 of the distal end 3626 with a fluid or other substance to expand the distal end 3626. The inflation conduit 3632 may be controlled from a proximal portion of the delivery system to expand or contract the distal end 3626, thus controlling the size and radial extent of the distal end 3626.

[0346] The distal end 3626 may be configured to be expanded, inflated, or deployed at a desired time for retrieval of the implant, and then may be unexpanded, contracted, or undeployed after retrieval or a time for withdrawing the delivery system from a portion of the patient's body. Thus, the distal end 3626 may move from the configuration shown in FIG. 73 back to the configuration shown in FIG. 72. Other configurations of the distal end 3626 may be utilized as desired.

[0347] The embodiments disclosed herein may be utilized in a method that includes disposing an elongate shaft at a location within a patient, the elongate shaft including a capsule surrounding an implant holding region that holds an implant for implantation within the patient. The capsule may then be moved proximally to expose a portion of the implant within the patient. The capsule may then be moved distally to retrieve a portion of the implant within the patient and pass a distal end 3616, 3626 of the capsule that is radially outwardly expanded over a portion of the retrieved implant. The retrieved portion of the implant may include an arm of the implant that may include an anchor of the implant. The distal end 3616, 3626 of the capsule may be positioned between the arms of the implant such that the distal end 3616, 3626 can push the chordae tendineae between the arms of the implant. The method may include using the distal end 3616, 3626 of the capsule to push the chordae tendineae from the arms of the implant.

[0348] The distal end embodiments disclosed in Figures 71-73 may be utilized alone or in conjunction with any embodiment of the delivery system or other systems, devices, or methods disclosed herein.

[0349] 74A and 74B show an embodiment in which a delivery system may utilize a pull tether 3700 coupled to a portion of the elongate shaft of the delivery system at or distal to the implant holding region and configured to deflect the distal end of the elongate shaft. With reference to FIG. 2B, for example, the implant holding region 16 is shown surrounded by a capsule 106 and has a nosecone shaft 27 extending into the implant holding region 16. However, the steerable rail assembly 20 is positioned proximal to the implant holding region 16. Thus, when the steerable rail assembly 20 bends, the nosecone 28 at the distal end of the elongate shaft follows the bend made by the steerable rail assembly 20 at a location proximal to the implant holding region 16. However, the embodiment of FIG. 74A and 74B couples the pull tether 3700 at a location at or distal to the implant holding region 16. Thus, greater torque and control of the distal end of the delivery system may be provided.

[0350] 74A and 74B, for example, a distal end of the pull tether 3700 is coupled to the nosecone 28. The distal end of the pull tether 3700 may be located at a distal portion of the nosecone 28. For example, the nosecone 28 may include a proximal portion 3702 and a distal portion 3704, and the pull tether 3700 may be coupled to the distal portion 3704 of the nosecone 28. The distal coupling location of the pull tether 3700 may increase the torque imparted on the nosecone 28. In other embodiments, other coupling locations, such as on the proximal portion 3702 of the nosecone 28, may be utilized.

[0351] The pull tether 3700 may have various configurations and may include a pull wire or another form of tether as disclosed herein. The pull tether 3700 shown in FIG. 74A and FIG. 74B may have at least a portion that extends outside the elongate shaft. Such a configuration may allow for increased torque on the distal end of the elongate shaft. At least a portion of the pull tether 3700 may then extend into an inner channel 3706 of the elongate shaft such that the pull tether 3700 does not extend completely outside the elongate shaft. For example, as shown in FIG. 74A and FIG. 74B, the pull tether 3700 may extend outside the capsule 106. The pull tether 3700 may be pulled and released to control the deflection of the distal end of the elongate shaft.

[0352] The distal end of the pull tether 3700 may be coupled to other locations as desired. For example, with reference to FIG. 2B, the distal end of the pull tether 3700 may be coupled to an inner nosecone shaft 27 that is coupled to the nosecone 28. The implant holding area 16 may include a proximal portion 3708 and a distal portion 3710, and the pull tether 3700 may be coupled to a portion of the elongated shaft within the distal portion 3710 of the implant holding area 16. Thus, the pull tether 3700 is located proximally of the implant holding area 16 and may apply a torque to the distal end of the elongated shaft in addition to any torque applied by the steerable rail assembly 20 that is configured to deflect the portion of the elongated shaft located proximally of the implant holding area 16.

[0353] Thus, the innermost assembly of the elongate shaft, shown in Figure 2B as nosecone assembly 31, may be steerable. A pull tether 3700 may extend proximally from the distal end of the elongate shaft for manipulation at the proximal end of the delivery system to control deflection of the distal end of the delivery system.

[0354] The coupling of the pull tether 3700 to a portion of the elongated shaft of the delivery system at or distal to the implant holding region may allow for greater control of the distal end of the elongated shaft. Thus, the nosecone 28 and nosecone shaft 27 that form the tip of the elongated shaft may have additional direction and degrees of flexion than those imparted by the steerable rail assembly 20. Additionally, the pull tether 3700 may impart flexion distal to the steerable rail assembly 20. Thus, the pull tether 3700 may allow for sharper rotations and greater precision of control of the distal end of the elongated shaft. In embodiments, the pull tether 3700 may be configured to allow for flexion in the same plane as that provided by the steerable rail assembly 20, or in a different plane.

[0355] The pull tether 3700 may also allow for the elimination of the use of a guidewire, if necessary. For example, the nosecone shaft 27 may lack a lumen for a guidewire. The additional control afforded by the pull tether 3700 may allow for control of the distal end of the elongate shaft such that a guidewire is not needed to guide the distal end of the elongate shaft. In other embodiments, a guidewire may be utilized. In other embodiments, the configuration of the pull tether 3700 may be altered.

[0356] In embodiments herein, a delivery system may include two elongated shafts, or at least two elongated shafts, that may be utilized in combination to deliver an implant to a location within a patient. A first elongated shaft may be steerable, and another or second elongated shaft may include an implant holding region configured to hold an implant and may include a placement mechanism. Each elongated shaft may include a respective axis along which the shaft extends. A coupler may couple the elongated shafts together such that the elongated shaft including the implant may slide relative to the steerable elongated shaft with the shaft axes offset from one another.

[0357] For example, FIG. 79 illustrates one embodiment of a steerable elongate shaft 3900 of a delivery system. The elongate shaft 3900 may be steerable utilizing mechanisms disclosed herein, for example, through the use of a pull tether, or may be steerable via another mechanism. The elongate shaft 3900 may be configured to form one or more bends in the elongate shaft 3900, and may be configured to be steerable and bend in at least one plane, or at least two planes, as disclosed herein. The steerable elongate shaft 3900 may be configured to be inserted into a patient's body and moved to a desired implantation site for the implant.

[0358] The elongated shaft 3900 may be configured to be steerable and may be constructed in a manner similar to the rail assembly 20 disclosed herein. For example, pull tethers may be utilized to control the deflection of the elongated shaft 3900 in one or more planes, or at least two planes, as desired. The elongated shaft 3900 may be inserted into a patient's body without an implant and its capsule to hold the implant, unlike the rail assembly 20 disclosed herein.

[0359] The embodiments disclosed herein may be utilized in a method that includes disposing an elongate shaft at a location within a patient, the elongate shaft including a proximal end, a distal end, and an implant holding region that holds an implant for implantation within the patient. The method may include deflecting the distal end of the elongate shaft utilizing a pull tether coupled to a portion of the elongate shaft at or distal to the implant holding region. The pull tether 3700 and configurations of the pull tether 3700 may be utilized alone or with any of the other devices, systems, or methods disclosed herein.

[0360] The elongate shaft 3900 may include a lumen 3902 that may be configured to hold components for a delivery system, such as an imaging sensor 3904, such as an intra-cardiac echo (ICE) sensor, or other form of imaging sensor as desired, configured to be located within the lumen 3902. The distal end 3906 of the shaft 3900 may include an expandable body 3908 that may be configured to expand to secure the distal end 3906 of the shaft 3900 in position and / or to determine whether a path formed by the shaft 3900 is clear (e.g., whether the distal end 3906 passes between the chordae tendineae of the patient's heart).

[0361] The elongate shaft 3900 may be first introduced into the patient's body and manipulated to the desired implantation site.

[0362] 80, the elongated shaft 3910 may comprise a shaft configured to hold an implant for deployment. The shaft 3910 may include, for example, a capsule 3912 at a distal end that holds the implant. The capsule 3912 may surround an implant holding area and hold the implant therein, as disclosed herein. The shaft 3910 may include a deployment mechanism for deploying the implant from the capsule 3912, as disclosed herein. For example, the capsule 3912 may retract to expose and deploy the implant. The shaft 3910 may be flexible and passively flexible to allow the shaft 3910 to follow a path formed by the steerable elongated shaft 3900.

[0363] A coupler 3914 may couple the elongate shaft 3910 to the steerable elongate shaft 3900. The coupler 3914 may have a variety of forms and may include a loop as shown in FIG. 80, or may include one or more of a magnet, hook, loop, or joint between the shafts 3910, 3900. The coupler 3914 may be configured to allow the elongate shaft 3910 to slide relative to the shaft 3900. In embodiments, the coupling may occur within the patient's body, or may occur outside the patient's body, if desired.

[0364] The elongated shafts 3900, 3910 may be coupled together such that the respective axes of the shafts 3900, 3910 are offset from one another. The coupler 3914 may be configured to couple the shafts 3900, 3910 together such that the shafts 3900, 3910 may slide with the respective axes of the shafts 3900, 3910 parallel to one another and with the outer surfaces of the shafts 3900, 3910 adjacent to one another. Thus, the alignment mechanism (utilized with the elongated shaft 3910) may be separated into a separate shaft from the steering mechanism (utilized with the elongated shaft 3900). Thus, the complexity of each shaft may be reduced from the embodiment shown in FIG. 1. Additionally, the capsule 3912 in such an embodiment is not located distal to the bent portion, which may improve the maneuverability of the capsule 3912 in the embodiment shown in FIG. 80.

[0365] In embodiments, the coupler 3914 may be configured to couple the shafts 3900, 3910 together in a defined orientation. For example, a joint such as a dovetail joint may be provided on either of the shafts 3900, 3910 such that the shafts 3900, 3910 may only be coupled in a defined orientation. Thus, the circumferential position of the shaft 3900 relative to the shaft 3910 may be defined. Such a feature may be beneficial in embodiments in which an asymmetric implant is disposed. Such an implant may be disposed with a steerable shaft 3900 in a defined position that may aid in the placement of the asymmetric implant. In embodiments, the coupler 3914 may be configured such that the coupling can be rotated to orient the implant to optimize the position of the implant for placement. In other embodiments, other forms of coupling may be utilized.

[0366] 79, during operation, the steerable elongate shaft 3900 may be advanced to a desired location for implantation within a patient. The steerable elongate shaft 3900 may be bent into a desired configuration and may retain that configuration within the patient. The distal end 3906 of the elongate shaft 3900 may be steered, for example, to the mitral valve or other valves as needed. In an embodiment, as shown in FIG. 80, an expandable body 3908 may be expanded to fix the distal end 3906 of the shaft 3900 in a position and / or to determine if the path formed by the shaft 3900 is clear of obstructions.

[0367] The steerable elongate shaft 3900 in position within the patient's body may act as a rail along which the elongate shaft 3910 bearing the implant slides. The elongate shaft 3910 may pass through a separate entrance within the patient's body, for example a separate leg or a separate venous body of the patient's body. In an embodiment, a coupler 3914 may couple the shafts 3900, 3910 together within the patient's body such that the shaft 3910 can slide along the steerable shaft 3900. The shaft 3910 may be advanced along the steerable shaft 3900 through the patient's body to the desired implantation site, as shown in FIG.

[0368] The shaft 3910 may be configured to flex around any bend in the steerable shaft 3900, as shown in FIG. 81. The flexing of the shaft 3910 may be passive, if desired. The shaft 3910 may then be utilized to deploy the implant from the capsule 3912. A deployment mechanism as disclosed herein may be manipulated and the capsule 3912 may be retracted to deploy the implant. After deployment, the shaft 3910 may be retracted, and then the shaft 3900 may be subsequently retracted. The shaft 3900, 3910 configuration may be utilized alone or with any of the other devices, systems, or methods disclosed herein.

[0369] From the above description, it will be appreciated that an approach for the present invention is disclosed for the product and implant delivery system. While certain components, techniques, and aspects have been described with a degree of specificity, it will be apparent that many modifications can be made to the specific designs, configurations, and methods described hereinabove without departing from the spirit and scope of the present disclosure. The present disclosure is not limited to the systems and devices disclosed herein, nor to methods utilizing such systems and devices.

[0370] Some features described in the present disclosure in the context of separate implementations may also be implemented in combination in a single implementation. Conversely, various features described in the context of a single implementation may also be implemented in multiple implementations separately or in any suitable subcombination. Furthermore, although features may be described above as acting in some combinations, one or more features from a claimed combination may, in some cases, be deleted from the combination, and the combination may be claimed as any subcombination or a variation of any subcombination.

[0371] Additionally, although methods may be shown in the figures or described herein in a particular order, such methods need not be performed in the particular order or sequence shown, and not all methods need to be performed to achieve the desired results. Other methods not shown or described can be incorporated into the exemplary methods and processes. For example, one or more additional methods can be performed before, after, simultaneously, or between any of the methods described. Additionally, in other implementations, methods can be rearranged or reordered. Also, it should be understood that the separation of various system components in the implementations described above should not be understood as requiring such separation in all implementations, and that the components and systems described can generally be integrated together in a single product or packaged in multiple products. Additionally, other implementations are within the scope of the present disclosure.

[0372] Conditional language such as "can," "could," "might," or "may" is generally intended to convey that some embodiments include or do not include some features, elements, and / or steps, unless specifically stated otherwise or understood otherwise within the context in which it is used. Thus, such conditional language is generally not intended to imply that features, elements, and / or steps are in some way required for one or more embodiments.

[0373] Conjunctive language, such as the phrase "at least one of X, Y, and Z," unless specifically stated otherwise, is understood differently in the context in which it is generally used to convey that an item, term, etc. can be either X, Y, or Z. Thus, such conjunctive language is not generally intended to imply that some embodiments require the presence of at least one of X, at least one of Y, and at least one of Z.

[0374] As used herein, language of degree, such as the terms "approximately," "about," "generally," and "substantially," refers to a value, amount, or characteristic close to the stated value, amount, or characteristic that still performs the desired function or achieves the desired result. For example, the terms "approximately," "about," "generally," and "substantially" can refer to an amount that is within 10% or less, 5% or less, 1% or less, 0.1% or less, and 0.01% or less of the stated amount. When the stated amount is 0 (e.g., none, not having), the ranges recited above can be specific ranges, not within a specific % of the value. For example, within 10 wt. / vol.% or less, within 5 wt. / vol.% or less, within 1 wt. / vol.% or less, within 0.1 wt. / vol.% or less, and within 0.01 wt. / vol.% or less of the stated amount.

[0375] Some embodiments have been described in connection with the accompanying drawings. Although the figures are drawn to scale, such scale should not be considered limiting, as dimensions and proportions other than those shown are contemplated and are within the scope of the disclosed invention. Distances, angles, and the like are merely illustrative and do not necessarily bear an exact relationship to the actual dimensions and layout of the illustrated devices. Components can be added, removed, and / or rearranged. Furthermore, any particular features, aspects, methods, properties, characteristics, qualities, attributes, elements, etc. disclosed herein in connection with various embodiments can be used in all other embodiments described herein. Furthermore, it will be recognized that any method described herein can be practiced using any device suitable for performing the recited steps.

[0376] Although several embodiments and variations thereof have been described in detail, other modifications and methods of using the same will become apparent to those skilled in the art. It is therefore to be understood that various applications, modifications, materials, and substitutions can be made from equivalents without departing from the inherent inventive disclosure herein or the scope of the claims. [Explanation of symbols]

[0377] 10 Delivery Systems 11 Proximal end 12 Thin Shaft 13 Distal end 14 Handle 14' Handle 16 Implant Retention Area 18 Inner Shaft Assembly 20 Rail Assembly 21 Central shaft assembly, intermediate shaft assembly 22 Outer Sheath Assembly 27 Nose cone shaft 28 Nosecone 31 Nose cone assembly, nose cone shaft assembly 40 Inner retaining ring, inner retaining member 42 Outer retaining ring, outer retaining member 43 Hypotube 44 Proximal Tube 51 Rib on Sheath 70 Implants, Replacement Mitral Valve Implants 72 Strut 74 Mushroom-shaped tub 80 Distal anchor 82 Proximal anchor 83 Heart 102 outer proximal shaft, shaft 104 Outer Hypotube 106 Capsules 107 Proximal Metal Coil 108 Distal Metal Coil 110 Tube part 124 Inner Proximal Shaft 126 Distal Section 132 Rail shaft 134 Rail Proximal Shaft 135 Connector 136 Rail Hypotube 137 Proximal Ring 138 Distal Pull Wire 139 Lumen 140 Proximal pull wire 202 Rail housing 204 Delivery Box 204' Delivery box 206 Distal pull wire knob 208 Proximal Pull Wire Knob 210 Outer sheath knob, control knob 210' control knob, distal most control knob 211 First Section 212 Depth knob 213 Cutting 214 Intermediate shaft knob, control knob 214' Control knob, intermediate control knob 215 Spine 216 Nobu 217 First Thin Cut 218 Rock 220 Second Section 222 Cutting Pair 226 First cut 228 Second cut 229 Droplet shape 230 Third Section 231 Hypotube Section 232 Cutting Pair 233 Proximal slotted hypotube section, proximal grooved section 235 Distal slotted hypotube section, distal grooved section 236 First Thin Incision 237 position 238 Second Cut 239 Droplet shape 240 Outer retaining ring, outer retaining ring reinforcement 241 Distal pull wire connection area 244 Thin cut 246 Long, egg-shaped hole 247 Terminal extension 249 Droplet shape 251 Lina 301 First end 303 Second End 402 Outer polymer layer, jacket 404 Metal layer 406 Adhesive layer 408 Fluorinated Ethylene Propylene (FEP) Section 410 Liner 500 Hypotube 502a~502h Cutting 504a~504d Ring 506 First Section 508 Spine 510 Spine 512 Outer part 514 Outer part 516 Second Section 518 Spine 520 Spine 522 Spine 524 Spine 600 Hypotube 602a~602c Cutting 604a, 604b Ring 606a~606c Spine 700 Hypotube 702a~702d Cutting 704a, 704b Ring 706 Spine 708 Spine 710 Spine 712 Spine 800 Hypotube 802a~802d Cutting 806a, 806b Ring 900 Hypotube 1000 Hypotube 1006 Spine 1008 Spine 1074 Ipsilateral femoral vein 1076 Right atrium 1078 Left atrium 1080 left ventricle 1106 Valve annulus, mitral annulus 1108 Mitral valve leaflets 1110 Chordae tendineae 1200 Guidewire Shield 1200' Guidewire Shield 1202 Lumen 1202' lumen 1204 Distal end 1204' Distal end 1206 Proximal end 1206' Proximal end 1208 Step 1600 Implants 1620 Inner frame 1624 Inner Frame Fixing Feature 1644 External fixation feature 1640 Outer Frame 1646a~1646c Cell 1648a~1648e Post 1652 Locking tab 1652a Post 1660 Valve body 1664 Intermediate Component 1662 Valve Leaflet 1680 Outer skirt 1690 Inner Skirt 1900 Coupler 1902 Shaft part 1904 Protrusion 2000 Coupler 2002 protrusion 2004 Channel 2100 Inflatable body 2102 Conduit 2200 braided layer 2202 Metal layer 2204 Inner liner layer 2214 Buffer Layer 2206 Outer jacket layer 2300 Cable Router 2302 Cable 2310 Control Mechanism 2400 Stopper 2404 Stopper 2500 Control Knob, Proximal Control Knob 2504 Slider 2506 Slider 2508 Slider 2510 Beam 2512 Beam 2514 Support 2516 Support 2518 Support 2520 Support 2522 Support 2800 Nosecone 2900 Nosecone 3000 Nosecone 3100 Nose Cone 3200 Nosecone 3202 Marker 3300 Nosecone 3302 Marker 3400 Marker 3404 Aperture 3614 Capsules 3624 Capsules 3628 Expandable body 3632 Expansion duct 3700 Pull Tether 3706 Channel 3800 markers 3802 Nosecone 3804 Capsules 3806 Indicator 3820 capsules 3826 Marker 3830 capsules 3836 Marker 3840 Marker 3900 Thin Shaft 3904 Image sensor 3908 Inflatable body 3910 Thin Shaft 3912 Capsules 3914 Coupler

Claims

1. A delivery system (10) for delivering an implant (70) to a location within a patient's body, comprising: an implant holding area (16) configured to hold said implant (70); a capsule (106) configured to surround the implant holding area (16), the capsule (106) including a hypotube (600) having a plurality of incisions (602a-c) forming a plurality of rings (604a,b); and an elongated shaft (12) having a proximal end (11) and a distal end (13) including: the plurality of cuts (602a-c) are circumferentially disposed along the length of the hypotube (600) to form a spiral along the length of the hypotube (600); 11. A delivery system (10), wherein the rings (604a,b) are configured to contact one another when a force is applied to the hypotube (600) in a distal direction.

2. 2. The delivery system of claim 1, wherein the hypotube (600) includes one or more spines (606a, 606b, 606c) connecting at least two of the plurality of rings (604a, b).

3. The delivery system of claim 2 , wherein the one or more spines (606a, 606b, 606c) extend longitudinally along the hypotube (600).

4. The delivery system of any one of claims 1 to 3, wherein the plurality of incisions (602a-c) bias the flexibility of the hypotube (600) in a predetermined direction.

5. 5. The delivery system of claim 4, wherein the hypotube (600) includes two spines (606a, 606b, 606c) each configured to extend along a neutral axis of bending when the hypotube (600) is bent in the predetermined direction.

6. 6. The delivery system of claim 1, wherein the plurality of cuts (602a-c) includes a first cut circumferentially spaced from a second cut, the width of the first cut being greater than the width of the second cut.

7. 7. The delivery system of claim 1, wherein the plurality of cuts (602a-c) includes a first plurality of cuts each longitudinally aligned and having a width greater than a second plurality of cuts each longitudinally aligned and each circumferentially spaced apart from the first plurality of cuts.

8. 8. The delivery system of claim 7, wherein the first plurality of cuts is located on an opposite side of the hypotube from the second plurality of cuts.

9. The delivery system of claim 4, wherein the predetermined direction is a first direction and the plurality of notches (602a-c) bias the flexibility of the hypotube (600) in a second direction.

10. The delivery system of any one of claims 1 to 9, wherein the plurality of cuts (602a-c) comprises a repeating pattern of staggered cuts.

11. 11. The delivery system of any one of claims 1 to 10, wherein the hypotube (600) includes a distal section, in which the plurality of notches (602a-c) bias the flexibility of the distal section in a single direction, and the hypotube (600) includes a proximal section, in which the plurality of notches (602a-c) bias the flexibility of the proximal section in at least two directions.

12. The delivery system of any one of claims 1 to 11, wherein the plurality of cuts (602a-c) comprises a repeating pattern of staggered cuts (602a-c), each of which has equal size.

13. The delivery system of any one of claims 1 to 12, wherein the plurality of cuts (602a-c) provide equal flexibility of the hypotube (600) in all radial directions.

14. 14. The delivery system of any one of claims 1 to 13, wherein the hypotube (600) comprises a first pair of spines (606a, 606c) positioned 180 degrees apart from each other and a second pair of spines (606b) offset 90 degrees from the first pair of spines (606a, 606c).

15. 15. The delivery system of claim 1, wherein the capsule (106) is configured to move proximally relative to the implant holding area (16) to enable deployment of the implant (70).

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