(19)
(11)EP 4 052 673 A1

(12)EUROPEAN PATENT APPLICATION

(43)Date of publication:
07.09.2022 Bulletin 2022/36

(21)Application number: 22157635.8

(22)Date of filing:  12.03.2014
(51)International Patent Classification (IPC): 
A61B 18/12(2006.01)
A61B 17/22(2006.01)
(52)Cooperative Patent Classification (CPC):
A61M 25/0041; A61M 25/0054; A61M 2025/0003; A61M 2025/09133; A61N 1/056; A61B 2018/00101; A61B 5/6852; A61B 5/0215; A61B 2090/3966; A61B 18/1492; A61B 2017/00309; A61B 2017/00986; A61M 2025/0059; A61B 2018/00077
(84)Designated Contracting States:
AL AT BE BG CH CY CZ DE DK EE ES FI FR GB GR HR HU IE IS IT LI LT LU LV MC MK MT NL NO PL PT RO RS SE SI SK SM TR

(30)Priority: 12.03.2013 US 201361777368 P
14.03.2013 US 201361781231 P

(62)Application number of the earlier application in accordance with Art. 76 EPC:
14763003.2 / 2968846

(71)Applicant: Baylis Medical Company Inc.
Mississauga, Ontario L4W 5P6 (CA)

(72)Inventors:
  • DAVIES, Gareth
    Toronto, M5R 2N5 (CA)
  • URBANSKI, John Paul
    Toronto, M4L 2N7 (CA)
  • ABOU-MARIE, Rund
    Ontario, L5N 7S5 (CA)

(74)Representative: KIPA AB 
Drottninggatan 11
252 21 Helsingborg
252 21 Helsingborg (SE)

 
Remarks:
This application was filed on 18.02.2022 as a divisional application to the application mentioned under INID code 62.
 


(54)MEDICAL DEVICE FOR PUNCTURING TISSUE


(57) A medical device for puncturing tissue is disclosed and includes an elongate member with a proximal region and a distal region, wherein the distal region has a flexible portion which is more flexible than the proximal region. The elongate member has a tubular configuration and includes a metallic layer which is electrically conductive. A rigid energy delivery device is provided at a distal end of the elongate member which is electrically connected to the metallic layer of the elongate member, wherein the rigid energy delivery device is configured to deliver electrical energy to tissue when electrical energy is supplied to the rigid energy delivery device through the metallic layer. The flexible portion includes at least one gap in a sidewall of the elongate member wherein the at least one gap comprises at least one cut in the sidewall.




Description

CROSS-REFERENCES TO RELATED APPLICATIONS



[0001] This application incorporates by reference, in their entirety, the contents of U.S. application 12/926,292, filed Nov. 8, 2010, and titled "Electrosurgical device for creating a channel through a region of tissue and methods of use thereof', and U.S. Patent Application 13/286,041, filed on October 31, 2011, and U.S. Patent 8,048,071, issued November 1, 2011. This application cross references co-pending application "Electrosurgical Device Having a Lumen" which is a non-provisional application based on provisional application 61/781,231, filed March 14, 2013.

TECHNICAL FIELD



[0002] The disclosure relates to a medical device. More specifically, it relates to an elongate medical device without a support spine.

SUMMARY OF THE DISCLOSURE



[0003] The present invention is defined by the appended claims only, in particular by the scope of appended independent claim 1. Reference(s) to "embodiments" throughout the description which are not under the scope of the appended claims merely represents possible exemplary executions and are therefore not part of the present invention.

[0004] An example of a medical device comprises a flexible elongate member that defines a lumen, and a support spine affixed to the distal end and extending proximally therefrom within the elongate member lumen (i.e. in typical examples the support spine is not attached to a lumen surface or embedded in the elongate member's sidewall). In some examples, the support wire is configured to support at least a portion of the elongate member. Some examples of the medical device provide for distal end fluid delivery by defining apertures at or near the distal end that enable fluid communication between the lumen and the outside environment. Furthermore, in some such examples, the support spine extends from the distal end within a distal portion of the lumen such that a proximal portion of the lumen is substantially unobstructed (i.e. not obstructed by the support spine), thereby reducing and minimizing effects on fluid flow, at least within the proximal portion of the lumen.

[0005] In a first broad aspect, embodiments of the present invention include a medical device comprising: a flexible elongate member configured for traversing body lumens, the elongate member defining a lumen that is in fluid communication with at least one distal aperture; a support spine extending proximally from the distal end of the medical device within a distal portion of the lumen; and a proximal end of the support spine being located within a distal portion of the lumen. As additional features, and in some embodiments, the elongate member is generally tubular in configuration; a distal portion of its sidewall has cuts therein to increase flexibility; and the support wire minimizes the bending stress on any one cut by supporting the wall of the elongate member and distributing the bending stress along the elongate member i.e. the spine can act as a bridge across the cuts to distribute the bending stress along the elongate member.

[0006] As a further feature of the first broad aspect, in some embodiments, the medical device further comprises an energy delivery device at the distal end of the elongate member that is operable to be electrically coupled to an energy source. In some such embodiments, energy can flow through the wall of the elongate member to the energy delivery device, leaving the lumen sufficiently open for functioning as a conduit for fluid flow. In certain embodiments, the wall is comprised of an electrically conductive material and the energy is electrical energy, for example in the radiofrequency range.

[0007] In a second broad aspect, embodiments of the present invention include a medical device comprising: an elongate member configured for traversing body lumens, the elongate member defining a lumen; and a support spine having a distal end coupled to a distal end of the medical device and extending proximally therefrom wherein a proximal end of the support spine is not coupled to the elongate member, the support spine being thereby configured to support a tensile side of the elongate member during bending. In some embodiments, the elongate member is generally tubular in configuration and a distal portion of its sidewall has cuts therein to increase flexibility. The cuts may be partially or completely through the sidewall. The support wire minimizes the bending stress on any one cut by supporting the wall of the elongate member to thereby distribute the bending stress along the length of the elongate member.

[0008] As a feature of the second broad aspect, in some embodiments of the medical device, the lumen is in fluid communication with at least one aperture at or near a distal end of the elongate member.

[0009] As another feature of the second broad aspect, in some embodiments of the medical device, an energy delivery device at the distal end of the elongate member is operable to be in communication with an energy source. In certain embodiments energy flows through the wall of the elongate member, whereby the lumen is left sufficiently open to function as a conduit for fluid flow. In certain embodiments, the wall is comprised of an electrically conductive material and the energy is electrical energy.

[0010] As another feature of the second broad aspect, in some embodiments of the medical device, the support wire/spine has shape memory.

[0011] As a further feature of the second broad aspect, in some embodiments of the medical device, a portion of the elongate member defines a curve. Alternative embodiments of the second broad aspect include the elongate member being substantially straight (i.e. not having a substantially curved portion).

[0012] In accordance with a third broad aspect of the invention, a method of surgery is described. In some embodiments, the method comprises: (i) introducing a medical device into a body of a patient, the medical device comprising an elongate member having a distal region and a proximal region, an energy delivery device proximate to the distal region capable of cutting material and a lumen and apertures operable to be in communication with a pressure sensing mechanism for determining pressure in the body proximate to the distal region; (ii) positioning the energy delivery device at a first desired location in the patient's body substantially adjacent material to be cut; (iii) delivering energy using the energy delivery device to cut said material; and (iv) measuring pressure in the body using the pressure sensing mechanism in order to determine the position of the medical device at least one of before and after step (iii). In some embodiments of this aspect, step (ii) comprises delivering fluid for imaging at the first desired location in the patient's body.

[0013] Some embodiments of the method further comprise a step of (v) advancing the device to a second desired location. In certain embodiments of this aspect, the medical device comprises at least one radiopaque marker and step (v) comprises monitoring at least one of said radiopaque markers before, during or after advancement. Some embodiments of the method comprise a further step of: (vi) measuring pressure at the second location to confirm the position of the medical device at the second location. In certain embodiments, the medical device comprises at least one radiopaque marker and step (vi) is performed after confirming the position of at least a portion of the pressure sensing mechanism (e.g. an aperture of the medical device) at the second location using said radiopaque markers.

[0014] In some embodiments of this method aspect, step (i) comprises introducing the device into the patient's vasculature and/or other body lumens. The step of introducing the device into the patient's vasculature typically comprises inserting the device into a dilator and a guiding sheath positioned in the patient's vasculature. In certain embodiments, the device and at least one of the dilator and sheath comprise a radiopaque marker and step (ii) comprises aligning the radiopaque markers of the devices to aid in positioning the devices. For certain alternative embodiments of the method, step (v) comprises advancing the dilator and the sheath into the second location together over the spatially fixed medical device. In other alternative embodiments, step (v) comprises advancing the dilator, sheath and medical device all together into the second location.

[0015] In accordance with the method aspect of the present invention, in certain embodiments, the material to be cut is tissue located on an atrial septum of a heart. In some embodiments, the region of tissue is the fossa ovalis of a heart. In such embodiments, the pressure measured at the second location is the blood pressure in the left atrium of the heart.

[0016] In some alternative embodiments, the method further includes delivering contrast (imaging) fluid that is visible using an imaging system in order to confirm the position of the medical device at the second desired location.

[0017] Certain embodiments of the method include the elongate member having a distal region capable of adopting a curved shape. In some such embodiments, after the medical device tip advances through a material or out the end of the dilator, the pre-shaped support spine biases the distal region to adopt a curved shape whereby the functional tip is directed in a desired direction. In some embodiments, the curved shape is defined by a radial arc and the functional tip is directed away from cardiac structures, for example, order to decrease the risk of unwanted injury. As an example, the distal region is configured to form a 270 degree curve.

BRIEF DESCRIPTION OF THE DRAWINGS



[0018] In order that the invention may be readily understood, embodiments of the invention are illustrated by way of examples in the accompanying drawings, in which:

Fig. 1 is an embodiment of a medical device with a generally straight elongate member;

Fig. 2 is an illustration of detail A of Fig 1;

Fig. 3 is an illustration of detail B of Fig, 1;

Fig. 4 is an illustration of a spine wire that is biased to be straight and an attached distal region energy delivery device;

Fig. 5 is an illustration of detail A of Fig 4;

Fig. 6 is an illustration of an elongate member with cuts therein;

Fig. 7 is an illustration of an embodiment of a medical device with a curved end portion and a handle;

Fig. 8 an illustration of detail A of Fig. 7;

Fig. 9 an illustration of detail A of Fig. 8;

Fig. 10 is a cut-away view of the embodiment of Fig. 8;

Fig. 11 an illustration of detail A of Fig. 10;

Fig. 12 is an illustration the embodiment of Fig. 8 with no external insulation layer;

Fig. 13 is an illustration of detail A of Fig. 12;

Fig. 14 is an illustration of the installed configuration of the core or support spine assembly of the embodiment of Fig. 10;

Fig. 15 is a cut-away view of the embodiment of Fig. 14;

Fig. 16 is an illustration of detail A of Fig. 15;

Fig. 17 is a partial cut-away view of the embodiment of Fig. 7;

Fig. 18 is a cut-away view of detail A of Fig. 17;

Fig. 19 is an illustration of detail A of Fig. 18;

Fig. 20 is an illustration of an embodiment of a support spine for a version of the medical device with a distal curve, before the spine is installed;

Fig. 21 is an illustration of detail A of Fig. 20;

Fig. 22 is an end view of the embodiment of Fig. 21;

Figs. 23A and 23B illustrate the before and after stages of a transseptal method;

Fig. 24 is cross section view of a curved embodiment with a support spine;

Figs. 25A and 25B are diagrams of a portion of an elongate member embodiment with a discontinuous spiral cut therein and a support wire;

Fig. 26 is a diagram showing a lumen distal portion containing a support spine and a proximal lumen portion that lacks the support spine;

Figs. 27A and 27B are embodiments with electrically conductive spines; and

Figs. 28 and 29 are embodiments with coiled markers.


DETAILED DESCRIPTION



[0019] The present inventors have conceived and reduced to practice a novel and inventive medical device for creating punctures or perforations in tissues. Embodiments of the medical device include features allowing for transfer of fluids through the device, while providing for internal support of the device, particularly when the device is bent or curved.

[0020] In typical embodiments of medical device 20, support spine 1 is connected to other features of device 20 at the distal end of the medical device and the proximal end of support spine 1 remains un-attached to, and independent of, elongate member 6 (or any other part of medical device 20), i.e. substantially only the distal end of support spine 1 is attached or otherwise connected to the medical device 20. This allows the proximal end of support spine 1 to be able to move longitudinally (and laterally) relative to the inner wall of the elongate member (e.g. a hypotube), which allows the distal end of medical device 20 (where the support spine 1 and elongate member 6 are joined) to bend or curve unimpeded by support spine 1. The ability of the distal end portion of medical device 20 to bend or curve facilitates advancing the device through tortuous vasculature and other body vessels.

[0021] Furthermore, a difference in bend radius between the wall of elongate member 6 and support spine 1 arises from differences in the bend axis due to the wall thickness of the elongate member and the position of the support wire. When the medical device 20 device is bent about its distal portion, the difference in bend radii results in different arc lengths for elongate member 6 and support spine 1. If the proximal end of support spine 1 were to be fixed at a proximal portion of medical device 20, the relative arc-lengths of elongate member 6 and support spine 1 would be fixed, and therefore the catheter curvature would be constrained by support spine 1.

[0022] Typical embodiments of medical device 20 have cuts 32 (Fig. 25a and 25B) into the sidewall of elongate member 6 to increase flexibility. Such cuts have the drawback of reducing the strength of a tubular structure and increase the chances of the device breaking. When elongate member 6 is bent during advancement through tortuous body lumens, support spine 1 is positioned against the tensile side of elongate member 6 whereby it provides support for elongate member 6 (Fig. 25). By providing support to the tensile side, the support spine is able to distribute the stress of the bend or curve along a longer length of elongate member 6 than in the case of an unsupported elongate member (i.e. that does not have a spine), and consequently the stress of the bend is spread amongst more cuts 32 and uncut (U) portions of the sidewall, resulting in reduced risk of elongate member being damaged (e.g. breaking at one isolated cut) by the stress forces of the bend or curve. Thus, the support spine, as shown in Fig. 25B, assists in distributing the load along elongate member 6 and furthermore, since an applied load must also deflect the support spine, the support spine takes some of the load directly.

[0023] Also, support spine 1 allows elongate member 6 to have a smoother curve than is provided by an unsupported elongate member (i.e. with no support spine) as the support spine functions as a spline (i.e. a supporting strip of material). Inclusion of support spine 1 reduces the frequency of abrupt bends along elongate member 6.

[0024] Some embodiments of medical device 20 include support spine 1 being comprised of a material with shape memory such as nitinol, whereby the device can be designed and manufactured to be biased towards a preconfigured shape, for example curved or straight.

[0025] As shown, for example, in Figure 26, typical embodiments of medical device 20 include support spine 1 being affixed to the distal end of medical device 20 inside lumen 26 and extending proximally within the lumen, and an aperture 25 that provides for delivering fluid at the distal end of medical device 20. (There are alternative embodiments that do not have an aperture 25). For typical embodiments, the support spine 1 extends from the distal end within lumen distal portion 36 such that a lumen proximal portion 35 is substantially unobstructed (i.e. not obstructed by the support spine), thereby reducing and minimizing effects on fluid flow.

[0026] With specific reference now to the drawings in detail, it is stressed that the particulars shown are by way of example and for purposes of illustrative discussion of certain embodiments of the present invention only. Before explaining at least one embodiment of the invention in detail, it is to be understood that the invention is not limited in its application to the details of construction and the arrangement of the components set forth in the following description or illustrated in the drawings. The invention is capable of other embodiments or of being practiced or carried out in various ways. Also, it is to be understood that the phraseology and terminology employed herein is for the purpose of description and should not be regarded as limiting.

[0027] A medical device as described herein comprises a flexible elongate member that defines a lumen, and an independent support spine affixed to the distal end and extending proximally therefrom within the elongate member lumen (i.e. the spine is not attached to a lumen surface or embedded in the elongate member's sidewall) whereby the support spine can support the elongate member. Some embodiments of the medical device further provide for delivering fluid at the device's distal end by having the flexible elongate member define apertures, at or near the device's distal end, that enable fluid communication between the lumen and the outside environment In some such embodiments, the support spine extends proximally from the distal end within a distal portion of the lumen such that a proximal portion of the lumen is substantially unobstructed (i.e. not obstructed by the support spine), thereby reducing and minimizing effects on fluid flow within the proximal portion of the lumen.

[0028] While some embodiments of the medical device have distal end apertures, alternative embodiments do not. Furthermore, while some embodiments of the medical device have distal end energy delivery means, alternative embodiments do not. For example, some embodiments include a sensor for gathering sensory input, such as probes having temperature sensors and/or impedance sensors. In some such embodiments, the probes have an elongate member that is comprised of electrically conductive material(s) and/or electrically non-conductive material(s).

Medical Device (straight embodiment) (Fig. 1)



[0029] Fig. 1 illustrates an embodiment of a medical device 20, which comprises an elongate member 6 having a proximal region 22 and a distal region 24, and an energy delivery device 15 (Fig. 2 and, in greater detail, Fig. 5) associated with the distal end of device 20. Elongate member 6 is tubular in configuration defining at least one lumen 26 (Fig. 2) extending substantially throughout its length, and is electrically conductive for conducting energy along the length of elongate member 6 to energy delivery device 15. In some embodiments, elongate member 6 is a hypotube. In addition, in typical embodiments, elongate member 6 defines at least one aperture 25 in a wall thereof (Fig. 2), which in typical embodiments is a distal aperture, i.e. an aperture which is at or near the distal end of elongate member 6 or medical device 20. The distal aperture and the lumen defined by the elongate member combine to form a pressure transmitting lumen, whereby fluid pressure from an external environment on the aperture is transmitted through a column of fluid located in the lumen to be measured at a proximal portion of the device. For example, the medical device may be operable to be coupled to a pressure sensing mechanism, such as a pressure sensor, to measure the pressure transmitted through the lumen. Medical device 20 further comprises a hub 9 (shown in detail in Fig. 3) associated with the proximal region 22 of elongate member 6. While the embodiment of elongate member 6 of Fig. 1 is biased towards a straight configuration, as illustrated, elongate member 6 is flexible enough to bend when being advanced through a curved lumen. Some alternative embodiments of elongate member 6 include a curved portion (e.g. Fig. 7).

Distal portion of medical device (Fig. 2)



[0030] Elongate member 6 and energy delivery device 15 (see Fig. 5 as well) are electrically coupled by one or more of a variety of connecting means. For example, connecting means include welding (including laser welding), soldering, electrically conductive adhesives, and/or press fitting.

[0031] Elongate member 6 is typically made from different electrically conductive materials. Examples of materials include stainless steel, copper, nickel, titanium, and alloys thereof. Some embodiments include elongate member 6 comprising a stainless steel hypotube or a nitinol hypotube.

[0032] The Fig. 2 embodiment of a distal portion of medical device 20 comprises an insulation layer 7 disposed on top of, or around, the distal region 24 of elongate member 6. Insulation layer 7 extends substantially from proximal region 22 to distal region 24 of elongate member 6. Insulation layer 7 may be made, for example, from an electrically insulative material such as PEBAX® (polyether block amide), PEEK (Polyether ether ketone), PTFE (Polytetrafluoroethylene), or another thermoplastic material. The Fig. 2 embodiment illustrates insulation layer 7 extending over a proximal portion of thermal shield 3.

[0033] Some embodiments of medical device 20 include elongate member 6 defining one or more aperture(s) 25, for example, as shown in Fig. 2. Aperture(s) 25 facilitate fluid communication between the outside environment and lumen 26.

Hub (Fig. 3)



[0034] Some embodiments of medical device 20 include a hub 9 that typically also functions as a handle for a physician when medical device 20 is used (Figs. 1, 3). Alternative embodiments of medical device 20, such as the example of Fig. 7, include an alternate hub 9 (also shown in Fig. 17).

[0035] In some embodiments, for example the embodiments of Figs. 1 and 3, proximal region 22 is coupled to a hub 9 (shown in detail in Fig. 3) which is coupled to flexible tubing 10, whereby proximal region 22 is in fluid communication with fluid connector 11. In certain embodiments, flexible tubing 10 is comprised of a flexible polymer, for example polyvinylchloride (PVC), or another flexible polymer, or Tygon®. Connector 11 is structured to be operatively connected to a source of fluid, for example a syringe or an aspirating device, or to a pressure sensing device, for example a pressure transducer.

[0036] Medical device 20 (Figs. 1 and 3) also includes means for electrically coupling proximal region 22 of elongate member 6 to an energy source. Proximal region 22 connects to hub 9. Insulated wire 13 is electrically coupled to proximal region 22 within hub 9. The proximal end of insulated wire 13 is connected to electrical connector 14 (e.g. a plug), which is electrically coupled to a source of energy, for example a generator.

[0037] Strain relief 8 (Figs. 1, 3, and 7) provides for a transition of stiffness between proximal region 22 of elongate member 6 and hub 9, i.e. strain relief 8 prevents an abrupt change of flexibility and rigidity at the location where hub 9 is connected to elongate member 6. In certain embodiments, strain relief 8 is a flexible layer, for example, heat shrink, which covers and surrounds insulation layer 7. Some alternative embodiments do not include strain relief 8.

Spine and markers (Figs. 4, 28 and 29)



[0038] Fig. 4 illustrates an embodiment of support spine 1 (or support wire) that is generally straight and that is appropriate for use in medical devices 20 that are generally straight (for example, medical device 20 of Fig. 1). An energy delivery device 15 and radiopaque markers 5 are attached to support spine 1 of Fig. 4. The support spine has a plurality of evenly spaced markers attached thereto.

[0039] In general, there is no minimum spine length and the maximum support spine length is limited by the length of the lumen containing the spine. The lumen containing support spine 1 is lumen 26 of elongate member 6, which is typically from about 60 cm to about 120 cm in length. In some embodiments the support spine 1 (or support wire) extends for a distance of about 10 cm (or about 4 inches). Various dimensions and specific limitations will be presently described. These specific dimensions and limitations are not mere design choices that would be obvious to one of skill in the art but are rather particularly advantageous for the embodiments of devices and methods described herein. For example, the support spine is typically somewhat (for example, a few millimeters) longer than a distal laser-cut section of elongate member 6 (Fig. 6) to provide overlap with an uncut portion of elongate member 6.

[0040] Typical embodiments of support spine 1 have a proximal portion that is straight. Alternative embodiments of the support spine 1 (e.g. Figs. 27A and B) have a curved proximal end to facilitate the proximal tip of the wire contacting the side of lumen 26 (i.e. an inner wall of elongate member 6) for electrical connection (i.e. electrical communication). Other alternative embodiments which also facilitate contact with elongate member 6 include the support spine being comprised of a spring, for example a helical spring or a leaf spring.

[0041] Typical embodiments of support spine 1 have a constant outer diameter. Alternative embodiments of the support spine 1 can have a varying or non-constant outer diameter. In some embodiments, the support spine tapers proximally to facilitate contact with elongate member 6 and thereby providing an alternative electrical path to electrode 19.

[0042] For ease of manufacturing, typical embodiments of support spine 1 are comprised of one wire. Alternative embodiments of support spine 1 are comprised of two or more wires joined side-by-side to provide a preferential bending direction or two or more wires braided together for greater strength and flexibility.

[0043] For ease of manufacturing, typical embodiments of support spine 1 are comprised of a solid wire. Alternative embodiments of support spine 1 are comprised of a ribbon to provide a preferential bending plane or direction.

[0044] For ease of manufacturing, typical embodiments of support spine 1 have a circular cross-section. Alternative embodiments of support spine 1 can have non-circular cross-sections, for example, D-shaped, triangular, or rectangular, which have preferential bending directions.

[0045] Radiopaque markers 5 are used to highlight the location of important landmarks on medical device 20. Such landmarks may include the location of energy delivery device 15 or the location of any aperture(s) 25 (e.g. Fig 11). In general, the radiopaque markers provide the radiopacity to more readily visualize the device under fluoroscopy or other medical imaging modalities. Some embodiments of marker 5 are comprised of platinum. Furthermore, some embodiments of energy delivery device 15 include a conductive spacer 4 (see, for example, Fig. 27B) that is comprised, for example, of platinum, whereby spacer 4 can also function as a visualization marker.

[0046] Some alternative embodiments have a spiral or a coiled marker 5 (Figs. 28 and 29) rather than band or ring markers, to provide greater flexibility. In the embodiments of Figs. 28 and 29, coiled markers 5 are installed on support spine 1 with a flare 12 adjacent each end of the marker. Each flare 12 acts as a restraint to prevent coiled marker 5 from moving or travelling along support spine 1. In the embodiment of Fig. 29, each flare 12 is comprised of a flattened portion of support spine 1 (or flattened wire). In other alternative embodiments, one or both ends of a coiled marker could be fixed in place by laser welding or crimping. A coiled marker 5 is typically comprised of platinum or tungsten. In the embodiment of Fig. 28, the coiled marker is proximal of the aperture 25 whereby it can help identify the location of the aperture so as to assist the physician in positioning the aperture. For example, by positioning coiled marker 5 outside (distal) of a dilator, a physician would ensure that aperture 25 is also located outside of the dilator whereby the aperture 25 could be used to deliver fluids.

Energy delivery device (Fig. 5)



[0047] Some embodiments of energy delivery device 15, for example the embodiment of Fig. 5, are comprised of an electrode 19 which is attached to and in electrical communication with an intermediate conductive element 18, with intermediate conductive element 18 being attached and in electrical communication with conductive spacer 4. Electrode 19 includes support structure 2 and a conductive dome 16. In the embodiment of Fig. 5, support structure 2 is a metallic puck (or disk-shaped element), and in certain embodiments is comprised of tantalum. In certain embodiments, conductive spacer 4 is comprised of platinum. The electrode of such embodiments is comprised of electrically conductive material, for example, stainless steels, copper, and/or platinum. In some embodiments, the electrode has a hemispherical, rounded, or domed end. In some alternative embodiments, the electrode has other configurations, for example, substantially cylindrical. The electrode is sized for creating a puncture in a tissue of a heart septum while minimizing hemodynamic instability

[0048] In some embodiments, intermediate conductive element 18 is covered (or surrounded) by a thermal shield 3, which in some examples is a ceramic, for example, a sapphire ceramic. In alternative embodiments, intermediate conductive element 18 is fabricated from other materials.

[0049] The Fig. 5 embodiment of medical device 20 has a support spine 1 extending proximally of conductive spacer 4, with spine 1 including a flare 12. Support spine 1 provides stiffness to the flexible portion of medical device 20 while leaving lumen 26 sufficiently unobstructed for flow of fluid, such as contrast fluid for imaging purposes. In some embodiments Support spine 1 is comprised of nitinol and provides shape memory properties to the device.

[0050] In some embodiments, flare 12 is attached to support spine 1, for example by welding. In alternative embodiments flare 12 and support spine 1 are integral (i.e. support spine 1 and flare 12 comprise a unitary part), such as in the case of support spine 1 and flare 12 being produced by the machining of a single piece of cylindrical metal. In some embodiments, flare 12 retains conductive spacer 4 in place. In some embodiments, intermediate conductive element 18 is an extension of support spine 1. In alternative embodiments, intermediate conductive element 18 is a separate part distinct from support spine 1, for example, a wire or rod.

[0051] While electrode 19 is typically attached to the other components of energy delivery device 15 by welding, in alternative embodiments, electrode 19 is operatively coupled to the other components of energy delivery device 15 by alternative means, for example, gluing. In alternative embodiments, conductive spacer 4 is replaced by other energy delivery elements to facilitate electrical communication between energy delivery device 15 and elongate member 6 (e.g. Fig.27). The embodiment of Fig. 5 includes a band marker 5, while alternative embodiments include a coiled marker, for example as described hereinabove. While the above described embodiment of Fig. 5 includes metallic parts, alternative embodiments comprise corresponding parts made of non-metallic electrically conducting materials.

Elongate member (Fig. 6)



[0052] In some embodiments, notches are cut into elongate member 6, for example by laser-cutting, to increase flexibility. Different configurations of cuts are possible, including: c-cuts, spiral shaped cuts, interrupted spiral cuts, interlocking cuts and dove-tail cuts. In some embodiments, the cuts traverse the wall thickness of elongate member 6. Embodiments include the distal portion of elongate member 6 having cuts ranging from about 3 cm in length to substantially the entire length of the shaft of elongate member 6, which is typically from about 60 cm to about 120 cm in length. In certain embodiments, medical device 20 has cuts made into the last 10 cm (i.e. the most distal 10 cm) of elongate member 6 and support spine 1 is about 10 to 11 cm in length, i.e. equivalent to or somewhat greater than the length of the portion of elongate member 6 having cuts.

[0053] The embodiment of Fig. 6 comprises cuts into elongate member 6 that include constant pitch portion B, variable pitch portion C and dual pitch portion D. Having a smaller pitch (i.e. the cuts being closer together) increases the flexibility of elongate member 6. For example, the distal part of variable pitch portion C has a smaller pitch than the proximal part of portion C and consequently is more flexible. Having a dual pitch (i.e. two cut lines) further increases the flexibility of elongate member 6, such as is found in dual pitch portion D. In an alternative embodiment, all of sections B, C and D have dual pitches.

[0054] A more flexible distal region 24 facilitates navigating through conduits in a patient's body, for example blood vessels, while a stiffer proximal region 22 facilitates pushability, or resistance to kinking (i.e. cross-sectional area collapse) under axial compression force. Also, a stiffer proximal region 22 improves torque response at the distal tip in response to forces applied at the proximal portion of the device.

[0055] The flexibility of an embodiment of elongate member 6 depends on its wall thickness and/or outer diameter. Alternative embodiments of elongate member 6 have different wall thickness dimensions and/or different outer diameters along the length of elongate member 6 to vary flexibility along elongate member 6 (with each such embodiment having constant thickness and diameter dimensions, respectively, along the length of elongate member 6).

[0056] In some embodiments of medical device 20, in which elongate member 6 is normally biased to be straight, the shape memory properties and stiffness of support spine 1 allows medical device 20 to behave similarly to a guide-wire and to revert to a straight configuration after being bent. Such embodiments of support spine 1 also provide stiffness to balance the flexibility created by any cuts made into elongate member 6.

[0057] In some embodiments of the medical device 20, the outer diameter of elongate member 6 ranges from about 0.010" (0.025 mm) to about 0.050" (0.13 mm). In some embodiments, the inner diameter of elongate member 6 ranges from about 0.005" (0.013 mm) to about 0.030" (0.076 mm), or, in some embodiments, from about 0.020" (0.051 mm) to about 0.030" (0.076 mm). Elongate member 6 is between about 60 cm and about 120 cm in length. In a specific embodiment, elongate member 6 has in an inner diameter of about 0.025 inches (0.064 cm) and an outer diameter of about 0.029 inches (0.074 cm). In another specific embodiment, elongate member 6 has in an inner diameter of about 0.0265 inches (0.067 cm) and an outer diameter of about 0.0325 inches (0.083 cm). The dimensions of elongate member 6 depend on one or more factors, including the distance to the target site, the tortuosity and/or diameter of the vessel(s) to be navigated, whether or not the elongate member is exchange length, as well as any other requirements imposed by auxiliary devices to be used with elongate member 6. For example, elongate member 6 may be sized to be compatible with a particular sheath and/or dilator.

Medical Device (embodiment with curve) (Fig. 7,17)



[0058] Some embodiments of medical device 20 include elongate member 6 comprising a distal curved portion 30 that has a distal end 28, such as the example of Fig. 7. The embodiment of Fig. 7 includes a hub 9 that also functions as a handle.

[0059] Fig. 17 is a partially cut away view of the embodiment of Fig. 7 that illustrates some details of hub 9. Hub 9 includes fluid connector 11 and electrical connector 14, as well as lumens communicating with the connectors.

Distal curved portion (Figs. 8, 9, 10, 12 to 16, 18, 20 to 22 and 24)



[0060] Distal curved portion 30 of Fig. 7 is shown in detail in Fig. 8. The embodiment illustrated in Fig. 8 includes: apertures 25 for allowing fluid flow between lumen 26 and the environment outside of medical device 20; as well as electrode 19 for delivering electrical energy, such as radiofrequency electrical energy (RF), to a treatment site. Fig. 9, which illustrates detail A of Fig. 8, includes enlarged views of apertures 25 and the electrode 19. Curved portion 30 is sufficiently flexible so that it may be substantially straightened out when it is inserted into a straight tube or vessel and may bend or curve when advanced through curved vasculature or other body lumens or when exiting the straight tube or vessel. Consequently, embodiments of medical device 20 having distal curved portion 30 may be used with a sheath and/or dilator for advancement through body lumens.

[0061] Fig. 10 is a diagrammatic cut-away view of an embodiment of medical device 20, including a curved portion 30.

[0062] Embodiments of medical device 20 having a distal curved portion 30 similar to that of Fig. 8 typically have a support spine 1 that includes, in an installed configuration, a curved distal end portion similar to the example of Fig. 14. The embodiment of Fig. 14 also illustrates band markers 5 and energy delivery device 15. Fig. 15 in a cut-away view of the embodiment of support spine 1 of Fig. 14. Fig. 16 is an illustration of the area marked "A" in Fig. 15. Energy delivery device 15 of the embodiments illustrated in Figs. 15 and 16 is comprised of a conductive dome 16 and conductive spacer 4.

[0063] For illustrative purposes, such as the example shown in Fig. 10, support spine 1 (the support wire) is shown substantially centered within lumen 26, while in actual use (as explained hereinbelow), support spine 1 is typically not centered within lumen 26 of elongate member 6.

[0064] Figs. 20 to 22 illustrate an embodiment of a support spine 1, before installation within elongate member 6, for a version of the medical device having a curved distal portion. Fig. 20 shows an entire support spine 1 including coiled portion 34. Fig. 21 is an illustration of detail A of Fig. 20 showing an enlargement of coiled portion 34, and Fig. 22 is an end view of the embodiment of Fig. 21. Figs. 21 and 22 illustrate that for this embodiment, support spine 1 overlaps itself in the coiled portion 34. Support spine 1 is elastically biased towards a curved or looped configuration prior to being inserted into lumen 26 of elongate member 6.

[0065] The support spine 1 acts to bias a portion of medical device 20, within which coiled portion 34 of support spine 1 is located, to have a curved section, while elongate member 6 is typically biased towards a straight configuration. Therefore, when support spine 1 (of Fig. 20) is installed within an elongate member 6, the biasing force of support spine 1 and the biasing force of elongate member 6 act against each other, resulting in the medical device having a curved portion 30 with a curvature between that of coiled portion 34 of support spine 1 and straight elongate member 6. An example of a curved portion 30 of medical device 20 is shown in Fig. 8. Fig. 8 illustrates one possible configuration of a curved portion: alternative embodiments of medical device 20 have a curved portion with a different shape or configuration, for example, the curved portion having a different size and/or radius of curvature.

[0066] In an assembled medical device 20 with a curved portion 30 (e.g. Fig. 8), support spine 1 is typically positioned against the inner radius side of lumen 26 through most of curved portion 30 to provide the curve.

[0067] An embodiment of curved portion 30 of medical device 20 is shown in Fig. 18, which is a cut-away view of detail A of Fig. 17. The particular embodiment of Fig. 18, in the illustrated position, includes a substantially 270 degree curve having a length dimension of about 10.5 mm (±50%), a lateral dimension of about 13.1 mm (±50%), the first 90 degrees of the curve having a radius of about 6.5 mm (±50%), and the last 90 degrees of the curve having a radius of about 4 mm (±50%). The curve is sized for fitting inside limited-size structures of human anatomy, for example, a left atrium.

[0068] In those embodiments of medical device 20 that are substantially biased towards a straight configuration when assembled, such as the examples of Figs. 1 to 6, it is typical for support spine 1 to be biased towards assembled straight configuration as well.

Alternative Embodiments



[0069] The two above mentioned embodiments of medical device 20 (generally straight and straight with a curved distal end portion), both use a support spine 1 (or support wire) that is pre-shaped to provide the device with a "default" position that the device is normally biased towards and which is not permanently altered by interaction with anatomy when advanced through body lumens or other structures. In other words, medical device 20 is resilient (i.e. it returns to its original form after being bent or otherwise manipulated from its default shape). Some embodiments of medical device 20 that are straight (and which include an energy delivery device 15) facilitate forward linear advancement, that is, along a substantially straight line, and may be used for cutting and channeling through tissue, for example, CTOs (chronic total occlusions). Embodiments of medical device 20 that have a distal curved portion 30 (and which also include an energy delivery device 15) may be used for cutting through other types of tissue that are more readily accessible using curved devices such as a septum of the heart in a transseptal procedure. Typically, in performing a transseptal procedure, the distal end of medical device 20 emerges from a support catheter and punctures a septum, whereupon embodiments with a distal curved (or curled) portion (e.g. a 270 degree curve) facilitate performing the procedure by orientating the electrode towards the center of the curl and away from the opposite heart chamber wall after advancement through the tissue, in order to increase patient safety by reducing the risk of accidental perforation of a heart wall or other vital structure.

[0070] While specific embodiments and uses are disclosed herein, all of the above described embodiments of medical device 20 (e.g. a generally straight device and a straight device with a curved distal end portion) can be used, for example, in applications involving channeling through tissue such as CTOs, or for general tissue puncture such as transseptal procedures. Furthermore, some embodiments include a heat shield (e.g. Fig. 2) and other embodiments do not include a heat shield (e.g. Fig. 11).

[0071] Figs. 12 and 13 are illustrations of the embodiments of Figs. 8 and 9 with insulation layer 7 being removed.

Energy delivery device of a curved embodiment (Fig. 11, 19, 26)



[0072] Fig. 11 shows a close-up view of detail A of Fig. 10. The embodiment of Fig. 11 includes energy delivery device 15, which is comprised of conductive dome 16 and spacer 4. In some embodiments, dome 16 is formed by end-welding a portion of support spine 1 that extends distally through the bore of spacer 4. The heat from welding support spine 1 also welds conductive dome 16 with the distal end surface of spacer 4, as well as welding a distal portion of support spine 1 to a distal portion of spacer 4 to form weld 27. In alternative embodiments, weld 27 has a different configuration than in the example of Fig. 11, for example, extending proximally a greater or lesser distance.

[0073] The example of Fig. 11 includes conductive spacer 4 being joined, i.e. electrically coupled, with elongate member 6, typically by tack welding. In alternative embodiments, conductive spacer 4 and member 6 are joined by other methods, including electrically conductive adhesives, solder, laser welding and/or press fitting. In some alternative embodiments, dome 16 is formed by machining cylindrical stock that is integral with support spine 1, and in other alternative embodiments, an electrode is squeezed onto the end of medical device 20 to engage other portions of the device using, for example, a friction fit. In some alternative embodiments, portions of the support spine 1, spacer 4, and elongate member 6 are melted (welded) substantially concurrently to form the dome and join the parts together.

[0074] In the embodiment of Fig. 11, conductive dome 16 is in direct contact with the distal end surface of elongate member 6 and support spine 1 extends proximally from conductive dome 16 to within lumen 26 of elongate member 6. Elongate member 6 is covered by insulation layer 7, leaving conductive dome 16 electrically exposed to define an electrode 19. Fig. 11 also illustrates a band marker 5 attached to support spine 1. Band marker 5 marks or highlights the position of some apertures without increasing the outer diameter of medical device 20, by being located within a lumen 26 of elongate member 6.

[0075] Fig. 11 illustrates that elongate member 6 is in electrical communication with spacer 4 and electrode 19. When in use, electrical energy flows from elongate member 6 to electrode 19 either directly from elongate member 6 or via spacer 4.

[0076] Fig. 19 illustrates a close-up of detail A of Fig. 18 and shows a specific embodiment of the distal end portion of medical device 20. Fig. 19 illustrates insulation layer 7 having an outer diameter of about 0.9 mm (0.0365 inches), elongate member 6 (e.g. a hypotube) having an outer diameter of about 0.8 mm (0.0325 inches) and an inner diameter of about 0.7 mm (0.0265 inches), and support spine 1 having an outer diameter of about 0.2 mm (0.008 inches). Alternative embodiments have other dimensions for these features, for example as disclosed in co-pending application serial number 61/781,231, entitled "Electrosurgical Device Having a Lumen". Some alternative embodiments include: insulation layer 7 having an outer diameter of between about 0.5 mm to about 1.0 mm, or, more specifically about 0.7 to about 1.0 mm; elongate member 6 having an outer diameter of between about 0.4 mm to about 0.9 mm or, more specifically, between about 0.6 and about 0.9 mm; elongate member 6 having an inner diameter of between about 0.3 mm to about 0.8 mm or, more specifically, between about 0.5 mm to about 0.8 mm; and support spine 1 having an outer diameter of between about 0.1 mm to about 0.3 mm. The small diameter of support spine 1 minimizes the obstruction of lumen 26 and thereby facilitates fluid flow, and also allows the spine to be flexible whereby it may make contact with the electrically conductive inner surface of the elongate member. The electrode of Fig. 19 has diameter substantially the same as the insulation layer's outer diameter of between about 0.5 mm to about 1.0 mm, and of about 0.9 mm in the illustrated embodiment. In one particular embodiment, insulation layer 7 has an outer diameter of about 0.96 mm (0.038 inches) and support spine 1 has an outer diameter of about 0.25 mm (0.010 inches), with the inner and outer diameters of elongate member 6 falling between these two values.

[0077] Instead of, or in addition to, electrical energy being delivered to electrode 19 via elongate member 6, electrical energy may also be delivered to electrode 19 through support spine 1, as further described herein: An elongate configuration of support spine 1 is illustrated in Figs. 14 and 15. Due to its elongate shape, support spine 1 is typically not self-supporting; rather, support spine 1 is typically floppy (i.e. loosely hanging at its proximal end). As a result, once support spine 1 is installed within lumen 26 of elongate member 6 (and in particular during use), a proximal end or portion of support spine 1 is normally in contact (at least, electrical contact) with a wall of lumen 26, such that electrical energy from elongate member 6 can flow through support spine 1 to electrode 19, whereby support spine 1 can provide a secondary pathway for electrical energy to electrode 19.

[0078] Another aspect of support spine 1 is illustrated in the example of Fig. 26. Support spine 1 is drawn using hatch-marks to indicate that it is a different material than elongate member 6. The hatch-marks are not intended to limit support spine 1 to having cuts therein, as support spine 1 may, or may not, have cuts made therein or therethrough. Fig. 26 illustrates an embodiment of elongate member 6 with a distal portion having cuts made into it (although the individual cuts are not shown in the figure), starting at the point labeled with a "C". In this embodiment, the support wire (or spine) extends proximally beyond point "C". During use (not as shown in Figure 26), at least a proximal portion of support spine 1 is typically in contact with a wall of lumen 26, whereby electrical energy from elongate member 6 can flow through support spine 1 to energy delivery device 15, as described hereinabove. In this specific example, since support spine 1 extends proximally beyond the cut portion of elongate member 6, (i.e. the proximal end of the support spine is proximal of the proximal end of the cut whereby the support spine overlaps with an uncut portion of the elongate member), whereby support spine 1 provides a backup or secondary electrical pathway in the case of a breakage or interruption in the pathway through the cut portion of elongate member 6.

Distal end attachment of support spine (Figs. 11 and 26)



[0079] In typical embodiments of medical device 20, support spine 1 is connected at the distal end of the medical device 20 and extends proximally therefrom, while the proximal end of support spine 1 remains un-attached to, and independent of, elongate member 6 (or any other part of medical device 20), i.e. substantially only the distal end of support spine 1 is attached or otherwise connected to the medical device 20.

[0080] Typically, support spine 1 extends proximally from the energy delivery device. While the embodiments of Figs. 1 to 27 show support spine 1 being joined to the center of electrode 19 of energy delivery device 15, alternative embodiments have support spine 1 attached or otherwise coupled to the device at other locations. For example, an alternative embodiment comprises a closed-ended lumen with the support wire (or spine) being attached off-center. Another alternative embodiment comprises an open-ended lumen with the support wire being attached to a side-wall defining the lumen about the distal end of medical device 20.

[0081] As noted hereinabove, the proximal end of support spine 1 is independent of (or relative to) the side of lumen 26 (i.e. it is not fixed to the side of the lumen). This allows the proximal end of support spine 1 to be able to move longitudinally (and laterally) relative to the inner wall of the elongate member (e.g. a hypotube), which allows the distal end of medical device 20 (where the support spine 1 and elongate member 6 are joined) to bend or curve unimpeded by support spine 1. The ability of the distal end portion of medical device 20 to bend or curve facilitates advancing the device through tortuous vasculature and other body vessels.

[0082] Furthermore, a difference in bend radius between the wall of elongate member 6 and support spine 1 arises from differences in the bend axis due to the wall thickness of the elongate member and the position of the support wire. When the medical device 20 device is bent about its distal portion, the difference in bend radii results in different arc lengths for elongate member 6 and support spine 1. If the support spine 1 were to be fixed at a proximal portion of medical device 20, the arc-lengths of elongate member 6 and support spine 1 would be fixed, and therefore the catheter curvature would be constrained. In some embodiments, fixing the arc-lengths of elongate member 6 and support spine 1 is beneficial if such constraint of curvature of the medical device 20 is desirable (i.e. if a user desires to limit the amount of bending that is applied to a distal portion of medical device 20).

Elongate member with a discontinuous spiral cut and support spine (Figs. 25A and 25B)



[0083] Fig. 25A is a diagram of a portion of an embodiment of medical device 20 showing a substantially straight portion of elongate member 6 with an interrupted (or discontinuous) spiral cut 32 through its sidewall. Some embodiments of elongate member 6 have an interrupted spiral cut 32 comprising a cut of about 120 degrees around the circumference of elongate member 6, followed by about 30 degrees of un-cut material around the circumference. Alternative embodiments include a different cut pattern. The embodiment of Fig. 25A includes a generally straight support spine 1 (represented in broken line in the figure) within lumen 26.

[0084] Fig. 25B illustrates the embodiment of Fig. 25A with a bend or curve. In this configuration, side "L" of elongate member 6 is in tension while side "R" is in compression. The U (uncut) portions of the sidewall of elongate member 6 on side L are being stretched, pulled or spread apart resulting in the spiral cuts 32 on the tensile side being larger (e.g. in length) than the cuts in Fig. 25A, where the device is shown at rest (i.e. in its straight configuration). The U (uncut) portions of the sidewall of elongate member 6 on side R are being compressed, pushed or squeezed together resulting in the spiral cuts 32 on the compressive side being smaller (e.g. in length) than the cuts shown in Fig. 25A.

[0085] These figures further illustrate a portion (for example, a proximal portion) of the support wire (or spine) that can move relative to (i.e. is substantially independent of) elongate member 6. While Fig. 25A shows support spine 1 as being positioned centrally within lumen 26, Fig. 25B shows the support spine 1 being positioned against the tensile side of elongate member 6 whereby it provides support for elongate member 6. By providing support to the tensile side, the support spine is able to distribute the stress of the bend or curve along a longer length of elongate member 6 than in the case of an unsupported elongate member (i.e. that does not have a spine), and consequently the stress of the bend is spread amongst more cuts 32 and uncut (U) portions of the sidewall, resulting in reduced risk of elongate member being damaged (e.g. breaking at one isolated cut) by the stress forces of the bend or curve. Thus, the support spine, as shown in Fig. 25B, assists in distributing the load along elongate member 6 and furthermore, since an applied load must also deflect the support spine, the support spine takes some of the load directly.

[0086] In some embodiments, the support spine 1 allows elongate member 6 to have a smoother curve than is provided by an unsupported elongate member (i.e. with no support spine) as the support spine functions as a spline. Inclusion of support spine 1 reduces the frequency of abrupt bends along elongate member 6.

[0087] In general, a device having stiffer vessel contact surfaces (i.e. the surfaces of the device that contact body vessels) is more traumatic when it is advanced through body vessels than a device with more flexible vessel contact surfaces. To provide the medical device 20 with a specific amount of stiffness or rigidity, the utilization of a support spine to provide some of the stiffness allows for the medical device to have suitable rigidity or stiffness while including an elongate member that is relatively more flexible than would be the case with a device without a support spine. Utilizing a more flexible elongate member results in a more flexible "vessel contacting surface" which, in turn, reduces traumatic effects of advancement of the medical device within body vessels. Of note, embodiments of the devices shown in the Figures are covered with a layer of insulation such that the sharp-angled cut surfaces, e.g. as shown in Fig. 25A, are prevented from making direct contact with the vessel wall.

[0088] An embodiment of elongate member 6 having a thinner sidewall and/or a greater number of cuts into the sidewall, will have a less rigidity (or greater flexibility) than another embodiment having a thicker sidewall and/or a lesser number of cuts (or no cuts), other factors being equal.

Fluid flow in lumen proximal and distal portions (Fig. 26)



[0089] Making reference to Fig. 26, typical embodiments of medical device 20 (including both the generally straight embodiment and the embodiment with a distal curved portion 30) include a flexible elongate member 6 that defines a lumen 26, an independent support spine 1 being affixed to the distal end of medical device 20 and extending proximally within the lumen, and apertures 25 that may provide for delivering fluid at the distal end of medical device 20. (There are alternative embodiments that do not have an aperture 25). For typical embodiments, the support spine 1 extends from the distal end within lumen distal portion 36 such that a lumen proximal portion 35 is substantially unobstructed (i.e. not obstructed by the support spine), thereby reducing and minimizing effects on fluid flow.

[0090] This can be appreciated by considering an example. In some embodiments of the medical device 20, cuts are made in the most distal 10 cm of the elongate member, the support spine 1 at the distal end of lumen 26 is about 10 or 11 cm in length and elongate member is from about 60 to about 120 cm in length. Considering the specific example of a 120 cm elongate member (with a 120 cm lumen) and a 10 cm support spine, a distally attached support spine would partially obstruct fluid flow in the distal 10 cm of the 120 cm lumen. A possible alternative device could have support spine 1 attached at the proximal end of lumen 26 but for it to provide support at the distal end (having cuts therein) it would have to extend the entire length of the lumen (e.g. 120 cm in the case of a 120 elongate member) and consequently obstruct fluid flow through the entire length of lumen 26 (a 120 cm long obstruction zone). When the dimensions of such examples are compared, one having a distally attached support spine that obstructs 10 cm of the lumen, and the other having a proximally attached support spine that obstructs 120 cm of the lumen, it can be understood that the distally attached support spine 1 obstructs a much smaller portion of the lumen and would thereby have significantly less effect on fluid flow. Minimizing the obstruction of fluid flow facilitates the delivery of fluids, such as fluids used for staining tissue or other imaging purposes.

Electrically conductive spine (Figs. 27A and 27B)



[0091] In some embodiments of medical device 20, the support spine 1 functions as the primary (or only) pathway for electrical energy to travel from elongate member 6 to energy delivery device 15. In the example of Fig. 27A, conductive spacer 4 is spaced apart from and not in contact with elongate member 6. Insulation layer 7 is a continuous layer of one material in Fig. 27A, but in alternative embodiments insulation layer 7 could be comprised of more than one type of material: for example, the portion of insulation layer 7 covering elongate member could be one (or more) type of material and the portion of insulation layer 7 distal of elongate member 6 could a different material (or materials). In general, at least some portion of insulation layer 7 distal of elongate member 6 is comprised of electrically non-conductive material, whereby electrical energy cannot flow through insulation layer 7 to energy delivery device 15. The embodiment of Fig. 27A includes a spinal curve 21 to facilitate support spine 1 contacting elongate member 6. Some alternative embodiments have a bend. Other alternative embodiments of medical device 20 could have a generally straight support spine 1 (i.e. lacking spinal curve 21) or some other configuration. Whether the distal portion of support spine 1 is curved, bent, straight, or some other configuration, support spine 1 is typically sufficiently elongate and floppy to facilitate it contacting elongate member 6 at some position along its length. While spacer 4 is typically a metallic material to facilitate welding electrode 19 to medical device 20 and securing support spine 1, in alternative embodiments, spacer 4 could be a non-metallic material and/or an electrically non-conductive material.

[0092] Making reference to Fig. 27B, some embodiments of medical device 20 have a thermal shield 3 comprised of non-conductive material whereby support spine 1 functions as the primary pathway for electrical energy to travel from elongate member 6 to energy delivery device 15. While thermal shield 3 is a single integral part in some embodiments (e.g. Fig. 27B), in alternative embodiments, thermal shield 3 could be comprised of more than one part and/or material. The embodiment of Fig. 27B does not include a conductive spacer 4 proximal of thermal shield 3 (as seen in the example of Fig. 5) to enable electrical communication between elongate member 6 and electrode 19. Some embodiments include an energy delivery device 15 comprised of support structure 2 and electrode 19, such as the example of Fig. 27B; alternative embodiments have other energy delivery device configurations, e.g. the distinct support structure 2 and electrode 19 being replaced by a single integral part. While the embodiment of Fig. 27B includes a spinal curve 21, alternative embodiments of medical device 20 have a distal portion of support spine 1 that is bent, straight, or some other configuration. Alternative embodiments include a flare 12, as previously described in reference to Fig. 5. In both of the embodiments illustrated in Figs. 27A and 27B, a non-conductive material restricts or impedes the electrical pathway from elongate member 6 to electrode 19 such that support spine 1 is the primary (or only) pathway of electrical conductivity between elongate member 6 and electrode 19. The non-conductive material could be, for example, a ceramic or a polymer.

Generator



[0093] Medical device 20 may be used in conjunction with any source of energy suitable for delivery to a patient's body. Sources of energy may include, for example, generators of ultrasonic, microwave, radiofrequency or other forms of electromagnetic energy. In embodiments utilizing ultrasonic energy, energy delivery device 15 typically comprises an ultrasound transducer. In one particular embodiment, the source of energy is a radiofrequency (RF) electrical generator, operable in the range of, for example, about 100 kHz to about 3000 kHz, designed to generate a high voltage in a short period of time. More specifically, the voltage generated by the generator may increase from about 0 Vrms to greater than about 400 Vrms in less than about 0.6 seconds. The maximum voltage generated by the generator may be between about 180V peak-to-peak and about 3000V peak-to-peak. The waveform generated may vary, and may include, for example, a sine-wave, or a rectangular-wave, amongst others. In some embodiments, because of the small size of the electrode, the impedance encountered during RF energy application may be very high. The generator may be operable to continue to maintain the voltage, even when the impedance of the tissue changes or is low. For example, energy may be delivered to a tissue within a body at a voltage that rapidly increases from 0 V to 400 V. Different embodiments of generators have power capabilities of 0 to 25 watts, 0 to 50 watts, or 0 to 300 watts.

Methods



[0094] In one specific embodiment of a method of use of the present invention, RF energy is delivered in such a way so as to result in the creation of an insulative vapor layer around the electrode, thereby resulting in an increase in impedance. For example, the impedance may increase to greater than 1500Ω. Increasing the voltage increases the intensity of fulguration, which may be desirable as it allows for an increased tissue puncture rate. An example of an appropriate generator for this application is a BMC RF Puncture Generator (model numbers RFP-100 and RFP-100A, Baylis Medical Company, Montreal, Canada). These generators are operable to deliver continuous RF energy at about 480 kHz. A grounding pad or dispersive electrode is connected to the generator for contacting or attaching to a patient's body to provide a return path for the RF energy when the generator is operated in a monopolar mode.

[0095] Medical device 20 may be used to deliver energy to a target site within a body of a human or animal. In some embodiments, the energy is RF current, and the energy functions to puncture or create a void or channel in the tissue at the target site. Further details regarding delivery of energy to a body are found in U.S. Patent Applications 10/347,366 (filed on January 21st, 2003), 10/760,749 (filed on January 21st, 2004), 10/666,288 (filed on September 19th, 2003), and 11/265,304 (filed on November 3rd, 2005), and U.S. Patent 7,048,733 (Application 10/666,301, filed on September 19th, 2003), all of which are incorporated herein by reference.

[0096] An aspect of the invention is a method of creating a puncture in tissue, for example using embodiments of a medical device as described herein above. Making reference to Figs. 23A and 23B, an embodiment of the method comprises: (i) introducing a medical device 20 into a body of a patient, the medical device 20 comprising an elongate member 6 having a distal region 24 and a proximal region 22 (Fig. 1), an energy delivery device 15 proximate to the distal region and capable of cutting material, and a lumen 26 and apertures 25 operable to be in communication with a pressure sensing mechanism (not shown) for determining pressure in the body proximate to the distal region 24; (ii) positioning the energy delivery device 15 to a first desired location in the patient's body adjacent material to be cut; (iii) delivering energy using the energy delivery device 15 to cut said material; and (iv) measuring pressure in the body using the pressure sensing mechanism in order to determine the position of the medical device 20 at least one of before and after step (iii). In some embodiments of this aspect, step (ii) comprises delivering fluid, for example contrast fluid, for imaging at the first desired location in the patient's body.

[0097] Some embodiments of the method further comprise a step of (v) advancing the device to a second desired location. In certain embodiments of this aspect, the medical device comprises at least one radiopaque marker 5 and step (v) comprises monitoring at least one of said radiopaque markers 5. Some embodiments of the method comprise a step (vi) of measuring pressure at the second location. In some embodiments, the medical device comprise at least one radiopaque marker 5 and step (vi) is performed after confirming the position of the pressure sensing mechanism at the second location using said radiopaque markers.

[0098] In some embodiments, step (i) comprises introducing the device into the patient's vasculature and/or other body lumens by inserting the device 20 into a dilator 52 and a guiding sheath 50 positioned in the patient's vasculature. In certain embodiments, the device 20 and at least one of the dilator 52 and sheath 50 comprise a radiopaque marking and step (ii) comprises aligning the radiopaque markings to aid in positioning the device. For certain alternative embodiments of the method, step (v) comprises advancing the dilator 52 and the sheath 50 into the second location together over the spatially fixed medical device 20. In other alternative embodiments, step (v) comprises advancing the dilator, sheath and medical device all together into the second location.

[0099] In certain embodiments the material to be cut is tissue located on an atrial septum 56 of a heart, for example, the fossa ovalis 60 of a heart. In such a case, the pressure measured at the first location is the blood pressure in the right atrium 54 and the pressure measured at the second location is the blood pressure in the left atrium 58.

[0100] In some alternative embodiments, the method further includes delivering imaging (i.e. contrast) fluid that is visible using an imaging system in order to confirm the position of the medical device 20 at the second desired location.

[0101] In certain embodiments of the method, the medical device, dilator, and sheath are introduced into the heart via the inferior vena (Figs. 23A and 23B). In alternative embodiments, the heart is accessed from the superior vena cava (not shown in figures). Further details regarding superior and inferior approaches to the heart is be found in U.S. Patent Applications 13/113,326 (filed on May 23rd, 2011), and 11/265,304 (filed on November 3rd, 2005) both of which are incorporated herein by reference in their entirety.

[0102] In accordance with the method, for certain embodiments, the medical device comprises an elongate member having a distal region capable of adopting a curved shape to define a curved portion 30. For example, a support spine with a bias towards a curved shape may be positioned within a distal portion of a lumen of the elongate member, as described herein above. When the medical device tip advances through the material, the pre-shaped support spine causes the distal region to adopt a curved shape to direct the functional tip in a desired direction. In some embodiments, the curved portion 30 is defined by a radial arc and the energy delivery device 15 is directed away from cardiac structures, as shown in Fig. 23B. For example, energy delivery device 15 may be directed away from cardiac structures in order to decrease the risk of unwanted injury. As a further example, the distal region is adapted to form a 270 degree curve.

[0103] In alternative applications of a method of the present invention, medical device 20 is be used to create a channel through an occluded or stenosed lumen or through other material within the body. Examples include blood vessels, stent-graft fenestrations, bile duct or airways of the respiratory tract. In such embodiments, medical device 20 is positioned such that the electrode is adjacent the material to be punctured. Energy is delivered from a source, such as a generator, via elongate member 6, to the target site such that a void, puncture, or channel is created in or through the tissue. Further details regarding delivery of energy to create channels through occlusions or other material is found in U.S. Patent Application 12/926,292, filed on November 8, 2010, U.S. Patent Application 13/286,041, filed on October 31, 2011, and U.S. Patent 8,048,071, issued November 1, 2011, all of which are incorporated herein by reference.

[0104] Thus, embodiments of the disclosure include a medical device comprising: a flexible elongate member that defines a lumen, and a support spine affixed to the distal end and extending proximally therefrom within the elongate member lumen (i.e. in typical embodiments the support spine is not attached to a lumen surface or embedded in the elongate member's sidewall). In some embodiments, the support wire is configured to support at least a portion of the elongate member. Some embodiments of the medical device provide for distal end fluid delivery by defining apertures at or near the distal end that enable fluid communication between the lumen and the outside environment. Furthermore, in some such embodiments, the support spine extends from the distal end within a distal portion of the lumen such that a proximal portion of the lumen is substantially unobstructed (i.e. not obstructed by the support spine), thereby reducing and minimizing effects on fluid flow, at least within the proximal portion of the lumen.

[0105] The embodiments of the invention described above are intended to be exemplary only. The scope of the invention is therefore intended to be limited solely by the scope of the appended claims.

[0106] It is appreciated that certain features of the invention, which are, for clarity, described in the context of separate embodiments, may also be provided in combination in a single embodiment. Conversely, various features of the invention, which are, for brevity, described in the context of a single embodiment, may also be provided separately or in any suitable sub-combination.

[0107] Although the invention has been described in conjunction with specific embodiments thereof, it is evident that many alternatives, modifications and variations will be apparent to those skilled in the art. Accordingly, it is intended to embrace all such alternatives, modifications and variations that fall within the broad scope of the appended claims. All publications, patents and patent applications mentioned in this specification are herein incorporated in their entirety by reference into the specification, to the same extent as if each individual publication, patent or patent application was specifically and individually indicated to be incorporated herein by reference. In addition, citation or identification of any reference in this application shall not be construed as an admission that such reference is available as prior art to the present invention.

Examples



[0108] Example 1. A medical device comprising: a flexible elongate member configured for traversing body lumens, the elongate member defining a lumen that is in fluid communication with at least one distal aperture; a support spine extending proximally from the distal end of the medical device within a distal portion of the lumen; anda proximal end of the support spine being located within a distal portion of the lumen.

[0109] Example 2. The medical device of example 1, wherein the elongate member is generally tubular in configuration and wherein a distal portion of a sidewall has at least one cut therein to increase flexibility.

[0110] Example 3. The medical device of example 2, wherein the at least one cut is partially through the sidewall

[0111] Example 4. The medical device of claim 2, wherein the at least one cut is completely through the sidewall.

[0112] Example 5. The medical device of example 2, wherein the at least one cut is an interrupted spiral cut comprising a plurality of cut segments, each cut segment comprising a cut of about 120 degrees around a circumference of the elongate member followed by about 30 degrees of un-cut material around the circumference.

[0113] Example 6. The medical device of example 2, wherein a proximal end of the support spine is proximal of a proximal end of the cut whereby the support spine overlaps with an uncut portion of the elongate member.

[0114] Example 7. The medical device of example 1, wherein the support spine is about 10 cm to about 11 cm in length and wherein the elongate member is from about 60 cm to about 120 cm in length.

[0115] Example 8. The medical device of example 7, wherein the support spine is about 10 cm in length and wherein the elongate member is about 120 cm in length

[0116] Example 9. The medical device of example 1, wherein the support spine has a curved proximal end

[0117] Example 10. The medical device of example 1, wherein the support spine has a curved portion for biasing the medical device into a curved configuration.

[0118] Example 11. The medical device of example 1, wherein the medical device includes a curved portion defining a substantially 270 degree curve.

[0119] Example 12. The medical device of example 11, wherein a first 90 degrees of the curved portion has a radius of about 6.5 mm, and a last 90 degrees of the curve has a radius of about 4 mm

[0120] Example 13. The medical device of example 1, wherein the support spine comprises a helical spring.

[0121] Example 14. The medical device of example 1, wherein the support spine defines a proximal taper.

[0122] Example 15. The medical device of example 1, wherein the support spine comprises a single wire.

[0123] Example 16. The medical device of example 15, wherein the support spine has an outer diameter between about 0.1 mm to about 0.3 mm

[0124] Example 17. The medical device of example 16, wherein the support spine has an outer diameter of about 0.2 mm.

[0125] Example 18. The medical device of example 1, wherein the support spine comprises a plurality of wires.

[0126] Example 19. The medical device of example 18, wherein the plurality of wires is coupled side-by-side.

[0127] Example 20. The medical device of example 18, wherein the plurality of wires is braided together.

[0128] Example 21. The medical device of example 1, wherein the support spine comprises a solid wire.

[0129] Example 22. The medical device of example 1, wherein the support spine comprises a hollow wire.

[0130] Example 23. The medical device of example 1, wherein support spine is a ribbon.

[0131] Example 24. The medical device of example 1, wherein support spine has a substantially D-shaped cross-section.

[0132] Example 25. The medical device of example 1, further comprising one or more visualization markers.

[0133] Example 26. The medical device of example 25, wherein the one or more visualization markers are radiopaque.

[0134] Example 27. The medical device of example 25, wherein the one or more visualization markers are coiled.

[0135] Example 28. The medical device of any one of examples 1-27, further comprising an energy delivery device at the distal end of the elongate member, the energy delivery device being operable to be electrically coupled to an energy source.

[0136] Example 29. The medical device of example 28, wherein the support spine extends proximally from the energy delivery device.

[0137] Example 30. The medical device of example 29, wherein the support spine is coupled to a center of an electrode of the energy delivery device.

[0138] Example 31. The medical device of example 30, further comprising a spacer proximal of the electrode, and wherein the support spine extends proximally through a bore of the spacer.

[0139] Example 32. The medical device of example 29, wherein the support spine is coupled to an electrode of the energy delivery device in an off-center position.

[0140] Example 33. The medical device of example 29, wherein the support spine is coupled to a sidewall defining the lumen at the distal end of the medical device.

[0141] Example 34. A medical device comprising: an elongate member configured for traversing body lumens, the elongate member defining a lumen; and a support spine having a distal end coupled to a distal end of the medical device and extending proximally therefrom wherein a proximal end of the support spine is not coupled to the elongate member, the support spine being thereby configured to support a tensile side of the elongate member during bending.

[0142] Example 35. The medical device of example 34 wherein the lumen is in fluid communication with at least one distal aperture.

[0143] Example 36. The medical device of example 34 further comprising an energy delivery device at the distal end of the elongate member, the energy device being operable to be electrically coupled to an energy source.

[0144] Example 37. The medical device of example 34 wherein the support spine comprises a material having shape memory.

[0145] Example 38. The medical device of example 37 wherein the support spine defines a curve.

[0146] Example 39. The medical device of example 34, wherein the elongate member is generally tubular in configuration and wherein a distal portion of a sidewall has at least one cut therein to increase flexibility.

[0147] Example 40. The medical device of example 39, wherein the at least one cut is partially through the sidewall.

[0148] Example 41. The medical device of example 39, wherein the at least one cut is completely through the sidewall.

[0149] Example 42. The medical device of example 39, wherein the at least one cut is an interrupted spiral cut comprising a plurality of cut segments, each cut segment comprising a cut of about 120 degrees around a circumference of the elongate member followed by about 30 degrees of un-cut material around the circumference.

[0150] Example 43. The medical device of example 39, wherein a proximal end of the support spine is proximal of a proximal end of the at least one cut whereby the support spine overlaps with an uncut portion of the elongate member.

[0151] Example 44. The medical device of example 34, wherein the support spine is about 10 cm to about 11 cm in length and the elongate member is from about 60 cm to about 120 cm in length.

[0152] Example 45. The medical device of example 44, wherein the support spine is about 10 cm in length and wherein the elongate member is about 120 cm in length.

[0153] Example 46. The medical device of example 34, wherein the support spine has a curved proximal end.

[0154] Example 47. The medical device of example 34, wherein the support spine has a curved portion for biasing the medical device into a curved configuration.

[0155] Example 48. The medical device of example 34, wherein the medical device includes a curved portion defining a substantially 270 degree curve.

[0156] Example 49. The medical device of example 34, wherein a first 90 degrees of the curved portion has a radius of about 6.5 mm, and a last 90 degrees of the curve has a radius of about 4 mm

[0157] Example 50. The medical device of example 34, wherein the support spine comprises a helical spring.

[0158] Example 51. The medical device of example 34, wherein the support spine defines a proximal taper.

[0159] Example 52. The medical device of example 34, wherein the support spine comprises a single wire.

[0160] Example 53. The medical device of example 52, wherein the support spine has an outer diameter between about 0.1 mm to about 0.3 mm

[0161] Example 54. The medical device of example 53, wherein the support spine has an outer diameter of about 0.2 mm.

[0162] Example 55. The medical device of example 34, wherein the support spine comprises a plurality of wires.

[0163] Example 56. The medical device of example 55, wherein the plurality of wires is coupled side-by-side.

[0164] Example 57. The medical device of example 55, wherein the plurality of wires is braided together.

[0165] Example 58. The medical device of example 34, wherein the support spine comprises a solid wire.

[0166] Example 59. The medical device of example 34, wherein the support spine comprises a hollow wire.

[0167] Example 60. The medical device of example 34, wherein the support spine comprises a ribbon.

[0168] Example 61. The medical device of example 34, wherein support spine has a substantially D-shaped cross-section.

[0169] Example 62. The medical device of example 34, further comprising one or more visualization markers.

[0170] 63. The medical device of example 62, wherein the one or more visualization markers are radiopaque.

[0171] Example 64. The medical device of example 62, wherein the one or more visualization markers are coiled.

[0172] Example 65. The medical device of example 36, wherein the support spine extends proximally from the energy delivery device.

[0173] Example 66. The medical device of example 65, wherein the support spine is coupled to a center of an electrode of the energy delivery device.

[0174] Example 67. The medical device of example 66, further comprising a spacer proximal of the electrode, and wherein the support spine extends proximally through a bore of the spacer.

[0175] Example 68. The medical device of example 65, wherein the support spine is coupled to an electrode of the energy delivery device in an off-center position.

[0176] Example 69. The medical device of example 65, wherein the support spine is coupled to a side-wall defining the lumen at the distal end of the medical device.

[0177] Example 70. The medical device of any one of examples 1 or 35, wherein the distal aperture and the lumen cooperatively define a pressure transmitting lumen.

[0178] Example 71. The medical device of any one of examples 1 or 65 to 68, wherein the support spine provides support to a side-wall defining the lumen.

[0179] Example 72. The medical device of example 30, wherein the electrode is sized for creating a puncture in a tissue of a heart septum while minimizing hemodynamic instability.

[0180] Example 73. The medical device of example 72, wherein the electrode has an outer diameter ranging from about 0.5 mm to about 1.0 mm

[0181] Example 74. The medical device of example 72, wherein the electrode has an outer diameter of about 0.9 mm

[0182] Example 75. The medical device of any one of examples 1 or 35, wherein the distal aperture is configured for delivering fluid from the lumen for staining tissue.

[0183] Example 76. The medical device of example 70, wherein the pressure transmitting lumen is operable to be coupled to a pressure sensing mechanism.

[0184] Example 77. The medical device of any one of examples 25, 26, 27, 62, 63, or 64, wherein the support spine comprises a plurality of evenly spaced markers attached thereto.

[0185] Example 78. The medical device of example 72, wherein the support spine and the elongate member have different bend radii.

[0186] Example 79. The medical device of example 66, wherein the electrode is sized for creating a puncture in a tissue of a heart septum while minimizing hemodynamic instability.

[0187] Example 80. The medical device of example 1, wherein a proximal end of the support spine is unconstrained within the lumen, the support spine being thereby configured to support a tensile side of the elongate member during bending.


Claims

1. A medical device for puncturing tissue comprising:

an elongate member comprising a proximal region and a distal region, wherein the distal region comprises a flexible portion which is more flexible than the proximal region;

the elongate member having a tubular configuration and including a metallic layer which is electrically conductive;

a rigid energy delivery device at a distal end of the elongate member which is electrically connected to the metallic layer of the elongate member, the rigid energy delivery device being configured to deliver electrical energy to tissue when electrical energy is supplied to the rigid energy delivery device through the metallic layer; and

wherein the flexible portion includes at least one gap in a sidewall of the elongate member wherein the at least one gap comprises at least one cut in the sidewall.


 
2. The medical device of claim 1, wherein the proximal region and energy delivery device are more rigid than the distal region.
 
3. The medical device of claim 1, wherein the elongate member defines a lumen, and the rigid energy delivery device comprises a conductive dome, a conductive spacer which is proximal of the conductive dome and which defines a bore, and a support spine extending within the lumen proximally from the bore, wherein the conductive dome, the conductive spacer, and the support spine are joined together distal of the lumen.
 
4. The medical device of claim 1, wherein the elongate member defines a lumen, and the distal region comprises a support spine in the lumen extending proximally from the distal end of the medical device along a length of the distal region.
 
5. The medical device of claim 1, wherein the distal region conforms to a tube or vasculature when the distal region is inserted or advanced through the tube or vasculature.
 
6. The medical device of claim 4, wherein the at least one gap of the distal region is partially blocked by the support spine.
 
7. The medical device of claim 4, wherein the support spine provides support to the distal region of the medical device.
 
8. The medical device of claim 4, wherein a proximal end of the support spine is independent of the sidewall of the elongate member and is unconstrained within the lumen whereby the support spine is operable during bending of the distal region to press against a tensile side of the distal region to provide support to the tensile side such that the support spine distributes stress along the distal region.
 
9. The medical device of claim 1, wherein the distal region is configured to form a curve whereby it curves away from a central axis of the proximal region.
 
10. The medical device of claim 1, wherein the elongate member defines a lumen extending from the proximal region to the distal end of the elongate member.
 
11. The medical device of claim 1, wherein the elongate member is comprised of the metallic layer such that energy is delivered along its length to the rigid energy delivery device.
 
12. The medical device of claim 4, wherein the support spine is comprised of electrically conductive material.
 
13. The medical device of claim 1, wherein the at least one cut is in a shape of a C-cut.
 
14. The medical device of claim 1, wherein the at least one cut is in a shape of an interrupted spiral shaped cut.
 
15. The medical device of claim 1, wherein the flexible portion includes an additional cut to thereby define an interlocking cut.
 




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Cited references

REFERENCES CITED IN THE DESCRIPTION



This list of references cited by the applicant is for the reader's convenience only. It does not form part of the European patent document. Even though great care has been taken in compiling the references, errors or omissions cannot be excluded and the EPO disclaims all liability in this regard.

Patent documents cited in the description