the present invention is directed to improved cooling cannula systems and methods for their use in cardiac surgery . the present invention may exist in numerous embodiments , including those that may be inserted peripherally thus avoiding the need for a major chest incision such a thoracotomy or median stemotomy . by utilizing fluoroscopic or ultrasound imaging , the cooling device when designed in combination with a cannula may be precisely positioned such that upon inflation of inflatable members such as balloons , the flow of blood into the right atrium is fully blocked thereby achieving total heart bypass . the combined cooling device and cannula may use conventional heat transfer media cooled by refrigeration systems known in the art , or it may use thermoelectric cooling devices to accomplish the desired cooling . by way of background , and in no way limiting the instant teachings , thermoelectric coolers are solid - state heat pumps that operate on the peltier effect , the theory that there is a heating or cooling effect when electric current passes through two conductors . a voltage applied to the free ends of two dissimilar materials creates a temperature difference . with this temperature difference , peltier cooling will cause heat to move from one end to the other . a typical thermoelectric cooler will consist of an array of p - and n - type semiconductor elements that act as the two dissimilar conductors . the array of elements is soldered between two ceramic plates , electrically in series and thermally in parallel . as a dc current passes through one or more pairs of elements from n - to p -, there is a decrease in temperature at the junction (“ cold side ”) resulting in the absorption of heat from the desired structure . the heat is carried through the cooler by electron transport and released on the opposite (“ hot ”) side as the electrons move from a high to low energy state . the heat pumping capacity of a cooler is proportional to the current and the number of pairs of n - and p - type elements ( or couples ). in accordance with one embodiment of the invention , there is provided a cooling cannula comprising an insertion piece for insertion into the right atrium through the superior vena cava . the insertion piece has a plurality of apertures for drainage of the inferior vena cava at its distal end , and is joined at its proximal end to the distal end of a connection piece . the connection piece is fitted at its proximal end with a coupling to a pump inlet of the heart heart - lung machine . the apertures collectively comprise a cross - section sufficient to accommodate the blood being bypassed . in one embodiment of the present invention , the cannula cools the right atrium to a temperature below 20 ° c . in another embodiment of the present invention , the cannula cools the right atrium to a temperature between 8 ° c . and 17 ° c . in a still further embodiment of the present invention , the cannula cools the right atrium to a temperature between 10 ° c . and 15 ° c . the above described , currently clinically utilized version of the instant teachings likewise feature a cannula which is preferably bent to form an angle between about a right angle and an obtuse angle of about 110 ° ( an angle of inclination from linearity of about 70 °). one skilled in the art would realize that other angles may be desired depending on the patient &# 39 ; s vasculature , and surgeon &# 39 ; s approach . the insertion piece has a side opening ( s ) positioned so as to drain the superior vena cava . in other embodiments the device can be constructed to enable insertion either through the superior vena cava , right atrium , inferior vena cava , or peripherally . in embodiments designed to be inserted through the inferior vena cava , the plurality of apertures drains the superior vena cava , and the side opening ( s ) drain the inferior vena cava . in embodiments designed to be inserted through the femoral vein , the plurality of apertures drains the superior vena cava , and the side openings ( s ) drain the inferior vena cava . in embodiments designed to be inserted through the jugular vein , the plurality of apertures drains the inferior vena cava , and the side opening ( s ) drains the superior vena cava . the internal diameter of the insertion piece and the internal diameter of the connecting piece are proportional to the volume of the transported bloodstream . the invention provides an improved means for cooling the surfaces of the atrium involved in cpb procedures . in one embodiment , the means for cooling comprise a radially expandable cooling membrane which in one expanded predetermined configuration has substantial engagement with the thick tissue shelves of the right atrium , but does not have substantial contact with the atrial appendages , tricuspid valve , coronary sinus , and other interior surfaces of said right atrium . in this way , damage to the thin tissue appendages , tricuspid valve , coronary sinus , and other interior surfaces of the right atrium is avoided . moreover , the supraventricular excitor and conduction systems are protected , thus providing intraoperative protection of the cooled tissues and ultimately reducing postoperative conduction disturbances . this invention provides indirect cooling means for the thin atrial appendages and other interior surfaces of said right atrium . the cooling means , in a preferred embodiment , comprises an inflatable membrane that has a separate inlet and outlet duct to allow a continual flow . a thin layer of liquid or blood between the membrane and the luminal aforementioned structures of the right atrium is sufficient to enable sufficient heat transfer to account for the observed cooling . in this way , damage to the thin atrial appendages and other interior surfaces of the right atrium is avoided . the heat radiation from the cannula in the right atrium is also absorbed by the inflatable membrane . the inflatable membrane , which is made of a biocompatible polymer such as polyurethane , may be made more conductive by the incorporation of particles of a biocompatible metal , or particles of a biocompatible metal alloy comprising at least two elements selected from the group consisting of iron , cobalt , chromium , nickel , titanium , niobium , and molybdenum . alternatively , the same metals or alloys can be formed into sheets to coat both the interior and exterior surfaces of said inflatable membrane . the following describes presently preferred embodiments of the invention only , and is not intended to exhaustively describe all possible embodiments in which the invention may be practiced . as discussed , unique aspects of cad , hvd , chf and the like disease states drive modifications of the described devices and methods such the artisans would be able to effect such changes , given the guidance of those descriptions with the claims appealed hereto . unless defined otherwise , all technical and scientific terms used herein have the same meaning as is commonly understood by one of skill in the art to which this invention belongs . all patents and publications referred to herein are incorporated in their entirety by reference . referring to fig1 , a portion of a heart , generally indicated by 1 , includes the right atrium 3 , the superior vena cava 72 , and the inferior vena cava 71 . during an operation where heart function is disconnected , and the circulation is taken over by a heart - lung machine , blood is extracted through the right atrium , the superior cavae or the inferior venae cavae . a cannula 10 , typically having an outer diameter between about 10 fr and about 55 fr is used for this purpose , and may include fluid communication access adapted for venous blood pressure measurement of said patient . as may be seen , the embodiment of the cannula 10 depicted in fig1 is generally tubular in shape . this tubular shape , which allows the cannula to be the axis of rotation , facilitates “ flipping ” the heart to provide access to the posterior portion during surgical procedures . the cannula 10 is not designed to fill the right atrium . fig2 provides and enlarged , cut - away , elevational view of the cooling cannula system of the present invention . cannula 10 consists of a connecting piece 20 and a thinner insertion piece 30 . connecting piece 20 and insertion piece 30 are joined to each other by an angle of inclination 40 . angle 40 can range between approximately 45 ° and approximately 180 ° depending on the physical properties of the material used to make cannula 10 . when such material is flexible and can be bent without occluding the lumen of the cannula , an angle larger than about 45 ° is permissible , preferably , the angle is between about 100 ° and 120 °, and even more preferably between about 105 ° and about 115 °. an opening 45 , which provides a connection with the superior vena cava , is positioned in this angle . the distal end of insertion piece 30 is provided with at least one hole 90 . the cross - section of hole 90 should be sufficient to accommodate the flow volume in the cannula . when in use , insertion piece 30 is inserted into superior vena cava , passed through right atrium , and extends into inferior vena cava . according to the invention , means for reinforcement such as metal spirals or other reinforcement means known in the art may be positioned to prevent buckling of the material from which the connecting piece 20 and the insertion piece 30 are made . venous drainage of inferior vena cava passes through hole 90 , and then through a lumen 110 in insertion piece 30 , and then through a lumen 120 in connecting piece 20 ( see fig3 - 4 ). venous drainage of superior vena cava 5 passes through hole 45 , and then through a lumen 120 in connecting piece 20 . connecting piece 20 is connected at its proximal end to a tube leading to a venous reservoir , not shown . according to one embodiment of the invention , cannula 10 is provided with cooling means . these consist of an inlet for coolant 130 and an outlet for coolant 140 , which are connected to a radially expandable membrane constructed of a biocompatible material . such material may be , for example , polyurethane , silicone , latex , polyvinylchloride , polyolefin , low - density polyethylene , or polycarbonate . however , other suitable biocompatible materials known in the art may also be used . the coolant may be any suitable heat transfer fluid including , but not limited to , water , aqueous saline solution , and calcium chloride solution and perfluorocarbon fluid . one skilled in the art will realize that other fluids or gels will also be suitable for use with the present invention . the membrane has at least one unexpanded predetermined configuration and at least one expanded predetermined configuration , which may comprise a substantially cylindrical form . when expanded , one end of the substantially cylindrical form may comprise a larger circumference than other portions . such size differential may be used to facilitate contact with the superior and inferior vena cavae . the substantially cylindrical form may be of any length suitable for insertion . in preferred embodiments , this length is between about 6 cm and about 14 cm . the middle portion may have any diameter suitable for insertion and inflation in the desired location . however , the expanded diameter is preferably between about 15 mm and about 30 mm . the expandable membrane is in the form of an inflatable balloon 60 in one embodiment of the invention . sections of the membrane may comprise at least two different thicknesses and may include a substantially cylindrical middle portion having at least one circumferential ring 70 formed on its inner surface . such ring , which provides structural support , may be formed from a section of biocompatible polymer , and may preferably be formed from a thickened section of such polymer . a passage 50 through balloon 60 is sealingly connected in fluid communication with right atrial suction tube 55 . when suction is applied to tube 55 , excess cardioplegic fluid used in the procedure is drained from right atrium 3 through passage 50 into tube 55 , which is connected to a suction means such as a vacuum pump , not shown . balloon 60 may be wrapped around insertion piece 30 so that it is possible to insert it easily into superior vena cava . by applying coolant pressure in the balloon the balloon is inflated and substantially engages the interior surfaces the right atrium , superior vena cava and inferior vena cava in order to occlude and cool them . by contrast , there is little or no contact with the atrial appendages , tricuspid valve , or coronary sinus . the expandable membrane may be produced by fabricating a substantially cylindrical mandrel having a circumference substantially equal to the circumference of the substantially cylindrical middle portion of the expandable membrane in its expanded configuration , fabricating at least one circumferential groove in the mandrel in areas corresponding to the substantially cylindrical middle portion of the expandable membrane , immersing the mandrel in a liquid dispersion of a biocompatible polymer , removing the mandrel from the dispersion , curing the biocompatible polymer on the mandrel ; and , removing the solidified membrane . alternatively , the membrane can be made by blow molding . fig5 is an elevational view of a cooling cannula system of the present invention , with like parts having the same numbers . in this view , it is possible to see the expandable membrane 60 and a plurality of circumferential ring 70 . such rings may be formed from a section of biocompatible polymer , and may preferably be formed from a thickened section of such polymer . opening 45 , which provides a connection with the superior vena cava , is positioned at angle 40 . the distal end of insertion piece 30 is provided with at least one hole 90 . as with other embodiments of the invention , the cross - section of hole 90 should be sufficient to accommodate the flow volume in the cannula . fig6 is an elevational view of a bifurcated cooling cannula system of the present invention , with like parts having the same numbers . such embodiment may be used in the atrial region like other embodiments of the present invention . one of ordinary skill in the art will realize that this embodiment of the present invention may also be used in other regions of the body . fig7 is an elevational view of a cooling cannula system of the present invention , with like parts having the same numbers . such embodiment may be inserted into the superior vena cava , thus accessing the heart without forming an incision in the right atrium . as discussed above , such atrial incisions may damage electrical conductivity pathways and produce transient conduction abnormalities . when properly placed , the cannula will block the superior vena cava and inferior vena cava inlets to the right atrium . such isolation of the right atrium eliminates backflow at the distal anastomoses . one of ordinary skill in the art will realize that this embodiment of the present invention may also be used in other regions of the body . in the embodiment of the present invention shown in fig7 , the balloon 60 is inflated to form a seal with the surrounding inferior vena cava 71 . likewise , the balloon 60 also forms a seal with the surrounding superior vena cava 72 . this occlusion of the superior vena cava and the inferior vena cava effectively isolates the right atrium and eliminates backflow at the distal anastomoses . with the backflow eliminated , addition blowers and suckers are no longer required to clear the field . also , the surgeon does not have to reduce the amount of arterial perfusion to reduce backflow through the coronaries . this results in a flaccid , empty heart and allows for superior access to posterior graft sites which , in turn , provides a faster , cleaner surgery . due to the occlusion of the superior and inferior vena cava inlets , blood and cardioplegia solution can drain out of the coronary sinus and accumulate in the right atrium . the embodiment of the present invention shown in fig7 also includes a drainage port 73 and line ( not shown ) for isolated drainage of the right atrium . this drainage port 73 and line thus allows the surgical team to isolate the additional fluid ( cardioplegia solution mixed with blood ) and reduce their hemodilution levels , while reducing the exposure of the patient to the potentially harmful effects of the cardioplegia solution . as discussed above , one of the functions of the present invention is to cool the surrounding tissue during surgery . to augment heat transfer , the polymer may incorporate dispersed particles of biocompatible metal such as iron , cobalt , chromium , nickel , titanium , niobium , silver , gold , platinum , aluminum , and molybdenum , or a biocompatible metal alloy comprising at least two elements selected from the group consisting of iron , cobalt , chromium , nickel , titanium , niobium , silver , gold , platinum , aluminum , and molybdenum . alternatively , such metal and metal alloys can be combined with the polymer in the form of layers . as used herein , the term “ augment ” is intended to mean that the augmented polymer transfers heat at a faster rate than untreated polymers . that is , using such metals with the polymer increases or augments the amount of heat that is transferred when compared to an un - augmented polymer . likewise , alternative cooling means will be well known to artisans , including at least the following ; chemical by means of some manner of endothermic reaction ( for example , an emergency cooling packs ) and / or a mechanical , or solvent / solute based reaction set , such as by using a pre - cooled gel that requires no circulating circuit ( as in a pre - frozen gel packs ). one could likewise inject chemical means , precursor means , media or related forms of an appropriate composition of matter , compound , or material ( for example dmso / rims050 ® brand as distributed by edwards lifesciences , utah , usa ) that has high freezing temperature . those skilled also understand the electrical way , as in the peltier example given , which only illustrates one of the many known techniques used recently . such mechanisms could include a refrigerant — external compressor and evaporator and for biochemical means from iontophoresis to some way to promote lower atp usage , or evaporative , or conductive mechanisms to cool the air external to appropriate anatomy via vortex tube . another alternative approach whereby at least one of the above cooling means could be used to cool the significant anatomy internally ( a device inserted into the right atrium ), or externally is within the scope of the instant teachings . all above cooling means could be combined with venous drainage cannulac or as stand - alone devices , according to the present invention . a method of use for providing drainage of venous blood using the invention comprises opening the vasculature , draining venous blood from at least one of the right atrium , superior vena cava and inferior vena cava ; and , cooling involved luminal surfaces . drainage of venous blood and cooling of cardiac tissue can be provided from a targeted location without opening the right atrium or the chest of a patient undergoing cardiac surgery . the method involves identifying a targeted location , inserting a guidewire in a jugular vein or femoral vein of a patient , observing the placement of the guidewire fluoroscopically while passing the guidewire through the vein until the distal end of the guidewire is situated in the targeted location ; threading the proximal end of the guide wire through the free end of the cannula ; passing the cannula along the guidewire while observing fluoroscopically until the radiopaque area lies in the targeted location ; withdrawing the guidewire ; draining venous blood and cooling involved luminal surfaces . a radiopaque area ( such as barium sulfate or stainless steel ) may be situated near the free end of the tubular insertion section to facilitate this method . the above - described method teaches the insertion of the present invention through a jugular or femoral vein of a patient . one of ordinary skill in the art will realize that the present invention may also be inserted through alternate peripheral vessels . such cooling may be used in association with known surgical techniques . alternatively , such cooling may be used as part of a cardiac surgical procedure whereby the heart is cooled while the patient &# 39 ; s body is maintained at a normothermic or tepid temperature . specifically , as part of a surgical procedure , the right atrium may be cooled while the patient &# 39 ; s body is maintained at a normothermic or tepid temperature . such selective cooling may be referred to as a warm body / cold heart procedure . cooling of the right atrium has the effect of also cooling the sa node and , indirectly , the av node and the connective tissue between the sa node and the av node . when used herein , the term ‘ normothermic ’ refers to a temperature that approximates the patient &# 39 ; s normal body temperature . such temperature is usually between 34 ° c . and 37 ° c ., and typically around 36 ° c . tepid refers to a temperature usually between 28 ° c . and 32 ° c . this temperature may be maintained during surgery by heating the patient &# 39 ; s blood through means known in the art . also within the present invention is an article of manufacture , comprising packaging material and the novel enhanced cardiac surgical cooling system contained within the packaging material , wherein the novel enhanced cardiac surgical cooling system is effective for cardiac surgery in a patient afflicted with cardiac disease , and the packaging material includes a label that indicates that said device is effective for said cardiac surgery . in the foregoing description , certain terms have been used for brevity , clearness and understanding , but no unnecessary limitations are to be implied therefrom beyond the requirements of the prior art . having described preferred embodiments of the invention with reference to the accompanying drawings , it is to be understood that the invention is not limited to those precise embodiments , and that the various changes and modifications may be effected therein by one skilled in the art without departing from the scope or spirit of the invention as defined in the appended claims and their equivalents . various additions , deletions , alterations and modifications may be made to the above - described embodiments without departing from the intended spirit and scope of the invention . it is , for example , possible to use other cooling means , such as tubing wrapped around the cannula , or other structures known in the art for efficient heat transfer , wherein insulation measures ensure that the contents of the tube are not affected . furthermore , warming can be done instead of cooling .
a novel improved enhanced cardiac surgical method yields unexpected results by having an enhanced intraluminally emplaced cooling system . in preferred device embodiments improvements include a first means for draining venous blood from at least one of the right atrium , superior vena cava and inferior vena cava and an improved means for cooling involved luminal surfaces . tissue insult and injury is substantially mitigated by engagement of the cooling means with select aspects of involved atrial tissue to augment transfer of heat . in one embodiment of the invention , the right atrium is cooled while the patient &# 39 ; s body is maintained at a normothermic temperature during surgery . the alternate cooling mechanisms disclosed have applicability both on - and off - pump in a variety of procedures ranging from traditional open cardiac surgical repair and by - pass to endovascular procedures using percutaneous access and minimally invasive therapies .