under general anesthesia and double - lumen ventilation , the patient is prepped and draped so as to allow ample surgical access to the right lateral , anterior and left lateral chest wall ( from the posterior axillary line on one side to the posterior axillary line on the other side ). as shown in fig1 , one or more thoracoscopic ports are inserted in the left chest through the intercostal spaces and an instrument 10 is inserted through one of these ports into the chest cavity . alternatively , a small ( 3 - 5 cm ) left thoracotomy is performed in the fifth or sixth intercostals space on the anterior axillary line . the patient is fully heparinized . after collapsing the left lung , the pericardium overlying the apex 12 of the left ventricle 14 is opened and its edges are suspended to the skin incision line . this provides close access to the apex of the heart . guidance of the intracardiac procedure is provided by a combination of transesophageal or intravascular echocardiography ( not shown in the drawings ) and with direct visualization through a fiber - optical system built into the instrument 10 as will be described in detail below . a double - pledgeted purse - string suture is placed on the apex of the left ventricle 12 and a stab incision is made at that location . the surgical instrument 10 is inserted through this incision , into the left ventricular chamber 14 of the beating heart . referring particularly to fig2 , the instrument 10 may be used to grasp a prolapsing segment of the mitral valve 16 and an artificial chorda 18 may be secured to its free edge . accurate positioning of the implanted artificial chorda 18 is guaranteed by both echo and direct fiberoptic visualization as will be described in detail below . the instrument 10 is then withdrawn from the left ventricle chamber 14 pulling the unattached end of the neo - implanted chorda 18 with it . hemostasis is achieved by tying the purse - string suture around the incision in the left ventricular apex 12 after the instrument 10 and chorda 18 are withdrawn . as shown in fig3 , the neo - implanted chorda 18 is appropriately tensioned under direct echo - doppler visualization and secured outside the apex 12 of the heart . that is , a tension is placed on the neo - implanted chorda 18 and the operation of the repaired valve 16 is observed on the ultrasound image . the tension is adjusted until regurgitation is minimized . while a single chorda 18 is implanted in the above description , additional chorda , or sutures , can be implanted and attached to the apex 12 of the heart wall with optimal tension . in this case the tensions in all the neo - implanted chorda 18 are adjusted until optimal valve operation is achieved . as shown in fig4 and 5 , the instrument 10 used to perform the above procedure includes a rigid metal shaft 100 having a handle 120 at its extrathoracic ( proximal ) end which enables the instrument to be manipulated and guided into position . actuating mechanisms for controlling the grasping mechanism and needle mechanism located at the distal end 140 of the instrument are also mounted near the handle 120 . as will be described below , the grasping mechanism is operated by squeezing the scissor - grip handle 120 , and the needle mechanism is operated by moving an up - turned control shaft 122 . located on the distal , intracardiac end 140 of the instrument 10 is a grasping mechanism which can be operated to hold a prolapsing valve leaflet . as shown in fig6 and 7 , in the preferred embodiment this mechanism is a tip 160 which is supported on the distal end of the shaft 100 by a set of rods 162 . the rods 162 slide within the shaft 100 to move the tip 160 between an open position as shown in fig6 b and 7 and a closed position as shown in fig6 a when the scissor - grip handle 120 is operated . as will be explained below , a mitral valve leaflet is located in the gap between the open tip 160 and the distal end of shaft 100 and it is captured by closing the tip 160 to pinch the valve leaflet therebetween . disposed in a needle lumen 164 formed in the shaft 100 is a needle 180 which connects to the control shaft 122 at the proximal end of shaft 100 . needle mechanism 180 slides between a retracted position in which it is housed in the lumen 164 near the distal end of the shaft 100 and an extended position in which it extends into the sliding tip 160 when the tip is in its closed position . as a result , if a valve leaflet has been captured between the tip 160 and the distal end of shaft 100 the needle may be extended from the lumen 164 by moving control shaft 122 to puncture the captured leaflet and pass completely through it . the distal end of the shaft 100 also contains an artificial chorda , or suture 18 that is to be deployed in the patient &# 39 ; s heart . the suture 18 is typically a 4 - 0 or 5 - 0 suture manufactured by a company such as gore - tex . this suture 18 is deployed by the operation of the grasping mechanism and the needle mechanism 180 as described in more detail below . the shaft 100 has a size and shape suitable to be inserted into the patient &# 39 ; s chest and through the left ventricle cardiac wall and form a water - tight seal with the heart muscle . it has a circular or ellipsoidal cross - section and it houses the control links between the handle end and the intracardiac end of the instrument as well as a fiber optic visualization system described in more detail below . as shown in fig8 a - 8f , the preferred embodiment of the suture deployment system at the distal end of the instrument 10 is positioned around a valve leaflet 16 to be repaired as shown in fig8 a . the suture 18 is folded at the middle to form a loop 19 that is positioned in the tip 160 . both ends of the suture 18 are disposed in a suture lumen 165 formed in the shaft 100 beneath the rods 162 . as shown in fig8 b , the valve leaflet 16 is grasped by closing the tip 160 , and the needle 180 is extended to puncture the leaflet 16 and extend into the tip 160 . a notch 166 formed on one side of the needle 180 hooks the suture loop 19 . the needle 180 is then retracted back through the leaflet 16 to pull the suture loop 19 through the puncture opening as shown in fig8 c . the leaflet 16 is then released and the instrument 10 is withdrawn from the heart as shown in fig8 d pulling both ends and the midpoint of the suture 18 with it . as shown in fig8 e , the suture 18 is released by the instrument 10 and the surgeon inserts the two suture ends 21 through the loop 19 at its midpoint . the ends 21 are then pulled and the loop 19 slides along the suture 18 back into the heart chamber 14 where it forms a larks head around the edge of the valve leaflet as shown in fig8 f . multiple sutures 18 may be implanted in this manner until a satisfactory result is obtained . after deployment of the sutures 18 , the heart wall incision is repaired by either a pre - positioned purse - string suture or by any kind of appropriate hemostatic device or technique . hemostasis is checked , appropriate chest drainage tubes are positioned and secured , and all incisions are closed . as shown in fig9 a - 9d , a second embodiment of the suture deployment system at the distal end of the instrument 10 is positioned around a valve leaflet 16 to be repaired as shown in fig9 a . the suture 18 in this embodiment is a closed loop with one end of the loop disposed in the tip 160 and its other end disposed in the lumen 164 and wrapped around the needle 180 . the needle 180 is extended through the grasped valve leaflet 16 into the instrument tip 160 where it hooks one end of the looped suture 18 in a notch 166 formed on one side of the needle as shown in fig9 b . the needle 180 is then retracted to pull the the looped suture 18 through the puncture opening in the leaflet 16 . the leaflet is then released as shown in fig9 c by sliding the tip 160 to its open position . the instrument 10 is then withdrawn as shown in fig9 d to slide the unhooked end of the looped suture 18 along the length of the needle toward the leaflet 16 where it forms a larks head around the leaflet edge . the instrument 10 is then withdrawing from the heart chamber 14 pulling the hooked end of the suture 18 through the heart wall . the suture 18 is secured to the outside of the heart apex . as shown in fig1 a - 10d , a third embodiment of the suture deployment system at the distal end of the instrument 10 is positioned around a valve leaflet 16 to be repaired as shown in fig1 a . the midpoint 17 of the suture 18 is looped around the lumen 164 and its two loose ends 20 are coiled up in the tip 160 . after the tip 160 is closed to capture the valve leaflet 16 , the needle 180 is extended through the grasped valve leaflet 16 into the instrument tip 160 . the free ends 20 of the suture 18 are positioned in the tip 160 to form a loop 19 and a notch 166 formed on one side of the needle extends through this loop 19 and “ hooks ” the free ends of the suture 18 as shown in fig1 b . the needle 180 is then retracted back into the lumen 164 to pull the hooked ends of the suture 18 through the puncture opening in the leaflet 16 . the leaflet is then released as shown in fig1 c by sliding the tip 160 to its open position . the instrument 10 is then withdrawn from the heart as shown in fig1 d to pull the free ends 20 back through the valve leaflet 16 and a larks head is formed around the leaflet edge by the midpoint 17 of the suture 18 . the instrument 10 is then withdrawn from the heart chamber 14 pulling the free ends 20 of the suture 18 through the heart wall . the free ends 20 of the suture 18 are secured to the outside of the heart apex . other suture deployment systems are possible where , for example , the needle may penetrate through the leaflet and link up with a snap fitting device that is attached to one end of the looped suture 18 in the instrument tip 160 . the needle then withdraws pulling the device and looped suture back through the penetration opening in the leaflet as described above . as shown in fig7 to enhance visibility during this procedure , four fiberoptic channels 170 extend along the length of the instrument shaft 100 and terminate at its distal end . each channel 170 contains at least one illuminating fiber which connects at its extrathoracic end to a white light source ( not shown in the drawings ). each channel 170 also contains at least one sensor fiber which conveys reflected light from the distal end back to a visualization monitor ( not shown in the drawings ) connected to its extrathoracic end . in the preferred embodiment each channel 170 includes two illuminating fibers and two sensor fibers . the four fiberoptic channels 170 are disposed around the needle lumen 164 such that when a valve leaflet 16 is properly grasped , the valve leaflet tissue 16 rests against the distal end of all the fibers 170 . as a result , light is reflected off the tissue back into the sensor fibers and four white circles are displayed on the visualization monitor . when the leaflet 16 is not properly pressed against the distal end of a channel 170 , light is not reflected from the leaflet 16 and the visualization monitor displays the red color reflected from blood . when no valve tissue is captured , the monitor shows four red dots and when valve tissue is captured , the dots corresponding to the fiberoptic channels 170 contacting the tissue turn white . if the monitor shows all four dots as white , it means that the valve tissue capture is optimal . if only the upper two dots turn white and the bottom dots remain red , the “ bite ” on the valve leaflet 16 is too shallow for a proper attachment of the suture 18 . in addition to the fiberoptic visualization system that insures that a valve leaflet is properly captured , other real - time visualization systems are employed to help guide the instrument 10 to the valve leaflet 16 . preferably a transesophageal or intravascular color - doppler echocardiography system is used for this purpose . as explained above , this imaging system is also used to determine the length of the neo - implanted artificial chordae in real - time by observing reduction or disappearance of regurgitation by transesophageal or intravascular color - doppler echocardiography .
an instrument for performing thorascopic repair of heart valves includes a shaft for extending through the chest cavity and into a heart chamber providing access to a valve needing repair . a movable tip on the shaft is operable to capture a valve leaflet and a needle is operable to penetrate a capture valve leaflet and draw the suture therethrough . the suture is thus fastened to the valve leaflet and the instrument is withdrawn from the heart chamber transporting the suture outside the heart chamber . the suture is anchored to the heart wall with proper tension as determined by observing valve operation with an ultrasonic imaging system .