this invention relates to the rapid fashioning , sizing , and implanting of a tissue annuloplasty band for the general purpose of cardiac valve repair . although the description provided herein describes the use of the system for mitral valve repair , the apparatus and method may be used for other applications as well . therefore , the following description is intended merely as an example of how the apparatus and method of the present invention may be used , and not by way of limitation . in accordance with the present invention , the graft tissue ( i . e ., pericardium , vein , or other autologous or non - autologous tissue ) is first cut to an appropriate size . this may be done with any appropriate cutting tool . preferably , however , a male / female cutting die is used to cut the tissue into the general size and shape appropriate to create the tissue annuloplasty band . more particularly , and looking now at fig1 there is shown a male / female cutting die 10 . cutting die 10 comprises a male die 20 having a groove 30 formed therein , and a female die 40 having a window 50 formed therein . when a piece of donor tissue ( e . g ., pericardium ) is placed between male die 20 and female die 40 , and the two die members are thereafter brought together , a piece of graft tissue ( corresponding in size to opening 50 in female die 40 ) will be cut from the donor tissue . once the graft tissue has been cut to an appropriate size , it is then fashioned into the appropriate shape , i . e ., an elongated length . this may be done by rolling , folding , bunching , etc . in one preferred form of the invention , the tissue is rolled about an axle using the male die as the base . more particularly , and looking now at fig2 after a piece of graft tissue 60 has been cut , and while graft tissue 60 is lying on male die 20 , an axle 70 is pressed down into groove 30 . then one tissue end 80 is folded over the other tissue end 90 , and axle 70 is rolled , so as to form a tissue annuloplasty band 100 . if desired , an adhesive , a sealant , a medication or the like may be applied to the tissue . by way of example , an adhesive might be applied to a final rolled edge so as to keep the tissue annuloplasty band from unrolling . axle 70 is made of a relatively flexible material such as pliable plastic or metal . the body of the axle , while being flexible , may or may not stretch along its linear axis . the two ends 110 a , 110 b of axle 70 preferably have elastic properties , allowing these portions of the axle to stretch along their linear axis . once the graft tissue has been rolled into tissue annuloplasty band 100 , it is mounted onto a mounting ring for sizing and implanting . this may be implemented in a variety of ways , using a variety of devices . in one preferred form of the invention , and looking now at fig3 - 7 , a first sizer 120 is used . first sizer 120 comprises a handle 130 and an adjustable mounting ring 140 . handle 130 preferably comprises two cylinders 150 , 160 which are able to move relative to one another . cylinder 150 is connected to mounting ring 140 by a drive cable 170 ( shown in phantom ). drive cable 170 is in turn connected to a central bevel gear 180 ( fig7 ) in adjustable mounting ring 140 . rotation of central bevel gear 180 in turn causes the additional bevel gears 190 to rotate . these bevel gears 190 are coupled to threaded shafts 200 . adjustable mounting ring segments 210 are internally threaded and ride on the threaded shafts 200 . the rotation of threaded shafts 200 causes mounting ring segments 210 to move radially and hence causes adjustable mounting ring 140 to expand and contract ( i . e ., to change in radial dimension ). accordingly , it will be seen that rotation of cylinder 150 relative to cylinder 160 results in a change in the geometry ( i . e ., the size ) of adjustable mounting ring 140 . cylinder 160 ( i . e ., the one that is not connected to adjustable mounting ring 140 by drive cable 170 ) serves as the support portion of the handle and remains in a relatively fixed orientation with respect to adjustable mounting ring 140 . cylinder 160 may have a constant outer diameter or , alternatively , it may have a stepped outer diameter such as that shown in fig3 and 4 . handle 130 also has a size indicator 220 on the outside of cylinder 160 that shows the size of the tissue annuloplasty band after it has been properly sized . as mentioned above , adjustable mounting ring 140 is ( i ) connected to cylinder 150 by drive cable 170 , and ( ii ) fixed to cylinder 160 . adjustable mounting ring 140 comprises a central body 230 that contains the aforementioned bevel gears 180 and 190 . these gears 180 and 190 are in turn coupled to the mounting ring segments 210 to which the tissue annuloplasty band 100 will be attached . these mounting ring segments 210 are attached to central body 230 by the threaded shafts 200 . accordingly , movement of the aforementioned bevel gear 180 via cable 170 causes the mounting ring segments 210 to expand and contract relative to central body 230 . hence , the tissue annuloplasty band 100 can be adjusted to the appropriate size for varying patient anatomies . mounting ring segments 210 can have additional support , e . g ., by lateral stays 240 interacting with each other . the outer edge 250 of each segment 210 preferably has a groove 260 in which the tissue annuloplasty band 100 is mounted . with the aforementioned first sizer 120 , the sizer &# 39 ; s handle 130 extends perpendicular to the plane of the sizer &# 39 ; s adjustable mounting ring 140 . alternatively , and looking now at fig8 - 11 , there is shown a second sizer 120 a in which the sizer &# 39 ; s handle 130 extends parallel to the plane of the sizer &# 39 ; s adjustable mounting ring 140 . the tissue annuloplasty band 100 ( fig2 ) is placed into groove 260 on adjustable mounting ring 140 ( fig1 ). then the elastic ends 110 a , 110 b of axle 70 are attached to one another . this creates tension on the tissue , which keeps the tissue annuloplasty band 100 in the groove 260 on the mounting ring . clamps , ties or sutures can be applied as necessary for increased stability . next , the appropriate size and shape of the tissue annuloplasty band 100 is determined . to do this , the tissue annuloplasty band 100 , which is now mounted on adjustable mounting ring 140 , is placed in the patient &# 39 ; s left atrium and visually compared to the patient &# 39 ; s mitral valve . alternatively , the mitral valve may be measured directly . the surgeon then adjusts the size of tissue annuloplasty band 100 by turning cylinder 150 of handle 130 until tissue annuloplasty band 100 is appropriately sized . any excess tissue is marked for later excision . next , sutures are placed through the patient &# 39 ; s annulus and subsequently through the tissue annuloplasty band 100 . the tissue annuloplasty band 100 is then guided into place with the assistance of sizer 120 ( or 120 a ). tissue annuloplasty band 100 is then tied down into place , while it is still mounted on adjustable mounting ring 140 , so as to maintain its shape during final seating . once tissue annuloplasty band 100 has been tied into place , the elastic ends 110 a , 110 b of axle 70 are detached from one another . any other stabilizing components such as clamps , ties , or sutures that aided in mounting tissue annuloplasty band 100 to adjustable mounting ring 140 are detached . adjustable mounting ring 140 is then removed , and axle 70 is withdrawn . any excess tissue previously marked is excised . if desired , sizer 120 ( 120 a ) can be constructed so that handle 130 may be detached from adjustable mounting ring 140 . with such a construction , handle 130 may be removed after guiding tissue annuloplasty band 100 to the surgical site , but before the band is removed from adjustable mounting ring 140 . it is also possible to practice the present invention using a pre - sized , fixed diameter mounting ring . more particularly , and looking now at fig1 , there is shown a set of third sizers 120 b , wherein each of the third sizers 120 b comprises a pre - sized , fixed diameter mounting ring 140 b ( preferably having a peripheral groove 260 b ) and an associated handle 130 b . each mounting ring 140 b may comprise a complete circle ( e . g ., as shown in fig1 ) or only a portion of a circle ( e . g ., as shown in fig2 ). in this form of the invention , an appropriate one of the pre - sized mounting rings 140 b is selected by directly measuring the mitral valve or by placing different pre - sized mounting rings in the left atrium and visually comparing them against the patient &# 39 ; s mitral valve . once the appropriate pre - sized mounting ring 140 b has been selected , tissue annuloplasty band 100 ( fig2 ) is mounted onto the pre - sized mounting ring 140 b , i . e ., by slipping tissue annuloplasty band 100 into the peripheral groove 260 b and attaching elastic ends 110 a , 110 b of axle 70 together . then tissue annuloplasty band 100 is transferred to the annulus of the patient &# 39 ; s mitral valve in the manner previously described . in another preferred form of the invention , and looking at fig1 - 22 , a tissue annuloplasty band 100 a ( fig2 ) is formed using an external structural mesh 300 ( fig1 ). more particularly , graft tissue 310 ( fig1 ) is cut into a preferred long length 320 using a tissue grasper 330 and a tissue cutter 340 , both being standard , commercially - available devices . to aid in inserting tissue length 320 into external mesh 300 , a temporary guide tube 340 ( fig1 ) may be used to hold open the external mesh 300 and guide the tissue length 320 through the mesh . looking at fig1 , external mesh 300 is preferably constructed of flexible but not stretchable material such as monofilament or braided suture for permanent implantation into the body . the weave is preferably constructed such that mesh 300 does not stretch in the direction of the long axis via straight members 350 . the weave could also provide a large mesh 360 to allow a significant amount of tissue to be exposed to the implant surface so as to promote implant - to - body tissue in - growth . purse string sutures 370 at the end of mesh 300 provide a means to secure the tissue graft 320 inside the external mesh and to secure the resulting tissue annuloplasty band 100 a to the mounting ring 140 ( or 140 b ). if various lengths of bands are required , either individual bands could be provided or a longer band could be cut to the required length . if a longer band is cut to length , extra sets of purse string sutures 370 a provide a means to shorten the band and still secure the tissue 320 within the external mesh . any unused purse string sutures 370 , 370 a can be cut prior to fixation of the band to the mounting ring . looking at fig1 , guide tube 340 has been inserted through external mesh 300 to provide a smooth path for tissue 320 . a tissue hook 382 and shaft 384 are inserted through guide tube 340 , and then tissue 320 is folded in half and insert through hook 382 ( fig1 ). for this embodiment , tissue 320 must be at least twice as long as the pre - sized band length . an alternative to hook 382 is a grasper ( not shown ) that pulls a single length of tissue through guide tube 340 . for such an alternative embodiment , a single length of tissue might be wider than a folded length of tissue , such that the volume of tissue inside the external mesh 300 is similar in both embodiments . looking next at fig1 - 20 , the tissue 320 is pulled through guide tube 400 by pulling on tissue retraction handle 386 . guide tube 340 is then pulled out from between tissue 320 and external mesh 300 . any excess tissue 320 is cut to the length of external mesh 300 and purse string sutures 370 are tied closed at 387 to secure the tissue 320 within external mesh 300 , forming a properly sized tissue annuloplasty band 100 a . looking at fig2 and 22 , tissue annuloplasty band 100 a is temporarily secured to a mounting ring ( e . g ., a pre - sized fixed - diameter mounting ring 140 b ) by tying a knot 388 ( fig2 ) using the remaining lengths of purse string sutures 370 . once the surgeon has sutured the tissue annuloplasty band 100 a to the mitral valve using standard surgical techniques , mounting ring 140 b is removed by cutting and retrieving purse string sutures 370 close to the ends of tissue annuloplasty band 100 a . it is to be understood that the present invention is by no means limited to the particular constructions and method steps disclosed above and / or shown in the drawings , but also comprises any modifications or equivalents within the scope of the claims .
this invention relates to a system used to fashion , size , and implant a tissue annuloplasty band . this system comprises a device to cut tissue ; a device to fashion the tissue into a band ; and a sizer that comprises an mounting ring which allows for determining and maintaining the proper size and shape of the tissue annuloplasty band while it is attached to the annulus of a heart valve . these components can be used alone , together as a system , or in any combination to fashion , size , and / or implant the tissue annuloplasty band .