US20050184122A1 - Method and apparatus for performing catheter-based annuloplasty using local plications - Google Patents

Abstract

A minimally invasive method of performing annuloplasty. According to one aspect, a method for performing annuloplasty includes creating a first plication in the tissue near a mitral valve of a heart, using at least a first plication element, and creating a second plication in the tissue near the mitral valve such that the second plication is substantially coupled to the first plication.

Description

• This application is a continuation of PCT/US03/33382 filed on Oct. 21, 2003 which claims priority of U.S. Provisional Patent Application No. 60/420,095, filed Oct. 21, 2002. The disclosure of each priority application is hereby incorporated by reference herein in its entirety.
CROSS REFERENCE TO RELATED APPLICATIONS
• The present invention is related to U.S. Pat. No. 6,619,291 entitled “Method and Apparatus for Catheter-Based Annuloplasty,” filed Apr. 24, 2001 and issued Sep. 16, 2003, and to co-pending U.S. patent application Ser. No. 09/866,550, entitled “Method and Apparatus for Catheter-Based Annuloplasty Using Local Plications, which are each incorporated herein by reference in their entireties.
BACKGROUND OF THE INVENTION
• 1. Field of Invention
• The present invention relates generally to techniques for treating mitral valve insufficiencies such as mitral valve leakage. More particularly, the present invention relates to systems and methods for treating a leaking mitral valve in a minimally invasive manner.
• 2. Description of the Related Art
• Congestive heart failure (CHF), which is often associated with an enlargement of the heart, is a leading cause of death. As a result, the market for the treatment of CHF is becoming increasingly prevalent. For instance, the treatment of CHF is a leading expenditure of Medicare and Medicaid dollars in the United States of America. Typically, the treatment of CHF enables many who suffer from CHF to enjoy an improved quality of life.
• Referring initially toFIG. 1, the anatomy of a heart, specifically the left side of a heart, will be described. The left side of aheart104 includes aleft atrium108 and aleft ventricle112. Anaorta114 receives blood fromleft ventricle112 through anaortic valve120, which serves to prevent regurgitation of blood back intoleft ventricle112. Amitral valve116 is disposed betweenleft atrium108 andleft ventricle112, and effectively controls the flow of blood betweenleft atrium108 andleft ventricle112.
• Mitral valve116, which will be described below in more detail with respect toFIG. 2a, includes an anterior leaflet and a posterior leaflet that are coupled tocordae tendonae124 which serve as “tension members” that prevent the leaflets ofmitral valve116 from opening indiscriminately. When leftventricle112 contracts,cordae tendonae124 allow the anterior leaflet to open upwards until limited in motion bycordae tendonae124. Normally, the upward limit of opening corresponds to a meeting of the anterior and posterior leaflets and the prevention of backflow. Cordae tendonae124 arise from acolumnae carnae128 or, more specifically, a musculi papillares ofcolumnae carnae128.
• Left ventricle112 includestrabeculae132 which are fibrous cords of connective tissue that are attached towall134 ofleft ventricle112.Trabeculae132 are also attached to aninterventricular septum136 which separatesleft ventricle112 from a right ventricle (not shown) ofheart104.Trabeculae132 are generally located inleft ventricle112 belowcolumnae carnae128.
• FIG. 2ais a cut-away top-view representation ofmitral valve116 andaortic valve120.Aortic valve120 has avalve wall204 that is surrounded by askeleton208aof fibrous material.Skeleton208amay generally be considered to be a fibrous structure that effectively forms a ring aroundaortic valve120. Afibrous ring208b, which is substantially the same type of structure asskeleton208a, extends aroundmitral valve116.Mitral valve116 includes ananterior leaflet212 and aposterior leaflet216, as discussed above.Anterior leaflet212 andposterior leaflet216 are generally thin, flexible membranes. Whenmitral valve116 is closed (as shown inFIG. 2a),anterior leaflet212 andposterior leaflet216 are generally aligned and contact one another to create a seal. Alternatively, whenmitral valve116 is opened, blood may flow through an opening created betweenanterior leaflet212 andposterior leaflet216.
• Many problems relating tomitral valve116 may occur and these insufficiencies may cause many types of ailments. Such problems include, but are not limited to, mitral regurgitation. Mitral regurgitation, or leakage, is the backflow of blood fromleft ventricle112 into theleft atrium108 due to an imperfect closure ofmitral valve116. That is, leakage often occurs when a gap is created betweenanterior leaflet212 andposterior leaflet216.
• In general, a relatively significant gap may exist betweenanterior leaflet212 and posterior leaflet216 (as shown inFIG. 2b) for a variety of different reasons. For example, a gap may exist due to congenital malformations, because of ischemic disease, or because a heart has been damaged by a previous heart attack. A gap may also be created when congestive heart failure, e.g., cardiomyopathy, or some other type of distress causes a heart to be enlarged. When a heart is enlarged, the walls of the heart, e.g.,wall134 of a left ventricle, may stretch or dilate, causingposterior leaflet216 to stretch. It should be appreciated thatanterior leaflet212 generally does not stretch. As shown inFIG. 2b, agap220 betweenanterior leaflet212 and stretchedposterior leaflet216′ is created whenwall134′ stretches. Hence, due to the existence ofgap220,mitral valve116 is unable to close properly, and may begin to leak.
• Leakage throughmitral valve116 generally causes a heart to operate less efficiently, as the heart must work harder to maintain a proper amount of blood flow therethrough. Leakage throughmitral valve116, or general mitral insufficiency, is often considered to be a precursor to CHF. There are generally different levels of symptoms associated with heart failure. Such levels are classified by the New York Heart Association (NYHA) functional classification system. The levels range from aClass 1 level which is associated with an asymptomatic patient who has substantially no physical limitations to a Class 4 level which is associated with a patient who is unable to carry out any physical activity without discomfort, and has symptoms of cardiac insufficiency even at rest. In general, correcting for mitral valve leakage may be successful in allowing the NYHA classification grade of a patient to be reduced. For instance, a patient with a Class 4 classification may have his classification reduced to Class 3 and, hence, be relatively comfortable at rest.
• Treatments used to correct for mitral valve leakage or, more generally, CHF, are typically highly invasive, open-heart surgical procedures. Ventricular assist devices such as artificial hearts may be implanted in a patient whose own heart is failing. The implantation of a ventricular assist device is often expensive, and a patient with a ventricular assist device must be placed on extended anti-coagulant therapy. As will be appreciated by those skilled in the art, anti-coagulant therapy reduces the risk of blood clots being formed, as for example, within the ventricular assist device. While reducing the risks of blood clots associated with the ventricular assist device is desirable, anti-coagulant therapies may increase the risk of uncontrollable bleeding in a patient, e.g., as a result of a fall, which is not desirable.
• Rather than implanting a ventricular assist device, bi-ventricular pacing devices similar to pace makers may be implanted in some cases, e.g., cases in which a heart beats inefficiently in a particular asynchronous manner. While the implantation of a bi-ventricular pacing device may be effective, not all heart patients are suitable for receiving a bi-ventricular pacing device. Further, the implantation of a bi-ventricular pacing device is expensive.
• Open-heart surgical procedures which are intended to correct for mitral valve leakage, specifically, involve the implantation of replacement valves. Valves from animals, e.g., pigs, may be used to replace amitral valve116 in a human. While the use of a pig valve may relatively successfully replace a mitral valve, such valves generally wear out, thereby requiring additional open surgery at a later date. Mechanical valves, which are less likely to wear out, may also be used to replace a leaking mitral valve. However, when a mechanical valve is implanted, there is an increased risk of thromboembolism, and a patient is generally required to undergo extended anti-coagulant therapies.
• A less invasive surgical procedure involves heart bypass surgery associated with a port access procedure. For a port access procedure, the heart may be accessed by cutting a few ribs, as opposed to opening the entire chest of a patient. In other words, a few ribs may be cut in a port access procedure, rather than opening a patient's sternum.
• One open-heart surgical procedure that is particularly successful in correcting for mitral valve leakage and, in addition, mitral regurgitation, is an annuloplasty procedure. During an annuloplasty procedure, an annuloplasty ring may be implanted on the mitral valve to cause the size of a stretchedmitral valve116 to be reduced to a relatively normal size.FIG. 3 is a schematic representation of an annuloplasty ring. Anannuloplasty ring304 is shaped approximately like the contour of a normal mitral valve. That is,annuloplasty ring304 is shaped substantially like the letter “D.” Typically,annuloplasty ring304 may be formed from a rod or tube of biocompatible material, e.g., plastic, that has a DACRON mesh covering.
• In order forannuloplasty ring304 to be implanted, a surgeon surgically attachesannuloplasty ring304 to the mitral valve on the atrial side of the mitral valve. Conventional methods forinstalling ring304 require open-heart surgery which involve opening a patient's sternum and placing the patient on a heart bypass machine. As shown inFIG. 4,annuloplasty ring304 is sewn to aposterior leaflet318 and ananterior leaflet320 of a top portion ofmitral valve316. Insewing annuloplasty ring304 ontomitral valve316, a surgeon generally alternately acquires a relatively large amount of tissue from mitral tissue, e.g., a one-eighth inch bite of tissue, using a needle and thread, followed by a smaller bite fromannuloplasty ring304. Once a thread has loosely coupledannuloplasty ring304 to mitral valve tissue,annuloplasty ring304 is slid ontomitral valve316 such that tissue that was previously stretched out, e.g., due to an enlarged heart, is effectively pulled in using tension applied byannuloplasty ring304 and the thread which bindsannuloplasty ring304 to the mitral valve tissue. As a result, a gap, such asgap220 ofFIG. 2b, betweenanterior leaflet320 andposterior leaflet318 may be substantially closed off. After the mitral valve is shaped byring304, the anterior andposterior leaflets320,318 will reform to create a new contact line and will enablemitral valve318 to appear and to function as a normal mitral valve.
• Once implanted, tissue generally grows overannuloplasty ring304, and a line of contact betweenannuloplasty ring304 andmitral valve316 will essentially enablemitral valve316 to appear and function as a normal mitral valve. Although a patient who receivesannuloplasty ring304 may be subjected to anti-coagulant therapies, the therapies are not extensive, as a patient is only subjected to the therapies for a matter of weeks, e.g., until tissue grows overannuloplasty ring304.
• A second surgical procedure which is generally effective in reducing mitral valve leakage involves placing a single edge-to-edge suture in the mitral valve. With reference toFIG. 5a, such a surgical procedure, e.g., an Alfieri stitch procedure or a bow-tie repair procedure, will be described. An edge-to-edge stitch404 is used to stitch together an area at approximately the center of agap408 defined between ananterior leaflet420 and aposterior leaflet418 of amitral valve416. Oncestitch404 is in place,stitch404 is pulled in to form a suture which holdsanterior leaflet420 againstposterior leaflet418, as shown. By reducing the size ofgap408, the amount of leakage throughmitral valve416 may be substantially reduced.
• Although the placement of edge-to-edge stitch404 is generally successful in reducing the amount of mitral valve leakage throughgap408, edge-to-edge stitch404 is conventionally made through open-heart surgery. In addition, the use of edge-to-edge stitch404 is generally not suitable for a patient with an enlarged, dilated heart, as blood pressure causes the heart to dilate outward, and may put a relatively large amount of stress on edge-to-edge stitch404. For instance, blood pressure of approximately 120/80 or higher is typically sufficient to cause the heart to dilate outward to the extent that edge-to-edge stitch404 may become undone, or tear mitral valve tissue.
• Another surgical procedure which reduces mitral valve leakage involves placing sutures along a mitral valve annulus around the posterior leaflet. A surgical procedure which places sutures along a mitral valve with be described with respect toFIG. 5b.Sutures504 are formed along an annulus540 of amitral valve516 around aposterior leaflet518 ofmitral valve516, and may be formed as a double track, e.g., in two “rows,” from a single strand of suture material.Sutures504 are tied off at approximately a central point506 ofposterior leaflet518.Pledgets546 are often positioned under selectedsutures504, e.g., at central point506, to preventsutures504 from tearing through annulus540. Whensutures504 are tied off, annulus540 may effectively be tightened to a desired size such that the size of agap508 betweenposterior leaflet518 and ananterior leaflet520 may be reduced.
• The placement ofsutures504 along annulus540, in addition to the tightening ofsutures504, is generally successful in reducing mitral valve leakage. However, the placement ofsutures504 is conventionally accomplished through open-heart surgical procedures. That is, like other conventional procedures, a suture-based annuloplasty procedure is invasive.
• While invasive surgical procedures have proven to be effective in the treatment of mitral valve leakage, invasive surgical procedures often have significant drawbacks. Any time a patient undergoes open-heart surgery, there is a risk of infection. Opening the sternum and using a cardiopulmonary bypass machine has also been shown to result in a significant incidence of both short and long term neurological deficits. Further, given the complexity of open-heart surgery, and the significant associated recovery time, people who are not greatly inconvenienced by CHF symptoms, e.g., people at aClass 1 classification, may choose not to have corrective surgery. In addition, people who most need open heart surgery, e.g., people at a Class 4 classification, may either be too frail or too weak to undergo the surgery. Hence, many people who may benefit from a surgically repaired mitral valve may not undergo surgery.
• Therefore, what is needed is a minimally invasive treatment for mitral valve leakage. Specifically, what is desired is a method for reducing leakage between an anterior leaflet and a posterior leaflet of a mitral valve that does not require conventional surgical intervention.
SUMMARY OF THE INVENTION
• The present invention relates to a non-invasive method of performing annuloplasty. Performing an annuloplasty on a mitral valve by accessing the left ventricle of the heart, as for example using a catheter, enables complicated surgical procedures to be avoided when treating mitral valve leakage. Avoiding open-heart surgical procedures generally makes annuloplasty more accessible to patients who may benefit from annuloplasty. As mitral valve leakage is often considered to be an early indicator of congestive heart failure, a minimally invasive annuloplasty procedure that corrects for leakage problems, such as one which involves positioning discrete plications in fibrous tissue around the mitral valve, may greatly improve the quality of life of many patients who might not be suitable for invasive annuloplasty procedures.
• According to one aspect of the present invention, a method for performing annuloplasty includes creating a first plication in the tissue near a mitral valve of a heart, using at least a first plication element, and creating a second plication in the tissue near the mitral valve such that the second plication is substantially coupled to the first plication. In one embodiment, the method also includes accessing a left ventricle of the heart to provide the first plication element to the left ventricle, and engaging the first plication element to the tissue near the mitral valve. Engaging the first plication element includes causing the first plication element to substantially pass through a portion of the tissue to substantially anchor the first plication element to the tissue near the mitral valve.
• According to another aspect of the present invention, a method for performing annuloplasty includes accessing a heart to provide a plurality of plication elements to the heart. The plurality of plication elements are provided to the heart through a catheter arrangement, and include a first anchor arrangement. The method also includes engaging the first anchor arrangement to tissue near a mitral valve of the heart using the catheter arrangement by causing the first anchor arrangement to substantially pass through the tissue to substantially anchor the first anchor arrangement to the tissue near the mitral valve. Finally, the method includes creating at least a first plication and a second plication using the first anchor arrangement.
• In accordance with still another embodiment of the present invention, a method for performing annuloplasty includes accessing an area of a heart to provide a first plication element to the area using a catheter arrangement which has a first portion and a second portion, and substantially anchoring the first portion of the catheter arrangement to tissue near a mitral valve of the heart. The method further includes positioning a tip of the second portion of the catheter arrangement at a first distance from the first portion, and substantially engaging the first anchor to the tissue near the mitral valve of the heart using the second portion of the catheter arrangement. Substantially engaging the first anchor includes causing the first anchor to substantially pass through a portion of the tissue to substantially anchor the first anchor to the tissue near the mitral valve using the second portion of the catheter arrangement. In one embodiment, substantially anchoring the first portion of the catheter arrangement to tissue near the mitral valve of the heart includes positioning the first portion of the catheter arrangement over a guide that is at least temporarily anchored to the tissue near the mitral valve.
• These and other advantages of the present invention will become apparent upon reading the following detailed descriptions and studying the various figures of the drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
• The invention may best be understood by reference to the following description taken in conjunction with the accompanying drawings in which:
• FIG. 1 is a cross-sectional front-view representation of the left side of a human heart.
• FIG. 2ais a cut-away top-view representation of the mitral valve and the aortic valve ofFIG. 1.
• FIG. 2bis a cut-away representation of a stretched mitral valve and an aortic valve.
• FIG. 3 is a representation of an annular ring that is suitable for use in performing a conventional annuloplasty procedure.
• FIG. 4 is a representation of a mitral valve and an aortic valve after the annular ring ofFIG. 3 has been implanted.
• FIG. 5ais a representation of a mitral valve and an aortic valve after a single edge-to-edge suture has been applied to reduce mitral regurgitation.
• FIG. 5bis a representation of a mitral valve and an aortic valve after sutures along a mitral valve annulus have been applied to reduce mitral regurgitation.
• FIG. 6ais a representation of a delivery tube and a J-catheter in accordance with an embodiment of the present invention.
• FIG. 6bis a cut-away front view of the left side of a heart in which the delivery tube and the J-catheter ofFIG. 6ahave been inserted in accordance with an embodiment of the present invention.
• FIG. 7ais a representation of a catheter assembly in accordance with an embodiment of the present invention.
• FIG. 7bis a cross-sectional representation of the catheter assembly ofFIG. 7ain accordance with an embodiment of the present invention.
• FIG. 7cis a cut-away top-view representation of a left ventricle in which the gutter catheter ofFIGS. 7aand7bhas been positioned in accordance with an embodiment of the present invention.
• FIG. 8 is a cut-away top-view representation of a left ventricle in which a guide wire has been positioned in accordance with an embodiment of the present invention.
• FIG. 9ais a cut-away top-view representation of a left ventricle of the heart in which local plication suture structures have been implanted in accordance with an embodiment of the present invention.
• FIG. 9bis a cut-away top-view representation of a left ventricle of the heart in which local plication suture structures which are coupled have been implanted in accordance with an embodiment of the present invention.
• FIG. 10ais a representation of a suture structure after T-bars have been introduced to an atrial side of a mitral valve through fibrous tissue near the mitral valve in accordance with an embodiment of the present invention.
• FIG. 10bis a representation of the suture structure ofFIG. 10aafter the T-bars have been engaged to the fibrous tissue in accordance with an embodiment of the present invention.
• FIG. 11 is a representation of a suture structure which includes a locking element with a spring in accordance with an embodiment of the present invention.
• FIG. 12ais a representation of a suture structure which includes a locking element with a resorbable component in accordance with an embodiment of the present invention.
• FIG. 12bis a representation of the suture structure ofFIG. 12aafter the resorbable component has degraded in accordance with an embodiment of the present invention.
• FIG. 12cis a representation of the suture structure ofFIG. 12bafter a plication has been created in accordance with an embodiment of the present invention.
• FIG. 13ais a representation of a first catheter which is suitable for use in delivering and implementing a suture structure in accordance with an embodiment of the present invention.
• FIG. 13bis a representation of a second catheter which is suitable for use in delivering and implementing a suture structure in accordance with an embodiment of the present invention.
• FIG. 13cis a representation of a third catheter assembly which is suitable for use in delivering and implementing a suture structure in accordance with an embodiment of the present invention.
• FIGS. 14aand14bare a process flow diagram which illustrates the steps associated with one method of performing annuloplasty using a suture structure and a catheter in accordance with an embodiment of the present invention.
• FIG. 15 is a cut-away top-view representation of a left ventricle of the heart in which local plication elements have been implanted in accordance with an embodiment of the present invention.
• FIG. 16ais a representation of a local plication element which has spring-like characteristics in accordance with an embodiment of the present invention.
• FIG. 16bis a representation of the local plication element ofFIG. 16aafter forces have been applied to open the local plication element in accordance with an embodiment of the present invention.
• FIG. 16cis a representation of the local plication element ofFIG. 16bafter tips of the local plication element pierce through tissue in accordance with an embodiment of the present invention.
• FIG. 16dis a representation of the local plication element ofFIG. 16cafter the tips of the local plication element engage the tissue to form a local plication in accordance with an embodiment of the present invention.
• FIG. 17ais a representation of a local plication element, which is formed from a shape memory material, in an open state in accordance with an embodiment of the present invention.
• FIG. 17bis a representation of the local plication element ofFIG. 17ain a closed state in accordance with an embodiment of the present invention.
• FIG. 18ais a representation of a first self-locking clip which is suitable for use in forming a local plication in accordance with an embodiment of the present invention.
• FIG. 18bis a representation of a second self-locking clip which is suitable for use in forming a local plication in accordance with an embodiment of the present invention.
• FIG. 19 is a representation of a plication-creating locking mechanism in accordance with an embodiment of the present invention.
• FIG. 20ais a representation of the plication-creating locking mechanism ofFIG. 19 as provided within the left ventricle of a heart in accordance with an embodiment of the present invention.
• FIG. 20bis a representation of the plication-creating locking mechanism ofFIG. 20aafter forces have been applied to cause tines of the mechanism to contact tissue in accordance with an embodiment of the present invention.
• FIG. 20cis a representation of the plication-creating locking mechanism ofFIG. 20bafter tissue has been gathered between the tines of the mechanism in accordance with an embodiment of the present invention.
• FIG. 20dis a representation of the plication-creating locking mechanism ofFIG. 20cafter a local plication has been formed in accordance with an embodiment of the present invention.
• FIGS. 21aand21bare a process flow diagram which illustrates the steps associated with one method of performing annuloplasty using a local plication element and a catheter in accordance with an embodiment of the present invention.
• FIG. 22ais a cut-away front view of the left side of a heart in which an L-shaped catheter has been inserted in accordance with an embodiment of the present invention.
• FIG. 22bis a cut-away front view of the left side of a heart in which an L-shaped catheter has been inserted and extended in accordance with an embodiment of the present invention.
• FIG. 22cis a cut-away front view of the left side of a heart in which an L-shaped catheter has been inserted, extended, and curved in accordance with an embodiment of the present invention.
• FIG. 23ais representation of a portion of a first catheter which may use suction to engage against tissue in accordance with an embodiment of the present invention.
• FIG. 23bis representation of a portion of a first catheter which may use suction to engage against tissue in accordance with an embodiment of the present invention.
• FIG. 24ais representation of a portion of a wire with a helical coil which may be used as a temporary anchor in accordance with an embodiment of the present invention.
• FIG. 24bis representation of a portion of a catheter with a helical coil which may be used as a temporary anchor in accordance with an embodiment of the present invention.
• FIG. 25 is a representation of an anchor which is deployed and anchored into tissue in accordance with an embodiment of the present invention.
• FIG. 26ais a representation of a portion of an incrementor catheter in a closed configuration which is positioned over a tail of an anchor in accordance with an embodiment of the present invention.
• FIG. 26bis a representation of a portion of an incrementor catheter in an open configuration which is positioned over a tail and is extended such that a first section and a second section of the incrementor have tips that are separated by a distance in accordance with an embodiment of the present invention.
• FIG. 27 is a representation of two anchors which may be used to create a plication in accordance with an embodiment of the present invention.
• FIGS. 28a-fare representations of anchors and lockers which are used in a process of creating a daisy chain of plications in accordance with an embodiment of the present invention.
• FIG. 29ais a cut-away front view of the left side of a heart in which a hook catheter has been inserted in accordance with an embodiment of the present invention.
• FIG. 29bis a cut-away front view of the left side of a heart in which a hook catheter is positioned beneath a mitral valve in accordance with an embodiment of the present invention.
• FIG. 29cis a cut-away front view of the left side of a heart in which a temporary anchor has been inserted in accordance with an embodiment of the present invention.
• FIG. 29dis a cut-away front view of the left side of a heart in which a hook catheter which carries a permanent anchor is inserted in accordance with an embodiment of the present invention.
• FIG. 29eis a cut-away front view of the left side of a heart in which a permanent anchor has been inserted in accordance with an embodiment of the present invention.
• FIG. 29fis a cut-away front view of the left side of a heart in which an incrementor catheter has been inserted in accordance with an embodiment of the present invention.
• FIG. 29gis a cut-away front view of the left side of a heart in which two permanent anchors have been inserted in accordance with an embodiment of the present invention.
• FIG. 29his a cut-away front view of the left side of a heart in which two permanent anchors and a locking device or locker have been inserted in accordance with an embodiment of the present invention.
• FIG. 30 is a process flow diagram which illustrates the steps associated with one method of creating a plication using an incrementor catheter in accordance with an embodiment of the present invention.
DETAILED DESCRIPTION OF THE EMBODIMENTS
• Invasive, open-heart surgical procedures are generally effective in the treatment of mitral valve leakage. However, open-heart surgical procedures may be particularly hazardous to some patients, e.g., frail patients or patients who are considered as being very ill, and undesirable to other patients, e.g., patients who are asymptomatic and do not wish to undergo a surgical procedure. As such, open-heart surgical procedures to correct mitral valve leakage or, more generally, mitral valve insufficiency, are not suitable for many patients who would likely benefit from reducing or eliminating the mitral valve leakage.
• A catheter-based annuloplasty procedure enables annuloplasty to be performed on a patient without requiring that the patient undergo open-heart surgery, or be placed on cardiopulmonary bypass. Catheters may be introduced into the left ventricle of a heart through the aorta to position a guide wire and plication implants on the ventricular side of a mitral valve, i.e., under a mitral valve. Catheters may also be used to couple the plication implants to fibrous tissue associated with the skeleton of the heart around the mitral valve.
• The use of catheters to perform an annuloplasty procedure by delivering and engaging plication implants or structures enables the annuloplasty procedure to be performed without open-heart surgery, and without a bypass procedure. Recovery time associated with the annuloplasty, as well as the risks associated with annuloplasty, may be substantially minimized when the annuloplasty is catheter-based. As a result, annuloplasty becomes a more accessible procedure, since many patients who might previously not have received treatment for mitral valve leakage, e.g., frail patients and asymptomatic patients, may choose to undergo catheter-based annuloplasty.
• To begin a catheter-based annuloplasty procedure, a delivery tube and a J-catheter may be inserted into a left ventricle of the heart through the aorta. Inserting the delivery tube and the J-catheter through the aorta enables the left ventricle of the heart to be reached substantially without coming into contact with trabeculae or the cordae tendonae in the left ventricle.FIG. 6ais a diagrammatic representation of a delivery tube and a J-catheter in accordance with an embodiment of the present invention.Delivery tube604 has a substantially circular cross section, and is configured to receive a J-catheter608. J-catheter608 is arranged to move longitudinally through and opening indelivery tube604 as needed.
• In general,delivery tube604 is an elongated body which may be formed from a flexible, durable, biocompatible material such as nylon, urethane, or a blend of nylon and urethane, e.g., PEBAX®. Likewise, J-catheter608, which is also an elongated body, may also be formed from a biocompatible material. A material used to form J-catheter608 is typically also relatively flexible. In the described embodiment, a tip of J-catheter608 is rigid enough to allow the tip of J-catheter608 to maintain a relatively curved shape, e.g., a “J” shape. The curve in J-catheter608 is configured to facilitate the positioning of a gutter catheter, as will be described below with respect toFIGS. 7a-c.
• FIG. 6bis a schematic representation ofdelivery tube604 and J-catheter608 positioned within a heart in accordance with an embodiment of the present invention. As shown, afterdelivery tube604 and J-catheter608 are effectively “snaked” or inserted through a femoral artery, portions ofdelivery tube604 and of J-catheter608 are positioned within anaorta620 of aheart616. Atip626 of J-catheter608, which is substantially oriented at a right angle from the body of J-catheter608, and an end ofdelivery tube604 are oriented such that they pass through anaortic valve630. Hence, an end ofdelivery tube604 andtip626 are positioned at a top portion ofleft ventricle624, wherewall632 ofleft ventricle624 is relatively smooth. The relative smoothness of the top portion ofleft ventricle624 enables a catheter to be properly positioned withinleft ventricle624 by guiding the tip of the catheter alongwall632. In one embodiment,tip626 is oriented such that it is positioned approximately just below amitral valve628 on the ventricular side ofmitral valve628.
• Once positioned withinleft ventricle624, J-catheter608 may be rotated withindelivery tube604 such thattip626 is may enable a gutter catheter fed therethrough to run along the contour ofwall632. Typically, the gutter catheter runs along the contour ofwall632 in an area that is effectively defined between a plane associated with papillary muscles640, a plane associated with the posterior leaflet ofmitral valve628,cordae tendonae642, andwall632. A “gutter” is located in such an area or region and, more specifically, is positioned substantially right undermitral valve628 where there is a relatively insignificant amount of trabeculae.
• With reference toFIGS. 7a-7c, a gutter catheter will be described in accordance with an embodiment of the present invention. Agutter catheter704, which is part of acatheter assembly702 as shown inFIG. 7a, is arranged to be extended through J-catheter626 such thatgutter catheter704 may be steered within a left ventricle just beneath a mitral valve.Gutter catheter704, which may include a balloon tip (not shown), is typically formed from a flexible material such as nylon, urethane, or PEBAX®. In one embodiment,gutter catheter704, which is steerable, may be formed using a shape memory material.
• As shown inFIG. 7aandFIG. 7b, which represents a cross section ofcatheter assembly702 taken at alocation710,gutter catheter704 is at least partially positioned within J-catheter608 which, in turn, is at least partially positioned withindelivery tube604.Gutter catheter704 may be free to rotate within and extend through J-catheter608, while J-catheter608 may be free to rotate within and extend throughdelivery tube604.
• Referring next toFIG. 7c, the positioning ofgutter catheter704 within a left ventricle of the heart will be described in accordance with an embodiment of the present invention. It should be appreciated that the representation ofgutter catheter704 within aleft ventricle720 has not been drawn to scale, for ease of illustration and ease of discussion. For instance, the distance between awall724 ofleft ventricle720 and amitral valve728 has been exaggerated. In addition, it should also be appreciated that the positioning ofdelivery tube604 and, hence, J-catheter608 andgutter catheter704 withinaortic valve732 may vary.
• Gutter catheter704 protrudes throughtip626 of J-catheter608, and, through steering, essentially forms an arc shape similar to that ofmitral valve728 along the contour of awall724 ofleft ventricle720 just beneathmitral valve728, i.e., along the gutter ofleft ventricle720.Wall724 ofleft ventricle720 is relatively smooth just beneathmitral valve728, i.e., generally does not include trabeculae. Hence, insertingcatheter assembly702 through anaortic valve732 into an upper portionleft ventricle720 allowsgutter catheter704 to be navigated withinleft ventricle720 alongwall724 substantially without being obstructed by trabeculae or cordae tendonae.
• Gutter catheter704 generally includes an opening or lumen (not shown) that is sized to accommodate a guide wire through which a guide wire may be inserted. The opening may be located along the central axis ofgutter catheter704, i.e.,central axis730 as shown inFIG. 7a. Delivering a guide wire throughgutter catheter704 enables the guide wire to effectively follow the contour ofwall724. In general, the guide wire may include an anchoring tip which enables the guide wire to be substantially anchored againstwall724.FIG. 8 is a diagrammatic top-view cut-away representation of a left side of a heart in which a guide wire has been positioned in accordance with an embodiment of the present invention. It should be appreciated that the representation of the left side of a heart inFIG. 8 has not been drawn to scale, and that various features have been exaggerated for ease of discussion. Aguide wire802 is positioned alongwall724 ofleft ventricle720. Onceguide wire802 is inserted throughgutter catheter704 ofFIGS. 7a-7c, and anchored againstwall724 using ananchoring tip806,gutter catheter704, along with J-catheter708, are withdrawn from the body of the patient. It should be appreciated thatdelivery tube604 typically remains positioned within the aorta afterguide wire802 is anchored to wall724.
• Guide wire802, which may be formed from a material such as stainless steel or a shape memory material, is generally anchored such thatguide wire802 effectively passes along a large portion ofwall724. Typically,guide wire802 serves as a track over which a catheter that carries plication structures may be positioned, i.e., a lumen of a catheter that delivers a plication element may pass overguide wire802. Such a catheter may include a balloon structure (not shown), or an expandable structure, that may facilitate the positioning of local plication structures by pushing the local plication structures substantially against the fibrous tissue around the mitral valve.
• Forming local plications causes bunches of the fibrous tissue around the mitral valve to be captured or gathered, thereby causing dilation of the mitral valve to be reduced. In general, the local plications are discrete plications formed in the fibrous tissue around the mitral valve using suture structures or discrete mechanical elements.FIG. 9ais a representation of a top-down cut-away view of a left ventricle of the heart in which local plication suture structures have been implanted in accordance with an embodiment of the present invention. Suture structures, which include T-bars904 andthreads907, are implanted in tissue near amitral valve916, e.g., an annulus ofmitral valve916. Typically, the tissue in which suture structures are implanted isfibrous tissue940 which is located substantially aroundmitral valve916. Suitable suture structures include, but are not limited to, structures which include T-bars904 andthreads907, as will be described below with reference toFIGS. 10a,10b,11, and12a-c.
• Since T-bars904 or similar structures, when implanted, may cut throughtissue940,pledgets905 may against aventricular side tissue940 to effectively “cushion” T-bars904. Hence, portions of T-bars904 are positioned abovemitral valve916, i.e., on an atrial side ofmitral valve916, whilepledgets905 are positioned on the ventricular side ofmitral valve916. It should be appreciated that additional or alternative pledgets may be positioned on the atrial side ofmitral valve916, substantially betweentissue940 and T-bars904. Catheters which deliversuture structures904 to an atrial side ofmitral valve916 from a ventricular side ofmitral valve916 will be discussed below with respect toFIGS. 13a-c.
• In the described embodiment, T-bars904 are coupled such that every two T-bars, e.g., T-bars904a, is coupled by a thread, e.g.,thread907a.Thread907ais configured to enable T-bars904ato be tensioned together and locked againsttissue940. Locking T-bars904aenablestissue940 to be bunched or slightly gathered, thereby effectively constraining the size, e.g., arc length, ofmitral valve916 by reducing the an arc length associated withtissue940. In other words, the presence of T-bars904 which cooperate withthread907 to function substantially as sutures, allows the size of agap908 between ananterior leaflet920 and aposterior leaflet918 to be reduced and, further, to be substantially prevented from increasing. As will be appreciated by those skilled in the art, over time, scar tissue (not shown) may form overpledgets905 and T-bars904.
• Generally, the number of T-bars904 used to locally bunch or gathertissue940 may be widely varied. For instance, when substantially only a small, localized regurgitant jet occurs inmitral valve916, only a small number of T-bars904 may be implemented in proximity to the regurgitant jet. Alternatively, when the size ofgap908 is significant, and there is a relatively large amount of mitral valve leakage, then a relatively large number of T-bars904 and, hence,pledgets905 may be used to reduce the size ofgap908 by reducing the arc length ofmitral valve916. Somepledgets905 may be arranged to at least partially overlap. To correct for a regurgitant jet that is centralized to only one section ofmitral valve916, T-bars904 may be implemented as plicating elements near the regurgitant jet, and as reinforcing elements away from the regurgitant jet, e.g., to prevent progression of mitral valve disease from causing a substantial gap to eventually form.
• While the coupling of two T-bars904awiththread907ahas been described, it should be understood that the number of T-bars904 coupled by a thread orthreads907 may vary. For example, if multiple T-bars904 are coupled bymultiple threads907, then it may be possible to gather more fibrous tissue using fewer total T-bars904. With reference toFIG. 9b, the use of multiple T-bars904 which are coupled bymultiple threads907 will be described. T-bars904care coupled by athread907c, while T-bars904dare coupled by athread907c. Similarly, T-bars904eare coupled by a thread907e. T-bar904d′ is further coupled by athread907fto T-bar904c″, and T-bars904d″ is also coupled by athread907gto T-bar904e′. As will be discussed below,threads907 enable T-bars904 to be pulled againstpledgets905 and, hence,tissue940. Such coupling of T-bars904 enables plications intissue940 to be made between T-bars904c, between T-bars904d, and between T-bars904e, while allowing tissue to be at least somewhat gathered between T-bar904c″ and T-bar904d′, and between T-bar904d″ and T-bar904e′.
• In general, the configurations of suture structures which include T-bars904 andthreads907 may vary. One embodiment of a suitable suture structure is shown inFIGS. 10aand10b.FIGS. 10aand10bare representations of a suture structure after T-bars have been introduced to an atrial side of fibrous tissue near a mitral valve in accordance with an embodiment of the present invention. For purposes of illustration, it should be understood that the elements and structures represented inFIGS. 10aand10b, as well as substantially all other figures, have not been drawn to scale. Asuture structure1000 includes T-bars904, or reinforcing elements, that are coupled tothread907 such that whenthread907 is pulled, T-bars904 effectively push againsttissue940. As shown inFIG. 10b, pulling onthread907 and pushing on alocking element1002causes locking element1002 to contact a ventricular side oftissue940 and to effectively hold T-bars904 againsttissue940. Specifically, pulling on aloop1004 ofthread907 while pushing on lockingelement1002 tightens T-bars904 againsttissue940 such that aplication1006 may be formed intissue940 when lockingelement1002 locks into position to lock T-bars904 into place.
• Pledgets905, as will be appreciated by those skilled in the art, may serve as plication anchors for T-bars904 which essentially function as sutures. That is,pledgets905 may prevent T-bars904 from cutting throughtissue940. In general, the configuration ofpledgets905 may vary widely. For example,pledgets905 may have a substantially tubular form, and may be formed from a material such as surgical, e.g., Dacron, mesh. However, it should be appreciated thatpledgets905 may be formed in substantially any shape and from substantially any material which promotes or supports the growth of scar tissue therethrough. Suitable materials include, but are not limited to silk and substantially any biocompatible porous or fibrous material.
• Lockingelement1002 may be a one-way locking element, e.g., an element which may not be easily unlocked once it is locked, that is formed from a biocompatible polymer. The configuration of alocking element1002 may be widely varied. Alternative configurations of lockingelement1002 will be described below with respect toFIG. 11 andFIGS. 12a-c. In order to engage lockingelement1002 againstpledgets905, a catheter which is used to deliver T-bars904 may be used to push lockingelement1002 into a locked position. A catheter which delivers T-bars904 and may also be used to engage lockingelement1002 will be discussed below with reference toFIGS. 13a-c.
• Like lockingelement1002, T-bars904 may also be formed from a biocompatible polymer.Thread907, which may be coupled to T-bars904 through tying T-bars904 tothread907 or molding T-bars904 overthread907, may be formed from substantially any material which is typically used to form sutures. Suitable materials include, but are not limited to, silk, prolene, braided Dacron, and polytetrafluoroethylene (PTFE, or GoreTex).
• As mentioned above, the configuration of lockingelement1002 may vary. For example, a locking element may include a spring element as shown inFIG. 11. Asuture structure1100 include T-bars1104, athread1107, and a locking element1102. For ease of illustration, the elements ofsuture structure1100 have not been drawn to scale. Althoughsuture structure1100 is not illustrated as including a pledget, it should be appreciated thatsuture structure1100 may include a pledget or pledgets which serve as reinforcing elements which generally support the growth of scar tissue.
• Locking element1102 includessolid elements1102aand aspring element1102b. Althoughsolid elements1102amay be formed from a biocompatible polymer,solid elements1102amay also be formed from material which is typically used to form pledgets.Spring element1102bis arranged to be held in an extended position, as shown, while aloop1114 inthread1107 is pulled on. Once T-bars1104 are in contact withtissue1140,solid elements1102amay come into contact withtissue1140, andspring element1102bmay contract to create a spring force that pullssolid elements1102atoward each other. In other words, once T-bars1104 are properly positioned againsttissue1140, locking element1102 may be locked to form a plication or local bunching oftissue1140.
• In one embodiment, the formation of scar tissue on the fibrous tissue which is in proximity to a mitral valve may be promoted before a plication is formed, or before the fibrous tissue is gathered to compensate for mitral valve insufficiency. With reference toFIGS. 12a-c, a locking element which promotes the growth of scar tissue before a plication is formed will be described in accordance with an embodiment of the present invention. As shown inFIG. 12a, asuture structure1200, which is not drawn to scale, includes alocking element1204, athread1207, and T-bars1204. Lockingelement1204, which includessolid elements1202a, aspring element1202b, and aresorbable polymer overmold1202cformed overspring element1202bis coupled tothread1207 on a ventricular side oftissue1240.
• Overmold1202c, which may be formed from a resorbable lactide polymer such as PURASORB, which is available from PURAC America of Lincolnshire, Ill., is formed overspring element1202bwhilespring element1202bis in an extended position.Overmold1202cis arranged to remain intact whilescar tissue1250 forms oversolid elements1202a. In one embodiment, in order to facilitate the formation of scar tissue,solid elements1202amay be formed from material that is porous or fibrous, e.g., “pledget material.”
• Once scar tissue is formed oversolid elements1202a,overmold1202cbreaks down, e.g., degrades, to exposespring element1202b, as shown inFIG. 12b. As will be understood by one of skill in the art, the chemical composition ofovermold1202cmay be tuned such that the amount of time that elapses before overmold1202cbreaks down may be controlled, e.g., controlled to break down after a desired amount of scar tissue is expected to be formed. Hence, once overmold1202cbreaks down, andspring element1202bis allowed to contract, as shown inFIG. 12c,enough scar tissue1250 will generally have formed oversolid elements1202ato effectively bondsolid elements1202aagainsttissue1240 to allow for the formation of a relatively strong plication or gathering oftissue1240.
• While aloop1214 ofthread1207 may be allowed to remain extended into a left ventricle of a heart,thread1207 may be cut, i.e.,loop1214 may be effectively removed, to reduce the amount ofloose thread1207 in the heart. Alternatively,loose thread1207 may effectively be eliminated by gatheringthread1207 around a cylindrical arrangement (not shown) positioned over locking element1202. That is, a spool or similar element may be included as a part ofsuture structure1200 to enableloose thread1207 to either be gathered within the spool or gathered around the exterior of the spool.
• The use ofovermold1202cenables anchoring forces which hold T-bars1204 and locking element1202 in position to be relatively low, as substantially no significant forces act ontissue1240 until after scar tissue or tissue ingrowth is created. Once scar tissue is created, and overmold1202chas degraded, then spring1202bcompresses. The anchoring forces generated at this time may be relatively high. However, as scar tissue has been created, the likelihood that T-bars1204 cut intotissue1240 at this time is generally relatively low.
• As mentioned above, catheters may be used to deliver suture structures into a heart, and to engage the suture structures to tissue around the mitral valve of the heart. One embodiment of a suture structure delivery catheter which is suitable for use in a catheter-based annuloplasty that uses local plications will be described with respect toFIG. 13a. Adelivery catheter1300 may be positioned over a guide wire, e.g.,guide wire802 as shown inFIG. 8, which serves as a track to enabledelivery catheter1300 to be delivered in the gutter of a heart. It should be appreciated that the elements ofdelivery catheter1302 have not been drawn to scale. Withindelivery catheter1300 is awire1308 which carries T-bars1304 of a suture structure. In one embodiment, T-bars1300 are coupled to athread1307 and alocking element1300 to form the suture structure. Typically, a pointed or sharpenedend1311 ofwire1308 is configured to penetrate tissue (not shown), e.g., fibrous tissue of the heart near a mitral valve. Onceend1311 and T-bar1304 are located above fibrous tissue, e.g., on an atrial side of a mitral valve,wire1308 may be retracted a repositioned. Afterwire1308 is repositioned,end1311 may once again penetrate tissue to effectively deposit T-bar1304 over tissue on the atrial side of the mitral valve.
• Wire1308 or, more specifically,end1311 may be used to pullthread1307 and to push lockingelement1302 into position against tissue near the mitral valve. By way of example,end1311 may pull onthread1307 until T-bars1304 contact the tissue. Then,end1311 may be used to locklocking element1302 against the tissue and, as a result, create a plication in the tissue to effectively shrink the annulus of the mitral valve.
• In order to create additional plications,wire1308 and, in one embodiment,delivery catheter1300, may be retracted entirely out of a patient to enable additional T-bars to be loaded ontowire1308. Once additional T-bars are positioned onwire1308,wire1308 may be reinserted intodelivery catheter1300, anddelivery catheter1300 may be used to enable another plication to be created in the tissue which is located near the mitral valve.
• FIG. 13bis a representation of a second catheter which is suitable for delivering a suture structure in accordance with an embodiment of the present invention. Acatheter1340, which is not drawn to scale and which may include a lumen (not shown) that is arranged to be inserted over a guide wire, includes twowires1348 which are arranged to cooperate to carry a suture structure. As shown,wire1348acarries a T-bar1344awhile wire1348bcarries a T-bar1344bwhich are coupled by athread1347 and, together with alocking element1342, form a suture structure. Tips1351 ofwires1348 pass through tissue near a mitral valve to deposit T-bars1344 above the mitral valve. Once T-bars1344 are deposited, tips1351 may be used to pull T-bars1344 against the tissue, as well as to locklocking element1342 against an opposite side of the tissue. By way of example,tip1351bmay be configured to pull onthread1347 whiletip1351apushes against lockingelement1342.
• With reference toFIG. 13c, a catheter arrangement which may deploy T-bars from its tip will be described in accordance with an embodiment of the present invention. A catheter arrangement1360 includes two catheters which each carry a T-bar1364. It should be appreciated that the elements ofFIG. 13chave not been drawn to scale for ease of illustration. Specifically,catheter1360acarries T-bar1364aat its tip, whilecatheter1360bcarries T-bar1364bat its tip. Athread1367 couples T-bars1364 together such that alocking element1362 through whichthread1367 passes may lock T-bars1364 substantially against tissue of a heart.
• In one embodiment, catheter arrangement1360 may require the use of two guide wires to guide each ofcatheter1360aandcatheter1360binto the gutter of the heart. Alternatively,catheter1360aandcatheter1360bmay be arranged such that bothcatheter1360aandcatheter1360bmay be guided through the gutter of the heart through the use of a single guide wire.
• Catheter1360ais configured to push T-bar1364athrough tissue near the mitral valve of the heart, and to release T-bar1364aonce T-bar1364ais located on an atrial side of the mitral valve. Similarly,catheter1360bis configured to push T-bar1364bthrough the tissue, and to release T-bar1364b. T-bars1364 may be released, for example, when heat is applied to a dielectric associated with catheters1360 that causes T-bars1364 to be effectively snapped off. Alternatively, a mechanical mechanism (not shown) that engages T-bars1364 to catheters1360 may be disengaged to release T-bars1354. Once T-bars1364 are positioned on the atrial side of the mitral valve, catheter1360 may be used to pull onthread1367 and to push on lockingelement1362.
• With reference toFIGS. 14aand14b, the performance of an annuloplasty procedure using a catheter-based system which implants suture structures in tissue near a mitral valve will be described in accordance with an embodiment of the present invention. Once a patient is prepared, e.g., sedated, anannuloplasty procedure1400 may begin with the insertion of a delivery tube and a J-catheter into the left ventricle of the heart of the patient. The delivery tube and the J-catheter may be inserted into the body of the patient through the femoral artery, and threaded through the femoral artery and the aorta into the left ventricle of the heart. Generally, the J-catheter is positioned within the delivery tube. One embodiment of the delivery tube and a J-catheter were described above with respect toFIGS. 6aand6b. As will be appreciated by those skilled in the art, the delivery tube and the J-catheter are typically each threaded through the aortic valve to reach the left ventricle.
• Once the delivery tube and the J-catheter are positioned within the left ventricle, a gutter catheter may be extended through the J-catheter instep1408. As was discussed above with reference toFIGS. 7a-c, the gutter catheter is arranged to effectively run against a gutter of the wall of the left ventricle substantially immediately under the mitral valve. Specifically, the gutter catheter may be positioned in the space in the left ventricle between the mitral valve and the musculi papillares, or papillary muscles. The gutter catheter often has a tip that is steerable and flexible. In one embodiment, the tip of the gutter catheter may be coupled to an inflatable balloon. The J-catheter serves, among other purposes, the purpose of allowing the gutter catheter to be initially oriented in a proper direction such that the gutter catheter may be positioned along the wall of the left ventricle.
• Instep1412, a guide wire with an anchoring feature may be delivered through the gutter catheter, e.g., through a lumen or opening in the gutter catheter. The guide wire is delivered through the gutter catheter such that it follows the contour of the gutter catheter against the wall of the left ventricle. After the guide wire is delivered, the anchoring feature of the guide wire is anchored on the wall of the left ventricle instep1416. Anchoring the guide wire, or otherwise implanting the guide wire, on the wall of the left ventricle enables the guide wire to maintain its position within the left ventricle.
• The J-catheter and the gutter catheter are pulled out of the left ventricle through the femoral artery instep1420, leaving the guide wire anchored within the left ventricle, as was discussed above with respect toFIG. 8. A T-bar assembly delivery catheter which carries a T-bar assembly is then inserted through the femoral artery into the left ventricle over the guide wire in step1436. In one embodiment, the T-bar assembly delivery catheter carries an uninflated balloon.
• After the T-bar assembly delivery catheter is inserted into the left ventricle, the balloon is inflated instep1428. Inflating the balloon, e.g., an elastomeric balloon, at a relatively modest pressure using, for example, an air supply coupled to the balloon through the T-bar assembly delivery catheter, serves to enable substantially any catheter which uses the guide wire as a track to be pressed up against the fibrous tissue around the mitral valve. Generally, the inflated balloon substantially occupies the space between the mitral valve and the papillary muscles. In one embodiment, more than one balloon may be inflated in the left ventricle.
• Once the balloon is inflated instep1428. The T-bar assembly delivery catheter effectively delivers T-bars, or similar mechanisms, pledgets, and thread which are arranged to attach or otherwise couple with an annulus of the mitral valve, e.g., the fibrous tissue of the skeleton around the mitral valve, to create plications. Suitable catheters were described above with respect toFIGS. 13a-c. Instep1440, a plication is created using the T-bar assembly in substantially any suitable tissue near the mitral valve. For example, a plication may be created by essentially forcing T-bars through the tissue, then locking the T-bars against the tissue using a locking mechanism of the T-bar assembly. Specifically, the plication or bunching of tissue may be created by extending sharpened wires which carry elements such as T-bars through the tissue, then retracting the sharpened wires, and pulling the T-bars into place. Positioning the T-bars, and locking the locking mechanism causes the tissue between the T-bars and the locking mechanism may bunch together.
• Once the plication is created instep1440, the balloon is generally deflated instep1442. The T-bar assembly delivery catheter may then be removed through the femoral artery instep1444. A determination is made instep1448 after the T-bar assembly delivery catheter is removed as to whether additional plications are to be created. If it is determined that additional plications are to be created, then process flow returns to step1436 in which the T-bar assembly delivery catheter, which carries a T-bar assembly or suture structure, is reinserted into the femoral artery.
• Alternatively, if it is determined instep1448 that there are no more plications to be created, then process flow proceeds to step1456 in which the guide wire may be removed. After the guide wire is removed, the delivery tube may be removed instep1460. Once the delivery tube is removed, the annuloplasty procedure is completed.
• In lieu of using suture structures such as T-bar assemblies to create local plications, other elements may also be used to create local plications in fibrous tissue near the mitral valve during an annuloplasty procedure.FIG. 15 is a cut-away top view representation of a left side of a heart in which local plications have been created using individual, discrete elements in accordance with an embodiment of the present invention.Local plication elements1522 are effectively implanted infibrous tissue1540 around portions of amitral valve1516 in order to reduce the size of agap1508 between ananterior leaflet1520 and aposterior leaflet1518, e.g., to reduce the arc length associated withposterior leaflet1518.Local plication elements1522 are arranged to gather sections oftissue1540 to create local plications. The local plications created bylocal plication elements1522, which are generally mechanical elements, reduce the size of the mitral valve annulus and, hence, reduce the size ofgap1508. As will be understood by those skilled in the art, over time, scar tissue may grow around or overlocal plication elements1522.
• The configuration oflocal plication elements1522 may be widely varied. For example,local plication elements1522 may be metallic elements which have spring-like characteristics, or deformable metallic elements which have shape memory characteristics. Alternatively, eachlocal plication element1522 may be formed from separate pieces which may be physically locked together to form a plication. With reference toFIGS. 16a-d, one embodiment of a local plication element which has spring-like characteristics will be described in accordance with an embodiment of the present invention. Alocal plication element1622 may be delivered to a ventricular side, or bottom side, oftissue1640 which is located near a mitral valve. When delivered, as for example through a catheter,element1622 is in a substantially folded, closed orientation, as shown inFIG. 16a. In other words,element1622 is in a closed configuration that facilitates the delivery ofelement1622 through a catheter. After an initial compressive force is applied atcorners1607 ofelement1622, sides ortines1609 ofelement1622 may unfold or open. Astines1609 open,tips1606 oftines1609 may be pressed againsttissue1640, as shown inFIG. 16b. The application of compressive force totines1609, as well as a pushing force to abottom1611 ofelement1622, allowstips1606 and, hence,tines1609 to grabtissue1640 astips1606 push throughtissue1640, as shown inFIG. 16c. The closing oftines1609, due to compressive forces applied totines1609, causestissue1640 to be gathered betweentines1609 and, as a result, causes aplication1630 to be formed, as shown inFIG. 16d. In one embodiment, the catheter (not shown) that deliverselement1622 may be used to apply forces toelement1622.
• As mentioned above, elements used to create local plications may be created from shape memory materials. The use of a shape memory material to create a plication element allows the plication element to be self-locking.FIG. 17ais a representation of one plication element which is formed from a shape memory material in accordance with an embodiment of the present invention. Aclip1704, which may be formed from a shape memory material, i.e., an alloy of nickel and titanium, is arranged to be in an expanded state or open state when it is introduced, e.g., by a catheter, into the gutter of the left ventricle. Typically, holdingclip1704 in an expanded state involves applying force to clip1704. In one embodiment, a catheter may holdsides1708 ofclip1704 to maintainclip1704 in an expanded state.
• Oncetips1706 ofclip1704 are pushed through the fibrous tissue near the mitral valve of the heart such thattips1706 are positioned on an atrial side of the mitral valve, force may be removed fromclip1704. Sinceclip1704 is formed from a shape memory material, once force is removed,clip1704 forms itself into its “rest” state of shape, as shown inFIG. 17b. In its rest state or preferred state,clip1704 is arranged to gather tissue in anopening1712 defined byclip1704. That is, the default state ofclip1704 is a closed configuration which is effective to bunch tissue to create a local plication.
• Another discrete self-locking plication element which is suitable for creating a local plication is a clip which may twist from an open position to a closed, or engaged position, once force applied to hold the clip in an open position is removed.FIG. 18ais a representation of another self-locking plication element shown in a closed position in accordance with an embodiment of the present invention. Aclip element1800, which may be formed from a material such as stainless steel or a shape memory material, is preloaded such that oncetissue1830 is positioned in agap1810 between atine1806 and atime1808,clip element1800 may return to a state which causestissue1830 to be pinched within a gap orspace1810.
• Tine1806 andtine1808first pierce tissue1830, e.g., the tissue of an annulus of a mitral valve. Astine1806 andtine1808 are drawn together to create a plication, thereby reducing the size ofgap1810 by reducing adistance1820, abottom portion1812 ofclip element1800 twists, as for example in a quarter turn, effectively by virtue of shape memory characteristics ofclip element1800. Thus, an effective lock that holdstine1806 andtine1808 in a closed position such thattissue1830 is gathered to form a local plication results.
• In lieu of a preloaded clip element, a clip element may include a lock mechanism which engages when force is applied.FIG. 18ais a representation of a self-locking plication element which includes a sliding lock in accordance with an embodiment of the present invention. Aclip element1850 includes abody1852 and aslider1862 which is arranged to slide over at least a portion ofbody1852.Clip element1850, which may be formed from a material such as stainless steel or a shape memory alloy, includes atip1856 and atip1858 which are substantially separated by agap1856 whenslider1862 is in an unlocked position. As shown,slider1862 is in an unlocked or open position whenslider1862 is positioned about atapered neck1854 ofbody1852.
• Whenclip element1850 is delivered into a left ventricle, e.g., using a catheter,clip element1850 is positioned within the left ventricle such thattip1856 andtip1858 are effectively pierced throughfibrous tissue1880 near the mitral valve. Aftertip1856 andtip1858 are positioned substantially on an atrial side oftissue1880, force may be applied toslider1862 to moveslider1862 in a y-direction1870boverbody1852. As slider moves in y-direction1870baway fromtapered neck1854,slider1862 forces tip1856 andtip1858 togetherclose gap1860, i.e.,tip1856 andtip1858 move towards each other in an x-direction1870a. Whentip1856 andtip1858 cooperate to closegap1860,tissue1880 is gathered withinclip element1850, thereby creating a local plication.
• In one embodiment, whenslider1862 is in a closed position such thattip1856 andtip1858 cooperate to closegap1856,slider1862 may contacttissue1880. Hence, in order to promote the growth of scar tissue over parts ofclip element1850 or, more specifically,slider1862, at least a top surface ofslider1862 may be covered with a pledget material, e.g., a mesh which supports the growth of scar tissue therethrough.
• Locking elements which create local plications may include elements which have two or more substantially separate pieces which lock together around tissue. An example of a locking element which includes two separate pieces is shown inFIG. 19. As shown inFIG. 19, alocking element2000 may include areceiver piece2002 and alocker piece2004, which may generally be formed from substantially any suitable material, as for example a biocompatible plastic material.Receiver piece2002 andlocker piece2004 each include a tine2006. Tines2006 are arranged to pierce and to engage tissue to create a local plication.
• Acable tie portion2010 oflocker piece2004 is configured to be drawn through anopening2008 which engagescable tie portion2010.Opening2008 includes features (not shown) which allowcable tie portion2010 to be pulled throughopening2008 and locked into position, and which preventcable tie portion2010 substantially from being pushed out ofopening2008.Cable tie portion2010 is locked inopening2008 when bevels2012 come into contact and effectively force tines2006 to clamp down. Once tines2006 clamp down, andlocker piece2004 is locked againstreceiver piece2002, a local plication is formed.
• The operation of lockingelement2000 will be described with respect toFIGS. 20a-din accordance with an embodiment of the present invention. As shown inFIG. 20a,receiver piece2002 andlocker piece2004 may be delivered substantially beneathfibrous tissue2050 near a mitral valve (not shown).Receiver piece2002 andlocker piece2004 may be delivered using a catheter which includes atop surface2054.Top surface2054 of the catheter is arranged to apply force to tines2006 such that tines2006 remain in an effectively undeployed, e.g., partially bent or folded, position while being delivered by the catheter.
• Oncereceiver piece2002 andlocker piece2004 are positioned undertissue2050 near a location where a plication is to be formed, forces are applied toreceiver piece2002 andlocker piece2004 to pushreceiver piece2002 andlocker piece2004 together and effectively through anopening2058 intop surface2054 of the catheter, as shown inFIG. 20b. The forces are typically applied by mechanisms (not shown) associated with the catheter. As tines2006 pass throughopening2058, tines2006 “open,” or deploy in order to piercetissue2050.
• After piercingtissue2050, tines2006 continue to penetrate and to gathertissue2050 whilereceiver piece2002 andlocker piece2004 are pushed together. Asreceiver piece2002 andlocker piece2004 are pushed together,cable tie portion2010 is inserted into opening2008 (shown inFIG. 19) ofreceiver portion2002, as shown inFIG. 20c.Cable tie portion2010 eventually locks with respect toopening2008 when bevels2012 come into contact. When bevels2012 come into contact, tines2006 close inwards, causingtissue2050 to be captured, i.e., causing alocal plication2060 to be formed. Once a local plication is formed, and force is no longer required to pushreceiver piece2002 andlocker piece2004 together, the catheter which deliveredreceiver piece2002 andlocker piece2004 may be removed from the left ventricle. Referring next toFIGS. 21aand21b, an annuloplasty procedure which uses a catheter-based system to create local plications in tissue near a mitral valve using discrete elements will be described in accordance with an embodiment of the present invention. After a patient is prepared, anannuloplasty procedure2100 may begin with the insertion of a delivery tube and a J-catheter into the left ventricle of the heart of the patient instep2104. Once the delivery tube and the J-catheter are positioned within the left ventricle, a gutter catheter may be extended through the J-catheter instep2108. The gutter catheter, as described above, is arranged to effectively run against a gutter of the wall of the left ventricle, e.g., between the mitral valve and the papillary muscles. The gutter catheter often has a tip that is steerable and flexible.
• Instep2112, a guide wire with an anchoring feature may be delivered through the gutter catheter, e.g., through a lumen or opening in the gutter catheter. The guide wire is delivered through the gutter catheter such that it follows the contour of the gutter catheter against the wall of the left ventricle. After the guide wire is delivered, the anchoring feature of the guide wire is anchored on the wall of the left ventricle instep2116.
• The J-catheter and the gutter catheter are pulled out of the left ventricle through the femoral artery instep2120, leaving the guide wire anchored within the left ventricle, as was discussed above with respect toFIG. 8. A plication element delivery catheter which carries a plication element and, in one embodiment, is arranged to engage the plication element to the fibrous tissue around the mitral valve is inserted through the femoral artery into the left ventricle over the guide wire instep2132. The plication element delivery catheter, in the described embodiment, is coupled to an uninflated balloon which is inflated instep2134 to effectively allow the plication element delivery catheter to be positioned substantially directly under the fibrous tissue. Once the plication element delivery catheter is positioned in the left ventricle, e.g., over the guide wire in the gutter of the left ventricle, and the balloon is inflated, the plication element delivered by the delivery catheter is engaged to the fibrous tissue instep2136. That is, the plication element is coupled to the fibrous tissue such that a local plication is formed in the fibrous tissue.
• After the local plication is created instep2136 by engaging tissue using the plication element, the balloon is deflated instep2138. Upon deflating the balloon, the plication element delivery catheter may be removed through the femoral artery instep2140. A determination is then made instep2142 as to whether additional local plications are to be created. That is, it is determined if other plication elements are to be introduced into the left ventricle. If it is determined that additional local plications are to be created, process flow returns to step2132 in which the plication element delivery catheter, which carries another plication element, is reinserted into the femoral artery.
• Alternatively, if it is determined instep2142 that there are no more local plications to be created, then the indication is that a sufficient number of local plications have already been created. Accordingly, the guide wire may be removed instep2148, and the delivery tube may be removed instep2152. After the delivery tube is removed, the annuloplasty procedure is completed.
• A catheter which may enable an orthogonal access to a mitral valve may enable the catheter to be more accurately positioned underneath the mitral valve. As discussed above, a catheter may become at least partially tangled in trabeculae which are located in the left ventricle of a heart. As such, inserting a catheter which does not extend too deeply into the left ventricle may prevent significant tangling. Any tangling may impede the efficiency with which the catheter may be positioned beneath a mitral valve. One catheter which may be less likely to become at least partially tangled in trabeculae, while also enabling an orthogonal access to a mitral valve, is an L-shaped catheter, which is shown inFIG. 22a. An L-shapedcatheter arrangement2200, which includes adelivery tube2201 and an L-shapedcatheter2202 which may be formed from a biocompatible material that is typically also relatively flexible, is arranged to allow the tip of L-catheter2202 to maintain an “L” shape when passed through anaortic valve2206 into aleft ventricle2204. Afterdelivery tube2201 and L-shapedcatheter2202 are effectively “snaked” or inserted through a femoral artery, atip2208 of L-shaped catheter may be positioned at a top portion ofleft ventricle2204, where there is typically a minimal amount of trabeculae.
• Tip2208 of L-shapedcatheter2202 may be extended in a straight orientation such thattip2208 effectively forms an “L” with respect todelivery tube2201 and the remainder of L-shapedcatheter2202. In one embodiment, astip2208 is extended under amitral valve2212, astring2210 or another part, e.g., a wire, that may be coupled totip2208 may extend through an opening indelivery tube2201 as shown inFIG. 22b.String2210 may effectively allowtip2208 to be bent or otherwise moved around underneath toposition tip2208 into contact withmitral valve2212, as shown inFIG. 22c.
• The use ofstring2210 to pull ontip2208 allows, in cooperation with extending L-shapedcatheter2202,tip2208 to be moved beneathmitral valve2212 into desired positions. Hence, desired locations beneathmitral valve2212 may relatively easily be reached to enable plications (not shown) to be created in the desired locations. In the described embodiment,string2210 may enable a curve to be created in L-shapedcatheter2202 that is substantially an approximately ninety degree curve.
• L-shapedcatheter2202 may be used to create plications inmitral valve2212 using a variety of different methods. Specifically,tip2208 of L-shapedcatheter2202 may be temporarily fixed in a position beneathmitral valve2212, e.g., in a gutter of the heart, during a process of creating a plication inmitral valve2212. In one embodiment, suction may be used to gather a portion of tissue nearmitral valve2212 either such that a plication may be made in the portion, or such that a temporary anchor point may be created. Suction generally enables tissue to be substantially gathered such that an apparatus, as for example a clip or a similar apparatus, may be put into place to hold the gathered tissue. Alternatively, suction may be used to secure or firmly anchortip2208 againstmitral valve2212 such that an anchor for a plication may be deployed with improved accuracy. Whentip2208 is anchored into tissue nearmitral valve2212, an anchor for a plication or a temporary anchor may be more precisely placed, as the position oftip2208 is effectively fixed.
• FIGS. 23aand23bare diagrammatic representations of orientations of a tip area of an L-shaped catheter which may be used with suction to anchor the tip area to a mitral valve in accordance with an embodiment of the present invention. As shown inFIG. 23a, atip2308 of a catheter such as an L-shaped catheter, e.g., L-shapedcatheter2202 ofFIG. 22c, may include anopening2314 on a side oftip2308.Opening2314 may be positioned undertissue2312 such that when suction is applied throughopening2314,tip2308 is effectively temporarily fixed againsttissue2312. Alternatively, as shown inFIG. 23b, atip2318 of an L-shaped catheter may include anend opening2324, i.e., an opening at an endpoint oftip2318, that allows opening2324 to contacttissue2322 such that when suction is applied throughopening2324,tip2312 is held relatively firmly againsttissue2322. Temporarily anchoring a catheter near a mitral valve generally allows plication elements to be more accurately deployed using the catheter.
• In lieu of using suction to anchor the tip area of a catheter to tissue near a mitral valve, a wire with a coil which may be extended through a catheter such that the wire may be temporarily anchored into tissue near the mitral valve such that other catheters may track over the wire. For example, a wire with a helical coil or a spiral at the tip may be engaged against tissue by applying force to the tip of the wire, turning the wire such that the helical coil portion of the wire turns through the tissue, the pushing the coil through the tissue.FIGS. 24aand24bare diagrammatic representations of a wire with a helical coil which may be suitable for use in as a temporary anchor that is anchored into tissue near a mitral valve in accordance with an embodiment of the present invention. Awire2430 with a coiledtip2432, as shown inFIG. 24a, may be extended through a catheter (not shown) while a tip of the catheter may, in one embodiment, effectively be anchored against tissue near a mitral valve.Wire2430 may be inserted in a catheter (not shown) such that a longitudinal axis ofwire2430 is parallel to a longitudinal axis of a tip (not shown) of the catheter. As shown inFIG. 24b, coiledtip2432 may extend through a lumen of atip2440 of an L-shaped catheter to enabletip2440 to be substantially anchored when coiledtip2432 is anchored against tissue.Coiled tip2432 is incorporated in the tip of the catheter, and would be engaged by rotating the entire catheter. This design features a working lumen that is coaxial with the center of the helical tip to enable a T-bar that is pushed down the lumen to pass through the center of the helix as the T-bar is effectively forced through tissue. It should be appreciated that, in one embodiment, a coiled tip may be included as a part of an L-shaped catheter, i.e., the catheter may include a coiled tip.
• Awire2430 with a coiledtip2432 may generally be used as a temporary anchor which may remain coupled to tissue even after a catheter through whichwire2430 was deployed is retracted. That is,wire2430 may serve as a track over which other catheters may be “run” to enable a particular position, i.e., a position identified by the location of coiledtip2432 with respect to the tissue, to be repeatedly accessed or located by catheters.
• In general, temporary fixation is a relatively reversible process. By effectively temporarily fixing or anchoring a catheter or a coiled tip of a wire against mitral valve tissue or tissue near a mitral valve, it is relatively easy to position, release, and re-position the wire and, hence, a catheter that tracks over the wire substantially without trauma, and substantially without causing an irreversible action to occur. A temporary anchor may provide a tension or counter-traction force for the application of a permanent anchor. That is, counter-traction on the temporary anchor may be used to provide a tissue penetration force for the permanent anchor. Possible permanent anchors generally include both single anchor points, e.g., applying one T-bar with a second T-bar being needed to for a plications, and dual anchor points, e.g., applying a clip or a staple which creates a plication between its points.
• Once a catheter is effectively anchored into position, as for example over a wire such aswire2430, then anchors which are used to create plications may be deployed. Typically, two anchor points are used to form a single plication.FIG. 25 is a diagrammatic representation of an anchor which is deployed and anchored into tissue in accordance with an embodiment of the present invention. Ananchor2504, which is coupled to a tether or atail2500, is deployed throughtissue2508 such thatanchor2504 is pushed throughtissue2508 whiletail2500 is allowed to extend, e.g., to an exterior of the body of a patient. In one embodiment,anchor2504 may be a temporary anchor which is not actually used in the creation of a plication but is, instead, used to allow anchors used for plications to be positioned. In such an embodiment,anchor2504 may be used to enable a first permanent anchor to be anchored. Alternatively,anchor2504 may be an anchor, e.g., a T-bar, which is intended to be used to create a plication. For ease of discussion,anchor2504 is described as being a first permanent anchor that was previously anchored into position by guiding a catheter over a temporary anchor (not shown).
• An incrementor catheter may usetail2500 as a guide over which the incrementor catheter may be positioned. An incrementor catheter, as shown inFIG. 26a, may generally include two sections. Afirst section2602 of anincrementor catheter2600, may be inserted overtail2500. In one embodiment,first section2602 may be used to insertanchor2504, e.g., whenincrementor catheter2600 is configured as an L-shaped catheter.
• Oncefirst section2602 is positioned overtail2500 such thatfirst section2602 is in relatively close proximity totissue2508, asecond section2604 may be extended away fromfirst section2602, as for example by a nominal separation or distance ‘d,’ as shown inFIG. 26b. The positioning offirst section2602 overtail2500 enablesfirst section2602 to be temporarily fixed. Withfirst section2602 being temporarily fixed,second section2604 may be controlled such that a tip ofsecond section2604 may be rotated, extended, or retraced to control the penetration angle of an anchor (not shown) that is to be deployed.
• Additionally, whenfirst section2602 is temporarily fixed, the position offirst section2602 may be maintained for enough time to perform substantially all desired tests and to withstand forces associated with the desired test. Further, substantially all forces associated with the manipulation ofincrementor catheter2602.
• Distance ‘d’ may be substantially any distance, and is typically selected to be a distance which allows a plication created usinganchor2504 and an anchor (not shown) that is to be deployed throughsecond section2604 to be effectively created. Whensecond section2604 is used to deploy either a temporary or permanent anchor (not shown),second section2604 is effectively a working lumen ofincrementor catheter2600.
• The location of anchors may generally be verified using a number of technologies which include, but are not limited to, ultrasound techniques, fluoroscopy techniques, and electrical signals. With some of the technologies, the injection of marking agents, e.g., contrast agents for fluoroscopy or microspheres for ultrasound, may increase contrast and promote visibility. Typically, such injections may be into a ventricular space, within mitral valve tissue, or in through the mitral valve tissue into atrial space. It should be appreciated that the verification of locations may further enable a distance ‘d’ between consecutive anchors to be more accurately maintained.
• FIG. 27 is a diagrammatic representation of two anchors which may be used to create a plication in accordance with an embodiment of the present invention.Anchor2504 and ananchor2704, which may be deployed usingsecond section2604 ofincrementor catheter2600 ofFIG. 26b, are separated by distance ‘d.’ Eachanchor2504,2704 has a tail section, i.e.,tail2500 and atail2700, respectively, which, afterincrementor catheter2600 ofFIG. 26bis withdrawn from underneathtissue2508, may be pulled on or tensioned such that a plication is effectively created betweenanchor2504 andanchor2704. Once a plication is created,tails2500,2700 may be trimmed.
• In general, a daisy chain of plications may be created using an incrementor catheter. That is, the incrementor catheter may be used to anchor a series of anchors which are each substantially separated by a distance ‘d.’ Once a daisy chain of anchors is in place in mitral valve tissue, pairs of the anchors may effectively be tied off to create a series or a daisy chain of plications. With reference toFIG. 28a-f, a process of creating a daisy chain of plications will be described in accordance with an embodiment of the present invention. As shown inFIG. 28a, afirst anchor2802a, which may be a T-bar, has atail2806asuch as a suture and is anchored totissue2804. Typically,tissue2804 is tissue of a mitral valve annulus, or tissue near a mitral valve. Asecond anchor2802b, which has atail2806bis also anchored intotissue2804. Typically, the distance betweensecond anchor2802bandfirst anchor2802ais a measured distance, i.e., the distance betweensecond anchor2802bandfirst anchor2802ais predetermined. In one embodiment, the distance is substantially controlled using an incrementor catheter.
• Oncefirst anchor2802aandsecond anchor2802bare in place, alocker2810ais delivered overtails2806a,2806b, as shown inFIG. 28b. Oncelocker2810ais delivered,tail2806amay be tensioned, substantially locked, and trimmed. Tensioning oftail2806b, as shown inFIG. 28c, allows afirst plication2820 to be effectively created.Tail2806bremains untrimmed, assecond anchor2802bis arranged to be included in a second plication of a daisy chain of plications. That is,second anchor2802bmay effectively be shared by more than one plication. Athird anchor2802cwhich has atail2806c, as shown inFIG. 28d, is anchored intotissue2804 at a specified distance fromsecond anchor2802b, e.g., through the use of an incrementor catheter.
• Alocker2810bmay be delivered overtail2806bandtail2806c, andtail2806bmay be tensioned, locked, and trimmed as shown inFIG. 28e. Whentail2806cis tensioned, asecond plication2830 is created, as shown inFIG. 28f. It should be appreciated that if tail2806 is also locked and trimmed, then a daisy chain of twoplications2820,2830 is completed. Alternatively, if more plications are to be added, then additional anchors and lockers may be positioned as appropriate such thattail2806cserves as a “starting point” for the additional plications.
• Instead of using an L-shaped catheter to create anchor points, substantially any other suitable catheter may be used to access tissue near a mitral valve or a mitral valve annulus, e.g., to achieve a substantially orthogonal access to mitral valve tissue. In one embodiment, a suitable catheter may be a hook catheter which effectively includes an approximately 180 degree curve may be used to create anchor points and plications.FIG. 29ais a diagrammatic representation of a hook catheter in accordance with an embodiment of the present invention. Ahook catheter2900, which includes atip2902 that is effectively a terminus of acurved portion2903 ofhook catheter2900, is inserted through anaortic valve2904 into aleft ventricle2906.
• Oncehook catheter2900 is positioned or, more specifically, oncetip2902 is positioned nearmitral valve tissue2908, astring2910 which may be coupled totip2902 as shown inFIG. 29b, may be pulled on or tensioned and slackened, as appropriate, to enabletip2902 to be positioned in a desired location with respect tomitral valve tissue2908. As will be appreciated by those skilled in the art,string2910 is often a wire such as a pull wire or a deflection wire that is axially translatable. By allowingstring2910 to enable tip902 to be positioned in a desired location,hook catheter2900 may effectively be considered to be a deflectable or steerable tip catheter. A temporary anchor, e.g., a helical coil such ashelical coil2432 ofFIG. 24a, may be anchored tomitral valve tissue2908 by deploying the temporary anchor throughhook catheter2900.FIG. 29cis a diagrammatic representation of a temporary anchor that is positioned within a heart in accordance with an embodiment of the present invention. Ananchoring coil2920, which is coupled to awire2922, may be anchored tomitral valve tissue2908 such thatwire2922 may serve as a guide over which a catheter, as for example either a catheter such as a hook catheter which delivers a permanent anchor or an incrementor catheter, which may also deliver a permanent anchor, may be positioned.
• In lieu of usinghook catheter2900 to deploy a temporary anchor,catheter2900 may instead be used to deploy a more permanent anchor such as a T-bar. As shown inFIG. 29d, a T-bar2940 may be pushed throughmitral valve tissue2908 usingtip2902 ofhook catheter2900. Whenhook catheter2900 is withdrawn fromleft ventricle2906, T-bar2940 effectively remains anchored inmitral valve tissue2908, while atail2942 of T-bar2940 may extend to an exterior of the body of a patient, as shown inFIG. 29e.
• After T-bar2940 or, more generally, an anchor is in position, then an incrementor catheter may be snaked or otherwise passed overtail2942.FIG. 29fis a diagrammatic representation of an incrementor catheter that is positioned overtail2942 in accordance with an embodiment of the present invention. Anincrementor catheter2950 is positioned such that afirst section2952 ofincrementor catheter2950 may be guided bytail2942 until a tip offirst section2952 is substantially directly under T-bar2940. Then, asecond section2954 ofincrementor catheter2950 may be extended until a tip ofsecond section2954 is positioned approximately a distance ‘d’ away from T-bar2940. A second T-bar (not shown) or anchor may then be deployed usingsecond section2954. Once a second T-bar is deployed,incrementor catheter2950 may be removed fromleft ventricle2906.
• The use of anincrementor catheter2950 allows two T-bars, e.g., T-bar2940 and T-bar2980 ofFIG. 29g, to be anchored tomitral valve tissue2908 such that T-bars2940,2980 may be spaced apart at approximately a distance ‘d,’ whiletails2942,2982, respectively, may extend outside of a body of a patient. In other words,incrementor catheter2950 generally enables the distance between adjacent T-bars to be more carefully controlled.
• In order to create a plication using T-bars2940,2980, a lockingbar2990, as shown inFIG. 29h, may be provided overtails2942,2982 such thatmitral valve tissue2908 may effectively be pinched between T-bars2940,2980 and lockingbar2990. Once a plication is created,tails2942,2982 may be trimmed or otherwise cut.
• With reference toFIG. 30, the steps associated with one method of creating a plication using an access catheter which has a 180 degree retrograde active-curve tip, e.g., a hook catheter, an incrementor catheter, and a helical coil for creating a temporary anchor will be described in accordance with an embodiment of the present invention. Aprocess3000 begins atstep3020 in which a catheter, e.g., a hook catheter, is inserted in a substantially straight configuration through an introducer into a femoral artery of a patient. Once the catheter is inserted, the tip of the catheter is prolapsed into a hook shape instep3040. A gap between an end of the hook portion and the main portion of the catheter may be reduced to a dimension that is small enough to prevent tangling of the tip in chords or leaflets of the heart. Prolapsing of the tip may generally occur within the aorta of a heart, at a femoral artery bifurcation, or within the left ventricle of the heart. It should be appreciated that when the tip of the catheter is deflectable, the tip of the catheter may be deflected or substantially actively changed into a hook shape within the aorta of the heart, or within the left ventricle of the heart.
• Instep3060, the tip of the catheter may be positioned within the left ventricle. By way of example, the catheter tip may be positioned at a level that is just inferior to the level of the mitral valve annulus, and the catheter segment that includes the hook shape may be rotated such that it lies against either the anterior or posterior aspect of the aortic outflow tract, depending upon which aspect is to be treated. In one embodiment, the distal catheter segment is aligned such that when extended, the tip of the catheter may point towards one of the entrances to the gutter of the heart. The entrances to the gutter of the heart may include substantially any relatively clear entrance to the gutter with respect to the leaflets of the heart, as for example a medial P1 location, a mid P2 location, or a lateral P3 location.
• After the tip of the catheter is positioned, the tip of the catheter may be hooked into the gutter instep3080. Hooking the catheter tip into the gutter may include repeatedly extending the retrograde tip to increase the gap between the tip and the proximal segment of the catheter, retracting the entire catheter and sensing engagement of the tip with the gutter, and, if necessary, one again positioning the tip of the catheter in the left ventricle before rehooking the tip.
• Once the catheter tip is hooked into the gutter, the location of the tip is confirmed instep3100. Confirming the location of the tip may include, but is not limited to, as previously mentioned, sensing electrical signals of the heart, fluoroscopy with or without the injection of contrast, and ultrasound with or without the injection of microspheres. When the tip location is confirmed, a temporary anchor may be attached instep3120. The temporary anchor may be a helical coil, e.g.,helical coil2432 ofFIG. 24a, that is attached by applying a longitudinal pressure and torque. Typically, when the helical coil is attached, a lumen or a tail of the helical coil remains connected to the helical coil.
• In the described embodiment, after the temporary anchor is attached, the location of the temporary anchor is confirmed instep3140. Methods used to confirm the location of the temporary anchor may be the same as methods used to confirm the location of a catheter tip, and may also include injecting contrast or microspheres into tissue or through tissue to the atrial space above a mitral valve.
• A permanent anchor is attached instep3160 using the connection to the temporary anchor as a guide. The permanent anchor may be attached to the same location, and may provide a counter-traction force for tissue engagement. Like the temporary anchor, the permanent anchor generally includes a tail.
• Once a permanent anchor is in place, an incrementor catheter is delivered into the heart instep3180. In general, the incrementor catheter is delivered in a closed configuration to the location of the first anchor, e.g., the permanent anchor attached instep3160, by tracking a first section of the incrementor catheter over the tail of the first anchor. After the incrementor catheter is delivered, the incrementor catheter may be deployed instep3200 to create a nominal distance or gap between the first anchor location and the working lumen, e.g., a second section, of the incrementor catheter. Then, instep3220, a second permanent anchor may be applied at the nominal distance from the first permanent anchor. It should be appreciated that temporary anchors may be used to facilitate the positioning of the second permanent anchor. Applying the second permanent anchor typically includes retracting the incrementor catheter once the second permanent anchor is anchored into a desired location.
• After both the first permanent anchor and the second permanent anchor are applied, a locker is delivered into the heart instep3240. Delivering the locker generally includes tracking the locker or locking device over the two tails of the first and the second permanent anchors. The locker may be fixed into position by applying tension to the locker to create a plication substantially between the two permanent anchors.
• Once the locker has been tensioned, the tails of the anchors may be severed, and the process of creating a plication is completed. It should be appreciated that, in one embodiment, steps3180 to3260 may generally be repeated to create a daisy chain of interlocking plications.
• Although only a few embodiments of the present invention have been described, it should be understood that the present invention may be embodied in many other specific forms without departing from the spirit or the scope of the present invention. By way of example, methods of introducing plication elements or suture structures into the left ventricle to correct for mitral valve leakage, or mitral valve insufficiency, may be applied to introducing plication elements or suture structures which correct for leakage in other valves. For instance, the above-described procedure may be adapted for use in repair a leaking valve associated with a right ventricle.
• While creating local plications in fibrous tissue associated with the mitral valve of the heart has generally been described, the plications may also be created in other types of tissue which are near, around, in proximity to, or include the mitral valve. As will be appreciated by those skilled in the art, other tissues to which plications may be formed that are near, around, in proximity to, or include the mitral valve include tissues associated with the coronary sinus, tissues associated with the myocardium, or tissues associated with the wall of the left ventricle. In one embodiment, a plication may be substantially directly formed in the leaflets of the mitral valve.
• It should be understood that although a guide wire has been described as including an anchoring tip to anchor the guide wire to a wall of the left ventricle, a guide wire may be anchored with respect to the left ventricle in substantially any suitable manner. By way of example, a guide wire may include an anchoring feature which is located away from the tip of the guide wire. In addition, a guide wire may more generally be any suitable guiding element which is configured to facilitate the positioning of an implant.
• While access to the gutter of the left ventricle has been described as being associated with a minimally invasive catheter annuloplasty procedure in which local plications are formed, it should be understood that the gutter of the left ventricle may also be accessed, e.g., for an annuloplasty procedure, as a part of a surgical procedure in which local plications are formed. For instance, the aorta of a heart may be accessed through an open chest surgical procedure before a catheter is inserted into the aorta to reach the left ventricle. Alternatively, suture structures or plications elements may be introduced on a ventricular side of a mitral valve through a ventricular wall which is accessed during an open chest surgical procedure.
• Pledgets have been described as being used in conjunction with, or as a part of, suture structures to facilitate the growth of scar tissue as a result of an annuloplasty procedure. It should be appreciated, however, that the use of pledgets is optional. In addition, although pledgets have generally not been described as being used with clip elements which create local plications, it should be understood that pledgets may also be implemented with respect to clip elements. By way of example, a clip element which includes tines may be configured such that the tines pierce through pledgets before engaging tissue without departing from the spirit or the scope of the present invention.
• When a clip element has tines that are arranged to pierce through a pledget before engaging tissue, the pledget may be of a hollow, substantially cylindrical shape that enables the pledget be delivered to a left ventricle over a guide wire positioned in the gutter of the left ventricle. The clip element may then be delivered by a catheter through the pledget. A substantially cylindrically shaped, hollow pledget which is to be used with a suture structure may also be delivered over a guide wire, and the suture structure may then be delivered through the pledget. Delivering the suture structure through the pledget may enable a loop of thread that remains after the suture structure is locked into place to remain substantially within the pledget.
• The configuration of clip elements may generally vary widely. Specifically, the shape of clip elements, the size of clip elements, and the materials from which the clip elements are formed may be widely varied. For instance, in addition to clip elements that are formed from shape memory material, preloaded, or self-locking using mechanical structures, clip elements may also be formed from thermally expandable materials. That is, a clip may be formed such that it is in an open or flat position when delivered into a left ventricle. Such a clip may have an outer or “bottom” element that has a relatively high coefficient of thermal expansion, and an inner or “top” element that deforms under the load generated by the outer element when heat is applied to cause the outer element to bend. Such a clip, once bent or deformed through the application of heat, may pierce tissue. When more heat is applied, the clip may bend more such that tissue is engaged between ends or sides of the clip to create a local plication. In such a system, the inner material may be arranged to maintain its deformed shape once heat is no longer applied, and the heat may be applied through a catheter.
• Suture structures and plication elements have been described as being used to correct for mitral valve insufficiency. In general, suture structures and plication elements may also be used to essentially prevent the onset of mitral valve insufficiency. That is, local plications may be created to effectively stem the progression of mitral valve insuffiency be reinforcing the perimeter of the annulus around the mitral valve.
• While suture structures that include T-bars, thread, and locking elements, and are delivered to a left ventricle using a catheter, may be used to form discrete plications in fibrous tissue around the mitral valve, it should be appreciated that sutures may also be sewn into the fibrous tissue. For example, a catheter which is inserted into the left ventricle through the aorta may be configured to sew sutures into the fibrous tissue using mechanisms carried by the catheter. Such sutures that are sewn into the fibrous tissue may be sewn in any conventional orientation, e.g., in an arc along the perimeter of the posterior leaflet of the mitral valve.
• Suture structures that include T-bars have generally been described as including two T-bars which are located at ends of a thread, with a locking element and pledgets located therebetween, as shown, for example, inFIG. 10a. The configuration of suture structures, however, may vary widely. By way of example, a suture structure with two T-bars may include one T-bar at one end of the thread and a second T-bar which is located along the length of the thread such that pulling on a loose end of the thread pulls the two T-bars together. Alternatively, a suture structure may include more than two T-bars.
• In general, the use of a single element type to create local plications during an annuloplasty procedure has been described. It should be understood that in one embodiment, different element types may be used in a single annuloplasty procedure. For instance, both clip elements and suture elements may be used to create plications during a single annuloplasty procedure. Alternatively, different types of clip elements or different types of suture elements may be used during a particular annuloplasty procedure.
• The steps associated with performing a catheter-based annuloplasty may be widely varied. Steps may generally be added, removed, reordered, and altered without departing from the spirit or the scope of the present invention. Therefore, the present examples are to be considered as illustrative and not restrictive, and the invention is not to be limited to the details given herein, but may be modified within the scope of the appended claims.

Claims (64)

1. A method for performing annuloplasty, the method comprising:

creating a first plication in the tissue near a mitral valve of a heart, the first plication being created using at least a first plication element; and

creating a second plication in the tissue near the mitral valve, wherein the second plication is substantially coupled to the first plication.

2. The method ofclaim 1 further including:

accessing a left ventricle of the heart to provide the first plication element to the left ventricle; and

engaging the first plication element to the tissue near the mitral valve, wherein engaging the first plication element includes causing the first plication element to substantially pass through a portion of the tissue to substantially anchor the first plication element to the tissue near the mitral valve.

3. The method ofclaim 2 wherein the first plication element is an anchor arrangement with a tail, and creating the first plication in the tissue near the mitral valve includes:

accessing the left ventricle of the heart to provide a second plication element to the left ventricle, the second plication element being an anchor arrangement with a tail;

engaging the second plication element to the tissue near the mitral valve, the second plication element being separated from the first plication element by a first distance, wherein engaging the second plication element includes causing the second plication element to substantially pass through the tissue to substantially anchor the second plication element to the tissue near the mitral valve; and

providing a first locker element over the tail of the first plication element and the tail of the second plication element.

4. The method ofclaim 3 wherein creating the second plication in the tissue near the mitral valve includes:

accessing the left ventricle of the heart to provide a third plication element to the left ventricle, the third plication element being an anchor arrangement with a tail;

engaging the third plication element to the tissue near the mitral valve, the third plication element being separated from the second plication element by a second distance, wherein engaging the third plication element includes causing the third plication element to substantially pass through the tissue to substantially anchor the third plication element to the tissue near the mitral valve; and

providing a second locker element over the tail of the second plication element and the tail of the third plication element.

5. The method ofclaim 4 wherein the first distance and the second distance are approximately the same.

6. The method ofclaim 2 wherein the first plication element is delivered to the left ventricle using a catheter.

7. The method ofclaim 5 wherein the catheter has a deflectable tip.

8. The method ofclaim 2 further including:

accessing the left ventricle using an incrementor catheter, the incrementor catheter including a first section and a second section, wherein the first section is arranged to be tracked over a tail of the first plication element.

9. The method ofclaim 8 further including:

deploying the incrementor catheter, wherein deploying the incrementor catheter includes positioning a tip of the second section at the first distance distance away from a tip of the first section.

10. A method for performing annuloplasty, the method comprising:

accessing a heart to provide a plurality of plication elements to the heart, the plurality of plication elements being provided to the heart through a catheter arrangement, the plication elements including a first anchor arrangement;

engaging the first anchor arrangement to tissue near a mitral valve of the heart using the catheter arrangement to substantially anchor the first anchor arrangement to the tissue near the mitral valve; and

creating at least a first plication and a second plication using the first anchor arrangement.

11. The method ofclaim 10 wherein engaging the first anchor arrangement includes causing the first anchor arrangement to substantially pass through the tissue near the mitral valve.

12. The method ofclaim 11 wherein the plurality of plication elements includes a first locking element and a second locking element, and accessing the heart to provide the plurality of elements to the heart includes:

accessing a left ventricle of the heart to provide the first locking element to the left ventricle;

substantially deploying the first locking element over the first anchor arrangement to create the first plication; and

substantially deploying the second locking element over the first anchor arrangement to create the second plication.

13. The method ofclaim 12 wherein the first anchor arrangement includes a tail portion, and substantially deploying the first locking element over the first anchor arrangement includes substantially deploying the first locking element over the tail portion and substantially deploying the second locking element over the second anchor arrangement includes substantially deploying the second locking element over the tail portion.

14. The method ofclaim 13 wherein creating at least the first plication and the second plication using the first anchor arrangement includes:

applying tension to the tail portion to create the first plication using the first locking element; and

applying tension to the tail portion to create the second plication using the second locking element.

15. The method ofclaim 14 wherein tension is applied to the tail portion to create the first plication and to create the second plication substantially simultaneously.

16. The method ofclaim 10 wherein the catheter arrangement has a deflectable tip.

17. A method for performing annuloplasty, the method comprising:

accessing an area of a heart using a catheter arrangement, the catheter arrangement including a first portion;

temporarily anchoring the first portion of the catheter arrangement to the tissue near the mitral valve of the heart;

providing an anchor element to the area; and

engaging the anchor element to the tissue near the mitral valve, wherein the first portion of the catheter arrangement is arranged to substantially provide a counter-traction force associated with engaging the anchor element.

18. The method ofclaim 17 wherein engaging the anchor element to the tissue near the mitral valve includes causing the anchor element to substantially pass through a portion of the tissue near the mitral valve to substantially anchor the anchor element to the tissue near the mitral valve.

19. The method ofclaim 18 wherein the area is a left ventricle of the heart.

20. The method ofclaim 19 further including:

substantially detaching the first portion of the catheter arrangement from the tissue near the mitral valve.

21. The method ofclaim 19 wherein the first portion of the catheter arrangement is a tip of the catheter arrangement.

22. The method ofclaim 19 wherein the first portion of the catheter arrangement is a coiled wire of the catheter arrangement.

23. The method ofclaim 19 wherein providing the anchor element to the left ventricle includes providing the anchor element using the catheter arrangement.

24. The method ofclaim 23 wherein the catheter arrangement has a deflectable tip and a pull wire arranged to deflect the deflectable tip to position one of the anchor element and the first portion.

25. A method for performing annuloplasty, the method comprising:

accessing an area of a heart using a catheter arrangement, the catheter arrangement including a first portion;

temporarily anchoring the first portion of the catheter arrangement to the tissue near the mitral valve of the heart;

providing an anchor element to the area; and

engaging the anchor element to the tissue near the mitral valve, wherein the first portion of the catheter arrangement is arranged to substantially position a tip of the catheter arrangement at the tissue near the mitral valve.

26. The method ofclaim 25 wherein engaging the anchor element to the tissue near the mitral valve includes causing the anchor element to substantially pass through a portion of the tissue near the mitral valve to substantially anchor the anchor element to the tissue near the mitral valve.

27. The method ofclaim 26 wherein the area is a left ventricle of the heart.

28. The method ofclaim 27 further including:

substantially detaching the first portion of the catheter arrangement from the tissue near the mitral valve.

29. The method ofclaim 27 wherein the first portion of the catheter arrangement is the tip of the catheter arrangement.

30. The method ofclaim 27 wherein the first portion of the catheter arrangement is a coiled wire of the catheter arrangement.

31. The method ofclaim 27 wherein providing the anchor element to the left ventricle includes providing the anchor element using the catheter arrangement.

32. The method ofclaim 31 wherein the catheter arrangement has a deflectable tip and a pull wire arranged to deflect the deflectable tip to position one of the anchor element and the first portion.

33. A method for performing annuloplasty, the method comprising:

accessing an area of a heart to provide a first plication element to the area using a catheter arrangement, the catheter arrangement including a first portion and a second portion;

substantially anchoring the first portion of the catheter arrangement to tissue near a mitral valve of the heart;

positioning a tip of the second portion of the catheter arrangement at a first distance from the first portion; and

substantially engaging the first anchor to the tissue near the mitral valve of the heart using the second portion of the catheter arrangement.

34. The method ofclaim 33 wherein substantially anchoring the first portion of the catheter arrangement to tissue near the mitral valve of the heart includes:

positioning the first portion of the catheter arrangement over a guide, the guide being substantially anchored to the tissue near the mitral valve.

35. The method ofclaim 33 wherein the first anchor includes a tail, the method further including:

substantially unanchoring the first portion of the catheter arrangement from tissue near a mitral valve of the heart;

positioning the first portion of the catheter arrangement over the tail;

positioning the tip of the second portion of the catheter arrangement at a second distance from the first portion; and

substantially engaging a second anchor to the tissue near the mitral valve of the heart using the second portion of the catheter arrangement.

36. The method ofclaim 35 further including:

creating a plication using at least the first anchor and the second anchor.

37. A method for performing annuloplasty, the method comprising:

accessing an area of a heart to provide a first plication element to the area using a catheter arrangement, the catheter arrangement including a deflectable tip area and a pull wire arranged to cause the deflectable tip area to deflect;

altering a curvature in the tip area to reach tissue near a mitral valve of the heart, wherein altering the curvature includes substantially actively controlling the pull wire; and

engaging the first plication element to the tissue near the mitral valve.

38. The method ofclaim 37 wherein engaging the first plication element includes causing the first plication element to substantially pass through a portion of the tissue to substantially anchor the first plication element to the tissue near the mitral valve.

39. The method ofclaim 38 wherein the area is a left ventricle of the heart.

40. The method ofclaim 38 wherein the catheter arrangement is a hook catheter arrangement, the tip area being substantially shaped as a hook.

41. The method ofclaim 40 wherein the catheter arrangement further includes a temporary anchor, and the method further includes:

deploying the temporary anchor; and

substantially temporarily anchoring the temporary anchor to the tissue near the mitral valve.

42. The method ofclaim 41 wherein the method further includes:

unanchoring the temporary anchor from the tissue near the mitral valve.

43. The method ofclaim 40 further including:

deploying an anchor element through the catheter arrangement; and

anchoring the anchor element to the tissue near the mitral valve.

44. A method for performing annuloplasty, the method comprising:

accessing an area of a heart using a catheter arrangement, the catheter arrangement including a deflectable tip portion and a pull wire arranged to cause the deflectable tip area to deflect;

altering a curvature in the tip area to reach tissue near a mitral valve of the heart, wherein altering the curvature includes substantially actively controlling the pull wire to position the tip area; and

temporarily engaging the tip area to the tissue near the mitral valve, wherein temporarily engaging the tip area to the tissue near the mitral valve enables the catheter arrangement to deliver at least a first plication element to the tissue near the mitral valve.

45. The method ofclaim 44 further including engaging the first plication element to the tissue near the mitral valve, wherein engaging the first plication element includes causing the first plication element to substantially pass through a portion of the tissue to substantially anchor the first plication element to the tissue near the mitral valve.

46. The method ofclaim 45 wherein the area is a left ventricle of the heart.

47. The method ofclaim 45 wherein the catheter arrangement is a hook catheter arrangement, the tip area being substantially shaped as a hook.

48. A method for performing annuloplasty, the method comprising:

accessing a left ventricle of a heart to provide a first plication element to the left ventricle using a catheter arrangement;

creating a curvature in the catheter arrangement to reach tissue near a mitral valve of the heart, the curvature being at an orthogonal orientation with respect to the mitral valve; and

engaging the first plication element to the tissue near the mitral valve, wherein engaging the first plication element includes causing the first plication element to substantially pass through a portion of the tissue to substantially anchor the first plication element to the tissue near the mitral valve.

49. The method ofclaim 48 wherein creating the curvature includes creating approximately a 180 degree curve in the catheter arrangement.

50. The method ofclaim 48 further including:

accessing the left ventricle using an incrementor catheter, the incrementor catheter including a first section and a second section, wherein the first section is arranged to be tracked over a tail of the first plication element.

51. The method ofclaim 50 further including:

deploying the incrementor catheter, wherein deploying the incrementor catheter includes positioning a tip of the second section at a distance away from a tip of the first section.

52. The method ofclaim 51 further including:

engaging a second plication element to the tissue at approximately the distance away from the first plication element using the second section.

53. The method ofclaim 52 further including:

creating a plication using the first plication element and the second plication element.

54. An incrementor catheter comprising:

a first lumen, the first lumen being arranged to track over a wire, the wire being substantially anchored within a left ventricle of a heart; and

a second lumen, the second lumen having a second tip that is arranged to be moved at a distance away from a first tip of the first lumen, wherein the second lumen is arranged to carry and to deploy a plication element.

55. A method for performing annuloplasty comprising:

temporarily fixing a helical coil of a first element in tissue near a mitral valve of the heart, the first element including a tail; and

tracking a catheter arrangement over the tail, wherein the catheter arrangement is arranged to substantially permanently fix a second element to the tissue.

56. The method ofclaim 55 wherein the catheter arrangement is an incrementor catheter.

57. The method ofclaim 55 wherein temporarily fixing the helical coil of the first element includes using one of an L-shaped catheter and a hook catheter to temporarily fix the helical coil.

58. An incrementor catheter comprising:

a main catheter, and first and second distal catheter portions coupled with the main catheter, the first and second distal catheter portions having respective first and second lumens,

the second distal catheter portion arranged to be moved laterally a first distance away from the first distal catheter portion,

an elongate guide member receivable in the first lumen, and

a first plication element receivable in and deployable from the second lumen.

59. The incrementor catheter ofclaim 58, wherein the elongate guide member further comprises a guide wire.

60. The incrementor catheter ofclaim 58, wherein the elongate guide member further comprises a tether coupled with a tissue anchor.

61. The incrementor catheter ofclaim 60, wherein the tissue anchor further comprises a temporary anchor.

62. The incrementor catheter ofclaim 60, wherein the tissue anchor further comprises a second plication element.

63. The incrementor catheter ofclaim 62, wherein the first and second plication elements are T-bars.

64. The incrementor catheter ofclaim 62 further comprising a locker configured to couple the first and second plication elements together.

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