US20150351906A1 - Ventricularly-anchored prosthetic valves - Google Patents

Abstract

Apparatus is provided, including: (A) a valve body (204) including a first frame (206) shaped to define a lumen therethrough, and a valve member (205) disposed within the lumen, (B) an upstream support (210), configured to be placed against an upstream surface of a native heart valve, and (C) a flexible sheet (214) that couples the upstream support to the valve body. The valve body has a compressed state in which the first frame has a first diameter, and an expanded state in which the first frame has a second diameter that is greater than the first diameter. The support includes a second frame (212) that has a compressed state, and an expanded state in which the second frame is annular, has an inner perimeter that defines an opening through the second frame, and has an outer perimeter. Other embodiments are also described.

Description

CROSS-REFERENCES TO RELATED APPLICATIONS
• The present application claims priority from U.S. provisional patent application 61/756,049 to HaCohen et al., filed Jan. 24, 2013, and entitled “Ventricularly-anchored prosthetic valve support”; and U.S. provisional patent application 61/756,034 to HaCohen et al., filed Jan. 24, 2013, and entitled “Tissue-engaging elements”, and is related to:
• US patent application publication 2012/0022639 to Hacohen et al., filed Jul. 21, 2010;
• US patent application publication 2012/0022640 to Gross et al., filed Feb. 24, 2011;
• U.S. patent application Ser. No. 13/811,308 to Gross et al., filed Jan. 21, 2013, which published as US 2013/0172992;
• U.S. patent application Ser. No. 13/412,814 to Gross et al., filed Mar. 6, 2012, which published as US 2013/0035759;
• PCT patent application IL2012/000292 to Gross et al., filed Aug. 5, 2012, which published as WO/2013/021374;
• PCT patent application IL2012/000293 to Gross et al., filed Aug. 5, 2012, which published as WO/2013/021375; and a US patent application to HaCohen et al., entitled “Anchoring of prosthetic valve supports”, filed on even date herewith, all of which are incorporated herein by reference.
FIELD OF THE INVENTION
• Some applications of the present invention relate in general to valve replacement. More specifically, some applications of the present invention relate to prosthetic cardiac valves and techniques for implantation thereof.
BACKGROUND
• Ischemic heart disease causes regurgitation of a heart valve by the combination of ischemic dysfunction of the papillary muscles, and the dilatation of the ventricle that is present in ischemic heart disease, with the subsequent displacement of the papillary muscles and the dilatation of the valve annulus.
• Dilation of the annulus of the valve prevents the valve leaflets from fully coapting when the valve is closed. Regurgitation of blood from the ventricle into the atrium results in increased total stroke volume and decreased cardiac output, and ultimate weakening of the ventricle secondary to a volume overload and a pressure overload of the atrium.
SUMMARY OF THE INVENTION
• For some applications of the invention, tissue anchors coupled to tethers are transluminally anchored to ventricular tissue of a native valve. A prosthetic valve component, such as a prosthetic valve assembly, a prosthetic valve body, or a support, is transluminally slid along a guide member coupled to the tethers, and is anchored to the tethers.
• For some applications, a prosthetic valve assembly comprises (1) a valve body shaped to define a lumen therethrough, and a valve member disposed within the lumen, (2) an upstream support configured to be placed against an upstream surface of a native heart valve, and (2) a flexible sheet that couples the upstream support to the valve body.
• For some applications, the prosthetic valve assembly comprises eyelets to facilitate sliding along the guide member.
• For some applications, the prosthetic valve assembly has a compressed delivery state in which the valve body and the upstream support are articulatably coupled to each other by the sheet. For such applications, a delivery tool houses the prosthetic valve assembly such that the valve body and upstream support are articulatable with respect to each other during transluminal delivery.
• For some applications, the prosthetic valve assembly comprises tethers that, when tensioned, move the valve body closer to the support. For such applications, the assembly typically comprises tissue-engaging elements that protrude from the valve body, and the tethers are tensioned to sandwich tissue of the native valve between the tissue-engaging elements and the support.
• For some applications, one or more forces is measured during implantation, and distributed among various anchoring elements. For some such applications, an intracorporeal spring is used that is extracorporeally observable using imaging techniques. For some such applications, the spring facilitates force distribution.
• For some applications, a prosthetic valve assembly comprises a flexible sheet forms a pocket between the sheet and a frame of the assembly, and facilitates sealing between the assembly and tissue of the native valve.
• For some applications of the invention, tissue anchors coupled to longitudinal members that are reversibly couplable to wires are transluminally advanced to the ventricle downstream of a native heart valve, and are anchored there. A prosthetic valve support comprising an upstream support portion is slid, in a compressed delivery configuration, over the wires and part of each longitudinal member, and into an atrium upstream of the native valve where it is deployed (e.g., expanded) and placed against an upstream surface (e.g., an atrial surface) of the native valve. A locking member is also slid over the wires and part of each longitudinal member, and locks to the longitudinal member, thereby securing the prosthetic valve support against the upstream surface of the native valve. A prosthetic valve is subsequently transluminally advanced to the native valve, and is implanted by coupling the prosthetic valve to leaflets of the native valve and to the prosthetic valve support.
• For some applications of the invention, a tubular member is slidable over the wire and the longitudinal member, and when disposed over the wire and the long member, inhibits decoupling of the wire from the longitudinal member. For such applications, the prosthetic valve support and the locking member are typically slidable over the tubular member.
• For some applications of the invention, a control rod, reversibly coupled to the locking member, is slid over the tubular member so as to push the locking member and the prosthetic valve support over the tubular member. For some such applications, the control rod is used to lock the locking member to the longitudinal member.
• There is therefore provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a subject, the apparatus including:
• a valve body:
• • including (1) a first frame shaped to define a lumen therethrough, and (2) a valve member disposed within the lumen,
  • having a compressed state in which the first frame has a first diameter, and
  • having an expanded state in which the first frame has a second diameter that is greater than the first diameter;
• an upstream support:
• • configured to be placed against an upstream surface of the native valve,
  • including a second frame,
    • having a compressed state, and
    • having an expanded state in which the second frame is annular, has
  • an inner perimeter that defines an opening through the second frame, and
  • has an outer perimeter; and
• a flexible sheet that couples the upstream support to the valve body.
• In an application, the upstream support is coupled to the valve body only via the sheet.
• In an application:
• the valve body has an upstream end, a downstream end, and a longitudinal axis therebetween along which the lumen is defined, and
• when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof:
• • the first frame is attached to the second frame at the inner perimeter of the second frame, and
  • the sheet is attached to the valve body and to the upstream support in a manner that defines a pocket region between the sheet and at least the inner perimeter of the second frame, the sheet not being attached to the first frame or the second frame in the pocket region.
• In an application, the sheet provides fluid communication between the opening and the lumen.
• In an application, the sheet is not attached to the inner perimeter of the second frame.
• In an application, the sheet is not attached to an upstream end of the valve body.
• In an application, the sheet is generally annular when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof.
• In an application, the sheet is generally frustoconical when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof.
• In an application, the sheet is attached to the inner perimeter of the second frame.
• In an application, the sheet is circumferentially attached to the second frame at a radius that is greater than a radius of the inner perimeter.
• In an application, the sheet is circumferentially attached to the second frame at the outer perimeter of the second frame.
• In an application, the sheet is attached to an upstream end of the valve body.
• In an application, the first frame is generally cylindrical in both the compressed state thereof and the expanded state thereof.
• In an application, the second frame is generally cylindrical in the compressed state thereof.
• In an application, the valve body includes at least one downstream anchor, configured such that, in the expanded configuration of the valve body, the anchor protrudes radially outward from the first frame.
• In an application, the apparatus further includes at least one tensioning element, coupled to the valve body and to the upstream support, a length of the tensioning element between the valve body and the upstream portion being adjustable such that a distance between the first frame and the second frame is adjustable.
• In an application, the at least one tensioning element includes a tether.
• In an application, the at least one tensioning element is coupled to the first frame, and slidably coupled to the second frame.
• In an application, the valve body, the upstream support and the sheet together define a prosthetic valve assembly, the prosthetic valve assembly:
• having an expanded state in which the valve body is in the expanded state thereof and the second frame of the upstream support is in the expanded state thereof,
• having a compressed state in which:
• • the prosthetic valve assembly has a longitudinal axis,
  • the valve body is in the compressed state thereof at a first zone of the longitudinal axis,
  • the upstream support is in the compressed state thereof at a second zone of the longitudinal axis, and
  • the prosthetic valve assembly defines an articulation zone, between the first zone and the second zone, in which at least part of the sheet is disposed, in which neither the first frame nor the second frame is disposed, and about which the valve body and the upstream support are articulatable with respect to each other.
• In an application, the apparatus further includes a delivery tool:
• including a first housing configured to house and maintain at least part of the upstream support in the compressed state thereof, and defining a first housing orifice through which the at least part of the upstream support is removable from the first housing,
• including a second housing configured to house and maintain at least part of the valve body in the compressed state thereof, and defining a second housing orifice through which the at least part of the valve body is removable from the second housing,
• having a contracted state in which the second housing is disposed at a first distance from the first housing, and in which the delivery tool is configured to transluminally advance the prosthetic valve assembly in the compressed state thereof, to the native valve, and
• having an extended state in which the second housing is disposed at a second distance from the first housing, the second distance being greater than the first distance, and the apparatus is configured such that, when the at least part of the upstream support is housed by the first housing and the at least part of the valve body is housed by the second housing, transitioning of the delivery tool from the contracted state into the extended state exposes at least part of at least one component selected from the group consisting of: the valve body and the upstream support, from the housing that houses the selected component.
• In an application:
• the apparatus is configured to be used with at least two guide members,
• the prosthetic valve assembly includes at least two eyelets, each eyelet being slidable over a respective one of the guide members, and
• the apparatus is configured such that the eyelets of the prosthetic valve assembly protrude radially outward and radially beyond an outer surface of the second housing while: (1) the at least part of the valve body, in the compressed state thereof, is housed by the second housing, and (2) the at least part of the upstream support, in the compressed state thereof, is housed by the first housing.
• In an application, the eyelets are pivotably coupled to the valve body.
• In an application, the delivery tool further includes at least two reference-force tubes, each reference-force tube configured (1) to be slidable over a respective one of the guide members, and (2) to apply a distally-directed force to the prosthetic valve assembly.
• In an application, in the compressed state of the prosthetic valve assembly, each reference-force tube extends distally (1) through a lumen defined by the second frame of the upstream support, (2) through the sheet, and (3) along an outside of at least part of the valve body.
• In an application, the apparatus further includes at least two locking members, each locking member:
• having an unlocked state in which the locking member is slidable along a respective one of the guide members,
• being transitionable into a locked state in which (1) the locking member is locked to the respective one of the guide members, and (2) the sliding of the eyelet over the guide member is inhibited.
• In an application, the apparatus further includes the at least two guide members:
• each guide member includes:
• • a tubular member, shaped to define a lumen therethrough,
  • a tether, coupled at a distal end thereof to a tissue anchor configured to be anchored to ventricular tissue of the heart, at least a proximal portion of the tether being disposed within the lumen of the tubular member, and
  • a pull-wire, coupled at a distal portion thereof to the proximal portion of the tether, at least the distal portion of the pull-wire being disposed within the lumen of the tubular member,
• the tubular member inhibits decoupling of the pull-wire from the tether while the distal portion of the pull-wire and the proximal portion of the tether are disposed within the lumen of the tubular member, and
• while the tubular member of each guide member is disposed within the respective locking member, the tubular member inhibits transitioning of the locking member into the locked state.
• In an application, the apparatus is configured such that, for each respective guide member and locking member, while (1) the tubular member is disposed within the locking member, (2) the distal portion of the pull-wire and the proximal portion of the tether are disposed within the lumen of the tubular member, and (3) the tissue anchor is coupled to the ventricular tissue:
• proximal sliding of the tubular member with respect to the tether facilitates automatic transitioning of the locking member into the locked state, and
• further proximal sliding of the tubular member with respect to the tether facilitates decoupling of the pull-wire from the tether.
• In an application, at least one housing selected from the group consisting of: the first housing and the second housing has a lateral wall that is shaped to define at least two slits, the eyelets being configured to protrude radially outward from the delivery tool via the slits.
• In an application, each slit of the at least one selected housing is continuous with the orifice of the at least one selected housing.
• In an application, the eyelets are coupled to and protrude radially outward from the valve body.
• In an application, the eyelets are pivotably coupled to the valve body.
• In an application:
• the articulation zone defined by the prosthetic valve assembly includes a first articulation zone, and
• while (1) the at least part of the valve body, in the compressed state thereof, is housed by the second housing, (2) the at least part of the upstream support, in the compressed state thereof, is housed by the first housing, and (3) the delivery tool is in the contracted state thereof, the apparatus defines a second articulation zone at a longitudinal zone of the apparatus (a) between the second housing and the first housing, and (b) in which is disposed at least part of the first articulation zone.
• In an application, the delivery tool further includes a housing-control rod that extends through the first housing and is coupled to the second housing such that a first portion of the housing-control rod is disposed within the first housing, a second portion of the housing-control rod is disposed within the second housing, and a third portion of the housing-control rod (1) is disposed within the second articulation zone, and (2) is more flexible than at least one portion of the housing-control rod selected from the group consisting of: the first portion and the second portion.
• In an application:
• the delivery tool further includes (1) a control rod assembly including at least a first housing-control rod coupled to the first housing, and (2) a second housing-control rod, more flexible than the first housing-control rod, extending through the first housing-control rod, extending through the second articulation zone, and coupled to the second housing.
• In an application, the second housing orifice faces the first housing orifice.
• In an application:
• the delivery tool further includes a flexible control rod assembly including (1) a first housing-control rod coupled to the first housing, (2) a second housing-control rod coupled to the second housing, and (3) a prosthesis-control rod reversibly couplable to the prosthetic valve assembly,
• longitudinal movement of the second housing-control rod with respect to the first housing-control rod transitions the delivery tool between the contracted state and the extended state thereof, and
• the valve body is removable from the second housing by moving the second housing-control rod with respect to the prosthesis-control rod.
• In an application, the prosthesis-control rod is reversibly couplable to the prosthetic valve assembly by being reversibly couplable to the valve body.
• In an application, at least part of the second housing-control rod is disposed within and slidable through the prosthesis-control rod, and at least part of the prosthesis-control rod is disposed within and slidable through the first housing-control rod.
• In an application, the outer perimeter of the second frame has a third diameter that is greater than the second diameter.
• In an application, the inner perimeter has a fourth diameter that is greater than the second diameter.
• In an application, when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof, a gap is defined between the first frame and the second frame, the sheet spanning the gap.
• In an application, no metallic structure is disposed within the gap.
• In an application, the sheet is configured to inhibit expansion of the second frame.
• In an application, the apparatus is configured such that when the second frame expands from the compressed state thereof toward the expanded state thereof, the sheet retains the second frame in a generally frustoconical shape by inhibiting expansion of at least the outer perimeter of the second frame.
• In an application, the sheet extends over at least part of the second frame to serve as a covering of the upstream support.
• In an application, the covering defines a tissue-contacting surface of the upstream support.
• In an application, the sheet extends over at least part of the first frame to serve as a covering of the valve body.
• In an application, the covering is disposed on an inner surface of the first frame.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a subject, the apparatus including:
• a prosthetic valve, configured to be percutaneously delivered to the native valve;
• an annular upstream support, configured to be placed against an upstream surface of the native valve, and to support the prosthetic valve at the native valve;
• a tissue anchor, including a tissue-engaging element configured to be anchored to ventricular muscle tissue of the heart;
• a tether, coupled to the tissue anchor; and
• a spring, couplable to the tether so as to elastically couple the tissue-engaging element to the prosthetic valve.
• In an application, the spring is shaped to define a repeating pattern.
• In an application, the spring is pre-loaded.
• In an application, the spring is a constant-force spring.
• In an application, the spring is configured to facilitate extracorporeal fluoroscopic observation of a state of the spring.
• In an application, the spring is coupled to a plurality of radiopaque markers such that a juxtaposition of the markers changes as the state of the spring changes, the juxtaposition of the markers being extracorporeally fluoroscopically observable.
• In an application, the spring is coupled to at least one radiopaque marker, and the apparatus further includes an intracorporeal reference, a juxtaposition between the radiopaque marker and the intracorporeal reference being extracorporeally fluoroscopically observable.
• In an application, the intracorporeal reference includes a scale including a plurality of radiopaque markers.
• In an application, the plurality of radiopaque markers includes a first plurality of radiopaque markers, and the at least one radiopaque marker includes a second plurality of radiopaque markers.
• In an application, the spring is configured to provide distinct indication that is observable using fluoroscopy, when the spring is experiencing a force that is within a margin force from a target force.
• In an application, the spring is configured to provide the distinct indication when the spring experiences a force that is above 300 g force.
• In an application, the spring is configured to provide the distinct indication when the spring experiences a force that is above 400 g force.
• In an application, the spring is configured to provide the distinct indication when the spring experiences a force that is about 500 g force.
• In an application, the spring is coupled to the prosthetic valve, and is intracorporeally lockable to the tether subsequently to anchoring of the tissue anchor to the ventricular muscle tissue.
• In an application, the spring is slidable along at least part of the tether, and is intracorporeally couplable to the tether by inhibiting the sliding.
• In an application, the prosthetic valve includes a generally cylindrical valve body having an upstream end, and the spring includes an elastically-deformable appendage that protrudes laterally from the valve body.
• In an application:
• the prosthetic valve includes a generally cylindrical valve body having an upstream end, a downstream end, and a longitudinal lumen therebetween, and
• the spring (1) includes a compression spring having a longitudinal axis, and (2) is disposed laterally from, the valve body such that the longitudinal axis of the spring is generally parallel with the longitudinal lumen.
• In an application, the prosthetic valve includes:
• a generally cylindrical valve body having an upstream end, a downstream end, and a longitudinal lumen therebetween; and
• one or more tissue-engaging legs, protruding laterally outward from the valve body, and configured to be placed against a ventricular surface of the native valve.
• In an application, the prosthetic valve is couplable to the upstream support intracorporeally by being expanded within an opening defined by the upstream support while the upstream support is disposed against the upstream surface.
• In an application, the apparatus is configured such that the coupling of the prosthetic valve to the upstream support couples the tether to the prosthetic valve.
• In an application, the apparatus is configured to sandwich a portion of the native valve between the tissue-engaging legs and the upstream support by providing a space having a height between the tissue-engaging legs and the upstream support.
• In an application, the apparatus is configured to facilitate altering the height without altering a force on the spring.
• In an application, the apparatus is configured such that altering the height automatically alters a force on the spring.
• In an application, the apparatus is configured to facilitate altering the height by moving the valve body through the opening defined by the upstream support.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a native heart valve of a subject, the apparatus including:
• a valve body:
• • having an upstream end, a downstream end, and a longitudinal axis therebetween,
  • including a lateral wall that circumscribes the longitudinal axis and defines a longitudinal lumen, and
  • including a valve member disposed within the lumen;
• an upstream support having an inner perimeter couplable to the valve body at a first longitudinal position of the valve body, the upstream support being configured to extend radially outward from the valve body and the inner perimeter; and
• a flexible sheet defining a first aperture, a second aperture and a lateral wall therebetween, a first portion of the sheet that defines the first aperture being circumferentially attached to the upstream support portion at a radius that is greater than a radius of the inner perimeter, and a second portion of the sheet that defines the second aperture being circumferentially attached to the valve body at a second longitudinal position of the valve body, such that a pocket region is defined between the sheet and at least the first longitudinal position.
• In an application, the second longitudinal position is closer to the downstream end of the valve body than is the first longitudinal position.
• In an application, the first aperture is larger than the second aperture.
• In an application, the sheet is attached to the upstream support at an outer perimeter of the upstream support.
• In an application, the sheet assumes a frustoconical shape.
• In an application, the sheet assumes a funnel shape.
• In an application, the apparatus is provided with the inner perimeter of the upstream support pre-coupled to the valve body at the first longitudinal position of the valve body.
• In an application, the apparatus is configured such that the inner perimeter of the upstream support is intracorporeally couplable to the valve body at the first longitudinal position of the valve body.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a native heart valve disposed between an atrium and a ventricle of a heart of a subject, the apparatus including:
• an annular upstream support defining an opening therethrough, and configured to be placed against an upstream surface of the native heart valve;
• a tubular valve body having an upstream end, a downstream end and a lumen therebetween, the lumen having a first diameter, and the valve body being separated from the upstream element by a gap between the upstream end of the valve body and the upstream element;
• one or more tissue-engaging elements that protrude radially outward from the valve body so as to define a second diameter that is greater than the first diameter; and
• a flexible sheet shaped to define a conduit, a downstream portion of the sheet being coupled to the valve body, an upstream portion of the sheet being coupled to the upstream element, and the sheet spanning the gap.
• In an application, the apparatus further includes at least one tether, a first portion of the tether being coupled to the valve body and a second portion of the tether being coupled to the upstream support, such that tensioning of at least a portion of the tether reduces the gap.
• In an application, the apparatus is configured such that tensioning of at least the portion of the tether rumples the sheet.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a native heart valve disposed between an atrium and a ventricle of a heart of a subject, the apparatus including:
• an annular upstream element defining an opening therethrough, and configured to be placed against an upstream surface of the native heart valve;
• a flexible sheet, shaped to define a conduit, and coupled to the upstream element such that the conduit is in fluid communication with the opening; and
• a valve body, coupled to the flexible sheet such that the conduit provides fluid communication between the prosthetic valve and the upstream element.
• In an application, the valve body includes:
• a generally cylindrical frame shaped to define a lumen therethrough, and
• a valve member coupled to the frame and disposed within the lumen.
• In an application, the frame is separated from the upstream element by a gap, and the conduit spans the gap.
• There is further provided, in accordance with an application of the present invention, apparatus, for use with a guide member that extends into a subject, the apparatus including:
• a delivery tool, including a housing, the housing:
• • being transluminally advanceable into the subject,
  • shaped to define an orifice at an end of the housing, and
  • having a lateral wall shaped to define a slit that is continuous with the orifice;
• an implant:
• • configured to be housed by the housing, and
  • including an eyelet that (1) is slidable over the guide member, and (2) when the implant is housed by the housing, extends through the slit and radially beyond the lateral wall such that the eyelet facilitates transluminal sliding of the implant and the housing along the guide member and into the subject,
    the apparatus being configured such that, while (1) the implant remains within the subject, and (2) the guide member remains disposed through the eyelet, (1) the implant is removable from the housing via the orifice, and (2) the housing is removable from the subject.
• In an application, the implant is configured to be implanted by being intracorporeally locked to the guide member.
• In an application, the implant has a compressed state and an expanded state, is configured to be housed by the housing while in the compressed state, and is configured to automatically expand toward the expanded state when removed from the housing.
• There is further provided, in accordance with an application of the present invention, a method for use with a native valve of a heart of a subject, the method including:
• transluminally anchoring a tissue anchor to ventricular tissue of a subject using an anchor-manipulation tool, the tissue anchor being coupled to a first portion of a tether;
• transluminally delivering an annular upstream support and a prosthetic valve to the heart, the prosthetic valve including (1) a valve body shaped to define a lumen therethrough, and (2) one or more tissue-engaging legs configured to protrude laterally outward from the valve body;
• pressing the tissue-engaging legs in an upstream direction against a ventricular surface of the native valve by applying a force to the prosthetic valve while measuring the force;
• applying, to the tether, a tension that changes a shape of a spring coupled to the tether, while observing the shape of the spring using imaging; and
• at least in part responsively to the observed shape of the spring, facilitating holding of the upstream support against an upstream surface of the native valve by locking a second portion of the tether to at least one component selected from the group consisting of: the prosthetic valve and the upstream support.
• In an application, measuring the force includes measuring the force using an extracorporeal force meter.
• In an application, measuring the force includes observing a shape of the tissue-engaging legs using imaging.
• In an application, applying the tension includes applying the tension while applying the force.
• In an application, locking the second portion to the selected component includes locking the second portion to the prosthetic valve.
• In an application, locking the second portion to the selected component includes locking the second portion to the upstream support.
• In an application, locking the second portion includes locking the second portion when the observed shape indicates that the spring is experiencing between 400 g force and 600 g force.
• In an application, locking the second portion includes locking the second portion subsequently to applying the tension, and applying the force includes applying the force subsequently to locking the second portion.
• In an application:
• anchoring the tissue anchor coupled to the tether includes anchoring a first tissue anchor coupled to a first tether, and applying the tension includes applying a first tension that changes a shape of a first spring coupled to the first tether,
• the method further includes:
• • anchoring a second tissue anchor to the ventricular tissue, the second tissue anchor being coupled to a first portion of a second tether; and
  • applying, to the second tether, a second tension that changes a shape of a second spring coupled to the second tether, while observing the shape of the second spring using imaging, and
• facilitating holding of the prosthetic valve against the upstream surface includes, at least in part responsively to the observed shape of the second spring, facilitating holding of the prosthetic valve against the upstream surface by locking a second portion of the second tether to the selected at least one component.
• In an application, facilitating holding includes locking the second portion of the first tether and the second portion of the second tether to the selected at least one component, at least in part responsively to a ratio between tension in the first tether and tension in the second tether, the ratio being derived from the observed shape of the first spring and the observed shape of the second spring.
• In an application, locking includes locking the second portion to the at least one component at least in part responsively to the observed shape.
• In an application, locking includes locking the second portion to the at least one component at least in part responsively to the measured force.
• In an application, applying the force includes moving the valve body in an upstream direction through an opening defined by the upstream support, and the method further includes coupling the prosthetic valve to the upstream support by expanding the valve body within the opening.
• In an application, coupling the prosthetic valve to the upstream support includes coupling the prosthetic valve to the upstream support at least in part responsively to the measured force.
• There is further provided, in accordance with an application of the present invention, a method, including:
• transluminally advancing a plurality of tissue anchors, coupled to a respective plurality of springs, into a body of a subject;
• anchoring the plurality of tissue anchors to tissue of the subject;
• tensioning at least one of the springs;
• using imaging, while the tension is applied to the at least one spring, observing a state of the at least one spring; and
• at least in part responsively to the observed state of at least one spring, adjusting a tension on at least one of the springs.
• There is further provided, in accordance with an application of the present invention, a method, for use with a native valve of a heart of a subject, the method including:
• applying a first tension to a tether that couples (a) a tissue anchor anchored to ventricular tissue of a subject, to (b) a prosthetic valve body, the tether having a length between the tissue anchor and the valve body;
• by applying an atrially-directed force to the prosthetic valve body, pressing, against tissue of the native valve, a tissue-engaging element that protrudes radially from the valve body
• transluminally advancing a prosthetic valve body to a native valve of the subject;
• while applying the atrially-directed force, measuring:
• • a pressing force of the tissue-engaging element against the tissue of the native valve, and
  • a second tension on the tether, the second tension differing from the first tension at least in part due to the atrially-directed force; and
• at least in part responsively to the measured pressing force and the measured second tension, performing an action selected from the group consisting of: adjusting the length of the tether between the tissue anchor and the valve body, and locking the valve body to the tether.
• There is further provided, in accordance with an application of the present invention, a method for use with a native valve of a heart of a subject, the method including:
• transluminally delivering a tissue anchor to a ventricle of the heart, and anchoring the tissue anchor to ventricular muscle tissue of the subject;
• transluminally delivering an upstream support to an atrium of the heart, and placing the upstream support against an upstream surface of an annulus of the native valve; and
• changing a shape of the upstream support by tensioning a tether coupled to upstream support and to the tissue anchor; and
• extracorporeally fluoroscopically observing the shape change of the upstream support.
• In an application, tensioning the tether coupled to the upstream support includes tensioning a tether that is coupled to a valve body coupled to the upstream support.
• In an application, before the tensioning, the upstream support is generally flat annular, and changing the shape includes making the support assume a frustoconical shape.
• In an application, before the tensioning, the upstream support is frustoconical, and changing the shape includes changing a slant of the frustoconical shape.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a valve of a heart of a subject, the apparatus including:
• a transluminally-deliverable tissue anchor;
• a tether, a first end thereof coupled to the tissue anchor; and
• a delivery tool, including:
• • a steerable catheter having a longitudinal axis, and being transluminally deliverable to the valve, and
  • an obstructing element:
    • disposed at a longitudinal site of the catheter,
    • configured to extend laterally outward from the catheter, and
    • dimensioned, when extending laterally outward from the catheter, to inhibit movement of at least the longitudinal site through the valve by abutting tissue of the valve, and
  • an anchor manipulator:
    • reversibly couplable to the tissue anchor,
    • slidable through the catheter, and
    • configured to drive the anchor into ventricular tissue of the heart of the subject.
• In an application, the anchor manipulator is slidably coupled to the catheter such that a distal end of the anchor manipulator is slidable distally no more than a pre-determined distance from the longitudinal site.
• In an application, the apparatus further includes an implant, intracorporeally lockable to the tether.
• In an application, the apparatus further includes a guide member, reversibly couplable to the tether, and the implant is intracorporeally slidable along the guide member toward the tether and the implant.
• In an application, the tether has exactly one locking site at which the implant is lockable to the tether.
• In an application, the exactly one locking site is disposed at a pre-determined distance from the anchor that is pre-determined at least in part dependently on a distance between the longitudinal site and a distal end of the catheter.
• There is further provided, in accordance with an application of the present invention, a method, including:
• transluminally anchoring a tissue anchor to tissue of a subject using an anchor-manipulation tool;
• subsequently applying to the anchor a pulling force having a given magnitude;
• using imaging, observing a movement of the tissue anchor in response to the pulling force; and
• at least in part responsively to the observed movement, performing an action selected from the group consisting of: de-anchoring the tissue anchor from the tissue, and decoupling the anchor-manipulation tool from the tissue anchor.
• There is further provided, in accordance with an application of the present invention, apparatus, for implantation at a native valve of a heart of a subject, the native valve being disposed between an atrium and a ventricle of the heart, the apparatus including:
• a tubular valve body:
• • having an upstream portion, configured to be disposed in the atrium of the heart of the subject,
  • having a downstream portion, configured to be disposed in the ventricle of the subject,
  • having an elastic portion, disposed between the upstream portion and the downstream portion, and elastically coupling the upstream portion to the downstream portion, and
  • shaped to define a continuous lumen through the upstream portion, the elastic portion, and the downstream portion; and
• at least one valve member, disposed in the lumen of the valve body, and configured to facilitate flow of blood of the subject from the upstream portion of the valve body to the downstream portion of the valve body, and to inhibit flow of the blood from the downstream portion of the valve body to the upstream portion of the valve body.
• In an application, the at least one valve member is coupled to the downstream portion of the valve body.
• In an application, the native valve includes a plurality of native leaflets, and the downstream portion of the valve body is configured to be coupled to the native leaflets.
• In an application, the apparatus further includes a plurality of clips, configured to facilitate the coupling of the downstream portion of the valve body to the native leaflets.
• In an application, each clip:
• includes at least two clip arms, articulatably coupled to each other, and
• is reversibly closeable.
• In an application, the clips are coupled to the downstream portion of the valve body, and the downstream portion of the valve body is configured to be coupled to the native leaflets by the clips being coupled to the native leaflets.
• In an application, each clip of the plurality of clips is articulatably coupled to the downstream portion of the valve body.
• In an application, the native valve includes an annulus having an upstream surface, and the apparatus further includes a prosthetic valve support:
• including (1) an upstream support portion, configured to be placed against the upstream surface of the annulus of the native valve, and (2) the plurality of clips, coupled to the upstream support portion,
• shaped to define an opening therethrough that is configured to receive the prosthetic valve,
• and the clips are configured to facilitate the coupling of the downstream portion of the valve body to the native leaflets by coupling the prosthetic valve support to the native leaflets.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a subject, the native valve having a plurality of leaflets that meet at a plurality of commissures, the apparatus including:
• at least one tissue anchor, configured to be anchored to a first site within a ventricle of the heart of the subject;
• at least one longitudinal member, coupled at a distal end thereof to a respective one of the at least one tissue anchors;
• an upstream support, including an upstream support portion configured to be slidable over the longitudinal member and placed against an upstream surface of the native valve; and
• at least one locking member, configured to be slidable over a respective one of the at least one longitudinal members, and to be lockable to the respective longitudinal member such that a portion of the respective longitudinal member that is disposed between the respective anchor and the upstream support portion is longer than 1 cm.
• In an application, the longitudinal member is flexible.
• In an application, the longitudinal member includes a suture.
• There is further provided, in accordance with an application of the present invention, a method for use with a native valve of a heart of a subject, the native valve having a plurality of leaflets that meet at a first commissure and at a second commissure, the method including:
• anchoring a first tissue anchor to a first site within a ventricle of the heart of the subject, the first tissue anchor being coupled to a distal end of a first longitudinal member;
• anchoring a second tissue anchor to a second site within the ventricle of the heart of the subject, the second tissue anchor being coupled to a distal end of a second longitudinal member;
• subsequently, placing at least an upstream support portion of a prosthetic valve support against an upstream surface of the native valve, the valve being disposed between the ventricle and an atrium of the heart of the subject; and
• securing the upstream support portion against the upstream surface of the valve by:
• • coupling the upstream support portion to the first longitudinal member such that at least part of a portion of the first longitudinal member that is disposed between the upstream support portion and the first tissue anchor, is disposed between the first and second leaflets at the first commissure, and
  • coupling the upstream support portion to the second longitudinal member such that at least part of a portion of the second longitudinal member that is disposed between the upstream support portion and the first tissue anchor, is disposed between the first and second leaflets at the second commissure.
• In an application, anchoring, placing, and securing include anchoring, securing, and placing without the use of cardiopulmonary bypass.
• In an application, anchoring to the first site and anchoring to the second site include anchoring to myocardium.
• In an application, placing the upstream support portion against the upstream surface includes sliding the upstream support portion over at least part of the first longitudinal member.
• In an application, coupling the upstream support portion to the first longitudinal member and to the second longitudinal member includes coupling the upstream support portion to the first longitudinal member in the atrium of the heart of the subject, and coupling the upstream support portion to the second longitudinal member includes coupling the upstream support portion to the second longitudinal member in the atrium of the heart of the subject.
• In an application, the leaflets move in response to beating of the heart of the subject, and securing the upstream support portion includes securing the upstream support portion without eliminating the movement of the native leaflets.
• In an application, coupling the upstream support portion to the first longitudinal member includes coupling the upstream support portion to the first longitudinal member such that a length of the portion of the first longitudinal member is greater than 1 cm.
• In an application, the method further includes:
• transluminally advancing at least the first tissue anchor to the first site while the respective longitudinal member coupled thereto is disposed within a respective tubular member; and
• subsequently to anchoring the at least first tissue anchor, and before coupling the upstream support portion to the respective longitudinal member, sliding the at least first tubular member off of at least part of the respective longitudinal member.
• In an application, sliding the at least first tubular member includes sliding at least part of the at least first tubular member through a channel defined by a locking member, and coupling the upstream support portion to the respective longitudinal member includes locking the locking member to the respective longitudinal member by narrowing at least a portion of the channel.
• In an application:
• advancing the at least first tissue anchor includes advancing the at least first tissue anchor while (1) the respective longitudinal member is reversibly coupled to a portion of a wire, and (2) the respective tubular member inhibits the portion of the wire from decoupling from the portion of the wire, and
• the method further includes facilitating decoupling of the wire from the respective longitudinal member by sliding the at least first tubular member off of the portion of the wire.
• In an application:
• advancing the at least first tissue anchor includes advancing the at least first tissue anchor while (1) the respective longitudinal member is shaped to define a loop, and is coupled to the portion of the wire by the portion of the wire being threaded through the loop, and (2) the respective tubular member inhibits the portion of the wire from unthreading from the loop, and
• facilitating decoupling of the wire from the respective longitudinal member includes facilitating unthreading of the wire from the loop by sliding the at least first tubular member off of the portion of the wire.
• In an application, sliding the at least first tubular member off of the portion of the wire includes sliding the at least first tubular member off of the portion of the wire by applying less than 500 g of pulling force to the at least first tubular member.
• In an application, applying less than 500 g of pulling force to the at least first tubular member includes applying less than 300 g of pulling force to the at least first tubular member.
• In an application, the method further includes, subsequently to securing the upstream support portion, coupling a prosthetic valve to the prosthetic valve support.
• In an application, the upstream support portion has an inner edge that defines an opening through the upstream support portion, and coupling the prosthetic valve to the prosthetic valve support includes placing at least a portion of the prosthetic valve within the opening, and expanding at least the portion of the prosthetic valve such that at least the portion of the prosthetic valve applies a radially-expansive force against the inner edge of the upstream support portion.
• In an application, the prosthetic valve includes one or more tissue-engaging elements, each of the one or more tissue-engaging elements including at least two arms, and the method further includes, subsequent to securing the upstream support portion, coupling the prosthetic valve to at least one of the leaflets by sandwiching the at least one of the leaflets between the at least clip arms of the one or more tissue-engaging elements.
• In an application, coupling the prosthetic valve to the at least one of the leaflets includes coupling the prosthetic valve to the at least one of the leaflets before coupling the prosthetic valve to the prosthetic valve support.
• In an application:
• the prosthetic valve includes a valve body, having an outer surface,
• the at least two arms include a first arm and a second arm, the first arm being longer than the second arm, and
• the method further includes:
• • delivering, within a delivery tube, the prosthetic valve in a delivery configuration thereof, in which the first arm and the second arm are constrained against the outer surface of the valve body;
  • facilitating deflection of the first arm away from the outer surface of the prosthetic valve, by advancing a first portion of the prosthetic valve out of the delivery tube such that the first arm automatically deflects away from the outer surface of the prosthetic valve; and
  • facilitating deflection of the second arm away from the outer surface of the prosthetic valve, by advancing a second portion of the prosthetic valve out of the delivery tube such that the second arm automatically deflects away from the outer surface of the prosthetic valve.
• In an application:
• facilitating deflection of the first arm includes facilitating deflection of the first arm a first angle from the outer surface of the prosthetic valve, and
• the method further includes facilitating deflection of the first arm away from the outer surface of the prosthetic valve a second angle that is greater than the first angle, by applying a force to the first arm using the delivery tube:
• • subsequently to facilitating deflection of the first arm the first angle, and
  • prior to facilitating deflection of the second arm.
• In an application, applying the force to the first arm using the delivery tube includes pushing on the first arm by sliding the delivery tube over at least part of the prosthetic valve.
• There is further provided, in accordance with an application of the present invention, apparatus for use with a body of a subject, the apparatus including:
• at least a first implantable member;
• a first longitudinal member, coupled at a distal end thereof to the first implantable member;
• a second longitudinal member, at least a portion of the second longitudinal member being reversibly couplable to the first longitudinal member; and
• a tubular member:
• • slidable over the first and second longitudinal members,
  • shaped to define a lumen therethrough, and
  • configured, when the portion of the second longitudinal member is (1) coupled to the first longitudinal member, and (2) disposed within the lumen of the tubular member, to inhibit decoupling of the portion of the second longitudinal member from the first longitudinal member.
• In an application, the portion of the second longitudinal member is configured, when (1) the portion of the second longitudinal member is coupled to the first longitudinal member, and (2) the portion of the second longitudinal member is disposed outside of the lumen of the tubular member, to be decouplable from the first longitudinal member by the second longitudinal member being pulled away from the first longitudinal member.
• In an application, at least one longitudinal member selected from the group consisting of: the first longitudinal member and the second longitudinal member, is flexible.
• In an application, the tubular member is more rigid than the first longitudinal member.
• In an application, the tubular member fits snugly over at least the portion of the second longitudinal member.
• In an application, the first implantable member includes a tissue anchor, configured to be anchored to a tissue of the subject.
• In an application, the apparatus further includes a second implantable member, slidable over the tubular member, and couplable to the first longitudinal member while the portion of the second longitudinal member is coupled to the first longitudinal member.
• In an application, the portion of the second longitudinal member is reversibly couplable to the first longitudinal member at a first site of the first longitudinal member, and the second implantable member is couplable to the first longitudinal member at a second site of the first longitudinal member that is distal to the first site of the longitudinal member.
• In an application, the apparatus further includes a locking member having an unlocked state and a locked state, and configured to be slid over the tubular member in the unlocked state and to be locked to the first longitudinal member by being transitioned to the locked state.
• In an application, the locking member is configured to facilitate coupling of the second implantable member to the first longitudinal member.
• In an application, the locking member is configured to be coupled to the first longitudinal member at least 1 cm away from the first implantable member.
• There is further provided, in accordance with an application of the present invention, apparatus for use at a native valve of a heart of a subject, the apparatus including:
• a tissue anchor, configured to be transluminally, transcatheterally advanced to a ventricle of the heart of the subject, and to be coupled to tissue of the ventricle;
• a longitudinal member, coupled at a distal end thereof to the tissue anchor;
• a wire, a portion of the wire being reversibly couplable to the longitudinal member;
• a tubular member:
• • slidable over the longitudinal member and the wire,
  • shaped to define a lumen therethrough, and
• configured, when the portion of the wire is (1) coupled to the longitudinal member, and (2) disposed within the lumen of the tubular member, to inhibit decoupling of the portion of the wire from the longitudinal member;
• a prosthetic valve support including an upstream support portion slidable over the tubular member, and to be placed against an upstream surface of an annulus of the native valve by sliding over the tubular member; and
• a locking member, slidable over the tubular element and lockable to the longitudinal member.
• In an application, the locking member is configured to be locked to the longitudinal member at a site of the longitudinal member that is distal to a site of the longitudinal member to which the portion of the wire is reversibly couplable.
• In an application, the tubular member is configured to be slid out of the locking member before the locking member is locked to the longitudinal member.
• In an application, the apparatus further includes a control rod, slidable over the tubular member, the locking member being reversibly coupled to a control rod, the control rod being configured to restrain the locking member in an unlocked configuration thereof, and to facilitate locking of the locking member by ceasing to restrain the locking member in the unlocked configuration.
• In an application, the control rod is configured to decouple from the locking member when the control rod ceases to restrain the locking member in the unlocked configuration thereof.
• In an application, the control rod is configured to cease to restrain the locking member in the unlocked configuration thereof by the control rod being rotated with respect to the locking member.
• In an application:
• the prosthetic valve support is shaped to define a hole through which the tubular member is slidable,
• at least while the control rod is coupled to the locking member, the control rod is not slidable through the hole defined by the prosthetic valve support, and
• the control rod is configured to facilitate the sliding of the prosthetic valve support over the tubular member by pushing the prosthetic valve support over the tubular member.
• The present invention will be more fully understood from the following detailed description of applications thereof, taken together with the drawings, in which:
BRIEF DESCRIPTION OF THE DRAWINGS
• FIGS. 1A-F are schematic illustrations of a system for implanting a prosthetic valve support and a prosthetic valve at a native valve of a heart of a subject, in accordance with some applications of the invention;
• FIG. 2 is a schematic illustration of the prosthetic valve being retrieved into a delivery tube, in accordance with some applications of the invention;
• FIGS. 3A-C are schematic illustrations of the introduction of guide members through the prosthetic valve support and a delivery tube, in accordance with some applications of the invention;
• FIGS. 4A-C are schematic illustrations of a locking member, and control thereof, in accordance with some applications of the invention;
• FIG. 5 is a schematic illustration of steps in the delivery and anchoring of tissue anchors, in accordance with some applications of the invention;
• FIG. 6 is a schematic illustration of a system for use with a prosthetic valve support, in accordance with some applications of the invention;
• FIGS. 7A-C are schematic illustrations of a system for facilitating transluminal delivery of a prosthetic valve assembly, in accordance with some applications of the invention;
• FIGS. 8A-H are schematic illustrations of a technique for use with the system ofFIGS. 7A-C, to transluminally implant a prosthetic valve assembly, in accordance with some applications of the invention;
• FIGS. 9A-B,10A-B,11A-B,12A-B,13A-B, and14A-B are schematic illustrations of prosthetic valve assemblies, in accordance with some applications of the invention;
• FIGS. 15A-C are schematic illustrations of a tool for facilitating application of force between a prosthetic valve assembly and tethers, in accordance with some applications of the invention;
• FIG. 16 is a schematic illustration of a system comprising a prosthetic valve assembly and one or more springs, via which the prosthetic valve assembly is elastically coupled to one or more tissue anchors, in accordance with some applications of the invention;
• FIG. 17 is a schematic illustration of a system comprising a prosthetic valve assembly and one or more springs, via which the prosthetic valve assembly is elastically coupled to one or more tissue anchors, in accordance with some applications of the invention;
• FIGS. 18A-B are schematic illustrations of springs coupled to respective tethers so as to elastically couple a tissue anchor to a prosthetic valve assembly, in accordance with some applications of the invention;
• FIGS. 19A-B are schematic illustrations of a system for facilitating delivery of a prosthetic valve body, in accordance with some applications of the invention;
• FIG. 20 is a schematic illustration showing examples in which force measurements described herein may be combined to facilitate implantation of a prosthetic valve, in accordance with some applications of the invention;
• FIGS. 21A-B are schematic illustrations of a prosthetic valve assembly, in accordance with some applications of the invention;
• FIGS. 22A-B are schematic illustrations of a prosthetic valve assembly comprising a prosthetic valve having a tubular valve body that comprises an upstream portion, a downstream portion, and an elastic portion disposed between the upstream portion and the downstream portion, in accordance with some applications of the invention; and
• FIGS. 23-24 are schematic illustrations of systems for facilitating anchoring of a tissue anchor in the heart of a subject, in accordance with some applications of the invention.
DETAILED DESCRIPTION OF EMBODIMENTS
• Reference is made toFIGS. 1A-F, which are schematic illustrations of asystem40 for implanting an upstreamprosthetic valve support42 and aprosthetic valve44 at anative valve10 of aheart4 of a subject, in accordance with some applications of the invention. Typically, applications of the invention are for use with the mitral valve of the subject (that is,native valve10 comprises the mitral valve of the subject), but it is to be noted that applications of the invention may be used at other heart valves of the subject, such as the tricuspid valve, the aortic valve, or the pulmonary valve, mutatis mutandis.
• Reference is now made toFIGS. 1A-B. Asheath46 is advanced transluminally (e.g., transfemorally) toright atrium12 of the heart, and is typically advanced through the fossa ovalis intoleft atrium6 of the heart using standard transseptal techniques. For some applications,sheath46 is steerable. For some such applications,sheath46 is steerable in two axes. One or more (typically two) tissue anchors48 are advanced throughsheath46, betweenleaflets14 of the native valve, and intoleft ventricle8 of the heart, and are there anchored to tissue (e.g., ventricular muscle tissue) of the heart.FIG. 1A shows afirst tissue anchor48abeing anchored at a first ventricular site, andFIG. 1B shows asecond tissue anchor48bbeing anchored at a second ventricular site. Typically, anchors48 are anchored to muscle of the heart, such as to the walls ofventricle8 and/or to papillary muscles. Typically, and as shown, anchors48 comprise helical anchors that are anchored by being rotated. However, other types of anchors may be used, such as barbed or harpoon-like anchors, e.g., that are anchored by being pushed into the tissue.
• State A ofFIGS. 1A and 1B show acatheter50 having been advanced throughsheath46 and intoventricle8, and an anchor-delivery tube52 having been advanced throughcatheter50 to the respective ventricular site. Typically, and as shown, the distal end ofdelivery tube52 is placed against the tissue at the ventricular site. Typically, at least a distal portion ofcatheter50 is steerable (e.g., independently of sheath46).
• State B ofFIGS. 1A and 1B each show arespective anchor48 being anchored to a respective ventricular site. Typically,anchor48 is reversibly coupled to an anchor manipulator54 (e.g., an anchor driver), which is slidable through at least part oftube52, and which is configured to apply a force (e.g., a rotational force) to the anchor so as to anchor the anchor at the ventricular site. For some applications,anchor manipulator54 andanchor48 are advanced from outside the subject to the ventricular site only once the distal end oftube52 is disposed against the ventricular site. For some applications, the manipulator and anchor are disposed within, and advanced with,tube52. For some applications,anchor48 is anchored by rotatinganchor manipulator54 andtube52 together. For some applications, aseparate anchor manipulator54 is used to deliver and anchor each anchor48 (e.g., eachanchor48 may be provided pre-coupled to a respective anchor manipulator). For some applications, oneanchor manipulator54 may be used to deliver and anchor all (e.g., both) anchors48 (e.g., eachanchor48 may be configured to be sequentially coupled to the anchor manipulator outside the body of the subject by the operating physician). It is to be noted that typically anchor48 is not exposed fromtube52 other than when being anchored. It is hypothesized that for some applications this reduces a likelihood of inadvertently engaging and/or damaging tissue of the heart (e.g., chordae tendineae).
• For some applications, subsequent to anchoring eachtissue anchor48 to the tissue, a testing pulling force of known magnitude is applied to the anchor (e.g., by applying the pulling force to anchor manipulator54), and movement of the tissue anchor in response to the pulling force is observed using imaging (e.g., fluoroscopy). The observed movement may be used to confirm successful and/or stable anchoring (e.g., relatively little movement may indicate firm anchoring in firm tissue) or to determine sub-optimal anchoring (e.g., relatively large movement may indicate weak anchoring and/or anchoring in weak tissue). Thus, at least in part responsively to the observed movement, the operating physician may decouplemanipulator54 fromanchor48, or may de-anchor the anchor from the tissue using the manipulator.
• State C ofFIGS. 1A and 1Bshow anchor manipulator54 having been decoupled fromanchor48, and the manipulator andtube52 being withdrawn proximally intocatheter50. Eachanchor48 is provided pre-coupled to a guide member56 (e.g., a first guide member56a, and a second guide member56b), described in more detail hereinbelow (e.g., with reference to FIGS.1D and4A-C). Asmanipulator54 andtube52 are withdrawn,guide member56 is exposed fromtube52.
• Typically, and as shown inFIGS. 1A-B, thesame catheter50 is used to deliver bothanchors48. For such applications, and as shown in states B and C ofFIG. 1B, when deliveringsecond tissue anchor48b, anchor-delivery tube52 fits alongside first guide member56awithincatheter50. Alternatively, and as described hereinbelow with reference toFIG. 5, a separate catheter is used for each anchor, in which case the second catheter fits alongside first guide member56awithinsheath46.
• State D ofFIGS. 1A and 1B showcatheter50 having been withdrawn proximally, intoatrium6. For some applications,catheter50 is withdrawn completely from the body of the subject. For some applications,catheter50 is used for delivery of components during later steps in the procedure.Guide members56 extend fromatrium6, betweenleaflets14, and to respective ventricular sites. Typically,guide members56 do not eliminate functioning ofleaflets14 and/orvalve10. For some applications, guidemembers56 are configured to automatically move toward respective commissures16 (e.g., into the joining corners at the commissures of leaflets14). For some applications, and as shown inFIG. 1C, prosthetic valve support42 (e.g., deployment thereof) pushesguide members56 toward the respective commissures.
• Reference is now made toFIG. 1C, which shows prosthetic valve support being delivered to, and deployed at,native valve10.Prosthetic valve support42 is advanced throughsheath46 and intoatrium6. Typically,support42 is delivered in a compressed configuration thereof, within a housing, such as adelivery tube80. For some applications,catheter50 is used to facilitate delivery ofprosthetic valve support42 and delivery tube80 (e.g., the support and delivery tube are advanced through catheter50). For some applications, a different catheter is used to facilitate delivery ofprosthetic valve support42 anddelivery tube80. For some applications,prosthetic valve support42 anddelivery tube80 are advanced directly throughsheath46.
• Prosthetic valve support42 comprises an annular upstream support portion43 which, in the delivery configuration of the prosthetic valve support, is generally cylindrical, and which, once the prosthetic valve is deployed and expands to an uncompressed configuration thereof, is generally annular. For some applications, upstream support portion43 is generally frustoconical in the uncompressed configuration thereof. Typically, a distal end of upstream support portion43 in the compressed, cylindrical configuration, defines an inner perimeter of the upstream support portion in the uncompressed configuration, the inner perimeter defining an opening through the upstream support portion.
• State A ofFIG. 1C showsdelivery tube80, containingsupport42, having been delivered toatrium6 overguide members56, andsupport42 starting to be subsequently exposed from the delivery tube, and automatically expanding. Upstream support portion43 ofprosthetic valve support42 is shaped to defineholes82 through which guidemembers56 are slidable, thereby facilitating sliding of the prosthetic valve support overguide members56. Typically, holes82 are disposed opposite each other around the generally annular shape of upstream support portion43. For some applications, holes82 are defined and/or reinforced by aneyelet84 or pledget (visible in states B and C ofFIG. 1C).Guide members56 extend proximally fromdelivery tube80, e.g., via holes in a proximal end of the delivery tube, such that the delivery tube, andprosthetic valve support42, in the compressed state within the delivery tube, are slidable over the guide members, the guide members thereby facilitating delivery of the prosthetic valve support within the delivery tube. Introduction ofguide members56 through the prosthetic valve support and delivery tube are described hereinbelow with reference toFIGS. 3A-C.
• State B ofFIG. 1C shows prosthetic valve support42 (e.g., upstream support portion43 thereof) having been completely deployed fromdelivery tube80, and having automatically expanded to the uncompressed configuration thereof.Guide members56 are typically pushed towardcommissures16 by the expansion ofsupport42. For some applications,delivery tube80 is subsequently removed from the body of the subject. Atubular control rod86 is advanced over eachguide member56 towardprosthetic valve support42, and is used to push prosthetic valve support42 (e.g., upstream support portion43 thereof) toward the annulus ofvalve10.Control rods86 have a cross-sectional diameter that is larger than that ofholes82, and may thereby be used to push against upstream support portion43 without passing through the holes.
• Typically, prosthetic valve support42 (e.g., upstream support portion43 thereof) is provided with one or more (e.g., two)control filaments88 reversibly coupled thereto. Typically,filaments88 are coupled to upstream support portion43 at sites that are disposed opposite each other around the generally annular shape of the upstream support portion, and disposed evenly between holes82. That is, in the expanded configuration of upstream support portion43, a straight line betweenholes82 is typically perpendicular to a straight line between the sites at whichfilaments88 are coupled to the upstream support portion. It should be noted that other numbers and arrangements of control filaments may also be used. Typically, each control filament88 (1) comprises two portions of a loop of filament that passes through upstream support portion43, loops around a downstream surface of the upstream support portion (i.e., the surface that is placed in contact with the annulus of the native valve), and passes back through the upstream support portion, and (2) is decouplable from the upstream support portion by releasing a first end of the filament and pulling a second end, thereby unthreading and/or unlooping the control filament from the upstream support portion.
• Control filaments88 facilitate some manipulation ofprosthetic valve support42 following deployment fromdelivery tube80. Typically,control rods86 further facilitate such manipulation. State C ofFIG. 1C shows such manipulation ofprosthetic valve support42. For example, it may be desirable to rotate the prosthetic valve support (e.g., to position and/or orient the upstream support portion correctly with respect tonative valve10, to control the order in which different regions of upstream support portion43 contact the native valve, and/or to uncoilcontrol rods86 and/orcontrol filaments88 from each other).
• Reference is now made toFIG. 1D, which show steps in securingprosthetic valve support42 against the upstream surface (e.g., the atrial surface) ofnative valve10. Eachguide member56 typically comprises a tether (e.g., a longitudinal member102), a pull-wire104 reversibly coupled to the longitudinal member, and atubular member100 in which the longitudinal member and the pull-wire are disposed, the tubular member fitting snugly over the longitudinal member and the pull-wire so as to inhibit the pull-wire from becoming decoupled from the longitudinal member (e.g., to maintain a state of coupling therebetween). Pull-wire104 may or may not be metallic and may have various cross-sectional shapes (e.g., circular or rectangular). Typically, (1)longitudinal member102 defines a loop (e.g., a closed loop) (2) a portion (e.g., a distal portion) of pull-wire104 is threaded through the loop defined by member102 (e.g., is looped through the loop), and (3) the snug fitting oftubular member100 overmember102 and pull-wire104 inhibits the portion of the pull-wire from unthreading from the loop. It is to be noted that, althoughlongitudinal member102 is shown as defining a loop that extends most (e.g., all) of the length of the longitudinal member, the loop may alternatively be defined only at a proximal end of the longitudinal member.
• For some applications,longitudinal member102 and pull-wire104 are coupled via complementary screw threads. For example,longitudinal member102 may comprise, or be coupled to, a screw at a proximal end thereof, and pull-wire104 may comprise, or be coupled to, a socket at a distal end thereof. For some applications,tubular member100 is used to decouple (e.g., unscrew) pull-wire104 fromlongitudinal member102.
• Tubular member100 is typically more rigid than pull-wire104 and/or longitudinal member102 (although it is still sufficiently flexible to be transluminally delivered). This rigidity reduces a likelihood of twisting, kinking, snagging, and/or other undesirable phenomenon or interactions within the transluminal delivery system (e.g., withinsheath46,catheter50, and/or anchor-delivery tube52). For some applicationstubular member100 has a smoother surface than does pull-wire104 orlongitudinal member102. For some applications,tubular member100, which is necessarily wider than pull-wire104 and/orlongitudinal member102, is also more visible using imaging techniques such as fluoroscopy. This advantageously allows an operating physician to monitor the intracorporeal juxtaposition of the tubular members and, if necessary, to intervene, such as by revolving the tubular members (e.g., proximal ends thereof) around each other.
• As described hereinabove,control rods86 are used to pushprosthetic valve support42 toward the annulus ofvalve10 by sliding the control rod over a respective guide member56 (i.e., over thetubular member100 of the respective guide member). Eachcontrol rod86 is reversibly coupled at a distal end thereof to arespective locking member110 that, in an unlocked state thereof, is slidable overguide member56. Thereby, the pushing ofprosthetic valve support42 is typically performed by pushing with bothcontrol rod86 and lockingmember110. State A ofFIG. 1D showscontrol rods86 andrespective locking members110 having been slid over respectivetubular members100 ofrespective guide members56, such thatprosthetic valve support42 has been pushed against the annulus ofvalve10. Typically, a counter force (e.g., a proximal pulling force) is applied to guide member56 (e.g., totubular member100,longitudinal member102, and pull-wire104) so as to facilitate such sliding.
• State B ofFIG. 1D showstubular member110 having been pulled proximally such that the distal end of the tubular member is disposed proximal to lockingmember110, thereby exposing, from the tubular member, progressive portions oflongitudinal member102, at least until the tubular member is not disposed between the longitudinal member and the locking member (e.g., such that the locking member can directly contact the longitudinal member). Typically, and as shown in state B ofFIG. 1D,tubular member100 is pulled proximally such that the distal end thereof is disposed distal to the point at whichlongitudinal member102 and pull-wire104 are coupled, thereby retaining the coupling therebetween. While in this state, lockingmember110 is locked to longitudinal member102 (e.g., to a portion of the longitudinal member that is disposed within a channel of the locking member). For some applications, lockingmember110 locks automatically in response to withdrawal oftubular member100. For some applications, locking of lockingmember110 is independent of the withdrawal of the tubular member. An embodiment of lockingmember110 and control thereof is described in more detail hereinbelow with respect toFIGS. 4A-C. It is to be noted that the scope of the invention also comprises the use of other locking members such as crimp-based locking members, and also comprises other locking techniques such as tying.
• Subsequently, and as shown in state C ofFIG. 1D,tubular member100 is pulled further proximally, such that the distal end of the tubular member is disposed proximal to the point at whichlongitudinal member102 and pull-wire104 are coupled, such that the pull-wire is decouplable from the longitudinal member (e.g., unthreadable from the loop defined by the longitudinal member).
• Typically, anchors48 andlongitudinal members102 are configured to withstand a pulling force of at least 500 g, so as to withstand forces within the beating heart. The apparatus is typically configured such that a pulling force required to pulltubular member100 proximally, is less than 500 g, such as less than 300 g. For some applications, such a configuration is achieved at least in part by reducing friction betweentubular member100 and pull-wire104, such as by thermally treating the pull-wire104.
• Subsequently,control rod86,tubular member100, and pull-wire104 are pulled proximally, as shown in state D ofFIG. 1D, thereby separating the control rod from lockingmember110, and the pull-wire fromlongitudinal member102. In order forcontrol rod86 to be pulled proximally, the control rod is decoupled from lockingmember110 prior to said pulling. For some applications, the decoupling ofcontrol rod86 from lockingmember110 is synchronous with the locking of the locking member (e.g., the same action locks the locking member and decouples the control rod from the locking member, such as described hereinbelow with respect toFIGS. 4A-C). For some applications, the decoupling of the control rod from the locking member is independent of the locking of the locking member.
• It is to be noted that, as shown inFIG. 1D, for some applications, prosthetic valve support42 (e.g., upstream support portion43 thereof) is secured to the upstream surface of the annulus ofnative valve10, only byanchors48 that are anchored to tissue inventricle8 of the subject. It is also to be noted thatprosthetic valve support42 is coupled tolongitudinal members102 inatrium6 of the subject. Typically, a distance L1 between eachanchor48 and the point of upstream support portion43 to which it is coupled (e.g., to arespective hole82 and/or locking member110) is greater than 0.5 cm, e.g., greater than 1 cm, such as greater than 2 cm. That is, the length of eachlongitudinal member102 that is disposed between a respective anchor and upstream support portion43 is typically greater than 0.5 cm, e.g., greater than 1 cm, such as greater than 2 cm. The length of eachlongitudinal member102 that is disposed between the respective anchor and the upstream support portion is typically less than 10 cm (e.g., less than 7 cm, such as less than 5 cm). Thereby, the ventricular sites at which anchors48 are anchored are typically more than 0.5 cm (e.g., more than 1 cm, such as more than 2 cm) away fromprosthetic valve support42.
• Reference is now made toFIG. 1E-F, which show steps in the delivery and implantation ofprosthetic valve44 atnative valve10, facilitated byprosthetic valve support42.Prosthetic valve44 is advanced in a delivery configuration (e.g., in a compressed state), throughsheath44, typically within adelivery tube120.Prosthetic valve44 comprises a stent-like valve body122, typically comprising an expandable frame that typically contains a shape-memory material such as nitinol.Valve body122 is shaped to define a lumen therethrough, and an inner surface of the valve body is typically lined with a covering, such as a fabric. One or more prosthetic valve members (not shown for clarity), such as prosthetic leaflets, are coupled tovalve body122 and disposed within the lumen thereof.
• Prosthetic valve44 further comprises one or more tissue-engagingelements124. Typically, and as shown,valve44 comprises two tissue-engagingelements124 coupled tovalve body122 at sites that are on opposite sides of the circumference of the valve body. Each tissue-engagingelement124 typically comprises two arms126 (e.g., a first clip arm126aand a second clip arm126b). For some applications, and as shown, each arm126 defines an arc that is coupled tovalve body122 at the base of the arc. For example, and as shown, each arm126 may comprise a single arc of the same shape-memory material as the frame ofvalve body122. For some applications, one or both arms126 of each tissue-engagingelement124 may be covered in a covering, such as a fabric.
• Whenvalve44 is in the compressed state thereof withindelivery tube120, arms126 are held againstvalve body122 with a tip127 of each arm disposed proximally to a site at which that arm is coupled to the valve body. Each tissue-engagingelement124 is configured such that atip127aof arm126ais disposed distal to atip127bof arm126b. For example, arm126amay be shorter than arm126b. Alternatively or additionally, arm126amay be coupled tovalve body122 at a site that is distal to a site at which arm126bis coupled to the valve body.
• Prosthetic valve44, withindelivery tube120, is advanced distally betweenleaflets14 ofnative valve10, and the prosthetic valve is progressively advanced distally out of a distal end of the delivery tube, as shown in states A-B ofFIG. 1E. It is to be noted thatleaflets14 typically continue to function following implantation ofprosthetic valve support42, and may further continue to function whiledelivery tube120 is disposed therebetween; the leaflets typically coapt around the delivery tube. At a given degree of advancement ofprosthetic valve44 out ofdelivery tube120, first arm126ais deployed: tip127aof each first arm126abecomes exposed from the delivery tube and each arm126aresponsively deflects radially outward fromvalve body122, toward a pre-set position (state B ofFIG. 1E).Tip127bof each arm126bremains withindelivery tube120. Throughout the procedure, as distal portions ofvalve body122 are progressively exposed fromdelivery tube120, they typically automatically expand toward an expanded state
• Subsequently, and as shown in state D ofFIG. 1E,prosthetic valve44 anddelivery tube120 are moved proximally (e.g., atrially) such that arm126aof each tissue-engagingelement124 engages (e.g., captures) aleaflet14 ofnative valve10, e.g., such that a portion of each leaflet is disposed between (1) each arm126aand (2) a respective second arm126bandvalve body122. Optionally, subsequently to deployment of first arm126aand prior to movingprosthetic valve44 proximally, the first arm is deflected further fromvalve body122 than its pre-set position by applying a force to the first arm using the delivery tube. That is, an angle between the first arm and an outer surface of the valve body is increased by applying the force to the first arm using the delivery tube.
• Typically, the force is applied by movingdelivery tube120 distally with respect to the prosthetic valve (e.g., sliding the delivery tube over at least part of the prosthetic valve), so as to push the arm, as shown in state C ofFIG. 1E. It is hypothesized that such “opening” of tissue-engagingelement124 facilitates engagement of leaflets14 (e.g., engagement of a larger portion of leaflets14). Subsequently,delivery tube120 is returned proximally with respect toprosthetic valve44, such that arm126areturns toward its pre-set position (state D ofFIG. 1E). For some applications, until at least the step shown in state D ofFIG. 1E,prosthetic valve44 is retrievable intodelivery tube120 and removable from the body of the subject, e.g., as described hereinbelow with respect toFIG. 2.
• Subsequently,delivery tube120 is pulled further proximally with respect toprosthetic valve44, such thattip127bof second arm126bof each tissue-engagingelement124 becomes exposed from the delivery tube, and each arm126bresponsively deflects radially outward fromvalve body122, toward a pres-set position (state A ofFIG. 1F), thereby coupling the tissue-engaging element to the leaflet by sandwiching a portion of aleaflet14 between the first and second arms of each tissue-engaging element. Second arm126bis typically configured, when completely unrestricted (e.g., in the absence of leaflet14) to have a pre-set position that is close to that of first arm126a, planar with that of first arm126a, and/or further fromvalve body122 than is arm126a. For some applications, the difference in size and/or position of the arc of second arm126bto that of first arm126afacilitates the second arm to move into plane with, and/or beyond the plane of, the first arm.
• Subsequently,prosthetic valve44 is fully deployed by a proximal end of the prosthetic valve (e.g.,valve body122 thereof) being exposed from delivery tube120 (e.g., by further withdrawing the delivery tube proximally with respect to the prosthetic valve)(state C ofFIG. 1F). The proximal end ofprosthetic valve44 responsively (e.g., automatically) expands toward the expanded state thereof. Expansion of the prosthetic valve (e.g., ofvalve body122 thereof) applies a radially-expansive force against prosthetic valve support42 (e.g., against an inner perimeter of upstream support portion43 thereof), thereby coupling the prosthetic valve to the prosthetic valve support. Typically, prosthetic valve support42 (e.g., the inner perimeter of upstream support portion43) restricts expansion ofprosthetic valve44, at least in part.
• For some applications, and as shown in state B ofFIG. 1F, subsequently to the coupling of tissue-engagingelements124 toleaflets14, and prior to coupling ofprosthetic valve44 toprosthetic valve support42, the prosthetic valve is pulled proximally, e.g., so as to align a portion ofvalve body122 with upstream support portion43 and/or to drawnleaflets14 toward the upstream support portion.
• It is to be noted that, for some applications, each tissue-engagingelement124 comprises only one arm126. For some such applications, the one arm126 comprises and/or functions like first arm126adescribed herein. For some such applications, the one arm126 is configured to couple to the leaflet by sandwiching a portion of the leaflet between the one arm andvalve body122. For some such applications, the one arm126 is configured, when the prosthetic valve is pulled proximally as shown in state B ofFIG. 1F, to sandwich a portion of the leaflet between the one arm and prosthetic valve support42 (e.g., upstream support portion43 thereof).
• State D ofFIG. 1F shows the implanted (e.g., final) state ofprosthetic valve support42 andprosthetic valve44, following implantation thereof atnative valve10. For some applications, in this implanted state,prosthetic valve support42 andprosthetic valve44 are inhibited from moving upstream (e.g., atrially) both by tissue anchors48 and by tissue-engagingelements124. That is, for some applications, resistance to forces onsupport42 andvalve44 from the functioning of the heart of the subject, is provided in part byanchors48 and in part byelements124. For some applications, in this implanted state,prosthetic valve support42 andprosthetic valve44 are inhibited from moving upstream mostly (e.g., solely) by tissue-engagingelements124. That is, for some applications, resistance to forces onsupport42 andvalve44 from the functioning of the heart of the subject, is provided mostly (e.g., solely) byelements124. For some such applications, anchors48 andlongitudinal members102 are thereby only required untilprosthetic valve44 has been implanted. It is to be noted that in both cases, prosthetic valve support42 (e.g., upstream support portion43 thereof) inhibits movement ventricularly ofprosthetic valve44, and of the prosthetic valve support itself.
• Reference is again made toFIGS. 1D-F. For some applications, locking of lockingmembers110 tolongitudinal members102 and/or decoupling of pull-wires104 from longitudinal members102 (FIG. 1D) is not performed until after implantation of prosthetic valve44 (FIGS. 1E-F). For such applications, it is thereby possible to adjust the length of the portion of longitudinal members102 (e.g., tension on the longitudinal members) after implantation ofprosthetic valve44. For some applications, a similar advantage is conferred by locking members being reversibly lockable, being locked before implantation ofprosthetic valve44, and subsequently to implantation of the prosthetic valve, being unlocked to allow re-adjustment oflongitudinal members102.
• Reference is again made toFIGS. 1A-F. For some applications, anatomical dimensions ofnative valve10 and/or surrounding tissues are determined (e.g., measured), andprosthetic valve support42 and/orprosthetic valve44 are selected accordingly (e.g., from a selection of prosthetic valve supports and/or prosthetic valves of different sizes). For example, an optimal lumen size (e.g., transverse cross-sectional area) for a prosthetic valve may be determined according to an area of the lumen defined by the annulus of the native valve of the subject. Responsively, a prosthetic valve having a lumen of that particular size may be selected. Similarly, a prosthetic valve support having an inner perimeter that defines an opening having a particular cross-sectional area may be selected, so as to restrict the expansion of a prosthetic valve to have a lumen of that particular size. Alternatively or additionally, a prosthetic valve support having an outer perimeter of a particular size may be selected according to determined dimensions of the annulus of the valve and/or walls of the atrium. It is to be noted that selecting a size according to determined anatomical dimensions may only in some cases comprise selecting a size that matches the anatomical dimensions. For example, an optimal size for the transverse cross-sectional area of a prosthetic valve is typically less than 90% of the area defined by the annulus of the native valve, so as to allow the leaflets of the native valve to coapt around the prosthetic valve and facilitate sealing.
• Becauseprosthetic valve support42 is typically implantable without eliminating functioning of the native leaflets, for some applications, the prosthetic valve support is implantable without the use of cardiopulmonary bypass. For some applications,prosthetic valve44 is also implantable without the use of cardiopulmonary bypass.
• Reference is made toFIG. 2, which is a schematic illustration ofprosthetic valve44 being retrieved intodelivery tube120, in accordance with some applications of the invention. As described hereinabove, for some applications, until at least the step shown in state D ofFIG. 1E,prosthetic valve44 is retrievable intodelivery tube120 and removable from the body of the subject.Delivery tube120 is moved distally with respect toprosthetic valve44, in a manner similar to that used to pusharms127a, described with reference toFIG. 1E (state C), but such thatdelivery tube120 is slid over the site at whicharms127aare coupled tovalve body122, thereby pushingarms127ato deflect distally.Prosthetic valve44, including at least part ofarms127a, is drawn into delivery tube120 (e.g., by sliding the prosthetic valve distally and/or the delivery tube proximally), and is typically subsequently removed from the body of the subject.
• Reference is made toFIGS. 3A-C, which are schematic illustrations of the introduction ofguide members56 throughprosthetic valve support42 anddelivery tube80, in accordance with some applications of the invention. As described hereinabove (e.g., with reference toFIG. 1C),prosthetic valve support42 is slidable towardnative valve10, overguide members56, including while the prosthetic valve support is compressed withindelivery tube80. Following coupling ofanchors48 to the ventricular sites, guidemembers56 extend from the anchors to outside of the body of the subject, and have respective free proximal ends57. Before introduction ofsupport42 withintube80 into the body of the subject (e.g., into sheath46),guide members56 are threaded throughholes82 in upstream support portion43 ofprosthetic valve42, and throughdelivery tube80, e.g., by the operating physician.
• Typically,prosthetic valve support42 is provided in the compressed state thereof, withindelivery tube80, e.g., as aunit140, coupled to a distal end of acontroller142 that is used to move the unit transluminally (e.g., within sheath46).Unit140 comprises (e.g., is provided having) one ormore introducer tubes144, each introducer tube being shaped to define a lumen therethrough, and having an opendistal end143 and an openproximal end145.Distal end143 of each tube is disposed outside a distal end ofsupport42 and/ortube80, andproximal end145 of each tube is disposed outside a proximal end of the support and/ortube80. Eachintroducer tube144 passes (1) from the distal end thereof, (2) through arespective hole82 in upstream support portion43 from the downstream surface of the support portion (which defines an outer surface of the support portion in the compressed state thereof) to an upstream surface of the support portion (which defines an inner surface of the support portion in the compressed state thereof), and (3) to the proximal end thereof.
• As shown inFIG. 3A, freeproximal end57 of eachguide member56 is advanced through arespective introducer tube144, thereby threading the guide member through upstream support portion43 ofprosthetic valve support42. Typically, and as shown inFIG. 3B,introducer tubes144 are subsequently removed, prior to introduction ofunit140 into the body of the subject. That is,introducer tubes144 are typically temporary.FIG. 3C shows upstream support portion43 ofprosthetic valve support42 having been partially exposed fromdelivery tube80, in order to illustrate the resulting threading ofguide members56 through upstream support portion43.
• Reference is made toFIGS. 4A-C, which are schematic illustrations of lockingmember110, and control thereof, in accordance with some applications of the invention. As described hereinabove, lockingmember110 is slidable over guide member56 (e.g., overtubular member100 thereof). As also described hereinabove, lockingmember110 is configured to lock tolongitudinal member102.
• FIG. 4A shows lockingmember110 in the unlocked state thereof, in which the locking member typically defines a channel therethrough through whichtubular member100 andlongitudinal member102, either within the tubular member or outside of the tubular member, are slidable. The channel of lockingmember110 is defined by a generallytubular portion160 of the locking member.Tubular portion160 defines one or more, such as two, oblique slits162 in the lateral walls thereof. Lockingmember110 comprises locking element, such as a lockingbar164, that is disposed generally orthogonally to the channel of the locking member, and passes through the slits (e.g., through both slits) of the tubular member. When lockingbar164 is slid distally and/or proximally, the locking bar thereby moves across at least part of the channel defined bytubular portion160. Lockingmember110 further comprises aspring166 that is configured to push lockingbar164 in a given direction (e.g., distally), thereby transitioning the locking member into the locked configuration thereof (i.e., locking the locking member)(FIG. 4B).
• Lockingmember110 is typically controllable using a holdingmember112 that inhibits (e.g., prevents) the locking member from locking, such as by inhibiting movement of lockingbar164. As described hereinabove, eachcontrol rod86, used to pushprosthetic valve support42 toward the annulus ofvalve10, is reversibly coupled at a distal end thereof to arespective locking member110, such that the pushing is typically performed by pushing withcontrol rod86 and lockingmember110. For some applications, and as shown inFIGS. 4A-C, holdingmember112 comprises and/or is defined bycontrol rod86. For such applications,control rod86 defines one ormore slits168 in a lateral wall thereof (e.g., twoslits168 on opposite sides of the lateral wall of the control rod). Typically, slits168 are L-shaped, thereby providing (1) a holding region170 that is generally orthogonal to the proximal-distal (e.g., longitudinal) axis ofcontrol rod86, and (2) arelease region172 that is generally parallel with the proximal-distal axis of the control rod, and that is open to the distal end of the control rod. Lockingbar164 is configured such that ends thereof extend at least into (e.g., through) slits168.
• In the unlocked state in which lockingmember110 is advanced overguide member56 toward upstream support portion43 and the annulus of the native valve, the ends of lockingbar164 are disposed in holding region170 of eachslit168, and the locking bar is thereby inhibited from moving distally and locking the locking member (FIG. 4A). In order to lock the locking member,control rod86 is rotated with respect to lockingmember110, such that the ends of lockingbar164 move intorelease region172 of eachslit168. In this position,spring166 is thereby able to move locking bar toward the distal end ofrelease region172, thereby locking the locking member (FIG. 4B).
• As described hereinabove,tubular member100 is typically withdrawn from lockingmember110 before the locking member is locked, and the locking member is locked tolongitudinal member102, e.g., by lockingbar164 sandwichinglongitudinal member102 against the inner surface of the channel of the locking member (e.g., effectively narrowing the channel at the site of the locking bar). Movement of the ends of lockingbar164 into and throughrelease region172 also decouplescontrol rod86 from the locking member, allowing the control rod to be removed from the body of the subject (typically along with tubular member100)(FIG. 4C). For some applications,longitudinal member102 comprises suture. For some applications,long member102 comprises a polymer, such as polyester. For some applications,longitudinal member102 comprises a metal. For example, the longitudinal member may comprise one or more wires, such as a plurality of wires twisted or braided into a cable. It is hypothesized that for some applications, a metallic composition reduces compressibility oflongitudinal member102 and/or facilitates locking of lockingmember110 to the longitudinal member.
• It is to be noted that lockingmember110 thereby (1) when unlocked, facilitates sliding therethrough of a relatively wide element,tubular member100, and (2) when locked, locks to a relatively narrow element,longitudinal member102. To facilitate this, between the locked and unlocked states, lockingbar164 thereby moves a sufficient distance across the channel defined by lockingmember110. That is, lockingbar164 moves a larger distance than would be necessary to lock a similar locking member that does not facilitate, in the unlocked state thereof, sliding therethrough of a tubular member that is wider than the longitudinal element.
• Reference is again made to FIGS.1D and4A-C. It is to be noted that lockingmember110 is typically configured to lock tolongitudinal member102 independently of (e.g., in the absence of) a complementary element, such as teeth, on the longitudinal member. For some applications, lockingmember110 is configured to be coupled to any part oflongitudinal member102.
• Reference is made toFIG. 5, which is a schematic illustration of steps in the delivery of tissue anchors48 toventricle8, and anchoring of the anchors in the ventricle, in accordance with some applications of the invention. For some applications, the steps shown inFIG. 5 (and/or states A-D thereof) can be used in place of the steps shown inFIG. 1B (and/or states A/D thereof), mutatis mutandis (e.g., after the steps shown inFIG. 1A and/or before the steps shown inFIG. 1C).FIG. 1B shows onedelivery catheter50 being used to deliver bothanchors48, and when deliveringsecond tissue anchor48b, anchor-delivery tube52 fitting alongside first guide member56awithincatheter50. As stated hereinabove, for some applications, a separate catheter is used for each anchor.FIG. 5 shows one such application.
• Typically,first anchor48ais delivered and anchored as described hereinabove with reference toFIG. 1A, whereincatheter50 inFIG. 1A comprises a first catheter50a. Subsequently, and as shown inFIG. 5, a second catheter50bis advanced throughsheath46, such that second catheter50bis disposed alongside first guide member56awithinsheath46. It is to be noted that, in bothFIG. 1B andFIG. 5, twoanchors48 are anchored at respective ventricular sites, and tworespective guide members56, extend from the anchors, throughatrium6, and typically out of the body of the subject.
• Reference is made toFIG. 6, which is a schematic illustration of asystem180 for use withprosthetic valve support42, in accordance with some applications of the invention. For such applications of the invention,prosthetic valve support42 is slidable towardnative valve10 overguide members56, including while the prosthetic valve support is compressed withindelivery tube80. Following coupling ofanchors48 to the ventricular sites, guidemembers56 extend from the anchors to outside of the body of the subject, and have respective free proximal ends57. Before introduction ofsupport42 withintube80 into the body of the subject (e.g., into sheath46),guide members56 are threaded throughholes82 in upstream support portion43 ofprosthetic valve42, and throughdelivery tube80, e.g., by the operating physician.
• FIGS. 3A-C and the descriptions thereof describeprosthetic valve support42 being provided as aunit140 comprisingintroducer tubes144, which are removed subsequently to advancement ofguide members56 through upstream support portion43 and prior to introduction of the unit into the body of the subject.FIG. 6 showssystem180, in which prosthetic valve support is provided withindelivery tube80, e.g., as aunit182, coupled to a distal end ofcontroller142, described hereinabove.
• Unit182 comprises (e.g., is provided having) one ormore introducer tubes184, each introducer tube being shaped to define a lumen therethrough, and having an opendistal end183.Distal end183 of each tube is disposed outside a distal end ofsupport42 and/ortube80, and eachintroducer tube184 extends out of a proximal end of the support and/ortube80. Similarly tounit140 described with reference toFIGS. 3A-C, eachintroducer tube144 ofsystem180 passes from the distal end thereof, through a respective hole in upstream support portion43 from the downstream surface of the support portion (which defines an outer surface of the support portion in the compressed state thereof) to an upstream surface of the support portion (which defines an inner surface of the support portion in the compressed state thereof). In contrast tounit140,introducer tubes184 extend from a proximal end ofdelivery tube80 to a proximal end portion of the apparatus. In further contrast tounit140,tubes184 remain in place asunit182 is advanced transluminally overguide members56.Tubes184 are typically flexible to facilitate transluminal advancement thereof.
• A lockingmember190 is disposed over eachintroducer tube184, such that the introduction ofguide member56 through the introducer tube also introduces the guide member through the locking member. Lockingmember190 is slidable over guide member56 (e.g., overtubular member100 thereof), and is configured to lock tolongitudinal member102. Typically, lockingmember190 is identical to lockingmember110, described hereinabove, except that lockingmember190 is configured (e.g., dimensioned) to be slidable also overintroducer tube184. Each lockingmember190 is disposed at the distal end of a respectivetubular control rod192, which is typically identical tocontrol rod86, described hereinabove, except thatcontrol rod192 is configured (e.g., dimensioned) to be slidable also overintroducer tube184.
• The use ofsystem180, includingintroducer tubes184, advantageously (1) removes the requirement for two separate introductions ofproximal end57 of guide member56 (i.e., through an introducer tube and subsequently through a locking member and control rod); and (2) facilitates control rods192 (and locking members190) being present in the atrium of the subject during expansion ofprosthetic valve support42, thereby reducing an interval between the expansion of the prosthetic valve support and pressing of the prosthetic valve support against the annulus of the native valve.
• Reference is made toFIGS. 7A-C, which are schematic illustrations of asystem200 for facilitating transluminal delivery of aprosthetic valve assembly202, in accordance with some applications of the invention.FIG. 7A showsprosthetic valve assembly202 in an expanded state thereof. Prosthetic valve assembly comprises (1) aprosthetic valve body204, which comprises a first frame206 (e.g., a wire frame), and is shaped to define alumen208 therethrough, (2) an annularupstream support210, which comprises a second frame212 (e.g., a wire frame), is shaped to define an opening through the upstream support, and is configured to be placed against an upstream surface (e.g., an atrial surface) of native valve10 (e.g., of an annulus thereof), and (3) aflexible sheet214 that couples the first frame to the second frame. In the expanded state of assembly202 (and thereby of body204),frame206 ofbody204 is generally cylindrical, and has a diameter d1. In the expanded state of assembly202 (and thereby of upstream support210),frame212 ofsupport210 is typically generally annular, and has anouter perimeter213 that has a diameter d2, which is greater than diameter d1.
• Sheet214 may be a fabric, a film, and/or another sheet-like structure, and may comprise a natural material, a polymer, a biomaterial, and/or any other suitable material. Typically,sheet214 comprises polyester, PTFE, and/or pericardial tissue.
• For some applications, and as shown inFIG. 7A, in the expanded state ofassembly202, and in the absence of external forces (e.g., if the assembly were resting on a table surface),sheet214 is generally annular and flat, and anupstream end218 offrame206 is disposed generally on a plane defined bysupport210. For such applications, aninner perimeter211 offrame212 defines an opening that has a diameter d3 that is greater than diameter d1.
• For some applications, in such an expanded and unconstrained state,sheet214 is generally frustoconical or funnel-shaped, andupstream end218 offrame206 is disposed below the plane defined bysupport210. (For some such frustoconical or funnel-shaped arrangements, the sheet may also be considered to be annular.)
• For some applications, in such an expanded and unconstrained state,sheet214 is generally tubular,upstream end218 offrame206 is disposed below the plane defined bysupport210. For such applications, diameter d3 is typically generally equal to diameter d1.
• Typically, one or both offrames206 and212 is covered on at least one side by acovering220. For some applications,sheet214 comprises a portion of covering220, e.g., the sheet is defined by a portion of the covering that is disposed betweenframes206 and212. For some applications, and as shown inFIG. 7A, covering220 is disposed (1) on a tissue-facing side of frame212 (e.g., defines a tissue-contacting surface of support210), and (2) on an inner surface of frame206 (i.e., lines the frame, and defines lumen208).
• A valve member205 (e.g., comprising one or more prosthetic leaflets; shown inFIGS. 8D-G) is coupled toframe206, is disposed withinlumen208, and provides valve (e.g., one-way) functionality toassembly202.Valve member205 may alternatively or additionally comprise a different valve member, such as a mechanical valve member.
• At least twoeyelets222 are disposed on an outer surface of body204 (i.e., protrude radially outward from body204). Typically, eyelets222 are pivotably coupled tobody204, e.g., such that the eyelets can pivot (e.g., rotate) in both directions by at least 5 degrees (e.g., more than 5 degrees and/or less than 90 degrees, such as between 5 and 90 degrees, e.g., between 5 and 60 degrees, such as between 5 and 45 degrees). For some applications, the eyelets can pivot in a plane parallel to a plane defined by a tangent of the valve body at the site to which the eyelet is coupled, as shown in the blowup box. Alternatively or additionally, the eyelets can pivot in a plane that is orthogonal to the plane defined by the tangent, e.g., such that the eyelets can point toward and/or away from the valve body. For some applications, eyelets222 are sutured tobody204.Eyelets222 are arranged in at least one pair; each eyelet of the pair being disposed on the opposite side ofbody206 from the other eyelet of the pair.
• FIG. 7B showssystem200 in a delivery configuration thereof.System200 comprises adelivery tool230, which comprises a first housing232 (e.g., a proximal housing) and a second housing234 (e.g., a distal housing), which are articulatably coupled to each other via a flexiblecontrol rod assembly240 disposed through the housings.
• In the delivery configuration ofsystem200,assembly202 is in a compressed state thereof, in which prosthetic valve body204 (in a compressed state thereof) is generally cylindrical, and upstream support210 (in a compressed state thereof) is also generally cylindrical. Typically, in the delivery configuration ofsystem200,sheet214 is also generally cylindrical.Assembly202, in the compressed configuration thereof, (1) has a central longitudinal axis, at one zone (e.g., at one end) of whichbody204 is disposed, and at another zone (e.g., the other end) of which support210 is disposed, and (2) defines anarticulation zone236 in which (a) at least part ofsheet214 is disposed, and (b) neitherframe206 ofbody204 norframe212 ofsupport210 is disposed, and about whichbody204 andsupport210 are articulatable with respect to each other.
• In the delivery configuration ofsystem200, at least part ofsupport210 is disposed within housing232 (which maintains the at least part of the support in the compressed state thereof), and at least part ofbody204 is disposed within housing234 (which maintains the at least part of the support in the compressed state thereof).Housing232 defines anorifice233 through which support210 is introducible into the housing, and removable from the housing.Housing234 defines anorifice235 that facesorifice233, and through whichbody204 is introducible into the housing, and removable from the housing. In the delivery configuration, eyelets222 protrude radially outward beyond the surface of delivery tool230 (e.g., beyond a lateral wall of housing234). Typically, housing234 (e.g., the lateral wall thereof) is shaped to define arespective slit237 for each eyelet, through which the eyelet protrudes beyond the surface of the housing. Eachslit237 is continuous with (i.e., is in communication with)orifice235 such that, as described hereinbelow, during deployment ofvalve body204,eyelet222 can slide out of the slit at the orifice.
• In the delivery configuration ofsystem200,tool230 is in a contracted state, in whichhousing232 is disposed at a distance d4 from housing234 (e.g.,orifice233 is disposed at distance d4 from orifice235). Distance d4 is typically greater than 1.5 mm and/or less than 30 mm, such as between 1.5 mm and 30 mm (e.g., between 10 and 15 mm). In this state, at least part ofsheet214 is exposed between the housings. The at least part of sheet214 (and thereby of articulation zone236) that is exposed betweenhousings232 and234 facilitates articulation ofhousing234 containingbody204 with respect tohousing232 containingsupport210, and thereby defines an articulation zone238 ofsystem200 in the delivery configuration thereof. Typically at least part ofcontrol rod assembly240 is flexible, so as to facilitate articulation at articulation zone238. For example, althoughassembly240 as a whole is typically sufficiently flexible so as to facilitate its transluminal delivery to the heart,control rods244 and246 may be more flexible than control rod240 (e.g., more flexible than required for transluminal delivery to the heart alone), so as to facilitate articulation at articulation zone238. For some such applications, respective portions ofcontrol rods244 and246 that are disposed within articulation zone238 whentool230 is in the contracted state (FIG. 7C) are more flexible than adjacent portions of the control rods (e.g., portions disposed withinhousings232 and234 whentool230 is in the contracted state). For example, and as shown, aportion245 ofcontrol rod244 may be narrower than adjacent portions of the control rod.
• Control rod assembly240 comprises (1) a first housing-control rod242, coupled tofirst housing232, (2) a second housing-control rod244, coupled tosecond housing234, and (3) a prosthesis-control rod246, coupled to amount248 that is reversibly couplable tovalve assembly202, e.g., via a plurality ofrecesses250 in the mount which receive respective portions ofassembly202. Typically,assembly202 is couplable to mount248 byvalve body204 being coupled to the mount, and further typically by a plurality ofprotrusions252 offrame206 being disposed withinrespective recesses250.Housing234 retains this coupling by inhibitingbody204 from expanding radially away frommount248.
• Typically, at least part of second housing-control rod244 is disposed within and slidable through prosthesis-control rod246, and at least part of the prosthesis-control rod is disposed within and slidable through first housing-control rod242 (e.g., coaxially).
• System200 (e.g.,tool230 thereof) further comprises at least two flexible reference-force tubes260, which extend, (a) from a proximal end of the system (e.g., from an extracorporeal portion of the system, such as from a handle of tool230), (b) through a proximal end ofhousing232, (c) through alumen254 defined bysupport210 in the compressed state thereof, (d) throughsheet214, (e) along the outside of at least part ofbody204, and typically (f) until a distal portion ofbody204. A lockingmember262 is disposed between eacheyelet222 and arespective tube260. Typically, lockingmembers262 are not directly coupled tobody204, but are instead each held in position betweeneyelet222 andtube260 by aguide member256 being disposed through the eyelet, the tube, and the locking member. For some applications, lockingmember262 is integral with eyelet222 (e.g.,eyelet222 is configured to and/or shaped to define locking member262).
• For some applications, guidemembers256 are identical to guidemembers56, described hereinabove.Guide members256 are described in more detail hereinbelow.
• Reference is now made toFIGS. 8A-H, which are schematic illustrations of a technique for use withsystem200, to transluminally implantprosthetic valve assembly202, in accordance with some applications of the invention. Typically,sheath46 is advanced transluminally (e.g., transfemorally) toright atrium12 ofheart4, through the fossa ovalis, and intoleft atrium6 using standard transseptal techniques, as described hereinabove with reference toFIGS. 1A-B. Subsequently,first tissue anchor48aandsecond tissue anchor48bare anchored at respective ventricular sites, e.g., as described with reference toFIGS. 1A-B and/or5, mutatis mutandis.
• Aguide member256 is coupled to each tissue anchor (e.g., the tissue anchors are provided pre-coupled to the guide members), such that after anchoring of the tissue anchors, each guide member extends from the anchor, out of the body of the subject, e.g., as described hereinabove with respect to guidemember56, mutatis mutandis. A proximal end of eachguide member256 is introduced through arespective eyelet222, lockingmember262, and reference-force tube260, such thatsystem200 appears as shown inFIG. 7B. As described hereinabove, eachguide member256 typically holds each lockingmember262 in place between itsrespective eyelet222 and reference-force tube260.
• System200 (e.g.,assembly202 within delivery tool230) is subsequently advanced alongguide members256 and viasheath46 to left atrium6 (FIG. 8A). Once exposed outside of the distal end ofsheath46,system200 is guided byguide members256 generally toward the ventricular sites at which anchors48 are anchored. Articulation of system200 (e.g., at articulation zone238, and/or at anotherarticulation zone239 proximal to housing232) facilitates transluminal advancement of the system past curves in the vasculature. The articulation also facilitates movement ofsystem200 from the distal end ofsheath46 and betweenleaflets14 ofvalve10, e.g., by facilitating steering of the system along a path defined byguide members256. This steering is typically further facilitated by (1) the position ofeyelets222 at a distal portion of system200 (e.g., at a distal portion of housing234), which turns the housing in response to encountering a turn inmembers256, and/or (2) the pivotable coupling ofeyelets222 tobody204, described hereinabove; pivoting ofeyelet222 reduces a likelihood of the eyelet snagging onguide member256 when encountering a turn in the guide member. For some applications, eyelets222 are internally coated with a material having a low coefficient of friction, such as polytetrafluoroethylene, to further facilitate sliding of the eyelet overguide member256.
• It is to be noted that, due to the described articulation, a distance d5 between a proximal end ofhousing232 and a distal end ofhousing234 may be greater than for a similar system that does not articulate. For example, distance d5 may be greater than a distance d6 along an atrioventricular axis between (a) a height on the atrioventricular axis of the upstream surface ofnative valve10, and (b) a height on the atrioventricular axis of the transseptal entry point into left atrium6 (e.g., the fossa ovalis). For some applications, distance d5 may be greater than the overall height ofleft atrium6. Distance d5 is typically greater than 25 mm and/or less than 100 mm, such as between 25 mm and 100 mm (e.g., 35-60 mm, such as 40-50 mm).
• Reference is made toFIG. 8B.System200 is advanced such thatdistal housing234, containingvalve body204 in the compressed state thereof, passes betweenleaflets14 ofnative valve10.Valve body204 is withdrawn out oforifice235 ofhousing234 by movingcontrol rod244 with respect tocontrol rod246. For example, and as shown inFIGS. 8B-C, control rod244 (and thereby housing234) may be moved distally intoventricle8, while control rod246 (and thereby mount248 and valve body204) remains stationary, thereby increasing the distance betweenhousing232 andhousing234.
• Whenprotrusions252 offrame206 become withdrawn fromhousing234, the portion ofvalve body204 coupled to the mount expands (e.g., automatically), thereby disengaging the protrusions fromrecesses250 ofmount248, and decoupling the valve body from the mount (FIG. 8C). For clarity,FIGS. 8C-D show the distal portion ofvalve body204 expanding before the proximal portion of the valve body. It is to be noted, however, that portions of the valve body typically expand as they become exposed fromhousing234, and therefore the proximal portion of the valve body typically expands while the distal portion of the valve body is still disposed withinhousing234.
• FIG. 8D showsvalve body204 having been completely removed fromhousing234, andsupport210 having been removed fromproximal housing232 by control rod242 (and thereby housing232) being withdrawn proximally, thereby further increasing the distance betweenhousing232 andhousing234. Typically, an opposing reference force is provided by reference-force tubes260, so as to holdassembly202 in place at the native valve whilehousing232 is withdrawn.
• During the withdrawal ofvalve body204 fromhousing234,eyelets222 typically slide throughslits237, and out of the slits atorifice235.
• For some applications,support210 is deployed fromhousing232 beforevalve body204 is deployed fromhousing234.
• Subsequently, tension is applied to guidemembers256 while an opposing reference force is provided toassembly202 bytubes260, thereby reducing a length of eachguide member256 that is disposed betweeneyelet222 and its respective tissue anchor48 (FIG. 8E). That is, eachguide member256 is slid proximally with respect to its respective reference-force tube260. Typically, the reference-force is provided toassembly202 by a distal end of each reference-force tube260 abutting a respective locking member; the reference force being transferred via the locking member (and typically further viaeyelet222 to valve body204).
• For some applications this tensioning movesvalve body204 at least slightly distally intoventricle8, such thatsheet214 becomes at least slightly frustoconical (e.g., as shown inFIG. 8E). For some applications this tensioning deformssupport210 and/or deflects the support with respect tobody204, e.g., such that the support becomes less flat (e.g., less planar). For example, before tensioning,support210 may be flat annular (as shown inFIG. 8D), and after tensioning the support may be frustoconical (as shown inFIG. 8E). Alternatively, and as described in more detail with reference toFIGS. 14A-B, mutatis mutandis, the prosthetic valve assembly may be configured such that the upstream support is frustoconical before tensioning, and the tensioning changes a slant of the frustoconical shape. For example, before tensioning, the upstream support may be frustoconical with the larger base of the frustum closer to a ventricular end of an atrioventricular axis than is the smaller base of the frustum, and after tensioning the support may become flatter, or may even invert, such that it becomes frustoconical with the smaller base closer to the ventricular end of the atrioventricular axis (e.g., the conformation shown inFIG. 8E, mutatis mutandis).
• For some applications, tensioning is performed before deployment ofsupport210 fromhousing232.
• Eachguide member256 typically comprises a tether282 (e.g., a longitudinal member), a pull-wire284, and atubular member280 in which the pull-wire and the tether are disposed. A distal portion of pull-wire284 is reversibly coupled to a proximal portion oftether282, andtubular member280 fits snugly over at least the distal portion of the pull-wire and the proximal portion of the tether so as to inhibit the pull-wire from becoming decoupled from the tether (e.g., to maintain a state of coupling therebetween). For some applications, and as shown, the reversible coupling is provided by pull-wire284 andtether282 defining respective mating surfaces. For some applications, the reversible coupling is provided as described hereinabove forguide member56.
• When each guide member256 (e.g., thetether282 thereof) is tensioned, the guide member is withdrawn proximally until at least part of tether282 (within tubular member280) is disposed within locking member262 (e.g., at least until the proximal portion of the tether has passed through the locking member;FIG. 8E state B).
• Reference is now made toFIG. 8F. Once a desired tension is obtained, the tension is fixed.Tubular member280 is withdrawn proximally with respect totether282, pull-wire284 and locking member262 (FIG. 8F). State A ofFIG. 8F showstubular member280 having been withdrawn untileyelet222. State B ofFIG. 8F showstubular member280 having been withdrawn until a distal end of the tubular member is disposed proximal to lockingmember262, thereby exposingtether282 to the locking member.
• Typically, lockingmember262 is biased (e.g., shape-set) to assume a locked state, and whiletubular member280 is disposed within the locking member, the tubular member inhibits locking of the locking member to tether282 (or to pull-wire284), and the removal of the tubular member from within the locking member facilitates automatic locking of the locking member to the tether (i.e., transitioning of the locking member into a locked state).Tubular member280 is slidable through lockingmember262 despite such biasing of the locking member, e.g., due to (a) the tubular member having a smooth surface, and/or (b) the tubular member retaininglocking elements263 of the locking member at an angle alpha_1 with respect to the tubular member, which is shallower than an angle alpha_2 with respect to tether282 that the locking elements assume when the tubular element is withdrawn (compareFIG. 8F state A to state B).
• Typically,tether282 defines a plurality ofnodules286, which facilitate locking of lockingmember262 to the tether. For some applications, lockingelements263 andnodules286 function as a ratchet. For some such applications, subsequently to transitioning of lockingmember262 into the locked state thereof, one-way movement oftether282 through the locking member is possible, thereby facilitating further increase, but not reduction, of tension.
• Reference is now made toFIG. 8G.Tubular member280 and pull-wire284 are decoupled fromtether282 andprosthetic valve assembly202, anddelivery tool230 is withdrawn proximally (e.g., intosheath46, and out of the body of the subject). Typically,housing234 and mount248 are withdrawn via the lumen of valve body204 (e.g., between the prosthetic leaflets disposed therein). For some applications,housing234,rods244 and246, and mount248 are withdrawn prior to the tensioning step (e.g., prior to withdrawal of reference-force tubes260, such as between the step shown inFIG. 8D and the step shown inFIG. 8E, mutatis mutandis).
• Typically,tubular member280 and pull-wire284 are decoupled fromtether282 by withdrawing the tubular member further proximally, such that the distal portion of pull-wire284 and the proximal portion oftether282 are exposed from the tubular member (state A ofFIG. 8G). Reference force for this withdrawal is provided by the anchoredtether282, and optionally also by reference-force tubes260.Tubular member280, pull-wire284, and reference-force tube260 are then withdrawn (state B ofFIG. 8H).
• FIG. 8H is a schematic illustration ofprosthetic valve assembly202 following implantation atnative valve10 ofheart4.Assembly202 provides replacement one-way valve functionality in which blood flows fromatrium6, through the opening defined byupstream support210,past sheet214, throughlumen208 ofvalve body204, and intoatrium8.Sheet214 thereby defines and/or serves as a conduit that provides fluid communication between the opening defined by upstream support210 (e.g., byframe212 thereof) andlumen208 ofvalve body204. Further typically, this conduit is uninterrupted except for holes (not shown) that may remain where reference-force tubes260 originally extended through the sheet.
• Regurgitation through these holes is typically minimal or absent due to their small size. The holes may be slit-like (rather than punched holes), such that in the absence of reference-force tubes260 the holes become generally closed. Additionally, coaptation ofleaflets14 and tissue growth over the holes may further facilitate sealing. Alternatively or additionally, the holes may be defined bytubular protrusions215 that extend from sheet214 (shown in the “optional” box,FIG. 7B).Tubular protrusions215 may comprise the same material assheet214, or may comprise a different material.Tubular protrusions215 may be flexible or rigid. The tubular protrusions are configured to provide a channel through whichtubes260 may pass, but which, in the absence oftubes260, inhibit movement of fluid therethrough. For example,tubes215 may inhibit fluid flow due to the ratio between their length and lumen diameter, and/or may act as duckbill valves. Therefore,sheet214 typically provides a generally sealed conduit betweenupstream support210 andvalve body204.
• The positioning ofprosthetic valve assembly202 at the native valve typically results inleaflets14 of the native valve coapting aroundvalve body204, thereby providing sealing that inhibits (e.g., prevents) perivalvular leakage.
• The positioning of prosthetic valve assembly typically also placessheet214 in contact with the annulus and/or leaflets of the native valve. In general, a prosthetic valve implanted at a native valve encounters forces due to beating of the heart and/or the resulting flow of blood. Small movements (e.g., oscillations) resulting from these forces may inhibit tissue growth (e.g., fibrosis) that would otherwise facilitate sealing between the prosthetic valve and the native valve. For some applications, such movements are reduced (e.g., dampened) at sites at which the contact betweenassembly202 and the surrounding tissue is provided bysheet214, e.g., due to flexibility of the sheet. Therebysheet214 typically provides stabilized (e.g., more constant) contact with tissue than would a less flexible structure in the same position; this is hypothesized to improve tissue growth and thereby sealing. Furthermore,sheet214 itself may be configured to promote tissue growth thereon, e.g., due to surface treatments and/or impregnation, and/or structure, such as weave and/or porosity, thereby further facilitating sealing.
• Reference is made toFIGS. 9A-14B, which are schematic illustrations of prosthetic valve assemblies, in accordance with some applications of the invention. Each prosthetic valve assembly shown inFIGS. 9A-14B comprises a valve body, an upstream support, and a sheet, which are typically identical, mutatis mutandis, tovalve body204,upstream support210 andsheet214 described hereinabove, except for where noted.
• FIGS. 9A-B show,prosthetic valve assembly202 described hereinabove, in a simplified (e.g., two-dimensional) schematic manner that illustrates the arrangement ofvalve body204,upstream support210 andsheet214, in the compressed state (FIG. 9A) and the expanded (e.g., implanted) state (FIG. 9B).FIGS. 9A-B are included at least in part in order to facilitate interpretation of the simplified schematic illustrations of the prosthetic valve assemblies ofFIGS. 10A-14B.FIG. 9A, likeFIGS. 10A,11A,12A and13A, shows the prosthetic valve assembly in the compressed state as if it were contained in the delivery tool thereof (e.g., tool230), but for clarity does not show the delivery tool. Typically,sheet214 is attached at least toinner perimeter211 ofupstream support210, and to anupstream end207 offrame206 ofvalve body204.
• FIGS. 10A-B show aprosthetic valve assembly302, which comprises a valve body304 comprising a first frame306, an upstream support310 comprising a second frame312, and aflexible sheet314. In the expanded state of support310 (FIG. 10B), frame312 defines anouter perimeter313 and aninner perimeter311 that defines an opening through the support. During implantation, support310 is placed against the upstream surface of the native valve, and valve body304 is subsequently intracorporeally coupled (e.g., directly coupled) to the support by being expanded within the opening of the support, e.g., as described hereinabove with reference toFIG. 1F, mutatis mutandis.
• Sheet314 is not attached toinner perimeter311 of frame312, but rather is circumferentially attached to frame312 at a radius that is greater than that of the inner perimeter. For example,sheet314 may be attached to frame312 atouter perimeter313.Sheet314 is also not attached to anupstream end307 of valve body304. Thereby apocket region316 is defined betweensheet314 and at leastinner perimeter311, in whichsheet314 is not attached to frame312 or frame306.
• In the compressed state (FIG. 10A),sheet314 is disposed alongside and outside at least part of frame312 and at least part of frame306. Frame312 is configured such that when the frame is in the compressed state,inner perimeter311 defines a downstream end of the frame (e.g., of the cylindrical shape of the frame), andouter perimeter313 defines an upstream end. Therefore, when frame312 expands, the upstream end of the frame expands radially outward more than does the downstream end of the frame.
• FIGS. 11A-B show aprosthetic valve assembly342, which comprises a valve body344 comprising a first frame346, an upstream support350 comprising a second frame352, and aflexible sheet354. In the expanded state of support350 (FIG. 11B), frame352 defines anouter perimeter353 and aninner perimeter351 that defines an opening through the support. During implantation, support350 is placed against the upstream surface of the native valve, and valve body344 is subsequently intracorporeally coupled (e.g., directly coupled) to the support by being expanded within the opening of the support, e.g., as described hereinabove with reference toFIG. 1F, mutatis mutandis.
• Sheet354 is not attached toinner perimeter351 of frame352, but rather is circumferentially attached to frame352 at a radius that is greater than that of the inner perimeter. For example,sheet354 may be attached to frame352 atouter perimeter353.Sheet354 is also not attached to anupstream end347 of valve body344. Thereby apocket region356 is defined betweensheet354 and at leastinner perimeter351, in whichsheet354 is not attached to frame352 or frame346.
• Frame352 is configured such that when the frame is in the compressed state, the frame has a generally cylindrical shape that defines a lumen therethrough,inner perimeter351 defines an upstream end of the frame (e.g., of the cylindrical shape of the frame), andouter perimeter353 defines a downstream end. Therefore, when frame352 expands, the downstream end of the frame expands radially outward more than does the upstream end of the frame. In the compressed state (FIG. 11A),sheet354 is disposed alongside and outside of at least part of frame346, and through at least part of the lumen defined by frame352.
• FIGS. 12A-B show aprosthetic valve assembly382, which comprises a valve body384 comprising a first frame386, an upstream support390 comprising a second frame392, and aflexible sheet394. In the expanded state of support390 (FIG. 12B), frame392 defines anouter perimeter393 and aninner perimeter391 that defines an opening through the support. Frame392 is coupled to frame386 prior to implantation (e.g.,assembly382 is provided with frame392 coupled to frame386). For some applications, frames392 and386 are integral, e.g., are defined by respective regions of a single frame. During implantation, valve body384 is advanced between leaflets of the native valve, and support390 is placed against the upstream surface of the native valve (e.g., as described with reference toFIGS. 8B-D, mutatis mutandis.
• Sheet394 is not attached toinner perimeter391 of frame392, but rather is circumferentially attached to frame392 at a radius that is greater than that of the inner perimeter. For example,sheet394 may be attached to frame392 atouter perimeter393.Sheet394 is also not attached to anupstream end387 of valve body384. Thereby apocket region396 is defined betweensheet394 and at leastinner perimeter391, in whichsheet394 is not attached to frame392 or frame386.
• Assembly382 is configured such that, in the compressed state thereof (FIG. 12A), frames386 and392 are generally collinear, and form a generally continuous cylinder. Frame392 is configured such that in the compressed state,outer perimeter393 defines an upstream end of the frame (and thereby of assembly382). Therefore, when frame392 expands, the upstream end of the frame expands radially outward more than does the downstream end of the frame. In the compressed state,sheet394 is disposed alongside and outside of at least part of frame386, and at least part of frame392.
• FIGS. 13A-B show aprosthetic valve assembly402, which comprises a valve body404 comprising a first frame406, an upstream support410 comprising a second frame412, and aflexible sheet414. In the expanded state of support410 (FIG. 13B), frame412 defines anouter perimeter413 and aninner perimeter411 that defines an opening through the support. Frame412 is coupled to frame406 prior to implantation (e.g.,assembly402 is provided with frame412 coupled to frame406). For some applications, frames412 and406 are integral, e.g., are defined by respective regions of a single frame. During implantation, valve body404 is advanced between leaflets of the native valve, and support410 is placed against the upstream surface of the native valve (e.g., as described with reference toFIGS. 8B-D, mutatis mutandis.
• Sheet414 is not attached toinner perimeter411 of frame412, but rather is circumferentially attached to frame412 at a radius that is greater than that of the inner perimeter. For example,sheet414 may be attached to frame412 atouter perimeter413.
• Sheet414 is also not attached to anupstream end407 of valve body404. Thereby apocket region416 is defined betweensheet414 and at leastinner perimeter411, in whichsheet414 is not attached to frame412 or frame406.
• Assembly402 is configured such that, in the compressed state thereof (FIG. 13A), frame412 is disposed generally alongside at least a portion of frame406. Frame412 is configured such that in the compressed state,outer perimeter413 defines a downstream end of the frame. Therefore, when frame412 expands, the downstream end of the frame expands radially outward more than does the upstream end of the frame. In the compressed state,sheet414 is disposed alongside and outside of at least part of frame406.
• FIGS. 14A-B show aprosthetic valve assembly422 an expanded state thereof, implanted atnative valve10, in accordance with some applications of the invention.Assembly422 comprises a valve body424 comprising a first frame426, an upstream support430 comprising a second frame432, and asheet434.
• Frame426 of valve body424 has anupstream end427 and adownstream end429. In the expanded state, in the absence of external forces, anouter perimeter433 of second frame432 of upstream support430 is disposed closer todownstream end429 than is aninner perimeter431 of the second frame. For example, upstream support430 may define a frustum, the larger base of which is disposed closer to downstream end429 (and closer to a ventricular end of an atrioventricular axis) than is the smaller base of the frustum. For some applications, the assembly is thus configured such that, when placed at the native valve,outer perimeter433 of the upstream support contacts the upstream surface of the native valve (e.g., the valve annulus), and the inner perimeter of the upstream support does not (FIG. 14A). For some such applications, frame432 may be flat annular in the absence of external forces, and in the expanded state,sheet434 retains the second frame in the frustoconical shape by inhibiting expansion of the second frame (e.g., expansion of at leastouter perimeter433 thereof). For some applications, frame432 curves downward toward the tissue thatouter perimeter433 contacts (configuration not shown).
• Sheet434 is not attached toinner perimeter431 of frame432, but rather is circumferentially attached to frame432 at a radius that is greater than that of the inner perimeter. For example,sheet434 may be attached to frame432 atouter perimeter433.Sheet434 is also not attached toupstream end427 of valve body424. Thereby apocket region436 is defined betweensheet434 and at leastinner perimeter431, in whichsheet434 is not attached to frame432 or frame426.
• For some such applications, such a configuration provides a spring functionality that allows valve body424 to move along an atrioventricular axis whileouter perimeter433 and/or portions ofsheet434 remain in contact with tissue (FIG. 14B). For example,assembly422 may be implanted using techniques described with reference toFIGS. 8A-H, mutatis mutandis, and the spring functionality may allow movement of valve body424 ventricularly during tensioning oftethers282 while maintaining contact betweenouter perimeter433 and the atrial surface. Similarly, such a configuration may allow oscillation of valve body424 along the atrioventricular axis (e.g., caused by beating of the heart and the resulting blood flow), while maintaining constant contact betweenouter perimeter433 and the tissue.
• For some applications, a compressed state ofassembly422 is as described for one or more of the prosthetic valve assemblies described with reference toFIGS. 10A-13B, mutatis mutandis. For example, for some applications frame426 of body424 is coupled to frame432 of support430 prior to implantation (e.g.,assembly422 is provided with frame426 coupled to frame432), such as described forassembly382 and/orassembly402, mutatis mutandis. Alternatively, frame426 is intracorporeally coupled to frame432, e.g., as described forassembly302 and/orassembly342, and/or with reference toFIG. 1F, mutatis mutandis.
• For some applications,assembly422 is implanted as described for one or more of the prosthetic valve assemblies described with respect toFIGS. 10A-13B, mutatis mutandis.
• Reference is again made toFIGS. 9A-B,10A-B, and11A-B. As described hereinabove, in its compressed state,assembly202 defines an articulation zone in which (a) at least part ofsheet214 is disposed, and (b) neitherframe206 ofbody204 norframe212 ofsupport210 is disposed, and about whichbody204 andsupport210 are articulatable with respect to each other. It is to be noted that in their compressed states,assemblies302 and342 also definerespective articulation zones336,376. For each assembly, at least part of the respective sheet is disposed in the articulation zone, neither the respective frame of the valve body nor the respective frame of the support is disposed in the articulation zone, and the respective valve body and support are articulatable with respect to each other, about the articulation zone.
• Reference is again made toFIGS. 10A-B,11A-B,12A-B,13A-B, and14A-B. As described hereinabove,assemblies302,342,382,402 and422 each define a respective pocket region between the respective sheet and at least the inner perimeter of the frame of the upstream support. As also described hereinabove, (e.g., with reference to assembly202), placement of the flexible sheet of the prosthetic valve assembly in contact with tissue provides stabilized contact with the tissue, and thereby improves tissue growth and sealing. Provision of a pocket region such as those described hereinabove is hypothesized to further improve sealing (e.g., by further facilitating tissue growth). For example, such configurations (1) may provide a greater surface area of the flexible sheet and/or a greater tissue-contact area of the sheet (e.g., due to an angle of the sheet), and/or (2) may hold the flexible sheet under less tension (e.g., compared to assembly202), such that the sheet is freer to move with movement of the valve assembly and/or tissue, thereby dampening movements that may otherwise inhibit tissue growth and/or sealing. This is illustrated inFIGS. 14A-B, which show an example of the contact betweenflexible sheet434 and tissue (e.g., leaflets14). For some applications, the sheet is elastic, so as to further facilitate maintenance of contact despite movement of the frames of the prosthetic valve assembly with respect to the native valve.
• As described hereinabove, the respective pocket region of eachassembly302,342,382,402 and422 is defined by the manner in which the sheet of the assembly is coupled to the frames of the assembly. When the assembly is in the expanded state thereof, the sheet is typically frustoconical and/or funnel-shaped. This shape is defined by a lateral wall (i.e., the sheet itself), and first and second apertures (at either end of the shape), the first aperture being larger than the second aperture. A portion of the sheet that defines the first aperture is circumferentially attached to the frame of the upstream support at a radius that is greater than a radius of the inner perimeter of the support. A portion of the sheet that defines the second aperture is circumferentially attached to the frame of the valve body at a longitudinal site that is closer to a downstream end of the valve body than is the longitudinal site at which the upstream support is coupled to the valve body.
• For some applications, the sheet extends radially past the radius at which it is coupled to the upstream support. As described hereinabove, for some applications the sheet is coupled to the upstream support at an outer perimeter of the upstream support. For some applications, the sheet extends radially past the outer perimeter of the upstream support.
• Reference is made toFIGS. 15A-C, which are schematic illustrations of atool460 for facilitating application of force betweenprosthetic valve assembly202 and guide members256 (e.g., tethers282 thereof), in accordance with some applications of the invention. For some applications,tool460 serves as a tension-detector tool. For some applications,tool460 alternatively or additionally serves as a tension-applicator tool.
• The boxes on the right-hand side ofFIGS. 15A-C shows assembly202 being implanted atnative valve10, as described hereinabove. The box ofFIG. 15A shows assembly202 having been deployed (e.g., delivered and expanded) at the native valve, e.g., as described with reference toFIG. 8D. The box ofFIG. 15B showstethers282 ofguide members256 having been tensioned with respect toassembly202, e.g., as described with reference toFIG. 8E. The box ofFIG. 15C showstubular member280 of eachguide member256 having been withdrawn proximally so as to (1) facilitate locking of therespective locking member262 to itsrespective tether282, e.g., as described with reference toFIG. 8F, and (2) decouple pull-wire284 fromtether282, e.g., as described with reference toFIG. 8G.
• The left-hand side ofFIGS. 15A-C shows (1) a proximal end of system200 (e.g., a proximal end ofdelivery tool230 thereof, e.g., including ahandle231 thereof), including a proximal portion of pull-wire284, a proximal portion oftubular member280, and a proximal portion of reference-force tube260, and (2)tool460 coupled to the proximal portion of pull-wire284 and the proximal portion of reference-force tube260. The left-hand side ofFIGS. 15A-C shows onetool460 being used with one pull-wire284,tubular member280,tube260 and tool460 (and one handle231). However it is to be noted thattool460 is typically used with each guide member (e.g., each tether282), either sequentially, or by providing more than onetool460 for use at generally the same time.
• Tool460 comprises a pull-wire-coupling element462, configured to be coupled to the proximal portion of pull-wire284 (e.g., to agrip464 of the pull-wire), and a reference-force-tube-coupling element466, configured to be coupled to the proximal portion of reference-force tube260 (e.g., to agrip468 of the tubular member). Couplingelements462 and466 are coupled to each other via anadjustment member470 that facilitates adjustment of a distance between the coupling elements.Adjustment member470 may comprise screw threads, a ratchet mechanism, or any other suitable adjustment mechanism.
• Pull-wire-coupling element462 is coupled to the proximal portion of pull-wire284 (e.g., to agrip464 of the pull-wire), and reference-force-tube-coupling element466 is coupled to the proximal portion of reference-force tube260 (e.g., to agrip468 of the tubular member), typically subsequently to delivery ofprosthetic valve assembly202 to the native valve (FIG. 15A). A distance d7 exists betweencoupling elements462 and466.
• Subsequently,adjustment member470 is used (e.g., actuated) so as to change (e.g., increase) the distance betweencoupling elements462 and466 (FIG. 15B; distance d8).
• This reduces the length oftether282 that is disposed distal to the distal end of reference-force tube282, (and thereby the length of the tether that is disposed betweeneyelet222 and anchor48), thereby applying tension to the tether). Typically, a length indicator471 (e.g., a rule) is provided ontool460 that indicates the change in length that has been made. Further typically,tool460 comprises aforce detector472 that detects and displays a force differential (e.g., a linear force differential) betweencoupling elements462 and466, and thereby provides an indication of the tensile state oftether282.
• When a desired tensile state oftether282 has been achieved (e.g., an absolute value and/or a value relative to other detected forces, such as the tensile state of the other tether282), the tension is fixed, and pull-wire284 is decoupled from tether282 (FIG. 15C). As described with reference toFIG. 8F, this is achieved by withdrawingtubular member280 proximally with respect totether282, pull-wire284 and lockingmember262.FIG. 15C shows a proximal portion of tubular member280 (e.g., agrip474 thereof) being withdrawn proximally with respect to (1) pull-wire284 (and therefore with respect to tether282 to which the pull-wire is coupled), and (2) reference-force tube260 (and therefore with respect to lockingmember262 which the distal end of the reference-force tube abuts). This is illustrated by a distance d10 betweengrips468 and474 inFIG. 15C, which is greater than a distance d9 betweengrips468 and474 inFIG. 15B. This thereby facilitates (1) locking of lockingmember262 to tether282, and (2) subsequently (i.e., after further proximal withdrawal of the tubular member), decoupling of pull-wire284 from the tether.
• For some applications, this is performed by one continuous movement oftubular member280. For some applications, visual and/or tactile indicators allow the operating physician to lock lockingmember262 to tether282 without decoupling pull-wire284 from the tether. This may advantageously allow the physician to further increase the tension on the tether (e.g., by using the ratchet functionality described with reference toFIG. 8F) before decoupling the pull-wire from the tether.
• Althoughtool460 is described hereinabove for facilitating implantation ofassembly202, the tool may also be used, mutatis mutandis, in combination with other systems described herein, such assystem40 described hereinabove and/orassembly552 described hereinbelow (e.g., for tensioningtethers582 thereof).
• Reference is now made toFIG. 16, which is a schematic illustration of a system480 comprising a prosthetic valve assembly482 and one ormore springs484 via which the prosthetic valve assembly is elastically coupled to one or more tissue anchors48, in accordance with some applications of the invention. For illustrative purposes, system480 is shown as comprising system200 (e.g., comprising prosthetic valve assembly202), described hereinabove, with the addition ofsprings484. However it is to be noted that the techniques described with reference toFIG. 16 may alternatively or additionally be used to facilitate implantation of other prosthetic valves and/or prosthetic valve assemblies described herein, mutatis mutandis (e.g., springs484 may be added to other prosthetic valves and/or prosthetic valve assemblies described herein).
• Eachspring484 is disposed outside ofvalve body204, typically laterally outside the valve body, and further typically betweeneyelet222 and locking member262 (e.g., coupling the eyelet to the locking member). For example, and as shown,spring484 may have a longitudinal axis that is generally parallel withlumen208 of the valve body. When reference-force tube260 provides the reference force to lockingmember262 during tensioning of guide member256 (e.g.,tether282 thereof), the reference force is transferred viaspring484. Typicallyspring484 serves as a compression spring, such that increasing tension on guide member256 (e.g., thetether282 thereof) compresses the spring.
• For some applications,spring484 provides an indication of a state of the spring that is observable and recognizable using imaging techniques (e.g., fluoroscopy). That is,spring484 is configured to change shape in response to a force applied to it, in a manner that is observable and recognizable using fluoroscopy. This functionality therefore provides intracorporeal measurement of tension on tether282 (in a manner that is itself observable extracorporeally). It is hypothesized that for some applications, this intracorporeal measurement advantageously detects the tension with reduced interference (e.g., noise) that may be present in extracorporeal measurement techniques. For example, for some applications, extracorporeal measurement of the tension by extracorporeally measuring tension on pull-wire284 (e.g., tension with respect to reference-force tube280) may be inhibited by interference by inherent elasticity of the pull-wire and other elements of the system, and by friction between elements of the system.
• For some applications, the shape ofspring484 alone provides the tension indication. For such applications,spring484 may be coated with a radiopaque material such as tantalum. For some applications,spring484 has (e.g., comprises and/or is coupled to) one or moreradiopaque markers486, and the juxtaposition of the markers facilitates extracorporeal detection of the shape of the spring. For example, whenspring484 serves as a compression spring, a reduction of a distance d11 (compare d11 to d11′) betweenadjacent markers486 indicates an increase in tension ontether282.
• For some applications, an intracorporeal reference (e.g., a scale)488 is provided, to facilitate identification of shape change of spring484 (e.g., to facilitate quantification of the shape change by (1) comparing the position ofmarkers486 toreference488, and/or (2) comparing the juxtaposition ofmarkers486 to the juxtaposition of elements of the scale. For example, and as shown inFIG. 16,scale488 may itself also comprise a plurality ofradiopaque markers490 disposed on valve body204 (e.g., coupled to frame206) at known (e.g., regular) intervals, and distance d11 (observed using fluoroscopy) is compared to a distance d12 between adjacent markers490 (observed using fluoroscopy) in order to determine the actual change in distance d11. That is, an observed relative change between d11 and d12 is used to determine an actual absolute change in d11.
• For some applications,spring484 also alters the relationship between (a) changes in the length oftether282 disposed betweeneyelet222 andanchor48 and (b) tension on the tether. For example, forsystem200 described hereinabove (i.e., in the absence of spring484), starting with slack ontether282 between the eyelet and the anchor, as the length of the tether between the eyelet and the anchor is reduced, tension ontether282 may remain constant and low despite the reduction in the length of the tether, until the tether encounters resistance provided bytissue anchor48, at which point tension increases relatively quickly for every unit reduction in length. For system480 (i.e., using spring484), the relationship between (a) the length oftether282 disposed between the eyelet and the anchor, and (b) the tension on the tether, is smoother (e.g., the transition between before and after resistance from the anchor is encountered is smoother). That is,spring484 absorbs some of the applied tensile force and in exchange provides additional length to the tether. This is hypothesized to advantageously provide more flexibility to the operating physician to adjust the length oftether282 disposed between the eyelet and the anchor, with reduced changes to tension on the tether.
• For some applications,spring484 is configured so as to provide a desired tension (e.g., a desired resistance) over a range of lengths of tether282 (e.g., over a range of compression states of the spring). That is, the spring constant of the spring is sufficiently low that a change in resistance is minimized per unit length change. For example, the spring constant may be less than 50 g/mm.
• For some applications, the desired tension is above 300 g force and/or below 700 g force, e.g., above 400 g force, and/or below 600 g force, such as between 400 g force and 600 g force, e.g., about 500 g force. For example, a desired target tether tension may be 500 g force, andspring484 may be configured to provide, over a range of compression states of the spring, resistance that results in a tether tension that is within a margin tension (e.g., within 200 g force, such as within 100 g force) of the target force.
• For some applications,spring484 is configured to provide a distinct indication, observable using fluoroscopy, when the spring experiences a force that is within a margin force (i.e., a force that corresponds to being within the margin tension). For example,spring484 may undergo (e.g., suddenly undergo) a more obvious shape change when such a force is experienced.
• For some applications,spring484 is configured to act as a constant-force spring or similar, so as to facilitate the behavior described above. For some applications,spring484 is pre-loaded (e.g., pre-tensioned or pre-compressed).
• Reference is made toFIG. 17, which is a schematic illustration of a system500 comprising a prosthetic valve assembly502 and one ormore springs504 via which the prosthetic valve assembly is elastically coupled to one or more tissue anchors48, in accordance with some applications of the invention. For illustrative purposes, system500 is shown as comprising system200 (e.g., comprising prosthetic valve assembly202), described hereinabove, with the addition ofsprings504. However it is to be noted that the techniques described with reference toFIG. 17 may alternatively or additionally be used to facilitate implantation of other prosthetic valves and/or prosthetic valve assemblies described herein, mutatis mutandis (e.g., springs504 may be added to other prosthetic valves and/or prosthetic valve assemblies described herein).
• Eachspring504 is disposed outside ofvalve body204, typically laterally outside the valve body, and further typically is disposed functionally between lockingmember262 and anchor48 (e.g., between lockingmember262 andeyelet222, or betweeneyelet222 andanchor48. For some applications, and as shown,spring504 is a cantilever spring, and may be defined by a protrusion offrame206 that extends away (e.g., laterally away) fromvalve body204. That is,spring504 may comprise an elastically-deformable appendage. For some applications, the protrusion is shaped to define aloop506 that providesspring504 with constant-force-spring functionality.
• Typically,spring504 provides similar functionality tospring484, described hereinabove, mutatis mutandis. For example, for some applications,spring504 provides an indication of a state of the spring that is observable and recognizable using fluoroscopy. That is,spring504 is configured to change shape in response to a force applied to it, in a manner that is detectable and recognizable using fluoroscopy. For some applications,spring504 also alters the relationship between (a) the length oftether282 disposed betweeneyelet222 andanchor48 and (b) tension on the tether, e.g., as described hereinabove with reference tospring484, mutatis mutandis.
• Reference is made toFIGS. 18A-B, which are schematic illustrations of springs coupled to tether282 so as to elastically couple tissue anchor48 (e.g., a tissue-engagingelement49 thereof) to prosthetic valve assembly202 (e.g., tovalve body204 thereof), in accordance with some applications of the invention.FIG. 18A shows aspring520 disposed partway alongtether282.FIG. 18B shows aspring530, one end of which is coupled to anchor48 (e.g., to ananchor head47 thereof) and the other end of which is coupled totether282.Springs520 and530 are typically tension springs. For some applications,spring530 is rigidly coupled to anchorhead47.
• For illustrative purposes, springs520 and530 are shown being used with system200 (e.g., with prosthetic valve assembly202), described hereinabove. However it is to be noted that the techniques described with reference toFIGS. 18A-B may alternatively or additionally be used to facilitate implantation of other prosthetic valves and/or prosthetic valve assemblies described herein, mutatis mutandis.
• Typically, springs520 and530 provide similar functionality tosprings484 and504, described hereinabove, mutatis mutandis. For example, for some applications, springs520 and530 provide an indication of a state of the spring that is observable and recognizable using fluoroscopy. That is, the springs are configured to change shape in response to a force applied to them, in a manner that is detectable and recognizable using fluoroscopy. For some applications, springs520 and530 also alter the relationship between (a) the length oftether282 disposed betweeneyelet222 andanchor48 and (b) tension on the tether, e.g., as described hereinabove with reference tosprings484 and504, mutatis mutandis.
• Reference is again made toFIGS. 16, and18A-B. Springs484,520 and530 are shown as helical springs. However it is to be noted that each of these springs may have a shapes other than a helix. For example, each of these springs may have a zigzag shape. For some applications, the use of a spring that defines a repeating (e.g., oscillating) pattern such as a helix or a zigzag facilitates fluoroscopic identification of the state of the spring. For example, whereas a linear elastically-stretchable member (e.g., a strip of elastic rubber) remains linear when stretched, the shape of a helical or zigzag spring changes as force increases.
• Reference is made toFIGS. 19A-B, which are schematic illustrations of asystem700 for facilitating delivery of aprosthetic valve body702, in accordance with some applications of the invention.System700 comprises adelivery tool704 that comprises adistal housing706, configured to housevalve body702 in a compressed state thereof, aproximal portion708, and a flexible longitudinal portion710 (e.g., a catheter) therebetween.Proximal portion708 typically comprises ahandle712.Housing706 is configured to be transluminally advanced to the heart of the subject (e.g., as described herein, mutatis mutandis, whileproximal portion708 remains outside the body of the subject. Proximal portion708 (e.g., handle712 thereof) comprises aforce detector716 that detects a force between (a) the proximal portion, and (b)housing706 and/orvalve body702 coupled thereto. Typically,force detector716 detects tension. That is, the force detector detects resistance ofvalve body702 to a proximally-directed force applied by tool704 (e.g., whentool704 is moved proximally).
• Housing706 is advanced throughnative valve10 and intoventricle8, andvalve body702 is partly advanced out of the housing, and automatically expands toward an expanded state (FIG. 19A).Valve body702 is coupled to a plurality of tissue-engaging elements (e.g., tissue-engaging legs)714 that protrude radially out from the valve body when exposed fromhousing706. Tissue-engagingelements714 are configured to engageleaflets14 of the native valve, thereby facilitating anchoring of the valve body.
• Typicallysystem700 is used for implantation ofvalve body702 at a native valve at which a prosthetic valve support (e.g., an upstream support) has already been delivered, and to which the valve body is intracorporeally coupled (e.g., as described elsewhere herein). For example, and as shown inFIGS. 19A-B,system700 may be used to implant valve body atnative valve10 after implantation ofsupport42 at the native valve. As described with reference toFIGS. 1A-D,support42 is secured against the upstream surface ofnative valve10 by being anchored, via tethers (e.g., longitudinal members102), to ventricular muscle tissue. (The tethers are not visible inFIGS. 19A-B.)
• Pullinghousing706 andvalve body702 proximally (i.e., atrially) while tissue-engagingelements714 are protruding pushes the tissue-engaging elements againstleaflets14, reducing a height of a gap between the tissue-engaging elements andsupport42, and sandwiching the leaflets against the support (FIG. 19B). Resistance to proximal movement of valve body702 (e.g., due tosupport42 and leaflets14) is detected and displayed byforce detector716. The operating physician is thereby able to couplevalve body702 to support42 (e.g., by fully deploying the valve body within the opening defined by the support) while a desired degree of tension is observed. The coupling of the valve body to the support fixes the degree of tension, such thatleaflets14 remain sandwiched, and the valve body remains secured to the native valve.
• For some applications, alternatively or additionally to usingextracorporeal force detector716, the force encountered by tissue-engagingelements714 is observed using fluoroscopy (e.g., by observing a shape and/or position of the tissue-engaging elements). For such applications, the tissue-engaging elements are typically configured to facilitate such observation, as described herein for various springs. For some applications,elements714 are configured (e.g., shaped) to define a loop, e.g., as described hereinabove forsprings504, mutatis mutandis.
• For some applications,valve body702 is coupled via tethers to tissue anchors that are anchored to ventricular muscle tissue, as described elsewhere herein. For some such applications, a spring couples the valve body to each tissue anchor (e.g., as described with reference toFIGS. 16-18B, mutatis mutandis). For some applications in which a spring couples the valve body to each tissue anchor, reducing the height of the gap automatically (and typically immediately) alters a force on the spring (e.g., when the valve body is locked to the tether before reducing the height of the gap). For some applications in which a spring couples the valve body to each tissue anchor, reducing the height of the gap does not necessarily alter the force on the spring (e.g., when the valve body is slidably couplable to the tether until after the height is reduced, and is subsequently locked to the tether. For example,tool230 and/ortool460 may be used, mutatis mutandis, to measure and control tension and length of the tether until the valve body is locked to the tether.
• It is to be noted that the above technique may be used for prosthetic valve assemblies in which the valve body is pre-coupled to the upstream support, mutatis mutandis. For such applications, the proximal pulling force is not a sandwiching force, but rather is a testing force, typically used in combination with another testing force, e.g., as described hereinbelow, e.g., with reference toFIG. 20.
• Reference is made toFIG. 20, which is a schematic illustration showing examples in which force measurements described herein may be combined to facilitate implantation of a prosthetic valve, in accordance with some applications of the invention. Each apparatus and technique described herein for measuring force (e.g., tension) is described in a particular context (e.g., with reference to a particular prosthetic valve assembly, prosthetic valve body, and/or support) for the purpose of clarity. It is to be understood that the apparatus and techniques described in one context may be used to measure force in another context (e.g., to facilitate controlled implantation of a different prosthetic valve assembly, prosthetic valve body, and/or support), and may be combined with one or more of the other apparatus and/or techniques.
• FIG. 20 shows examples of combinations of apparatus and techniques described herein, which include:
• (1) Extracorporeal detection of tension on tethers (box722). This is described, for example, with reference to forcedetector472 oftool460 ofFIGS. 15A-C.
• (2) Extracorporeal detection of atrially-directed force of valve-mounted tissue-engaging elements against tissue (e.g., leaflets or annulus) of the native valve (box742). This is described, for example, with reference toFIGS. 19A-B.
• (3) Extracorporeal detection of sandwiching force (box720). That is, extracorporeal detection of the force of tissue-engaging elements coupled to the valve body against the native valve tissue and/or the upstream support. This is described, for example, (a) with reference toFIGS. 19A-B, and (b) with reference to forcedetector472 of tool460 (FIGS. 15A-C) being used to augment the apparatus and facilitate the techniques described with reference toFIGS. 21A-B.
• (4) Intracorporeal detection (observed using imaging) of tension on tethers (724). This is described, for example, with reference to the springs described with reference toFIGS. 16,17, and18A-B.
• (5) Intracorporeal detection (observed using imaging) of atrially-directed force of valve-mounted tissue-engaging elements against tissue (e.g., leaflets or annulus) of the native valve (box744). This is described, for example, with reference toFIGS. 19A-B.
• (6) Intracorporeal detection (observed using imaging) of sandwiching force (box726). This is described, for example, with reference to one or more of the springs described with reference toFIGS. 16,17, and18A-B being used to augment the apparatus and facilitate the techniques described with reference toFIGS. 21A-B.
• (7) Intracorporeal detection (observed using imaging) of ventricularly-directed force of the upstream support against the native annulus (box728). For some applications, this is achieved by using imaging (e.g., fluoroscopy) to extracorporeally observe intracorporeal changes in the shape of the upstream support (e.g., changes described with reference toFIGS. 8D-E,14A-B, and/or15A-B), in a similar manner to that described for extracorporeally observing changes in the shape of springs (e.g., described with reference toFIGS. 16,17, and18A-B), mutatis mutandis.
• It is hypothesized that combining two or more of the force-measurement techniques described herein may provide synergistic benefits when implanting an implant (e.g., a prosthetic valve assembly, prosthetic valve body, and/or prosthetic valve support), so as to facilitate controlled implantation (box730). The ability to control various forces that secure the implant allows, inter alia, the forces to be spread as desired by the operating physician. For example, it may be desirable:
• • that tension is equally (or otherwise) distributed between the tethers,
  • that tension on a given tether is optimized (discussed hereinbelow),
  • that, during operation of the valve, resistance to a force that pushes the valve body in an atrial direction (e.g., during ventricular systole) is optimally balanced between the various anchoring elements, such as between (a) tissue anchors48 and tethers coupled thereto and (b) other tissue-engaging elements (e.g., tissue-engaging elements714 (FIGS. 19A-B) or tissue-engaging elements580 (FIGS. 21A-B), thereby balancing the anchoring forces between different tissue sites, and/or
  • that sandwiching forces are greater than, equal to, or less than the tensile force provided by the tethers.
• It is to be noted that the example combinations provided hereinabove are intended to be illustrative, and not limiting.
• As described hereinabove, it may be desirable to that tension on a given tether is optimized. For example, it may be desirable that tension on the given tether to be maximized within a tension range that is known to be supported by (1) the tissue anchor to which the tether is coupled, and (2) the tissue to which the tissue anchor is anchored. For some applications, subsequently to anchoring the tissue anchor, the operating physician applies a testing pulling force to the tissue anchor. The testing pulling force is used to confirm that the anchored tissue anchor is capable of supporting an overload tension that is greater than an expected tension that it is expected that the anchor will encounter during operation. The expected tension may be determined at least in part based on possible ventricular blood pressure and the cross-sectional area of the lumen of the valve body.
• For some applications, the testing pulling force is applied (e.g., via the tether or via the anchor manipulator), and movement of the tissue anchor is observed using imaging, e.g., as described with reference toFIGS. 1A-B). For some applications, the testing pulling force is applied while measuring tension using an extracorporeal force detector such as detector472 (FIGS. 15A-C), mutatis mutandis.
• For some applications, the testing pulling force is applied by applying tension to the tether, and the tension is measured using intracorporeal springs and fluoroscopy, as described hereinabove, mutatis mutandis. It is to be noted that, for such applications, the same technique is used (1) to confirm that the anchored tissue anchor is capable of supporting the overload tension, and (2) to facilitate the application of the tension (e.g., the anchoring tension) that will be fixed when the locking member is locked to the tether.
• As described hereinabove, it may be desirable that, during operation of the valve, resistance to a force that pushes the valve body in an atrial direction (e.g., during ventricular systole) is optimally balanced between the various anchoring elements. For some applications, the following technique is used:
• (1) Anchor at least one tissue anchor coupled to a respective at least one tether (e.g., within guide members).
• (2) Advance a valve body that comprises at least one tissue-engaging element (e.g., a tissue-engaging leg) over at least part of the tether (e.g., by advancing over a guide member), such that a length of the tether is disposed between the valve body and the tissue anchor. Examples of such tissue-engaging elements are described with reference toFIGS. 19A-B and21A-B. The valve body may or may not be pre-coupled to an upstream support.
• (3) Apply a first tension to the tether (measured intracorporeally or extracorporeally).
• (4) Apply proximal pulling force to the valve body such that the tissue-engaging element applies force against tissue of the native valve, such as leaflets and/or annulus. This pulling typically automatically increases the tension on the tether.
• (5) While applying the proximal pulling force, intracorporeally and/or extracorporeally measure (a) force of tissue-engaging element against tissue, and (b) tension on the tether (e.g., the change in tension on the tether caused by the proximal pulling.
• (6) At least in part based on measurements (a) and (b) of step 5, adjust the length of the tether disposed between the valve body and the tissue anchor, and/or lock the valve body to the tether (i.e., fix the length of the tether disposed between the valve body and the tissue anchor).
• It is hypothesized that the above technique provides a prediction of the force distribution between the various anchoring elements that will exist during operation of the prosthetic valve assembly (e.g., during the lifetime thereof). For example, the technique provides a prediction of force distribution between the ventricular anchors and the valve-mounted tissue-engaging elements if/when atrially-directed force increases (e.g., as will be encountered during ventricular systole and/or increases in systemic blood pressure). Based on this indication, the technique facilitates adjustment of this distribution, via adjustment of the length of tethers disposed between the valve body and the tissue anchors.
• Reference is made toFIGS. 21A-B, which are schematic illustrations of aprosthetic valve assembly552, in accordance with some applications of the invention.Prosthetic valve assembly552 comprises (1) aprosthetic valve body554, which comprises a first frame556 (e.g., a wire frame), and is shaped to define a lumen therethrough, (2) an annularupstream support560, which comprises a second frame562 (e.g., a wire frame), is shaped to define an opening through the upstream support, and is configured to be placed against an upstream surface (e.g., an atrial surface) of native valve10 (e.g., of an annulus thereof), and (3) aflexible sheet564 that couples the first frame to the second frame.FIG. 21A shows assembly552 in an expanded state thereof (e.g., in the absence of external forces, such as if the assembly were resting on a table surface). In the expanded state of assembly552 (and thereby of body554),frame556 ofbody554 is generally cylindrical, and has a diameter d13. In the expanded state of assembly552 (and thereby of upstream support560),frame562 ofsupport560 is typically generally annular, and has anouter perimeter563 that has a diameter d14, which is greater than diameter d13.
• Assembly552 comprises one or more tissue-engaging elements580 (e.g., legs) that protrude radially outward fromvalve body554 so as to define a diameter d15, which is greater than diameter d13. Typically, and as shown inFIGS. 21A-B,frame556 ofbody554 is shaped to define tissue-engagingelements580.Assembly552 further comprises one or more tensioning elements (e.g., contraction wires) such as one ormore tethers582, a first portion (e.g., a distal end) of each tether being coupled tovalve body554, and a second portion of each tether being coupled (e.g., slidably coupled) to a portion ofassembly552 that is configured to be placed upstream ofvalve body554. For example, and as shown, the second portion of eachtether582 may be slidably coupled to an upstream region ofsheet564. Alternatively or additionally, the second portion of eachtether582 may be slidably coupled to frame562 ofsupport560. For some applications, this is facilitated byframe562 being shaped to define one or more respective protrusions that protrude radially inward from the annular shape of the frame, to the site at which eachtether582 is shown inFIG. 21A passing through the sheet.
• For some applications, except for (1) the presence of tissue-engagingelements580 andtethers582, and (2) the absence ofeyelets222,assembly552 is identical to (e.g., comprises the same components as, and/or has identical functionality to)assembly202, described hereinabove. Identically-named components ofsystem202 andsystem552 are typically identical in structure and/or function.
• For some applications,assembly202 comprises tissue-engagingelements580 and/or tethers582. For some applications,assembly552 compriseseyelets222 and/or lockingmembers262 for sliding over and locking to guide members.
• Bothsupport560 ofassembly552 andsupport210 ofassembly202 may be flat annular (e.g., as shown for support210) or frustoconical (as shown for support560).
• FIG. 21B shows assembly552 being implanted. Following transluminal delivery tonative heart valve10,valve body554 is typically deployed first (i.e., before support560), as shown in state A ofFIG. 21B. For some applications, valve body is deployed sufficiently far into the ventricle that tissue-engagingelements580 can expand freely without interfering withleaflets14 of the native valve, and valve assembly is subsequently moved atrially into the position shown in state A ofFIG. 21B.
• Subsequently,upstream support560 is deployed, e.g., by adelivery housing584 thereof being retracted (state B ofFIG. 21B).Support560 becomes placed against the upstream (e.g., atrial) surface ofnative valve10, such as against the annulus of the valve and/or against the upstream surface ofnative leaflets14. Typically, immediately subsequently to deployment ofbody554 andsupport560,assembly552 has a total height d16 from a proximal end ofsupport560 to a distal end of body554 (e.g., a height along an atrioventricular axis), and a distance d17 (e.g., a gap) measured along the height exists between a distal end offrame562 and a proximal-most part of frame554 (e.g., tissue-engagingelements580 defined by the frame).
• Subsequently, tethers582 are tensioned so as to drawsupport560 andbody554 closer to each other, thereby reducing the total height ofassembly552 to height d18, and reducing the distance between the distal end offrame562 and the proximal-most part offrame554 to a distance d19 (state C ofFIG. 21B). This movesbody554 and tissue-engagingelements580 closer toleaflets14, thereby sandwiching the leaflets between the tissue-engaging elements andsupport560, and thereby anchoringassembly552 at the native valve.Sheet564 maintains fluid communication (e.g., sealed fluid communication) throughassembly252, while also allowing the described contraction of the assembly. Typically, this characteristic is due tosheet564 having tensile strength, but not compressive strength, and therefore rumpling when tethers582 are tensioned.
• Tensioning oftethers582 may be accomplished by any suitable technique. For some applications, the tensioning is performed usingcontrol rods86 and lockingmembers110, e.g., as described with reference toFIGS. 1C-D, mutatis mutandis. For some applications, the tensioning is performed using reference-force tubes and locking members, e.g., as described with reference toFIGS. 7B-8H, mutatis mutandis. For some applications,support560 comprises a ratchet mechanism that facilitates the tensioning by allowing only one-way movement oftether582 through the support. For some applications,assembly552 comprises a spool mechanism for each tether, and tensioning is performed by rotating the spool mechanism.
• For some applications,assembly552 has a compressed state (e.g., for transluminal delivery) in which the assembly defines an articulation zone betweenframes556 and562, e.g., as described hereinabove forassembly202, mutatis mutandis.
• For some application, one or more of the techniques described hereinabove may be used to (1) control applied totethers582, and/or (2) facilitate intracorporeal measurement of tension on the tethers (and optionally fluoroscopic detection of that measurement). For example,assembly552 may comprise a tension spring midway along eachtether582, and/or may comprise a compression spring at the coupling point ofsupport560 and the tether (e.g., between the support and a lockingmember262 configured to lock a respective tether to the support). Alternatively or additionally, for applications in which the tensioning is performed using reference-force tubes and locking members (e.g., as described with reference toFIGS. 7B-8H),tool460 may be used, mutatis mutandis, to extracorporeally detect the tension applied totethers582.
• Reference is made toFIGS. 22A-B, which are schematic illustrations of aprosthetic valve assembly602, comprising aprosthetic valve603 having atubular valve body604 that comprises anupstream portion606, adownstream portion608, and anelastic portion610 disposed between the upstream portion and the downstream portion, in accordance with some applications of the invention. Prosthetic valve603 (e.g.,valve body604 thereof) is shaped to define a continuous lumen throughportions606,610, and608.Prosthetic valve603 is configured to be implanted atnative valve10 such thatupstream portion606 is disposed inatrium6 of the heart of the subject, and such thatdownstream portion608 is disposed inventricle8 of the heart of the subject. For example,prosthetic valve603 may be coupled to aprosthetic valve support612 that has been previously placed against (e.g., coupled to) to the native valve, and that defines an opening.Support612 may comprise (1) a support described elsewhere herein (e.g.,support42 described with reference toFIGS. 1A-F and19A-B, support310 described with reference toFIGS. 10A-B, and/or support350, described with reference toFIGS. 11A-B, and/or (2) a support described in U.S. Provisional Patent application 61/756,034 to HaCohen et al., from which the present application claims priority, and which is incorporated herein by reference.
• For some applications, and as shown inFIG. 22B,prosthetic valve support612 comprises one or more tissue-engagingelements618, an annularupstream support portion620, and a flexible stabilizingmember622, such as a stabilizing band, coupled to the tissue-engaging elements, and configured to form a ring that is shaped to define an opening therethrough. Tissue-engagingelements618 may comprise, as shown inFIGS. 22A-B, clips configured to be coupled toleaflets14 of the native valve.
• Tubular valve body604 typically comprises aframe614, such as a stent-like wire frame. As shown inFIG. 22A,prosthetic valve603 typically further comprises a covering616, disposed over (e.g., covering) an inner surface offrame614, thereby providing a sealed lumen from an upstream end to a downstream end of the tubular valve body. Typically, an excess of covering616 is provided in the vicinity ofelastic portion610, so as to facilitate elastic stretching of the elastic portion.
• Typically,prosthetic valve603 comprises an expandable prosthetic valve, and is deployed such that it (1) expands within the opening defined byupstream support portion620 and/or the opening defined by stabilizingmember622, (2) applies a radially-expansive force against the upstream support portion and/or the stabilizing member, and (3) thereby becomes coupled thereto. Typically, and as shown inFIG. 22B,downstream portion608 is expanded and coupled to stabilizingmember622 beforeupstream portion606 is expanded and coupled toupstream support portion620. Whiledownstream portion608 is coupled tomember622, and beforeupstream portion606 is coupled toportion620,elastic portion610 may be stretched and compressed e.g., such as by movingupstream portion606 further upstream and downstream. Such stretching and compressing changes a length ofprosthetic valve603, and for some applications, facilitates the coupling of a pre-determined portion of the prosthetic valve (e.g., of upstream portion606) toupstream support portion620, irrespective, to some degree, of (a) a distance between tissue-engagingelements618 andupstream support portion620, and/or (b) a dimension of native valve10 (e.g., a length of leaflets14). For some applications, such stretching and compressing adjusts a degree of tension ofelastic portion610, and may alternatively or additionally facilitate “tightening” ofleaflets14 against the implanted apparatus, such as drawing of the leaflets towardupstream support portion620.
• For some applications,prosthetic valve603 may be used in combination with other apparatus and techniques described herein. For example,valve body604 may be substituted for another valve body described herein, mutatis mutandis, including valve bodies that are described herein as being intracorporeally coupled to an upstream support, and valve bodies that are described herein as being provided pre-coupled to an upstream support (either directly, or via a flexible sheet).
• Reference is made toFIGS. 23-24, which are schematic illustrations of respective systems for facilitating anchoring of a tissue anchor in the heart of a subject, in accordance with some applications of the invention. Each system comprises a delivery tool that comprises (1) a steerable catheter configured to be transluminally advanced to the heart of the subject (e.g., via sheath46), and (2) an obstructing element disposed at a longitudinal site of the catheter, and configured to extend laterally (e.g., radially) outward from the catheter so as to inhibit movement of at least the longitudinal site of the catheter through the heart valve by abutting tissue of the heart valve.
• FIG. 23 shows asystem640, comprising a delivery tool642 that comprises acatheter644 and an obstructingelement646. Obstructingelement646 is typically collapsible for transluminal delivery (e.g., via sheath46), and expandable inatrium6 of the heart. For some applications,element646 is configured to expand automatically upon becoming exposed from the distal end ofsheath46. Obstructingelement646 is disposed at alongitudinal site648 ofcatheter644, and is dimensioned, when in the expanded state thereof, to not pass through native valve10 (i.e., betweenleaflets14 of the native valve). When adistal end645 of the catheter is extended throughnative valve10, obstructingelement646 abuts the atrial surface of the native valve (e.g., one or more leaflets, or the annulus), and thereby inhibits movement of at leastlongitudinal site648 of the catheter from passing through the valve. Therefore a known length d20 of catheter644 (i.e., the length betweenlongitudinal site648 and distal end645) is disposed downstream of the atrial surface ofvalve10.Distal end645 is thereby placeable against ventricular tissue at ventricular sites that are disposed at a distance from the atrial surface (e.g., from a portion of the atrial surface thatelement646 abuts) that is generally equal to d20. Adistal portion652 ofcatheter644, disposed distal tolongitudinal site648, is typically steerable, so as to facilitate placement ofdistal end645 against many (e.g., any) ventricular site that is disposed at that distance from the atrial surface.
• Atissue anchor48 is advanced throughcatheter644 using ananchor manipulator650, and anchored to tissue at the ventricular site at whichdistal end645 is disposed. Typically, little or none ofanchor48 ormanipulator650 becomes exposed fromdistal end645 during anchoring.
• FIG. 24 shows asystem660, comprising adelivery tool662 that comprises acatheter664 and an obstructingelement666. Obstructingelement666 is typically collapsible for transluminal delivery (e.g., via sheath46), and expandable inatrium6 of the heart, and may be identical to obstructingelement646, described hereinabove. For some applications,element666 is configured to expand automatically upon becoming exposed from the distal end ofsheath46. Obstructingelement666 is disposed at alongitudinal site668 ofcatheter664, and is dimensioned, when in the expanded state thereof, to not pass through native valve10 (i.e., betweenleaflets14 of the native valve). When adistal end665 of the catheter is extended throughnative valve10, obstructingelement666 abuts the atrial surface of the native valve (e.g., one or more leaflets, or the annulus), and thereby inhibits movement of at leastlongitudinal site668 of the catheter from passing through the valve. Therefore a known length d21 of catheter664 (i.e., the length betweenlongitudinal site668 and distal end665) is disposed downstream of the atrial surface ofvalve10.
• Length d21 ofsystem660 is typically shorter than length d20 ofsystem640, and in contrast tosystem640, forsystem660,catheter664 is not configured fordistal end665 to be placed against ventricular tissue. Rather, ananchor manipulator670 advancestissue anchor48 throughcatheter664, out of thedistal end665, and toward a ventricular site at which it anchors the tissue anchor. Typically,anchor manipulator670 is slidably coupled tocatheter664 such that a distal end of the anchor manipulator is slidable distally no more than a pre-determined distance d22 from longitudinal site668 (and thereby no more than a pre-determined distance fromdistal end665 of catheter664).Anchor manipulator670 is thereby used to anchoranchor48 at a ventricular site that is disposed at a distance from the atrial surface (e.g., from a portion of the atrial surface thatelement666 abuts) that is generally equal to d22. Typically, anchor manipulator670 (or at least adistal portion672 thereof that is exposable fromdistal end665 of catheter664) is steerable independently ofcatheter664.
• It is to be noted that, forsystems640 and660, the distance from the atrial surface at which anchor48 is anchored is generally equal, but not necessarily exactly equal, to d20 or d22. For example,anchor48 may be anchored at a site that is closer to another portion of the atrial surface than to the portion of the atrial surface that the obstructing element abuts. Alternatively or additionally, curvature of the catheter and/or the anchor manipulator may result in a direct distance between the atrial surface and the tissue anchor being smaller than d20 or d22.
• Typically,anchor48 is coupled to a tether, guide member, and/or other longitudinal member (e.g., as described hereinabove with reference to other systems). When the anchor driver is decoupled from the anchor and withdrawn proximally, the tether extends proximally from the anchor (e.g., out of the body of the subject) so that an implant, such as a prosthetic valve, prosthetic valve support, and/or a prosthetic valve assembly (e.g., those described hereinabove) may be advanced therealong and/or locked thereto, e.g., as described hereinabove for other systems, mutatis mutandis. Because the distance between the tissue anchor and the atrial surface is known, for some applications the tether coupled to the tissue anchor may comprise fewer locking sites for locking to the implant, a relatively shorter locking site, and/or only one locking site. It is hypothesized that this may provide the possibility of using simpler, smaller and/or more effective mechanisms to lock the implant to the tether.
• Reference is again made toFIGS. 7A-C,8A-H,9A-B,15A-C,16,17,18A-B, and21A-B. The flexible sheets described hereinabove typically have tensile strength but very low compressive strength along the longitudinal axis ofassembly202. Due to this characteristic, inter alia, implant-control rod246 is coupled (via mount248) toassembly202 by being coupled tovalve body204, such that when the valve body is pushed distally, the valve body pullsupstream support210 viasheet214. (It is hypothesized that it would be less effective for the implant-control rod to be coupled to the support, because in such acase sheet214 may rumple and the support may move toward the valve body, possibly reducing articulation at the articulation zone. Nevertheless, for applications in which such reduced articulation is in any case sufficient, the implant-control rod may be coupled to the support) This characteristic of the flexible sheet also facilitates the height-adjustment ofassembly552 and its sandwiching of the native leaflets by tensioningtethers582.
• Although each of the prosthetic valve assemblies is shown implanted in a generally symmetrical state, it is to be noted that for some applications this characteristic of the sheet facilitates asymmetrical implantation. For example, the assembly may better conform to the native anatomy, and/or one tether ofassembly552 may be tensioned more than another so as to alter the anchoring, sealing, and/or flow characteristics of the assembly, e.g., in response to the native anatomy.
• For some applications it may be advantageous for the valve body to be disposed at a particular rotational orientation withinventricle8, and for the upstream support to be disposed at a particular rotational orientation withinatrium6. For example, for prosthetic valve assemblies such asassembly202 that are tethered to ventricular anchors, it may be advantageous for each eyelet to be aligned with a respective anchor, and for the point at which each guide members passes through the upstream support to be aligned with a respective commissure. Alternatively or additionally, the upstream support may be geometrically asymmetric, and a particular rotational orientation with respect to atrial tissue may be advantageous. (Examples of such upstream supports are described in PCT patent application publication WO/2013/021374 to Gross et. al, which is incorporated herein by reference.) Alternatively or additionally, the upstream support may be asymmetric with respect to rigidity (i.e., some regions of the support may be more rigid than others). Alternatively or additionally, it may be advantageous to place the holes insheet214 through whichtubes260 pass in a particular rotational orientation with respect to the native valve.
• For some applications, the sheet facilitates implantation of the upstream support in a different rotational position to its valve body, e.g., by twisting. For example, the upstream support may be implanted at more than 5 degrees (e.g., more than 10 degrees, such as more than 20 degrees) rotational offset with respect to the valve body.
• Reference is again made toFIGS. 7A-14B,16-18B, and21A-B. For some applications the first frame of the valve body is coupled to the second frame of the upstream support by the sheet (e.g., generally only by the sheet) in the compressed state (e.g.,assemblies202,302,342 and552) and/or in the expanded state (e.g.,assemblies202 and552). As used in the present application, including in the claims, (a) the first and second frames being “coupled by the sheet”, and/or (b) the sheet “coupling the first frame to the second frame”, do not include applications in which the frames are primarily and/or independently coupled to each other by a different means, and the covering extends over both frames. For example, the first and second frames are not “coupled to each other by the sheet” (1) inassemblies382,402 and422, in which the frames are provided pre-coupled directly to each other, or (2) in the expanded state ofassemblies302 and342, in which the frames are intracorporeally coupled directly to each other.
• For applications in which the first frame of the valve body is coupled to the second frame of the upstream support by the sheet, a gap typically exists between the first frame and the second frame. For some such applications, no metallic structure is disposed within the gap.
• For some applications (including some applications in which the first and second frames are coupled independently of the sheet), the flexible sheet comprises, in addition to the sheet-like structure, one or more flexible longitudinal members, such as metallic or polymer wires (e.g., embedded within or attached to a surface of the sheet-like structure). These flexible longitudinal members may provide a small amount of rigidity to the sheet without detracting from the general nature of the sheet. For example, the flexible longitudinal members may facilitate opening of the sheet during deployment of the prosthetic valve assembly.
• It is to be noted that for applications in which the first and second frames are coupled by the sheet, even when the sheet comprises flexible longitudinal members that are metallic wires, the frame of the valve body and the frame of the upstream support are typically distinct from each other, and can be considered to be coupled to each other by the sheet (e.g., generally only by the sheet).
• For some applications, within the total height of the prosthetic valve assembly, a distance exists within which no rigid and/or metallic structure is disposed. For example, forassembly552, typically no rigid and/or metallic structure is disposed within distance d17 and/or distance d19. It is to be noted that a similar distance exists forassembly202 betweenframes210 and206 (e.g., when implanted; seeFIGS. 8F-G). For some applications, forassembly552,only sheet564 andtethers582 are disposed within distances d17 and d19. However, for some applications, tissue-engagingelements580 extend proximally towardframe562 such that the distance in which no rigid and/or metallic structure is disposed is reduced and/or absent (e.g., when tethers582 are tensioned).
• Reference is again made toFIGS. 1A-F,3A-C,6 and7A-8H. For some applications of the invention,tissue anchor48 and/or the guide member coupled thereto (e.g.,guide member56,guide member256, and/or the components thereof) are included as components of the provided apparatus. That is, they are typically provided with the prosthetic valve assembly. For some applications of the invention, the tissue anchor and/or the guide member coupled thereto are not included as components of the provided apparatus (e.g., they are obtained separately).
• It will be understood that, although the terms “first, “second,” etc. may be used in the present application (including the specification and the claims) to describe various elements and/or directions, these terms should not be limiting. These terms are only used to distinguish one element and/or direction from another. Thus, a “first” element described herein could also be termed a “second” element without departing from the teachings of the present disclosure.
• As used in the present application, including in the claims, a “central longitudinal axis” of a structure (e.g., an elongate structure) is the set of all centroids of transverse cross-sectional sections of the structure along the structure. Thus the cross-sectional sections are locally perpendicular to the central longitudinal axis, which runs along the structure. (If the structure is circular in cross-section, the centroids correspond with the centers of the circular cross-sectional sections.)
• It will be appreciated by persons skilled in the art that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof that are not in the prior art, which would occur to persons skilled in the art upon reading the foregoing description.

Claims (165)

1. Apparatus for use with a native valve of a heart of a subject, the apparatus comprising:

a valve body:

comprising (1) a first frame shaped to define a lumen therethrough, and (2) a valve member disposed within the lumen,

having a compressed state in which the first frame has a first diameter, and

having an expanded state in which the first frame has a second diameter that is greater than the first diameter;

an upstream support:

configured to be placed against an upstream surface of the native valve,

comprising a second frame,

having a compressed state, and

having an expanded state in which the second frame is annular, has an inner perimeter that defines an opening through the second frame, and has an outer perimeter; and

a flexible sheet that couples the upstream support to the valve body.

2. The apparatus according toclaim 1, wherein the upstream support is coupled to the valve body only via the sheet.

3. The apparatus according toclaim 1, wherein:

the valve body has an upstream end, a downstream end, and a longitudinal axis therebetween along which the lumen is defined, and

when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof:

the first frame is attached to the second frame at the inner perimeter of the second frame, and

the sheet is attached to the valve body and to the upstream support in a manner that defines a pocket region between the sheet and at least the inner perimeter of the second frame, the sheet not being attached to the first frame or the second frame in the pocket region.

4. The apparatus according toclaim 1, wherein the sheet provides fluid communication between the opening and the lumen.

5. The apparatus according toclaim 1, wherein the sheet is not attached to the inner perimeter of the second frame.

6. The apparatus according toclaim 1, wherein the sheet is not attached to an upstream end of the valve body.

7. The apparatus according toclaim 1, wherein the sheet is generally annular when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof.

8. The apparatus according toclaim 1, wherein the sheet is generally frustoconical when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof.

9. The apparatus according toclaim 1, wherein the sheet is attached to the inner perimeter of the second frame.

10. The apparatus according toclaim 1, wherein the sheet is circumferentially attached to the second frame at a radius that is greater than a radius of the inner perimeter.

11. The apparatus according toclaim 1, wherein the sheet is circumferentially attached to the second frame at the outer perimeter of the second frame.

12. The apparatus according toclaim 1, wherein the sheet is attached to an upstream end of the valve body.

13. The apparatus according toclaim 1, wherein the first frame is generally cylindrical in both the compressed state thereof and the expanded state thereof.

14. The apparatus according toclaim 1, wherein the second frame is generally cylindrical in the compressed state thereof.

15. The apparatus according to any one ofclaims 1-14, wherein the valve body comprises at least one downstream anchor, configured such that, in the expanded configuration of the valve body, the anchor protrudes radially outward from the first frame.

16. The apparatus according toclaim 15, further comprising at least one tensioning element, coupled to the valve body and to the upstream support, a length of the tensioning element between the valve body and the upstream portion being adjustable such that a distance between the first frame and the second frame is adjustable.

17. The apparatus according toclaim 16, wherein the at least one tensioning element comprises a tether.

18. The apparatus according toclaim 16, wherein the at least one tensioning element is coupled to the first frame, and slidably coupled to the second frame.

19. The apparatus according to any one ofclaims 1-14, wherein the valve body, the upstream support and the sheet together define a prosthetic valve assembly, the prosthetic valve assembly:

having an expanded state in which the valve body is in the expanded state thereof and the second frame of the upstream support is in the expanded state thereof,

having a compressed state in which:

the prosthetic valve assembly has a longitudinal axis,

the valve body is in the compressed state thereof at a first zone of the longitudinal axis,

the upstream support is in the compressed state thereof at a second zone of the longitudinal axis, and

the prosthetic valve assembly defines an articulation zone, between the first zone and the second zone, in which at least part of the sheet is disposed, in which neither the first frame nor the second frame is disposed, and about which the valve body and the upstream support are articulatable with respect to each other.

20. The apparatus according toclaim 19, further comprising a delivery tool:

comprising a first housing configured to house and maintain at least part of the upstream support in the compressed state thereof, and defining a first housing orifice through which the at least part of the upstream support is removable from the first housing,

comprising a second housing configured to house and maintain at least part of the valve body in the compressed state thereof, and defining a second housing orifice through which the at least part of the valve body is removable from the second housing,

having a contracted state in which the second housing is disposed at a first distance from the first housing, and in which the delivery tool is configured to transluminally advance the prosthetic valve assembly in the compressed state thereof, to the native valve, and

having an extended state in which the second housing is disposed at a second distance from the first housing, the second distance being greater than the first distance, wherein the apparatus is configured such that, when the at least part of the upstream support is housed by the first housing and the at least part of the valve body is housed by the second housing, transitioning of the delivery tool from the contracted state into the extended state exposes at least part of at least one component selected from the group consisting of: the valve body and the upstream support, from the housing that houses the selected component.

21. The apparatus according toclaim 20, wherein:

the apparatus is configured to be used with at least two guide members,

the prosthetic valve assembly comprises at least two eyelets, each eyelet being slidable over a respective one of the guide members, and

the apparatus is configured such that the eyelets of the prosthetic valve assembly protrude radially outward and radially beyond an outer surface of the second housing while: (1) the at least part of the valve body, in the compressed state thereof, is housed by the second housing, and (2) the at least part of the upstream support, in the compressed state thereof, is housed by the first housing.

22. The apparatus according toclaim 21, wherein the eyelets are pivotably coupled to the valve body.

23. The apparatus according toclaim 21, wherein the delivery tool further comprises at least two reference-force tubes, each reference-force tube configured (1) to be slidable over a respective one of the guide members, and (2) to apply a distally-directed force to the prosthetic valve assembly.

24. The apparatus according toclaim 23, wherein, in the compressed state of the prosthetic valve assembly, each reference-force tube extends distally (1) through a lumen defined by the second frame of the upstream support, (2) through the sheet, and (3) along an outside of at least part of the valve body.

25. The apparatus according toclaim 21, further comprising at least two locking members, each locking member:

having an unlocked state in which the locking member is slidable along a respective one of the guide members,

being transitionable into a locked state in which (1) the locking member is locked to the respective one of the guide members, and (2) the sliding of the eyelet over the guide member is inhibited.

26. The apparatus according toclaim 25, further comprising the at least two guide members, wherein:

each guide member comprises:

a tubular member, shaped to define a lumen therethrough,

a tether, coupled at a distal end thereof to a tissue anchor configured to be anchored to ventricular tissue of the heart, at least a proximal portion of the tether being disposed within the lumen of the tubular member, and

a pull-wire, coupled at a distal portion thereof to the proximal portion of the tether, at least the distal portion of the pull-wire being disposed within the lumen of the tubular member,

the tubular member inhibits decoupling of the pull-wire from the tether while the distal portion of the pull-wire and the proximal portion of the tether are disposed within the lumen of the tubular member, and

while the tubular member of each guide member is disposed within the respective locking member, the tubular member inhibits transitioning of the locking member into the locked state.

27. The apparatus according toclaim 26, wherein the apparatus is configured such that, for each respective guide member and locking member, while (1) the tubular member is disposed within the locking member, (2) the distal portion of the pull-wire and the proximal portion of the tether are disposed within the lumen of the tubular member, and (3) the tissue anchor is coupled to the ventricular tissue:

proximal sliding of the tubular member with respect to the tether facilitates automatic transitioning of the locking member into the locked state, and

further proximal sliding of the tubular member with respect to the tether facilitates decoupling of the pull-wire from the tether.

28. The apparatus according toclaim 21, wherein at least one housing selected from the group consisting of: the first housing and the second housing has a lateral wall that is shaped to define at least two slits, the eyelets being configured to protrude radially outward from the delivery tool via the slits.

29. The apparatus according toclaim 28, wherein each slit of the at least one selected housing is continuous with the orifice of the at least one selected housing.

30. The apparatus according toclaim 21, wherein the eyelets are coupled to and protrude radially outward from the valve body.

31. The apparatus according toclaim 30, wherein the eyelets are pivotably coupled to the valve body.

32. The apparatus according toclaim 20, wherein:

the articulation zone defined by the prosthetic valve assembly comprises a first articulation zone, and

while (1) the at least part of the valve body, in the compressed state thereof, is housed by the second housing, (2) the at least part of the upstream support, in the compressed state thereof, is housed by the first housing, and (3) the delivery tool is in the contracted state thereof, the apparatus defines a second articulation zone at a longitudinal zone of the apparatus (a) between the second housing and the first housing, and (b) in which is disposed at least part of the first articulation zone.

33. The apparatus according toclaim 32, wherein the delivery tool further comprises a housing-control rod that extends through the first housing and is coupled to the second housing such that a first portion of the housing-control rod is disposed within the first housing, a second portion of the housing-control rod is disposed within the second housing, and a third portion of the housing-control rod (1) is disposed within the second articulation zone, and (2) is more flexible than at least one portion of the housing-control rod selected from the group consisting of: the first portion and the second portion.

34. The apparatus according toclaim 32, wherein:

the delivery tool further comprises (1) a control rod assembly comprising at least a first housing-control rod coupled to the first housing, and (2) a second housing-control rod, more flexible than the first housing-control rod, extending through the first housing-control rod, extending through the second articulation zone, and coupled to the second housing.

35. The apparatus according toclaim 20, wherein the second housing orifice faces the first housing orifice.

36. The apparatus according toclaim 20, wherein:

the delivery tool further comprises a flexible control rod assembly comprising (1) a first housing-control rod coupled to the first housing, (2) a second housing-control rod coupled to the second housing, and (3) a prosthesis-control rod reversibly couplable to the prosthetic valve assembly,

longitudinal movement of the second housing-control rod with respect to the first housing-control rod transitions the delivery tool between the contracted state and the extended state thereof, and

the valve body is removable from the second housing by moving the second housing-control rod with respect to the prosthesis-control rod.

37. The apparatus according toclaim 36, wherein the prosthesis-control rod is reversibly couplable to the prosthetic valve assembly by being reversibly couplable to the valve body.

38. The apparatus according toclaim 36, wherein at least part of the second housing-control rod is disposed within and slidable through the prosthesis-control rod, and at least part of the prosthesis-control rod is disposed within and slidable through the first housing-control rod.

39. The apparatus according to any one ofclaims 1-14, wherein the outer perimeter of the second frame has a third diameter that is greater than the second diameter.

40. The apparatus according toclaim 39, wherein the inner perimeter has a fourth diameter that is greater than the second diameter.

41. The apparatus according to any one ofclaims 1-14, wherein, when the valve body is in the expanded state thereof and the upstream support is in the expanded state thereof, a gap is defined between the first frame and the second frame, the sheet spanning the gap.

42. The apparatus according toclaim 41, wherein no metallic structure is disposed within the gap.

43. The apparatus according to any one ofclaims 1-14, wherein the sheet is configured to inhibit expansion of the second frame.

44. The apparatus according toclaim 43, wherein the apparatus is configured such that when the second frame expands from the compressed state thereof toward the expanded state thereof, the sheet retains the second frame in a generally frustoconical shape by inhibiting expansion of at least the outer perimeter of the second frame.

45. The apparatus according to any one ofclaims 1-14, wherein the sheet extends over at least part of the second frame to serve as a covering of the upstream support.

46. The apparatus according toclaim 45, wherein the covering defines a tissue-contacting surface of the upstream support.

47. The apparatus according to any one ofclaims 1-14, wherein the sheet extends over at least part of the first frame to serve as a covering of the valve body.

48. The apparatus according toclaim 47, wherein the covering is disposed on an inner surface of the first frame.

49. Apparatus for use with a native valve of a heart of a subject, the apparatus comprising:

a prosthetic valve, configured to be percutaneously delivered to the native valve;

an annular upstream support, configured to be placed against an upstream surface of the native valve, and to support the prosthetic valve at the native valve;

a tissue anchor, comprising a tissue-engaging element configured to be anchored to ventricular muscle tissue of the heart;

a tether, coupled to the tissue anchor; and

a spring, couplable to the tether so as to elastically couple the tissue-engaging element to the prosthetic valve.

50. The apparatus according toclaim 49, wherein the spring is shaped to define a repeating pattern.

51. The apparatus according toclaim 49, wherein the spring is pre-loaded.

52. The apparatus according toclaim 49, wherein the spring is a constant-force spring.

53. The apparatus according to any one ofclaims 49-52, wherein the spring is configured to facilitate extracorporeal fluoroscopic observation of a state of the spring.

54. The apparatus according toclaim 53, wherein the spring is coupled to a plurality of radiopaque markers such that a juxtaposition of the markers changes as the state of the spring changes, the juxtaposition of the markers being extracorporeally fluoroscopically observable.

55. The apparatus according toclaim 53, wherein the spring is coupled to at least one radiopaque marker, and the apparatus further comprises an intracorporeal reference, a juxtaposition between the radiopaque marker and the intracorporeal reference being extracorporeally fluoroscopically observable.

56. The apparatus according toclaim 55, wherein the intracorporeal reference comprises a scale comprising a plurality of radiopaque markers.

57. The apparatus according toclaim 56, wherein the plurality of radiopaque markers comprises a first plurality of radiopaque markers, and the at least one radiopaque marker comprises a second plurality of radiopaque markers.

58. The apparatus according toclaim 53, wherein the spring is configured to provide distinct indication that is observable using fluoroscopy, when the spring is experiencing a force that is within a margin force from a target force.

59. The apparatus according toclaim 58, wherein the spring is configured to provide the distinct indication when the spring experiences a force that is above 300 g force.

60. The apparatus according toclaim 59, wherein the spring is configured to provide the distinct indication when the spring experiences a force that is above 400 g force.

61. The apparatus according toclaim 60, wherein the spring is configured to provide the distinct indication when the spring experiences a force that is about 500 g force.

62. The apparatus according to any one ofclaims 49-52, wherein the spring is coupled to the prosthetic valve, and is intracorporeally lockable to the tether subsequently to anchoring of the tissue anchor to the ventricular muscle tissue.

63. The apparatus according toclaim 62, wherein the spring is slidable along at least part of the tether, and is intracorporeally couplable to the tether by inhibiting the sliding.

64. The apparatus according toclaim 62, wherein the prosthetic valve comprises a generally cylindrical valve body having an upstream end, and the spring comprises an elastically-deformable appendage that protrudes laterally from the valve body.

65. The apparatus according toclaim 62, wherein:

the prosthetic valve comprises a generally cylindrical valve body having an upstream end, a downstream end, and a longitudinal lumen therebetween, and

the spring (1) comprises a compression spring having a longitudinal axis, and (2) is disposed laterally from, the valve body such that the longitudinal axis of the spring is generally parallel with the longitudinal lumen.

66. The apparatus according to any one ofclaims 49-52, wherein the prosthetic valve comprises:

a generally cylindrical valve body having an upstream end, a downstream end, and a longitudinal lumen therebetween; and

one or more tissue-engaging legs, protruding laterally outward from the valve body, and configured to be placed against a ventricular surface of the native valve.

67. The apparatus according toclaim 66, wherein the prosthetic valve is couplable to the upstream support intracorporeally by being expanded within an opening defined by the upstream support while the upstream support is disposed against the upstream surface.

68. The apparatus according toclaim 67, wherein the apparatus is configured such that the coupling of the prosthetic valve to the upstream support couples the tether to the prosthetic valve.

69. The apparatus according toclaim 67, wherein the apparatus is configured to sandwich a portion of the native valve between the tissue-engaging legs and the upstream support by providing a space having a height between the tissue-engaging legs and the upstream support.

70. The apparatus according toclaim 69, wherein the apparatus is configured to facilitate altering the height without altering a force on the spring.

71. The apparatus according toclaim 69, wherein the apparatus is configured such that altering the height automatically alters a force on the spring.

72. The apparatus according toclaim 69, wherein the apparatus is configured to facilitate altering the height by moving the valve body through the opening defined by the upstream support.

73. Apparatus for use with a native heart valve of a subject, the apparatus comprising:

a valve body:

having an upstream end, a downstream end, and a longitudinal axis therebetween,

comprising a lateral wall that circumscribes the longitudinal axis and defines a longitudinal lumen, and

comprising a valve member disposed within the lumen;

an upstream support having an inner perimeter couplable to the valve body at a first longitudinal position of the valve body, the upstream support being configured to extend radially outward from the valve body and the inner perimeter; and

a flexible sheet defining a first aperture, a second aperture and a lateral wall therebetween, a first portion of the sheet that defines the first aperture being circumferentially attached to the upstream support portion at a radius that is greater than a radius of the inner perimeter, and a second portion of the sheet that defines the second aperture being circumferentially attached to the valve body at a second longitudinal position of the valve body, such that a pocket region is defined between the sheet and at least the first longitudinal position.

74. The apparatus according toclaim 73, wherein the second longitudinal position is closer to the downstream end of the valve body than is the first longitudinal position.

75. The apparatus according toclaim 73, wherein the first aperture is larger than the second aperture.

76. The apparatus according toclaim 73, wherein the sheet is attached to the upstream support at an outer perimeter of the upstream support.

77. The apparatus according toclaim 73, wherein the sheet assumes a frustoconical shape.

78. The apparatus according toclaim 73, wherein the sheet assumes a funnel shape.

79. The apparatus according toclaim 73, wherein the apparatus is provided with the inner perimeter of the upstream support pre-coupled to the valve body at the first longitudinal position of the valve body.

80. The apparatus according to any one ofclaims 73-79, wherein the apparatus is configured such that the inner perimeter of the upstream support is intracorporeally couplable to the valve body at the first longitudinal position of the valve body.

81. Apparatus for use with a native heart valve disposed between an atrium and a ventricle of a heart of a subject, the apparatus comprising:

an annular upstream support defining an opening therethrough, and configured to be placed against an upstream surface of the native heart valve;

a tubular valve body having an upstream end, a downstream end and a lumen therebetween, the lumen having a first diameter, and the valve body being separated from the upstream element by a gap between the upstream end of the valve body and the upstream element;

one or more tissue-engaging elements that protrude radially outward from the valve body so as to define a second diameter that is greater than the first diameter; and

a flexible sheet shaped to define a conduit, a downstream portion of the sheet being coupled to the valve body, an upstream portion of the sheet being coupled to the upstream element, and the sheet spanning the gap.

82. The apparatus according toclaim 81, further comprising at least one tether, a first portion of the tether being coupled to the valve body and a second portion of the tether being coupled to the upstream support, such that tensioning of at least a portion of the tether reduces the gap.

83. The apparatus according toclaim 82, wherein the apparatus is configured such that tensioning of at least the portion of the tether rumples the sheet.

84. Apparatus for use with a native heart valve disposed between an atrium and a ventricle of a heart of a subject, the apparatus comprising:

an annular upstream element defining an opening therethrough, and configured to be placed against an upstream surface of the native heart valve;

a flexible sheet, shaped to define a conduit, and coupled to the upstream element such that the conduit is in fluid communication with the opening; and

a valve body, coupled to the flexible sheet such that the conduit provides fluid communication between the prosthetic valve and the upstream element.

85. The apparatus according toclaim 84, wherein the valve body comprises:

a generally cylindrical frame shaped to define a lumen therethrough, and

a valve member coupled to the frame and disposed within the lumen.

86. The apparatus according to any one ofclaims 84-85, wherein the frame is separated from the upstream element by a gap, and the conduit spans the gap.

87. Apparatus, for use with a guide member that extends into a subject, the apparatus comprising:

a delivery tool, comprising a housing, the housing:

being transluminally advanceable into the subject,

shaped to define an orifice at an end of the housing, and

having a lateral wall shaped to define a slit that is continuous with the orifice;

an implant:

configured to be housed by the housing, and

comprising an eyelet that (1) is slidable over the guide member, and (2) when the implant is housed by the housing, extends through the slit and radially beyond the lateral wall such that the eyelet facilitates transluminal sliding of the implant and the housing along the guide member and into the subject,

the apparatus being configured such that, while (1) the implant remains within the subject, and (2) the guide member remains disposed through the eyelet, (1) the implant is removable from the housing via the orifice, and (2) the housing is removable from the subject.

88. The apparatus according toclaim 87, wherein the implant is configured to be implanted by being intracorporeally locked to the guide member.

89. The apparatus according to any one ofclaims 87-88, wherein the implant has a compressed state and an expanded state, is configured to be housed by the housing while in the compressed state, and is configured to automatically expand toward the expanded state when removed from the housing.

90. A method for use with a native valve of a heart of a subject, the method comprising:

transluminally anchoring a tissue anchor to ventricular tissue of a subject using an anchor-manipulation tool, the tissue anchor being coupled to a first portion of a tether;

transluminally delivering an annular upstream support and a prosthetic valve to the heart, the prosthetic valve including (1) a valve body shaped to define a lumen therethrough, and (2) one or more tissue-engaging legs configured to protrude laterally outward from the valve body;

pressing the tissue-engaging legs in an upstream direction against a ventricular surface of the native valve by applying a force to the prosthetic valve while measuring the force;

applying, to the tether, a tension that changes a shape of a spring coupled to the tether, while observing the shape of the spring using imaging; and

at least in part responsively to the observed shape of the spring, facilitating holding of the upstream support against an upstream surface of the native valve by locking a second portion of the tether to at least one component selected from the group consisting of: the prosthetic valve and the upstream support.

91. The method according toclaim 90, wherein measuring the force comprises measuring the force using an extracorporeal force meter.

92. The method according toclaim 90, wherein measuring the force comprises observing a shape of the tissue-engaging legs using imaging.

93. The method according toclaim 90, wherein applying the tension comprises applying the tension while applying the force.

94. The method according toclaim 90, wherein locking the second portion to the selected component comprises locking the second portion to the prosthetic valve.

95. The method according toclaim 90, wherein locking the second portion to the selected component comprises locking the second portion to the upstream support.

96. The method according toclaim 90, wherein locking the second portion comprises locking the second portion when the observed shape indicates that the spring is experiencing between 400 g force and 600 g force.

97. The method according toclaim 90, wherein locking the second portion comprises locking the second portion subsequently to applying the tension, and applying the force comprises applying the force subsequently to locking the second portion.

98. The method according to any one ofclaims 90-97, wherein:

anchoring the tissue anchor coupled to the tether comprises anchoring a first tissue anchor coupled to a first tether, and applying the tension comprises applying a first tension that changes a shape of a first spring coupled to the first tether,

the method further comprises:

anchoring a second tissue anchor to the ventricular tissue, the second tissue anchor being coupled to a first portion of a second tether; and

applying, to the second tether, a second tension that changes a shape of a second spring coupled to the second tether, while observing the shape of the second spring using imaging, and

facilitating holding of the prosthetic valve against the upstream surface comprises, at least in part responsively to the observed shape of the second spring, facilitating holding of the prosthetic valve against the upstream surface by locking a second portion of the second tether to the selected at least one component.

99. The method according toclaim 98, wherein facilitating holding comprises locking the second portion of the first tether and the second portion of the second tether to the selected at least one component, at least in part responsively to a ratio between tension in the first tether and tension in the second tether, the ratio being derived from the observed shape of the first spring and the observed shape of the second spring.

100. The method according to any one ofclaims 90-97, wherein locking comprises locking the second portion to the at least one component at least in part responsively to the observed shape.

101. The method according toclaim 100, wherein locking comprises locking the second portion to the at least one component at least in part responsively to the measured force.

102. The method according to any one ofclaims 90-97, wherein applying the force comprises moving the valve body in an upstream direction through an opening defined by the upstream support, and the method further comprises coupling the prosthetic valve to the upstream support by expanding the valve body within the opening.

103. The method according toclaim 102, wherein coupling the prosthetic valve to the upstream support comprises coupling the prosthetic valve to the upstream support at least in part responsively to the measured force.

104. A method, comprising:

transluminally advancing a plurality of tissue anchors, coupled to a respective plurality of springs, into a body of a subject;

anchoring the plurality of tissue anchors to tissue of the subject;

tensioning at least one of the springs;

using imaging, while the tension is applied to the at least one spring, observing a state of the at least one spring; and

at least in part responsively to the observed state of at least one spring, adjusting a tension on at least one of the springs.

105. A method, for use with a native valve of a heart of a subject, the method comprising:

applying a first tension to a tether that couples (a) a tissue anchor anchored to ventricular tissue of a subject, to (b) a prosthetic valve body, the tether having a length between the tissue anchor and the valve body;

by applying an atrially-directed force to the prosthetic valve body, pressing, against tissue of the native valve, a tissue-engaging element that protrudes radially from the valve body

transluminally advancing a prosthetic valve body to a native valve of the subject;

while applying the atrially-directed force, measuring:

a pressing force of the tissue-engaging element against the tissue of the native valve, and

a second tension on the tether, the second tension differing from the first tension at least in part due to the atrially-directed force; and

at least in part responsively to the measured pressing force and the measured second tension, performing an action selected from the group consisting of: adjusting the length of the tether between the tissue anchor and the valve body, and locking the valve body to the tether.

106. A method for use with a native valve of a heart of a subject, the method comprising:

transluminally delivering a tissue anchor to a ventricle of the heart, and anchoring the tissue anchor to ventricular muscle tissue of the subject;

transluminally delivering an upstream support to an atrium of the heart, and placing the upstream support against an upstream surface of an annulus of the native valve; and

changing a shape of the upstream support by tensioning a tether coupled to upstream support and to the tissue anchor; and

extracorporeally fluoroscopically observing the shape change of the upstream support.

107. The method according toclaim 106, wherein tensioning the tether coupled to the upstream support comprises tensioning a tether that is coupled to a valve body coupled to the upstream support.

108. The method according toclaim 106, wherein, before the tensioning, the upstream support is generally flat annular, and changing the shape comprises making the support assume a frustoconical shape.

109. The method according to any one ofclaims 106-108, wherein, before the tensioning, the upstream support is frustoconical, and changing the shape comprises changing a slant of the frustoconical shape.

110. Apparatus for use with a valve of a heart of a subject, the apparatus comprising:

a transluminally-deliverable tissue anchor;

a tether, a first end thereof coupled to the tissue anchor; and

a delivery tool, comprising:

a steerable catheter having a longitudinal axis, and being transluminally deliverable to the valve, and

an obstructing element:

disposed at a longitudinal site of the catheter,

configured to extend laterally outward from the catheter, and

dimensioned, when extending laterally outward from the catheter, to inhibit movement of at least the longitudinal site through the valve by abutting tissue of the valve, and

an anchor manipulator:

reversibly couplable to the tissue anchor,

slidable through the catheter, and

configured to drive the anchor into ventricular tissue of the heart of the subject.

111. The apparatus according toclaim 110, wherein the anchor manipulator is slidably coupled to the catheter such that a distal end of the anchor manipulator is slidable distally no more than a pre-determined distance from the longitudinal site.

112. The apparatus according to any one ofclaims 110-111, further comprising an implant, intracorporeally lockable to the tether.

113. The apparatus according toclaim 112, further comprising a guide member, reversibly couplable to the tether, wherein the implant is intracorporeally slidable along the guide member toward the tether and the implant.

114. The apparatus according toclaim 112, wherein the tether has exactly one locking site at which the implant is lockable to the tether.

115. The apparatus according toclaim 114, wherein the exactly one locking site is disposed at a pre-determined distance from the anchor that is pre-determined at least in part dependently on a distance between the longitudinal site and a distal end of the catheter.

116. A method, comprising:

transluminally anchoring a tissue anchor to tissue of a subject using an anchor-manipulation tool;

subsequently applying to the anchor a pulling force having a given magnitude;

using imaging, observing a movement of the tissue anchor in response to the pulling force; and

at least in part responsively to the observed movement, performing an action selected from the group consisting of: de-anchoring the tissue anchor from the tissue, and decoupling the anchor-manipulation tool from the tissue anchor.

117. Apparatus, for implantation at a native valve of a heart of a subject, the native valve being disposed between an atrium and a ventricle of the heart, the apparatus comprising:

a tubular valve body:

having an upstream portion, configured to be disposed in the atrium of the heart of the subject,

having a downstream portion, configured to be disposed in the ventricle of the subject,

having an elastic portion, disposed between the upstream portion and the downstream portion, and elastically coupling the upstream portion to the downstream portion, and

shaped to define a continuous lumen through the upstream portion, the elastic portion, and the downstream portion; and

at least one valve member, disposed in the lumen of the valve body, and configured to facilitate flow of blood of the subject from the upstream portion of the valve body to the downstream portion of the valve body, and to inhibit flow of the blood from the downstream portion of the valve body to the upstream portion of the valve body.

118. The apparatus according toclaim 117, wherein the at least one valve member is coupled to the downstream portion of the valve body.

119. The apparatus according toclaim 117, wherein the native valve includes a plurality of native leaflets, and wherein the downstream portion of the valve body is configured to be coupled to the native leaflets.

120. The apparatus according toclaim 119, further comprising a plurality of clips, configured to facilitate the coupling of the downstream portion of the valve body to the native leaflets.

121. The apparatus according toclaim 120, wherein each clip:

comprises at least two clip arms, articulatably coupled to each other, and

is reversibly closeable.

122. The apparatus according toclaim 120, wherein the clips are coupled to the downstream portion of the valve body, and wherein the downstream portion of the valve body is configured to be coupled to the native leaflets by the clips being coupled to the native leaflets.

123. The apparatus according toclaim 120, wherein each clip of the plurality of clips is articulatably coupled to the downstream portion of the valve body.

124. The apparatus according toclaim 120, the native valve including an annulus having an upstream surface, wherein the apparatus further comprises a prosthetic valve support:

comprising (1) an upstream support portion, configured to be placed against the upstream surface of the annulus of the native valve, and (2) the plurality of clips, coupled to the upstream support portion,

shaped to define an opening therethrough that is configured to receive the prosthetic valve,

wherein the clips are configured to facilitate the coupling of the downstream portion of the valve body to the native leaflets by coupling the prosthetic valve support to the native leaflets.

125. Apparatus for use with a native valve of a heart of a subject, the native valve having a plurality of leaflets that meet at a plurality of commissures, the apparatus comprising:

at least one tissue anchor, configured to be anchored to a first site within a ventricle of the heart of the subject;

at least one longitudinal member, coupled at a distal end thereof to a respective one of the at least one tissue anchors;

an upstream support, comprising an upstream support portion configured to be slidable over the longitudinal member and placed against an upstream surface of the native valve; and

at least one locking member, configured to be slidable over a respective one of the at least one longitudinal members, and to be lockable to the respective longitudinal member such that a portion of the respective longitudinal member that is disposed between the respective anchor and the upstream support portion is longer than 1 cm.

126. The apparatus according toclaim 125, wherein the longitudinal member is flexible.

127. The apparatus according to any one ofclaims 125-126, wherein the longitudinal member comprises a suture.

128. A method for use with a native valve of a heart of a subject, the native valve having a plurality of leaflets that meet at a first commissure and at a second commissure, the method comprising:

anchoring a first tissue anchor to a first site within a ventricle of the heart of the subject, the first tissue anchor being coupled to a distal end of a first longitudinal member;

anchoring a second tissue anchor to a second site within the ventricle of the heart of the subject, the second tissue anchor being coupled to a distal end of a second longitudinal member;

subsequently, placing at least an upstream support portion of a prosthetic valve support against an upstream surface of the native valve, the valve being disposed between the ventricle and an atrium of the heart of the subject; and

securing the upstream support portion against the upstream surface of the valve by:

coupling the upstream support portion to the first longitudinal member such that at least part of a portion of the first longitudinal member that is disposed between the upstream support portion and the first tissue anchor, is disposed between the first and second leaflets at the first commissure, and

coupling the upstream support portion to the second longitudinal member such that at least part of a portion of the second longitudinal member that is disposed between the upstream support portion and the first tissue anchor, is disposed between the first and second leaflets at the second commissure.

129. The method according toclaim 128, wherein anchoring, placing, and securing comprise anchoring, securing, and placing without the use of cardiopulmonary bypass.

130. The method according toclaim 128, wherein anchoring to the first site and anchoring to the second site comprise anchoring to myocardium.

131. The method according toclaim 128, wherein placing the upstream support portion against the upstream surface comprises sliding the upstream support portion over at least part of the first longitudinal member.

132. The method according toclaim 128, wherein coupling the upstream support portion to the first longitudinal member and to the second longitudinal member comprises coupling the upstream support portion to the first longitudinal member in the atrium of the heart of the subject, and coupling the upstream support portion to the second longitudinal member comprises coupling the upstream support portion to the second longitudinal member in the atrium of the heart of the subject.

133. The method according toclaim 128, wherein the leaflets move in response to beating of the heart of the subject, and wherein securing the upstream support portion comprises securing the upstream support portion without eliminating the movement of the native leaflets.

134. The method according toclaim 128, wherein coupling the upstream support portion to the first longitudinal member comprises coupling the upstream support portion to the first longitudinal member such that a length of the portion of the first longitudinal member is greater than 1 cm.

135. The method according to any one ofclaims 128-134, further comprising:

transluminally advancing at least the first tissue anchor to the first site while the respective longitudinal member coupled thereto is disposed within a respective tubular member; and

subsequently to anchoring the at least first tissue anchor, and before coupling the upstream support portion to the respective longitudinal member, sliding the at least first tubular member off of at least part of the respective longitudinal member.

136. The method according toclaim 135, wherein sliding the at least first tubular member comprises sliding at least part of the at least first tubular member through a channel defined by a locking member, and wherein coupling the upstream support portion to the respective longitudinal member comprises locking the locking member to the respective longitudinal member by narrowing at least a portion of the channel.

137. The method according to any one ofclaims 128-134, wherein:

advancing the at least first tissue anchor comprises advancing the at least first tissue anchor while (1) the respective longitudinal member is reversibly coupled to a portion of a wire, and (2) the respective tubular member inhibits the portion of the wire from decoupling from the portion of the wire, and

the method further comprises facilitating decoupling of the wire from the respective longitudinal member by sliding the at least first tubular member off of the portion of the wire.

138. The method according toclaim 137, wherein:

advancing the at least first tissue anchor comprises advancing the at least first tissue anchor while (1) the respective longitudinal member is shaped to define a loop, and is coupled to the portion of the wire by the portion of the wire being threaded through the loop, and (2) the respective tubular member inhibits the portion of the wire from unthreading from the loop, and

facilitating decoupling of the wire from the respective longitudinal member comprises facilitating unthreading of the wire from the loop by sliding the at least first tubular member off of the portion of the wire.

139. The method according toclaim 138, wherein sliding the at least first tubular member off of the portion of the wire comprises sliding the at least first tubular member off of the portion of the wire by applying less than 500 g of pulling force to the at least first tubular member.

140. The method according toclaim 139, wherein applying less than 500 g of pulling force to the at least first tubular member comprises applying less than 300 g of pulling force to the at least first tubular member.

141. The method according to any one ofclaims 128-134, further comprising, subsequently to securing the upstream support portion, coupling a prosthetic valve to the prosthetic valve support.

142. The method according toclaim 141, wherein the upstream support portion has an inner edge that defines an opening through the upstream support portion, and wherein coupling the prosthetic valve to the prosthetic valve support comprises placing at least a portion of the prosthetic valve within the opening, and expanding at least the portion of the prosthetic valve such that at least the portion of the prosthetic valve applies a radially-expansive force against the inner edge of the upstream support portion.

143. The method according toclaim 141, wherein the prosthetic valve includes one or more tissue-engaging elements, each of the one or more tissue-engaging elements including at least two arms, and wherein the method further comprises, subsequent to securing the upstream support portion, coupling the prosthetic valve to at least one of the leaflets by sandwiching the at least one of the leaflets between the at least clip arms of the one or more tissue-engaging elements.

144. The method according toclaim 143, wherein coupling the prosthetic valve to the at least one of the leaflets comprises coupling the prosthetic valve to the at least one of the leaflets before coupling the prosthetic valve to the prosthetic valve support.

145. The method according toclaim 143, wherein:

the prosthetic valve includes a valve body, having an outer surface,

the at least two arms include a first arm and a second arm, the first arm being longer than the second arm, and

the method further comprises:

delivering, within a delivery tube, the prosthetic valve in a delivery configuration thereof, in which the first arm and the second arm are constrained against the outer surface of the valve body;

facilitating deflection of the first arm away from the outer surface of the prosthetic valve, by advancing a first portion of the prosthetic valve out of the delivery tube such that the first arm automatically deflects away from the outer surface of the prosthetic valve; and

facilitating deflection of the second arm away from the outer surface of the prosthetic valve, by advancing a second portion of the prosthetic valve out of the delivery tube such that the second arm automatically deflects away from the outer surface of the prosthetic valve.

146. The method according toclaim 145, wherein:

facilitating deflection of the first arm comprises facilitating deflection of the first arm a first angle from the outer surface of the prosthetic valve, and

the method further comprises facilitating deflection of the first arm away from the outer surface of the prosthetic valve a second angle that is greater than the first angle, by applying a force to the first arm using the delivery tube:

subsequently to facilitating deflection of the first arm the first angle, and

prior to facilitating deflection of the second arm.

147. The method according toclaim 146, wherein applying the force to the first arm using the delivery tube comprises pushing on the first arm by sliding the delivery tube over at least part of the prosthetic valve.

148. Apparatus for use with a body of a subject, the apparatus comprising:

at least a first implantable member;

a first longitudinal member, coupled at a distal end thereof to the first implantable member;

a second longitudinal member, at least a portion of the second longitudinal member being reversibly couplable to the first longitudinal member; and

a tubular member:

slidable over the first and second longitudinal members,

shaped to define a lumen therethrough, and

configured, when the portion of the second longitudinal member is (1) coupled to the first longitudinal member, and (2) disposed within the lumen of the tubular member, to inhibit decoupling of the portion of the second longitudinal member from the first longitudinal member.

149. The apparatus according toclaim 148, wherein the portion of the second longitudinal member is configured, when (1) the portion of the second longitudinal member is coupled to the first longitudinal member, and (2) the portion of the second longitudinal member is disposed outside of the lumen of the tubular member, to be decouplable from the first longitudinal member by the second longitudinal member being pulled away from the first longitudinal member.

150. The apparatus according toclaim 148, wherein at least one longitudinal member selected from the group consisting of: the first longitudinal member and the second longitudinal member, is flexible.

151. The apparatus according toclaim 148, wherein the tubular member is more rigid than the first longitudinal member.

152. The apparatus according toclaim 148, wherein the tubular member fits snugly over at least the portion of the second longitudinal member.

153. The apparatus according toclaim 148, wherein the first implantable member comprises a tissue anchor, configured to be anchored to a tissue of the subject.

154. The apparatus according to any one ofclaims 148-153, further comprising a second implantable member, slidable over the tubular member, and couplable to the first longitudinal member while the portion of the second longitudinal member is coupled to the first longitudinal member.

155. The apparatus according toclaim 154, wherein the portion of the second longitudinal member is reversibly couplable to the first longitudinal member at a first site of the first longitudinal member, and wherein the second implantable member is couplable to the first longitudinal member at a second site of the first longitudinal member that is distal to the first site of the longitudinal member.

156. The apparatus according toclaim 154, further comprising a locking member having an unlocked state and a locked state, and configured to be slid over the tubular member in the unlocked state and to be locked to the first longitudinal member by being transitioned to the locked state.

157. The apparatus according toclaim 156, wherein the locking member is configured to facilitate coupling of the second implantable member to the first longitudinal member.

158. The apparatus according toclaim 156, wherein the locking member is configured to be coupled to the first longitudinal member at least 1 cm away from the first implantable member.

159. Apparatus for use at a native valve of a heart of a subject, the apparatus comprising:

a tissue anchor, configured to be transluminally, transcatheterally advanced to a ventricle of the heart of the subject, and to be coupled to tissue of the ventricle;

a longitudinal member, coupled at a distal end thereof to the tissue anchor;

a wire, a portion of the wire being reversibly couplable to the longitudinal member;

a tubular member:

slidable over the longitudinal member and the wire,

shaped to define a lumen therethrough, and

configured, when the portion of the wire is (1) coupled to the longitudinal member, and (2) disposed within the lumen of the tubular member, to inhibit decoupling of the portion of the wire from the longitudinal member;

a prosthetic valve support comprising an upstream support portion slidable over the tubular member, and to be placed against an upstream surface of an annulus of the native valve by sliding over the tubular member; and

a locking member, slidable over the tubular element and lockable to the longitudinal member.

160. The apparatus according toclaim 159, wherein the locking member is configured to be locked to the longitudinal member at a site of the longitudinal member that is distal to a site of the longitudinal member to which the portion of the wire is reversibly couplable.

161. The apparatus according toclaim 159, wherein the tubular member is configured to be slid out of the locking member before the locking member is locked to the longitudinal member.

162. The apparatus according to any one ofclaims 159-161, further comprising a control rod, slidable over the tubular member, the locking member being reversibly coupled to a control rod, the control rod being configured to restrain the locking member in an unlocked configuration thereof, and to facilitate locking of the locking member by ceasing to restrain the locking member in the unlocked configuration.

163. The apparatus according toclaim 162, wherein the control rod is configured to decouple from the locking member when the control rod ceases to restrain the locking member in the unlocked configuration thereof.

164. The apparatus according toclaim 162, wherein the control rod is configured to cease to restrain the locking member in the unlocked configuration thereof by the control rod being rotated with respect to the locking member.

165. The apparatus according toclaim 162, wherein:

the prosthetic valve support is shaped to define a hole through which the tubular member is slidable,

at least while the control rod is coupled to the locking member, the control rod is not slidable through the hole defined by the prosthetic valve support, and the control rod is configured to facilitate the sliding of the prosthetic valve support over the tubular member by pushing the prosthetic valve support over the tubular member.

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