TISSUE

BACKGROUND

[0001] The tricuspid valve controls blood flow from the right atrium to the right ventricle of the heart, preventing blood from flowing backwards from the right ventricle into the right atrium so that it is instead forced through the pulmonary valve and into the pulmonary arteries for delivery to the lungs. A properly functioning tricuspid valve opens and closes to enable blood flow in one direction. However, in some circumstances the tricuspid valve is unable to close properly, allowing blood to regurgitate back into the atrium. Such regurgitation can result in shortness of breath, fatigue, heart arrhythmias, and even heart failure.

[0002] Tricuspid valve regurgitation has several causes. Functional tricuspid valve regurgitation (FTR) is characterized by structurally normal tricuspid valve leaflets that are nevertheless unable to properly coapt with one another to close properly due to other structural deformations of surrounding heart structures. Often, the right ventricle is dilated as a result of pulmonary hypertension or an abnormal heart muscle condition (cardiomyopathy).

[0003] Other causes of tricuspid valve regurgitation are related to defects of the tricuspid valve leaflets, tricuspid valve annulus, or other tricuspid valve tissues. In some circumstances, tricuspid valve regurgitation is a result of infective endocarditis, blunt chest trauma, rheumatic fever, Marfan syndrome, carcinoid syndrome, or congenital defects to the structure of the heart. Tricuspid valve conditions are also often associated with problems related to the left side of the heart, such as mitral valve regurgitation.

[0004] Tricuspid valve regurgitation is often treated by replacing the tricuspid valve with a replacement valve implant or by repairing the valve through an interventional procedure. One method for repairing the tricuspid valve is through annuloplasty. Annuloplasty is accomplished by delivering and implanting a ring or band in the annulus of the tricuspid valve to attempt to return the annulus to a functioning shape. In tricuspid valve repair procedures, a surgeon attempts to reshape or reposition tricuspid valve leaflets so that they can better coapt with one another to sufficiently close the valve and prevent regurgitation.

[0005] The subj ect matter claimed herein is not limited to embodiments that solve any disadvantages or that operate only in environments such as those described above. Rather, this background is only provided to illustrate one exemplary technology area where some embodiments described herein may be practiced.

BRIEF SUMMARY

[0006] Certain embodiments described herein are directed to devices and methods for repairing tissue, such as tissue of a malfunctioning cardiac valve, including a regurgitant tricuspid valve. Some embodiments are directed to methods for repairing tissue by positioning a repair device at a targeted location. The repair device includes a pair of distal arms and a pair of corresponding proximal arms disposed opposite the pair of distal arms, each proximal arm and corresponding opposite distal arm forming an arm pair. The repair device is actuated to grasp leaflet tissue of the targeted valve between the proximal and distal arms. A first arm pair grasps tissue at a first engagement point, and a second arm pair grasps tissue at a second engagement point. Preferably, the first and second engagement points are located respectively on first and second adjacent leaflets of a tricuspid valve.

[0007] The leaflet tissue at the second engagement point is sutured. For example, one or more suture lines are passed through the leaflet tissue and are anchored at the second engagement point to prevent the one or more suture lines from detaching or tearing away from the second engagement point. In some embodiments, a suturing catheter is positioned near the second arm pair and engages with the second arm pair to enable deployment of the one or more suture lines at the leaflet tissue grasped by the second arm pair.

[0008] After deploying the one or more suture lines at the second engagement point, the second arm pair is pivoted to a third engagement point (e.g., the third tricuspid leaflet) while the first arm pair remains engaged at the first engagement point (e.g., the first tricuspid leaflet). The pivoting motion carries the one or more suture lines deployed at the second engagement point (e.g., the second tricuspid leaflet) to the third engagement point. Tension in the one or more suture lines can then be adjusted to tie together the tissue of the second engagement point and third engagement point to a desired degree. The repair device remains deployed across the first and third engagement points to tie together the tissue of the first and third engagement points. The repair device can be adjusted to tie the grasped tissue together to a desired degree.

[0009] In certain embodiments, at least a first arm pair of the repair device includes a point element configured to engage against leaflet tissue to function as a pivot point allowing a second arm pair to rotate about the pivot point. In some embodiments, at least the second arm pair includes a set of through holes through which one or more suture lines are passable to enable suturing of leaflet tissue grasped by the second arm pair. In some embodiments, the second arm pair is independently adjustable so that the first arm pair can remain in a closed/grasped configuration during pivoting while the second arm pair is in a more open configuration to allow it to rotate around the first engagement point.

[0010] In some embodiments, a heart valve repair system includes a repair device and a suturing catheter. The suturing catheter includes an internal lumen through which one or more suture lines are extendable, the suturing catheter being configured to engage with the second arm pair of the repair device to enable passage of the one or more suture lines through the leaflet tissue grasped by the second arm pair.

[0011] In certain embodiments, a repair device includes a proximal member with an axial lumen and a plurality or extendable arms which may be extended to an open position transverse to the axial lumen, and a distal member disposed at least partially within the axial lumen of the proximal member so as to be axially translatable relative to the proximal member. The distal member includes an end section extending distally beyond the proximal member. The end section includes a plurality of extendable arms which are extendable to an open position transverse to an axis of the distal member.

[0012] This summary is provided to introduce a selection of concepts in a simplified form that are further described below in the Detailed Description. This Summary is not intended to identify key features or essential features of the claimed subject matter, nor is it intended to be used as an aid in determining the scope of the claimed subject matter.

BRIEF DESCRIPTION OF THE DRAWINGS

[0013] In order to describe the manner in which the above-recited and other advantages and features of the invention can be obtained, a more particular description of the invention briefly described above will be rendered by reference to specific embodiments thereof which are illustrated in the appended drawings. Understanding that these drawings depict only typical embodiments of the invention and are not therefore to be considered to be limiting of its scope, the invention will be described and explained with additional specificity and detail through the use of the accompanying drawings in which:

[0014] Figure 1 illustrates a human heart showing normal blood flow paths; [0015] Figure 2 illustrates a superior view of a normally functioning tricuspid valve in a closed position;

[0016] Figure 3 illustrates a superior view of a tricuspid valve in an open position;

[0017] Figure 4 illustrates a superior view of a malfunctioning tricuspid valve unable to properly close;

[0018] Figure 5 illustrates an exemplary embodiment of a repair device that may be utilized to perform a tricuspid repair procedure as described herein;

[0019] Figures 6-8 illustrate another embodiment of a repair device that may be utilized to perform a tricuspid repair procedure as described herein, showing deployment of extendable arms of the device and grasping of leaflet tissue therebetween;

[0020] Figures 9 and 10 illustrate a superior view of a tricuspid valve showing a repair procedure using the repair device of Figures 6-8 to tie the leaflets of the tricuspid valve together to bring them closer together;

[0021] Figures 11 and 12 illustrate a side view of another exemplary embodiment of a clip device that may be utilized to perform a tricuspid repair procedure, showing grasping of two adjacent leaflets of a tricuspid valve using the device;

[0022] Figure 13 illustrates a superior view of the clip device after grasping the two adjacent leaflets;

[0023] Figures 14 to 16 illustrate side views of the clip device showing the deployment of a suture line in a valve leaflet using a suturing catheter;

[0024] Figure 17 illustrates a superior view of the clip device after a pivot procedure to grasp another leaflet of the tricuspid valve;

[0025] Figures 18 and 19 illustrate superior views of the clip device showing a cinching procedure using the deployed suture line to tie adjacent valve leaflets to one another;

[0026] Figures 20 and 21 illustrate side views of the clip device showing an altemative repair procedure which deploys a second suture line into a second valve leaflet;

[0027] Figures 22 and 23 illustrate superior views of the clip device showing a cinching procedure utilizing the two deployed suture lines to tie adjacent valve leaflets to one another; and

[0028] Figure 24 illustrates closing of the clip device to bring the grasped valve leaflets closer to one another. DETAILED DESCRIPTION

[0029] At least some of the embodiments described herein are directed to devices and methods for repairing a malfunctioning cardiac valve, such as a regurgitant tricuspid valve. Some embodiments are directed to devices and methods configured to provide repair of a regurgitant tricuspid valve through a "lasso" technique capable of tethering and/or tightening the three leaflets of the tricuspid valve together in a desired configuration to improve valve closure and minimize or eliminate regurgitation at the tricuspid valve.

[0030] Although many of the examples illustrated and described herein are directed to tricuspid valve regurgitation, it will be understood that the principles, features, and components described herein may also be applied in other applications, such as repair of other heart valves, or use in other interventional procedures or treatment applications.

[0031] Figure 1 illustrates a cross-sectional view of a heart 10 showing the normal blood flow path. Deoxygenated blood enters the right atrium 16 through the superior vena cava 14 and superior vena cava 12. During diastole, suction from expansion of the right ventricle 20 and contraction of the right atrium 16 forces blood from the right atrium 16 across the tricuspid valve 18 and into the right ventricle 20. During ventricular systole, blood is then forced from the right ventricle 20 through the pulmonary valve 22 and into the pulmonary arteries for delivery to the lungs. In a normally functioning heart, the tricuspid valve 18 closes during systole to prevent backwards movement of blood from the right ventricle 20 back into the right atrium 16. When a tricuspid valve is not functioning properly, it may fail to fully close such that some of the blood passes back across the tricuspid valve 18 and into the right atrium 16, rather than through the pulmonary valve 22.

[0032] Oxygenated blood returning from the lungs enters the left atrium 24, where it is then passed through the mitral valve 26 and into the left ventricle 28. During ventricular systole, the blood is then passed from the left ventricle through the aortic valve for delivery throughout the body. Similar to the right side of the heart, failure of the mitral valve 26 to fully close during ventricular systole leads to regurgitation of blood from the left ventricle 28 back into the left atrium 24. In some circumstances, problems related to mitral valve regurgitation or other issues with the left side of the heart also cause or are associated with structural issues on the right side of the heart, such as tricuspid valve regurgitation. [0033] Figures 2-4 illustrate superior views of a tricuspid valve 18 in various states and positions. Figure 2 illustrates a properly functioning tricuspid valve 18 in a closed position. A properly functioning tricuspid valve 18 takes this form during ventricular systole in order to block backflow of blood. As shown, when in the closed position, the three leaflets of the tricuspid valve 18 coapt to fully close the valve. Figure 3 illustrates a properly functioning tricuspid valve 18 in an open position. When open, the leaflets of the tricuspid valve 18 extend downward into the right ventricle so that passage of blood through the tricuspid valve 18 is provided.

[0034] Figure 4 illustrates a defective tricuspid valve 18 during ventricular systole. In contrast to the properly closed tricuspid valve of Figure 2, the leaflets of the defective tricuspid valve are unable to fully coapt, leaving a passage through which regurgitant blood may pass. The inability to fully close may be due to defects to the leaflets themselves, or to defects to other structures of the heart which deform the tricuspid valve annulus or stretch the chordae tendineae, for example.

[0035] Figure 5 illustrates a cross-sectional view of an embodiment of a repair device 100 that may be utilized to reduce or eliminate regurgitation in a defective valve. The illustrated embodiment includes a proximal member 102 and a distal member 104 disposed within the proximal member 102 and configured to be axially translatable relative to the proximal member 102. Each of the distal member 104 and the proximal member 102 include arms extending transversely from respective longitudinal axes. In the illustrated embodiment, for example, the distal member 104 and proximal member 102 are configured with T shaped cross sections. As indicated by arrows 106, the distal member 104 is translatable relative to the proximal member 102 such that the space between the arms of the distal member 104 and the proximal member 102 may be selectively expanded or reduced.

[0036] As explained in more detail below, the repair device 100 may be utilized to grasp tissue between the respective arms of the distal member 104 and proximal member 102 by positioning the distal member 104 on a first side of the targeted tissue, with the proximal member 102 positioned on the opposite side of the targeted tissue, and translating the distal member 104 relative to the proximal member 102 to reduce the space between the arms of the distal member 104 and proximal member 102 to grasp the targeted tissue therebetween. [0037] Figures 6-8 depict another embodiment of a repair device and an exemplary method for deploying a repair device to grasp tricuspid valve tissue for repair of a regurgitant tricuspid valve. Figure 6 illustrates a repair device including a distal member 204 positioned within a proximal member 202 and extending out of and distally beyond a distal end of the proximal member 202. In the illustrated embodiment, the distal member 204 is translatable relative to the proximal member 202 such that the distal member 204 may be selectively extended distally or retrieved proximally relative to the proximal member 202.

[0038] In some embodiments, the repair device is delivered to the targeted tricuspid valve 18 by positioning the repair device in the right atrium, superior to the tricuspid valve 18, and extending the distal member 204 through the tricuspid valve 18 into the right ventricle. For example, the repair device may be delivered via a transfemoral approach so that the device passes through the inferior vena cava into the right atrium. Alternatively, the device may be delivered through a transjugular approach, transapical approach, or other approach.

[0039] Although the example depicted in Figures 6-8 is related to an approach in which the device is delivered to the right atrium and positioned superior to the tricuspid valve prior to deployment (e.g., through a transfemoral approach), it will be understood that the described principles and features may be applied to other approaches. For example, in a transapical approach, the repair device may be inserted into the right ventricle and be positioned inferior to the tricuspid valve. In the illustrated example, the repair device is deployed by extending the distal member 204 from the right atrium through the tricuspid valve 18 and into the right ventricle. It will be understood that from an inferior approach, the repair device may be deployed by extending the distal member 204 from the right ventricle through the tricuspid valve and into the right atrium.

[0040] As shown in Figure 6, the proximal member 202 includes extendable arms 208 and 210, and the distal member 204 includes extendable arms 212 and 214. Figure 6 illustrates the arms 208, 210, 212, and 214 in a retracted or collapsed position, providing the device with a low profile for delivery to the targeted tricuspid valve 18. In the illustrated embodiment, the extendable arms 208, 210, 212, and 214 are coupled to the axial bodies of the proximal member 202 and distal member 204, respectively, through a hinged attachment to enable actuation from the retracted position to an extended position. Alternatively, or additionally, one or more arms may be provided with the ability to selectively extend and retract through use of spring biasing and/or tension wire controls (e.g., one or more tension wires extending from a respective arm to a proximal handle/control element).

[0041] In some embodiments, the distal member 204 and/or proximal member 202 may be delivered in a sheathed configuration such that the corresponding arms, which are biased toward an expanded position, are held in a collapsed position by the sheath. The arms may then be selectively opened to the expanded position by retracting the corresponding sheath and/or pushing the respective member out from the sheath. The arms may be retracted to a collapsed position by repositioning the corresponding sheath over the arms to force them back into the retracted position.

[0042] As shown in Figure 6, the distal member 204 may be positioned so as to pass through the plane of the tricuspid valve 18 and be positioned on a ventricular side of the valve, while the proximal member 202 remains on the atrial side of the valve. As shown in Figure 7, the extendable arms 208, 210, 212, and 214 may then be opened to the extended position so that arms 208 and 210 of the proximal member 202 remain on the atrial side of the valve 18 and arms 212 and 214 remain on the ventricular side of the valve 18. As shown in Figure 8, the distal member 204 may then be proximally retracted and/or the proximal member 202 may then be distally extended so as to bring the proximal (atrial side) arms 208 and 210 closer to the distal (ventricular side) arms 212 and 214 so as to grasp the tricuspid valve tissue 18 therebetween, as indicated by the arrows 216. In some embodiments, one or more of the arms 208, 210, 212, and 214 may include tines, hooks, protrusions, or other structures to enhance tissue grasping.

[0043] As shown, the proximal arms 208 and 210 are each substantially aligned with a corresponding distal side arm 212 and 214 to form an arm pair. In the illustrated embodiment, the proximal arm 208 and the distal arm 212 form a first arm pair, and the proximal arm 210 and distal arm 214 form a second arm pair. Additional examples of repair devices are provided in U. S. Patent Application No. 7,666,204, which is incorporated herein by reference in its entirety. One or more of the clip device components and/or features described therein may be utilized for grasping tricuspid valve leaflet tissue as part of a tricuspid valve repair procedure described herein.

[0044] Figures 9 and 10 illustrate superior views of the tricuspid valve 18 showing deployment of any of the repair devices described herein in order to affix the tricuspid valve leaflets so as to reduce or prevent regurgitation through the tricuspid valve 18. Referring to Figure 9, a first leaflet and a second leaflet of the tricuspid valve 18 may be grasped according to the procedure illustrated by Figures 6-8 or through another grasping process. From the superior view of Figure 9, the proximal arms 208 and 210 of the proximal member are shown extending across the first and second leaflets so that a first end of the proximal member is located on the first leaflet at a first engagement point 216, and a second end of the proximal member is located on the second leaflet at a second engagement point 218 (i.e., so that the first arm pair is located at the first engagement point 216 and the second arm pair is located at the second engagement point 218).

[0045] From this position, one or more suture lines are passed from the first engagement point 216 to the second engagement point 218, or vice versa, to tie the first and second leaflets together. For example, one or more suture lines may be tied or otherwise attached (e.g., using buttons, anchors, pledgets, etc.) at the first engagement point 216, and passed to the second engagement point 218 where they may be likewise attached. Alternatively, one or more suture lines may be anchored at or tied to the second engagement point 218, but not passed to or from the first engagement point 216.

[0046] In some embodiments, one or more suture loops are attached at the first and/or second engagement points. For example, one or more suture lines may be passed from the first engagement point 216 to the second engagement point 218 where they are passed through a suture loop attached at the second engagement point 218. The one or more sutures may then be further routed to other areas of the tricuspid valve 18, as described in more detail below.

[0047] In alternative implementations, one or more suture lines may be anchored to one of the engagement points but not passed between the first and second engagement points 216 and 218. For example, one or more suturing lines may be attached (e.g., using buttons, anchors, pledgets, or other anchoring structures) at the second engagement point 218. The first and second leaflets are not sutured together, but the one or more suture lines anchored to the second leaflet at the second engagement point 218 are subsequently passed to the third leaflet to tie the second leaflet to the third leaflet. The one or more suture lines may be passed to the third leaflet in this manner by a pivoting motion of the repair device, as shown in Figure 10.

[0048] As shown in Figure 10, the repair device is then pivoted so that the second arm pair is pivoted about a pivot point to position the second end at the third leaflet. For example, as indicated by arrow 222 in the illustrated embodiment, the first engagement point 216 is used as a pivot point, and the second arm pair is pivoted so that the second arm pair is located on the third leaflet at a third engagement point 220. In some embodiments, one or more suture lines may be passed from the second engagement point 218 to the third engagement point 220 to tie the second leaflet to the third leaflet. Additionally, in some implementations, one or more suture lines may be passed from the third engagement point 220 to the first engagement point 216 to tie the third leaflet to the first leaflet.

[0049] In some embodiments, one or more suture lines are anchored at or threaded through the leaflet tissue at through least two of the various engagement points 216, 218, and 220 to form a suture lasso. Additionally, or alternatively, one or more suture lines are passed through one or more suture loops positioned at the engagement points 216, 218, and/or 220. In some embodiments, one or more sutures are tied to the first leaflet at the first engagement point 216 then passed through suture loop(s) at engagement point 218 (and in some embodiments passed additionally through engagement point 220), or are tied/anchored to the second leaflet at the second engagement point 218 then passed through suture loop(s) at engagement point 220. The one or more suture lines are then tightened to bring the leaflets of the tricuspid valve 18 closer together to reduce or eliminate regurgitation through the valve. In some embodiments, one or more sutures are tied at the first engagement point 216, then passed to both the second engagement point 218 and third engagement point 220 before being passed back to the first engagement point 216 to tie all three leaflets together.

[0050] The various engagement points 216, 218, and 220 may be positioned relative to one another so as to provide a desired degree of tightening and/or a desired amount of valve closure when the leaflets are cinched closer together with a suture lasso. Further, the suture lasso may be tightened so as to provide a desired degree of closure to the leaflets. For example, in a procedure where a targeted tricuspid valve has a relatively greater degree of structural deformity, a suture lasso may be tightened to a greater degree and/or one or more engagement points may be positioned relatively further from the valve annulus and relatively closer to a respective leaflet margin. In contrast, in a procedure where a targeted tricuspid valve has a relatively lower amount of structural deformity, the suture lasso may be tightened to a lesser degree and/or one or more engagement points may be positioned relatively closer to the valve annulus and further from a respective leaflet margin. [0051] Figures 1 1 and 12 illustrate an exemplary embodiment of a repair device configured as a clip device 300, which may be utilized to grasp tricuspid valve leaflet tissue and to aid in suturing at least two adjacent leaflets to one another. The illustrated clip device 300 includes a pair of proximal arms 308 and 310, and a corresponding pair of opposing distal arms 312 and 314. The arms 308, 310, 312, and 314 are pivotally connected to the shaft 324 so as to be adjustable between a more open configuration (as shown in Figure 11 where the arms are relatively more aligned to the axis of the shaft 324 and the device has a lower profile) and a more closed position (as shown in Figure 12 where the proximal and distal arms are brought toward one another to grasp tissue therebetween). Proximal arms 308 and 310 can also include point elements 328 that can engage or penetrate into the valve tissue when proximal arms 308 and 310 are positioned against the tricuspid valve 18.

[0052] Typically, as shown in Figures 1 1 and 12, the clip device 300 is positioned with distal arms 312 and 314 disposed on the distal side of the tricuspid valve 18 (e.g., the ventricular side when a transfemoral approach is used) with the proximal arms 308 and 310 remaining on the proximal side of the valve (e.g., atrial side). The distal arms 312 and 314 are then positioned against the leaflet tissue of the valve 18 and the proximal arms 308 and 310 are then brought down to engage the leaflet tissue as shown in Figure 12. After grasping, the arms 308, 310, 312, and 314 can be adjusted to move the clip device 300 into a closed position to bring grasped tissue closer together (see Figure 24). The clip device may then be detached from the shaft 324 at detachment point 326 and left within the heart valve as an implant.

[0053] The clip device 300 may include one or more control lines, actuator rods, and/or other control mechanisms operably coupled to a handle to enable adjustments to the clip arms, detachment of the device, etc. The clip device 300 is preferably delivered using a transfemoral approach, although a tranjugular approach, transapical approach, or other suitable approach method may also be utilized.

[0054] The illustrated clip device 300 is also configured to enable suturing of grasped leaflet tissue. As shown, the distal arms 312 and 314 include through holes 330 and 332 for receiving suturing components. The proximal arms 308 and 310 also include corresponding through holes 350 and 352 (best seen in the superior view of Figure 13). The corresponding through holes are formed so as to align when opposing arms are closed against tissue. As explained in more detail below, this allows suturing components to pass through a proximal through hole, through leaflet tissue, and into a distal through hole, in order to provide passage and/or positioning of one or more suture lines.

[0055] Figure 13 illustrates a superior view of the clip device 300 that has grasped a first leaflet 41 and second leaflet 42 of the tricuspid valve 18. From this view, the proximal arms 308 and 310 are visible, as well as associated through holes 350 and 352 which provide passage through the proximal arms 308 and 310 to the underlying leaflet tissue. After leaflet tissue has been grasped in this manner, a suturing procedure can be carried out using the repair device 300 to tie two or more of the leaflets together.

[0056] Figure 14 illustrates, in side view, the same grasping position shown in Figure 13. While the first and second leaflets 41 and 42 are grasped by the clip device 300, a suturing catheter 402 is routed to the vicinity of the tricuspid valve. The suturing catheter 402 may be routed through a tranjugular approach or transfemoral approach (e.g., using the femur opposite from the one used for transfemoral delivery of the clip device 300). The illustrated embodiments show a transjugular approach where the suturing catheter 402 is positioned on the proximal side of the clip device 300 (e.g., on the atrial side) and passing one or more suture lines through leaflet tissue from the proximal side to the distal side, but it will be understood that the same components and principles of operation may be utilized by positioning the suturing catheter 402 on the distal side of the clip device 300 and passing one or more suture lines through from the distal side to the proximal side.

[0057] As shown in Figure 14, a first suture deployment catheter 404 is extended from the suturing catheter 402, and is extended to the proximal arm 310. The first suture deployment catheter 404 is positioned through the proximal through hole 352, the second leaflet 42, and into the corresponding distal through hole 332. A first suture line 408 (or optionally two or more suture lines) is associated with the first suture deployment catheter 404 so that as the first suture deployment catheter 404 is passed from one side of the leaflet 42 to the other, the first suture line 408 is also passed through the leaflet 42. In some implementations, a guide wire can first be passed out of the suturing catheter 402, through the proximal through hole 352, through the leaflet 42, and into the distal through hole 332 prior to moving the first suture deployment catheter 404, in order to establish a guided path for the first suture deployment catheter 404.

[0058] In the illustrated embodiment, the first suture line 408 includes at a distal end a first suture anchor 412. The first suture anchor 412 can be a pledget, button, bight or bundle or suture, or other structure capable of holding position against the leaflet 42 to prevent movement or tearing through the leaflet 42 when tightening tension is applied to the first suture line 408. In some embodiment, the first suture anchor 412 is flexible enough to bend and/or fold to a lower profile shape when passed through the leaflet 42, and is capable of expanding and/or folding into a larger profile shape once passed to the distal side of the leaflet 42.

[0059] After deploying the first suture line 408, the first suture deployment catheter 404 is retracted, leaving the first suture line 408 deployed in the leaflet 42, as shown in Figure 15. From this position, the clip device 300 can be selectively actuated to allow one end of the clip device 300 to be moved to another leaflet, while the other end of the clip device 300 remains anchored in place, thereby allowing another leaflet to be sutured and tied to the already sutured leaflet 42.

[0060] As shown in Figure 16, the proximal arm 310 is lifted from the leaflet 42. The first suture line 408 is still deploy ed/anchored to the leaflet 42 and still passes through the proximal arm 310. The opposite proximal arm 308 is held in a closed position against leaflet 41 so that the point element 328 of the proximal arm 308 can act as a pivot point for moving, via a pivoting motion, the clip device 300 from the previous position (in which the proximal arm 310 and distal arm 314 were positioned on either side of leaflet 42) to a new position in which the proximal arm 310 and distal arm 314 are positioned on either side of adjacent leaflet 43. In some implementations, the distal arm 314 may be additionally moved away from the leaflet 42. However, in a typical application, inherent fluctuations in leaflet position will allow the leaflet 42 to be freed simply by lifting the proximal arm 310.

[0061] Figure 17 illustrates a superior view of the tricuspid valve 18 showing the clip device 300 after the pivoting motion. As shown, the proximal arm 308 remains grasped against the first leaflet 41, while proximal arm 310 has been swung from the second leaflet 42 to the third leaflet 43. At this position, the proximal arm 310 and/or corresponding distal arm 314 is/are adjusted to grasp the third leaflet 43. As shown, the first suture line 408 now extends from the second leaflet 42, where it is anchored at engagement point 318, to the third leaflet 43, where it is held in place by the proximal arm 310. The free end of the first suture line 408 passes up through the through hole 352 and into the suturing catheter 402 (not shown in this view). [0062] As shown in Figure 18, the first suture line 408 can be tensioned (by pulling upward as indicated by arrow 336) to pull the second leaflet 42 and third leaflet 43 toward one another to a desired degree, as indicated by arrows 334. As shown by Figure 19, a lock 416 may then be applied to maintain the length and/or tension of the first suture line 408 between the engagement point 318 and the proximal through hole 352.

[0063] The lock 416 may be a cinch, clamp, grommet, stop, or other fastening device capable of engaging against the suture line 408 to hold it in place and prevent it from slipping past the lock 416. In some embodiments, the lock 416 may be applied using the suturing catheter 402. In other embodiments, the lock 416 may form part of the clip device 300 and may be selectively actuated to engage against the suture line 408. In some embodiments, the suture line 408 may be slipped through a bight or otherwise knotted, in addition to or as an alternative to the lock 416, in order to hold the position of the suture line 408. Excess suture material may be cut from the device 300 prior to finishing the repair procedure.

[0064] After tensioning the first suture line 408 to tie the second leaflet 42 and third leaflet 43 together, the clip device 300 may also be kept in the position shown to tie the third leaflet 43 and first leaflet 41 together. The clip device 300 may be adjusted toward a more closed position, as shown in Figure 24 and as indicated by arrows 344, to effectively bring and hold together grasped tissue from the leaflets 43 and 41.

[0065] Figures 20 through 23 illustrate an embodiment in which a second suture line 410 is also deployed to tie targeted leaflet tissue together. Figure 20 shows a side view of the repair device 300 after it has been pivoted to the position shown in Figure 17. In this position, the first suture line 408 extends from the second leaflet 42 (not shown in this view) to the proximal arm 310, where it passes up through the through hole 352 and into the suturing catheter 402. As shown, a second suture deployment catheter 406 is extended from the suturing catheter 402. The second suture deployment catheter 406 deploys a second suture line 410 in a manner similar to that of the first suture deployment catheter 404 and first suture line 408, by passing through the through hole 352, through the third leaflet 43, and into the through hole 332. A second suture anchor 414 functions to hold the second suture line 410 in a manner similar to that of the first suture anchor 412 holding the first suture line 408.

[0066] As shown in Figure 21, the second suture deployment catheter 406 is then retracted, leaving the first and second suture lines 408 and 410 in position extending through the proximal arm 310 and into the suturing catheter 402. Figure 22 shows a superior view of the repair device 300 in this position. From this position, tension may be selectively applied to the first and/or second suture lines 408, 410 to cinch and bring the second leaflet 42 and third leaflet 43 closer to one another. As shown in Figure 23, a lock 416 may be deployed to maintain the positions of the first and second suture lines 408, 410. Excess suture material may be cut from the device 300. As described above, the clip device 300 may also be kept in place across the third leaflet 43 and first leaflet 41 , and may be moved to a closed position as shown in Figure 24 to effectively bring and hold together tissue from the grasped leaflets 43 and 41.

[0067] The combination of suturing a pair of adjacent leaflets and deploying the clip device 300 across another pair of adjacent leaflets beneficially provides effective repair of the tricuspid valve and effective reduction or elimination of regurgitant flow through the valve. In some embodiments, even further closing of a targeted tricuspid valve is achieved by adding a suture to the first leaflet 41 (e.g., by passing a suture deployment catheter through the proximal through hole 350 of the proximal arm 308 in a manner similar to that described above) and connecting that suture to the engagement point 318 of the second leaflet 42 to thereby stitch all three leaflets together.

[0068] The terms "approximately," "about," and "substantially" as used herein represent an amount or condition close to the stated amount or condition that still performs a desired function or achieves a desired result. For example, the terms "approximately," "about," and "substantially" may refer to an amount or condition that deviates by less than 10%, or by less than 5%, or by less than 1%, or by less than 0.1 %, or by less than 0.01% from a stated amount or condition.

[0069] Elements described in relation to any embodiment depicted and/or described herein may be combinable with elements described in relation to any other embodiment depicted and/or described herein. For example, any element described in relation to a repair device of Figures 5 to 8 may be combinable with any element described in relation to a clip device as illustrated by Figures 1 1 through 24.

[0070] The present invention may be embodied in other forms, without departing from its spirit or essential characteristics. The described embodiments are to be considered in all respects only as illustrative and not restrictive. The scope of the invention is, therefore, indicated by the appended claims rather than by the foregoing description. All changes which come within the meaning and range of equivalency of the claims are to be embraced within their scope.