SUTURING DEVICES AND METHODS FOR SUTURING AN ANATOMIC

VALVE

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit under 35 U.S.C. § 119(e) of U.S. Provisional Application No. 61/052,146, filed May 9, 2008, titled SUTURING DEVICE AND METHOD OF SUTURING AN ANATOMIC VALVE, the entire contents of which is hereby incorporated by reference herein and made a part of this specification.

TECHNICAL FIELD

[0002] Embodiments of the present inventions relate to suturing devices and methods. Some embodiments of the present invention relate to suturing devices and methods for suturing an anatomic valve, for example, a heart valve such as a mitral valve, an aortic valve, a tricuspid valve, or a pulmonary valve.

BACKGROUND

[0003] Health practitioners frequently use sutures to close various openings such as cuts, punctures, and incisions in various places in the human body. Generally, sutures are convenient to use and function properly to hold openings in biological tissue closed thereby aiding in blood clotting, healing, and prevention of scaring.

SUMMARY OF THE DISCLOSURE

[0004] There are some circumstances under which it is not feasible to use conventional sutures and suturing methods to close an opening. Additionally, there are some circumstance under which the use of conventional sutures and suturing methods require invasive procedures that subject a patient to risk of infection, delays in recovery, increases in pain, and other complications.

[0005] Some heart valves may be weakened or stretched, or may have other structural defects, such as congenital defects, that cause them to close improperly, which can lead to blood flow contrary to the normal flow direction. This condition, referred to as regurgitation, incompetence, or insufficiency, can reduce blood flow in the normal direction. Regurgitation causes the heart to work harder to compensate for backflow of blood through these valves, which can lead to enlargement of the heart that reduces cardiac performance. While the tricuspid valve and the pulmonary valve may present

these conditions, the mitral valve and aortic valve more frequently demonstrate these conditions.

[0006] A number of procedures have been developed to repair valves that do not close properly. Among these procedures is the Alfieri technique, sometimes called edge-to-edge repair, which involves suturing edges of the leaflets and pulling the leaflets closer together. In another technique, the chordae tendineae are replaced or shortened. A patch is sometimes applied to leaflets that have openings therein. In some instances, leaflets are reshaped by removing a section of the leaflet that is to be treated and the surrounding portion of the leaflet is sutured closed. Some valves are treated by attaching a ring around the outside of the malfunctioning valve. Other valves may be replaced with biological or mechanical replacements. These procedures are frequently performed by highly invasive procedures, which sometimes require opening a patient's chest, stopping the patient's heart and routing blood through a heart-lung machine. Robotically-assisted procedures have been employed to reduce the size of the openings required for such procedures.

[0007] Embodiments of suturing devices and methods for suturing biological tissue are disclosed herein. The suturing devices and their methods of use can be useful in a variety of procedures, such as treating (e.g., closing) wounds and naturally or surgically created apertures or passageways. For example, the suturing devices can be used to treat an anatomical valve, such as a heart valve, including heart valves that may be weakened or stretched, or have other structural defects, such as congenital defects, that cause them to close improperly. In some embodiments, one or more suturing devices can be used to treat or repair valves, such as the tricuspid, pulmonary, mitral, and aortic valves, for example. In some embodiments, one or more suturing devices can be used to perform procedures such as the Alfieri technique (edge-to-edge repair), replacement of the chordae tendineae, shortening of the chordae tendineae, patch application, leaflet reshaping, and attachment of prosthetics, such as rings and biological or mechanical replacement valves, for example.

[0008] In some embodiments, the suturing devices can be used to close or reduce a variety of other tissue openings, lumens, hollow organs or natural or surgically created passageways in the body. In some embodiments, the suturing devices can be used to suture prosthetics, synthetic materials, or implantable devices in the body. For example, the devices can be used to suture pledget within the body.

[0009] In some embodiments, a device for suturing an anatomic valve comprises an elongate body, a needle, an arm, and a recess positioned between the elongate body and the arm. The needle can be operatively coupled to the elongate body for movement between a retracted position and an advanced position. The arm can be attached to the elongate body near a distal end of the elongate body for movement between a retracted position and an extended position. The arm can comprise a suture mount that is configured to releasably retain a suture portion. The suture mount can be positioned on the arm such that the needle retrieves the suture portion retained in the suture mount when the needle is moved from the retracted position to the advanced position and returned to the retracted position. The recess can be sized and shaped to receive a leaflet of a valve between the elongate body and the arm without damaging the leaflet.

[0010] In some embodiments, an anatomic valve can be sutured A suturing device comprising an elongate body can be positioned at least partially within the anatomic valve. A first arm can be deployed from the elongate body with the first arm releasably holding a first suture portion. The first arm can be at least partially closed about a first leaflet of the anatomic valve. While the first arm is at least partially closed about the first leaflet, a first needle can be advanced through the first leaflet to engage the first suture portion. The first suture portion can be drawn through the first leaflet. A second suture portion can be passed through a second leaflet. The first and second suture portions can be secured together.

[0011] In some embodiments, a heart valve can be sutured. A first elongate member can be advanced to a heart valve. A first arm can be extended from the elongate member around a first heart valve portion with the first arm releasably holding a first suture portion. A first needle can be advanced from the elongate member through a first heart valve portion to retrieve a first suture portion from the first arm. A second arm can be extended around a second heart valve portion with the second arm releasably holding a second suture portion. A second needle can be advanced through a second heart valve portion to retrieve the second suture portion from the second arm. The first and second suture portions can be secured to each other.

[0012] In some embodiments, the anatomic valve can be sutured using a single device, while in other embodiments the anatomic valve can be sutured using multiple

devices. In embodiments using multiple devices, any two devices can be introduced to the treatments site using the same access or different accesses.

[0013] The disclosure describes examples of some embodiments of the inventions. The designs, figures, and description are non-limiting examples of some embodiments of the inventions. Other embodiments of the devices and methods may or may not include the features disclosed herein. Moreover, disclosed advantages and benefits may apply to only some embodiments of the inventions, and should not be used to limit the inventions.

BRIEF DESCRIPTION OF THE DRAWINGS

[0014] The above-mentioned and other features disclosed herein are described below with reference to the drawings of specific embodiments. The illustrated embodiments are intended for illustration, but not limitation. The drawings contain the following figures:

[0015] Figure 1 illustrates a method of providing access to an exemplifying use environment, such as an aortic valve of a heart.

[0016] Figure 2 illustrates a method of providing access to an exemplifying use environment, such as a mitral valve of a heart.

[0017] Figure 3 is a perspective view of an embodiment of a suturing device with suture clasp arms in a retracted position and a casing shown in cross-section.

[0018] Figure 4 is an enlarged perspective view of the embodiment of Figure 3 with the casing shown in cross-section, showing suture catch mechanisms in a partially advanced position.

[0019] Figure 5 is a perspective view of the embodiment of Figure 3, with the suture clasp arms in an extended position and the suture catch mechanisms in a partially advanced position.

[0020] Figure 6 is a perspective view of the embodiment of Figure 3, as in Figure 5, showing a casing attached to the device.

[0021] Figure 7 A is a plan view of the embodiment of Figure 3, with the suture clasp arms in an extended position.

[0022] Figure 7B is a plan view as in Figure 7A ₅ but with the suture clasp arms retracted.

[0023] Figure 8 is a cross-sectional view of the embodiment of Figure 3, along a line VIII-VIII in Figure 6.

[0024] Figure 9 is a cross-sectional view of the embodiment of Figure 3, along a line IX-IX in Figure 7 A.

[0025] Figure 10 is a schematic representation an embodiment of a suturing device positioned in a passage through a valve.

[0026] Figure 11 is a schematic representation as in Figure 10 with suture clasp arms positioned around first and second leaflets of the valve.

[0027] Figure 12 is a schematic representation as in Figure 11 with suture clasp arms retracted.

[0028] Figure 13 is a schematic representation as in figure 12 showing suture catch mechanisms engaging the suture clasp arms.

[0029] Figure 14 is a schematic representation as in Figure 13 showing the suture catch mechanisms and suture portions retracted through the first and second leaflets.

[0030] Figure 15 is a schematic representation as in Figure 14 showing the suture portions extending through the first and second leaflets and being joined by a knot.

[0031] Figure 16 is a plan view of an embodiment of a suturing device with a suture clasp arm in an extended position.

[0032] Figure 17 is an enlarged perspective view of the distal end of the suturing device of Figure 16 with the suture clasp arm in an extended position.

[0033] Figure 18 is a schematic representation an embodiment of a first suturing device positioned in a passage through a valve.

[0034] Figure 19 is a schematic representation as in Figure 18 with a suture clasp arm positioned around a first leaflet of the valve.

[0035] Figure 20 is a schematic representation as in Figure 19 showing a suture catch mechanism engaging the suture clasp arm.

[0036] Figure 21 is a schematic representation as in Figure 20 showing the suture catch mechanism and a suture portion retracted through the first leaflet.

[0037] Figure 22 is a schematic representation as in Figure 21 showing a second suturing device positioned in the passage through the valve.

[0038] Figure 23 is a schematic representation as in Figure 22 with the suture clasp arm positioned around a second leaflet of the valve.

[0039] Figure 24 is a schematic representation as in Figure 23 showing a suture catch mechanism engaging the suture clasp arm.

[0040] Figure 25 is a schematic representation as in Figure 24 showing the suture catch mechanism and a suture portion retracted through the second leaflet.

[0041] Figure 26 is a schematic representation as in Figure 25 showing the suture portions extending through the first leaflet and the second leaflet and being joined by a first knot.

[0042] Figure 27 is a plan view of an embodiment of a suturing device with a suture clasp arm in an extended position.

[0043] Figure 28 is an enlarged perspective view of the distal end of the suturing device of Figure 27 with the suture clasp arm in an extended position.

[0044] Figure 29 is a schematic representation of an embodiment of a first suturing device positioned in a passage through a valve.

[0045] Figure 30 is a schematic representation as in Figure 29 with a suture clasp arm positioned around a first leaflet of the valve.

[0046] Figure 31 is a schematic representation as in Figure 30 showing a suture catch mechanism engaging the suture clasp arm.

[0047] Figure 32 is a schematic representation as in Figure 31 showing the suture catch mechanism and a suture portion retracted through the first leaflet.

[0048] Figure 33 is a schematic representation as in Figure 32 showing a second suturing device positioned in the passage through the valve so as to permit a suture clasp arm to extend from the second suturing device.

[0049] Figure 34 is a schematic representation as in Figure 33 with the suture clasp arm positioned around a second leaflet of the valve.

[0050] Figure 35 is a schematic representation as in Figure 34 showing a suture catch mechanism engaging the suture clasp arm.

[0051] Figure 36 is a schematic representation as in Figure 35 showing the suture catch mechanism and a suture portion retracted through the second leaflet.

[0052] Figure 37 is a schematic representation as in Figure 36 showing the suture portions extending through the first leaflet and the second leaflet and being joined by a first knot.

[0053] Figure 38 illustrates placement of suture through a bicuspid valve near a central portion of each leaflet.

[0054] Figure 39 illustrates placement of suture through a bicuspid valve at locations spaced from the center of each leaflet.

[0055] Figure 40 illustrates placement of suture through a bicuspid valve at multiple locations spaced from the center of each leaflet.

[0056] Figure 41 illustrates placement of suture through a tricuspid valve.

[0057] Figure 42 illustrates placement of suture through a valve.

[0058] Figure 43 illustrates placement of suture through a valve.

[0059] Figure 44 illustrates placement of suture through chordae tendineae and myocardium.

DETAILED DESCRIPTION OF SPECIFIC EMBODIMENTS

[0060] Embodiments of suturing devices and methods for suturing biological tissue are disclosed herein. The suturing devices and their methods of use can be useful in a variety of procedures, such as treating (e.g., closing) wounds and naturally or surgically created apertures or passageways. For example, the suturing devices can be used to treat an anatomical valve, such as a heart valve, including heart valves that may be weakened or stretched, or have other structural defects, such as congenital defects, that cause them to close improperly. In some embodiments, one or more suturing devices can be used to treat or repair valves, such as the tricuspid, pulmonary, mitral, and aortic valves, for example. In some embodiments, one or more suturing devices can be used to perform procedures such as the Alfieri technique (edge-to-edge repair), replacement of the chordae tendineae, shortening of the chordae tendineae, patch application, leaflet reshaping, and attachment of prosthetics, such as rings and biological or mechanical replacement valves, for example.

[0061] In some embodiments, the suturing devices can be used to close or reduce a variety of other tissue openings, lumens, hollow organs or natural or surgically created passageways in the body. In some embodiments, the suturing devices can be used to suture prosthetics, synthetic materials, or implantable devices in the body. For example, the devices can be used to suture pledget within the body.

[0062] Figure 1 illustrates an exemplifying use environment for suturing an aortic valve 4. Adaption of the devices and methods disclosed herein for suturing a heart valve may also be made with respect to procedures for suturing other bodily tissue and procedures for suturing prosthetics, synthetic materials, or implantable devices in the body. As depicted by Figure 1, a guidewire 10 can be advanced through the aorta 2 to a position at or near the aortic valve 4. The guidewire 10 can be advanced into the aorta 2 through a subclavian artery (not shown). It is anticipated that the heart may be accessed

through any of a variety of pathways. For example, the heart may be accessed through the inferior vena cava 3, the superior vena cava 5, or other vascular access. With the guidewire 10 in place, the physician can insert a sheath 12 to a position at or near the aortic valve 4. This sheath 12 is typically a single lumen catheter with a valve on its proximal end. The valve can be used, for example, to prevent extraneous bleed back or to introduce medication into the patient's body. A suturing device, such as those described further below, can then be advanced through the lumen of the sheath 12. In an alternative embodiment, the suturing device can be advanced over the guidewire 10 and positioned at or near the aortic valve 4 without the need to insert an introducer sheath 12.

[0063] Figure 2 illustrates another exemplifying use environment for suturing a mitral valve 8. As depicted by Figure 2, a guidewire 10 is advanced into the left ventricle 6 of the heart through a puncture or incision 9 near an apex 7 of the left ventricle 6. The heart may be accessed through a limited thoracotomy, small trocar puncture, or small catheter puncture. Other access paths may be used. The guidewire 10 can then be further positioned at or near the mitral valve 8. With the guidewire 10 in place, the physician can insert a sheath 12 to the left ventricle 6. The sheath 12 can be placed at or near the mitral valve 8. The suturing device can then be advanced through the lumen of the sheath 12. In an alternative embodiment, the suturing device can be advanced over the guidewire 10 and positioned at or near the mitral valve 8 without the need to insert an introducer sheath 12.

[0064] Figures 3-9 illustrate an embodiment of a suturing device 100 that can be used to suture an anatomical valve, such as a heart valve. While the device 100 will be described with reference to suturing an anatomical valve, such as a heart valve, the device 100 could be used to suture other biological tissue and implantable devices and materials. The suturing device 100 can comprise a distal assembly 102, one or more suture clasp arms 104, and one or more suture catch mechanisms 106. The suturing device 100 can further comprise an elongate member (not shown) to facilitate manipulation of the suture clasp arm(s) 104 and the suture catch mechanism(s) 106 from a remote location. For example, the elongate member can comprise one or more lumens to accommodate a length of suture, or one or more actuator rods for manipulating the suture clasp arm(s) 104 and the suture catch mechanism(s) 106, or both. In some embodiments, the distal assembly 102 can comprise a portion of the elongate member.

[0065] The distal assembly 102 can comprise a proximal mount 108, distal mount 110, a hub 112, and a casing 114 (Figure 6). The proximal mount 108 can be fixedly connected to the distal mount 110 by the casing 114. The hub 112 can be positioned within the casing 114 for sliding movement between the proximal mount 108 and the distal mount 110.

[0066] The proximal mount 108 can be connected to the elongate member (not shown). Alternatively, a distal end of the elongate member can form or be integrally formed with the proximal mount 108. In some embodiments, the elongate member can comprise the casing 114. The proximal mount 108 can comprise one or more lumens 116, as shown in Figures 3 and 5.

[0067] The hub 112 can be fixedly connected to the suture catch mechanism(s) 106 and an actuator rod 118. The actuator rod 118 can move through a lumen 116 in the proximal mount 108. Accordingly, distal advancement of the actuator rod 118 causes distal advancement of the suture catch mechanism(s) 106. The hub 112 can comprise one or more lumens 120.

[0068] The suture clasp arm(s) 104 can be pivotally connected to the distal mount 110 such that the suture clasp arm(s) 104 can move between a retracted position, illustrated in Figures 3-4, and an extended position, illustrated in Figures 5-7A. Although the arms 104 of the device 100 that is illustrated in Figures 3-9 pivot about a distal end of the arms 104, the arms 104 can pivot about a proximal end of the arms 104 in other embodiments.

[0069] The suture clasp arm(s) 104 can be connected to an actuator rod 124, which can move through a lumen 116 in the proximal mount 108. The arm(s) 104, the distal mount 110, and the rod 124 can be connected such that distal movement of the rod 124 causes the arm(s) 104 extend and proximal movement of the rod 124 causes the arm(s) 104 to retract. In some embodiments, the arm(s) 104 can extend to a position that is substantially perpendicular to their fully-retracted position. In other embodiments, the arm(s) 104 can move less than 90° between the fully-retracted position and the fully- extended position.

[0070] The distal mount 110 can comprise one or more lumens 122 (Figure 5) to allow movement of the suture catch mechanism(s) 106 through the distal mount 110. Additionally or alternatively, the one or more lumens 122 can accommodate a length of suture, the actuator rod 124, or both.

[0071] The suture clasp arm(s) 104 can have suture clasps 126 to releasably hold a suture portion 130. The suture catch mechanism(s) 106 can be advanced to engage the suture portion(s) 130 held by the suture clasp arms(s). Once the suture catch mechanism(s) 106 have engaged the suture end portion(s) 130, the suture catch mechanism(s) 106 can be retracted to pull the suture ends from the suture claps 126.

[0072] In some embodiments, the suture clasps 126 can be positioned on the suture clasp arm 104 such that the suture catch mechanism 106 retrieves the suture end portion 130 retained in the suture clasp 126 while the suture clasp arm 104 is at least partially retracted from its fully-extended position. In some embodiments, the suture clasps 126 can be positioned on the suture clasp arm 104 such that the suture catch mechanism 106 retrieves the suture end portion 130 retained in the suture clasp 126 while the suture clasp arm 104 is fully retracted. In some embodiments, the suture catch mechanism 106 can be advanced in a continuously longitudinal direction to engage the suture clasp 126 of the suture clasp arm 104 while the suture clasp arm is fully retracted. In some embodiments, the suture clasp 126 can be located on a proximally-facing side of a suture clasp arm 104 that pivots about a distal end of the suture clasp arm. In some embodiments, the suture clasp 126 can be located on a distally-facing side of a suture clasp arm 104 pivots about a proximal end of the suture clasp arm.

[0073] In some embodiments, the suture clasp arm 104 can be configured to receive a tissue-piercing portion of the corresponding suture catch mechanism 106. For example, in some embodiments, when the suture catch mechanism 106 is fully advanced, the tissue-piercing portion can be fully received with the corresponding suture clasp arm 104. In some embodiments, the suture clasp arm 104 can receive the tissue-piercing portion of the suture catch mechanism 106 when the arm is at least partially closed. In some embodiments, suture clasp arm 104 can receive the tissue-piercing portion of the suture catch mechanism 106 when the arm is fully retracted.

[0074] In some embodiments, the device 100 can comprise a recess 140 between the suture clasp arm 104 and the distal mount 110, or other component of the distal assembly 102, when the suture clasp arm 104 is fully retracted, as illustrated in Figure 7B. In some embodiments, a tissue portion, such as a valve leaflet, can be received with the recess 140 with the suture clasp arm 104 fully retracted and without damaging the tissue portion. In some embodiments, the tissue portion can be held in the recess 140 by the suture clasp arm 104 while the suture clasp arm is fully retracted. In some

embodiments, the tissue portion can be held in the recess 140 by the suture clasp arm 104 while the suture clasp arm is at least partially retracted.

[0075] In some embodiments, the recess 140 can have a size and shape to receive a leaflet of a valve between the elongate body and the arm when the arm is at least partially retracted without damaging the leaflet. In some embodiments, the recess 140 can have a size and shape to receive a leaflet of a valve between the elongate body and the arm when the arm is fully retracted without damaging the leaflet. In some embodiments, the recess 140 can have a size and shape to retain the leaflet between the elongate body and the arm when the arm is at least partially retracted without damaging the leaflet. In some embodiments, the recess 140 can have a size and shape to retain the leaflet between the elongate body and the arm when the arm is fully retracted without damaging the leaflet.

[0076] In some embodiments, the device 100 can be manipulated with the suture clasp arm(s) 104 in the extended position to place a tissue portion, such as a leaflet of a valve, between the suture clasp arm 104 and the distal mount 110, as shown, for example, in Figure 11. In some embodiments, the suture clasp arm 104 can be at least partially closed about the tissue portion. In some embodiments, the suture clasp arm 104 can be fully closed about the tissue portion. In some embodiments, the suture clasp arm 104 can be at least partially retracted to securely hold the tissue portion between the suture clasp arm 104 and the distal mount 110. In some embodiments, the suture clasp arm 104 can be moved to the retracted position to securely hold the tissue portion between the suture clasp arm 104 and the distal mount 110, as shown, for example, in Figure 12. In some embodiments, the tissue portion is not damaged by closing the suture clasp arm 104 about the issue portion or holding the tissue portion between the suture clasp arm 104 and the distal mount 110.

[0077] With the tissue portion held between the arm 104 and the distal mount 110, the corresponding suture catch mechanism 106 can be advanced to engage the suture portion 130 held by the suture clasp 126 of the arm 104, as shown, for example, in Figure 13. The suture portion 130 can then be drawn through the tissue portion by the suture catch mechanism 106, as shown, for example, in Figure 14. In other embodiments, the suture catch mechanism(s) 106 can be advanced toward the suture clasp arm(s) 104 and retrieve the suture ends from the suture clasps 126 when the arm(s) 104 are in the extended position. In some embodiments, the suture catch mechanism can be a needle.

[0078] In some embodiments, the distal assembly 102 can comprise a tube or conduit 128 to accommodate a suture and prevent damage to the suture by any component of the device 100. In some embodiments, the conduit 128 extends through a lumen 116 in the proximal mount 108, a lumen 120 in the distal mount 110, and a lumen 122 in the hub 112.

[0079] Further details regarding devices, structures, and methods that may be incorporated with the above embodiments are provided in U.S. Patent No. 7,090,686 and U. S Patent Application Publication No. 2008/0269786, published on October 30, 2008, the entireties of all of which are hereby incorporated by reference herein and form a part of this specification. For example, in some embodiments having plural arms 106 and plural suture catch mechanisms 106, each arm 104 and each suture catch mechanism 106 of the device 100 can be independently actuated to move individually between the retracted position and the extended position.

[0080] Figures 10-15 illustrate a method for suturing an anatomical valve according to one embodiment. The distal end of a suturing device 100 can be positioned between leaflets 132 of a valve, as shown in Figure 10. The device 100 can be advanced through the vasculature to the desired position. For example, the device 100 can be advanced through the inferior vena cava into right atrium and through the septum and positioned in the passage through the mitral valve 8 (Figure 2).

[0081] The suturing device 100 can be advanced to allow suture clasp arms 104 to extend from the distal assembly 102. The suture clasp arms 104 can then be extended and the device 100 can be retracted until the suture clasp arms 104 extend around a first leaflet 132A and a second leaflet 132B of the valve, as shown in Figure 11.

[0082] Once the suture clasp arms 104 have been properly positioned around the first and second leaflets 132, the suture clasp arms 104 can be retracted to trap portions of the first and second leaflets 132, for example between the suture clasp arms 104 and the distal mount 110 in the recess 140, as illustrated in Figure 12.

[0083] With the first and second leaflets 132 trapped the suture catch mechanisms 106 can be advanced from the distal assembly 102 to penetrate the first and second leaflets 132 and engage the suture portions 130 held by the suture clasp arms 104, as illustrated in Figure 13.

[0084] After the suture portions 130 has been engaged, the suture catch mechanisms 106 and engaged suture portions 130 are then retracted through the tissue of

the first and second leaflets 132 into the distal assembly 102, as shown in Figure 14. The suture clasp arms 104 can be extended to release the first and second leaflets 132. After the first and second leaflets have been released, the device 100 can be advanced slightly so that the suture clasp arm 104 can be moved to the retracted position without pinching the leaflets 132. The first suturing device 100 can then be withdrawn fiom the valve.

[0085] As shown in Figure 15, after the suturing device 100 has been withdrawn, the suture portions 130 extend from the leaflets 132. The suture portions 130 can be pulled to draw the first leaflet 132 A and the second leaflet 132B towards one another. The suture portions 130 can then be secured together to limit movement of the leaflets 132A, 132B relative to one another, as illustrated in Figure 15 for example. In some embodiments, the sutures 130 can hold a portion of the leaflets 132A, 132B in contact with one another. In other embodiments, the sutures 130 merely hold the leaflets 132A, 132B in closer proximity to one another than they had previously been. The suture portions 130 can be secured together by tying a knot 134 according to any known method or by applying a knot 134, such as described in U.S. Patent Publication No. 2007/0010829 Al ₅ published January 11, 2007, the entirety of which is hereby incorporated herein by reference. The suture portions 130 can be secured together exterior to the body or within the body. Any excess portion of sutures 130 can be trimmed.

[0086] Figures 16 and 17 illustrate an embodiment of a suturing device 100 that can be used to suture an anatomical valve, such as a heart valve. The suturing device 100 can comprise a distal assembly 102, a single suture clasp arm 104, and a single suture catch mechanism 106.

[0087] As illustrated in Figures 16 and 17, the suturing device 100 can comprise an elongate member 142 to facilitate manipulation of the suture clasp arm 104 and the suture catch mechanism 106 from a remote location. For example, the elongate member can comprise one or more lumens to accommodate a length of suture, or one or more actuator rods for manipulating the suture clasp arm 104 and the suture catch mechanism 106, or both. The suturing device 100 can comprise a handle 144 with one or more actuators and/or pulls 146 for moving the suture clasp arm 104 and the suture catch mechanism 106. Further details regarding handles and associated components, including actuator rods, are provided in U. S Patent Application Publication No. 2008/0269786, published on October 30, 2008, the entirety of which is hereby incorporated by reference herein and forms a part of this specification.

[0088] In some embodiments, the suture clasp arm 104 can pivot about an axis located at a distal end of the suture clasp arm 104 when the suture clasp arm 104 is in a retracted position, as illustrated in Figures 16 and 17.

[0089] Figures 18-26 illustrate a method according to one embodiment for suturing an anatomical valve. Although the illustrated method involves two devices 100, each having a single suture clasp arm 104 and a single suture catch mechanism 106, the illustrated method can also be practiced using a single suturing device 100 having more than one arm 104 and more than one suture catch mechanism 106.

[0090] The distal end of a first suturing device 100 can be positioned between leaflets 132 of a valve, as shown in Figure 18. The device 100 can be advanced through the vasculature to the desired position. For example, the device 100 can be advanced through the inferior vena cava into right atrium and through the septum and positioned in the passage through the mitral valve 8 (Figure 2).

[0091] The suturing device 100 can be advanced to allow a suture clasp arm 104 to extend from the distal assembly 102. The suture clasp arm 104 can then be extended and the device 100 can be retracted until the suture clasp arm 104 extends around a first leaflet 132A of the valve, as shown in Figure 19.

[0092] Once the suture clasp arm 104 has been properly positioned around the first leaflet 132A, the suture catch mechanism 106 can be advanced from the distal assembly 102 to penetrate the first leaflet 132A and engage the suture portion 130 held by the suture clasp arm 104, as illustrated in Figure 20. In some embodiments, the suture clasp arm 104 can be moved to the retracted position to securely hold a portion of the first leaflet 132 A between the arm 104 and the distal mount 100 in the recess 140, for example, before the suture catch mechanism 106 is advanced through the first leaflet 132A to engage the suture end, as described above.

[0093] After the suture portion 130 has been engaged, the suture catch mechanism 106 and engaged suture portion 130 are then retracted through the tissue of the first leaflet 132 A into the distal assembly 102, as shown in Figure 21. The device 100 can be advanced slightly so that the suture clasp arm 104 can be moved to the retracted position without pinching the first leaflet 132A. The first suturing device 100 can then be withdrawn from the valve.

[0094] A second suturing device 100 can then be advanced into the heart and positioned between the leaflets 132A, 132B of the valve, as shown in Figure 22. The

suture clasp arm 104 can then be extended and the device 100 can be advanced such that the suture clasp arm 104 extends around the tip of the second leaflet 132B, as shown in Figure 23.

[0095] Once the suture clasp arm 104 has been properly positioned around the second leaflet 132B, the suture catch mechanism 106 can be advanced from the distal assembly 102 to penetrate the second leaflet 132B and engage the suture portion 130 held by the suture clasp arm 104, as illustrated in Figure 24. As noted above with respect to the first leaflet 132A, in some embodiments, the suture clasp arm 104 can be moved to the retracted position to securely hold a portion of the second leaflet 132B between the arm 104 and the distal assembly 102 before the suture catch mechanism 106 is advanced through the second leaflet 132B to engage the suture portion 130.

[0096] After the suture portion 130 has been engaged, the suture catch mechanism 106 and engaged suture portion 130 are then retracted through the tissue of the second leaflet 132B into the distal assembly 102, as illustrated in Figure 25. The suture clasp arm 104 can then be closed after slightly advancing the device 100 to avoid pinching the second leaflet 132B as the arm 104 is closed. Once the suture clasp arm 104 is closed, the suturing device 100 can be withdrawn from the patient's heart.

[0097] As shown in Figure 26, after the suturing device 100 has been withdrawn, the suture portions 130 will extend proximaily from the leaflets 132A, 132B. The suture portions 130 can then be secured together, as illustrated in Figure 26, by tying a knot 134 according to any known method or by applying a knot 134. The suture portions 130 can be secured together exterior to the body or within the body. Any excess portion of sutures 130 can be trimmed. The suture portions 130 can and can then be pulled to draw the first leaflet 132A and the second leaflet 132B towards one another. A second knot can then be tied or applied to the sutures 130 to limit movement of the leaflets 132A, 132B relative to one another, as described above. In some embodiments, the sutures 130 can hold a portion of the leaflets 132 A, 132B in contact with one another. In other embodiments, the sutures 130 merely hold the leaflets 132A ₅ 132B in closer proximity to one another than they had previously been.

[0098] When a device 100 having plural arms 104 and plural suture catch mechanisms 106 is used, the device 100 can be configured to place a single suture 130 through both the first leaflet 132A and the second leaflet 132B. The single suture 130 can be placed through the first and second leaflets 132 either simultaneously or sequentially.

In some embodiments, the suture portions 130 can be pulled to draw the first leaflet 132 A and the second leaflet 132B towards one another without applying a knot to the suture 130 beforehand. Accordingly, a single knot 134 can be applied to the suture 130 to hold the leaflets 132A, 132B in proximity to one another.

[0099] Figures 27 and 28 illustrate an embodiment of a suturing device 100 that can be used to suture an anatomical valve, such as a heart valve. The suture device 100 illustrated in Figures 27 and 28 is similar is some respects to the suturing devices 100 illustrated and described above. For example, the suturing device 100 of Figures 27 and 28, like the suturing device 100 of Figures 16 and 17, can comprise a distal assembly 102, a single suture clasp arm 104, and a single suture catch mechanism 106.

[0100] As illustrated in Figures 27 and 28, the suturing device 100 can comprise an elongate member 142 to facilitate manipulation of the suture clasp arm 104 and the suture catch mechanism 106 from a remote location. For example, the elongate member can comprise one or more lumens to accommodate a length of suture, or one or more actuator rods for manipulating the suture clasp arm 104 and the suture catch mechanism 106, or both. The suturing device 100 can comprise a handle with one or more actuators and/or pulls 146 for moving the suture clasp arm 104 and the suture catch mechanism 106. Further details regarding handles and associated components, including actuator rods, are provided in U.S Patent Application Publication No. 2008/0269786, published on October 30, 2008, the entirety of which is hereby incorporated by reference herein and forms a part of this specification,

[0101] In some embodiments, the suture clasp arm 104 can pivot about an axis located at a proximal end of the suture clasp arm 104 when the suture clasp arm 104 is in a retracted position, as illustrated in Figures 16 and 17.

[0102] A method of suturing anatomical valves is illustrated in Figures 29-37. Although the illustrated method involves two devices 100, each having a single suture clasp arm 104 and a single suture catch mechanism 106, the illustrated method can also be practiced using a device 100 having more than one arm 104 and more than one suture catch mechanism 106, as discussed above, for example.

[0103] The distal end of a first suturing device 100 can be positioned between leaflets 132 of a valve, as shown in Figure 29. The device 100 can be advanced through the vasculature to the desired position. For example, the device 100 can be advanced through a subclavian artery into the aorta to position the device 100 in the passage

through the aortic valve 4 (Figure 1). Alternatively, the device 100 can be inserted through a puncture or small incision 9 in the heart to position the device 100 in the passage through the mitral valve 8, as shown in Figure 2. Such a puncture can be located at or near the apex of the heart 7.

[0104] As illustrated in Figure 29, the suturing device 100 can be positioned to allow a suture clasp arm 104 to extend from the distal assembly 102. The suture clasp arm 104 can then be extended and the device 100 can be advanced until the suture clasp arm 104 extends around a first leaflet 132 A of the valve, as shown in Figure 30.

[0105] Once the suture clasp arm 104 has been properly positioned around the first leaflet 132 A, the suture catch mechanism 106 can be advanced from the distal assembly 102 to penetrate the first leaflet 132A and engage the suture portion 130 held by the suture clasp arm 104, as illustrated in Figure 31. In some embodiments, the suture clasp arm 104 can be moved to the retracted position to securely hold a portion of the first leaflet 132A between the arm 104 and the distal assembly 102 before the suture catch mechanism 106 is advanced through the first leaflet 132 A to engage the suture end, as described above, for example.

[0106] As shown in Figure 32, once the suture portion 130 has been engaged, the suture catch mechanism 106 and engaged suture portion 130 are then retracted through the tissue of the first leaflet 132A into the distal assembly 102. The device 100 can be retracted slightly so that the suture clasp arm 104 can be moved to the retracted position without pinching the first leaflet 132A. The first suturing device 100 can then be withdrawn from the valve.

[0107] A second suturing device 100 can then be advanced into the heart and positioned between the leaflets 132A, 132B of the valve, as shown in Figure 33. The suture clasp arm 104 can then be extended and the device 100 can be advanced such that the suture clasp arm 104 extends around the tip of the second leaflet 132B, as shown in Figure 34.

[0108] In the illustrated embodiment, once the suture clasp arm 104 has been properly positioned around the second leaflet 132B, the suture catch mechanism 106 can be advanced from the distal assembly 102 to penetrate the second leaflet 132B and engage the suture portion 130 held by the suture clasp arm 104, as illustrated in Figure 35. As noted above with respect to the first leaflet 132 A, in some embodiments, the suture clasp arm 104 can be moved to the retracted position to securely hold a portion of the second

leaflet 132B between the arm 104 and the distal assembly 102 before the suture catch mechanism 106 is advanced through the second leaflet 132B to engage the suture portion 130.

[0109] After the suture portion 130 has been engaged, the suture catch mechanism 106 and engaged suture portion 130 are then retracted distally through the tissue of the second leaflet 132B into the distal assembly 102, as illustrated in Figure 36. The suture clasp arm 104 can then be closed after slightly retracting the device 100 to avoid pinching the second leaflet 132B. Once the suture clasp arm 104 is closed, the suturing device 100 can be withdrawn from the patient's heart.

[0110] As shown in Figure 37, after the suturing device 100 has been withdrawn, the suture portions 130 will extend proximally from the leaflets 132A ₅ 132B. The suture portions 130 can then be secured together, as illustrated in Figure 37, by tying a knot 134 according to any known method or by applying a knot 134. The suture portions 130 can be secured together exterior to the body or within the body. Any excess portion of sutures 130 can be trimmed. The suture portions 130 can and can then be pulled to draw the first leaflet 132A and the second leaflet 132B towards one another. A second knot can then be tied or applied to the sutures 130 to limit movement of the leaflets 132A, 132B relative to one another, In some embodiments, the sutures 130 can hold a portion of the leaflets 132A, 132B in contact with one another. In other embodiments, the sutures 130 merely hold the leaflets 132 A, 132B in closer proximity to one another than they had previously been.

[0111] When a device 100 having plural arms 104 and plural suture catch mechanisms 106 is used, the device 100 can be configured to place a single suture 130 through both the first leaflet 132A and the second leaflet 132B, either simultaneously or sequentially. In some such embodiments, the suture portions 130 can be pulled to draw the first leaflet 132 A and the second leaflet 132B towards one another without applying a knot to the suture 130 beforehand. Accordingly, a single knot 134 can be applied to the suture 130 to hold the leaflets 132 A, 132B in proximity to one another.

[0112] The suture or sutures 130 can be placed through the leaflets 132 at locations selected by the physician to treat a problem of a particular valve. For example, in some embodiments, a suture or sutures 130 can be passed through the leaflets 132 at locations in or near a central region of the leaflets 132, as illustrated in Figure 38. In some embodiments, a suture or sutures 130 can be passed through a portion of the leaflets

132 that is in proximity to a periphery of the valve, as illustrated in Figure 39. In some embodiments, sutures 130 can be applied to multiple locations between two leaflets 132, as illustrated in Figure 40. In some embodiments, sutures 130 can be applied to multiple locations between more than two leaflets 132, as illustrated in Figure 41 with respect to a tricuspid valve.

[0113] Figures 42 and 43 illustrate other manners of placing suture through leaflets of a valve. In some embodiments, suture can be placed as shown in Figure 42 or 43 using the devices 100 illustrated in Figures 16-17 and 27-28. The devices 100 can be introduced through the same or different access routes. For example, one device can be introduced to the heart through the vasculature while another device is introduced transapically. In some embodiments, a first suture can be placed through a first leaflet by a first device 100 as illustrated in Figures 18-21 and a second suture can be placed through a second leaflet by a second device 100 as illustrated in Figures 29-32. The second suture can be placed before the first suture in some embodiments. In embodiments involving the placement of multiple sutures, the multiple sutures can be joined with a single knot or with multiple knots. Further information regarding devices and methods for placing suture as shown in Figures 42 and 43 is provided in the incorporated by reference U.S Patent Application Publication No. 2008/0269786, published on October 30, 2008, and, in particular, the embodiments described in association with Figures 10I-L, 27-28B, 36-39A-K.

[0114] The devices and methods described and referenced herein can be used to perform other techniques for valve repair. For example, the devices and methods described above can be used to apply a suture to one or more of the chordae tendineae 136 and myocardium 138, as illustrated in Figure 44, to restore tension to chordae tendineae that have been come elongated. The devices and methods described above can be used to suture a patch to natural or surgically-created openings in leaflets. The devices and methods described above can be used to attach a ring around the outside of the malfunctioning valve. The devices and methods described above can be used to suture prosthetics to the heart.

[0115] Although the foregoing description of the preferred embodiments has shown, described and pointed out the fundamental novel features of the invention, it will be understood that various omissions, substitutions, and changes in the form of the detail of the apparatus as illustrated as well as the uses thereof, may be made by those skilled in

the art, without departing from the spirit of the invention. For example, while the suturing device is described with respect to suturing a valve of a patient's heart, it is further envisioned that the suturing device could used to close or reduce a variety of other tissue openings, lumens, hollow organs or natural or surgically created passageways in the body. The suturing device can have any suitable number of arms, such as two or four or more, and any given arm can have one or more suture clasps or openings.