TRANSVALVULAR INTRAANNULAR IMPLANT FOR VALVE REPAIR

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims priority benefit to U.S. Provisional Patent Application No. 63/373140 filed August 22, 2022, each of which is incorporated herein by reference in its entirety for all purposes.

BACKGROUND

Field of the Invention

[0002] Embodiments of the present invention relate generally to treatment of valve prolapse and regurgitation, and more specifically, relate to the use of a transvalvular implant to treat mitral valve prolapse and mitral regurgitation and relate to the use of a transvalvular implant to treat the tricuspid valve prolapse and tricuspid regurgitation.

Description of the Related Art

[0003] The heart is a double (left and right side), self-adjusting muscular pump, the parts of which work in unison to propel blood to all parts of the body. The right side of the heart receives poorly oxygenated (“venous”) blood from the body from the superior vena cava and inferior vena cava and pumps it through the pulmonary artery to the lungs for oxygenation. The left side receives well-oxygenated (“arterial”) blood from the lungs through the pulmonary veins and pumps it into the aorta for distribution to the body.

[0004] The heart has four chambers, two on each side — the right and left atria, and the right and left ventricles. The atria are the blood-receiving chambers, which pump blood into the ventricles. A wall composed of membranous and muscular parts, called the interatrial septum, separates the right and left atria. The ventricles are the blood-discharging chambers. A wall composed of membranous and muscular parts, called the interventricular septum, separates the right and left ventricles.

[0005] The synchronous pumping actions of the left and right sides of the heart constitute the cardiac cycle. The cycle begins with a period of ventricular relaxation, called ventricular diastole. The cycle ends with a period of ventricular contraction, called ventricular systole.

[0006] The heart has four valves that ensure that blood does not flow in the wrong direction during the cardiac cycle; that is, to ensure that the blood does not back flow from the ventricles into the corresponding atria, or back flow from the arteries into the corresponding ventricles. The valve between the left atrium and the left ventricle is the mitral valve. The valve between the right atrium and the right ventricle is the tricuspid valve. The pulmonary valve is at the opening of the pulmonary artery. The aortic valve is at the opening of the aorta.

[0007] Various disease processes can impair the proper functioning of one or more of these valves. These include degenerative processes (e.g., Barlow’s Disease, fibroelastic deficiency, congenital heart defects, Ebstein’s anomaly, Marfan syndrome), inflammatory processes (e.g., Rheumatic Heart Disease) and infectious processes (e.g., endocarditis, infective endocarditis). In addition, damage to the ventricle from prior heart attacks or diseases (i.e., myocardial infarction secondary to coronary artery disease, coronary artery disease, cardiomyopath) or other heart diseases or trauma (e.g., cardiomyopathy, blunt chest trauma) , or procedures (e.g., pacemaker or implantable device leads, endomyocardial biopsy, radiation) can distort the valve’s geometry causing it to dysfunction.

[0008] The mitral valve is comprised of an anterior leaflet and a posterior leaflet. The bases of the leaflets are fixed to a circumferential partly fibrous structure, the annulus, preventing dehiscence of the valve. A subvalvular apparatus of chordae and papillary muscles prevents the valve from prolapsing into the left atrium. Mitral valve disease can be expressed as a complex variety of pathological lesions of either valve or subvalvular structures, but can also be related to the functional status of the valve. Functionally the mitral valve disease can be categorized into two anomalies, increased leaflet motion i.e. leaflet prolapse leading to regurgitation, or diminished leaflet motion i.e. restricted leaflet motion leading to obstruction and/or regurgitation of blood flow.

[0009] Leaflet prolapse is defined as when a portion of the leaflet overrides the plane of the orifice during ventricular contraction. The mitral regurgitation can also develop secondary to alteration in the annular ventricular apparatus and altered ventricular geometry, followed by incomplete leaflet coaptation. In ischemic heart failure this can be attributed to papillary or lateral wall muscle dysfunction, and in non-ischemic heart failure it can be ascribed to annular dilation and chordal tethering, all as a result of dysfunctional remodeling.

[0010] The predominant cause of dysfunction of the mitral valve is regurgitation which produces an ineffective cardiac pump function resulting in several deleterious conditions such as ventricular and atrial enlargement, pulmonary hypertension and heartfailure and ultimately death.

[0011] The main objective for the surgical correction is to restore normal function and not necessarily anatomical correction. This is accomplished by replacing the valve or by reconstructing the valve. Both of the procedures require the use of cardiopulmonary bypass and is a major surgical operation carrying a non-negligible early morbidity and mortality risk, and a postoperative rehabilitation for months with substantial postoperative pain. Historically, the surgical approach to patients with functional mitral regurgitation was mitral valve replacement, however with certain adverse consequences such as thromboembolic complications, the need for anticoagulation, insufficient durability of the valve, loss of ventricular function and geometry.

[0012] Reconstruction of the mitral valve is therefore the preferred treatment for the correction of mitral valve regurgitation and typically consists of a quadrangular resection of the posterior valve (valvuloplasty) in combination with a reduction of the mitral valve annulus (annuloplasty) by the means of suturing a ring onto the annulus. These procedures are surgically demanding and require a bloodless and well-exposed operating field for an optimal surgical result. The technique has virtually not been changed for more than three decades.

[0013] More recently, prolapse of the valve has been repaired by anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the opposing leaflet and thereby restoring apposition but not necessarily coaptation. In this procedure a ring annuloplasty is also required to attain complete coaptation.

[0014] This method commonly referred to as an edge-to-edge or “Alfieri” repair also has certain drawbacks such as the creation of a double orifice valve and thereby reducing the effective orifice area. Several less invasive approaches related to the edge-to- edge technique has been suggested, for repairing mitral valve regurgitation by placing a clip through a catheter to suture the valve edges. However, it still remains to conduct an annuloplasty procedure, which has not yet been resolved by a catheter technique and therefore is to be performed by conventional surgery, which makes the method impractical.

[0015] Notwithstanding the presence of a variety of presently available surgical techniques and promising catheter based procedures for the future, there remains a need for a simple but effective device and corresponding surgical, minimally invasive or transvascular procedure to treat the mitral or tricuspid valve.

SUMMARY

[0016] Further features and advantages of the present invention will become apparent to those of skill in the art in view of the detailed description of preferred embodiments which follows, when considered together with the attached drawings and claims.

[0017] Some embodiments of this invention are directed to a transvalvular intraannular implant to treat mitral valve prolapse and mitral regurgitation. The terminology “transvalvular” as used herein encompasses “across”, “over”, or “through” the valve surfaces by any means, and “intraannular” provides an axial spatial reference to within the native valve annulus or an annular implant that serves to function within the valve annulus. Axial with respect to the valve axis means along the axis of the valve and can describe position relative to the atrium, “supra”, or relative to the ventricle, “infra”. Specifically, it creates an axis through which a plane is pierced by the aforementioned axis, and encompasses an embodiment that is intraannular to address coaptation at the valvular plane or series of valvular planes created during each cardiac cycle, but does not obviate other salient features of the invention that may be clearly infraannular or supraannular during the cardiac cycle. Further, the terminology in the following descriptions may use “transannular implant” or “implant” and it means to include all features that may be infraannular, intraannular, or suprannular without or with stating each axially descriptive term. As well “offset” refers to directionally displaced from a frame of reference.

[0018] In some embodiments, a transvalvular implant is provided. The transvalvular implant can include an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. In some embodiments, the central portion comprises an arcuate shape. In some embodiments, the elongate body comprises a wire form curved body. In some embodiments, the first anchoring portion comprises two eyelets and the second anchoring portion comprises two eyelets. In some embodiments, the center of the elongate body comprises an opening.

[0019] In some embodiments, the central portion is configured to be displaced transversely from the intraannular plane which includes the valve annulus and is transverse to the direction of blood flow when the elongate body is attached to the annulus. In some embodiments, the first end and the second end are configured to be attached to the mitral valve annulus within the intraannular plane and the central portion is configured to be convex in the direction of outflow to support the valve leaflets at a point displaced toward the ventricle from the intraannular plane. In some embodiments, the first end and the second end are configured to reside on a generally septal-lateral axis transverse to the coaptive edges of the valve leaflets when the elongate body is attached to the valve annulus. In some embodiments, the transvalvular implant does not comprise an annuloplasty ring. In some embodiments, the transvalvular implant is configured to be implanted onto a cardiac valve annulus for treatment of valve leak. In some embodiments, the transvalvular implant is configured for a mitral valve or a tricuspid valve, hi some embodiments, the transvalvular implant is configured for straddling the mitral valve orifice in a septal lateral diameter of mitral valve annulus. In some embodiments, the transvalvular implant is configured for the treatment of mitral valve regurgitation caused by dilatation of mitral valve annulus and deformation of mitral valve leaflets. In some embodiments, the first end and the second end are configured to be anchored to the annulus. In some embodiments, sutures coupled to anchors are threaded through the first anchoring portion and the second anchoring portion. In some embodiments, caps are configured to hold the transvalvular implant to the annulus. In some embodiments, the elongate body is made of single wire. In some embodiments, the elongate body is made of a plurality of wires. In some embodiments, the elongate body comprises stainless steel or nitinol.

[0020] In some embodiments, a method is provided. The method can include delivering one or more anchors to a valve annulus of a heart valve. The method can include delivering the transvalvular implant to the valve annulus.

[0021] In some embodiments, the heart valve is a mitral valve. In some embodiments, the method can include treating functional mitral regurgitation by reducing the septal lateral diameter sufficiently to bring the posterior annulus towards the anterior annulus to achieve full closure of leaflets and competent mitral valve during systole preventing mitral regurgitation. In some embodiments, the transvalvular implant straddles the valve orifice in an annular horizontal plane in a septal lateral dimension of the annulus. In some embodiments, the central portion is curved towards the left ventricular cavity. In some embodiments, the central portion is curved left atrial cavity. In some embodiments, the one or more anchors comprise a helical screw. In some embodiments, the one or more anchors comprise a center pin. In some embodiments, the one or more anchors comprise a center post. In some embodiments, the one or more anchors comprise a quadrangular helix top mount.

[0022] In some embodiments, a transvalvular implant is provided. The transvalvular implant can include an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. In some embodiments, the central portion comprises an arcuate shape. In some embodiments, the elongate body comprises a wire form curved body. In some embodiments, the first anchoring portion comprises one or more eyelets and the second anchoring portion comprises one or more eyelets. In some embodiments, the center of the elongate body comprises an opening.

[0023] In some embodiments, the first anchoring portion comprises two or more eyelets. In some embodiments, the second anchoring portion comprises two or more eyelets. In some embodiments, the first anchoring portion comprises one or more eyelets and the second anchoring portion comprises two or more eyelets. In some embodiments, the first anchoring portion comprises a single eyelet. In some embodiments, the second anchoring portion comprises a single eyelet. In some embodiments, the central portion is configured to be displaced transversely from the intraannular plane which includes the valve annulus and is transverse to the direction of blood flow when the elongate body is attached to the annulus. In some embodiments, the first end and the second end are configured to be attached to the mitral valve annulus within the intraannular plane and the central portion is configured to be convex in the direction of outflow to support the valve leaflets at a point displaced toward the ventricle from the intraannular plane. In some embodiments, the first end and the second end are configured to be attached to the tricuspid valve annulus within the intraannular plane and the central portion is configured to be convex. In some embodiments, the first end and the second end are configured to reside on an axis generally transverse to the coaptive edges of the valve leaflets when the elongate body is attached to the valve annulus. In some embodiments, the first end and the second end are configured to reside on a generally septal- lateral axis in the mitral annulus. In some embodiments, the first end and the second end are configured to reside on a generally septal-lateral axis transverse to the coaptive edges of the valve leaflets when the elongate body is attached to the valve annulus. In some embodiments, the first end and the second end are configured to reside on a generally anterior-posterior axis in the tricuspid annulus. In some embodiments, the first end and the second end are configured to reside on a generally anterior-posterior axis transverse to the coaptive edges of the valve leaflets when the elongate body is attached to the valve annulus. In some embodiments, the transvalvular implant does not comprise an annuloplasty ring. In some embodiments, the transvalvular implant is configured to be implanted onto a cardiac valve annulus for treatment of valve leak. In some embodiments, the transvalvular implant is configured for a mitral valve or a tricuspid valve. In some embodiments, the transvalvular implant is configured for straddling the valve orifice. In some embodiments, the transvalvular implant is configured for straddling the mitral valve orifice in a septal lateral diameter of mitral valve annulus. In some embodiments, the transvalvular implant is configured for straddling the tricuspid valve orifice in an anterior-posterior diameter of tricuspid valve annulus. In some embodiments, the transvalvular implant is configured for the treatment of mitral valve regurgitation caused by dilatation of mitral valve annulus and deformation of mitral valve leaflets. In some embodiments, the first end and the second end are configured to be anchored to the annulus. In some embodiments, tethers coupled to anchors are threaded through the one or more eyelets of the first anchoring portion and the second anchoring portion. In some embodiments, caps or clips are configured to secure the transvalvular implant to anchors. In some embodiments, the elongate body is made of single wire. In some embodiments, the elongate body is made of a plurality of wires. In some embodiments, the elongate body comprises stainless steel or nitinol. In some embodiments, the first anchoring portion comprises three eyelets. In some embodiments, the second anchoring portion comprises three eyelets. In some embodiments, at least one eyelet comprises a rivet. In some embodiments, at least one eyelet facilitates compression of the implant. Tn some embodiments, the second anchoring portion comprises adjacent eyelets. In some embodiments, the second anchoring portion comprises a figure eight eyelet. In some embodiments, the first anchoring portion comprises two or more eyelets. In some embodiments, the implant is generally triangular. In some embodiments, the implant is generally X-shaped. In some embodiments, the implant tapers inward toward the central portion. In some embodiments, the implant is generally diamond shaped. In some embodiments, the implant tapers outward the central portion.

[0024] In some embodiments, a method is provided. The method can include delivering one or more anchors to a valve annulus of a heart valve. The method can include delivering the transvalvular implant described herein to the valve annulus.

[0025] In some embodiments, the method can include providing a guide catheter and an annular steering catheter. In some embodiments, the method can include providing an anchor delivery catheter and a multi-lumen bridge delivery catheter. In some embodiments, the heart valve is a mitral valve. In some embodiments, the heart valve is a tricuspid valve. In some embodiments, the method can include treating functional mitral regurgitation by reducing the septal lateral diameter sufficiently to bring the posterior annulus towards the anterior annulus to achieve full closure of leaflets and competent mitral valve during systole preventing mitral regurgitation. In some embodiments, the method can include treating functional tricuspid regurgitation by reducing the anterior-posterior diameter of the tricuspid valve annulus sufficiently to bring the anterior annulus to the septal and or posterior annulus to achieve full closure of the tricuspid leaflets and competent tricuspid valve preventing tricuspid valve regurgitation. In some embodiments, the transvalvular implant straddles the valve orifice in an annular horizontal plane of the annulus. In some embodiments, the transvalvular implant straddles the mitral valve orifice in an annular horizontal plane in a septal lateral dimension of the mitral annulus. In some embodiments, the transvalvular implant straddles the tricuspid valve orifice in an annular horizontal plane in an anterior- posterior dimension of the tricuspid valve annulus. In some embodiments, the central portion is curved towards the left ventricular cavity. In some embodiments, the central portion is curved towards the right ventricular cavity, as in the tricuspid valve. In some embodiments, the central portion is curved towards the left atrial cavity. In some embodiments, the one or more anchors comprise a helical screw. Tn some embodiments, the one or more anchors comprise a center pin. In some embodiments, the one or more anchors comprise a center post. In some embodiments, the one or more anchors comprise a quadrangular helix top mount. In some embodiments, the method can include advancing a pusher rod to deliver the transvalvular implant. In some embodiments, the method can include advancing a pusher rod to deliver a clip. In some embodiments, the clip comprises one or more flanges and a central opening, wherein the pusher rod advances the clip onto a central post of an anchor. In some embodiments, the method can include positioning at least one catheter in a sled holder. In some embodiments, the method can include inserting the one or more anchors at a 45 degree angle.

[0026] In some embodiments, a method of treating a tricuspid valve is provided. The method can include positioning a transvalvular bridge comprising an elongate body having a first anchoring portion, a second anchoring portion, and a central portion. The method can include anchoring the transvalvular bridge only on the annulus. The method can include anchoring the transvalvular bridge at the anterior annulus. The method can include anchoring the transvalvular bridge only on the anterior annulus and the posterior annulus. The method can include anchoring the transvalvular bridge at the posterior annulus. The method can include anchoring the transvalvular bridge between an anterior annulus and straddling the commissure between the septal annulus and the posterior annulus. The method can include anchoring the transvalvular bridge only on the posterior annulus beyond the septal-posterior commissure.

[0027] In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to two anchors attached to the anterior annulus. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to two anchors near a midpoint of the anterior annulus. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to an anchor attached to the posterior annulus. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to an anchor attached to the septal annulus. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to span the coaptive edge between the anterior leaflets and both the posterior and septal leaflets. In some embodiments, positioning a transvalvular bridge comprises positioning the transvalvular bridge to extend transversely across coaptive edge formed by the closure of the anterior leaflet during systole. In some embodiments, positioning a transvalvular bridge comprises positioning the central portion convex in the direction of the right ventricle. In some embodiments, the method can include elevating the position of the coaptive edges during valve closure to thereby cause early coaption relative to the cardiac cycle. In some embodiments, anchoring the transvalvular bridge does not affect the size and shape of the tricuspid annulus.

[0028] In some embodiments, a method of treating a tricuspid valve is provided. The method can include positioning a transvalvular bridge comprising an elongate body having a first anchoring portion, a second anchoring portion, and a longitudinal axis. The method can include anchoring the transvalvular bridge, wherein the longitudinal axis resides generally on an anterior- septal-posterior diameter extending from the anterior annulus along the coaptive edge between the septal annulus and posterior annulus.

[0029] In some embodiments, anchoring the transvalvular bridge comprises anchoring to the anterior annulus, the posterior annulus, and the septal annulus. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to straddle the posteroseptal commissure. In some embodiments, anchoring the transvalvular bridge comprises positioning a post of an anchor relative to an aperture of the first anchoring portion. In some embodiments, anchoring the transvalvular bridge comprises lowering the transvalvular bridge relative to anchors. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to span the valve opening. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge on both sides of a midpoint of the anterior annulus. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge more toward the posterior annulus than the septal annulus.

[0030] In some embodiments, a method of treating a tricuspid valve is provided. The method can include positioning a transvalvular bridge comprising an elongate body having a plurality of apertures and a longitudinal axis. The method can include anchoring the transvalvular bridge to the anterior annulus, the posterior annulus, and the septal annulus. [0031] Tn some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to straddle the commissure between the posterior annulus and the septal annulus.

[0032] In some embodiments, a method of treating a tricuspid valve is provided. The method can include anchoring a first anchor to an anterior annulus. The method can include anchoring a second anchor between the septal annulus and the posterior annulus. The method can include positioning a transvalvular bridge comprising an elongate body having a first anchoring portion, a second anchoring portion, and a central portion. The method can include anchoring the transvalvular bridge to the first anchor and the second anchor.

[0033] In some embodiments, positioning the transvalvular bridge comprises sliding the transvalvular bridge relative to a tether attached to the first anchor. In some embodiments, positioning the transvalvular bridge comprises sliding the transvalvular bridge relative to a tether attached to the second anchor. In some embodiments, the method can include sliding a locking clip relative to a tether attached to the first anchor. In some embodiments, the method can include sliding a locking clip relative to a tether attached to the second anchor. In some embodiments, anchoring the transvalvular bridge comprises anchoring the transvalvular bridge to span the coaptive edge between the anterior leaflet and both the posterior and septal leaflets. In some embodiments, positioning a transvalvular bridge comprises positioning the transvalvular bridge to extend transversely across the coaptive edge formed by the closure of the anterior leaflet during systole. In some embodiments, positioning a transvalvular bridge comprises positioning the central portion convex in the direction of the right ventricle. In some embodiments, the method can include elevating the position of the coaptive edges during valve closure to thereby cause early coaption relative to the cardiac cycle. In some embodiments, anchoring the transvalvular bridge does not affect the size and shape of the tricuspid annulus. In some embodiments, the method can include advancing an anchor driver relative to a clip driver. In some embodiments, the method can include loading the first anchor, the second anchor, the transvalvular bridge, a first locking clip, and a second locking clip into a steerable catheter. In some embodiments, the method can include providing a sheath disposed between a tether attached to the first anchor and a steerable catheter. In some embodiments, the first anchor comprises an inverted helix coil. In some embodiments, the first anchor comprises cone needle tip stylet. Tn some embodiments, the method can include a steering catheter comprising a stabilizing tip. In some embodiments, the method can include applying tension to a tether attached to the first anchor to engage an anchor driver. In some embodiments, the method can include releasing tension to a tether attached to the first anchor to disengage an anchor driver. In some embodiments, the method can include abutting a hard stop to prevent advancement of the first anchor. In some embodiments, the method can include adjusting the travel distance of the first anchor relative to a steering catheter.

[0034] In some embodiments, a transvalvular implant can be provided. The implant can include an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. In some embodiments, the elongate body comprises a wire form curved body. In some embodiments, the first anchoring portion comprises one or more eyelets and the second anchoring portion comprises one or more eyelets. In some embodiments, the center of the elongate body comprises an opening.

[0035] In some embodiments, the first anchoring portion comprises only one eyelet. In some embodiments, the second anchoring portion comprises only one eyelet. In some embodiments, the elongate body is configured to be attached to the tricuspid valve annulus. In some embodiments, the elongate body is configured to reside on an anterior- septal-posterior diameter. In some embodiments, the elongate body is configured to span the tricuspid valve opening. In some embodiments, the elongate body is configured to extend from the anterior annulus along the coaptive edge between the septal annulus and posterior annulus.

[0036] In some embodiments, a system is provided. The system can include the transvalvular implant. The system can include a delivery system.

[0037] In some embodiments, the delivery system comprises an anchor driver configured to rotate an anchor. In some embodiments, the delivery system comprises an implant pusher configured to advance a locking clip and the transvalvular implant relative to a tether coupled to an anchor. In some embodiments, the delivery system comprises a steerable catheter, wherein the transvalvular implant, an anchor, and a locking clip are configured to be loaded into the steerable catheter. In some embodiments, the delivery system comprises a sheath comprising a hemostasis seal. Tn some embodiments, the delivery system comprises a sheath configured to receive a dilator. In some embodiments, the delivery system comprises a steerable catheter comprising a stabilizing tip. In some embodiments, the delivery system comprises an anchor slider depth adjustment and a hard stop. In some embodiments, the delivery system comprises an anchor driver, wherein tension on a tether coupled to an anchor is configured to engage the anchor with the anchor driver. In some embodiments, the delivery system comprises one or more snares. In some embodiments, the delivery system comprises one or more anchors. In some embodiments, the delivery system comprises an anchor and an implant pusher, wherein the anchor comprises an anchor marker band and the implant pusher comprises a pusher marker band. In some embodiments, the delivery system comprises an anchor comprising an inverted helix coil.

[0038] In some embodiments, a transvalvular implant is provided. The transvalvular implant comprises an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. The elongate body comprises a spring.

[0039] In some embodiments, the spring is configured to reduce tension on a posts of an anchor. In some embodiments, the transvalvular implant further comprises a first anchor and a second anchor, wherein the first anchor is configured to engage the first anchoring portion and the second anchor is configured to engage the second anchoring portion. In some embodiments, the spring comprises nitinol. In some embodiments, the spring is located near the first anchoring portion. In some embodiments, the spring is located near the central portion. In some embodiments, the spring extends between the first end and the second end. In some embodiments, the first anchoring portion comprises only one eyelet. In some embodiments, the second anchoring portion comprises only one eyelet. In some embodiments, the elongate body is configured to be attached to the tricuspid valve annulus. In some embodiments, the elongate body is configured to reside on an anterior-septal- posterior diameter. In some embodiments, the elongate body is configured to span the tricuspid valve opening. In some embodiments, the elongate body is configured to extend from the anterior annulus along the coaptive edge between the septal annulus and posterior annulus. In some embodiments, the elongate body is configured to reduce the anterior- posterior distance. Tn some embodiments, the elongate body is shaped to adjust the amount of spring tension. In some embodiments, a wire diameter of the elongate body is shaped to adjust the amount of spring tension.

[0040] In some embodiments, a transvalvular implant is provided. The transvalvular implant comprises an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. The elongate body comprises a coil.

[0041] In some embodiments, the coil controls the spring force on a posts of an anchor. In some embodiments, the coil is configured to reduce tension on posts of anchors. In some embodiments, the transvalvular implant further comprises a first anchor and a second anchor, wherein the first anchor is configured to engage the first anchoring portion and the second anchor is configured to engage the second anchoring portion. In some embodiments, the coil comprises nitinol. In some embodiments, the coil is configured to align with the natural tension that the heart provides.

BRIEF DESCRIPTION OF THE DRAWINGS

[0042] FIG. 1 is a simplified cross-sectional view of the heart with a normal mitral valve during systole. The intraaannular plane is illustrated relative to supraannular and infrannular.

[0043] FIG. 2 is a cross-sectional view of the heart with a normal mitral valve during diastole. The axis of the mitral valve is illustrated, and shown piercing the intraannular plane.

[0044] FIG. 3 is a bottom view of the normal mitral valve of FIG. 1 during systole looking from the left atrium to the left ventricle.

[0045] FIG. 4 is a bottom view of the normal mitral valve of FIG. 2 during diastole looking from the left atrium to the left ventricle.

[0046] FIG. 5 is a cross-sectional schematic view of the normal mitral valve of FIG. 1 during systole, illustrating the depth of the coaption zone.

[0047] FIG. 6 is a cross-sectional schematic view of the normal mitral valve of FIG. 2 during diastole. [0048] FTG. 7 is a cross-sectional view of the heart during systole showing a mitral valve with a prolapsed anterior leaflet caused by the rupture of the chordae tcndincac attached to the anterior leaflet.

[0049] FIG. 8 is a bottom view of the mitral valve of FIG. 7 having a prolapsed anterior leaflet looking from the left atrium to the left ventricle.

[0050] FIG. 9 is a cross-sectional view of the heart during systole showing a mitral valve with a prolapsed posterior leaflet caused by the rupture of the chordae tendineae attached to the posterior leaflet.

[0051] FIG. 10 is a bottom view of the mitral valve of FIG. 9 having a prolapsed posterior leaflet looking from the left atrium to the left ventricle.

[0052] FIG. 11 is a cross-sectional view of the heart during systole showing a mitral valve with anterior leaflet prolapse.

[0053] FIG. 11A is a cross sectional view as in FIG. 11, showing posterior leaflet prolapse.

[0054] FIG. 11B is a cross sectional view as in FIG. 11, showing bileaflet prolapse with mitral regurgitation.

[0055] FIG. 11C illustrates a dilated mitral annulus with little or no coaption of both leaflets causing central mitral regurgitation in ischemic cardiomyopathy.

[0056] FIGS. 12A-12D illustrate an embodiment of a transvalvular bridge.

[0057] FIGS. 12E-12H illustrate views of the underlying skeleton layer of the transvalvular bridge.

[0058] FIG. 13A-13B are diagrammatic representations of a tricuspid valve.

[0059] FIG. 14 is a view of a tricuspid valve.

[0060] FIG. 15 is a view of a transvalvular bridge positioned on a tricuspid valve.

[0061] FIG. 16A-16B are view of alignments of a transvalvular bridge on tricuspid annulus.

[0062] FIG. 17 is a view of anchors.

[0063] FIG. 18 is a view of an alignment on a tricuspid annulus.

[0064] FIG. 19 illustrates the position of the anchors for the transvalvular bridge.

[0065] FIGS. 20A-20C are views of an embodiment of a transvalvular implant.

[0066] FIGS. 21A-21C are views of an embodiment of a transvalvular implant. [0067] FIGS. 22A-22F are views of an embodiment of a transvalvular implant.

[0068] FIGS. 23A-23E arc views of embodiments of anchors.

[0069] FIGS. 24A-24B are views of embodiments of anchors and tethers.

[0070] FIGS. 25A-25B are views of embodiments of anchors and delivery catheters.

[0071] FIGS. 26A-26B are views of embodiments of anchors and mounts.

[0072] FIGS. 27A-27D are views of embodiments of anchors and mounts.

[0073] FIG. 28 is a view of an embodiment of an anchor.

[0074] FIGS. 29A-29C ire views of an embodiment of an anchor and driver.

[0075] FIGS. 3OA-3OB are views of an embodiment of a delivery catheter.

[0076] FIGS. 31A-31B are views of an embodiment of an anchor and driver.

[0077] FIGS. 32A-32B are views of an embodiment of an anchor and delivery catheter.

[0078] FIGS. 33A-33B are views of an embodiment of an anchor and cap.

[0079] FIGS. 34A-34D are views of an embodiment of delivery systems.

[0080] FIG. 35 is an embodiment of anchors deployed.

[0081] FIG. 36 is a view of an embodiment of a transvalvular implant and delivery catheter.

[0082] FIGS. 37A-37D are views of an embodiment of a transvalvular implant deployed.

[0083] FIGS. 38 is a view of an embodiment of a template catheter.

[0084] FIGS. 39A-39B are views of an embodiment of a template catheter.

[0085] FIGS. 40A-40B are views of an embodiment of a template catheter.

[0086] FIGS. 41A-41C are views of embodiments of a transvalvular implant.

[0087] FIGS. 42A-42B are views of embodiments of a transvalvular implant.

[0088] FIGS. 43A-43D are views of embodiments of a transvalvular implant.

[0089] FIG. 44A is a view of an embodiment of a catheter delivery system.

[0090] FIG. 44B is a view of an embodiment of an anchor and delivery catheter.

[0091] FIG. 45 is a view of an embodiment of catheters.

[0092] FIG. 46 is a view of an embodiment of catheters.

[0093] FIG. 47 is a view of an embodiment of a catheter. [0094] FTG. 48 is a view of an embodiment of a catheter.

[0095] FIG. 49 is a view of an embodiment of a catheter.

[0096] FIGS. 5OA-5OB is a view of additional components of an embodiment of a catheter delivery system.

[0097] FIG. 51A-51G are views of embodiments of clips.

[0098] FIG. 52 is a view of an embodiment of a catheter.

[0099] FIG. 53 is a view of an embodiment of a transvalvular implant.

[0100] FIG. 54 is a view of an embodiment of a transvalvular implant.

[0101] FIG. 55 is a view of an embodiment of a transvalvular implant deployed.

[0102] FIGS. 56A-56D are views of embodiments of a transvalvular implant.

[0103] FIG. 57 is a view of an embodiment of a transvalvular implant.

[0104] FIG. 58 is a view of an embodiment of an anchor.

[0105] FIGS. 59A-59C are views of an embodiment of a tether cutter.

[0106] FIGS. 60A-60C are views of methods.

[0107] FIGS. 61A-61C are views of systems and system components.

[0108] FIGS. 62A-62B are views of a delivery system.

[0109] FIGS. 63A-63O are views of methods.

[0110] FIGS. 64A-63L are views of methods.

[0111] FIG. 65 is a view of a delivery system.

[0112] FIGS. 66A-66B are views of workflow.

[0113] FIGS. 67A-67E are views of systems that control anchor attachment.

[0114] FIGS. 68A-68B are views of a delivery system.

[0115] FIGS. 69A-69C are views of an anchor marker band.

[0116] FIGS. 70A-70N are views of anchors.

[0117] FIGS. 71A-71N are views of a bridge delivery system.

[0118] FIGS. 72A-72C are views of embodiments of a transvalvular implant.

[0119] FIGS. 73A-73C are views of embodiments of a transvalvular implant.

[0120] FIGS. 74A-74D are views of embodiments of a transvalvular implant.

[0121] FIG. 75 is a view of a double helical screw.

[0122] FIG. 76 is a view of a clamp and an anchor.

[0123] FIGS. 77A-77C are views of an anchor. [0124] FIGS. 78A-78E are views of work flow.

DETAILED DESCRIPTION

[0125] FIG. 1 illustrates a cross-sectional view of the heart 10 with a normal mitral valve 18 in systole. As illustrated, the heart 10 comprises the left atrium 12 which receives oxygenated blood from the pulmonary veins 14 and the left ventricle 16 which receives blood from the left atrium 12. The mitral valve 18 is located between the left atrium 12 and left ventricle 16 and functions to regulate the flow of blood from the left atrium 12 to the left ventricle 16. During ventricular diastole, the mitral valve 18 is open which allows blood to fill the left ventricle 16. During ventricular systole, the left ventricle 16 contracts, which results in an increase in pressure inside the left ventricle 16. The mitral valve 18 closes when the pressure inside the left ventricle 16 increases above the pressure within the left atrium 12. The pressure within the left ventricle 16 continues increasing until the pressure within the left ventricle 16 exceeds the pressure within the aorta 20, which causes the aortic valve 22 to open and blood to be ejected from the left ventricle and into the aorta 20.

[0126] The mitral valve 18 comprises an anterior leaflet 24 and a posterior leaflet 26 that have base portions that are attached to a fibrous ring called the mitral valve annulus 28. Each of the leaflets 24 and 26 has respective free edges 36 and 38. Attached to the ventricular side of the leaflets 24 and 26 are relatively inelastic chordae tendineae 30. The chordae tendineae 30 are anchored to papillary muscles 32 that extend from the intraventricular septum 34. The chordae tendineae 30 and papillary muscle 32 function to prevent the leaflets 24 and 26 from prolapsing and enable proper coaptation of the leaflets 24 and 26 during mitral valve 18 closure. Also shown schematically is line 9 through the valve annulus 28 representing the intraannular plane. Arrow 8 points supraannularly, toward the left atrium 12, while arrow 7 points infraannularly, toward the left ventricle 16.

[0127] FIG. 2 illustrates a cross-sectional view of the heart 10 with a normal mitral valve 18 in diastole. After the left ventricle 16 has ejected the blood into the aorta, the left ventricle relaxes, which results in a drop in pressure within the left ventricle 16. When the pressure in the left ventricle 16 drops below the pressure in the aorta 20, the aortic valve 22 closes. The pressure within the left ventricle 16 continues dropping until the pressure in the left ventricle 16 is less than the pressure in the left atrium 12, at which point the mitral valve 18 opens, as shown in FTG. 2. During the early filling phase, blood passively fills the left ventricle 16 and this accounts for most of the filling of the left ventricle 16 in an individual at rest. At the end of the filling phase, the left atrium 12 contracts and provides a final kick that ejects additional blood into the left ventricle. Also shown is intraannular plane 9 as described above, and line 6 representing the longitudinal axis 6 of the valve 18.

[0128] FIG. 3 illustrates a bottom view of normal mitral valve 18 in systole, looking from the left atrium and to the left ventricle. As shown, the anterior leaflet 24 and posterior leaflet 26 are properly coapted, thereby forming a coaptive edge 40 that forms a seal that prevents retrograde flow of blood through the mitral valve 18, which is known as mitral regurgitation. FIG. 4 illustrates a bottom view of normal mitral valve 18 in diastole. FIG. 5 provides a side cross-sectional view of a normal mitral valve 18 in systole. As shown in FIG. 5, the valve leaflets 24 and 26 do not normally cross the plane P defined by the annulus and the free edges 36 and 38 coapt together to form a coaptive edge 40.

[0129] FIG. 5 also illustrates a coaption zone 41. Preferably the depth of coaption (length of zone 41 in the direction of blood flow, in which the leaflets 24 and 26 are in contact) is at least about 2 mm or 5 mm, and is preferably within the range of from about 7 mm to about 10 mm for the mitral valve.

[0130] Thus, implantation of the devices in accordance with the present invention preferably achieves an increase in the depth of coaption. At increase of at least about 1 mm, preferably at least about 2 mm, and in some instances an increase of at least about 3 mm to 5 mm or more may be accomplished.

[0131] In addition to improving coaption depth, implantation of devices in accordance with the present invention preferably also increase the width of coaptation along the coaption plane. This may be accomplished, for example, by utilizing an implant having a widened portion for contacting the leaflets in the area of coaption such as is illustrated in connection with FIG. 19A and 19B below. A further modification of the coaptive action of the leaflets which is accomplished in accordance with the present invention is to achieve early coaption. This is accomplished by the curvature or other elevation of the implant in the ventricle direction. This allows the present invention to achieve early coaption relative to the cardiac cycle, relative to the coaption point prior to implantation of devices in accordance with the present invention. [0132] FIGS. 4 and 6 illustrate normal mitral valve 18 in diastole. As shown, the anterior leaflet 24 and posterior leaflet 26 arc in a fully opened configuration which allows blood to flow from the left atrium to the left ventricle.

[0133] FIGS. 7 and 8 illustrate a heart 10 in systole where the anterior leaflet 24 of the mitral valve 18 is in prolapse. Anterior leaflet 24 prolapse can be caused by a variety of mechanisms. For example, as illustrated in FIG. 7, rupture 42 of a portion of the chordae tendineae 30 attached to the anterior leaflet 24 can cause the free edge 36 of the anterior leaflet 24 to invert during mitral valve 18 closure. As shown in FIG. 8, inversion 44 of the anterior leaflet 24 can prevent the mitral valve leaflets 24 and 26 from properly coapting and forming a seal. This situation where the free edge 36 of the anterior leaflet 24 crosses into the left atrium 12 during mitral valve 18 closure can lead to mitral regurgitation.

[0134] Similarly, FIGS. 9 and 10 illustrate posterior leaflet 26 prolapse caused by a rupture of the chordae tendineae 30 attached to the posterior leaflet 26. In this case, the posterior leaflet 26 can invert and cross into the left atrium 12 during mitral valve 18 closure. The inversion of the posterior leaflet 26 prevents the mitral valve leaflets 24 and 26 from properly coapting and forming a seal, which can lead to mitral regurgitation.

[0135] Mitral regurgitation can also be caused by an elongated valve leaflet 24 and 26. For example, an elongated anterior leaflet 24, as shown in FIG. 11, can prevent the valve leaflets 24 and 26 from properly coapting during mitral valve 18 closure. This can lead to excessive bulging of the anterior leaflet 24 into the left atrium 12 and misalignment of the free edges 36 and 38 during coaptation, which can lead to mitral regurgitation.

[0136] FIGS. 12A-12D illustrate another embodiment of a transvalvular bridge 500. FIG. 12A is a perspective view of the transvalvular bridge 500. The transvalvular bridge 500 can include a first attachment structure 504 at a first end of the bridge 500 and a second attachment structure 526 at a second end of the bridge 500. Both attachment structures 504, 526 can include a variety of structures for anchoring to the valve annulus. As illustrated, the attachment structures 504, 526 can have one or more layers 515. The material can be a mesh and having an underlying frame for supporting the mesh. The material can be a velour such as a 6111 Polyester Double Velour Fabric. The mesh material can advantageously promote tissue ingrowth in some embodiments. The attachment structures 504, 526 can also include one or a plurality of apertures 508 that can be configured to allow an anchor to attach the transvalvular bridge 500 to the valve annulus. Each attachment structures 504, 526 can include two apertures 508. Each attachment structures 504, 526 can include a plurality of apertures 508. The apertures 508 of the first attachment structure 504 can be aligned. The apertures 508 of the first attachment structure 504 can be a predetermined distance apart. The apertures 508 of the second attachment structure 526 can be aligned. The apertures 508 of the second attachment structure 526 can be a predetermined distance apart. In some methods, the distance can be determined based on the anatomy of the tricuspid valve of the patient.

[0137] Still referring to FIG. 12A, the transvalvular bridge 500 can also include an arcuate central portion 502 which can be generally convex in the direction of the ventricle. As illustrated, the central portion 502 can include a plurality of struts 516 that form a generally “X” shape. The plurality of struts 516 can be monolithically formed. The plurality of struts 516 can cross at intersection zone or junction 518. The struts 516 can be made of any appropriate material, such as a metal. The struts 516 can be made of a shape memory metal such as Nitinol. The struts 516 can be treated or coated. The struts 516 can be encapsulated with silicone or another appropriate material, in order to eliminate untoward effects such as thrombosis or corrosion. The spaces 514 in between the struts 516 can be treated or coated. The spaces 514 in between the struts 516 can be encapsulated with silicone or another appropriate material. The spaces 514 in between the struts 516 can be open. The transvalvular bridge 500 can have one or more open spaces between the struts 516.

[0138] FIG. 12B is a top view of the transvalvular bridge 500 of FIG. 1A. As shown, the central portion 502 spans between the first attachment portion 504 and the second attachment portion 526, and can have a transverse width laterally that is substantially the same as that of the attachment portions 504, 526, but can become narrower toward the center toward intersection zone 518. In some embodiments, the width C in the central intersection zone 518 (measured perpendicular to blood flow) is between about 20% and about 80%, such as between about 25% and about 50%, or about 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% of the width of the central portion 502 just proximate to the attachment portions 504, 526, and can gradually narrow toward the center as illustrated. In some embodiments, the width C in the central intersection zone 518 can be between about 4mm and about 7mm, such as between about 5 mm and about 6mm, or about 5mm, about 5.2mm, about 5.4mm, about 5.6mm, about 5.8mm, or about 6mm. By narrowing the central portion 502, the resistance to blood flow can advantageously be reduced.

[0139] FIG. 12C is a side view of the transvalvular bridge 500 illustrated and described in connection with FIGS. 12A-12B. In some embodiments, the thickness T2 of the central portion 502 can be defined by the strut 516 and any encapsulation layer or coating surrounding the strut, if present. In some embodiments, the thickness T1 of the attachment portions 504, 526 can be defined by the ends of the struts 516, any encapsulation layer or coating surrounding the strut 516, if present, and/or one or more the material layers 515. The attachment portions 504, 526 can have a relatively greater thickness than the thickness of the central portion 502. In some embodiments, the attachment portions 504, 526 can have a thickness that is between about 25% and about 75% greater than that of the central portion 502, such as between about 40% and about 60% greater, or about 25%, 30%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% greater than the thickness of the central portion 502. In some embodiments, the central portion 502 can have a thickness T1 of between about 0.5mm and about 1.0mm, such as about 0.6mm, 0.7mm, or 0.8mm. In some embodiments, the attachment portions 504, 526 can have a thickness of between about 0.8mm and about 1.3mm, such as about 0.9mm, 1.0mm, 1.05mm, 1.07mm, 1.1mm, or 1.2mm.

[0140] Still referring to FIG. 12C, the transvalvular bridge 500 can have an entire axial length A in some embodiments of between about 15mm and about 40mm, such as between about 20mm and about 32mm depending on the patient’s anatomy. The central portion 502 of the transvalvular bridge 500 can have an axial length in some embodiments of between about 8mm and about 24mm, such as between about 12mm and about 20mm in some embodiments.

[0141] FIG. 12D illustrates an end view of the transvalvular bridge 500 illustrated and described in connection with FIGS. 12A-12C above, showing the stmts 516, the encapsulation layer, and attachment portion 504. In some embodiments, the width W of the attachment structures 504, 526 can be between about 10mm and about 20mm, and about 15mm in some embodiments.

[0142] FIGS. 12E-12H illustrate views of the skeleton layer 560 of the transvalvular bridge 500. In some embodiments, the encapsulation layer is not present. The struts 516 are uncoated. In some embodiments, the material layers 515 are not present. In some embodiments, the transvalvular bridge 500 consists of a wire frame. Tn some embodiments, the transvalvular bridge 500 can include the plurality of apertures 508 for anchoring. In some embodiments, the transvalvular bridge 500 does not include additional material 515 connecting the plurality of apertures 508. The skeleton layer 560 can be formed of a shape set Nitinol that can be convex in the direction of the ventricle as previously described. FIG. 12E is a perspective view of the shape memory skeleton 560 of the transvalvular bridge 500, which can include struts 516. The struts 516 can be monolithically formed from a single piece of material. The struts 516 can be separately formed and cross at intersection zone 518. The lateral ends of the skeleton 560 can include eyelets 509 defining apertures 508 that can be utilized for anchoring. The skeleton layer 560 near the central portion 502 of the transvalvular band 500 can include lateral curved transition zone 521 of the struts 516, which has a first curvature, which is in turn connected to medial curved transition zone 522 of the strut 516 which has a second curvature different from the first curvature, which is in turn connected to the intersection zone 518 which includes the vertex of the arcuate central portion 502. The skeleton layer 560 can have one or more curvatures. The skeleton layer 560 can have one or more radius of curvature. FIG. 12F is a top view of the skeleton layer 560 of FIG. 12E. As illustrated, in some embodiments the lateral curved transition zones 521 of the struts 516, while configured to slope downwardly as shown, can run substantially parallel to the longitudinal axis of the transvalvular bridge 500, while the medial curved transition zone 522 can be oblique to the longitudinal axis of the transvalvular bridge 500. In some embodiments, the axial length CC of the skeleton layer 560 can be between about 13mm and about 25mm, and the width BB of each strut 516 can be between about 1mm and about 2mm, such as between about 1.3mm and about 2.0mm. FIG. 12G is a side view, and FIG. 12H is an end view of the skeleton of FIGS. 12E-12F.

[0143] FIG. 13A-13B are diagrammatic representations of a tricuspid valve. The tricuspid valve is the right atrioventricular valve. The tricuspid valve separates the right atrium from the right ventricle. The tricuspid valve has three leaflets. The tricuspid valve includes an anterior leaflet, a posterior leaflet, and a septal leaflet. The anterior leaflet is the largest leaflet. The posterior leaflet is typically the smallest leaflet. The leaflets are connected via chordae tendineae to the papillary muscles of the right ventricle. [0144] The tricuspid valve includes an anteroseptal commissure between the anterior leaflet and the septal leaflet. The tricuspid valve includes a posteroseptal commissure between the posterior leaflet and the septal leaflet. The tricuspid valve includes an anteroposterior commissure between the anterior leaflet and the posterior leaflet. The mitral valve and the tricuspid valve are disposed relative to the aorta. The mitral valve is located posteriorly and to the left. The tricuspid valves is located inferiorly and to the right. The mitral valve and the tricuspid valve are generally adjacent to the aortic root. The tricuspid valve includes an annulus. The tricuspid annulus can include one or more planes. The tricuspid valve can be a saddle-shaped valve.

[0145] The tricuspid valve closes during systole to prevent blood flow from the right atrium to the right ventricle. The tricuspid valve opens during diastole allowing blood to flow from the right atrium to the right ventricle The healthy tricuspid valve prevents regurgitation of blood when the valve is closed. Tricuspid regurgitation is the backflow of blood from the right ventricle to the right atrium during systole. The tricuspid valve fails to close properly or tightly allowing blood to flow back into the right atrium. The failure can interfere with the proper direction of blood flow and force the ventricles to work harder to eject blood. The function of the tricuspid valve depends on interactions between many structures of the heart including the tricuspid annulus, the tricuspid leaflets, the papillary muscles, the chordae tendinae, and the right atrial and right ventricular muscular tissue.

[0146] FIG. 14 is a view of a tricuspid valve. FIG. 14 illustrates the clinical surgical tricuspid annulus. The annulus can be divided into three segments. The tricuspid annulus can include the anterior annulus, the posterior annulus, and the septal annulus. The three segments of the annulus are shown.

[0147] FIG. 15 illustrates the transvalvular bridge 500 positioned relative to the tricuspid valve. The location of the transvalvular bridge 500 on the tricuspid valve can be relative to anchoring positions. The transvalvular bridge 500 can be located on the annulus. The transvalvular bridge 500 can be located on the anterior annulus. The transvalvular bridge 500 can be located on the posterior annulus. The transvalvular bridge 500 can be straddling the commissure between the septal and posterior annulus. The method can include anchoring the transvalvular bridge between an anterior annulus and the posterior annulus.. The transvalvular bridge 500 can be located between the midpoints of anterior annulus and the annulus straddling the commissure between septal and posterior annulus. The transvalvular bridge 500 can include the first attachment structure 504 at a first end of the bridge 500 and the second attachment structure 526 at a second end of the bridge 500. The first attachment structure 504 can be located on the anterior annulus. The second attachment structure 526 can be located on the septal annulus and the posterior annulus. The transvalvular bridge 500 can include the plurality of apertures 508. The plurality of apertures 508 can align with anchoring locations on the anterior annulus, posterior annulus, and the septal annulus. The transvalvular bridge 500 alignment contacts all three segments of the tricuspid annulus.

[0148] The transvalvular bridge 500 can include a narrowed central portion to reduce resistance to blood. The narrowed central portion is separated from the first anchoring portion 504 and second anchoring portion 526. The length of the central portion can be less than about 50% of the overall length of the device. The length of the central portion can be less than about 30% of the overall length of the device. The length of the central portion can minimize the obstruction to the flow path. The transvalvular bridge 500 can include a wider transverse surface for supporting the leaflets when the valve is closed. The narrowed central portion can extend out of a reference plane. The narrowed central portion extends transversely across a coaptive edge formed by two or three valve leaflets when the transvalvular bridge is positioned.

[0149] The transvalvular bridge 500 can oriented in the annulus so that the transvalvular bridge 500 is positioned approximately transversely to the coaptive edge formed by the closure of the leaflets. The transvalvular bridge 500 is positioned approximately transversely to the coaptive edge extending from the anteroposterior commissure to the anteroseptal commissure. The transvalvular bridge 500 is positioned approximately transversely to the coaptive edge extending between the anterior leaflet and both the posterior leaflet and the septal leaflet. The transvalvular bridge 500 is positioned toward the posteroseptal commissure. The transvalvular bridge 500 is positioned approximately parallel to the coaptive edge between the posterior leaflet and the septal leaflet.

[0150] The transvalvular bridge 500 can function to reduce the anterior posterior diameter of the tricuspid annulus in functional regurgitation. The transvalvular bridge 500 can be positioned over a portion of the anterior leaflet, a portion of the posterior leaflet, and a portion of the septal leaflet. The transvalvular bridge 500 can directly support a portion of the anterior leaflet, a portion of the posterior leaflet, and a portion of the septal leaflet. The transvalvular bridge 500 can be anchored to the annulus and span the coaptive edges formed by the leaflets. The transvalvular bridge 500 can directly reduce the anterior posterior diameter to reduce annular enlargement and dysfunction . The transvalvular bridge 500 can reshape the anterior posterior diameter. The transvalvular bridge 500 can correct a geometric distortion of the tricuspid valve. The transvalvular bridge 500 can keep the anterior leaflet, the posterior leaflet, and the septal leaflet in a more normal spatial relationship relative to each other. The transvalvular bridge 500 can keep the anterior leaflet, the posterior leaflet, and the septal leaflet in a more normal spatial relationship relative to the tricuspid annulus. The transvalvular bridge 500 can position the anterior leaflet, the posterior leaflet, and the septal leaflet preventing or reducing regurgitation.

[0151] The transvalvular bridge 500 can have an effect on the tricuspid valve during systole. The anterior leaflet, the posterior leaflet, and the septal leaflet are supported by the transvalvular bridge 500 during closure of the tricuspid valve. The transvalvular bridge 500 can function to maintain the anterior posterior diameter of the tricuspid annulus. The transvalvular bridge 500 can function to maintain the relationship between leaflets. The transvalvular bridge 500 can function to enable the anterior leaflet, the posterior leaflet, and the septal leaflet to form coaptive edges. The transvalvular bridge 500 can function to improve the tricuspid valve seal. In some embodiments, the leaflets rest upon the transvalvular bridge 500 during closure. In some embodiments, the leaflets rest upon each other during closure. The pressure exerted by the blood upon the distal portion of the leaflets can form the coaptive edge. The leaflets close to prevent blood from flowing from the right atrium to the right ventricle during systole.

[0152] The performance of the tricuspid valve during diastole is not substantially affected by the transvalvular bridge 500. The transvalvular bridge 500 allows the valve to open. The leaflets open to allow blood to flow from the right atrium to the right ventricle. The transvalvular bridge 500 can include a narrowed or tapered central portion. The transvalvular bridge 500 can include one or more central openings. The transvalvular bridge 500 can include one or more pathways for blood to flow therethrough during diastole. [0153] Tn some methods, a single transvalvular bridge 500 is implanted. The transvalvular bridge 500 can provide support to the tricuspid valve leaflets. The transvalvular bridge 500 can support all three leaflets. The transvalvular bridge 500 can be attached to anchors located at the annulus. The transvalvular bridge 500 can be characterized by a longitudinal axis. The transvalvular bridge 500 is oriented in the tricuspid valve such that the longitudinal axis of the transvalvular bridge 500 is oriented substantially transversely to the coaptive edge formed between the anterior leaflet and both the posterior and septal leaflets. The transvalvular bridge 500 is oriented in the tricuspid valve such that the longitudinal axis of the transvalvular bridge 500 is oriented toward the posteroseptal commissure. The transvalvular bridge 500 can be convex or inclined in the direction of the ventricle. The transvalvular bridge 500 can be convex or inclined to advance the coaptation of the valve leaflets in the direction of the ventricle.

[0154] In some embodiments, the transvalvular bridge 500 can be oriented in a particular fashion to enhance performance of the transvalvular bridge 500. The configuration of the transvalvular bridge 500 allows a larger surface area to make contact with and support the valve leaflets. The configuration of the transvalvular bridge 500 allows a larger surface area near the apertures 508. The configuration of the transvalvular bridge 500 allows a larger surface area for anchoring on the annulus. The configuration of the transvalvular bridge 500 allows for reinforcement of apertures for anchoring. The configuration of the transvalvular bridge 500 presents a streamlined shape over the valve opening. The configuration of the transvalvular bridge 500 provides less resistance to blood flowing from the right atrium to the right ventricle when the tricuspid valve is open. In some methods, decreasing the resistance to blood flow is desirable because it can reduce turbulence and reduce the impedance of the transvalvular bridge 500 on the filling of the right ventricle.

[0155] In some embodiments, the transvalvular bridge 500 is formed from a single length of material. The skeleton frame of the transvalvular bridge 500 can be unitarily formed. The transvalvular bridge 500 can be monolithic. In some embodiments, the transvalvular bridge 500 is formed or several lengths of material. The transvalvular bridge 500 can include two or more struts. The transvalvular bridge 500 can include crossing or overlapping struts. The transvalvular bridge 500 can include a shape memory material. In some embodiments, the bend angles and orientation of the struts can be readily altered, to accommodate the desired axes of compression which may be desirable for a particular deployment procedure.

[0156] The transvalvular bridge 500 can include an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. The first anchoring portion and the second anchoring portion are configured to be attached to the annulus. In some embodiments, the first anchoring portion and the first anchoring portion reside on an anterior-septal-posterior diameter. The A- S-P diameter spans the valve opening. The A-S-P diameter extends from the anterior annulus along the coaptive edge between the septal annulus and posterior annulus. This anterior- septal-posterior alignment of the transvalvular bridge 500 on tricuspid is illustrated in FIG. 3B. This anterior-septal-posterior alignment of the transvalvular bridge 500 is transverse to coaptive edge formed by the anterior leaflet. This anterior-septal-posterior alignment of the transvalvular bridge 500 is along to coaptive edge formed by the posterior and septal leaflets.

[0157] In some embodiments, transvalvular bridge 500 can include a plurality of crossing struts. The struts can comprise Nitinol. The struts can form an X shape. The struts can comprise a shape memory material. In some embodiments, transvalvular bridge 500 can include a plurality of crossing struts encapsulated by a material. The transvalvular bridge 500 does not comprise an annuloplasty ring. The transvalvular bridge 500 can be configured for trileaflet valves.

[0158] In some embodiments, the central portion comprises a convex arcuate shape. In some embodiments the central portion is configured to be displaced transversely from an intraannular plane when the transvalvular bridge 500 is attached to an annulus. In some embodiments, the central portion is configured to be convex in a direction of outflow to support valve leaflets at a point displaced toward a ventricle from the intraannular plane. In some embodiments, the central portion is curved downward toward the right ventricle. In some embodiments, the central portion lowers the leaflets toward the right ventricle. In some embodiments, the central portion lowers the point of coaptation.

[0159] Tricuspid regurgitation is prevalent in patients with heart disease. However, treatment has been lagging behind treatment for the mitral valve. Surgical treatment is increasing. The transvalvular bridge 500, as well as the alignment of the transvalvular bridge 500, can be advantageous.

[0160] FIG. 16A-16B are view of alignments of the transvalvular bridge 500 relative to the tricuspid annulus. The transvalvular bridge 500 alignment has no known predicate either in surgical or transcatheter tricuspid repair. The transvalvular bridge 500 can be positioned along the A-S-P diameter. The transvalvular bridge 500 can be anchored on the anterior annulus on the A-S-P diameter. The transvalvular bridge 500 can be anchored on the posterior annulus on the A-S-P diameter. The transvalvular bridge 500 can be anchored on the septal annulus on the A-S-P diameter. The A-S-P diameter extends between the anterior annulus and both the septal annulus and posterior annulus. The transvalvular bridge 500 can extend across one or more leaflets on the A-S-P diameter. The A-S-P diameter can extend through a midpoint of the anterior leaflet. The A-S-P diameter can extend over the anterior leaflet. The A-S-P diameter can extend along the coaptive edge formed from the posterior leaflet and the septal leaflet. The A-S-P diameter can extend along the posterior leaflet. The A-S-P diameter can extend along the septal leaflet. The A-S-P diameter can extend over all three leaflets. The A-S-P diameter can position the transvalvular bridge 500 relative to all three leaflets. The longitudinal axis of the transvalvular bridge 500 can align along the A-S-P diameter. The A-S-P diameter can allow for anchoring of the transvalvular bridge 500 on the annulus. FIG. 16A illustrates this alignment with a blue arrow.

[0161] FIG. 16B illustrates the location of anchors for the transvalvular bridge 500 implantation. The blue area represents the anterior anchors. The green area represents the septal posterior anchors. The blue area can correspond to the first attachment structure 504 at the first end of the transvalvular bridge 500. The green area can correspond to the second attachment structure 526 at the second end of the transvalvular bridge 500. The attachment structures 504, 526 can include one or more apertures 508 which can anchor the transvalvular bridge 500 to the annuluses. The first attachment structure 504 can include two apertures 508. The first attachment structure 504 can couple to two anchors coupled to the anterior annulus. The second attachment structure 526 can include two apertures 508. The second attachment structure 526 can couple to two anchors. In some embodiments, the second attachment structure 526 can couple to one anchor coupled to the posterior annulus and one anchor coupled to the septal annulus. In some embodiments, the second attachment structure 526 can couple one or more anchors coupled to the posterior annulus. Tn some embodiments, the second attachment structure 526 can couple one or more anchors coupled to the septal annulus. In some embodiments, the second attachment structure 526 can couple to the posterior annulus beyond the septal-posterior commissure. In some embodiments, the second attachment structure 526 can couple to the septal annulus beyond the septal-posterior commissure.

[0162] FIG. 17 illustrates an embodiment of an anchor 550 for anchoring the transvalvular bridge 500. The anchors can engage the annulus. The valve annulus can be a fibrous ring or structure which provides support. In some embodiments, the anchors engage the more robust tissue of the annulus than the leaflets. The anchors can be subannular anchors. The anchors can be expanding anchors. The anchors can be helical anchors. The anchors can include a central post 552 configured to engage the transvalvular bridge 500. The central post 552 can extend through the aperture of the transvalvular bridge 500. The anchors can include sutures 554 that act as guide rails for delivery of the transvalvular bridge 500. In some methods, the anchors 550 are inserted into tissue before the transvalvular bridge 500 is positioned. The suture 554 can be threaded through the aperture 508 of the first anchoring portion 504. The transvalvular bridge 500 can include two or more aperture 508 of the first anchoring portion 504. The transvalvular bridge 500 can include two or more aperture 508 of the second anchoring portion 526.

[0163] The anchor 550 can be positioned on the anterior annulus. In some methods, two or more anchors can be positioned on the anterior annulus. The two or more anchors can be aligned. The two or more anchors can be parallel. The two or more anchors can be spaced apart a predetermined distance. The two or more anchors can be positioned on either side of a midpoint of the anterior annulus. The two or more anchors can be positioned through the anterior annulus to a subannuluar space.

[0164] The anchor 550 can be positioned on the posterior annulus. In some methods, one or more anchors can be positioned on the posterior annulus. The anchor 550 can be positioned on the septal annulus. In some methods, one or more anchors can be positioned on the septal annulus. The two or more anchors can be positioned beyond the posteroseptal commissure. The two or more anchors can be positioned beyond and on either side of the posteroseptal commissure.

-SO- [0165] The anchor 550 on the posterior annulus and the anchor 550 on the septal annulus can be aligned. The anchor 550 on the posterior annulus and the anchor 550 on the septal annulus can be parallel. The anchor 550 on the posterior annulus and the anchor 550 on the septal annulus can be spaced apart a predetermined distance. The anchor 550 can be positioned on the annulus beyond the beyond the septal-posterior commissure. The anchor 550 on the posterior annulus and the anchor 550 on the septal annulus can be positioned beyond and on either side of the coaptive edge of the septal leaflet and the posterior leaflet. The anchor 550 on the posterior annulus and the anchor 550 on the septal annulus can be positioned through the posterior annulus and the septal annulus.

[0166] FIG. 18 is a view of an alignment of the transvalvular bridge 500 on tricuspid annulus. The transvalvular bridge 500 alignment has no known predicate. The transvalvular bridge 500 can be anchored to the tricuspid annulus on the A-S-P diameter. The A-S-P diameter provides advantages to anchoring the transvalvular bridge 500. The transvalvular bridge 500 can be anchored to the anterior annulus. The transvalvular bridge 500 can be anchored to the posterior annulus, the septal annlulus, or both the posterior annulus and the septal annulus. In some embodiments, the transvalvular bridge 500 can be anchored to all three annuluses. The transvalvular bridge 500 can span across the valve along a midpoint of the valve. In some embodiments, the transvalvular bridge 500 can be anchored to the anterior and septal annulus of the tricuspid valve. In some embodiments, the transvalvular bridge 500 can be anchored to the anterior and posterior annulus of the tricuspid valve. In some embodiments, the transvalvular bridge 500 can be anchored to the anterior, posterior, and septal posterior annulus of the tricuspid valve. The transvalvular bridge 500 can span across the tricuspid valve. In some embodiments, the transvalvular bridge 500 can couple all three annuluses. The annulus can provide more robust anchoring than the leaflet. The transvalvular bridge 500 couples spans across all three leaflets. In some embodiments, the transvalvular bridge 500 can be anchored to all three annuluses. In some embodiments, the transvalvular bridge 500 can be anchored to at least two annuluses of the tricuspid valve.

[0167] The transvalvular bridge 500 alignment is shown in red. In some embodiments, the transvalvular bridge 500 alignment can extend from a midpoint of the anterior leaflet. In some embodiments, the transvalvular bridge 500 alignment is centered on the anterior leaflet. Tn some embodiments, the transvalvular bridge 500 alignment passes toward the posterior septal commissure. In some embodiments, the transvalvular bridge 500 alignment passes between the posterior annulus and the septal annulus. In some embodiments, the transvalvular bridge 500 alignment positions the bridge on the posterior leaflet and the septal leaflet. In some embodiments, the transvalvular bridge 500 alignment is anchored to all three annuluses. In some embodiments, the transvalvular bridge 500 alignment is anchored to the anterior annulus, the posterior annulus, and the septal annulus with a single device. In some embodiments, the transvalvular bridge 500 alignment spans the coaptive edge formed by the anterior leaflet and both the septal leaflet and the posterior leaflet.

[0168] FIG. 19 illustrates the position of the anchors for the transvalvular bridge 500 alignment. The anchors can be on both sides of the midpoint of the anterior annulus. The anchors can straddle the commissure between the posterior and septal annulus. The anchors can be deployed at the red marks. In some embodiments, transvalvular bridge 500 alignment can be more toward the posterior annulus than the septal annulus. In some embodiments, transvalvular bridge 500 alignment can be more toward the septal annulus than the posterior annulus. In some embodiments, transvalvular bridge 500 alignment is located at a midpoint between the posterior annulus and the septal annulus. In some embodiments, transvalvular bridge 500 alignment straddles the posteroseptal commissure.

[0169] Any of a wide variety of specific tissue anchor constructions may be utilized in combination with the transvalvular bridge 500. In addition, a variety of features have been described as illustrative in connection with a variety of implementations of the transvalvular bridge 500. Any of the features described above, may be recombined with any other of the embodiments disclosed herein, without departing from the present invention, as should be apparent to those of skill in the art. In some embodiments, the transvalvular bridge 500 does not include a complete or partial annuloplasty ring, and/or does not affect or substantially affect the size and/or shape of the valve annulus when operably attached to the valve annulus.

[0170] While the foregoing detailed description has set forth several exemplary embodiments of the apparatus and methods of the present invention, it should be understood that the above description is illustrative only and is not limiting of the disclosed invention. It will be appreciated that the specific dimensions and configurations disclosed can differ from those described above, and that the methods described can be used within any biological conduit within the body.

[0171] FIGS. 20A-20C illustrate an embodiment of a transvalvular implant 100. The transvalvular implant 100 can improve valve leaflet coaptation and prevent or reduce mitral regurgitation. The transvalvular implant 100 can also be referred to herein as a transvalvular bridge. FIG. 20A is a perspective view of the transvalvular implant 100. FIG. 20B is a side view of the transvalvular implant 100. FIG. 20C is a top view of the transvalvular implant 100.

[0172] In some embodiments, the transvalvular implant 100 comprises an elongate and curved structure. The transvalvular implant 100 can include a first end 102 and a second end 104. The second end 104 can be opposite the first end 102. The transvalvular implant 100 can have a length between the first end 102 and the second end 104 to span the valve as described herein. The transvalvular implant 100 can have a length between the first end 102 and the second end 104 that is capable of extending across the annulus. The transvalvular implant 100 can include a central portion 106. The central portion 106 can be located between the first end 102 and the second end 104.

[0173] The transvalvular implant 100 can be symmetrical. The transvalvular implant 100 can be symmetrical about the central portion 106. The transvalvular implant 100 can be symmetrical vertically. The transvalvular implant 100 can be symmetrical horizontally. Features described in relation to the first end 102 can apply to features of the second end 104. The first end 102 and the second end 104 can be identical. The first end 102 and the second end 104 can be substantially similar. In some embodiments, the first end 102 has different features than the second end 104. The first end 102 and the second end 104 can have different dimensions. The first end 102 and the second end 104 can have different attachment structures.

[0174] The transvalvular implant 100 can include a lower surface 106 disposed toward the annulus and an upper surface disposed away from the annulus. The transvalvular implant 100 can include a leaflet contact surface 108. The leaflet contact surface 108 can be convex along the longitudinal axis. The leaflet contact surface 108 can be configured to contact one or both leaflets, as described herein. In other embodiments, the leaflet contact surface 108 can have a different shape and profile. The leaflet contact surface 108 can be concave. The leaflet contact surface 108 straight. The leaflet contact surface 108 can be a combination of convex, concave and/or straight. The leaflet contact surface 108 can include two concave or straight portions joined together at an apex.

[0175] The transvalvular implant 100 can have a substantially maximum width at the first end 102. The transvalvular implant 100 can have a substantially maximum width at the second end 104. The transvalvular implant 100 can have a substantially maximum width at either end 102, 104 or both ends 102, 104. The transvalvular implant 100 can have a substantially minimum width at the central portion 106. The transvalvular implant 100 can taper along a portion of the length of the transvalvular implant 100. The transvalvular implant 100 can taper from the maximum width at the ends 102, 104 to the minimum width at the central portion 106. The transvalvular implant 100 can form a generally X shape. The sides of the transvalvular implant 100 can include in an indent toward the central portion 106. The sides of the transvalvular implant 100 can form a generally V shape. The sides of the transvalvular implant 100 can be pinched inward.

[0176] The transvalvular implant 100 can include a first anchoring portion 112. The transvalvular implant 100 can include a second anchoring portion 114. The first anchoring portion 112 can be disposed toward the first end 102. The second anchoring portion 114 can be disposed toward the second end 104. In some embodiments, the first end 102 can include the first anchoring portion 112 and the second end 104 can include the second anchoring portion 114.

[0177] The anchoring portions 112, 114 can have eyelets 116. The first anchoring portion 112 can include one or more eyelets 116. The first anchoring portion 112 can include two eyelets 116. The two eyelets 116 of the first anchoring portion 112 can be aligned. The two eyelets 116 of the first anchoring portion 112 can be offset. The two eyelets 116 of the first anchoring portion 112 can be spaced apart. The second anchoring portion 114 can include one or more eyelets 116. The second anchoring portion 114 can include two eyelets 116. The two eyelets 116 of the second anchoring portion 114 can be aligned. The two eyelets 116 of the second anchoring portion 114 can be offset. The two eyelets of the second anchoring portion 114 can be spaced apart. [0178] The eyelets 1 16 can be for accepting anchors. The eyelets 1 16 can be for accepting sutures. The eyelets 116 can be for accepting tethers than extend from a portion of the anchors, as described herein. The eyelets 116 can be for accepting a central post of the anchors, as described herein. The eyelets 116 can be for accepting any device that allow the transvalvular implant 100 to be secured to the annulus. In some embodiments, the anchors are implanted before the transvalvular implant 100 is positioned relative to the annulus. The eyelets 116 can serve as guides as the transvalvular implant 100 is lowered toward the annulus. The transvalvular implant 100 can slide along a guide tether that extends through the eyelets 116. Alternatively, in other embodiments the anchoring portions 112 and 114 can have other means for securing the transvalvular implant 100 to the annulus.

[0179] The transvalvular implant 100 can have a central opening 118. The central opening 118 can be enclosed by the transvalvular implant 100. The central opening 118 can have a length and width. The transvalvular implants can become narrower toward the center. In some embodiments, the width of the central opening 118 is between about 5% and about 80% of the maximum width of the transvalvular implant 100, such as between about 25% and about 50%, or about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or 80% of the width of the first end 102 and the second end 104. In some embodiments, the length of the central opening 118 is between about 5% and about 80% of the maximum length of the transvalvular implant 100, such as between about 25% and about 50%, or about 5%, 10%, 15%, 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, 75% or 80% of the length between the first end 102 and the second end 104.

[0180] The central opening 118 can be any shape. The central opening 118 can be X shaped. The central opening 118 can be completely open to allow blood to flow through. The central opening 118 can be completely open to allow tools or other implants to be passed through. The central opening 118 can be separated and distinct from the holes of the anchoring portions 112, 114. The central opening 118 can be uncoated. The c transvalvular implant 100 does not obstruct the flow of blood during use due to the central opening 118. The outline of the transvalvular implant 100 can form the central opening 118. The central opening 118 can extend through the central portion 106.

[0181] The central portion 106 can have a variety of shapes. For example, the shape of the central portion 106 can be substantially X shaped, rectangular, circular, oblong or triangular. The edges of the transvalvular implant 100 can be rounded or otherwise configured so that the transvalvular implant 100 presents an atraumatic surface to the valve leaflets. In some embodiments, the shape can be oriented in a particular fashion to enhance performance of the transvalvular implant 100. The transvalvular implant 100 can include generally two shaped ends which can be designed so that a relatively larger surface is toward the ends while a smaller surface is towards the middle. This configuration allows a larger surface area to make contact with the annulus. This configuration allows a smaller surface area to be in the direction of flow. This design can be a more streamlined shape that provides less resistance to blood flowing from the left atrium to the left ventricle. Decreasing the resistance to blood flow is desirable because it can reduce turbulence and reduce the impedance of the transvalvular implant 100 on the filling of the left ventricle. The transvalvular implant 100 can have any shape that increases the surface area for contact with the valve leaflets and/or reduces the resistance to blood flow.

[0182] The dimensions of the transvalvular implant 100 will vary, depending upon the specific configuration of the transvalvular implant 100 as well as the intended patient. In general, the transvalvular implant 100 will have an axial length from first end 102 to second end 104 within the range of from about 20 mm to about 32 mm. In one embodiment, intended for a typical male adult, the axial length of the transvalvular implant 100 is about 24 mm to 26 mm. The width of the transvalvular implant 100 in the central zone 106 may be varied depending upon the desired performance, as will be discussed herein. In general, the leaflet contact surface 108 is preferably large enough to minimize the risk of erosion resulting from repeated contact between the closed leaflets and the transvalvular implant 100. The width of the leaflet contact surface 108 is preferably minimized to minimize flow turbulence and flow obstruction. In general, widths of the leaflet contact surface 108 measured perpendicular to the flow of blood are presently contemplated to be less than about 5 mm, and often within the range of from about 5 mm to about 10 mm in the zone of coaptation.

[0183] The central portion 106 of the transvalvular implant 100 can be narrower in width, measured perpendicular to blood flow than the first and second anchoring portions 112 and 114. By narrowing the central portion 106, the resistance to blood flow can be reduced. In some embodiments, narrowing the central portion 106 reduces the surface area of the leaflet contact surface 108 that supports the valve leaflets. Tn some embodiments, the narrowed central portion 106 is separated from the first anchoring portion 112 and the second anchoring portion 114 by a first shoulder 122 and a second shoulder 124. The length of the central portion 106, between first shoulder 122 and second shoulder 124, can be less than about 50% of the overall length of the transvalvular implant 100. The length of the central portion 106 can be less than about 30% of the overall length of the transvalvular implant 100. The length of the central portion 106 can be less than about 10% of the overall length of the transvalvular implant 100. The length of the central portion 106 can be designed to minimize the obstruction in the center of the flow path. Alternatively, the length of the central portion 106 may be greater than 50%, and in some embodiments greater than 75% of the overall length of the transvalvular implant 100. The transvalvular implant 100 can present a wider transverse surface for supporting the leaflets when the valve is closed. In some embodiments, the central portion 106 can be generally convex in the direction of the ventricle. In some embodiments, the central portion 106 can be generally concave.

[0184] The transvalvular implant 100 can be formed from a single length of wire. The transvalvular implant 100 can be formed form several lengths of wire. The transvalvular implant 100 can be formed from a continuous wire. The transvalvular implant 100 can be formed from separate pieces of wire joined together. The transvalvular implant 100 can be formed from flexible wire. The bend angles and orientation of the wire can be readily altered to accommodate the desired axes of compression which may be desirable for a particular deployment procedure. The transvalvular implant 100 can be formed from any biocompatible material. The transvalvular implant 100 can be formed from stainless steel. The transvalvular implant 100 can be formed metal. The transvalvular implant 100 can be formed shape memory material. The transvalvular implant 100 can be formed from Nitinol. In some embodiments, a portion of the transvalvular implant 100 is coated. In some embodiments, the transvalvular implant 100 is uncoated. In some embodiments, at least the central opening 118 of the transvalvular implant 100 is uncoated. In some embodiments, the transvalvular implant 100 is not encased with a material. In some embodiments, at least the central opening 118 of the transvalvular implant 100 is not encased with a material.

[0185] The transvalvular implant 100 can include a shaped body. The transvalvular implant 100 comprises an elongate flexible wire formed into a X shaped pattem. The transvalvular implant 100 can includes four legs forming the X shape. The transvalvular implant 100 can include open spaces between the legs. The transvalvular implant 100 can include an outline of the X shaped pattern. The transvalvular implant 100 can be any shape for providing a support for the valve leaflets as discussed herein. The transvalvular implant 100 can include a wire which may be formed such that it bows or inclines in the direction of the ventricle to achieve early closure as discussed herein. The wire may extend to form the first end 102 and the second end 104. The wire may form a complete circle to enclose the eyelet 116 of the first anchoring portion 112. The wire may form a complete circle to enclose the eyelet 116 of the second anchoring portion 114. The wire may form two eyelets 116 of the first anchoring portion 112. The wire may form two eyelets 116 of the second anchoring portion 114. The wire may enclose the central opening 118.

[0186] The transvalvular implant 100 can form a continuous shape. The wire can extend from a starting point, form an coil or eyelet 116 of the first anchoring portion 112, extend along the side of the implant forming a pinched in shape near the central portion 106, form an coil or eyelet 116 of the second anchoring portion 114, form a bowed inward shape, form an coil or eyelet 116 of the second anchoring portion 114, extend along the side of the implant forming a pinched in shape near the central portion 106, form an coil or eyelet 116 of the first anchoring portion 112, form a bowed inward shape to the starting point. The transvalvular implant 100 can form an outlined shape. The transvalvular implant 100 can include two legs of the first anchoring portion 112 separated by a bowed inward shape. The transvalvular implant 100 can include two legs of the second anchoring portion 114 separated by a bowed inward shape. The transvalvular implant 100 can include a leg of the first anchoring portion 112 and a leg of the second anchoring portion 114 pinched inward near the central portion 106. The transvalvular implant 100 can include the other leg of the first anchoring portion 112 and the other leg of the second anchoring portion 114 pinched inward near the central portion 106. The transvalvular implant 100 can include a continuous outline. The transvalvular implant 100 can include a X shaped enclosed space. The transvalvular implant 100 can include one or more coils that form each eyelet 116. The transvalvular implant 100 can form an closed shape. The transvalvular implant 100 can connect the starting point and the ending point. [0187] This design can provide a relatively large support footprint against the valve leaflets, while at the same time optimizing the area of open space to permit maximum blood flow therethrough. The transvalvular implant 100 can be made of any appropriate material, such as a metal. The transvalvular implant 100 can be made of a shape memory metal such as Nitinol. The transvalvular implant 100 may be formed from any of a variety of flexible materials, including various polymers described elsewhere herein as well as titanium, titanium alloy, Nitinol, stainless steel, elgiloy, MP35N, or other metals known in the art. The transvalvular implant 100 can be treated or coated. The transvalvular implant 100 can be encapsulated with silicone or another appropriate material, in order to eliminate untoward effects such as thrombosis or corrosion. The design may be treated or coated with silicone or other suitable material to eliminate untoward effects such as thrombosis or corrosion. Treatments may be sequential and include more than one listed but not limited to electropolishing, harperization, tumbling, pickling, plating, encapsulation or physical vapor deposition of appropriate materials. The transvalvular implant 100 can be free from a coating.

[0188] The transvalvular implant 100 can be made of single Nitinol wire. The transvalvular implant 100 can be free of any silicone central implant. The transvalvular implant 100 can include the central opening 118 in the center of the implant. The central opening 118 can be completely open, allowing blood to flow through the implant. The transvalvular implant 100 can allow potential for future transcatheter intervention with other transcatheter devices. The transvalvular implant 100 can be generally X shaped. The transvalvular implant 100 can include attachment points. The transvalvular implant 100 can include two eyelets 116 at each end 102, 104. The transvalvular implant 100 can include the arcuate central portion 106. The transvalvular implant 100 can be curved downward into left ventricle cavity or into left atrium. The transvalvular implant 100 can from an arch. The transvalvular implant 100 can from a mitral arch. The transvalvular implant 100 can from a tricuspid arch. The transvalvular implant 100 can form a mitral straddle. The transvalvular implant 100 can form a tricuspid straddle. The transvalvular implant 100 can straddle the valve.

[0189] FIGS. 21A-21C illustrate an embodiment of a transvalvular implant 200. The transvalvular implant 200 can improve valve leaflet coaptation and prevent or reduce regurgitation. The transvalvular implant 200 can improve mitral valve leaflet 24 and 26 coaptation and prevent or reduce mitral regurgitation. The transvalvular implant 200 can improve tricuspid valve leaflet coaptation and prevent or reduce tricuspid regurgitation. The transvalvular implant 200 can include any features of the transvalvular implant 100 described herein. The transvalvular implant 200 can also be referred to herein as a transvalvular bridge or a mitral bridge. FIG. 21A is a top view of the transvalvular implant 200. FIG. 2 IB is a view of the transvalvular implant 200 positioned relative to the anatomy. FIG. 21C is a top view of the transvalvular implant 200 with an additional feature. The transvalvular implant 200 can include a first end 202 and a second end 204. The transvalvular implant 200 can include a central portion 206. The transvalvular implant 200 can include a leaflet contact surface 208. The transvalvular implant 200 can include a first anchoring portion 212 and a second anchoring portion 214. The transvalvular implant 200 can have eyelets 216 and a central opening 218.

[0190] The transvalvular implant 200 comprises an elongate flexible wire formed into a shaped pattern. The transvalvular implant 200 can be formed from a single length of wire. The transvalvular implant 200 can be formed form several lengths of wire. The transvalvular implant 200 can be formed from shape set wire. The bend angles and orientation of the wire can be altered before implantation to accommodate the desired axes of compression. The transvalvular implant 200 can be formed of a single nitinol wire.

[0191] The transvalvular implant 200 comprises an elongate flexible wire formed into a shaped pattern. The transvalvular implant 200 can be any shape for providing a support for the valve leaflets as has been discussed herein. The transvalvular implant 200 can include a shape which can be planar. The transvalvular implant 200 can include a shape which can be non-planar. The wire may extend to from the first end 202 and the second end 204. The wire may form a complete circle to enclose the eyelet 216 of the first anchoring portion 212. The wire may form a complete circle to enclose the eyelet 216 of the second anchoring portion 214. The wire may form two eyelets 216 of the first anchoring portion 212. The wire may form two eyelets 216 of the second anchoring portion 214.

[0192] The transvalvular implant 200 can form a continuous shape. The wire can form an coil or eyelet 116 of the first anchoring portion 212, extend along the side of the implant forming a pinched in shape near the central portion 206, form an coil or eyelet 116 of the second anchoring portion 214, extend generally straight across the second anchoring portion 214, form an coil or eyelet 116 of the second anchoring portion 214, extend along the side of the implant forming a pinched in shape near the central portion 206, form an coil or eyelet 116 of the first anchoring portion 212. The coils or eyelets of the first anchoring portion 212 can be not directly connected. The transvalvular implant 200 can form an open shape. The starting point and the ending point of the transvalvular implant 200 can be disconnected.

[0193] The transvalvular implant 200 can include two eyelets 216 of the first anchoring portion 212 separated and unconnected. The transvalvular implant 200 can include two eyelets 216 of the second anchoring portion 214 separated and connected by the wire. The transvalvular implant 200 can include a leg of the first anchoring portion 212 and a leg of the second anchoring portion 214 pinched inward near the central portion 206. The transvalvular implant 200 can include the other leg of the first anchoring portion 212 and the other leg of the second anchoring portion 214 pinched inward near the central portion 206. The transvalvular implant 200 can include a discontinuous outline. The transvalvular implant 200 can include any shape. The transvalvular implant 200 can include one or more coils that form each eyelet 216. The transvalvular implant 100, 200 can have any shape to cover any anatomical area.

[0194] In ischemic mitral regurgitation, the MR jet is pointed between the P2 and P3 junction. Other current surgical and transcatheter mitral bridge designs may not cover this area, leading to recurrences in extreme cases of IMR. The transvalvular implant 100, 200 can have any shape to cover any anatomical area.

[0195] The transvalvular implant 200 can be symmetrical. The transvalvular implant 200 can be symmetrical about one axis extending across the valve. The transvalvular implant 200 can be asymmetrical about another axis. The transvalvular implant 200 can be asymmetrical about the central portion 206. The first end 202 and the second end 204 can be different. Figure 21C illustrates the transvalvular implant 200 with an additional feature. The transvalvular implant 200 can have one or more additional strands of wire. The transvalvular implant 200 can include a wire connecting the second end 204 or a portion thereof to a side. The transvalvular implant 200 can include an expanded posterior part. The transvalvular implant 200 can include can include an asymmetric feature. The transvalvular implant 200 can include an expanded part that is non-planar with the single wire that forms the shape. The additional feature can provide support to the transvalvular implant 200. The additional feature can act as a spring.

[0196] FIGS. 22A-22F illustrate additional features of transvalvular implants described herein. Figure 22A illustrates a central opening. The central opening 118, 218 can be designed to have a bigger opening. The central opening 118, 218 can have any size. The central opening 118, 218 can be a 9 Fr. central opening 118, 218. The central opening 118, 218 can be 1 Fr., 2 Fr., 3 Fr., 4 Fr., 5 Fr., 6 Fr., 7 Fr., 8 Fr., 9 Fr., 10 Fr., 11 Fr., 12 Fr., 13 Fr., 14 Fr., 15 Fr., 16 Fr., 17 Fr., 18 Fr., 19 Fr., 20 Fr., or any range of two of the foregoing values. The transvalvular implants can include floating anchor attachment points. The transvalvular implants can include eyelets that are separate and distinct. The transvalvular implants can include eyelets are that are not directly and longitudinally connected. The transvalvular implants can include eyelets that are on the ends of each leg. Figure 22A illustrates floating anchor attachment points.

[0197] The transvalvular implants can include fixed anchor attachment points. The transvalvular implants can include eyelets that are linked. The transvalvular implants can include eyelets are that are directly and longitudinally connected. The transvalvular implants can include eyelets that are on the ends of each leg, wherein each leg further connected. Figure 22B illustrates fixed anchor attachment points. The transvalvular implants can include a felt pad attachment at the anchor point. The transvalvular implants can include additional structures at the anchor points. For example, the anchoring portions can be made of a membrane or other fabric-like material such as Dacron or ePTFE. Sutures can be threaded directly through the fabric and through the eyelets. The fabric can be attached to the other portions of the transvalvular implants by a variety of techniques. For example, the fabric can be attached to the other portions of the transvalvular implants with the use of an adhesive, by suturing, by tying, by clamping or by fusing the parts together. The transvalvular implants can include silicone over mold over nitinol wire frame. The central opening 118, 218 can remain open.

[0198] Figure 22C illustrates some dimensions of the transvalvular implants. The dimensions of the transvalvular implants will vary, depending upon the specific configuration of the transvalvular implants as well as the intended patient. In the illustrated embodiment, the transvalvular implant has a length of 24 mm. The transvalvular implant has a central opening with a length of 5.7 mm. The transvalvular implant has a central opening with a width of 3.2 mm. The transvalvular implant has a width of 9.7 mm from eyelet to eyelet. Figure 22D illustrates that the transvalvular implants can form a serpentine shape. The transvalvular implants can expand to annulus bridge.

[0199] Figure 22E illustrates two designs. The top design has a central opening and the bottom design has a larger central opening. In the illustrated top embodiment, the transvalvular implant has a .11 Fr dimension. The transvalvular implant has a central opening with a length of 6.6 mm. The transvalvular implant has a central opening with a width of 3.6 mm. In the illustrated bottom embodiment, the transvalvular implant has a .18 Fr dimension. The transvalvular implant has a central opening with a length of 11 mm. The transvalvular implant has a central opening with a width of 6 mm. In the illustrated bottom embodiment, the central orifice is opened up. The central opening can be enlarged to facilitate MitraClip® deployment. The MitraClip® can be deployed in addition to the transvalvular implants. The MitraClip® can be deployed in case of failure the transvalvular implants.

[0200] Figure 22F illustrates deployment of the transvalvular implants. The key attributes can include reducing the annular diameter. The key attributes can include reducing the septo-lateral mitral annular diameter. The key attributes can include promoting early coaptation of the valve leaflets. The key attributes can include that it does not constrain future interventions. The key attributes can include transcatheter delivery. The transvalvular implants can be considered an arch or straddle. The transvalvular implants can be for functional regurgitation. The transvalvular implants can be considered a mitral arch or mitral straddle. The transvalvular implants can be for function mitral regurgitation. The transvalvular implants can be considered a tricuspid arch or tricuspid straddle. The transvalvular implants can be for function tricuspid regurgitation. The transvalvular implants can include a first anchoring portion and a second anchoring portion. The transvalvular implants can include a skeleton.

[0201] The transvalvular implants can include an elongate body having a first end, a second end, and a central portion connected to the first end and the second end. The central portion can include a convex arcuate shape. The elongate body can form a generally X shape skeleton comprising Nitinol. The transvalvular implants can include a first anchoring portion of the skeleton which includes two rings, each ring defining an aperture. The first anchoring portion can be located proximate the first end. The transvalvular implants can include a second anchoring portion of the skeleton which includes two rings, each ring defining an aperture. The second anchoring portion can be located proximate the second end. The central portion can be configured to be displaced transversely from an intraannular plane when the implant is attached to an annulus. The first anchoring portion and the second anchoring portion can be configured to be attached to the annulus within the intraannular plane. The central portion can be configured to be convex in a direction of outflow to support valve leaflets at a point displaced toward a ventricle from the intraannular plane. The first end and the second end reside on a septal-lateral axis transverse to coaptive edges of the valve leaflets when the transvalvular implant is attached to the annulus. The transvalvular implants do not comprise an annuloplasty ring.

[0202] The transvalvular implants can become narrower toward the center. In some embodiments, the width in the central portion is between about 20% and about 80%, such as between about 25% and about 50%, or about 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% of the width of the first end and the second end. The transvalvular implants can gradually narrow toward the center as illustrated. In some embodiments, the width in the central portion can be between about 4 mm and about 7 mm, such as between about 5mm and about 6mm, or about 5 mm, about 5.2 mm, about 5.4 mm, about 5.6 mm, about 5.8 mm, or about 6 mm. By narrowing the central portion, the resistance to blood flow can advantageously be reduced.

[0203] The transvalvular implants can include a thickness. The thickness can correspond to the diameter of the wire. The thickness can correspond to the coils of wire at the eyelets. The thickness can be defined by any layers added to the anchoring portions. The transvalvular implants can omit an encapsulation layer. The transvalvular implants can omit an encapsulation layer to form the central opening. The transvalvular implants can include one or more additional layers near the anchoring portions. The anchoring portions can have a relatively greater thickness than the thickness of the central portion. In some embodiments, the anchoring portions can have a thickness that is between about 25% and about 75% greater than that of the central portion, such as between about 40% and about 60% greater, or about 25%, 30%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% greater than the thickness of the central portion. In some embodiments, the central portion can have a thickness of between about 0.5 mm and about 1.0 mm, such as about 0.6 mm, 0.7 mm, or 0.8 mm. In some embodiments, the anchoring portions can have a thickness of between about 0.8 mm and about 1.3 mm, such as about 0.9 mm, 1.0 mm, 1.05 mm, 1.07 mm, 1.1 mm, or 1.2 mm.

[0204] The transvalvular implants can have an axial length of between about 15 mm and about 40 mm, such as between about 20 mm and about 32 mm depending on the patient’s anatomy. The central portion of the transvalvular implants can have an axial length in some embodiments of between about 8 mm and about 24 mm, such as between about 12 mm and about 20 mm in some embodiments. In some embodiments, the width of the anchoring portions can be between about 10 mm and about 20 mm, and about 15 mm in some embodiments.

[0205] The transvalvular implants can include a wire which forms a skeleton layer. The transvalvular implants be formed of a shape set Nitinol skeleton. The transvalvular implants can be convex in the direction of the ventricle. The lateral ends of the skeleton can include eyelets defining apertures that can be utilized for anchoring. The skeleton can include a lateral curved transition zone, which has a first curvature. The skeleton can include a medial curved transition zone which has a second curvature different from the first curvature. The skeleton can include any curvature. The skeleton can include a planar surface. The skeleton can the vertex of the arcuate central portion.

[0206] As described above, the mitral valve and supporting structures are composed of the valve annulus, two leaflets, chordae tendineae, and papillary muscles. The anterior and posterior leaflets, oriented in the septal-lateral direction, provide for closing the valve opening during systole. During systole, the annulus and valvular surface create a saddle shape optimizing forces during closure by arching. The chordae and papillary muscles work together to limit the leaflet coaptation to the intraannular plane. The mitral valve has a saddle shape. As the saddle gets deeper, the commissures drop, and the anteroposterior diameter contracts. This contraction results in a compressive load on the transvalvular implant. During this contraction, the pressure behind the leaflets causes them to contact the transvalvular implant. In some embodiments, the transvalvular implant is configured to withstand a total circumferential or compressive force applied to the transvalvular implant of at about or at least about O.35N, 0.40N, 0.45N, 0.50N, or about 0.368N per cardiac cycle in some embodiments. Tn some embodiments, the transvalvular implant can be configured to tolerate a septal-lateral displacement of about or at least about 0.4mm, 0.5mm, or 0.6mm during the cardiac cycle. As such, the transvalvular implant can be configured to withstand load in cyclic fatigue without damage allowing long term function; maintain an AP diameter or septal-lateral diameter for early coaptation eliminating regurgitation; and/or maintain an AP diameter facilitating LV remodeling. In some embodiments the transvalvular implant can be configured to tolerate a displacement of about 0.5mm in compression and tension. The average force to displace a device ± 0.5mm is between about 0.80N and about O.85N, such as about 0.8358N in tension; and between about 0.60N and about 0.70N, such as about 0.63808N in compression. The forces found are over double the circumferential forces. The transvalvular implant can be configured, when implanted, to withstand such forces and continue to stably function to improve valve coaptation without being damaged, displaced, or substantially displaced as noted above. The transvalvular implant can thus be configured to tolerate, in some embodiments, a tension force of about or at least about 0.75N, 0.80N, 0.85N, 0.90N, 0.95N, l.OON, or more. The transvalvular implant can thus be configured to tolerate, in some embodiments, a compression force of about or at least about 0.55N, 0.60N, 0.65N, 0.70N, 0.75N, 0.80N, or more.

[0207] One of the objectives of the present invention is to not merely provide support to the leaflets during systole, but to elevate the plane of coaption in the direction of the ventricle, to cause early coaption (closure) relative to the cardiac cycle, as is discussed elsewhere herein. The variation in conditions, and other patient to patient variations may warrant production of the transvalvular implant of the present invention in an array of sizes and/or configurations, so that clinical judgment may be exercised to select the appropriate implant for a given case. Alternatively, the transvalvular implant may be provided in an adjustable form or a modular form so that an implant of the desired configuration can be constructed or modified intraoperatively at the clinical site.

[0208] The transvalvular implants can be made of any of a variety of materials that are compatible with implantation within a patient’s body and which has the requisite structural integrity to support the valve leaflets. The transvalvular implants can be made of any of a variety of materials that are compatible with implantation within a patient’s body and which has the requisite structural integrity to support the mitral valve leaflets. The transvalvular implants can be made of any of a variety of materials that are compatible with implantation within a patient’s body and which has the requisite structural integrity to support the tricuspid valve leaflets. For example, suitable materials include titanium, titanium alloys, stainless steel, stainless steel alloys, nitinol, elgiloy, MP35N, other metals and alloys, ceramics, and polymers such as PTFE, polycarbonate, polypropylene, UHMWPE, HDPE, PEEK, PEBAX and the like.

[0209] In order to reduce the thrombogenicity of the transvalvular implants, the transvalvular implants can be provided with a smooth surface or appropriately micro-texture the surface in some embodiments, such as via a porous or microporous structure. Other factors such as surface chemistry, energy, morphology, macrofeatures, and general material properties matching the in situ needs can also be considered in tailoring the surface of the implant. In addition, the transvalvular implants can be coated with a variety of substances to reduce thrombogenicity. For example, the transvalvular implants can be coated with a antithrombogenic agent such as heparin, a polymer such as PTFE, or a polymer conjugated with heparin or another antithrombogenic agent. Heparin coatings can be achieved in a variety of methods, one of which may be to coat or drip the prosthesis in TDMAC -heparin (Tridodecylmethylammonium heparinate).

[0210] The transvalvular implant can be implanted in the plane of the valve annulus. The transvalvular implant can be implanted in the plane of the mitral valve annulus 28 in a patient. The transvalvular implant can be implanted in the plane of the tricuspid valve annulus in a patient. The transvalvular implant can be attached to the annulus 28 by a variety of techniques, such as sutures, anchors, barbs, stapes, self-expanding stents, or other techniques that are known or are apparent to those of skill in the art. The transvalvular implant is oriented in the annulus so that the transvalvular implant is positioned approximately transversely to a coaptive edge formed by the closure of valve leaflets. The transvalvular implant is oriented in the annulus 28 so that the transvalvular implant is positioned approximately transversely to the coaptive edge 42 formed by the closure of the mitral valve leaflets 24 and 26. The transvalvular implant is oriented in the annulus so that the transvalvular implant is positioned as described herein relative to the tricuspid leaflets. The transvalvular implant in accordance with the present invention can be implanted via an open surgical procedure, via thoracotomy (e.g. transapically) or alternatively, via a percutaneous procedure using a translumcnally implantable embodiment.

[0211] FIGS. 23A-23E illustrate anchoring design concepts. In some embodiments, disclosed herein is a system for delivering and anchoring an implant to a valve annulus. The system can include an anchor catheter configured to deliver an annular anchor to a valve annulus of a heart of a patient. The annular anchor can have a variety of configurations. In some embodiments, the annular anchor comprises barbs to engage tissue. In some embodiments, the annular anchor is a coil or helix. In some embodiments, the annular anchor comprises a suture. Also disclosed herein is a method for delivering and anchoring an implant to a valve annulus of a valve. The transvalvular implant can be utilized with any anchor described herein.

[0212] Figure 23A illustrates an embodiment of an annular anchor. The annular anchor can be a treble hook anchor 300. The treble hook anchor 300 uses multiple hooks to avoid dehiscence. The treble hook anchor 300 can include three hooks 302, 304, 306. The annular anchor can include any number of hooks, including one hook, two hooks, three hooks, four hooks, five hooks, six hooks, or any range of two of the forgoing values. The hooks 302, 304, 306 can curve upward forming a J shape. The hooks 302, 304, 306 can include barbs 308. The barbs 308 can face inward. The treble hook anchor 300 can be delivered in a compressed configuration through a hole in the annulus. The treble hook anchor 300 can expand in a subannular space. The treble hook anchor 300 can be pulled to engage tissue. The treble hook anchor 300 can be located in the subannular space.

[0213] Figure 23B illustrates an embodiment of an annular anchor. The annular anchor can be a hex screw 310. The hex screw 310 can be twist type anchor. The hex screw 310 can have a spring 312. The spring 312 can be flexible. The spring 312 can be rigid. The spring 312 can have a sharpened tip to engage tissue. The hex screw 310 can have a needle 314. The needle 314 can have a sharpened tip. The spring 312 can drive the needle 314. In some methods, the hex screw 310 is rotated to drive the spring 312 into tissue. As the hex screw 310 is rotated, the needle 314 passes further into tissue. The hex screw 310 can include a hub 316. The needle 314 can be centrally located on the hub 316. The hub 316 can be rotated by a driver. In some embodiments, the hub 316 is a hex and the driver has a hex socket. The hub 316 can include a washer 318 to distribute pressure of the hub 316. [0214] Figure 23C illustrates an embodiment of an annular anchor. The annular anchor can be a locking screw 320. The locking screw 320 can be twist type anchor. The locking screw 320 can have a spring 322. The spring 322 can be flexible or rigid. The spring 322 can have a sharpened tip to engage tissue. The locking screw 320 can have an off center pin 324. The off center pin 324 can have a sharpened tip. The off center pin 324 can stop rotation. In some embodiments, the spring 322 is rotated to be driven into tissue. After the spring 322 is in position, the off center pin 324 can be released to prevent further rotation of the spring 322. Other methods of use are contemplated.

[0215] Figure 23D illustrates an embodiment of an annular anchor. The annular anchor can be a single piece wire screw 330. The single piece wire screw 330 can be twist type anchor. The single piece wire screw 330 can be formed from a single piece of wire. The single piece wire screw 330 can have a spring 332. The spring 332 can have one or more coils. The spring 332 can have a sharpened tip to engage tissue. The single piece wire screw 330 can have a needle 334. The needle 334 can have a sharpened tip. The spring 332 can drive the needle 334. In some methods, the single piece wire screw 330 is rotated to drive the spring 332 into tissue. As the single piece wire screw 330 is rotated, the needle 334 passes further into tissue. The single piece wire screw 330 can include a hub 336. The needle 334 can be centrally located on the hub 336. The hub 336 can include one or more coils. The one or more coils of the hub 336 can be perpendicular to one or more coils of the spring 332. The hub 336 can be rotated by a driver. The single piece wire screw 330 can be turned by a flathead screwdriver. The flathead screwdriver can be inserted between the one or more coils and then rotated.

[0216] Figure 23E illustrates an embodiment of an annular anchor. The annular anchor can be a single piece wire screw 340. The single piece wire screw 340 can have a spring 342. The spring 342 can have one or more coils. The single piece wire screw 340 can include a hub 346. The hub 346 can include an eyelet. The eyelet of the hub 346 can be perpendicular to one or more coils of the spring 342. The eyelet of the hub 346 can be rotated by a driver. The single piece wire screw 340 can omit a needle or offset locking pin.

[0217] The anchors 300, 310, 320, 330, 340 can be a radially symmetrical embedded anchors. The anchor 300, 310, 320, 330, 340 can embed itself in tissue by expanding after entry. In some embodiments, the anchor 300, 310, 320, 330, 340 is rigid and has a fixed shape. Tn some embodiments, the anchor 310, 320, 330, 340 can be rotated to engage tissue. In some embodiments, the anchor 300, 310, 320, 330, 340 can comprise a shape memory shape. In some embodiments, the anchor 300, 310, 320, 330, 340 can comprise a shape memory material that assumes a preformed shape. In some embodiments, the anchor 300, 310, 320, 330, 340 can comprise a shape that expands after implantation. For instance, the spring 312, 322, 332, 342 can expand after entry to embed into tissue. For instance, the hooks 302, 304, 306 can expand after entry to embed into tissue. The anchor 300, 310, 320, 330, 340 can be radially symmetrical. The anchor 300, 310, 320, 330, 340 can radially expand.

[0218] The annular anchor can include one or more barbs. The annular anchor can include one or more hooks. The annular anchor can include can include a helix. The annular anchor can include a needle. The annular anchor can include a head. The annular anchor can include an interface to be engaged by a driver. The annular anchor can include a washer. The annular anchor can include a hub. The annular anchor can include a single piece construction. The annular anchor can include a multiple piece construction. The annular anchor can include an off center pin. The annular anchor can include a central needle. The annular anchor can include one or more coils. The annular anchor can be expandable. The annular anchor can be self-expandable. The annular anchor can prevent retraction. The annular anchor can have any combination of features of annular anchors described herein. The annular anchor can have any engagement portion to engage tissue. The annular anchor can have any hub. The annular anchor can have any secondary feature such as barbs, needles, or pins to further engage tissue.

[0219] The annular anchor can include one or more key attributes. The annular anchor can require minimal insertion force. The annular anchor can be repositionable. The annular anchor can be simple to deploy. The annular anchor can have excellent retention force. The annular anchor can be delivered via transcatheter delivery.

[0220] Figures 24A-24B illustrate anchor and tether designs. In some embodiments, the annular anchor 360 can be coupled to a tether 370. The tether 370 can be a monofilament tether as shown in Figure 24 A. The annular anchor 360 can have any feature of the annular anchors described herein. The annular anchor 360 can include a spring 362. The annular anchor 360 can include a hub 366. The hub 366 can be bent upward. The hub 366 can be a top portion of the spring 362. The system can include an anchor crimp 372. The anchor crimp 372 can crimp the tether 370 to the hub 366 of the anchor 360. In some embodiments, the anchor crimp 372 is a tubular structure that surrounds the hub 366 and the tether 370. The anchor crimp 372 can have pressure applied to secure the hub 366 and the tether 370 together.

[0221] In some embodiments, the annular anchor 360 can be coupled to a tether 374. The tether 374 can be a looped monofilament fiber or braided suture as shown in Figure 24B. The tether 374 can be made of polyester. The system can include an anchor crimp 376 shown in Figure 24B. The anchor crimp 376 can crimp the tether 374 to the hub 366 of the anchor 360. In some embodiments, the anchor crimp 376 is a tubular structure that surrounds the hub 366. The anchor crimp 376 can include an opening to accept the tether 374. The tether 374 can be looped through the anchor crimp 376.

[0222] The anchor crimp 372, 376 can be in an offset position. The anchor crimp 372 can be offset relative to the center of the spring 362. The anchor crimp 372, 376 can be stainless steel. The anchor crimp 372, 376 can be titanium. The outer diameter of the annular anchor 360 can be 0.095”. The height of the annular anchor 360 can be 6 mm. The anchor can have a different wire diameter. The anchor can have a different pitch. The anchor can have a different anchor diameter.

[0223] Figures 25A-25B illustrate anchor and tether designs. The annular anchor can be an anchor with center point 380. The anchor with center point 380 can have a spring 382. The anchor with center point 380 can have a center point 384. The center point 384 can have a sharpened tip. The center point 384 can hold the position during deployment. The center point 384 can be centrally disposed within the spring 382. The central point 384 can be centrally located on the anchor. The spring 382 can drive the needle 384.

[0224] The anchor with center point 380 can include a hub 386. In some embodiments, the hub 386 can include a central post. The central post of the hub 386 can extend proximally. The central post can be centrally located on the anchor. The center post can be centrally located on the hub 386. The center post can be rotated by a driver. The center post can be keyed and the corresponding driver can have a keyed socket. The anchor with center point 380 can include a tether 388. The tether 388 can be coupled to the central post of the hub 386. The tether 388 can be crimped to the center post. The anchor with center point 380 can include an anchor crimp and tether 388 all in central position. Tn some embodiments, the center point 384 and the central post of the hub 386 arc continuous. In some embodiments, the center point 384 and the central post of the hub 386 are axially aligned.

[0225] The anchor with center point 380 can include an outside diameter of 0.092”. The anchor with center point 380 can have a length of 6 mm. The anchor with center point 380 can be made stainless steel 316L. The anchor with center point 380 can be made of titanium.

[0226] The anchor with center point 380 can be delivered with a delivery catheter 390. The delivery catheter 390 can include a Pebax outer sheath. The delivery catheter 390 can include 35D Pebax at an articulation section of the delivery catheter 390. The delivery catheter 390 can have an enlarged distal section to accommodate the anchor with center point 380. The delivery catheter 390 can accommodate a driver 392. The driver 392 can engage the central post of the hub 386. The driver 392 can rotate the anchor with center point 380. The driver 392 can slide along the tether 388. In some embodiments, the tether 388 can have tension applied during delivery to facilitate coupling the driver 392 to the anchor with center point 380.

[0227] Figures 26A-26B illustrate anchor and mount designs. In some embodiments, the annular anchor 400 can be coupled to a mount 410. The annular anchor 400 can have any feature of annular anchors described herein. The annular anchor 400 can include a spring 402. The annular anchor 400 can include a needle 404. The annular anchor 400 can include a hub 406. The hub 406 can include a central post. The needle 404 and the central post of the hub 406 can be separately formed. The annular anchor 400 can include a tether 408 coupled to the central post of the hub 406. The tether 408 can be crimped onto the central post of the hub 406.

[0228] The spring 402 can include a portion that is bent. The spring 402 can include a cross-pin at the top of the coil. The top coil can be turned inward. The mount 410 can include an opening 412. The opening 412 can be sized to accept the cross-pin of the spring 402. The top of the spring 402 can be inserted into the drilled hole. The coil of the anchor extends through the mount 410. The mount 410 can include a flange 414. The flange 414 can extend to the diameter of the coil. [0229] The needle 404 can have a length of 7 mm. The central post of the huh 406 can have a length of 5.5 mm. The needle 404 and the central post of the hub 406 can be separately formed. These features can be cut to length. The mount 410 can be positioned on the central post. The length of 3.3 mm of the center post can extend above the flange 414. The opening 412 can extend through the mount 410. The opening 412 can extend through the central post of the hub 402. The mount 410 can include a hypotube. The hypotube can form the opening 412. The annular anchor 400 can include the spring 402. The top of the spring 402 can be passed through the opening 412. The spring 402 can be 6.66 mm. The needle 404 can extend beyond the spring 402.

[0230] Figures 27A-27D illustrate anchor and mount designs. In some embodiments, an annular anchor 420 can be coupled to a mount 430. The annular anchor 420 can have any feature of annular anchors described herein. The annular anchor 420 can include a spring 422. The spring 422 can include a cross-pin at the top coil. Figure 27A illustrates an extra coil 434. The extra coil 434 can be proximal to the spring 422. The annular anchor 420 can include a needle 424. The annular anchor 420 can include a hub 426. The hub 426 can have a quadrangular luer-lock type of fit. The annular anchor 420 can include a quadrangular mounting structure. The annular anchor 420 can include the extra coil 434 coupled to the quadrangular mounting structure.

[0231] The hub 426 can include a central post. The needle 424 and the central post of the hub 426 can be separately formed. The annular anchor 420 can include a tether 428 coupled to the central post of the hub 426. Figure 27B illustrates two lengths from tip of the needle 424 to the top of the helix of the spring 422. The two lengths are 6 mm and 8 mm. The anchor can include a driver 436. The driver 436 can couple to the central post of the hub 426. The driver 436 can include a socket to engage the central post of the hub 426.

[0232] The mount 430 can include a diameter of 0.060”. The mount 430 can include a taper with a length of 0.025”. The mount 430 can include a length of 0.060”. The taper can have a 25 degree angle. The mount 430 can include an opening 432. The opening 432 can be sized to accept the cross-pin of the spring 422. The mount 430 can be less than the diameter of the spring 422.

[0233] The central post of the hub 426 can include a hypotube. The hypotube can be pressed into the mount 430. The central post of the hub 426 can have a length of 2 mm below the mount 430. The opening 432 can be drilled into the mount 430. The opening 432 can be drilled into the central post of the hub 426. The opening 432 can be 0.018”. The opening 432 can be 0.037” below the top of the mount 430. The needle 424 can have a length of 8 mm. The needle 424 can be inserted into the hypotube of the central post of the hub 426. The spring 422 can have a cross-pin formed from the top coil. The top coils of the spring 422 are shown. The spring 422 can be attached to the mount 430. The top of the spring 422 can be inserted into the opening 412 in the mount 430.

[0234] Figure 28 illustrates an annular anchor 440. The annular anchor 440 can have any feature described herein. The annular anchor 440 can be an optimized anchor with tapered anchoring end. The annular anchor 440 can omit the central pin. The annular anchor 440 can include a spring 442. The annular anchor 440 can include a hub 446. The annular anchor 440 can include a mount 448. Figure 28 schematically illustrates the position of the annular anchor 440 relative to the transvalvular implant 100, 200. The annular anchor 440 can be positioned relative to the mitral valve annulus ring. The annular anchor 440 can be positioned relative to the anchoring portion of the transvalvular implant 100, 200. The mount 448 can be positioned within the eyelet of the transvalvular implant 100, 200. The system can include an anchor cap as described herein. The mount 448 of the annular anchor 440 can be distal to the anchor cap.

[0235] Figures 29A-29C illustrate a delivery catheter 450. The delivery catheter 450 can be an anchor therapy catheter. The delivery catheter 450 can be utilized with any anchor described herein. The delivery catheter 450 can have an inner diameter. The delivery catheter 450 can be 12 Fr (0.205” 5.2mm) inner diameter compatible. Figure 29A illustrates a keyed driver 452. The keyed driver 452 can include a hypotube shaft. The keyed driver 452 can include a keyed slot. The keyed slot can accept a cross-pin of an anchor 454. The crosspin of an anchor 454 can slide distally within the slot as the keyed driver 452 is rotated. The keyed driver 452 for anchor attachment is shown in Figure 29A. Figure 29B illustrates the anchor 454 preloaded. The anchor 454 can be inserted into the distal end of the delivery catheter 450. The keyed driver 452 can rotate thereby deploying the anchor 454. The system can include a hemostatic flush line. The system can be configured for single use deployment. The anchor 454 can omit the tether. [0236] Figure 29C illustrates the delivery catheter 390 described herein. The delivery catheter 390 can accommodate the driver 392. The driver 392 can engage the central post of the hub 386. The driver 392 can include a keyed socket to engage a keyed portion of the central post. In some embodiments, the tether 388 can be coupled to the annular anchor 380. The tether 388 can facilitate engagement of the driver 392 with the annular anchor 380 after deployment to reposition the annular anchor 380. The system can be configured for deployment and redeployment.

[0237] Figures 3OA-3OB illustrate a sheath for the delivery catheter 390, 450. The material can be 0.0050” 30 x-series stainless steel. The parts can be delivered still attached to the sheet of raw material by connector sprues. The orientation and number of sprues to be determined by the laser cutting vendor. The sprues that attach the laser cut component to the sheet of raw material can be made as narrow as possible while still maintaining part quality to facilitate ease of detachment and to minimize the amount of secondary operations including filing needed to remove evidence of sprue. The sheath can have a length of 72.3”. The wall thickness can be 0.010”. The diameter can be 0.078” in a middle section. The diameter can be 0.137” in an end section. The first end section can have a length of 70”. The first end section can be 72D Pebax. The middle section can have a length of 1.6”. The middle section can be 35D Pebax. The second end section can have a length of 0.60”. The second end section can be 72D Pebax. The second end section can include a tip. The tip can be 35D Pebax. The tip can have a length of 0.065”.

[0238] Figures 31A-31B illustrate the driver 392 and the central post of the hub 386. The driver 392 can include a keyed socket to engage a keyed portion of the central post of the hub 386. The annular anchor 380 can include an anchor triangle drive. The annular anchor 380 can have the center point 384. The central point 384 can be centrally located on the annular anchor 380. The central post of the hub 386 can be centrally located on the annular anchor 380. The tether 388 can be crimped to the center post. The anchor to tether crimping process can create a triangle shaped feature. This feature is used to couple to a matching feature of the driver 392. The annular anchor 380 can include a crimp. The crimp can be triangular. The driver 392 can include a triangular recess to mate with the crimp.

[0239] Figures 32A-32B illustrate the delivery catheter 390 described herein. The system can include the annular anchor 380. The annular anchor 380 can include the center point 384. The center point 384 can be a stabilizing center pin. The system can include the driver 392. The driver 392 can include a triangular drive mechanism. The annular anchor 380 can include the tether 388. The tether 388 can extend from the annular anchor 380. The annular anchor 380 can include the central post of the hub 386. The central post of the hub 386 can be an anchoring post for the transvalvular implant 100, 200. The system can include the delivery catheter 390.

[0240] Figures 33A-33B illustrate bridge to anchor attachment concepts. The system can include the transvalvular implant 100, 200. The transvalvular implant 100, 200 can be disposed relative to the valve. The system can include any anchor described herein. Figure 33B illustrates the anchor 380. The system can include a cap 460. The cap 460 can be a push-on cap. The cap 460 can be round. The cap 460 can function as a locking clip to hold the transvalvular implant 100 in position. The cap 460 can be positioned over the central post of the hub 386 of the anchor 380. The cap 460 can be pushed on the central post of the hub 386. In some embodiments, the cap 460 is not attached to a suture. In some embodiments, the tether 388 can be cut to release the annular anchor 380 after deployment. In some embodiments, the anchor is not reversible after release of the tether 388. In some embodiments, the cap 480 can be photo etched titanium or stainless steel. The cap 480 remains in place after the transvalvular implant 100, 200 is deployed. The cap 480 can securely lock the transvalvular implant 100, 200 in position.

[0241] Figure 34A-34D illustrates delivery design concepts. The delivery can include one or more key attributes. The systems can be configured for transcatheter delivery. The systems can be configured for a trans-septal approach. The systems can include custom guide catheters. The systems can be a custom steerable delivery system. In some embodiments, the systems can be configured to place the anchors and then the transvalvular implant. In some embodiments, the systems can be configured to place the anchors and transvalvular implant together.

[0242] Figures 34A-34D illustrates a method of delivery. In some embodiments, one or more anchors are delivered. The anchors can be any anchors described herein. In some embodiments, four anchors are delivered. In some embodiments, the anchors can be delivered individually. In some embodiments, the anchors can be delivered in pairs. In some embodiments, the anchors can be delivered together. Figure 34A illustrates a delivery method. The anchors are seated within the tissue. The anchors can include tethers as described herein. In some embodiments, a sleeve is advanced relative to the tethers. The advancing sleeve can tighten the tethers. The transvalvular implant can then be positioned. The transvalvular implant can slide along the tethers into positon relative to the valve. Figure 34B illustrates a delivery method. A first anchor set is seated within the tissue. The first anchor set can include two anchors. The two anchors can correspond to the first anchoring portion of the transvalvular implant. The method can include seating the transvalvular implant relative to the first anchor set. The method can include pulling against the septum. Then a second anchor set is seated within tissue. The second anchor set can include two anchors. The two anchors can correspond to the second anchoring portion of the transvalvular implant. The method can include seating the transvalvular implant relative to the second anchor set.

[0243] Figure 34C illustrates the Freudenberg modular systems. The systems can include a handle platform. The systems can include composite catheter shafts. The systems can include tubing. Figure 34D illustrates the surgical design. The system can include a delivery handle. The systems can include a suture or tether. The suture can wrap around the delivery handle. The suture can include one more suture knots. The system can include the transvalvular implant.

[0244] Figure 35 illustrates the annular anchors deployed in a heart of a pig. The anchors are embedded in the annulus. The tethers extend from the anchors. While three anchors are shown, any number of anchors can be deployed. In some methods, the tethers can serve as a means to deliver the transvalvular implant to the annulus. In some methods, the tethers can serve as a means to cinch the annulus before delivery of the implant.

[0245] Figure 36 illustrates an embodiment of the transvalvular implant delivery catheter 470. The transvalvular implant 100 can be delivered via the delivery catheter 470. The delivery catheter 470 can be 12 Fr (0.320” 8.2mm) inner diameter compatible. The delivery catheter 470 can be configured for single use deployment. The delivery catheter 470 can include a Pebax sheath with PTFE liner. The delivery catheter 470 can include any features described herein. The delivery catheter 470 can be configured for hemostasis with flush line. The delivery catheter 470 can include a pushrod 472. The pushrod 472 can facilitate delivery of the transvalvular implant 100. Other delivery catheter and systems are contemplated for transvalvular implants described herein.

[0246] Figures 37A-37D illustrates the transvalvular implant 100 in place. Figure 37A illustrates the four deployed annular anchors. The anchors can include tethers extending proximally. The transvalvular implant 100 can include the first anchoring portion 112 and the second anchoring portion 114. The anchoring portions 112, 114 can have eyelets 116. In some methods, the eyelets 116 can accept the tethers. In some methods, the transvalvular implant 100 can be delivered with the anchors. In some methods, the tethers are threaded through the eyelets 116 of transvalvular implant 100 in situ. In some methods, the tethers are threaded through the eyelets 116 of transvalvular implant 100 outside the body. The tethers can act as guides as the transvalvular implant 100 is positioned. In some methods, the transvalvular implant 100 can be delivered after the anchors. The transvalvular implant 100 can have a central opening 118. The transvalvular implant 100 can be very low profile. The transvalvular implant 100 can straddle the valve. The transvalvular implant 100 can form an arch over the valve.

[0247] Figure 37B illustrates the cap 460. The cap 460 can be positioned over the transvalvular implant 100. The cap 460 can couple to the central post of the hub of the anchor. In some methods, the cap 460 does not couple to the tether. The cap 460 can lock the position of the transvalvular implant 100 relative to the valve. Figures 37C-37D illustrates the deployment schematically. The anchor is deployed in the annulus. The anchor is deployed in the mitral annulus. The anchor is deployed in the tricuspid annulus. The central post of the hub of the anchor extends from the annulus. The central post of the hub of the anchor is coupled to the tether. The transvalvular implant 100 is positioned over the annulus. The cap 460 is positioned over the transvalvular implant 100. The cap 460 is coupled to the central post of the hub of the anchor. The cap 460 maintains the position of the transvalvular implant 100 relative to the annulus. The cap 460 maintains the position of the transvalvular implant 100 relative to the anchor. Figure 37D illustrates two caps 460 relative to the annulus.

[0248] Figure 38 illustrates an embodiment of a transcatheter system. The system can include a guide catheter to provide a transseptal conduit to, for example, the left atrium. The guide catheter can be placed in the left atrium through the transseptal access. The system can include a guide wire. The guide wire can span between the right atrium and the left atrium. The guide wire can extend from the left atrium, through the valve annulus and toward the left ventricle. While some embodiments are described in the context of the transvalvular implant, other implants that span the annulus can be utilized, and the method adapted to other valve annuli including the tricuspid, aortic, and/or pulmonic valve annuli depending on the desired clinical result.

[0249] In some embodiments, a template catheter 570 can be utilized after the guide catheter is placed. The template catheter 570 can be delivered in a compressed configuration. The template catheter 570 can be deployed in an atrium to direct the system appropriately to the valve. The template catheter 570 can be deployed in the left atrium to direct the system appropriately to the mitral valve. The template catheter 570 can be deployed in the right atrium to direct the system appropriately to the tricuspid valve. Figure 38 illustrates the template catheter 570 being deployed according to some embodiments. The template catheter 570 can slide along the guide wire toward the valve. The template catheter 570 can slide along the guide wire toward the mitral valve. The template catheter 570 can slide along the guide wire toward the tricuspid valve. The template catheter 570 can include one or more struts 572 that fold outward as shown. In some embodiments, each strut can comprise a pair of apertures through which an anchor catheter conduit 576 passes. In the illustrated embodiment, the template catheter 570 can include four struts 572 with four corresponding anchor catheter conduits 576. The anchor catheter conduit 576 can be a flexible tube.

[0250] The template catheter 570 can be positioned across the anterior and posterior leaflets. The template catheter 570 can provide the appropriate spacing for the anchors via anchor catheter conduits 576. The anchor catheter conduits 576 can be positioned at or near the 5 o’clock, 7 o’clock, 11 o’clock, and 1 o’clock positions. In some embodiments, two anchors can be spaced apart from another two anchors along an axis of symmetry. The 5 o’clock and 7 o’clock positions can be the locations of the anchors on the posterior annulus. The 11 o’clock and 1 o’clock positions can be the locations of the anchors on the anterior annulus. Other positions are contemplated (e.g., 1 o’clock, 2 o’clock, 3 o’clock, 4 o’clock, 5 o’clock, 6 o’clock, 7 o’clock, 8 o’clock, 9 o’clock, 10 o’clock, 11 o’clock, 12 o’clock, or any range including two or more values). The template catheter 570 can be rotated relative to the guide wire to position the anchor catheter conduits 576. Figure 38 illustrates the position of the template catheter 570 against the leaflets and the annulus, according to some embodiments. A portion of the template catheter 570 can extend toward the left ventricle and between the leaflets. The struts 572, or a portion thereof, can be positioned against the annulus. The anchor catheter conduits 576 can extend in an appropriate direction such as downward toward the annulus.

[0251] The template catheter 570 can be utilized with any anchor disclosed herein. The template catheter 570 can be utilized with any driver disclosed herein. The driver can be sized to pass through the anchor catheter conduit 576 toward the annulus. In some embodiments, the anchors can be delivered sequentially such that the driver can be removed from one anchor catheter conduit 506 after anchor delivery, and can be inserted into a second anchor catheter conduit 576 for delivery of a second anchor, until all four anchors are sequentially delivered. In other embodiments, two or more of the anchors can be delivered simultaneously. There can be four tethers extending from the four anchors according to some embodiments. In some embodiments, after all four anchors are delivered, the template catheter 570 can be removed. In some embodiments, the template catheter 570 including the anchor catheter conduit 576 can provide tether management. Each tether can extend through the anchor catheter conduit 576 such that the tethers are prevented from tangling or tangling is reduced.

[0252] In some embodiments, the annulus is cinched. In some embodiments, with the anchors in place and the tethers extending from the anchors, the annulus can be cinched, in other words, the opposing sides of the annulus can be brought closer together along part of the annulus. The cinching can confirm securement of the annular anchors. The cinching can reduce any slack in the teethers. The cinching can confirm the correct size of the transvalvular implant. The cinching can confirm the desired spacing or length between the pair of tethers associated with the posterior leaflet and the pair of tethers associated with the anterior leaflet. The length of the transvalvular implant can be selected to maintain the cinched position of the annulus. In some embodiments, tension is applied to the tethers to cinch the tethers and thus the underlying anatomy. The cinching can increase the engagement between the posterior and anterior leaflet to enhance coaptation, as described herein. [0253] The transvalvular implant 100, 200 can be deployed after the anchors are deployed. The transvalvular implant 100, 200 can be guided into place through the guide catheter via the tethers which are permanently attached to the anchors. The transvalvular implant 100, 200 can include apertures or eyelets through which the tethers can pass. In some embodiments, each aperture can be designed to accept one tether. The first end of the transvalvular implant 100, 200 can include two apertures 116 designed to accept two tethers, respectively. The second end of the transvalvular implant 100, 200 can include two apertures 116 designed to accept two tethers, respectively. Once positioned, the transvalvular implant 100, 200 can be used in conjunction with the anchored tethers to cinch the posterior annulus toward the anterior annulus to facilitate proper leaflet coaptation. Each cap 460 can slide along the corresponding tether during delivery. The cap 460 can secure transvalvular implant 100, 200 to the anchor.

[0254] The systems and methods can include the template catheter 570. The template catheter 570 can have key attributes. The template catheter 570 can facilitates center alignment from midpoint A2 to P2. In some methods of use, the transvalvular implant 100, 200 is placed between midpoints of A2 - P2. The template catheter 570 can properly position the transvalvular implant 100, 200 relative the annulus. The template catheter 570 can be scaled to fit any annular dimensions. The template catheter 570 can be scaled to fit any septal-lateral diameter (SLD). The template catheter 570 can be available in a range of sizes depending on the anatomy to be treated. The template catheter 570 can include an inter- commissural diameter. The template catheter 570 can be scaled to fit any inter-commissural diameter. The template catheter 570 can add another dimension, an inter-commissural diameter, in the template for more stability, perfect center lining alignment. The template catheter 570 can also be set in an offset diameter to cover the P#-P@ area in ischaemic mitral regurgitation (IMR) with retracted posterior leaflet. The template catheter 570 can include specificity for anchor delivery at 1, 5, 7, and 11 clock positions on the annulus. The template catheter 570 can provide stabilization of annulus during anchor delivery. The template catheter 570 can provide a counter force during anchor delivery into the annulus by holding the template. The template catheter 570 can facilitate the angle of anchor entry into the annulus. By matching the apertures on the expanded template, the angle of entry into the annulus is maintained. [0255] The systems and methods can include system for delivering and anchoring an implant to a valve annulus. The system can include a template catheter configured to deliver an anchor to a valve annulus of a heart of a patient. The template catheter can include a pathway through which the anchor is delivered. The system can include the anchor. The system can include a driver. The system can include an implant configured to be delivered to the valve annulus. The implant can include a first anchoring portion aligned with the pathway.

[0256] Figures 39A-39B illustrate embodiments of transcatheter systems. Figures 39A-39B illustrate rail road concepts for the template. The template catheter 580 can include rails 582. The template catheter 580 can include open ended annular circumference at the ends 584. The template catheter 580 can extend 3/4 of the circumference at the ends 584. The template catheter 580 can include a central coaxial guide wire. The template catheter 580 can include thin blades. The template catheter 580 can have 1/4 circle rails for anchor catheters or drivers. The template catheter 580 can be positioned between A2 and P2. The ends 584 can have slots for anchor catheters or drivers. The tether can be pulled to the side. Figure 39B illustrates the compressed configuration. The template catheter 580 can include the rails 582. The template catheter 580 can include a removable collar. The template catheter 580 can have an anchor catheter entrance near the ends 514.

[0257] Figures 40A-40B illustrate embodiments of transcatheter systems. The template catheter 590 can include delivery catheters 592. All four delivery catheters 592 can expand. All four delivery catheters 592 can sit on the annulus. The template catheter 590 can include a collapsible element between the anchor points. The template catheter 590 can include feet 594. The template catheter 590 can include features to give stability.

[0258] The systems and methods can include any features or combination of features described herein. The systems and methods can include trans catheter delivery systems for implanting an arching or straddling implant on to a cardiac valve annulus for treatment of valve leak. The systems and methods can be for mitral or tricuspid valves. Methods, devices and systems can be used for implanting an arch implant straddling the valve orifice. Methods, devices and systems can be used for implanting an arch implant straddling the mitral valve orifice in a septal lateral diameter of mitral valve annulus for the treatment of mitral valve regurgitation caused by dilatation of mitral valve annulus and deformation of mitral valve leaflets. Methods, devices and systems can be used for implanting an arch implant straddling the tricuspid for the treatment of valve regurgitation caused by dilatation of valve annulus and deformation of valve leaflets. The arch implant can be made of wire form curved body with an opening in its center and the implant can straddle across the mitral valve orifice in a septal lateral diameter. The arch implant can be made of wire form curved body with an opening in its center and the implant can straddle across the tricuspid valve orifice.

[0259] Both ends of the wire implant can be anchored to the annulus by delivering it to the annulus with two anchors or more in the front and back part of the mitral annulus. The different sizes of the implant can help to reduce the septal lateral diameter of the annulus to varying degree to facilitate the closure of mitral valve leaflets. The implant can be delivered to the annulus via percutaneous access through a vein in the leg after delivering the anchors with long tethers on to the annulus and threading the implant through the tethers of the anchors outside the body and delivered via the percutaneous delivery catheters on to the mitral annulus. Locking clips can be delivered through the percutaneous catheters to hold the implant onto the anchors on the annulus.

[0260] FIGS. 41A-41C illustrate an embodiment of a transvalvular implant 600. The transvalvular implant 600 can have any feature of any implant describe herein. The transvalvular implant 600 can improve coaptation of the mitral valve leaflets and prevent or reduce mitral regurgitation. FIG. 41A is a top view of the transvalvular implant 600. FIG. 4 IB is a view of the transvalvular implant 600 positioned in a delivery catheter. FIG. 41C is a schematic view of the transvalvular implant 600. The transvalvular implant 600 can include a first end 602 and a second end 604. The transvalvular implant 600 can include a central portion 606. The transvalvular implant 600 can include a first anchoring portion 612 and a second anchoring portion 614. The transvalvular implant 600 can have eyelets 616. The transvalvular implant 600 can have a central opening 618. The central opening 618 can allows later trans catheter intervention with another device through the central opening 618.

[0261] The transvalvular implant 600 can include a central eyelet 616. The transvalvular implant 600 can include a pair of central eyelets 616. The first anchoring portion 612 can include a central eyelet 616. The eyelets 616 of the first anchoring portion 612 can be aligned along an axis. The eyelets 616 of the first anchoring portion 612 can be on opposite sides of the wire. The first eyelet 616 of the first anchoring portion 612 can be outwardly disposed, the central eyelet 616 of the first anchoring portion 612 can be inwardly disposed, and the third eyelet 616 of the first anchoring portion 612 can be outwardly disposed. The central eyelet 616 can be an additional anchor point if needed. The central eyelet 616 of the first anchoring portion 612 can be a rivet.

[0262] The second anchoring portion 612 can include a central eyelet 616. The trans valvular implant 600 can be symmetrical. The first anchoring portion 612 can mirror the second anchoring portion 614. The eyelets 616 of the second anchoring portion 614 can be aligned along an axis. The eyelets 616 of the second anchoring portion 614 can be on opposite sides of the wire. The first eyelet 616 of the second anchoring portion 614 can be outwardly disposed, the central eyelet 616 of the second anchoring portion 614 can be inwardly disposed, and the third eyelet 616 of second anchoring portion 614 can be outwardly disposed.

[0263] The transvalvular implant 600 comprises an elongate flexible wire formed into a shaped pattern. The transvalvular implant 600 can be formed from a single length of wire. The transvalvular implant 600 can be formed from several lengths of wire. The wire may extend from the first end 602 and the second end 604. The wire may form a complete coil to enclose the one or more eyelets 616 of the first anchoring portion 612. The wire may form a complete coil to enclose the one or more eyelets 616 of the second anchoring portion 614. The wire may form three eyelets 616 of the first anchoring portion 612. The wire may form three eyelets 616 of the second anchoring portion 614. The transvalvular implant 600 can form a continuous shape. The transvalvular implant 600 can form a closed shape.

[0264] The transvalvular implant 600 can have advantageous features. The central folds on either sides are removed. The transvalvular implant 600 can be shaped to avoid LVOT obstruction. The infra annular curvature is maintained. The eyelets 616 are enlarged to have a tight fit on anchor posts. The transvalvular implant 600 can be more robust with central rivets.

[0265] The transvalvular implant 600 can be easily folded inside the delivery catheter as shown in Fig. 4 IB. The transvalvular implant 600 can be easily deployed from the delivery catheter. The central eyelets 616 can be points about which the transvalvular implant 600 folds for compression within a delivery catheter. The upper and lower portions can be brought toward each other. The first and third eyelets 616 of the first anchoring portion 612 can be positioned near or adjacent to each other. The first and third eyelets 616 of the second anchoring portion 614 can be positioned near or adjacent to each other. The narrowed central portion 606 can be brought together to overlap. The transvalvular implant 600 can lengthen. The transvalvular implant 600 can be pinched together for delivery.

[0266] Figure 41C illustrates the transvalvular implant 600 schematically. The transvalvular implant 600 can have an inter anchor distance. The distance can be measured between first and third eyelets 616 of the first anchoring portion 612. The distance can be measured between the first and third eyelets 616 of the second anchoring portion. The frame of the transvalvular implant 600 can be extended. The inter anchor distance can be 14 mm, 16 mm, 18 mm or any range of two of the foregoing values. The inter anchor distance can be extended to account for varying degrees of ischaemic mitral regurgitation (IMR) and restriction at the P3 scallop.

[0267] The wire can form a first coil or eyelet 616 of the first anchoring portion 612, extend along the side of the implant forming a pinched in shape near the central portion 606, form a first coil or eyelet 616 of the second anchoring portion 614, form the central coil or eyelet 616 of the second anchoring portion 614, form a third coil or eyelet 616 of the second anchoring portion 614, extend along the side of the implant forming a pinched in shape near the central portion 606, form a third coil or eyelet 616 of the first anchoring portion 612, form the central coil or eyelet 616 of the first anchoring portion 612, and connect with the first coil or eyelet 616 of the first anchoring portion 612. The coils or eyelets of the first anchoring portion 612 can be directly connected. The starting point and the ending point of the transvalvular implant 600 can be connected. In some embodiments, the central coil or eyelet 616 of the first anchoring portion 612 can be reinforced.

[0268] FIGS. 42A-42B illustrate an embodiment of the transvalvular implant 600. The transvalvular implant 600 can be positioned relative to the anatomy. The eyelets 616 can be in a horizontal plane in FIG. 42A. The eyelets 616 of the first anchoring portion 612 can be generally axially aligned. The eyelets 616 of the second anchoring portion 614 can be generally axially aligned. The transvalvular implant 600 can span the valve.

[0269] The eyelets 616 can be at a 45 degree angle in FIG. 42B. The transvalvular implant 600 can flex to accommodate different angles of the eyelets. The transvalvular implant 600 is aligned well to the saddle shaped mitral annulus. The transvalvular implant 600 is aligned well to the angled anchor posts. The transvalvular implant 600 can allow for changes in the eyelet angle. The angle can be 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, or any range of two of the foregoing values. In some embodiments, the angle is approximately 45 degrees.

[0270] FIGS. 43A-43D illustrate embodiments of the transvalvular implant. FIG. 43A illustrates the transvalvular implant 600. FIG. 43B-43D illustrate variations to the transvalvular implant. The transvalvular implant comprises an elongate flexible wire formed into a shaped pattern. The transvalvular implant can be any shape for providing a support for the valve leaflets as discussed herein. The wire may form a coil to enclose the eyelet. The transvalvular implant can be shaped to facilitate collapsing of the implant. The transvalvular implant can encourage the sides to come toward each other. The transvalvular implant can form a continuous or discontinuous shape.

[0271] FIG. 43B illustrates a transvalvular implant 700. FIG. 43C illustrates a transvalvular implant 800. FIG. 43D illustrates a transvalvular implant 900. The transvalvular implants 700, 800, 900 can have any feature of any implant describe herein. The transvalvular implant 700, 800, 900 can include a first end 702, 802, 902 and a second end 704, 804, 904. The transvalvular implant 700, 800, 900 can include a central portion 706, 806, 906. The transvalvular implant 700, 800, 900 can include a first anchoring portion 712, 812, 912 and a second anchoring portion 714, 814, 914. The transvalvular implant 600 can have eyelets 716, 816, 916.

[0272] The transvalvular implant 700 can have two eyelets 716 for one anchoring portion. The transvalvular implant 700 can have three eyelets 716 for another anchoring portion. The additional eyelet can be utilized for anchoring to the anatomy. The wire can form a first coil or eyelet of the first anchoring portion 712, extend along the side of the implant forming a pinched in shape near the central portion 706, form a first coil or eyelet 716 of the second anchoring portion 714, extend inward and to a second coil or eyelet 716 of the second anchoring portion 714, form a third coil or eyelet 716 of the second anchoring portion 714, extend along the side of the implant forming a pinched in shape near the central portion 706, form a second coil or eyelet 716 of the first anchoring portion 712, and extend inward and connect with the first coil or eyelet 716 of the first anchoring portion 712. The coils or eyelets of the first anchoring portion 712 can be directly connected. The coils or eyelets of the second anchoring portion 714 can be directly connected. The starting point and the ending point of the transvalvular implant 700 can be connected to form a closed shape.

[0273] The transvalvular implant 800 can have two eyelets 816 for one anchoring portion. The transvalvular implant 800 can have two or more eyelets 816 for another anchoring portion. The transvalvular implant 800 can have one more central eyelets 816. The central eyelet 816 can facilitate folding of the implant. The central eyelet 816 can be for anchoring if needed. The central eyelet 816 can form a figure eight. The central eyelet 816 can include two adjacent eyelets. The wire can form a first coil or eyelet 816 of the first anchoring portion 812, extend along the side of the implant forming a pinched in shape near the central portion 806, form a first coil or eyelet 816 of the second anchoring portion 814, form the central eyelet 816 which can be a figure eight, form a third coil or eyelet 816 of the second anchoring portion 814, extend along the side of the implant forming a pinched in shape near the central portion 806, and form a second coil or eyelet 816 of the first anchoring portion 812. The coils or eyelets of the first anchoring portion 812 can be disconnected. The coils or eyelets of the second anchoring portion 814 can be directly connected. The starting point and the ending point of the transvalvular implant 800 can form an open shape.

[0274] The transvalvular implant 900 can have two eyelets 916 for one anchoring portion. The transvalvular implant 900 can have three eyelets 916 for another anchoring portion. The central eyelet can be positioned inward. The central eyelet 916 can anchor to a third location on the anatomy. The transvalvular implant 900 can have a central eyelet 916. The wire can form a first coil or eyelet 916 of the first anchoring portion 912, extend along the side of the implant forming a pinched in shape near the central portion 906, form a first coil or eyelet 916 of the second anchoring portion 914, form the central eyelet 916 of the second anchoring portion 914, form a third coil or eyelet 916 of the second anchoring portion 914, extend along the side of the implant forming a pinched in shape near the central portion 906, and form a second coil or eyelet 916 of the first anchoring portion 912. The coils or eyelets of the first anchoring portion 912 can be disconnected. The first coil or eyelet 916 of the second anchoring portion 914 can be inward. The central eyelet 916 can be outward. The third coil or eyelet 916 of the second anchoring portion 914 can be inward. The coils or eyelets of the second anchoring portion 914 can be directly connected. The starting point and the ending point of the transvalvular implant 900 can form an open shape.

[0275] FIG. 44A illustrates a catheter delivery system 1000 for the transvalvular implant. A guide catheter 1002 can be provided. The guide catheter 1002 can be 24Fr. Other sizes are contemplated. The guide catheter 1002 can be utilized as a trans septal conduit to the left atrial cavity. An annular steering catheter 1004 can be provided. The annular steering catheter 1004 can be 16 Fr. Other sizes are contemplated. The annular steering catheter 1004 can be steerable to the annulus. The annular steering catheter 1004 can be steerable to the mitral annulus. The annular steering catheter 1004 can be steerable to the tricuspid annulus. An anchor delivery catheter 1006 can be provided. The anchor delivery catheter 1006 can be 12 Fr. Other sizes are contemplated. The anchor delivery catheter 1006 can deliver the anchors to the annulus. The anchor delivery catheter 1006 can have any features of the anchor delivery catheters described herein. The anchor can be preloaded inside the anchor delivery catheter 1006, as shown in FIG. 44B. A multi-lumen bridge delivery catheter 1008 can be provided. The multi-lumen bridge delivery catheter 1008 can be 18 Fr. Other sizes are contemplated. The multi-lumen bridge delivery catheter 1008 can deliver the transvalvular implant. The transvalvular implant 600 is illustrated in FIG. 44A but the catheter delivery system 1000 can deliver any implant described herein The multi-lumen bridge delivery catheter 1008 can secure the transvalvular implant. The catheters can be removed and the procedure finished after the transvalvular implant is secured. The catheter delivery system 1000 can be ergonomically easy to use. The catheter delivery system 1000 can simplify and reduce procedure times. The catheter delivery system 1000 can include catheter sizes and additional functionality of commercial systems.

[0276] FIG. 45 illustrates the guide catheter 1002 and the annular steering catheter 1004. The catheter can include a hemostasis valve 1010. The catheter can include a pinch valve for hemostasis 1012. The catheter can include a guide catheter dilator 1014. The catheter can include a control knob 1016.

[0277] FIG. 46 illustrates the guide catheter 1002 and the annular steering catheter 1004. The catheter delivery system 1000 can include tether guards or guides 1020. The tether guards 1020 can prevent tangling of tethers 1022 during anchor delivery. The annular steering catheter 1004 can include the tether guards or guides 1020. The tether guards or guides 1020 can be on an outer surface of the annular steering catheter 1004. The guide catheter 1002 an include the tether guards or guides 1020. The tether guards or guides 1020 can be on an inner surface of the guide catheter 1002. The tether guards or guides 1020 can be grooves or channels that separate the tethers 1022.

[0278] FIG. 47 illustrate the anchor deployment system. The anchor delivery catheter 1006 can deliver an anchor to the annulus. The anchor can be disposed inside the anchor delivery catheter 1006. The distal end of the anchor delivery catheter 1006 is shown in the top left corner. The proximal end of the anchor delivery catheter 1006 is also shown. The anchor delivery catheter 1006 can include a hemostatic valve 1030. The anchor delivery catheter 1006 can include an anchor deployment travel indicator 1032. The anchor deployment travel indicator 1032 can provide a visual representation of how deep the anchor has traveled relative to the anchor delivery catheter 1006. The anchor delivery catheter 1006 can include anchor tension lock 1034. The anchor delivery catheter 1006 can include a hemostatic valve 1036.

[0279] FIG. 48 illustrates the bridge deployment system. The multi-lumen bridge delivery catheter 1008 can be provided. The transvalvular implant can be disposed inside the multi-lumen bridge delivery catheter 1008. The distal end of the multi-lumen bridge delivery catheter 1008 is shown in the top left comer. The proximal end of the multi-lumen bridge delivery catheter 1008 is also shown. A pusher rod 1040 can be provided. The pusher rod 1040 can be for transvalvular implant deployment. The pusher rod 1040 can push the transvalvular implant from the catheter. A plurality of pusher rods 1042 can be provided. In some embodiments, four pusher rods 1042 can be provided. The pusher rods 1042 can be for bridge and clip anchor attachments. Each pusher rod 1042 can push a clip toward the transvalvular implant. The clip can slide along the tether of an anchor. The clip can secure the transvalvular implant to the anchor. The clip, the tether, and/or the anchor can have any of the features described herein. The multi-lumen bridge delivery catheter 1008 can include a lumen for the pusher rod 1040. The multi-lumen bridge delivery catheter 1008 can include a lumen each pusher rod 1042.

[0280] FIG. 49 illustrates the fully deployed transvalvular implant. The pusher rod 1040 can be pushed toward the distal end of the catheter. Each pusher rod 1042 can be pushed toward the distal end of the catheter. In this positon, the transvalvular implant is deployed and positioned relative to the anchors. Tn this positon, the clips are deployed and positioned relative to the transvalvular implant. The clips secure the transvalvular implant.

[0281] FIGS. 5OA-5OB illustrates additional components of the catheter delivery system 1000. The catheter delivery system 1000 can include sled holders 1050. The sled holders 1050 can support the guide catheter 1002. The sled holders 1050 can support the annular steering catheter 1004. The sled holders 1050 can support the anchor delivery catheter 1006. The sled holders 1050 can support the multi-lumen bridge delivery catheter 1008.

[0282] FIG. 51A-51G illustrate embodiments of clips. The clips can have any features of the caps or clips described herein. The system can include a clip. The clip can be a push-on cap. The clip can be round. The clip can function as a locking clip to hold the transvalvular implant in position. The clip can be positioned over the central post of a hub of an anchor. The clip can be pushed on the central post of the hub. The clip can be guided by a suture coupled to the anchor.

[0283] FIG. 51A illustrates an embodiment of a clip 1100. The clip 1100 can be an uncoated clip. The clip 1100 can have five point contact. The clip 1100 can have a round anchor contact point. The clip 1100 can have five flanges 1102 which surround a central opening 1104. The five flanges 1102 contact the anchor post to couple the clip 1100 to the anchor. The central opening 1104 can include a shape and size complementary to the central post of the anchor. The central opening 1104 can be circular, oval or rounded. The central opening 1104 can be polygonal such as triangular, square or rectangular. Other shapes are contemplated.

[0284] FIG. 5 IB illustrates an embodiment of a clip 1110. The clip 1110 can include can have five flanges 1112 which surround a central opening 1114. The clip can have additional cutouts or openings 1116. The additional cutouts or openings can change the flexibility of the clip. The additional cutouts or openings can reduce the weight of the clip.

[0285] FIG. 51C illustrates an embodiment of a clip 1120. The clip 1120 can include a plurality of flanges 1122 which surround a central opening 1124. The clip 1120 can have eleven flanges 1122. The clip 1120 can have any number of flanges including three, four, five, six, seven, eight, nine, ten, eleven, twelve, thirteen, fourteen, fifteen, or any range of two of the foregoing values. [0286] FTG. 51 D illustrates the clip 1100 positioned relative to the transvalvular implant 600. The transvalvular implant 600 can be locked in by the round contact point clip. In the illustrated embodiment, four anchors are implanted in the heart. The sutures extend from the anchors. The transvalvular implant 600 is slid along the sutures toward the anchors. The central posts of the anchors extend through the corresponding eyelets. Each clip 1100 is slid along a respective suture toward an anchor. The flanges 1102 form the central opening 1104. The central opening 1104 tightly fits onto the central post of the anchor, thereby securing the transvalvular implant 600. The clips can provide permanent securement for the transvalvular implant 600.

[0287] FIG. 5 IE illustrates the clip 1100 positioned relative to the transvalvular implant 600 during deployment of the clip 1100. Each pusher rod 1042 can push the clip 1100 toward the transvalvular implant 600. The pusher rod 1042 slides the clip 1100 toward the anchor. The pusher rod 1042 provides force to snap the clip 1100 onto the post of the anchor. Each pusher rod 1042 slides along a respective suture or tether. Each pusher rod 1042 can prevent tangling of the sutures.

[0288] FIG. 5 IF illustrates an embodiment of a clip 1130. The clip 1130 can have a plurality of flanges 1132 which surround a central opening 1134. The opening 1134 can be generally triangular. The opening 1134 can have three flat edges. The triangular shape can be formed by the flanges 1132. The flanges 1132 can have an irregular shape. The clip 1130 can have six flanges 1132. The clip 1130 can have any number of flanges. A pair of flanges forms a triangular contact point. The triangular contact point can maximize holding force. The triangular contact point can decrease push force in some embodiments.

[0289] FIG. 51G illustrates an embodiment of a clip 1140. The clip 1140 can include a plurality of flanges 1142 which surround a central opening 1144. The clip 1140 can include lamination on both sides of clip 1140. The lamination can prevents tether snagging during deployment. The clips described herein can be uncoated, coated or laminated on one side, or coated or laminated on both sides.

[0290] FIG. 52 illustrates the distal section of the multi-lumen bridge delivery catheter 1008. The pusher rod 1040 can be for transvalvular implant deployment. The pusher rods 1042 can be for clip deployment. Each pusher rod 1042 can push a clip toward the transvalvular implant. In some embodiments, the pusher rods can be strengthened. More column strength can be provided by adding an Ultem® sleeve to inside or outside of push tube. Ultem® is a high strength plastic material. The coating or sleeve can enhance the ability of the pusher rod 1040, 1042 to apply a force to the transvalvular implant and/or clip.

[0291] FIG. 53 illustrate an embodiment of a transvalvular implant 1200. The transvalvular implant 1200 can have any feature of any implant describe herein. The transvalvular implant 1200 can include a first end 1202 and a second end 1204. In some embodiments, the first end 1202 is an anterior end. In some embodiments, the second end 1204 is a posterior end. The transvalvular implant 1200 can include a central portion 1206. The transvalvular implant 1200 can include a first anchoring portion 1212 and a second anchoring portion 1214. The transvalvular implant 1200 can have eyelets 1216. The transvalvular implant 1200 can have a central opening 1218. The central opening 1218 can allows catheters, tools, or other devices to pass through the central opening 1218.

[0292] The transvalvular implant 1200 can include a total of three eyelets. The first anchoring portion 1212 can include a central eyelet 1216. The second anchoring portion 1214 can include a pair of eyelets 1216. The transvalvular implant 1200 can be asymmetrical. The transvalvular implant 1200 comprises an elongate flexible wire formed into a shaped pattern. The transvalvular implant 1200 can be formed from a single length of wire. The transvalvular implant 1200 can be formed from several lengths of wire. The wire may extend from the first end 1202 to the second end 1204. The wire may form a complete coil to enclose the one or more eyelets 1216. The transvalvular implant 1200 can form a continuous shape. The transvalvular implant 1200 can form a closed shape.

[0293] The wire can form coil or eyelet 1216 of the first anchoring portion 1212, extend along the side of the implant forming a generally tapered shape near the central portion 1206, form a first coil or eyelet 1216 of the second anchoring portion 1214, form a second coil or eyelet 1216 of the second anchoring portion 1214, extend along the side of the implant forming a generally tapered shape near the central portion 1206, and connect with the coil or eyelet 1216 of the first anchoring portion 1212. The starting point and the ending point of the transvalvular implant 1200 can be connected. The transvalvular implant 1200 can be generally triangular.

[0294] The first anchoring portion 1212 can include a single anchor location. The first anchoring portion 1212 can include a single eyelet. The single eyelet can be centrally located. The first anchoring portion 1212 can he configured to be positioned anteriorly. The second anchoring portion 1214 can include two anchor locations. The second anchoring portion 1214 can include a pair of eyelets. The second anchoring portion 1214 can be configured to be positioned posteriorly. The transvalvular implant 1200 can be implanted with a bifid catheter to deliver two anchors. The catheter can have a bifid partial template as a facilitating tool. The transvalvular implant 1200 can have a template to facilitate placement of the anchors associated with the second anchoring portion 1214. The transvalvular implant 1200 can have a template to facilitate placement of the anchors associated with the first anchoring portion 1212 and the second anchoring portion 1214. The transvalvular implant 1200 can facilitate easier anchor implantation. The transvalvular implant 1200 can facilitate easier implant delivery. The transvalvular implant 1200 can reduce the number of anchors delivered. The transvalvular implant 1200 can include a larger central opening 1218. The opening 1218 can facilitate future catheter intervention. The opening 1218 can allow passage of clips, such as clips to secure the leaflets. The opening 1218 can allow passage of a catheter system. The opening 1218 can allow passage for systems and/or tools for transcatheter mitral valve repair. The opening 1218 can be enlarged. The opening 1218 can be triangular. The transvalvular implant 1200 can be utilized with three instead of four anchors. In some embodiments, the three anchors can simplify the procedure and reduce the overall procedural time. In some embodiments, the transvalvular implant 1200 can also make future transcatheter intervention easier.

[0295] FIG. 54 is a view of an embodiment of a transvalvular implant 1300. The transvalvular implant 1300 can include any feature described herein. The transvalvular implant 1300 can be used in any method. The transvalvular implant 1300 can be deployed in any orientation described herein. The transvalvular implant 1300 can be used in the mitral valve. The transvalvular implant 1300 can be used in the tricuspid valve.

[0296] In some embodiments, the transvalvular implant 1300 comprises an elongate structure. The elongate structure can include a longitudinal axis between two anchoring sites. The elongate structure can be greater in length than in width. The transvalvular implant 1300 can be curved. The transvalvular implant 1300 can curve relative to the annulus. The transvalvular implant 1300 can be displaced from a plane. In some embodiments, the transvalvular implant 1300 curves upward. Tn some embodiments, the transvalvular implant 1300 curves downward.

[0297] The transvalvular implant 1300 can include a first end 1302 and a second end 1304. The second end 1304 can be opposite the first end 1302. The first end 1302 and the second end 1304 can be diametrically opposed. The first end 1302 and the second end 1304 can be axially aligned. The first end 1302 and the second end 1304 can be the same or similar. The first end 1302 and the second end 1304 can be identical. The first end 1302 and the second end 1304 can be different. In some embodiments, the first end 1302 has different features than the second end 1304. The first end 1302 and the second end 1304 can have different dimensions. The first end 1302 and the second end 1304 can have different eyelet configurations. The first end 1302 and the second end 1304 can have different attachment structures. Features described in relation to the first end 1302 can apply to features of the second end 1304.

[0298] The transvalvular implant 1300 can have a length between the first end 1302 and the second end 1304. The length can be configured to span the valve. The length can be configured to allow anchoring at specific locations on the annulus. The transvalvular implant 1300 can have a length between the first end 1302 and the second end 1304 that is capable of extending across one or more edges formed by leaflets. The transvalvular implant 1200 can include a central portion 1306. The central portion 1306 can be located between the first end 1302 and the second end 1304. The central portion 1306 can include one radius of curvature. The central portion 1306 can include two or more radii of curvature.

[0299] The transvalvular implant 1300 can be symmetrical. The transvalvular implant 1300 can include one plane of symmetry. The transvalvular implant 1300 can include two planes of symmetry. The transvalvular implant 1300 can include zero planes of symmetry. The transvalvular implant 1300 can be symmetrical about the central portion 1306. The transvalvular implant 1300 can be symmetrical widthwise. The transvalvular implant 1300 can be symmetrical lengthwise.

[0300] The transvalvular implant 1300 can include a lower surface disposed toward the annulus and an upper surface disposed away from the annulus. The central portion 1306 can include a leaflet contact surface. The leaflet contact surface can be curved along the longitudinal axis. The leaflet contact surface can be configured to contact one or more leaflets, as described herein. Tn other embodiments, the leaflet contact surface can have a different shape and profile. The leaflet contact surface can be concave. The leaflet contact surface can be straight. The leaflet contact surface can be a combination of convex, concave and/or straight segments. The leaflet contact surface can include two concave or straight portions joined together at an apex.

[0301] The transvalvular implant 1300 can have a substantially minimum width at the first end 1302. The transvalvular implant 1300 can have a substantially minimum width at the second end 1304. The transvalvular implant 1300 can have a substantially maximum width at the central portion 1306. The transvalvular implant 1300 can have a substantially maximum width near a midpoint of the central portion 1306. The transvalvular implant 1300 can taper along a portion of the length of the transvalvular implant 1300. The transvalvular implant 1300 can taper from the minimum width at the ends 1302, 1304 to the maximum width at the central portion 1306. The transvalvular implant 1300 can form a generally diamond shape. The transvalvular implant 1300 can form a generally parallelogram shape. The transvalvular implant 1300 can form a generally rectangular shape. The transvalvular implant 1300 can form a generally rhombus shape. The sides of the transvalvular implant 1300 can include an indent toward the first end 1302. The sides of the transvalvular implant 1300 can include in an indent toward the second end 1304. The sides of the transvalvular implant 100 can form a generally V shape. The sides of the transvalvular implant 100 can be pinched toward the ends 1302, 1304.

[0302] The transvalvular implant 1300 can include a first anchoring portion 1312. The transvalvular implant 1300 can include a second anchoring portion 1314. The first anchoring portion 1312 can be near the first end 1302. The second anchoring portion 1314 can be near the second end 1304. In some embodiments, the first end 1302 can include the first anchoring portion 1312 and the second end 1304 can include the second anchoring portion 1314.

[0303] The first anchoring portion 1312 can include one or more eyelets. The first anchoring portion 1312 can include a first eyelet 1316. The first anchoring portion 1312 can include only one eyelet 1316. The first anchoring portion 1312 can include a single eyelet 1316. The second anchoring portion 1314 can include one or more eyelets. The second anchoring portion 1314 can include a second eyelet 1318. The second anchoring portion 1314 can include only one eyelet 1318. The second anchoring portion 1314 can include a single eyelet 1318.

[0304] The first eyelet 1316 of the first anchoring portion 1312 and the second eyelet 1318 of the second anchoring portion 1316 can be aligned. The first eyelet 1316 of the first anchoring portion 1312 and the second eyelet 1318 of the second anchoring portion 1316 can be offset. The first eyelet 1316 of the first anchoring portion 1312 and the second eyelet 1318 of the second anchoring portion 1316 can be spaced apart.

[0305] The eyelets 1316, 1318 can be for accepting at least a portion of anchors 1350. The eyelets 1316, 1318 can be for accepting tethers 1354 that extend from a portion of the anchors 1350, as described herein. The eyelets 1316, 1318 can be for accepting a central post 1352 of the anchors 1350, as described herein. The eyelets 1316, 1318 can be for accepting any device that allow the transvalvular implant 1300 to be secured to the annulus. In some embodiments, the anchors 1350 are implanted before the transvalvular implant 1300 is positioned relative to the annulus. The eyelets 1316, 1318 can serve as guides as the transvalvular implant 1300 is lowered toward the annulus. The eyelets 1316, 1318 can receive the central post 1352. The eyelets 1316, 1318 can receive the tether 1354. The transvalvular implant 1300 can slide along the guide tether 1354 that extends through the eyelets 1316, 1318. Alternatively, in other embodiments the anchoring portions 1312 and 1314 can have other means for securing the transvalvular implant 1300 to the annulus.

[0306] The transvalvular implant 1300 can have a central opening 1320. The central opening 1320 can be enclosed by the transvalvular implant 1300. The central opening 1320 can have a length and width. The transvalvular implant 1300 can become wider toward the center or midpoint. In some embodiments, the width of the central opening 1320 extends along the majority of the length of the transvalvular implant 1300. In some embodiments, the length of the central opening 1320 extends along the majority of the width of the transvalvular implant 1300. The area of the central opening 1320 can be maximized.

[0307] The central opening 1320 can be any shape. The central opening 1320 can be diamond shaped. The central opening 1320 can be rhombus shaped. The central opening 1320 can be any generally elongate shape. The central opening 1320 can be open to allow blood to flow through. The central opening 1320 can be open to allow tools or other implants to be passed through. The central opening 1320 can be separate and distinct from the eyelets 1316, 1318 of the anchoring portions 1312, 1314. The central opening 1320 can be enclosed. The eyelets 1316, 1318 can be enclosed. The central opening 1320 can be uncoated. The central opening 1320 can be open along the entire length or a portion thereof. The central opening 1320 can be open along the entire width or a portion thereof. The transvalvular implant 1300 does not obstruct the flow of blood through the central opening 1320. The outline of the transvalvular implant 1300 can form the central opening 1320. The central portion 1306 can include the central opening 1320.

[0308] The central portion 1306 can have a variety of shapes. For example, the shape of the central portion 1306 can be substantially diamond shaped, rectangular, rhombus, parallelogram, rectangular, square, circular, oblong, or any other elongate shape. The central portion 1306 can have a three dimensional curved shaped. The edges of the transvalvular implant 1300 can be rounded or otherwise configured so that the transvalvular implant 1300 presents an atraumatic surface to the valve leaflets. In some embodiments, the shape can be oriented in a particular fashion to enhance performance of the transvalvular implant 1300. The transvalvular implant 1300 can include generally two shaped ends 1302, 1304. The ends 1302, 1304 have a relatively smaller surface area while a larger surface area is towards the central portion 1306. This configuration allows a larger surface area for the central opening 1320 to allow blood to flow therethrough. This configuration allows a larger opening 1320 to be in the direction of flow. This configuration can be a streamlined shape that provides less resistance to blood flow. Decreasing the resistance to blood flow is desirable because it can reduce turbulence and reduce the impedance of the transvalvular implant 1300 on the filling of the left ventricle. The transvalvular implant 1300 can have any shape that provides a central opening 1320 that reduces the resistance to blood flow.

[0309] The dimensions of the transvalvular implant 1300 will vary, depending upon the specific configuration of the transvalvular implant 1300 as well as the intended patient. In some embodiments, the transvalvular implant 1300 will have an axial length from first end 1302 to second end 1304 within the range of from about 20 mm to about 40 mm. In some embodiments, the transvalvular implant 1300 will have a width near the central portion 1306 within the range of from about 5 mm to about 15 mm. The width of the transvalvular implant 1300 in the central portion 1306 may be varied depending upon the desired performance, as will be discussed herein. The central portion 1306 can be large enough to minimize the risk of erosion resulting from repeated contact between the closed leaflets and the transvalvular implant 1300. The central portion 1306 including the central opening 1320 is designed to minimize flow turbulence and flow obstruction.

[0310] The central portion 1306 of the transvalvular implant 1300 can be greater in width, measured perpendicular to blood flow than the first and second anchoring portions 1312 and 1314. By enlarging the central portion 1306 and thus the opening 1320, the resistance to blood flow can be reduced. In some embodiments, enlarging the central portion 1306 increases the surface area of the leaflet contact surface that supports the valve leaflets.

[0311] In some embodiments, the enlarged central portion 1306 is separated from the first anchoring portion 1312 and the second anchoring portion 1314 by a first shoulder 1322 and a second shoulder 1324. The first shoulder 1322 can change the curvature. The first shoulder 1322 can be an inflection point. The second shoulder 1324 can change the curvature. The second shoulder 1324 can be an inflection point. The transvalvular implant 1300 can include one or more curved segments. The transvalvular implant 1300 can include concave segments and convex segments. The transvalvular implant 1300 can be convex near the ends 1302, 1304. The transvalvular implant 1300 can be concave near the shoulders 1322, 1324. The transvalvular implant 1300 can be convex near the central portion 1306.

[0312] In some embodiments, the length of the central portion 1306 can be the majority of the length of the transvalvular implant 1300. In some embodiments, the length of the central portion 1306 can be a portion of the length of the transvalvular implant 1300. In some embodiments, the length of the central portion 1306 may be greater than 50%, and in some embodiments greater than 75% of the overall length of the transvalvular implant 1300. The length of the central portion 1306, between first shoulder 1322 and second shoulder 1324, can be less than about 50% of the overall length of the transvalvular implant 1300. The length of the central portion 1306, between first shoulder 1322 and second shoulder 1324, can be less than about 30% of the overall length of the transvalvular implant 1300. The length of the central portion 1306, between first shoulder 1322 and second shoulder 1324, can be less than about 10% of the overall length of the transvalvular implant 1300. The length of the central portion 1306 can be designed to minimize the obstruction in the center of the flow path. The transvalvular implant 1300 can present a wider transverse surface for supporting the leaflets when the valve is closed. Tn some embodiments, the central portion 1306 can be generally convex in the direction of the ventricle. In some embodiments, the central portion 1306 can be generally concave.

[0313] The transvalvular implant 1300 can be formed from a single length of wire. The single length of wire can form a loop. The single length of wire can be welded at the ends. The transvalvular implant 1300 can be formed from several lengths of wire. The several lengths of wires can have different diameters. The several lengths of wires can have different lengths. The several lengths of wires can have different materials. The several lengths of wires can have different functions. The several lengths of wires can be welded at the ends.

[0314] The transvalvular implant 1300 can be formed from a continuous wire. The transvalvular implant 1300 can be formed from separate pieces of wire. The transvalvular implant 1300 can be formed from flexible material. In some embodiments, the bend angles and orientation of the material can be altered by the user to accommodate the desired axes of compression. In some embodiments, the bend angles and orientation of the material cannot be readily altered. In some embodiments, the bend angles and orientation are formed in a shape memory material. In some embodiments, the bend angles and orientation are biased toward a memory shape.

[0315] The transvalvular implant 1300 can be formed from a biocompatible material. The transvalvular implant 1300 can be formed from any material described herein. The transvalvular implant 1300 can be formed shape memory material. The transvalvular implant 1300 can recover the original shape. The transvalvular implant 1300 can comprise shape memory metal or polymer. In some embodiments, a portion of the transvalvular implant 1300 comprises a coating. In some embodiments, the transvalvular implant 1300 is uncoated. In some embodiments, at least the central opening 1320 of the transvalvular implant 1300 is uncoated. In some embodiments, the wire of the transvalvular implant 1300 is encased with a material.

[0316] The transvalvular implant 1300 can include a shaped body. The transvalvular implant 1300 can include one or more curved segments. The transvalvular implant 1300 can include an elongate flexible material formed into a diamond shaped pattern. The transvalvular implant 1300 can include four legs forming the diamond shape. The transvalvular implant 1300 can include open spaces between the legs. The transvalvular implant 1300 can include an outline of the diamond shaped pattern. The transvalvular implant 1300 can include the central portion 1306 formed such that the central portion 1306 bows or inclines in the direction of the ventricle to achieve early closure. The material may extend to form the first end 1302 and the second end 1304. The material may form a coil to enclose the eyelet 1316 of the first anchoring portion 1312. The material may form a coil to enclose the eyelet 1318 of the second anchoring portion 1314. The material may form the single eyelet 1316 of the first anchoring portion 1312. The material may form the single eyelet 1318 of the second anchoring portion 1314. The material may enclose the central opening 1320. The material may enclose a single central opening 1320.

[0317] The transvalvular implant 1300 can form a continuous shape as shown in Figure 57. The material can be Nitinol. The material can be in the form of a wire. The material can have a diameter or cross-section of 0.02”, 0.04”, 0.06”, 0.08”, 0.10”, 0.12”, 0.14”, 0.16”, 0.18”, 0.20”, 0.22”, 0.24”, 0.26”, 0.28”, 0.30”, 0.32”, 0.34”, 0.36”, about 0.18”, or any range of two of the foregoing values. The ends of the transvalvular implant 1300 can be laser welded. The width of the transvalvular implant 1300 can be 2 mm, 4 mm, 6 mm, 8 mm, 10 mm, 12 mm, 14 mm, 16 mm, 18 mm, 20 mm, about 10 mm, or any range of two of the foregoing values. The length of the transvalvular implant 1300 can be 20 mm, 22 mm, 24 mm, 26 mm, 28 mm, 30 mm, 32 mm, 34 mm, 36 mm, 38 mm, 40 mm, 42 mm, 44 mm, 46 mm, 48 mm, 50 mm, about 34 mm, or any range of two of the foregoing values. The length can be at least two times greater than the width. The length can be at least three times greater than the width. The height of the transvalvular implant 1300 can be less than 1 mm, 1 mm, 3 mm, 5 mm, 7 mm, 9 mm, 11 mm, 13 mm, 15 mm, 17 mm, 19 mm, about 7 mm, or any range of two of the foregoing values. The curve of the central portion 1306 can form the height. The height can extend downward from the plane of the annulus. The width can be greater than the height. The width and the height can be the same or similar.

[0318] The material can extend from a starting point. The starting point can be along the length of the transvalvular implant 1300. The starting point can be offset from the first end 1302. The material can extend from the starting point to the first end 1302. The material can form an coil or eyelet 1316 of the first anchoring portion 1312. The material can form one or more coils. The material can form can form three coils. The material can form coils to provide strength to the eyelet 1316. The material can form coils to prevent deformation of the eyelet 1316. The material can form coils to reinforce the eyelet 1316.

[0319] The material extends along the side of the implant forming a first leg to the central portion 1306. The first leg can include a first curve. The first leg can taper outward. The first leg can include a straight segment. The first leg can include a complex curve. The first leg can includes a curve with two radii of curvature. The first leg can extend to the midpoint of the transvalvular implant 1300. The first leg can form the first shoulder 1322. The first leg can form at least a portion of the central portion 1306.

[0320] The material extend along the side of the implant forming a second leg from the central portion 1306. The second leg can form at least a portion of the central portion 1306. The second leg can include a complex curve. The second leg can includes a curve with two radii of curvature. The second leg can extend from the midpoint of the transvalvular implant 1300. The second leg can form the second shoulder 1324. The second leg can include a straight segment. The second leg can include a second curve. The second leg can taper inward. The second leg can extend to the second end 1304. The material can form an coil or eyelet 1318 of the second anchoring portion 1314. The material can form one or more coils. The material can form can form three coils. The material can form coils to provide strength to the eyelet 1318. The material can form coils to prevent deformation of the eyelet 1318. The material can form coils to reinforce the eyelet 1318.

[0321] The material extend along the side of the implant forming a third leg to the central portion 1306. The third leg can include a third curve. The third leg can taper outward. The third leg can include a straight segment. The third leg can include a complex curve. The third leg can includes a curve with two radii of curvature. The third leg can extend to the midpoint of the transvalvular implant 1300. The third leg form the second shoulder 1324. The third leg can form at least a portion of the central portion 1306.

[0322] The material extend along the side of the implant forming a fourth leg from the central portion 1306. The fourth leg can form at least a portion of the central portion 1306. The fourth leg can include a complex curve. The fourth leg can includes a curve with two radii of curvature. The fourth leg can extend from the midpoint of the transvalvular implant 1300. The fourth leg can form the first shoulder 1323. The fourth leg can include a straight segment. The fourth leg can extend to the starting point. The fourth leg can include a laser weld. The fourth leg can form a continuous shape.

[0323] The transvalvular implant 1300 can be pinched in shape near the first end 1302. The transvalvular implant 1300 can be pinched in shape near the second end 1304. The transvalvular implant 1300 can include a small footprint near the eyelets 1316, 1318. The transvalvular implant 1300 can be enlarged near the central portion 1306. The transvalvular implant 1300 can include a large footprint near the central portion 1306. The transvalvular implant 1300 can include one or more segments that extend between the ends 1302, 1304. The one or more segments can be curved. The one or more segments can be straight. The one or more segments can be bowed inward. The one or more segments can be bowed outward.

[0324] The transvalvular implant 1300 can form an outlined shape. The transvalvular implant 1300 can include two legs connected to the first anchoring portion 1312 separated by a tapered outward shape. The transvalvular implant 1300 can include two legs connected to the second anchoring portion 1314 separated by a tapered outward shape. The transvalvular implant 1300 can include legs connected to the first anchoring portion 1312 and legs connected to the second anchoring portion 1314 pinched inward near the ends 1302, 1304. The transvalvular implant 1300 can include a continuous outline. The transvalvular implant 1300 can include a diamond shaped enclosed opening 1320. The transvalvular implant 100 can include one or more coils that form each eyelet 1316, 1318. The transvalvular implant 1300 can form a closed shape. The transvalvular implant 1300 can connect the starting point and the ending point.

[0325] The transvalvular implant 1300 can provide a relatively large support footprint against the valve leaflets, while optimizing the area of open space to permit maximum blood flow therethrough. The transvalvular implant 1300 can be made of any of a variety of flexible materials, including various polymers described elsewhere herein as well as titanium, titanium alloy, Nitinol, stainless steel, elgiloy, MP35N, or other metals known in the art. The material of the transvalvular implant 1300 can be treated or coated. The transvalvular implant 1300 can be encapsulated with silicone or another appropriate material, in order to eliminate untoward effects such as thrombosis or corrosion. The transvalvular implant 1300 can be uncoated. [0326] The transvalvular implant 1300 an be made of single wire. The transvalvular implant 1300 can be free of any material obstructing the central opening 1320. The central opening 1320 can be at or near the center of the implant. The central opening 1320 can be completely open, allowing blood to flow through the implant. The transvalvular implant 1300 can allow for future transcatheter intervention with other transcatheter devices through the opening 1320. The opening 1320 can allow access to the valve. The transvalvular implant 1300 can include attachment points. The transvalvular implant 1300 can include a single eyelet 1316, 1318 at each end 1302, 1304. The transvalvular implant 1300 can include the arcuate central portion 1306. The transvalvular implant 1030 can be curved downward into left ventricle cavity or into left atrium. The transvalvular implant 1300 can from an arch. The transvalvular implant 1300 can form a mitral arch. The transvalvular implant 1300 can form a tricuspid arch. The transvalvular implant 1300 can form a mitral straddle. The transvalvular implant 1300 can form a tricuspid straddle. The transvalvular implant 100 can straddle the valve.

[0327] Figure 54 illustrates a complete bridge system. The complete bridge system can include transvalvular implant 1300. The transvalvular implant 1300 can be a single eyelet bridge. The transvalvular implant 1300 can be a single eyelet mitral bride. The transvalvular implant 1300 can be a single eyelet tricuspid bride. The transvalvular implant 1300 can include the first eyelet 1316 near the first end 1302. The transvalvular implant 1300 can include the second eyelet 1318 near the second end. Each side of the transvalvular implant 1300 can include one eyelet. The transvalvular implant 1300 can include a total of two eyelets 1316, 1318. The transvalvular implant 1300 can include one or more angled eyelets. The eyelets 1316, 1318 can be rounded. The eyelets 1316, 1318 can be circular. The eyeletsl316, 1318 can be formed from coils. The eyelets 1316, 1318 can be diametrically opposed. The transvalvular implant 1300 can include one plane of symmetry. The transvalvular implant 1300 can include two planes of symmetry.

[0328] The eyelets 1316, 1318 can include angled eyelets. The angled eyelets 1316, 1318 can be at 45 degrees. The angled eyelets 1316, 1318 can be at other angles, such as 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, 80 degrees, 85 degrees, 90 degrees, or any range of two of the foregoing values. The anchors 1350 can be inserted at an angle. The central posts 1 52 of the anchor 1350 can be angled. The central post 1352 receives a single eyelet 1316, 1318. The clips 1380 are locking discs on the central posts 1352. The complete bridge system can include angled anchor posts 1352. The complete bridge system can include a single eyelet bridge 1300. The complete bridge system can include 45 degree eyelets 1316, 1318. The complete bridge system can include a single eyelet 1316, 1318 to engage on the threads and post of the anchor 1350. The complete bridge system can include locking disc clips 1370 on the anchor posts 1352.

[0329] The transvalvular implant 1300 can be positioned relative to the anatomy. Figure 55 illustrates the transvalvular implant 1300 in a pig heart on the tricuspid annulus. The transvalvular implant 1300 can include a simplified two eyelet design. The eyelets 1316, 1318 can be in a horizontal plane, as shown in Figures 56A-56B. The eyelets 1316, 1318 of the anchoring portions 1312, 1314 can be generally axially aligned. The eyelets 1316, 1318 of the anchoring portions 1312, 1314 can lie on a single plane. The eyelets 1316, 1318 of the anchoring portions 1312, 1314 can be flat. The transvalvular implant 1300 can span the valve.

[0330] The eyelets 1316, 1318 can be angled relative to a horizontal plane, as shown in Figures 56C-56D. The eyelets 1316, 1318 can be at a 45 degree angle to a horizontal plane. The eyelets 1316, 1318 can lie on skewed planes. The eyelets 1316, 1318 can lie on intersecting planes. The eyelets 1316, 1318 can lie on different planes. In some embodiments, the transvalvular implant 1300 can flex to accommodate different angles of the eyelets 1316, 1318. The central portion 1306 can flex to increase the angle of the eyelets 1316, 1318. The central portion 1306 can flex to decrease the angle of the eyelets 1316, 1318. The transvalvular implant 1300 can be angled to engage the saddle shaped annulus of the valve. The transvalvular implant 1300 is angled engage the angled anchor posts 1352. The anchors 1350 can be implanted at an angle. The central posts 1352 can extend at an angle when implanted. The transvalvular implant 1300 can include eyelets 1316, 1318 that mirror then angle of the central post 1352 when implanted. In some embodiments, the transvalvular implant 1300 can allow for changes in the eyelet angle. In some embodiments, the user can bend the transvalvular implant 1300 to change the angle. The transvalvular implant 1300 can include eyelets at angles relative to the horizontal plane. The transvalvular implant 1300 can include eyelets at angles relative to the plane of the annulus. The angle can be 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, or any range of two of the foregoing values. In some embodiments, the angle is approximately 45 degrees. The transvalvular implant 1300 can include a bridge design with angled eyelets 1316, 1318. The transvalvular implant 1300 can include single eyelets. The transvalvular implant 1300 can include angled eyelets.

[0331] The transvalvular implant 1300 can be used in combination with the anchors 1350. Figures 54 and 55 illustrate the anchor 1350 with the transvalvular implant 1300. The system can include a cap 1370. The cap 1370 can be any cap described herein. The cap 1370 can be a push-on cap. The cap 1370 can slide relative to the central post 1352 of the anchor 1350. The cap 1370 can slide along the suture 1354. The cap 1370 can be rounded. The cap 1370 can match the shape of the eyelet 1316, 1318. The cap 1370 can be larger in cross-section or diameter than the eyelet 1316, 1318. The cap 1370 can rest against the eyelet 1316, 1318. The cap 1370 can push the transvalvular implant 1300 toward the anchor 1350. The cap 1370 can push the transvalvular implant 1300 along the central post 1352. The cap 1370 can function as a locking clip to hold the transvalvular implant 1300 in position relative to the anchor 1350. The cap 1370 can form a friction fit with the central post 1352 of the anchor 1350. The cap 1370 can be pushed downward on the central post 1352 until a gap between the transvalvular implant 1300 and the coil of the anchor 1350 is reduced. In some embodiments, the cap 1370 does not form a frictional fit with the suture 1354. In some embodiments, the suture 1354 can be cut to release the annular anchor 1350 after the cap 1370 is locked. In some embodiments, the anchor 1350 is not reversible after release of the suture 1354. In some embodiments, the cap 1370 can include a pattern to enhance the locking, such as the patterns shown in Figure 43A-43C. The cap 1370 can remain in place after the transvalvular implant 1300 is deployed. The cap 1370 can securely lock the transvalvular implant 1300 in position relative to the anchor 1350.

[0332] Figure 58 is another view of the anchor 1350. In some embodiments, the anchor 1350 can be coupled to a tether 1354. The tether 1354 can be a monofilament tether. The tether 1354 can be a multifilament tether. The anchor 1350 can have any feature of the anchors described herein. The anchor 1350 can be configured to engage the annulus. The anchor 1350 can include coils 1356. The anchor 1350 can include a central post 1352. The central post 1352 can extend upward. The central post 1 52 can be a top portion of the anchor 1350. The coils 1356 can be a bottom portion of the anchor 1350. The coils 1356 can function as a thread. The tether 1354 can be coupled to the central post 1352. The tether 1354 can be crimped to the central post 1352. The central post 1352 can include a tubular structure that surrounds the tether 1354. The anchor 1350 can have a tip 1358. The anchor 1350 can be configured to penetrate the annulus. The anchor 1350 can be configured to be inserted at an angle. The tip 1358 can guide the initial engagement with the annulus. The tip 1358 can be sharpened. The tip 1358 can be a vertical tip. The anchor 1350 can includes sharpened edges 1360. The sharpened edges 1360 can extend from the tip 1358. The sharpened edges 1360 can extend along a portion of the coils 1356. The sharpened edges 1360 can extend along a full revolution of a coil 1356. The sharpened edges 1360 can extend along two revolutions of coils 1356. The sharpened edges 1360 can extend along a portion of the coils 1356. The sharpened edges 1360 can be on the bottom two coils.

[0333] The transvalvular implant 1300 can include a simplified two eyelet design. The transvalvular implant 1300 can be used with two anchors. The anchor tip 1358 can be straight. The anchor tip 1358 can be generally vertical. The anchor tip 1358 can be sharp for minimal implantation force. The anchor tip 1358 can include sharp edges. The anchor 1350 can include sharp edges 1360 of the bottom two threads.

[0334] In some embodiments, the central post 1352 can be angled with respect to the coils 1356. The central post 1352 can include an angled post. The central post 1352 can be at 45 degrees relative to the coil 1356. The central post 1352 can be at other angles relative to the coil 1356, such as 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, 80 degrees, 85 degrees, 90 degrees, or any range of two of the foregoing values. In some embodiments, the central post 1352 can be coaxial with respect to the coils 1356. The central post 1352 can extend from the annulus at an angle. The central post 1352 can be at 45 degrees relative to the annulus. The central post 1352 can be at other angles relative to the annulus, such as 5 degrees, 10 degrees, 15 degrees, 20 degrees, 25 degrees, 30 degrees, 35 degrees, 40 degrees, 45 degrees, 50 degrees, 55 degrees, 60 degrees, 65 degrees, 70 degrees, 75 degrees, 80 degrees, 85 degrees, 90 degrees, or any range of two of the foregoing values. [0335] The central post 1352 can include a groove 1 62. The groove 1362 can be shaped to accommodate the clip 1370. The groove 1362 can allow for better sccurcmcnt of the locking clip 1370. The clip 1370 can be a disc. The groove 1362 can have a height equal to or greater than the height of the of the clip 1370. The groove 1362 and the clip 1370 can form a frictional fit. The groove 1362 can prevent or reduce translation of the clip 1370 relative to the anchor 1350.

[0336] FIGS. 59A-59C are views of an embodiment of a tether cutter 1380. The tether cutter 1380 can include a barrel 1382. The tether cutter 1380 can include a cutter shaft 1384. The tether cutter 1380 can be spring loaded. The spring 1386 can be disposed within the barrel 1382. The spring 1386 can bias the cutter shaft 1384 away from the barrel 1382. The tether cutter 1380 can include one or more cutters 1388. The tether cutter 1380 can include two cutters 1388. The two cutters 1388 can be coupled to the cutter shaft 1384. The movement of the cutter shaft 1384 relative to the barrel 1382 can cause movement of the two cutters 1388. The barrel 1382 can include a conical opening 1390. The barrel 1382 can include a lumen 1392. The barrel 1382 can include one or more stops 1394. The barrel 1382 can include two stops 1394. The two stops 1394 can be shaped surfaces within the barrel 1382.

[0337] The tether cutter 1380 can be lowered relative to the anchor 1350. The barrel 1382 can receive the central post 1352. The tether 1354 can extend through barrel 1382. The tether 1354 can extend through the cutter shaft 1384. The tether cutter 1380 can be lowered until the locking clip 1370 engages the conical opening 1390. The central post 1352 can extend through the lumen 1392 of the barrel 1382. The tether cutter 1380 can be loaded with the tether 1354. The tether 1354 can be coupled to the central post 1352 of the anchor 1350.

[0338] The cutter shaft 1384 can be moved relative to the barrel 1382. The cutter shaft 1384 can compress the spring 1386. The cutter shaft 1384 can move the two cutters 1388. The cutter shaft 1384 can move the two cutters 1388 toward the two stops 1394. The two stops 1394 can pivot the two cutters 1388. The two stops 1394 can cause the two cutters 1388 to pivot toward the tether 1354. The two cutters 1388 can pivot toward each other. The two cutters 1388 can shear the tether 1354. The two cutters 1388 can cut the tether 1354 at a predetermined tether cut point. The tether cutter 1380 can be withdrawn. The cut end of the tether 1354 can be withdrawn.

[0339] The systems and methods can treat mitral valve regurgitation. The systems and methods can treat tricuspid valve regurgitation. In a healthy heart, the blood flows one way from the atrium to the ventricle. The mitral valve closes between the left atrium and the left ventricle. The tricuspid valve closes between the right atrium and the right ventricle. When the mitral and tricuspid valves are not working well, blood leaks back into the upper chambers and into lungs and the rest of the body, causing mitral and tricuspid leaks or regurgitation. Mitral and tricuspid valve regurgitation leads to heart failure. Mitral and tricuspid valve regurgitation can cause weakness, fatigue, shortness of breath, swelling of legs and feet. There is a high morbidity and mortality, with the risks growing as the population ages and increases in cardiovascular disease. There are types of mitral and tricuspid regurgitation. Degenerative mitral regurgitation includes abnormalities in the leaflets, for example mitral valve prolapse. Functional mitral regurgitation includes normal leaflets. Functional mitral regurgitation can include annular dilatation and retracted leaflets. Functional tricuspid regurgitation can include annular dilatation and retracted leaflets. There can be primary tricuspid regurgitation. There can be secondary tricuspid regurgitation. There can be isolated tricuspid regurgitation. The systems and methods can treat degenerative mitral regurgitation, functional mitral regurgitation, and/or functional tricuspid regurgitation. Functional mitral regurgitation and functional tricuspid regurgitation predict poor patient outcomes.

[0340] There is a need for intervention in addition to medical therapy. There is a need for achieving at least mild (1+ grade or less) mitral regurgitation or tricuspid regurgitation after treatment. There are at least 250,000 new diagnoses of mitral regurgitation annually, including at least 100,000 in the US and Europe and at least 50,000 in China. These conditional affect 16 million in the US and Europe and 10 million in China. In China, the prevalence of mitral regurgitation for the population over 60 years of age is 13.5%. Only 40,000 patients are treated surgically annually. Less than 3% of patients who could benefit from therapy receive therapy. Without treatment, 5% of patients with severe mitral regurgitation die per year, with a similar prevalence and mortality with tricuspid regurgitation. The systems and methods can treat millions of patients per year, since mitral and tricuspid regurgitation is a large and growing problem.

[0341] The fundamental problem in functional mitral and tricuspid regurgitation includes an increased anterior-posterior diameter of the mitral and tricuspid annulus. With functional mitral regurgitation and a diseased mitral valve, the leaflets may not close in the center with a large central orifice causing mitral regurgitation. The mitral valve leaflets do not close along the anterior-posterior diameter. With functional tricuspid regurgitation and a diseased tricuspid valve, the leaflets may not close in the center with a large central orifice causing tricuspid regurgitation. The tricuspid valve leaflets do not close along the anterior- posterior diameter. To achieve excellent clinical outcomes, there is a need for interventional procedures to achieve aggressive and sufficient reduction of the diameter of the central portion of the annulus with sufficient functional mitral regurgitation and function tricuspid regurgitation reduction at least one regurgitant grade and preservation of native annular function, annular saddle shape, and leaflet dynamics

[0342] The systems and methods described herein can achieve better results than annuloplasty rings or other devices that rely on circumferential cinching. These other devices can have a negative impact on leaflet coaptation geometry. These other devices can stress the leaflet. The systems and methods described herein can achieve better results than edge to edge repair devices. These other devices can lead to recurrence of moderate mitral regurgitation. These other devices can have a high exclusion rate due to anatomical ineligibility. The systems and methods described herein can achieve better results than suturing the leaflets. The systems and methods described herein can achieve better results than a permanent double orifice mitral valve.

[0343] The systems and methods can treat mitral and tricuspid regurgitation. The device allows for the valve to respond in native fashion with commissural flexing. The device allows for low filling gradients at rest and exercise preserving the natural saddle shape and leaflet dynamics. The device creates direct SLD reduction and early phase leaflet deep central coaptation of leaflets. The device allows the mitral or tricuspid annulus, beyond the central part, to self-adjusts around the central coaptation. The device can include a transannular bridge for functional mitral regurgitation and functional tricuspid regurgitation. The device can include one or more anchoring pads, The device can include a silicon-nitinol body. The device can have a centered, infra-annular curvature.

[0344] The device can include direct annular A-P diameter reduction in contrast to annuloplasty rings or other device. The device can include no circumferential cinching. The device can include no reduction in inter-commissural diameter. The device can preserve leaflet curvature and dynamics. The device can preserve annular saddle shape and function. The device can reduce mitral valve regurgitation from severe to mild/trace in 96% of patients at four years, based on data from 34 patients. Similar results were shown at 12 months. There was low mitral gradients at rest and exercise. The mean gradient at rest can be 2.15 mmHg. The mean gradient at peak exercise can be less than 5mmHg. The mean gradient at peak systolic pressure can be less than 40 mmHg. Similar results were shown with tricuspid regurgitation. The device can reduce tricuspid valve regurgitation from severe to mild/trace in a surgical feasibility study patients at two years, based on data from 6 patients. Similar results were shown at 18 months. There is low tricuspid gradients at rest and exercise. The mean gradient at peak exercise can be less than 3 mmHg.

[0345] The systems and methods can replicate the cornerstone of sound surgical repair. The systems and methods can be customizable, repositionable, and retrievable. The systems and methods can leave options for future transcatheter interventions. The systems and methods can use the transfemoral vein. The systems and methods can use transseptal access.

[0346] The systems and methods can include an echocardiography-assisted, catheterization lab procedure without cardiopulmonary bypass. The systems and methods can include segmented sequential stepwise and controlled implantation of transcatheter implants described herein. The systems and methods can include a three step procedure. The systems and methods can include the ability to test the anchor strength prior to delivering the implant. The systems and methods can include retrievable and repositionable anchors.

[0347] The systems and methods can include SLD (A-P diameter) cinching prior to implant selection and loading enabling optimization of implant size selection. The systems and methods can include segmented steps and procedural simplicity enhance the safety of the procedure with potential for generalizable wider adoption. The systems and methods can target a broader patient population when compared to the existing devices in the mitral and tricuspid space.

[0348] Figure 60A-60C illustrate methods steps. The systems and methods can include annular anchors implantation, as shown in Figure 60A. The systems and methods can include deploying two annular anchors 1350 as shown. The anchors 1350 can be located on the anterior annulus. The anchors 1350 can be located on the posterior annulus. The anchors 1350 can be located on the septal annulus. The anchors 1350 can have sutures 1354 extending from the anchors 1350. The systems and methods can include extracorporeal implant loading, as shown in Figure 60B. The transvalvular implant 600 can be loaded on the sutures 1354 that extend from the annular anchors 1350. The transvalvular implant 600 can be loaded outside of the body of the patient, and slid toward the patient via a delivery catheter. The systems and methods can include implant delivery and annular securement, as shown in Figure 60C. The transvalvular implant 600 can slide toward the annular anchors 1350. The methods can include any implant described herein. The methods can include any anchor described herein. The methods can include or omit any method step described herein.

[0349] Figure 61A-61C illustrate the transcatheter mitral and tricuspid repair system. The system can include the anchors 1350. The systems and methods can include any anchor described herein. The system can include the transvalvular implant 1300. The systems and methods can include any implant described herein. The anchors 1350 and the transvalvular implant 1300 can combine into a repair system. The anchors 1350 can combine with any implant described herein, including transvalvular implant 600. The procedure can be echo and fluroscopy driven. The procedure can be trans-femoral with trans-septal access. The annular anchors can be fully retrievable, repositionable, with minimal implantation force. The implant can have a design to achieve the desired form and function. The implant can be easily folded and delivered via catheter. The implant can have an open central area for options for future transcatheter repair or replacement. The implant can be compatible with other repair or replacement devices. The catheter delivery system can include a guide catheter, such as 23 Fr. The catheter delivery system can include a steering catheter, such as 16 Fr. The catheter delivery system can include an anchor delivery catheter, such as 10 Fr. The catheter delivery system can include an implant delivery catheter, such as 16 Fr. The catheter delivery system can be ergonomically easy to use. The catheter delivery system can simplify and reduce procedure times.

[0350] Figure 62A-62B illustrate the delivery system. Figure 62A illustrates a guide catheter 1400 and a steering catheter 1402. Figure 62B illustrates a implant delivery catheter 1402. The delivery system can be comparative in size to other systems. The delivery system can be simpler than other delivery systems.

[0351] The systems and methods have been tested in vitro and in pig hearts. The systems and methods have been tested with acute beating heart live animal studies. The systems and methods have shown successful anchoring and implant delivery. The systems and methods have shown good anchor depths and inter-anchor distances. The systems and methods have achieved excellent direct SLD cinching of the annulus with the implanted anchors. The systems and methods have shown high magnitude of mitral regurgitation reduction. The systems and methods have shown evidence of long term left ventricle remodeling. The systems and methods can have synergy with other technology. The systems and methods has optimal results with little or no residual regurgitation after the procedure. The systems and methods have less procedural complexity than other devices and methods.

[0352] The systems and methods include validated technology with over sixty surgical patients. The systems and methods can be used for trans-septal treatment of functional mitral regurgitation and function tricuspid regurgitation. The systems and methods can include a simplified implant with a simplified implantation procedure coupled with clinical validation of the concept by the clinical results with the surgical follow up. The systems and methods provide a simple, versatile annular technology with only a limited number of attachment points in contrast to other annuloplasty rings and other devices with complex procedures. The systems and methods conform to patient’s specific annular geometry thus applicable to more patients. The systems and methods allow aggressive SLD reduction adaptable to different degrees of leaflet restriction and left ventricle dilatation, thus expanding widely the adoption to many patient population. The systems and methods allow for effective treatment of both functional mitral regurgitation and functional tricuspid regurgitation, with a single transcatheter platform. The systems and methods have standard of care potential for cardiac valve repair. [0353] Figures 63A-63O are schematic views of methods of use of a transcatheter system, according to some embodiments. The systems and methods can revolutionize the treatment of mitral and tricuspid regurgitation. In a simple procedure, surgeons can treat mitral or tricuspid valve regurgitation in vivo, as an alternative to open heart surgery. Figure 63A shows the transcatheter system, external to the patient. The catheter delivery system can include the guide catheter 1400. The catheter delivery system can include the steering catheter 1402. The catheter delivery system can include an anchor delivery catheter 1404. The catheter delivery system can include the implant delivery catheter 1406. Figure 63A shows the guide catheter 1400 and the steering catheter 1402.

[0354] Figure 63B shows the entry into the patient. Figure 63B shows the guide catheter 1400 and the steering catheter 1402. Figure 63C shows the progression of the guide catheter 1400 toward the heart. The catheter system can be introduced via the femoral vein or other access point and delivered to the heart. The catheter system can be delivered using a transseptal puncture. Figure 63D shows the guide catheter 1400 gaining access to the heart. In some embodiments, a guide wire 1408 can be positioned to the left atrium. The guide catheter 1400 can be navigated into the heart along the guide wire 1408. The guide wire 1408 can span between the right atrium and the left atrium. The guide wire 1408 can extend from the left atrium, through the valve annulus and toward the left ventricle. The guide catheter 1400 can gain access to the mitral valve. The mitral valve can continue to function during the procedure. The heart is not stopped. The catheters of transcatheter system can include any of the features of catheters described herein. While some embodiments are described in the context of transvalvular implant 1300, other implants that span the annulus can be utilized, and the method adapted to other valve annuli including the tricuspid, aortic, and/or pulmonic valve annuli depending on the desired clinical result.

[0355] Figure 63E illustrates the guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404. The guide catheter 1400 can provide a transseptal conduit to, for example, the left atrium. The guide catheter 1400 can be placed in the left atrium through the transseptal access. In some embodiments, the steering catheter 1402 can be utilized after the guide catheter 1400 is placed. The steering catheter 1402 can be positioned relative to the annulus. The steering catheter 1402 can be deployed in the left atrium to direct the system appropriately to the mitral valve annulus. The steering catheter 1402 can be steered toward the posterior annulus, as shown in Figure 63E. The anchor delivery catheter 1404 can extend from the steering catheter 1402. The anchor delivery catheter 1404 can telescope within the steering catheter 1402. The steering catheter 1402 can telescope within the guide catheter 1400. The guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404 can be positioned to deliver the first anchor 1350 to the posterior annulus. The first anchor 1350 can be driven into the posterior annulus.

[0356] Figure 63F illustrates the anchor delivery catheter 1404 according to some embodiments. The anchor delivery catheter 1404 can have any features described herein. The anchor delivery catheter 1404 can deliver a single anchor. The anchor delivery catheter 1404 can rotate the first anchor 1350 to drive the anchor into the posterior annulus. The anchor delivery catheter 1404 can rotate relative to the steering catheter 1402. The anchor delivery catheter 1404 can rotate relative to guide catheter 1400.

[0357] Figure 63G illustrates the guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404. The first anchor 1350 is secured to the posterior annulus. The first suture 1354 extends from the first anchor 1350. The steering catheter 1402 can be repositioned relative to the anterior annulus. The steering catheter 1402 can be deployed in the left atrium to direct the system appropriately to the anterior annulus. The steering catheter 1402 can be steered toward the anterior annulus, as shown in Figure 63G. The anchor delivery catheter 1404 can extend from the steering catheter 1402. The anchor delivery catheter 1404 can telescope within the steering catheter 1402. The steering catheter 1402 can telescope within the guide catheter 1400. The guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404 can be positioned to deliver the second anchor 1350 to the anterior annulus. The second anchor 1350 can be driven into the anterior annulus. In other embodiments, the first anchor 1350 can be driven into the posterior annulus and the second anchor 1350 can be driven into the anterior annulus.

[0358] Figure 63H illustrates both anchors 1350. The first anchor 1350 is secured to the posterior annulus. The first suture 1354 extends from the first anchor 1350. The second anchor 1350 is secured to the anterior annulus. The second suture 1354 extends from the second anchor 1350. The anchor delivery catheter 1404 can be retracted. The steering catheter 1402 can be retracted. In some embodiments, the guide catheter 1400 or another cinching catheter can be advanced to cinch the sutures 1354. The transvalvular implant 1300 can be positioned relative to the tails of the sutures 1354 which are external to the patient. Each suture 1354 can extend through a corresponding eyelet of the transvalvular implant 1300. The transvalvular implant 1300 can be compressed within the implant delivery catheter 1406. The transvalvular implant 1300 can engage the sutures 1354 when compressed within the implant delivery catheter 1406.

[0359] Figure 631 illustrates the implant delivery catheter 1406. The implant delivery catheter 1406 can extend through the guide catheter 1400. The implant delivery catheter 1406 can include an implant pusher 1410. In some embodiments, the implant pusher 1410 can be releasably secured to the locking disc clip 1370. In some embodiments, the implant pusher 1410 can be releasably secured to the transvalvular implant 1300. In some embodiments, the implant pusher 1410 merely pushes the locking disc clip 1370 and the transvalvular implant 1300. The implant pusher 1410 can slide along the suture 1354 which extends from the anchor 1350. The suture 1354 can guide the transvalvular implant 1300 toward the anchor 1350. The implant pusher 1410 can push the locking disc clip 1370 and the transvalvular implant 1300 toward the anchor 1350. The implant pusher 1410 can push transvalvular implant 1300 over the central post 1352. The implant pusher 1410 can push the locking disc clip 1370 over the central post 1352. The locking disc clip 1370 can engage the groove 1362 of the central post 1352, as shown in Figure 58. At least a portion of the transvalvular implant 1300 can remain within the implant delivery catheter 1406.

[0360] Figure 63J illustrates the implant delivery catheter 1406. The implant delivery catheter 1406 can be retracted toward the guide catheter 1400. The implant delivery catheter 1406 can be retracted to release the transvalvular implant 1300. The implant pusher 1410 can be retracted. The implant pusher 1410 can retract along the first suture 1354. The locking disc clip 1370 can remain engaged with the groove 1362 of the central post 1352 of the first anchor 1350. The locking disc clip 1370 can retain the transvalvular implant 1300 relative to the first anchor 1350. The transvalvular implant 1300 can be secured to the posterior annulus. At least a portion of the transvalvular implant 1300 can remain within the implant delivery catheter 1406.

[0361] Figure 63K illustrates the transvalvular implant 1300. The implant delivery catheter 1406 can be retracted toward the guide catheter 1400. The implant delivery catheter 1406 can be retracted to release the transvalvular implant 1300. The transvalvular implant 1300 can be secured to the posterior annulus. The second suture 1354 extends through the eyelet of the transvalvular implant 1300. The transvalvular implant 1300 is not yet secured to the anteriror annulus.

[0362] Figure 63L illustrates the implant delivery catheter 1406. The implant delivery catheter 1406 can be steered toward the anterior annulus. In some embodiments, the implant pusher 1410 can be slid along the second suture 1354. In some embodiments, one implant pushers 1410 is utilized for both anchors 1350. In some embodiments, two implant pushers 1410 are utilized, one for each anchor 1350. In some embodiments, the implant pusher 1410 can be releasably secured to the second locking disc clip 1370. In some embodiments, the implant pusher 1410 can be releasably secured to the transvalvular implant 1300. In some embodiments, the implant pusher 1410 merely pushes the second locking disc clip 1370 and the transvalvular implant 1300. The implant pusher 1410 can slide along the second suture 1354 which extends from the second anchor 1350. The second suture 1354 can guide the transvalvular implant 1300 toward the second anchor 1350. The implant pusher 1410 can push the second locking disc clip 1370 and the transvalvular implant 1300 toward the second anchor 1350. The implant pusher 1410 can push the transvalvular implant 1300 over the central post 1352 of the second anchor 1350. The implant pusher 1410 can push the second locking disc clip 1370 over the central post 1352 of the second anchor 1350. The second locking disc clip 1370 can engage the groove 1362 of the central post 1352 of the second anchor 1350.

[0363] Figure 63M illustrates the transvalvular implant 1300. The implant delivery catheter 1406 can be retracted toward the guide catheter 1400. The implant pusher 1410 can be retracted. The transvalvular implant 1300 can be secured to both anchors 1350. The valve can normally close. Figure 63N illustrates the transvalvular implant 1300. The valve can normally open. Figure 630 illustrates the transvalvular implant 1300 relative to a tricuspid valve. The tricuspid valve can normally open and close. The transvalvular implant 1300 can be placed according to any method described herein. The anchor 1350 can be delivered first. The transvalvular implant 1300 and the locking clip 1370 can be delivered after the anchors 1350 are secured. There is coupling of the transvalvular implant 1300 on the top of the anchor 1350. The transvalvular implant 1300 is locked in by the locking clip 1370. [0364] Tn some embodiments, the implant pusher 1410 can provide suture management. Each suture 1354 can extend through a separate implant pusher 1410 such that the sutures 1354 are prevented from tangling or tangling is reduced. In some embodiments, the sutures 1354 can extend through separate eyelets of the transvalvular implant 1300 for suture management.

[0365] In some embodiments, the method can include the cinching of the annulus. In some embodiments, with the anchors 1350 in place and the sutures 1354 extending from the anchors 1350, the annulus can be cinched, in other words, the opposing sides of the annulus can be brought closer together along part of the annulus. The cinching can confirm securement of the anchors 1350. The cinching can reduce any slack in the sutures 1354. The cinching can confirm the correct size of the transvalvular implant 1300. The cinching can confirm the desired spacing or length between the pair of anchors 1350 associated with the posterior annulus and the anterior annulus. The length of the transvalvular implant 1300 can be selected to maintain the cinched position of the annulus. In some embodiments, the guide catheter 1400 or another cinching catheter can be brought toward the annulus to cinch the sutures 1354, and thus the anchors 1350. In some embodiments, as the guide catheter 1400 or cinching catheter moves toward the annulus, the sutures 1354 can be moved toward each other. In some embodiments, tension is applied to the sutures 1354 to cinch the sutures 1354. The sutures 1354 can be connected to the annulus via the annular anchors 1350 in order to move the annulus. The cinching can increase the engagement between the posterior and anterior leaflet to enhance coaptation, as described herein. The transvalvular implant 1300 can include any of the features of any implant described herein. The transvalvular implant 1300 can be deployed after the anchors 1350 are deployed. The transvalvular implant 1300 can be guided into place via the sutures 1354 which are permanently attached to the anchors 1350. The transvalvular implant 1300 can include eyelets through which the sutures 1354 can pass. In some embodiments, each eyelet can be designed to accept one suture 1354. The first end of the transvalvular implant 1300 can include one eyelet designed to accept one suture 1354. The transvalvular implant 1300 can be compressed for delivery. Figures 63M and 630 illustrates the transvalvular implant 1300 deployed in the mitral valve and the tricuspid valve. The transvalvular implant 1300 can slide along the anchored sutures 1354 toward the annulus. The second end of the transvalvular implant 1300 can include one eyelet designed to accept one suture 1354. The two eyelets can correspond to the two sutures 1 54. The two eyelets can provide suture management to prevent the sutures 1354 from being tangled during delivery.

[0366] The implant delivery catheter 1406 and the implant pusher 1410 can move the transvalvular implant 1300 toward the annulus. Once positioned, the transvalvular implant 1300 can be used in conjunction with the anchor 1350 to cinch the posterior annulus toward the anterior annulus to facilitate proper leaflet coaptation. The implant pusher 1410 can move locking disc clip 1370 toward the annulus. Each locking disc clip 1370 can slide along the corresponding suture 1354 during delivery. The locking disc clip 1370 can secure the transvalvular implant 1300 to the anchor 1350. The suture 1354 can be threaded through the locking disc clip 1370. The locking disc clip 1370 can allow movement of the locking disc clip 1370 toward the annulus but prevent or limit movement of the locking disc clip 1370 away from the annulus once in the groove 1362 of the anchor 1350. In some embodiments, the transvalvular implant 1300 and the locking disc clip 1370 can be simultaneously delivered. In some embodiments, the transvalvular implant 1300 can be delivered first and the locking disc clip 1370 can be delivered after. In some embodiments, the locking disc clips 1370 can be sequentially delivered.

[0367] Figures 63M and 630 illustrate the deployed transvalvular implant 1300 according to some embodiments. The transvalvular implant 1300 can be sized to maintain the position of the anchors 1350 and underlying annulus. The transvalvular implant 1300 can be sized to cinch the anchors 1350 and therefore the annulus. In some embodiments, a trimming catheter is provided. The trimming catheter can slide along the suture 1354 toward the annulus. The trimming catheter can trim the suture 1354 above the locking disc clips 1370. In some embodiments, both sutures 1354 can be sequentially trimmed by the trimming catheter. The trimming catheter can allow the suture 1354 to be retrieved by pulling the suture from the body of the patient.

[0368] Figures 64A-64E are schematic views of methods of use of a transcatheter system, according to some embodiments. Certain aspects of the systems and methods can improve the treatment of tricuspid regurgitation. In an improved procedure, surgeons can treat tricuspid valve regurgitation in vivo, as an alternative to open heart surgery. Figure 64A shows the transcatheter system, external to the patient in the lower right comer. The system can include any features described in relation to Figures 63A-63O. The catheter delivery system can include the guide catheter 1400. The catheter delivery system can include the steering catheter 1402. The catheter delivery system can include an anchor delivery catheter 1404. The catheter delivery system can include the implant delivery catheter 1406. The system can enter the patient as described herein. The guide catheter 1400 can be moved toward the tricuspid valve. The catheter system can be introduced via the femoral vein or other access point and delivered to the heart. In some embodiments, the guide catheter 1400 can be guided by use of a guide wire. The guide catheter 1400 can gain access to the tricuspid valve. The tricuspid valve can continue to function during the procedure. The heart is not stopped. The catheters of transcatheter system can include any of the features of catheters described herein. While some embodiments are described in the context of transvalvular implant 1300, other implants that span the annulus can be utilized, and the method adapted to other valve annuli including the tricuspid, aortic, and/or pulmonic valve annuli depending on the desired clinical result.

[0369] Figure 64A illustrates the guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404. The guide catheter 1400 can be placed in the right atrium. In some embodiments, the steering catheter 1402 can be utilized after the guide catheter 1400 is placed. The steering catheter 1402 can be positioned relative to the tricuspid annulus. The steering catheter 1402 can be deployed in the right atrium to direct the system appropriately to the tricuspid annulus. The steering catheter 1402 can be steered toward the anterior annulus of the tricuspid valve, as shown in Figure 64A. The anchor delivery catheter 1404 can extend from the steering catheter 1402. The anchor delivery catheter 1404 can telescope within the steering catheter 1402. The steering catheter 1402 can telescope within the guide catheter 1400. The guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404 can be positioned to deliver the first anchor 1350 to the anterior annulus. The first anchor 1350 can be driven into the anterior annulus of the tricuspid valve.

[0370] Figure 64B illustrates the anchor delivery catheter 1404 according to some embodiments. The anchor delivery catheter 1404 can have any features described herein. The anchor delivery catheter 1404 can deliver a single anchor. The anchor delivery catheter 1404 can rotate the first anchor 1350 to drive the anchor into the anterior annulus. The anchor delivery catheter 1404 can rotate relative to the steering catheter 1402. The anchor delivery catheter 1404 can rotate relative to guide catheter 1400. The transvalvular bridge 1300 can be positioned along the A-S-P diameter. The transvalvular bridge 1300 can be anchored on the anterior annulus on the A-S-P diameter.

[0371] Figure 64C illustrates the first anchor 1350 is secured to the anterior annulus. The first suture 1354 extends from the first anchor 1350. Figure 64D illustrates the e steering catheter 1402. The steering catheter 1402 can be repositioned relative to the posterior and septal annulus. The transvalvular bridge 1300 can be anchored on the posterior annulus on the A-S-P diameter. The transvalvular bridge 1300 can be anchored on the septal annulus on the A-S-P diameter. The A-S-P diameter extends between the anterior annulus and both the septal annulus and posterior annulus. The transvalvular bridge 1300 can extend across one or more leaflets on the A-S-P diameter. The steering catheter 1402 can be deployed in the right atrium to direct the system appropriately to the posterior annulus and septal annulus. The steering catheter 1402 can be steered toward the septal annulus and posterior annulus, as shown in Figure 64D. The anchor delivery catheter 1404 can extend from the steering catheter 1402. The anchor delivery catheter 1404 can telescope within the steering catheter 1402. The steering catheter 1402 can telescope within the guide catheter 1400. The guide catheter 1400, the steering catheter 1402, and the anchor delivery catheter 1404 can be positioned to deliver the second anchor 1350 to the annulus. The second anchor 1350 can be driven into the annulus. In other embodiments, the first anchor 1350 can be driven into the anteriro annulus and the second anchor 1350 can be driven into the septal annulus or posterior annulus.

[0372] Figure 64E illustrates both anchors 1350. The first anchor 1350 is secured to the anterior annulus. The first suture 1354 extends from the first anchor 1350. The second anchor 1350 can be secured to along the coaptive edge between the septal annulus and posterior annulus. The second anchor 1350 can be secured to the septal annulus. The second anchor 1350 can be secured to the posterior annulus. The first anchor 1350 can be anchored on the anterior annulus on the A-S-P diameter. The second anchor 1350 can be anchored on the posterior annulus on the A-S-P diameter. The second anchor 1350 can be anchored on the septal annulus on the A-S-P diameter. The second suture 1354 extends from the second anchor 1350. The anchor delivery catheter 1404 can be retracted. The steering catheter 1402 can be retracted. [0373] Figure 64F illustrates cinching the sutures 1354. Tn some embodiments, the steering catheter 1402, the guide catheter 1400 or another cinching catheter can be advanced to cinch the sutures 1354. The sutures 1354 can be cinched to determine the appropriate size for the transvalvular implant 1300. The transvalvular implant 1300 can be positioned relative to the tails of the sutures 1354 which are external to the patient. Each suture 1354 can extend through a corresponding eyelet of the transvalvular implant 1300. The transvalvular implant 1300 can be compressed within the implant delivery catheter 1406. The transvalvular implant 1300 can engage the sutures 1354 when compressed within the implant delivery catheter 1406.

[0374] Figure 64G illustrates the implant delivery catheter 1406. The implant delivery catheter 1406 can extend through the guide catheter 1400. The implant delivery catheter 1406 can include an implant pusher 1410. In some embodiments, the implant pusher 1410 can be releasably secured to the locking disc clip 1370. In some embodiments, the implant pusher 1410 can be releasably secured to the transvalvular implant 1300. In some embodiments, the implant pusher 1410 merely pushes the locking disc clip 1370 and the transvalvular implant 1300. The implant pusher 1410 can slide along the suture 1354 which extends from the anchor 1350. The suture 1354 can guide the transvalvular implant 1300 toward the first anchor 1350. The implant pusher 1410 can push the locking disc clip 1370 and the transvalvular implant 1300 toward the first anchor 1350. The implant pusher 1410 can push transvalvular implant 1300 over the central post 1352. The implant pusher 1410 can push the locking disc clip 1370 over the central post 1352. The locking disc clip 1370 can engage the groove 1362 of the central post 1352, as shown in Figure 58. At least a portion of the transvalvular implant 1300 can remain within the implant delivery catheter 1406.

[0375] Figure 64H illustrates the implant delivery catheter 1406. The implant delivery catheter 1406 can be retracted from the first anchor 1350. The implant delivery catheter 1406 can be retracted to release the transvalvular implant 1300. The implant pusher 1410 can be retracted. The implant pusher 1410 can retract along the first suture 1354. The locking disc clip 1370 can remain engaged with the groove 1362 of the central post 1352 of the first anchor 1350. The locking disc clip 1370 can retain the transvalvular implant 1300 relative to the first anchor 1350. The transvalvular implant 1300 can be secured to the anterior annulus. The implant delivery catheter 1406 can be retracted to release the transvalvular implant 1300. The eyelet of the transvalvular implant 1 00 can slide along the second suture 1354. The transvalvular implant 1300 can slide toward the second anchor 1350.

[0376] Figure 641 illustrates the implant delivery catheter 1406. The implant delivery catheter 1406 can be steered toward a position between the posterior annulus and the septal annulus.

[0377] Figure 64J illustrates the implant delivery catheter 1406. In some embodiments, the implant pusher 1410 can be slid along the second suture 1354. In some embodiments, one implant pushers 1410 is utilized for both anchors 1350. In some embodiments, two implant pushers 1410 are utilized, one for each anchor 1350. In some embodiments, the implant pusher 1410 can be releasably secured to the second locking disc clip 1370. In some embodiments, the implant pusher 1410 can be releasably secured to the transvalvular implant 1300. In some embodiments, the implant pusher 1410 merely pushes the second locking disc clip 1370 and the transvalvular implant 1300. The implant pusher 1410 can slide along the second suture 1354 which extends from the second anchor 1350. The second suture 1354 can guide the transvalvular implant 1300 toward the second anchor 1350. The implant pusher 1410 can push the second locking disc clip 1370 and the transvalvular implant 1300 toward the second anchor 1350. The implant pusher 1410 can push the transvalvular implant 1300 over the central post 1352 of the second anchor 1350. The implant pusher 1410 can push the second locking disc clip 1370 over the central post 1352 of the second anchor 1350. The second locking disc clip 1370 can engage the groove 1362 of the central post 1352 of the second anchor 1350.

[0378] Figures 64K-64L illustrate the transvalvular implant 1300. The implant delivery catheter 1406 can be retracted toward the guide catheter 1400. The implant pusher 1410 can be retracted. The transvalvular implant 1300 can be secured to both anchors 1350. The valve can normally close. Figure 64K illustrates the transvalvular implant 1300 relative to the tricuspid valve. The valve can normally open. Figure 64L illustrates the transvalvular implant 1300 relative to the tricuspid valve. The valve can normally close. The transvalvular implant 1300 can be placed according to any method described herein. The anchor 1350 can be delivered first. The transvalvular implant 1300 and the locking clip 1370 can be delivered after the anchors 1350 are secured. There is coupling of the transvalvular implant 1300 on the top of the anchor 1 50. The transvalvular implant 1 00 is locked in hy the locking clip 1370. The transvalvular implant 1300 can be secured to two positions on the annulus.

[0379] In some embodiments, the method can include the cinching of the tricuspid annulus. In some embodiments, with the anchors 1350 in place and the sutures 1354 extending from the anchors 1350, the tricuspid annulus can be cinched, in other words, the opposing sides of the tricuspid annulus can be brought closer together along part of the tricuspid annulus. The cinching can confirm securement of the anchors 1350. The cinching can reduce any slack in the sutures 1354. The cinching can confirm the correct size of the transvalvular implant 1300. The cinching can confirm the desired spacing or length between the pair of anchors 1350. The length of the transvalvular implant 1300 can be selected to maintain the cinched position of the tricuspid annulus. The sutures 1354 can be connected to the tricuspid annulus via the anchors 1350. The cinching can increase the engagement between the leaflets to enhance coaptation, as described herein.

[0380] Once positioned, the transvalvular implant 1300 can be used in conjunction with the anchors 1350 to facilitate proper leaflet coaptation. The transvalvular implant 1300 can be sized to maintain the position of tricuspid annulus. In some embodiments, a trimming catheter is provided. The trimming catheter can slide along the suture 1354 toward the annulus. The trimming catheter can trim the suture 1354 above the locking disc clips 1370.

[0381] Figure 65 is a diagram for an all-in-one mitral and tricuspid delivery system. The system can include a retractable anchor driven tip. The system can include a clip push-on tip. The system can include the steering catheter 1402. The system can include the anchors 1350. The system can include the tethers 1354. The system can include the transvalvular implant 1300. The tethers 1354 can extend through the eyelets of the transvalvular implant 1300. The system can include the locking clips 1370. The system can include a combination anchor delivery system 1420 for the anchor 1350 and the locking clip 1370. The system can include a combination bridge delivery system 1422 for the anchor 1350 and the transvalvular implant 1300. The anchor delivery system 1420 can include an anchor drive key. The anchor drive key can rotate the anchor 1350 to drive the anchor 1350 into tissue. The anchor delivery system 1420 can include a shape memory flexture. The bridge delivery system 1422 can include a clip driver. The clip driver can advance the locking clips 1370. The clip driver can advance the transvalvular implant 1 00. The anchor delivery system 1420 can advance from the bridge delivery system 1422. The anchor delivery system 1420 can advance by being pushed. The anchor delivery system 1420 can advance with the anchor 1350 attached. The anchor delivery system 1420 retract into the bridge delivery system 1422. he anchor delivery system 1420 retract into the bridge delivery system 1422 for attaching the locking clip 1370 to the central post 1352 of the first anchor 1350. The bridge delivery system 1422 can guide the locking clip 1370 relative to the anchor 1350. The system can allow the anchor 1350, the transvalvular implant 1300, and the clip 1370 to be loaded into the steering catheter 1402. The steering catheter 1402 can be an all-in- one bi-plane steerable catheter. The steering catheter 1402 can deliver the anchor 1350. The steering catheter 1402 can deliver the locking clip 1370. The steering catheter 1402 can deliver the transvalvular implant 1300. The steering catheter 1402 can facilitate anchor delivery. The steering catheter 1402 can facilitate clip attachment.

[0382] In some embodiments, the guide catheter 1400 can have a diameter of 23F. The outer diameter can be 0.300” and the inner diameter can be 0.240”. In some embodiments, the steering catheter 1402 can have a diameter of 16F. The outer diameter can be 0.205” and the inner diameter can be 0.160”. In some embodiments, the system can include a sheath 1430 with dilator 1432 which can have a diameter of 17F. The outer diameter can be 0.223”. The system can include the new sheath 1430. The new sheath 1430 can be compatible with a dilator 1432. The new sheath 1430 can be compatible with the steering catheter 1402. The sheath 1430 can be compatible with a hemostasis valve.

[0383] Figures 66A-66B illustrate workflows. The workflow can include the guide catheter 1400 and the steering catheter 1402. The first anchor 1350 can be secured to the annulus. The first tether 1354 can extend from the first anchor 1350. The first tether 1354 can extend through the steering catheter 1402. In the first position, the steering catheter 1402 can extend through the guide catheter 1400. In the second position, the steering catheter 1402 can be retracted. The tether 1354 can extend from the anchor 1354 through the guide catheter 1400. In the third position, the steering catheter 1402 can be advanced. The second anchor 1350 can be secured to the annulus. The second tether 1354 can extend from the second anchor 1350. The steering catheter 1402 can push on the first tether 1354 when the steering catheter 1402 is advanced. In the fourth position, the steering catheter 1402 can be retracted. The steering catheter 1402 can pull on the first tether 1354 when the steering catheter 1402 is retracted. The steering catheter 1402 can pull on the first anchor 1350 when the steering catheter 1402 is retracted.

[0384] The workflow can include the guide catheter 1400 and the steering catheter 1402. The first anchor 1350 can be secured to the annulus. The first tether 1354 can extend from the first anchor 1350. The first tether 1354 can extend through the steering catheter 1402. In the first position, the steering catheter 1402 can extend through the guide catheter 1400. The steering catheter 1402 can be retracted. In the second position, the sheath 1430 with the dilator 1432 can be inserted into the guide catheter 1400. The dilator 1432 can extend through the sheath 1430. The sheath 1430 can extend along the first tether 1354. The sheath 1430 can have a distal section and a proximal section. The dilator 1432 can be pulled back into the sheath 1430. In the third position, the steering catheter 1402 can be advanced through the sheath 1430. The second anchor 1350 can be secured to the annulus. The second tether 1354 can extend from the second anchor 1350. In the fourth position, the steering catheter 1402 can be retracted. The first tether 1354 can extend on the outside of the sheath 1430. The sheath 1430 can be protect the tether 1354. The second tether 1354 can extend through the sheath 1430. In the fifth position, the sheath 1430 can be retracted. The distal section of the sheath 1430 can be 40/50D. The distal section of the sheath 1430 can be 72D. The sheath 1430 can include an hemostasis seal.

[0385] Figures 67A-67E illustrate systems that control anchor attachment to the tricuspid annulus. The systems can include a steering and anchor delivery system. The steering and anchor delivery system can include a distal section, steering and anchor delivery system can include a handle depth control. The systems can include an anchor and driver. The systems can include an anchor attachment process.

[0386] Figures 67A-67B illustrate the distal section including the anchor and anchor delivery system. The system can include the steering catheter 1402. The system can include the anchor delivery catheter 1404. The anchor delivery catheter 1404 can include one or more stabilizing tips 1440. The stabilizing tip 1440 can be a composite tricuspid stabilizing tip. The stabilizing tips 1440 can be rounded to engage the annulus. The system can include a helical anchor and drive. The system can include the helical anchor 1350. The system can include the central post 1352. The system can include a keyed driver 1442. The system can include an anchor delivery system 1444. The system can include a steering catheter tip to anchor delivery system surface registration control 1446.

[0387] Figures 67C-67D illustrate the handle anchor delivery system. The system can include an anchor attachment depth hard stop. The system can include an anchor tether tensioner and lock 1450. The anchor tether tensioner and lock 1450 can apply tension to the tether 1354. The anchor tether tensioner and lock 1450 can lock the tether 1354. The system can include an anchor rotation knob 1452. The anchor rotation knob 1452 can rotate to drive the anchor 1350 into tissue. The system can include an anchor slider depth adjustment 1454. The anchor slider depth adjustment 1454 can slide as the anchor 1350 is advanced. The system can include a hard stop 1456 for the anchor depth control. The anchor slider depth adjustment 1454 can abut the hard stop 1456 to limit further advancement of the anchor 1350.The system can include a slider locking shaft 1458. The system can include the steering catheter tip to anchor delivery system surface registration control 1446. The system can include the steering catheter 1402.

[0388] Figure 67E illustrates the helical anchor and driver. The system can include the helical anchor 1350. The system can include the central post 1352. The system can include a keyed driver 1442. The system can include the tether 1354. The tether 1354 can be tensioned in direction A to engage driver. The tether 1354 can be released in direction B to disengage driver.

[0389] The system can include an anchor attachment process. The method can include setting the travel stop to 4mm. The anchor slider depth adjustment 1454 can be positioned relative to the hard stop 1456. The method can include positioning the steering catheter 1402 to be in firm contact with tricuspid annulus. The method can include pushing the anchor delivery slide in 4mm and hold up against hard stop 1456. The method can include rotating anchor attachment knob 1452 two full turns counterclockwise to set tip. The method can include rotating anchor attachment knob 1452 clockwise one full turn then back drive 1/2 turn. The method can include repeating four time until anchor attachment knob 1452 is at the 4mm hard stop 1456. The method can include resetting travel stop to add an additional 4mm of travel. The method can include repeat rotating clockwise one full turn then back drive 1/2 turn until anchor attachment knob is at the 4mm hard stop 1456. The method can include using eco to confirm position and attachment depth of anchor 1350. The method can include releasing tether tension to disengage driver 1442. The method can include removing the anchor delivery system from guide catheter 1400.

[0390] Figures 68A-68B illustrate the bridge delivery system. The bridge delivery system can be all-in-one. Figure 68A illustrates snares in relation to the transvalvular implant 1300. Figure 38B illustrates another view of the snares. The anterior snare 1460 is green and the posterior snare 1462 is white. The locking clips 1370 are pre-loaded onto the loading posts as part of the snares 1460, 1462. The snare 1460, 1462 are inserted into the lumens of the implant delivery catheter 1406. The snare 1460, 1462 can include loops. The loops of the snare 1460, 1462 are feed through eyelets of transvalvular implant 130 and loaded into the implant delivery catheter 1406.

[0391] Figure 69A-69C are views of the anchor marking bands. The system can include the implant pusher 1410. The implant pusher 1410 can be a clip pusher. The implant pusher 1410 can include a marker band 1464. The anchor 1350 can include a marker band 1466. Figure 69A-69C show what the pusher to anchor marker band attachment with fluoroscopy. Figure 69A illustrates the anchor 1350 unclipped without the transvalvular implant 1300. Figure 69C illustrates the anchor 1350 and the transvalvular implant 1300 clipped to central post 1352. Figure 69C illustrates the anchor 1350 clipped without the transvalvular implant 1300. The center to center of the marker bands can be 1 mm.

[0392] Figures 70A-70N are views of anchors. The anchors can include any feature described herein. The anchors can be used in any method described herein. Figure 70A illustrates the anchor 1500 with an anchor helix of 2.37x5mm. The anchor 1500 can include a cutting tip/leading edge. The anchor 1500 can include a helix that expands at the post attachment interface. Figure 70B illustrates the anchor 1502. The anchor 1502 can include a tip to penetrate the annulus. The anchor 1502 can be a helix anchor. The anchor 1502 can include distal post attachment. The anchor 1502 can include tip stylet. The anchor 1502 can include a trocar needle tip stylet. The anchor 1502 can include a cone needle tip stylet. The anchor 1502 can include a helix needle tip stylet. The anchor 1502 can be laser welded between the helix and the post. The anchor 1502 can include a radiopaque marker at annulus. The anchor 1502 can include a helix attachment post which flexes at the distal attachment point. Figure 70C illustrates the anchor 1504. The anchor 1504 can have higher pull out strength. The anchor 1504 can include an inverted helix coil. The anchor 1504 can include a helix anchor. The anchor 1504 can include a distal post attachment. The anchor 1504 can be configured for sub-annular attachment. The anchor 1504 can include a 40 degree tapered helix. Figure 70D illustrates anchor 1506. The anchor 1506 can include a center post attachment point. The anchor 1506 can be configured to couple to a triangle driver. The anchor 1506 can include a distal drive post attachment. Figure 70E illustrates anchor 1508. The anchor 1508 can include a center post attachment point. The anchor 1508 can be configured to couple to a triangle driver. The anchor 1508 can include a distal drive post attachment.

[0393] Figures 70F-70H illustrate anchor 1510. The anchor 1510 can be configured for sub-annular anchor attachment. The anchor 1510 can be configured for post attachment at the distal end of the helix coil. The anchor 1510 can have higher pull out strength. The anchor 1510 can include an inverted helix coil. The anchor 1510 can be used with the locking clip 1370. The anchor 1510 can be used with the drivers described herein. Figures 70I-70N illustrate additional designs of the anchor and drivers. Figures 701 illustrates the anchor 1502 shown in Figure 70B. Figures 70J illustrates a driver 1512 for an additional anchoring design. Figures 70K illustrates the anchor 1504 shown in Figure 70C. Figure 70L illustrates an anchor 1514. The anchor 1514 can expand by compression of tines. Figure 70M illustrates the anchor 1514. Figure 70L illustrates an anchor 1516. The anchor 1516 can expand by compression of tines. The tines can engage tissue. The anchor 1514, 1516 can be configured for sub-annular anchoring.

[0394] Figures 71A-71N illustrate a bridge delivery system. Figure 71A is a cross-sectional view. Figure 7 IB illustrates a side view. Figure 71C illustrates a top view. Figure 7 ID illustrates a back view. The system can include the implant delivery catheter 1406. The implant delivery catheter 1406 can include a pusher braid lumen 1470. The implant delivery catheter 1406 can include a distal single lumen 1472. The implant delivery catheter 1406 can include a multi-lumen 1474. The implant delivery catheter 1406 can include a hypo tube pusher 1476. Figures 71E-71F illustrate the distal single lumen 1472. Figures 71G-71J illustrate the multi-lumen 1474. Figures 71K-71N illustrate the hypo tube pusher 1476.

[0395] FIGS. 72A-72C are views of embodiments of a transvalvular implant 1600. The transvalvular implant 1600 can include any feature described herein. The transvalvular implant 1600 can be used in any method. The transvalvular implant 1600 can be deployed in any orientation described herein. The transvalvular implant 1600 can be used in the mitral valve. The transvalvular implant 1600 can be used in the tricuspid valve.

[0396] In some embodiments, the transvalvular implant 1600 comprises an elongate structure. The elongate structure can be greater in a first dimension than a second dimension. The transvalvular implant 1600 can be rounded, for instance in an oval shape. In some embodiments, the transvalvular implant 1600 can be curved relative to the annulus. In some embodiments, the transvalvular implant 1600 can be planar. The transvalvular implant 1600 can include one or more features to provide flexibility in positioning the eyelets relative to the anatomy. The transvalvular implant 1600 can include one or more features to that allow the transvalvular implant 1600 to conform to the anatomy. The transvalvular implant 1600 can include one or more features that allow the transvalvular implant 1600 to change shape. The transvalvular implant 1600 can include one or more features that allow the transvalvular implant 1600 that reduce tension on the anchors.

[0397] The transvalvular implant 1600 can include a first end 1602 and a second end 1604. The first end 1602 and the second end 1604 can be axially aligned. The first end 1602 and the second end 1604 can be offset. The first end 1602 and the second end 1604 can be the same or similar. The first end 1602 and the second end 1604 can be different. The transvalvular implant 1600 can have a length between the first end 1602 and the second end 1604. The length can be configured to allow anchoring at specific locations. The transvalvular implant 1600 can include a central portion 1606 located between the first end 1602 and the second end 1604. The transvalvular implant 1600 can include a lower surface disposed toward the annulus and an upper surface disposed away from the annulus.

[0398] The transvalvular implant 1600 can be symmetrical. The transvalvular implant 1600 can include one plane of symmetry, two planes of symmetry, three planes of symmetry, four planes of symmetry, or any range of two of the forgoing values. The transvalvular implant 1600 can be asymmetrical.

[0399] The transvalvular implant 1600 can have a substantially minimum width at the first end 1602 and/or the second end 1604. The transvalvular implant 1600 can have a substantially maximum width at the central portion 1606. The transvalvular implant 1600 can taper from the minimum width at the ends 1602, 1604 to the maximum width at the central portion 1606. The transvalvular implant 1600 can form a generally elliptical shape. The trans valvular implant 1600 can form a generally oval shape. The transvalvular implant 1600 can form a generally rounded shape.

[0400] The transvalvular implant 1600 can include a first anchoring portion 1612. The first anchoring portion 1612 can be near the first end 1602. The first anchoring portion 1612 can include a first eyelet 1616. The transvalvular implant 1600 can include a second anchoring portion 1614. The second anchoring portion 1614 can be near the second end 1604. The second anchoring portion 1614 can include a second eyelet 1618. Each eyelet 1616, 1618 can be for accepting at least a portion of an anchor described herein. Each eyelet 1616, 1618 can be for accepting at least a portion of a tether extending from an anchor. Each eyelet 1616, 1618 can be for accepting at least a portion of a central post extending from an anchor. Each eyelet 1616, 1618 can serve as guides as the transvalvular implant 1600 is lowered toward the annulus. Each eyelet 1616, 1618 can be enclosed. Each eyelet 1616, 1618 can be formed as a coil of wire.

[0401] The transvalvular implant 1600 can have a central opening 1620. The central opening 1620 can be separate and distinct from the eyelets 1616, 1618 of the anchoring portions 1612, 1614. The transvalvular implant 1600 does not obstruct the flow of blood through the central opening 1620. The dimensions of the transvalvular implant 1600 can depend on the valve being treated and/or the patient.

[0402] The transvalvular implant 1600 can include one or more springs. FIG. 72A illustrates an embodiment of the transvalvular implant 1600 with four springs 1650, 1652, 1654, 1656. The springs 1650, 1652 can be near the first end 1602. The springs 1650, 1652 can be near the first eyelet 1616. The springs 1654, 1656 can be near the second end 1604. The springs 1654, 1656 can be near the second eyelet 1618. The central portion 1606 can be free of springs. The springs 1650, 1652 can be near the first end 1602 can be separated from the springs 1654, 1656 can be near the second end 1604. The springs 1650, 1652, 1654, 1656 can provide flexibility in positioning the eyelets 1616, 1618 relative to the anatomy. The springs 1650, 1652, 1654, 1656 can allow the eyelets 1616, 1618 to be displaced from a plane. The springs 1650, 1652, 1654, 1656 can allow the eyelets 1616, 1618 to conform to the shape of the anatomy. The springs 1650, 1652, 1654, 1656 can reduce tension on the anchors coupled to the anchoring portions 1612, 1614. The springs 1650, 1652, 1654, 1656 can reduce tension by flexing.

[0403] FIG. 72B illustrates an embodiment of the transvalvular implant 1600 with two springs 1660, 1662. The springs 1660, 1662 can be near the central portion 1606. The springs 1660, 1662 can be spaced apart from the first end 1602. The springs 1660, 1662 can be spaced apart from the second end 1604. The springs 1660, 1662 can be spaced apart from the eyelets 1616, 1618. The first end 1602 and the second end 1604 can be free of springs. The springs 1660, 1662 can provide flexibility in positioning the central portion 1606 relative to the anatomy. The springs 1660, 1662 can allow the central portion 1606 to be displaced from a plane. The springs 1660, 1662 can allow the central portion 1606 to conform to the shape of the anatomy. The springs 1660, 1662 can reduce tension on the anchors coupled to the anchoring portions 1612, 1614. The springs 1660, 1662 can reduce tension by flexing.

[0404] FIG. 72C illustrates an embodiment of the transvalvular implant 1600 with two springs 1670, 1672. The spring 1670 can extend along the entire length between the first eyelet 1616 and the second eyelet 1618. The spring 1670 can extend along at least a portion of the length between the first eyelet 1616 and the second eyelet 1618. The spring 1672 can extend along the entire length between the first eyelet 1616 and the second eyelet 1618. The spring 1672 can extend along at least a portion of the length between the first eyelet 1616 and the second eyelet 1618. The springs 1670, 1672 can provide flexibility in positioning the transvalvular implant 1600 relative to the anatomy. The springs 1670, 1672 can allow the eyelets 1616, 1618 to be displaced from a plane. The springs 1670, 1672 can allow the eyelets 1616, 1618 to conform to the shape of the anatomy. The springs 1670, 1672 can allow the central portion 1606 to be displaced from a plane. The springs 1670, 1672 can allow the central portion 1606 to conform to the shape of the anatomy. The springs 1670, 1672 can reduce tension on the anchors coupled to the anchoring portions 1612, 1614. The springs 1670, 1672 can reduce tension by flexing.

[0405] The transvalvular implant 1600 can include a spring. The transvalvular implant 1600 can include a single spring. The transvalvular implant 1600 can include one spring, two springs, three springs, four springs, five springs, six springs, seven springs, eight springs, nine springs, ten springs, or any range of two of the foregoing values. The transvalvular implant 1600 can include one eyelet, two eyelets, three eyelets, four eyelets,

-Il l- five eyelets, six eyelets, , or any range of two of the foregoing values. The transvalvular implant 1600 can be symmetrical. The transvalvular implant 1600 can be asymmetrical.

[0406] The transvalvular implant 1600 can be formed from a single length of wire. The single length of wire can form the eyelets 1616, 1618. The single length of wire can form the central portion 1606. The single length of wire can form the springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672. The transvalvular implant 1600 can be formed from several lengths of wire. The several lengths of wires can have different diameters. The several lengths of wires can have different materials. The several lengths of wires can form the eyelets 1616, 1618. The several lengths of wires can form the central portion 1606. The several lengths of wires can form the springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672. The transvalvular implant 1600 can be formed from any material described herein. The transvalvular implant 1600 can be formed of shape memory material. The transvalvular implant 1600 can be formed of Nitinol.

[0407] The transvalvular implant 1600 can utilize different size wire. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be formed form different size wire than the eyelets 1616, 1618. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be formed form different size wire than the central portion 1606. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be formed form different size wire than another portion of the transvalvular implant 1600. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be formed of a wire to impart the desired stiffness. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be formed of a wire to impart the desired flexibility.

[0408] The transvalvular implant 1600 can be considered a spring designed bridge. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be formed of multiple coils. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be provided to control the spring force and tension on the anchor posts. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 to control the spring force and tension near the eyelets 1616, 1618. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 to control the spring force and tension near the central portion 1606. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 to provide flexibility relative to the anchors.

[0409] The transvalvular implant 1600 can provide flexibility during the cardiac cycle. The transvalvular implant 1600 can compress. The transvalvular implant 1600 can expand. The transvalvular implant 1600 can flex based on the cardiac movement. The transvalvular implant 1600 can flex based on the cardiac pressure.

[0410] The transvalvular implant 1600 can have one or more advantages. The transvalvular implant 1600 can reduce the tension on the central posts of the anchors during diastole. The transvalvular implant 1600 can provide coaptation of the valve leaflets during systole. The transvalvular implant 1600 can reduce tension as the valve opens and closes. The transvalvular implant 1600 can reduce tension on the anchors. The transvalvular implant 1600 can reduce tension by flexing. The transvalvular implant 1600 can reduce tension with the use of springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can comprise nitinol material. The nitinol material has unique properties. The nitinol allows the springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 to flex and return to its original shape. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can have shape memory.

[0411] The transvalvular implant 1600 can allow the heart valve to open without additional force on the anchors within the annulus. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can stretch to reduce tension on the anchors as the valve opens. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can compress to reduce tension on the anchors as the valve closes. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can flex with each heartbeat. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can return to a neutral shape during the cardiac cycle. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can stretch and compress without fatigue. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can advantageously reduce fatigue of the transvalvular implant 1600.

[0412] The transvalvular implant 1600 can allow for the valve to open without additional force on the anchors within the annulus. The transvalvular implant 1600 can advantageously allow the anchors within the annulus to stay over time. The transvalvular implant 1600 can have a bridge tensioning mechanism to relieve the stress on tissue anchors. The transvalvular implant 1600 can reduce the force on the central posts of the anchors.

[0413] The transvalvular implant 1600 can allow the valve to open but pull the tissue toward each other to reduce the anterior to posterior distance. The springs 1650, 1652, 1654, 1656, 1660, 1662, 1670, 1672 can be designed to compress in the anterior to posterior direction. The mechanical properties of the transvalvular implant 1600 can be customized with a specific force to bring the anterior and posterior annulus closer but allows with a spring action to not provide stress to the anchors within the tissue.

[0414] FIGS. 73A-73D are views of embodiments of a transvalvular implant 1700. The transvalvular implant 1700 can include any feature described herein. The transvalvular implant 1700 can be used in any method. The transvalvular implant 1700 can be deployed in any orientation described herein. The transvalvular implant 1700 can be used in the mitral valve. The transvalvular implant 1700 can be used in the tricuspid valve.

[0415] The transvalvular implant 1700 can be considered a coil bridge. The transvalvular implant 1700 can utilize different size wire and multiple coils to control the spring force and tension on the anchor posts. The transvalvular implant 1700 can have the additional advantage that as the heart rotates it is aligned with the natural tension that the heart provides itself during each compression.

[0416] The transvalvular implant 1700 can include a first end 1702 and a second end 1704. The transvalvular implant 1700 can include a central portion 1706. The central portion 1706 can be located between the first end 1702 and the second end 1704. The transvalvular implant 1700 can include a first anchoring portion 1712. The first anchoring portion 1712 can be near the first end 1702. The first anchoring portion 1712 can include a first eyelet 1716. The transvalvular implant 1700 can include a second anchoring portion 1714. The second anchoring portion 1714 can be near the second end 1704. The second anchoring portion 1714 can include a second eyelet 1718. Each eyelet 1716, 1718 can be for accepting at least a portion of an anchor described herein. Each eyelet 1716, 1718 can be for accepting at least a portion of a tether extending from an anchor. Each eyelet 1716, 1718 can be for accepting at least a portion of a central post extending from an anchor.

[0417] The transvalvular implant 1700 can include a coil 1750. The coil 1750 can be located between the first end 1702 and the second end 1704. The coil 1750 can be near the central portion 1706. The coil 1750 can be spaced apart from the first end 1702. The coil 1750 can be spaced apart from the second end 1704. The coil 1750 can be spaced apart from the eyelets 1716, 1718. The coil 1750 can extend along the entire length between the first eyelet 1716 and the second eyelet 1718. The coil 1750 can extend along at least a portion of the length between the first eyelet 1716 and the second eyelet 1718. The coil 1750 can

-In provide flexibility in positioning the central portion 1706 relative to the anatomy. The coil 1750 can allow the central portion 1706 to be displaced from a plane. The coil 1750 allow the central portion 1706 to conform to the shape of the anatomy. The coil 1750 can reduce tension on the anchors coupled to the anchoring portions 1712, 1714. The coil 1750 can reduce tension by flexing. The coil 1750 can reduce tension by rotating.

[0418] The transvalvular implant 1700 can form a coiled shaped. The transvalvular implant 1700 can form a helical shape. The transvalvular implant 1700 can have multiple coils. The transvalvular implant 1700 can have coils of the same diameter. The transvalvular implant 1700 can have coils of different diameters. The transvalvular implant 1700 can form stacked coils. The transvalvular implant 1700 can be symmetrical. The transvalvular implant 1700 can be asymmetrical. FIGS. 73A-73D show different embodiments of the coil shape.

[0419] The transvalvular implant 1600, 1700 can utilize nitinol to provides a spring response. The amount of spring tension can be adjusted with the shape of the transvalvular implant 1600, 1700 and/or the wire diameter. As shown in FIG. 74A, the force is related to the spring constant k multiplied by the distance (F=kx). As shown in FIG. 74B, the spring constant k value can be increased by increasing the wire diameter. In other words, increasing the wire diameter increases the spring force. As shown in FIG. 74C, the k value can be increased by changing the angle of the transvalvular implant 1600, 1700. In other words, more opening reduces the spring force. The transvalvular implant 1600 can be designed to optimize the distribution of forces.

[0420] FIG. 75 is a view of a double helical screw 1800. The double helical screw 1800 can include any feature of the anchors described herein. The anchors can include tissue anchors with screw threads to insert within the annulus. The double helical screw 1800 can include a first helical portion 1802. The double helical screw 1800 can include a second helical portion 1804. The first helical portion 1802 and the second helical portion 1804 can be different in at least one aspect. The first helical portion 1802 and the second helical portion 1804 can have different diameters. The first helical portion 1802 and the second helical portion 1804 can have different pitches. The first helical portion 1802 and the second helical portion 1804 can have different coils. The first helical portion 1802 and the second helical portion 1804 can have different helix angles. The first helical portion 1802 and the second helical portion 1804 can be the same in at least one aspect. The first helical portion 1802 and the second helical portion 1804 can have the same diameter. The first helical portion 1802 and the second helical portion 1804 can have the same pitch. The first helical portion 1802 and the second helical portion 1804 can have the same coils. The first helical portion 1802 and the second helical portion 1804 can have the same helix angles. The first helical portion 1802 and the second helical portion 1804 can be coaxial. The first helical portion 1802 and the second helical portion 1804 can have the same axis of the helix.

[0421] The first helical portion 1802 and the second helical portion 1804 can perform different functions. The first helical portion 1802 can engage the tissue. The second helical portion 1804 can expand from within the first helical portion 1802 to provide a larger diameter and ultimately more tension. The second helical portion 1804 can increase anchoring within the tissue. The second helical portion 1804 can have a larger footprint. The second helical portion 1804 can reduce pullout of the double helical screw 1800. The double helical screw 1800 can include a central post. The double helical screw 1800 can include a teether.

[0422] FIG. 76 is a view of a clamp 1850 and the anchor 1350. The anchor 1350 can include any of the features of the anchors described herein. The anchor 1350 can be coupled to the tether 1354. The anchor 1350 can include the central post 1352. The tether 1354 can extend from the central post 1352. The central post 1352 can engage an eyelet of the transvalvular implant, as described herein. The anchor 1350 can include coils 1356. The anchor 1350 can have a tip 1358. The central post 1352 can be a top portion of the anchor 1350. The coils 1356 can be a bottom portion of the anchor 1350. The anchor 1350 can be configured to engage the annulus. The anchor 1350 can include an initial screw that engages the tissue. The anchor 1350 can be utilized in combination with the clamp 1850. The clamp 1850 can be positioned over the anchor 1350 as shown in FIG. 76.

[0423] The clamp 1850 can be an alligator clamp. The clamp 1850 can be advanced over the anchor 1350. The clamp 1850 can include two arms. The clamp 1850 can include a plurality of arms. The clamp 1850 can grab the tissue from two sides. The clamp 1850 can have teeth that can grip into and around the anchor 1350 to provide additional anchoring within the tissue. The clamp 1850 can be surrounded with a fabric. The fabric can be a polyester fabric. The fabric can allow ingrowth of tissue in and around the anchor 1350. [0424] The clamp 1850 can be a lock that holds the transvalvular implant. The clamp 1850 can grab the transvalvular implant from two sides. The clamp 1850 can have teeth that can grip into the transvalvular implant. The clamp 1850 can have teeth that can grip around the anchor 1350 to provide additional anchoring.

[0425] FIGS. 77A-77C are view of an anchor 1900. FIG. 77A illustrates step 1. FIG. 77B illustrates step 2. FIG. 77C illustrates step 3. The anchor 1900 can be split anchor. The anchor 1900 can be an expansion anchor. The anchor 1900 can include a first member 1902. The first member 1902 can be a helical anchor. The first member 1902 can have any features of anchors described herein. The anchor 1900 can include a second member 1904. The second member 1904 can be a sleeve. The first member 1902 can be disposed within the second member 1904. The second member 1904 can be splitable. The second member 1904 can be expandable. The second member 1904 can include a tip 1906. The tip 1906 can facilitate insertion into tissue. The second member 1904 can include one or more slits 1908. The slits 1908 can facilitate expansion of the second member 1904. The second member 1904 can include internal threads 1910. The first member 1902 can rotate relative to the internal threads 1910 of the second member 1904.

[0426] FIG. 77 A illustrates the anchor 1900. The anchor 1900 can be driven into tissue. The anchor 1900 can have a low profile. The first member 1902 can be disposed within the second member 1904. The first member 1902 can be located in a proximal position. FIG. 77B illustrates the anchor 1900 during deployment. The first member 1902 can be rotated relative to the second member 1904. The anchor 1900 can split as first member 1902 is rotated inside the second member 1904. The anchor 1900 can provide an increase surface area. The anchor 1900 can provide additional locking force from the split design. FIG. 77C illustrates the anchor 1900 after deployment. The anchor 1900 can further split as first member 1902 is rotated inside the second member 1904. The first member 1902 can be located in a distal position. The anchor 1900 provides an increase surface area. The anchor 1900 provides additional locking force from the split design.

[0427] FIGS. 78A-78E are views of work flow. In some embodiments, one or more methods are provided. The methods can include treating the tricuspid. The method can include one or more steps as described herein. [0428] Tn some embodiments, the method can include setting up the sled. Figure 78A illustrates the sled 2001. Figure 78A illustrates the guide catheter 2002. Figure 78A illustrates the steering catheter 2003. This figure illustrates the overall sled 2001 setup showing the guide catheter 2002 and the steering catheter 2003 loaded. The sled 2001 allows the physician to maneuver the two catheters, the guide catheter 2002 and the steering catheter 2003, for precise anchor placement. Figure 78B illustrates the overall sled for the guide catheter 2004. Figure 78B illustrates the guide catheter holder 2005. Figure 78B illustrates the steering catheter 2003 inside the guide catheter hub 2006. Figure 78C illustrates the hemostasis valve 2007 at the back of the guide catheter 2002. Figure 78D illustrates the sled

2008 for the steering catheter 2003 and the anchor delivery system 2010. Figure 78D illustrates the holder 2009 for the steering catheter 2003. Figure 78D illustrate the anchor delivery system 2010 loaded in the steering catheter 2003. Figure 78E illustrates the hemostasis valve 2011 for the steering catheter 2003. Figure 78E illustrates the hemostasis valve 2012 for the anchor delivery system 2010. Figure 78E illustrates the spacers 2013 of the anchor delivery system 2010.

[0429] Figures 78A-78E show the various devices and how they are used to deliver the anchors and position the bridge over the anchors. The workflow can include setting up the sled 2001 and loading and flushing the guide catheter 2002. The delivery system can be comparative in size to other systems. The method can include setting up the sled 2001. The sled 2001 can support the delivery system during use. The method can include loading the guide catheter 2002. The method can include flushing the guide catheter 2002. The method can include opening the guide catheter hemostasis valve 2007, shown in Figure 78C. The method can include inserting a dilator (not shown). The method can include positioning the guide catheter sled 2004 at the center of travel allowing the sled 2004 to go both forward and backward. The method can include placing the steering catheter holder

2009 in the furthest position on the sled 2001. The method can include loading the guide catheter 2002 with the first anchor delivery system 2010, shown in Figure 78D. The method can include flushing the system.

[0430] The method can include preparing the anchor delivery system 2010. The method can include first loading the white tether anchor delivery system. The method can include tensioning the tether. The method can include opening the hemostasis valve 2012 on the anchor delivery system to allow the drive cable to slide. The method can include retracting the anchor to ensure the drive cable is engaged. The method can include positioning the anchor through the steering catheter 2003. The method can include closing the hemostasis valve 2011 on the steering catheter 2003 and the hemostasis valve 2012 on the anchor delivery system catheter 2010. The method can include flushing both the steering catheter 2003 and the anchor delivery system catheter 2010. The method can include opening the hemostasis valve 2012 on the anchor delivery system 2010 to allow sliding of the anchor delivery system 2010 within the steering catheter 2003.

[0431] The method can include anchor placement. The method can include inserting the steering catheter 2003 through the guide catheter 2002. The method can include positioning the steering catheter 2003 in the proximal holding portion of the sled 2001. The method can include advancing the steering catheter 2003 and the guide catheter 2002 toward the first anchor target location by rotating the knobs to advance or retract either catheter. In addition to both catheters sliding within each other, the catheters can each be rotated to give optimum angulation. The method can include adjusting the slider with two 4mm spacers 2013 shown in Figure 78E and set the distance of the anchor delivery system 2010 against this stop. This will ensure that the anchor will be rotated 8mm to engage the annulus tissue. The method can include pulling one of the 4mm spacers 2013 and pushing the anchor drive cable forward. The method can include rotating counter clockwise (CCW) two turns to engage the tip into the tissue. The method can include rotating clockwise (CW) three times allowing recoil after each rotation. The anchor drive cable should now have traveled the 4mm. The method can include removing the second spacer 2013. The method can include continuing to rotate CW three turns with relaxation after each rotation

[0432] The method can include unloading the anchor delivery system 2010. The method can include removing tension on the tether. The method can include retracting the driver by rotating the green knob 1/4 CCW and CW while pulling back gently until the anchor delivery system disengages from the anchor. The method can include opening the guide catheter hemostasis valve 2007. The method can include removing tension on the tether and the post to allow the steering catheter 2003 and the anchor delivery system 2010 to retract and slide over the tether. The tether with the with anchor engaged in the tissue will remain through the guide catheter 2002. [0433] The method can include reloading the steering catheter 2003 with the second anchor delivery system 2010. The method can include positioning the second anchor delivery system 2010 into the steering catheter 2003. The method can include using the same steps as above to set the distance. The method can include placing the steering catheter 2003 with the second anchor delivery system 2010 loaded into the guide catheter 2002. The method can include articulating both catheters toward the second target location. The method can include delivering the second anchor using the same technique as the first anchor. The method can include removing the drive cable, the steering catheter 2003, and the second anchor delivery system 2010 leaving the second anchor and tether within the guide catheter 2002.

[0434] The method can include loading the bridge delivery catheter. The bridge delivery catheter can be comprises of a multi-lumen catheter with two push rods. One push rod can be for the anterior side and the other push rod can be for the posterior side. Each push rod can have a clip that can lock over the anchor and slide over the tether. The method can including inserting the bridge delivery catheter over each of the tethers and through the guide catheter 2002. The method can include advancing the bridge delivery catheter to the distal end of the guide catheter 2002 and advancing the anterior push rod. The method can include retracting the bridge delivery catheter, maintaining the position of the push rod to allow the bridge to be released from the bridge delivery catheter. The method can include advancing the posterior push rod so that the clip is positioned over the posterior anchor. The method can include continuing to advance the posterior push rod to lock the clip over the anchor post. The method can include repeating the process for the anterior push rod. The method can include, once the bridge is deployed and aligned on the post, advancing the anterior push rod and locking the clip over the anterior anchor post. The method can include removing the bridge delivery catheter, leaving the tethers of both the anterior and posterior anchors within the guide catheter.

[0435] The method can include advancing the tether cutter over one of the tethers. The method can include sliding the end of the tether cutter all the way to the anchor post. The method can include pulling the tether cutter mechanism by sliding the two hubs together and cutting the tether at the most distal end. The method can include repeating for the second tether. The method can include removing the guide catheter 2002 and closing the femoral vein access. Tn some embodiments, the mitral bridge delivery utilizes the same procedural steps. In some embodiments, the guide catheter 2002 and steering catheter 2003 must cross the atrial septum.

[0436] Disclosed herein are methods of percutaneous transcatheter delivery of embodiments of a transvalvular implant, which can also be referred to herein as a transvalvular bridge. The transvalvular implant can be delivered to the valve for repair of regurgitation. The transvalvular implant can be delivered to the mitral valve to repair of mitral regurgitation. The transvalvular implant can be delivered to the tricuspid valve to repair of tricuspid regurgitation.

[0437] The systems and methods can include various features or advantages. The systems and methods can replicate an open procedure. The systems and methods can guarantee anchor placement. The systems and methods can show a surgeon the suture count prior to securing the first locking clip The systems and methods can provide positional identification of the anchors relative to the annulus. The systems and methods can be conducted on beating heart. The systems and methods can be echogenic. The systems and methods can prevent or limit occlusions. The systems and methods can prevent or limit leaflet damage. The systems and methods can prevent or limit chordae damage. The systems and methods can allow for complete bail out or reversal until the first locking clip is secured. The systems and methods can allow for complete identification and count of all catheter delivery components and suture-tail cuts. The systems and methods can allow for a low pressure delivery of one or more anchors. The systems and methods can allow for flexible deployment of a retaining system. The systems and methods can allow for percutaneous securement by locking clip. The systems and methods can allow for transseptal delivery. The systems and methods can allow for over the wire delivery. The systems and methods can allow for one catheter placement that enables delivery of two individual anchors. The systems and methods can allow for single anchor delivery which is repeated two times to secure the transvalvular bridge and locking clips with annular anchors. The systems and methods can allow for one or more catheters that secure the transvalvular implant. The transvalvular implant can slide along sutures connected to anchors . The transvalvular implant can reshape the annulus along a diameter. The transvalvular implant can be anchored to the annulus. The transvalvular implant can span the valve orifice. [0438] The methods can include transseptally placing a guide catheter. The methods can include sequentially advancing a steering catheter to the annulus and deliver one or more anchors, e.g., two anchors, three anchors, four anchors, five anchors, six anchors, etc. The methods can include deploying the transvalvular implant along sutures. The methods can include cinching the anchors, sutures, and/or the transvalvular implant. The methods can include deploying the one or more locking clips, e.g., deploying one locking clip for each anchor. The methods can include inserting a trimming catheter. The methods can include cutting the excess suture.

[0439] From an end user point, the sutures are pre-assembled to the anchors. In some embodiments, the transvalvular bridge can slide along the sutures once the anchors are placed. The transvalvular implant can include eyelets to receive the sutures. The transvalvular implant can include a pre-shape form to reshape the annulus. The transvalvular implant can be anchored on the annulus. The transvalvular implant can be anchored along an anatomical diameter. The transvalvular implant can be anchored at the anterior annulus. The transvalvular implant can be anchored on the anterior annulus and the posterior annulus. T The transvalvular implant can be anchored at the posterior annulus. The transvalvular implant can be anchored between an anterior annulus and straddling the commissure between the septal annulus and the posterior annulus. The transvalvular implant can be anchored on the posterior annulus beyond the septal-posterior commissure.

[0440] In some embodiments, the heart valve is a mitral valve. The transvalvular implant can be used to treat functional mitral regurgitation. The transvalvular implant can reduce the septal lateral diameter of the mitral valve annulus sufficiently to bring the posterior annulus towards the anterior annulus. The transvalvular implant can be used to achieve full closure of mitral valve leaflets during systole, thereby preventing mitral regurgitation. The transvalvular implant can straddle the valve orifice in an annular horizontal plane of the annulus. The transvalvular implant can straddle the mitral valve orifice in an annular horizontal plane in a septal lateral dimension of the mitral annulus. The central portion of the transvalvular implant can be curved towards the left ventricular cavity.

[0441] In some embodiments, the heart valve is a tricuspid valve. The transvalvular implant can be used to treat functional tricuspid regurgitation by reducing the anterior-posterior diameter of the tricuspid valve annulus sufficiently to bring the anterior annulus to the septal and/or posterior annulus. The transvalvular implant can be used to achieve full closure of the tricuspid leaflets during systole, thereby preventing tricuspid valve regurgitation. The transvalvular implant can straddle the tricuspid valve orifice in an annular horizontal plane in an anterior-posterior dimension of the tricuspid valve annulus. The central portion of the transvalvular implant can be curved towards the right ventricular cavity.

[0442] The systems and methods can related generally to the field of heart valve repair devices, methods, and kits more specifically to trans catheter methods and devices for treatment of valve regurgitation from dilated annulus and/or from deformed and retracted valve leaflets by use of an arching implant which straddles the valve orifice. The systems and methods can related generally to the field of heart valve repair devices, methods, and kits more specifically to trans catheter methods and devices for treatment of mitral valve regurgitation from dilated mitral annulus and/or from deformed and retracted mitral valve leaflets by use of an arching implant which straddles the mitral valve orifice in a septal- lateral dimension. The systems and methods can related generally to the field of heart valve repair devices, methods, and kits more specifically to trans catheter methods and devices for treatment of tricuspid valve regurgitation from dilated tricuspid annulus and/or from deformed and retracted tricuspid valve leaflets by use of an arching implant which straddles the tricuspid valve orifice.

[0443] The heart has a total of four valves which allows the blood to flow through the four chambers of the heart in one direction. The mitral valve has two valve leaflets, anterior and posterior. They are attached to the mitral valve annulus. The leaflets are supported by chordae tendinae from their free edges towards the wall of the left ventricle by papillary muscle. Normally when the left ventricle contracts the leaflets close together preventing blood to leak backwards into the left atrium, the upper pumping chamber. Sometimes one or both leaflets do not close properly as a result of alteration in the annular ventricular apparatus and altered ventricular geometry. In ischemic heart failure this can be due to papillary or lateral left ventricle wall muscle dysfunction, and in non-ischemic heart failure it can be ascribed to mitral annular dilatation and chordal tethering, all as a result of dysfunctional remodeling of left ventricle. This causes incomplete leaflet coaptation and allows the blood to leak backwards into the left atrium during left ventricular contraction (systole). This type of mitral regurgitation is commonly referred as functional mitral regurgitation in which the predominant pathophysiology is the increased distance from the anterior to posterior annular dimension, increased septal-lateral diameter.

[0444] The main objective of the treatment of functional mitral regurgitation can be to reduce the septal lateral diameter sufficiently to bring the posterior annulus towards the anterior annulus to achieve full closure of leaflets and competent mitral valve during systole preventing mitral regurgitation. The standard treatment for more than three decades has been implantation of an annuloplasty ring on the mitral annulus with circumferential cinching of the entire or part of the annulus to achieve an indirect reduction of septal-lateral diameter of the annulus. This has resulted in only partial success due to limitations of the extent of annular cinching with increasing obstruction to blood flow across the mitral valve (increased mitral Gradient). Alternatively, a mitral valve replacement device can be implanted by replacing the original valve. Both these approaches are very invasive and met with frequent complications. Several less invasive catheter-based treatment and approaches has emerged recently including an edge to edge repair of leaflets, including MitraClip. Notwithstanding the presence of a variety of presently available surgical and trans catheter procedures, there still remains a need for a simple but effective disruptive trans catheter procedure and devices and systems to effectively treat a larger proportion of the patients with functional mitral regurgitation.

[0445] The systems and methods can include the implant which can be referred to as an arch or straddle. The implant can straddle the valve orifice in an annular horizontal plane in a septal lateral dimension (from anterior to posterior) of the annulus. The arch refers to a curved body which can be concave either towards the left ventricular cavity or left atrial cavity. The implant can be made of single or plurality of wires. The implant can be made stainless steel or nitinol or any other material. The implant can have four eyelets, two in the front and two in the back part of the frame of the implant. The shape and configurations of the wire form implant can vary to different geometries. The implant can have a feature in the center with a hole created by the configuration of the embodiments. The center hole enables introduction of any other trans catheter device for additional treatment modalities. The wire form can allow the implant to be folded in any dimension to be delivered via a delivery catheter. The implant can be of various sizes in mm length in its longitudinal dimension. [0446] The systems and methods can include anchors. The anchor which can hold the implant onto the annulus can be made of various material, including stainless steel, nitinol, titanium and other compatible material. The anchor can have a configuration of a helical screw. The anchor can have length varying from 8 mm to 4 mm. The anchor can have the last few threads (2-4) sharpened and tapered with tip grind at the outer coil face of helix. The anchor can be coated with silicon or other materials. The anchor can have a straight center pin which fits into the helical screw anchor to stabilize as well facilitate penetration of the annulus during anchor implantation on to the valve annulus. The anchor can have a center post made of hypo tube which is bonded to a quadrangular helix top mount. The quadrangular helix top mount can be machine made to fit tightly into the top of the helical screw anchor. This mount serves as the holding platform for the implant and the locking clip or cap. The top of this anchor post can hold the anchor tether inside the post. The tether can be inserted 4 mm into the anchor post tube. The tether can crimped in place.

[0447] Any of a wide variety of specific tissue anchor constructions may be utilized in combination with the transvalvular implant of the present invention. In addition, a variety of features have been described as illustrative in connection with a variety of implementations of the invention. Any of the features described above, may be recombined with any other of the embodiments disclosed herein, without departing from the present invention, as should be apparent to those of skill in the art.

[0448] While the foregoing detailed description has set forth several exemplary embodiments of the apparatus and methods of the present invention, it should be understood that the above description is illustrative only and is not limiting of the disclosed invention. It will be appreciated that the specific dimensions and configurations disclosed can differ from those described above, and that the methods described can be used within any biological valve within the body.

[0449] Various other modifications, adaptations, and alternative designs are of course possible in light of the above teachings. Therefore, it should be understood at this time that within the scope of the appended claims the invention may be practiced otherwise than as specifically described herein. It is contemplated that various combinations or subcombinations of the specific features and aspects of the embodiments disclosed above may be made and still fall within one or more of the inventions. Further, the disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with an embodiment can be used in all other embodiments set forth herein. Accordingly, it should be understood that various features and aspects of the disclosed embodiments can be combined with or substituted for one another in order to form varying modes of the disclosed inventions. Thus, it is intended that the scope of the present inventions herein disclosed should not be limited by the particular disclosed embodiments described above. Moreover, while the invention is susceptible to various modifications, and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. It should be understood, however, that the invention is not to be limited to the particular forms or methods disclosed, but to the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the various embodiments described and the appended claims. Any methods disclosed herein need not be performed in the order recited. The methods disclosed herein include certain actions taken by a practitioner; however, they can also include any third-party instruction of those actions, either expressly or by implication. For example, actions such as “attaching an implant to the mitral valve annulus” includes “instructing the attaching of an implant to the mitral valve annulus.” For example, actions such as “attaching a transvalvular bridge to the tricuspid valve annulus” includes “instructing the attaching of a transvalvular bridge to the tricuspid valve annulus.” The ranges disclosed herein also encompass any and all overlap, sub-ranges, and combinations thereof. Language such as “up to,” “at least,” “greater than,” “less than,” “between,” and the like includes the number recited. Numbers preceded by a term such as “approximately”, “about”, and “substantially” as used herein include the recited numbers (e.g., about 10% = 10%), and also represent an amount close to the stated amount that still performs a desired function or achieves a desired result. For example, the terms “approximately”, “about”, and “substantially” may refer to an amount that is within less than 10% of, within less than 5% of, within less than 1% of, within less than 0.1% of, and within less than 0.01% of the stated amount.