# Patent

## Title
Devices and methods for heart valve treatment

## Abstract

Devices and methods for improving the function of a valve (e.g., mitral valve) by positioning a spacing filling device outside and adjacent the heart wall such that the device applies an inward force against the heart wall acting on the valve. A substantially equal and opposite force may be provided by securing the device to the heart wall, and/or a substantially equal and opposite outward force may be applied against anatomical structure outside the heart wall. The inward force is sufficient to change the function of the valve, and may increase coaptation of the leaflets, for example. The space filling device may be implanted by a surgical approach, a transthoracic approach, or a transluminal approach, for example. The space filling portion may be delivered utilizing a delivery catheter navigated via the selected approach, and the space filling portion may be expandable between a smaller delivery configuration and a larger deployed configuration.

## Background
CROSS-REFERENCE TO RELATED APPLICATIONS
This application claims the benefits of priority of U.S. Provisional Application No. 60/425,519, filed Nov. 12, 2002, the entire contents of which are incorporated by reference herein.


FIELD OF THE INVENTION
The present invention relates to devices and associated methods for treating and improving the performance of dysfunctional heart valves. More particularly, the invention relates to devices and methods that passively assist to reshape a dysfunctional heart valve to improve its performance.
BACKGROUND OF THE INVENTION
Various etiologies may result in heart valve insufficiency depending upon both the particular valve as well as the underlying disease state of the patient. For instance, a congenital defect may be present resulting in poor coaptation of the valve leaflets, such as in the case of a monocusp aortic valve, for example. Valve insufficiency also may result from an infection, such as rheumatic fever, for example, which may cause a degradation of the valve leaflets. Functional regurgitation also may be present. In such cases, the valve components may be normal pathologically, yet may be unable to function properly due to changes in the surrounding environment. Examples of such changes include geometric alterations of one or more heart chambers and/or decreases in myocardial contractility. In any case, the resultant volume overload that exists as a result of an insufficient valve may increase chamber wall stress. Such an increase in stress may eventually result in a dilatory process that further exacerbates valve dysfunction and degrades cardiac efficiency.
Mitral valve regurgitation often may be driven by the functional changes described above. Alterations in the geometric relationship between valvular components may occur for numerous reasons, including events ranging from focal myocardial infarction to global ischemia of the myocardial tissue. Idiopathic dilated cardiomyopathy also may drive the evolution of functional mitral regurgitation. These disease states often lead to dilatation of the left ventricle. Such dilatation may cause papillary muscle displacement and/or dilatation of the valve annulus. As the papillary muscles move away from the valve annulus, the chordae connecting the muscles to the leaflets may become tethered. Such tethering may restrict the leaflets from closing together, either symmetrically or asymmetrically, depending on the relative degree of displacement between the papillary muscles. Moreover, as the annulus dilates in response to chamber enlargement and increased wall stress, increases in annular area and changes in annular shape may increase the degree of valve insufficiency. Annular dilatation is typically concentrated on the posterior aspect, since this aspect is directly associated with the dilating left ventricular free wall and not directly attached to the fibrous skeleton of the heart. Annular dilatation also may result in a flattening of the valve annulus from its normal saddle shape.
Alterations in functional capacity also may cause valve insufficiency. In a normally functioning heart, the mitral valve annulus contracts during systole to assist in leaflet coaptation. Reductions in annular contractility commonly observed in ischemic or idiopathic cardiomyopathy patients therefore hamper the closure of the valve. Further, in a normal heart, the papillary muscles contract during the heart cycle to assist in maintaining proper valve function. Reductions in or failure of the papillary muscle function also may contribute to valve regurgitation. This may be caused by infarction at or near the papillary muscle, ischemia, or other causes, such as idiopathic dilated cardiomyopathy, for example.
The degree of valve regurgitation may vary, especially in the case of functional insufficiency. In earlier stages of the disease, the valve may be able to compensate for geometric and/or functional changes in a resting state. However, under higher loading resulting from an increase in output requirement, the valve may become incompetent. Such incompetence may only appear during intense exercise, or alternatively may be induced by far less of an exertion, such as walking up a flight of stairs, for example.
Conventional techniques for managing mitral valve dysfunction include either surgical repair or replacement of the valve or medical management of the patient. Medical management typically applies only to early stages of mitral valve dysfunction, during which levels of regurgitation are relatively low. Such medical management tends to focus on volume reductions, such as diuresis, for example, or afterload reducers, such as vasodilators, for example.
Early attempts to surgically treat mitral valve dysfunction focused on replacement technologies. In many of these cases, the importance of preserving the native subvalvular apparatus was not fully appreciated and many patients often acquired ventricular dysfunction or failure following the surgery. Though later experience was more successful, significant limitations to valve replacement still exist. For instance, in the case of mechanical prostheses, lifelong therapy with powerful anticoagulants may be required to mitigate the thromboembolic potential of these devices. In the case of biologically derived devices, in particular those used as mitral valve replacements, the long-term durability may be limited. Mineralization induced valve failure is common within ten years, even in younger patients. Thus, the use of such devices in younger patient groups is impractical.
Another commonly employed repair technique involves the use of annuloplasty rings. These rings originally were used to stabilize a complex valve repair. Now, they are more often used alone to improve mitral valve function. An annuloplasty ring has a diameter that is less than the diameter of the enlarged valve annulus. The ring is placed in the valve annulus and the tissue of the annulus sewn or otherwise secured to the ring. This causes a reduction in the annular circumference and an increase in the leaflet coaptation area. Such rings, however, generally flatten the natural saddle shape of the valve and hinder the natural contractility of the valve annulus. This may be true even when the rings have relatively high flexibility.
To further reduce the limitations of the therapies described above, purely surgical techniques for treating valve dysfunction have evolved. Among these surgical techniques is the Alfiere stitch or so-called bowtie repair. In this surgery, a suture is placed substantially centrally across the valve orifice joining the posterior and anterior leaflets to create leaflet apposition. Another surgical technique includes plication of the posterior annular space to reduce the cross-sectional area of the valve annulus. A limitation of each of these techniques is that they typically require opening the heart to gain direct access to the valve and the valve annulus. This generally necessitates the use of cardiopulmonary bypass, which may introduce additional morbidity and mortality to the surgical procedures. Additionally, for each of these procedures, it is very difficult to evaluate the efficacy of the repair prior to the conclusion of the operation.
Due to these drawbacks, devising effective techniques that could improve valve function without the need for cardiopulmonary bypass and without requiring major remodeling of the valve may be advantageous. In particular, passive techniques to change the shape of the heart chamber and/or associated valve and reduce regurgitation while maintaining substantially normal leaflet motion may be desirable. Further, advantages may be obtained by a technique that reduces the overall time a patient is in surgery and under the influence of anesthesia. It also may be desirable to provide a technique for treating valve insufficiency that reduces the risk of bleeding associated with anticoagulation requirements of cardiopulmonary bypass. In addition, a technique that can be employed on a beating heart would allow the practitioner an opportunity to assess the efficacy of the treatment and potentially address any inadequacies without the need for additional bypass support.
SUMMARY OF THE INVENTION
To address these needs, the present invention provides, in exemplary non-limiting embodiments, devices and methods for improving the function of a valve (e.g., mitral valve) by positioning a spacing filling device outside and adjacent the heart wall such that the device applies an inward force against the heart wall acting on the valve. The device may be remotely secured to the heart wall. The securement may provide a substantially equal and opposite force to the inward force, or a substantially equal and opposite outward force may be applied against anatomical structure outside the heart wall. The inward force is sufficient to change the function of the valve, and may increase coaptation of the leaflets, for example. The spacing filling device may be implanted outside the epicardium, such as between the epicardium and the pericardium, and may be attached to epicardium while remaining free of the pericardium.
The space filling device may be implanted by a surgical approach, a transthoracic approach, or a transluminal approach, for example. The space filling device may be delivered utilizing a delivery catheter navigated via the selected approach, and the space filling device may be expandable between a smaller delivery configuration and a larger deployed configuration. For example, the space filling device may include an expandable structure such as a balloon or a mechanical structure. The balloon may be filled with a liquid, a curable liquid, a solid, or a semi-solid, for example, and may include a mechanical reinforcement member disposed therein. The expandable balloon may be inflated upon implantation or subsequently by, for example, a transdermally accessible port fluidly connected to the balloon.



BRIEF DESCRIPTION OF THE DRAWINGS
FIGS. 1A–1D are cross sectional views of a patient's trunk at the level of the mitral valve of the heart, showing the effects of space filling devices on mitral valve function;
FIGS. 2A–2B are long axis cross sectional views of a patient's heart showing space filling devices in various positions;
FIGS. 3A–3J are schematic illustrations showing various approaches for implanting space filling devices;
FIG. 4 is a schematic plan view of a catheter and guide wire for use in delivering space filling devices by transluminal techniques;
FIGS. 5A and 5B are cross sectional views of the catheter shown in FIG. 4 taken along line 5—5;
FIG. 6 is a cross sectional view of the catheter shown in FIG. 4 taken along line 6—6;
FIGS. 7A and 7B are schematic top and side views of a transdermal access port connected to a space filling device by a flexible tube;
FIG. 8 is a schematic plan view of a guide catheter for use in delivering space filling devices by transluminal techniques;
FIG. 9 is a schematic plan view of an isolation catheter for use in delivering space filling devices by transluminal techniques;
FIGS. 10–22 are schematic illustrations of various design alternatives of space filling devices; and
FIGS. 23A and 23B are schematic views of a catheter for use in delivering space filling devices by transthoracic techniques.



DETAILED DESCRIPTION OF THE INVENTION
The following detailed description should be read with reference to the drawings in which similar elements in different drawings are numbered the same. The drawings, which are not necessarily to scale, depict illustrative embodiments and are not intended to limit the scope of the invention.
General Description of Space Filling Device Function and Use
The various aspects of the devices and methods described herein generally pertain to devices and methods for treating heart conditions, including, for example, dilatation, valve incompetencies, including mitral valve leakage, and other similar heart failure conditions. Each disclosed device may operate passively in that, once placed in the heart, it does not require an active stimulus, either mechanical, electrical, hydraulic, pneumatic, or otherwise, to function. Implanting one or more of the devices operates to assist in the apposition of heart valve leaflets to improve valve function.
In addition, these devices may either be placed in conjunction with other devices that, or may themselves function to, alter the shape or geometry of the heart, locally and/or globally, and thereby further increase the heart's efficiency. That is, the heart experiences an increased pumping efficiency through an alteration in its shape or geometry and concomitant reduction in stress on the heart walls, and through an improvement in valve function.
However, the devices disclosed herein for improving valve function can be “stand-alone” devices, that is, they do not necessarily have to be used in conjunction with additional devices for changing the shape of a heart chamber or otherwise reducing heart wall stress. It also is contemplated that a device for improving valve function may be placed relative to the heart without altering the shape of the chamber, and only altering the shape of the valve itself. In other words, the devices and methods described herein involve geometric reshaping of portions of the heart and treating valve incompetencies. In some embodiments of the devices and methods described herein, only a localized portion of the heart is altered to treat valve incompetencies. In other embodiments, the entire chamber geometry may be altered to return the heart to a more normal state of stress.
The devices and methods described herein offer numerous advantages over the existing treatments for various heart conditions, including valve incompetencies. The devices are relatively easy to manufacture and use, and the transluminal, transthoracic, and surgical techniques and tools for implanting the devices do not require the invasive procedures of current surgical techniques. For instance, these techniques do not require removing portions of the heart tissue, nor do they necessarily require opening the heart chamber or stopping the heart during operation. For these reasons, the techniques for implanting the devices disclosed herein also are less risky to the patient than other techniques. The less invasive nature of these techniques and tools may also allow for earlier intervention in patients with heart failure and/or valve incompetencies.
Although the methods and devices are discussed hereinafter in connection with their use for the mitral valve of the heart, these methods and devices may be used for other valves of the heart for similar purposes. One of ordinary skill in the art would understand that the use of the devices and methods described herein also could be employed for other valves of the heart. The mitral valve has been selected for illustrative purposes because a large number of the disorders occur in connection with the mitral valve.
The devices and methods described herein are discussed herein with reference to the human heart H, but may be equally applied to other animal hearts not specifically mentioned herein. For purposes of discussion and illustration, several anatomical features are labeled as follows: left ventricle LV; right ventricle RV; left atrium LA; ventricular septum VS; right ventricular free wall RVFW; left ventricular free wall LVFW; atrioventricular groove AVG; mitral valve MV; tricuspid valve TV; aortic valve AV; pulmonary valve PV; papillary muscle PM; chordae tendeneae CT (or simply chordae); anterior leaflet AL; posterior leaflet PL; coaptation line CL; annulus AN; ascending aorta AA; thoracic aorta TA; pulmonary trunk PT; inferior vena cava IVC; superior vena cava SVC; azygos vein AZV; coronary sinus CS; cardiac vein CV; right coronary artery RCA; left anterior descending artery LAD; circumflex artery CFX; left lung LL; right lung RL; dermal layer DL; sternum ST; xiphoid XPH; diaphragm DPH; vertebrae VRT; esophagus ES; and trachea TR.
With reference to FIGS. 1A–1D, cross sectional views of a patient's trunk at the level of the mitral valve MV of the heart H show the effects of a space filling devices 10 on mitral valve MV function. As seen in FIG. 1A, an incompetent mitral valve MV is shown during systole, as rendered incompetent by, for example, a dilated valve annulus AN, a displaced papillary muscle PM due to ventricular dilation or other mechanism. As seen in FIG. 1B, the formerly incompetent mitral valve MV is shown during systole as corrected with space filling device 10. The space filling device 10 causes inward displacement of a specific portion of the heart wall adjacent the mitral valve MV resulting in re-configuration and re-shaping of the annulus AN and/or the papillary muscles PM, thus providing more complete closure of the mitral valve leaflets AL/PL during systole, as shown by closed coaptation line CL in FIG. 1B.
As shown in FIGS. 1B–1D, the space filling device 10 may be positioned outside and adjacent the heart wall such that the device 10 applies an inward force against the heart wall acting on the mitral valve MV. A substantially equal and opposite force may be provided by securing the device 10 to the heart wall, and/or a substantially equal and opposite outward force may be applied against anatomical structure outside the heart wall, such as left lung LL as shown. The inward force may be applied throughout the cardiac cycle. The size of the device 10 is sufficient to push away from anatomical structure outside the heart wall and push against the heart wall and act on the mitral valve MV in order to change the function of the mitral valve MV, such as increasing coaptation of the leaflets PL/AL. To maximize the effectiveness of the inward force, the device may be sized, configured and positioned to create a normal force against the heart wall that is generally orthogonal to the coaptation line CL formed by the leaflets PL/AL. This may be achieved, for example, by positioning the device 10 in a posterior-lateral projection of the mitral valve MV generally orthogonal to the middle tangent of the coaptation line CL.
The space filling device 10 occupies sufficient space outside the epicardium of the heart H to generate the inward force described above. To this end, the space filling device 10 may take on a number of different sizes, shapes and configurations, some of which are described in detail herein with reference to FIGS. 10–17. For example, as seen in FIG. 1B, the space filling device comprises a generally uniform mass or protrusion. Alternatively, the space filling device 10 may comprise a plurality of integral protrusions as seen in FIG. 1C or a plurality of individual protrusions as seen in FIG. 1D.
The space filling device 10 may also take on a number of different implanted positions, a select few of which are described herein for purposes of illustration, not necessarily limitation. In the short axis view as seen in FIGS. 1B–1D, the space filling device 10 may extend along all of, a portion of, or beyond the posterior-lateral projection of the mitral valve MV. In the long axis view as seen in FIGS. 2A and 2B, the space filling device 10 may extend along all of, a portion of, or beyond the posterior-lateral projection of the mitral valve MV structures, including the papillary muscles PM, the chordae CT, the leaflets PL/AL, and the annulus AN. For example, as seen in FIG. 2A, the space filling device 10 may be positioned adjacent the annulus AN (e.g., extending slightly above and below the annulus AN near the AV groove), or adjacent the papillary muscles PM (e.g., extending slightly above and below the papillary muscles PM). To avoid compression of the coronary arteries and cardiac veins, the space filling device 10 may have a relatively large surface area in contact with the heart wall as shown in FIG. 2A, or the space filling device 10 may have relatively small contact areas selected and positioned to establish contact with the heart wall while avoiding compression of the coronary arteries and cardiac veins as shown in FIG. 2B. For example, the space filling device 10 may be positioned inferior of the circumflex artery between the second and third obtuse marginals.
Description of Delivery Techniques and Approaches
With reference to FIGS. 3A–3J, various approaches for implanting space filling devices 10 are shown. For purposes of illustration, not necessarily limitation, the space filling device 10 may be implanted outside the wall of the heart H adjacent the mitral valve MV to improve valvular function as illustrated in FIG. 3A. The space filling device may be implanted outside the epicardium, such as between the epicardium and pericardium, or between the pericardium and the pleural sac, for example. There are a number of different approaches and techniques for positioning the space filling device 10 as such, and these approaches generally include surgical, transluminal and transthoracic techniques. An example of a suitable surgical technique is conventional open heart surgery similar to that which is performed for coronary artery bypass surgery (CABG) or valve repair, which may be performed on-pump or off-pump. Examples of transluminal and transthoracic approaches are described in more detail with reference to FIGS. 3B–3J. Suitable delivery catheters, guide catheters, guide wires, and other tools are described in more detail with reference to FIGS. 4–9.
In FIG. 3B, a transluminal approach via the coronary sinus CS is shown as a dashed line with a distal arrow. The coronary sinus CS may be catheterized by, for example, using a guide catheter and guide wire navigated through the inferior vena cava IVC or superior vena cava SVC from a convenient venous access site such as a femoral, brachial or jugular approach. The guide catheter may be navigated into the right atrium RA and the distal end of the guide catheter may be seated in the ostium of the coronary sinus CS. The delivery catheter may be navigated through the guide catheter into the coronary sinus CS, with its distal end positioned near the desired exit point into the pericardial space. The guide wire may be advanced through the delivery catheter, out the distal end of the delivery catheter, and penetrate through the wall of the coronary sinus CS at the exit point. The delivery catheter may be advanced over the guide wire and through the hole in the coronary sinus CS and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof.
The space filling device 10, which may be predisposed at the distal end of the delivery catheter or advanced to the distal end thereof, is then manipulated into the desired position and expanded. The position of the space filling device 10 may be monitored and confirmed using medical imaging techniques such as radiographic techniques, for example, with radiopaque material incorporated into the space filling device 10 and/or the distal end of the delivery catheter. Upon deployment and expansion of the space filling device, assessment of the position of the space filling device 10 relative to internal mitral valve MV structures such as leaflets AL/PL, papillary muscles PM, and regurgitant jet may be performed with ultrasonic imaging such as trans-esophageal or epicardial echocardiography. These techniques may also be used to refine the position of the space filling device 10 until the desired acute effect is established. Once in the desired position, the space filling device 10 may be detached or otherwise disengaged from the distal end of the delivery catheter, and the delivery catheter, guide wire and guide catheter may be removed. If desired, a catheter or small tube may remain permanently or temporarily attached to the space filling device 10 to selectively adjust the degree of expansion by adding or removing material therefrom.
In FIG. 3C, a transluminal approach via a cardiac vein CV is shown as a dashed line with a distal arrow. This approach is similar to the carotid sinus CS approach described above except that the delivery catheter is navigated further through the carotid sinus CS and into a desirable cardiac vein CV near the desired implant site. The cardiac vein CV may be catheterized by, for example, using a guide catheter and guide wire navigated through the inferior vena cava IVC or superior vena cava SVC from a convenient venous access site such as a femoral, brachial or jugular approach. The guide catheter may be navigated into the right atrium RA and the distal end of the guide catheter may be seated in the ostium of the coronary sinus CS. The delivery catheter may be navigated through the guide catheter into the coronary sinus CS, into a cardiac vein CV, with its distal end positioned near the desired exit point into the pericardial space. The guide wire may be advanced through the delivery catheter, out the distal end of the delivery catheter, and penetrate through the wall of the cardiac vein CV at the exit point. The delivery catheter may be advanced over the guide wire and through the hole in the cardiac vein CV and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3D, a transluminal approach via the azygos vein AZV is shown as a dashed line with a distal arrow. The azygos vein AZV extends past the posterior aspect of the heart H near the left-right midline as best seen in FIG. 1A. The azygos vein AZV may NW be catheterized by, for example, using a guide catheter and guide wire navigated through the venous system from a convenient venous access site such as a femoral vein. The guide catheter may be navigated up to and adjacent the desired exit point adjacent the mitral valve MV or a specific part thereof. The delivery catheter may be navigated through the guide catheter until the distal end of the delivery catheter exits the distal end of the guide catheter and is positioned near the desired exit point. The guide wire may be advanced through the delivery catheter, out the distal end of the delivery catheter, and penetrate through the wall of the azygos vein AZV at the exit point. The delivery catheter may be advanced over the guide wire and through the hole in the azygos vein AZV and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3E, a transluminal approach via the right atrium RA is shown as a dashed line with a distal arrow. The pericardial space may be accessed via the right atrium RA using a percutaneous transatrial technique wherein the right atrium or right atrial appendage is catheterized by, for example, using a guide catheter and guide wire navigated through the inferior vena cava IVC from a convenient venous access site such as a femoral approach. The guide catheter may be navigated into the right atrium or atrial appendage and the guide wire may be used to puncture through the atrial wall to gain access to the pericardial space. The delivery catheter may be advanced over the guide wire and through the hole in the atrial wall and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3F, a transluminal approach via the left ventricle LV is shown as a dashed line with a distal arrow. The pericardial space may be access via the left ventricle LV using a percutaneous transventricular technique wherein the left ventricle LV is catheterized by, for example, using a guide catheter and guide wire navigated through the ascending aorta AA from a convenient arterial access site such as a femoral approach. The guide catheter may be navigated into the left ventricle LV and the guide wire may be used to puncture through the ventricular wall to gain access to the pericardial space. The delivery catheter may be advanced over the guide wire and through the hole in the ventricular wall and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3G, another transluminal approach via the left ventricle LV is shown as a dashed line with a distal arrow. The pericardial space may be access via the left ventricle LV using a percutaneous transventricular technique wherein the left ventricle LV is catheterized by, for example, using a guide catheter and guide wire navigated through the inferior vena cava IVC from a convenient venous access site. The guide wire may be navigated into the right atrium RA, through the atrial septum, into the left atrium LA, through the mitral valve MV, into the left ventricle LV, and punctured through the left ventricular wall to gain access to the pericardial space. The delivery catheter may be advanced over the guide wire and through the hole in the ventricular wall and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3H, a transluminal approach via the left atrium LA is shown as a dashed line with a distal arrow. The pericardial space may be access via the left atrium LA using a percutaneous transatrial technique wherein the left atrium LA is catheterized by, for example, using a guide catheter and guide wire navigated through the inferior vena cava IVC from a convenient venous access site. The guide wire may be navigated into the right atrium RA, through the atrial septum, into the left atrium LA, and punctured through the left atrial wall to gain access to the pericardial space. The delivery catheter may be advanced over the guide wire and through the hole in the atrial wall and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3I, a transluminal approach via the esophagus ES is shown as a dashed line with a distal arrow. The esophagus ES extends past the heart H near the posterior aspect of the right atrium as best seen in FIG. 1A. Because the esophagus ES does not provide a sterile environment, as isolation catheter such as the catheter described with reference to FIG. 9 may be used to isolate a portion of the esophageal lumen and establish a sterile environment. The isolation catheter may be inserted through nasal passage, past the pharynx, and into the esophagus ES as shown by the dashed line in FIG. 3I. Alternatively, the isolation catheter may be inserted into the esophagus ES via the mouth. The distal portion of the isolation catheter may be positioned adjacent the heart H at the level of the mitral valve MV as confirmed by a suitable visualization techniques such as ultrasonic imaging (e.g., trans-esophageal, trans-thoracic or epicardial echocardiography). Once in the desired position, the balloons of the isolation catheter may be inflated and the space between the balloons may be flushed with a suitable sterilizing wash. Having established an isolated sterile environment between the balloons of the isolation catheter, a guide wire may be advanced through the isolation catheter exiting between the balloons and puncturing the esophageal wall at the desired exit point. The delivery catheter may be advanced over the guide wire and through the hole in the esophageal wall and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
In FIG. 3J, two transthoracic approaches are shown as dashed lines with a distal arrow. The anterior approach may comprise a subxiphoid approach to establish access to the pericardial space similar to the techniques described by Schmidt et al. in U.S. Pat. No. 6,206,004, the entire disclosure of which is incorporated herein by reference. The posterior approach may utilize similar tools and techniques to access the pericardial space from the back between the ribs and extending into the thoracic cavity. Once pericardial access is established with, for example, a thoracic guide catheter used in such techniques, a delivery catheter may be advanced over or together with a guide wire and manipulated to the desired deployment position in the pericardial space adjacent the mitral valve MV or a specific part thereof. The remaining steps for implantation may be the same or similar to those described above with reference to FIG. 3B.
Description of Delivery and Ancillary Tools
With reference to FIG. 4, a schematic plan view of a delivery catheter 20 and a guide wire 40 is shown for use in delivering a space filling device 10 by the transluminal techniques described above, for example. Delivery catheter 20 includes an elongate shaft 22 that is sized appropriately as a function of the delivery approach, both in terms of the size of the lumen and the distance from the access point to the deployment point. As seen in FIG. 5A, the elongate shaft 22 may comprise a coaxial over-the-wire design with an outer tube 32 coaxially disposed about an inner tube 34. The inner tube may define a guide wire lumen 35 and the annular space between the outer tube 32 and the inner tube 34 may define an inflation lumen 33. Alternatively, as seen in FIG. 5B, the elongate shaft 22 may comprise an innerless, semi-movable wire, or fixed-wire design with the outer tube 32 coaxially disposed about the guide wire 40, and a distal (movable, semi-movable or fixed) fluid seal provided between the distal end of the outer tube 32 and a distal portion of the guide wire 42. In this alternative design, the outer tube 32 may define a combined guide wire lumen 35 and inflation lumen 33. In both designs, the outer tube 32 includes an opening (not shown) to establish fluid communication with the interior 12 of the space filling device 10.
A manifold 24 may be connected to the proximal end of the elongate shaft 22 and may include an inflation lumen arm 26 and a through lumen arm 28. The inflation lumen arm 26 is in fluid communication with the inflation lumen 33 extending through the shaft 22 and the interior 12 of the space filling device 10. The through lumen arm 28 provides access for the guide wire 40 to extend into the guide wire lumen 35 through the shaft 22 and through the space filling device 10. The inflation lumen arm 26 may be connected to an inflation device or other source of filler material such that material may be selectively added to or removed from the interior 12 defined by wall 14 of the space filling device 10.
The space filling device 10 may be releasably connected to a distal portion of the shaft 22 by a release mechanism 30 (shown schematically). The release mechanism 30 may comprise a wide variety of forms known in the art related to detachable balloons and detachable coils. The release mechanism 30 may be actuated at the proximal end of the catheter 20 by an appropriate means depending on the type of release mechanism utilized. The release mechanism 30 operates to secure the space filling device 10 to the distal portion of the shaft 22 during delivery until the space filling device 10 is the desired deployment position. Once the space filling device is in the desired position and expanded, the release mechanism 30 may be actuated to sever the connection between the delivery catheter 20 and the space filling device 10.
The guide wire 40 may have sufficient length to extend through the delivery catheter, and sufficient flexibility and column strength to facilitate manipulation, navigation and tissue puncture capabilities. The size and shape of the distal tip 42 of the guide wire 40 may be selected as a function of what lumen need to be navigated and what tissue needs to be penetrated. For example, the distal tip 42 may comprise a rounded tip having a diameter similar to a coronary guide wire to enable navigation through the vasculature and pericardial space, but with sufficient stiffness to puncture venous walls and atrial walls. Alternatively, the distal tip 42 may have a smaller diameter or may be sharpened to puncture ventricular walls, esophageal walls, etc.
With reference to FIGS. 7A and 7B, schematic top and side views of a transdermal access port 50 connected to a space filling device 10 by a flexible catheter 60. The transdermal access port 50 may be used to selectively add or remove material to or from (e.g., inflate or deflate) the space filling device 10 after the device 10 has been deployed and the delivery procedure has been completed. For example, if the desired acute effect is achieved during deployment of the space filling device 10, but thereafter the effect diminishes or otherwise changes in an undesirable way, it may be desirable to modify the size and/or shape of the space filling device 10 by selectively adding or removing material form the device 10 using the transdermal access port 50.
The transdermal access port 50 generally includes a base housing 52 and a reservoir housing 54 containing a reservoir (not visible) therein. A septum 56 is disposed over the top of the reservoir in the housing 54 and permits a needle to be inserted into the reservoir. The catheter 60 is connected to the reservoir housing 54 at strain relief 58 and is in fluid communication with the reservoir therein. The transdermal access port 50 may be implanted just below the dermal layer DL at a convenient access point such as in the pectoral region. The catheter 60 extends from the subdermal location of the transdermal access port 50 to the space filling device 10 located adjacent the heart. With this arrangement, a needle may be used to inject fluid, for example, through the septum 56 and into the reservoir of the transdermal access port 50. From the reservoir of the transdermal access port 50, the fluid passes through the flexible catheter 60 and into the interior 12 of the space filling device 10 to increase its size and/or shape. In a similar manner, a needle may be used to withdraw fluid from the interior 12 of the space filling device 10 to decrease its size and/or shape. The catheter 60 may be connected to the space filling device 10 prior to deployment thereof and snaked to the transdermal access port 50 via the delivery path defined by the delivery catheter or via an alternative route to the transdermal access port 50, which may be surgically placed in a subdermal pocket. Alternatively, the catheter 60 may be connected to the space filling device 10 after deployment thereof.
With reference to FIG. 8, a schematic plan view of a guide catheter 70 is shown, for use in delivering a space filling device 10 by transluminal techniques, for example. The guide catheter 70 includes an elongate shaft 72 that is sized appropriately as a function of the delivery approach, both in terms of the size of the lumen and the distance from the access point to the deployment point. A hub 74 may be connected to the proximal end of the shaft 72 to facilitate insertion of a delivery catheter and/or guide wire, and to permit connection to a syringe for infusion of fluids such as radiopaque media. The construction of the shaft 72 may be conventional, such as a multilayered design with composite braid and polymeric layers. The distal portion 76 of the shaft 72 may be curved with one or more curves in two or three dimensions to facilitate navigation and seating in the luminal path chosen. By way of example, not limitation, the guide catheter 70 may comprise a commercially available 8 French multipurpose guide catheter.
With reference to FIG. 9, a schematic plan view of an isolation catheter 80 is shown, for use in delivering a space filling device 10 by transluminal techniques, such as a transesophageal approach. The isolation catheter 80 includes an elongate shaft 82 that is sized appropriately as a function of the delivery approach, both in terms of the size of the lumen and the distance from the access point to the deployment point. For example, for a transesophageal approach, the shaft 82 may have a diameter sized to fit into the esophagus ES and a length sufficient to extend from the nose or mouth to a point adjacent the heart H.
The shaft 82 includes a through lumen (not visible) for passage of a delivery catheter and/or guide wire, and a distal window or opening 83 through which the space filling member 10, the delivery catheter and/or the guide wire may exit the catheter 80 between two balloons 84, and through which a sterilizing wash solution may be flushed to aspirate the region between the balloons 84. The shaft 82 also includes an inflation lumen (not visible) to selectively inflate and deflate the balloons 84. Upon inflation in the luminal passage (e.g., esophageal lumen), the balloons 84 define an isolation zone therebetween that may be sterilized and isolated from the remainder of the passage. A manifold 86 may be connected to the proximal end of the shaft 82, and may include an inflation lumen arm 87 in fluid communication with the inflation lumen in the shaft 82 and a through lumen arm 85 to provide access to the through lumen in the shaft 82 and window 83.
With reference to FIGS. 23A and 23B, side and top views, respectively, of anchor catheter 2300 are illustrated. Anchor catheter 2300 is particularly useful for delivering space filling devices by transthoracic techniques. Anchor catheter 2300 includes an elongate tubular shaft 2302 comprising a relatively rigid material such as stainless steel, NiTi, a braided composite. The elongate shaft 2302 may be straight or gently curved depending on the approach (subxiphoid or posterior). A suction cup 2304 may be connected to the distal end of the shaft 2302. The suction cup 2304 defines an interior 2308, and may have an open top and bottom, or an open bottom and closed top. For example, the suction cup 2304 may have an open top and bottom facing both the pericardium and epicardium, or an open bottom facing the epicardium and a closed top facing the pericardium.
The interior 2308 of the suction cup 2304 is in fluid communication with a vacuum lumen extending through the shaft 2302 to hub 2306, which may be connected to a vacuum source (not shown). A flexible guide wire 2320 extends alongside the shaft 2302, with its distal end connected to the suction cup 2304 and its proximal end free. A guide wire tube 2310 may extend through the suction cup 2304 to slidably accommodate pericardial space guide wire 2330 shown in phantom. A radiopaque marker 2312 may be disposed about the guide wire tube 2310 to facilitate visualization by radiography.
Pericardial space guide wire 2330 may be delivered into the pericardial space using a subxiphoid transthoracic cardiac access technique similar to that which is described by Schmidt et al. in U.S. Pat. No. 6,206,004, the entire disclosure of which is incorporated herein by reference. The pericardial space guide wire 2330 provides access to the pericardial space, but typically has a free distal end and therefore may not be easily positioned or anchored in the desired location. Accordingly, the anchor catheter 2300 may be advanced over the pericardial space guide wire 2330, manipulated to the desired implant location using semi-rigid shaft 2302, and anchored in place using vacuum. Application of vacuum to suction cup 2304 effectively anchors the distal end of the catheter 2300 to the heart wall and permits delivery catheter 1900 (described hereinafter) to be advanced thereover.
Description of Design Alternatives for Space Filling Devices
With reference to FIGS. 10–22, schematic illustrations of various design alternatives of space filling devices 10 are shown. In FIGS. 10–15, a bottom view is shown in Figures labeled “A” and a side view (cross sectional in some) is shown in Figures labeled “B”. The bottom view generally corresponds to the surface or surfaces facing the wall of the heart H and may lie directly against the epicardium, for example. The side view may represent a superior/inferior view, and/or a lateral view, depending on the selected orientation of the device. The size, shape and orientation of the space filling devices 10 may be selected as a function of the implant site, such as the anatomical features associated with the implant site, and as a function of the desired effect(s) on valve function. The design alternatives schematically illustrated in FIGS. 10–17 are given by way of example, not limitation, and may be used individually or collectively.
Each space filling device 10 described herein may have virtually any desired size, shape or configuration to meet the particular clinical requirements and to have the desired clinical effect(s) as described previously, some of which have been illustrated in FIGS. 1B–1D, and variations of which are described with reference to FIGS. 10–17. Generally, the space filling device may comprise a single large mass or single large protrusion to uniformly apply force to the heart wall and to avoid focused compression of the coronary arteries and cardiac veins. Alternatively, the space filling device 10 may have a relatively small contact area defined by one or a plurality of protrusions selected and positioned to establish localized contact with the heart wall while avoiding contact with and compression of the coronary arteries and cardiac veins.
In FIGS. 10A and 10B, the space filling device 1010 includes a base 16 defining a wall 14 and an interior 12. A single circular protrusion 18 extends from the base 16, which may be in fluid communication therewith. The base 16 and/or the protrusion 18 may be expanded to the desired size and shape. The base 16 may include a securement as described hereinafter, such as a tissue in-growth promoting surface 17.
In FIGS. 1A and 1B, the space filling device 1110 is similar to device 1010 described above except that a plurality (e.g., two, three or more) of circular protrusions 18 extend from the base 16. This embodiment illustrates that any suitable number of protrusion(s) 18 may be utilized.
In FIGS. 12A and 12B, the space filling device 1210 is similar to device 1010 except that a single oblong protrusion 18 extends from the base 16. This embodiment illustrates that the protrusion(s) 18 may assume a wide variety of geometries, including circular and non-circular geometries.
In FIGS. 13A and 13B, the space filling device 1310 the space filling device 1210 is similar to device 1010 except that one or more elongate protrusions 18 are integrally formed with and extend from both sides of the base 16. In addition, reinforcement strips 19 may be disposed at the apex of the protrusions 18 to enhance rigidity thereof. This embodiment illustrates that the protrusions 18 may be integrally formed with the base 16, and/or may extend from both sides of the base 16, and/or may be selectively reinforced.
In FIGS. 14A and 14B, the space filling device 1410 is similar to device 1310 except that the protrusion 18 includes a reinforcement structure 19 (e.g., 2-dimensional or 3-dimensional coil or stent) disposed in the interior 12 thereof to enhance the hoop strength of the protrusion 18. The reinforcement structure 19 disposed in the elongate protrusion 18 illustrates that the hoop strength or holding power of the protrusion(s) 18 may be increased by mechanical means.
In FIGS. 15A and 15B, the space filling device 1510 is similar to device 1010 except that the device 1510 comprises one or more discrete protrusions 18. This embodiment illustrates that the space filling device 1510 may comprise one or more individual and separate protrusions 18 used collectively, which may not define a discrete base portion and a discrete protrusion portion.
Each space filling device 10 described herein, including protusions 18, may be expanded, inflated, or filled by different materials and/or structures, each of which may dictate a different construction of the device 10 as illustrated by the following discussion with reference to FIGS. 16A–16F which schematically illustrate different embodiments of a space filling device 1610. The space filling device 1610 may include an interior 12 defined by wall 14, wherein the interior 12 is filled by a fluid as shown in FIG. 16A. The fluid may remain a liquid (e.g., saline) or a gas (e.g., carbon dioxide) as shown in FIG. 16A, or may comprise or cure into a solid or semi-solid (e.g., gel, expandable foam, sponge, PVA, collagen) as shown in FIG. 16B. In addition or in the alternative, a mechanical structure 19 such as a stent or coil may be placed in the interior 12 as shown in FIG. 16C. To the extent that the wall 14 is not necessary to contain the solid filler material, the device 1610 may have dissolvable walls or may not have walls at all as shown in FIG. 16D. Similarly, to the extent a mechanical structure 19 such as a stent or coil is used, the device 1610 may not require walls as shown in FIG. 16E, and the device 1610 may simply comprise the mechanical structure 19 itself.
In addition, each of the space filling devices 10 may include a means to secure itself to the heart H wall and/or other surrounding tissue. The securement may comprise tines, screws, sutures, or other structural anchors, and/or the securement may comprise a material (e.g., Dacron fabric) that promotes tissue in-growth. The securement may be remotely activated. For example, the securement may comprise curled wires disposed on either side of the space filling device, wherein the wires curl into the heart wall as they are advanced out of a catheter lumen. The securement may selectively anchor to some tissue while remaining free of other tissue. For example, the securement may anchor to the epicardium and/or myocardium, while remaining free of the pericardium. It has been observed that the epicardium is a relatively tough tissue, thus providing a good anatomical structure to secure the space filling device 10.
In the embodiments described with reference to FIGS. 10–15, the securement is shown as a tissue in-growth promoting surface on the bottom, and a smooth surface on the top, thus establishing, for example, a secure connection to the epicardium while remaining free of the pericardium. In the embodiment shown in FIG. 16F, the device 1610 includes an transmyocardial securement 1602 having an intra-chamber anchor pad 1604 and a connection member 1606. The intra-chamber pad 1604 resides within a chamber (e.g., left ventricle LV) of the heart H, and the connection member 1606 extends through the heart wall (endocardium, myocardium and epicardium) to the space filling device 1610 disposed outside the heart wall. The transmyocardial securement 1602 is particularly suited for the transventricular approach described previously.
Each space filling device 10 described herein may be expandable between a relatively small delivery configuration and a relatively large deployed configuration. The smaller delivery configuration permits the device 10 to be low profile to facilitate advancement through catheter lumens in the various transluminal approaches described herein. For example, the space filling device 1710 may be expanded radially as shown by arrows 1700A in FIG. 17A, or unfurled as shown by arrow 1700B in FIG. 17B. Radial expansion may be appropriate when the device 1710 is constructed of highly elastic materials (e.g., silicone rubber, latex, elastomeric polymers, etc.) and unfurling may be appropriate when the device 1710 is constructed of relatively inelastic materials (e.g., PET, HDPE, PTFE, SST, Nitinol, etc.).
In FIGS. 18A and 18B, side and bottom views, respectively, are shown of space filling device 1810. Space filling device 1810 includes a base 1812 which may comprise, for example, a flexible polymer sheet having resistance to elongation. Two or more suction cups 1814 are connected to opposite ends of the base 1812. The suction cups 1814 have an open bottom portion, with the top portion thereof sealing connected to the base 1812. One or more pins 1816 extend through and across each of the suction cups 1814. The pins 1816 may be inserted and locked in holes defined in the walls of the suction cups 1814. A inflatable and deflatable balloon 1818 is connected to and extends from the bottom of the base 1812. The balloon 1818 may be filled with a variety of materials as described previously.
In FIG. 19, a bottom view of a delivery catheter 1900 connected to the space filling device 1810 is shown. Delivery catheter 1900 includes an inflation tube 1902 releasably connected to and in fluid communication with the balloon 1818. Inflation tube 1902 includes an inflation lumen extending therethrough, and may include a guide wire lumen for advancement over guide wire 2320 as shown and described with reference to FIGS. 23A and 23B. The proximal end (not shown) of the inflation tube 1902 may be connected to an inflation device to selectively inflate and deflate the balloon 1818. Delivery catheter 1900 also includes vacuum tubes 1904 releasably connected to and in fluid communication with each of the suction cups 1814. The proximal ends (not shown) of the vacuum tubes 1904 may be connected to an vacuum source to selectively apply suction to the suction cups 1814. The pins 1816 are releasably connected to push/pull wires (not shown) extending through the vacuum tubes 1904 such that the pins may be remotely and selectively advanced and retracted by manipulating the proximal ands of the push/pull wires.
In FIGS. 20A–20D, an example of a method of deploying the space filling device 1810 is schematically shown. The space filling device 1810 may be positioned adjacent the heart wall HW (e.g., between the epicardium and pericardium) as shown in FIG. 20A, using delivery catheter 1900 (not shown) advanced over guide wire 2320 (shown in FIGS. 23A and 23B), by a transthoracic approach, for example. The balloon 1818 of space filling device 1810 may be positioned adjacent the MV or a specific part thereof (e.g., annulus AN or papillary muscles PM) as confirmed using by echocardiography, with the suction cups 1814 avoiding coronary vasculature as confirmed by radiography. For example, the balloon 1818 may be positioned adjacent the annulus and/or posterior papillary muscle PPM, with the suction cups 1814 disposed on opposite sides of the second and third obtuse marginals, such that the device 1810 is inferior of the circumflex artery CFX and straddles the second and third obtuse marginals.
Suction is applied to the suction cups 1814 by vacuum tubes 1904 (not shown), causing a portion of the heart wall HW to be displaced into the interior of each suction cup 1814 as shown in FIG. 20B. Pins 1816 may then be advanced through the vacuum tubes 1904 and into each of the suction cups 1814 by remotely pushing on the push/pull wires, thus causing the pins 1816 to pierce the portion of the heart wall HW displaced into the interior of the suction cups 1814 as shown in FIG. 20C. The vacuum source may then be deactivated to release the vacuum applied to the suction cups 1814 via vacuum tubes 1904. Because the epicardium of the heart wall HW is a relatively tough tissue, the pins 1816 provide a secure connection to the heart wall HW. As an alternative, the pericardium may be suctioned into the suction cups 1814 such that the pins 1816 pierce the pericardium as well. The balloon 1818 may then be inflated as shown in FIG. 20D, and the desired acute effect may be confirmed by echocardiography. The catheter 1900 may then be disconnected from the space filling device 1810, leaving the balloon 1818 inflated and the pins 1816 secured to the heart wall HW in suction cups 1814.
In FIG. 21A, a bottom view is shown of an alternative space filling device 2110, which may be similar in design and substantially the same in use as space filling device 1810 described previously. In this alternative embodiment, space filling device 2110 includes a base 2110 which may comprise, for example, a flexible polymer sheet having resistance to elongation. Two series of three suction cups 2114 each are uniformly distributed along and connected to opposite sides of the base 2112, and are interconnected by tubes 2115. A pin 2116 extends through and across each series of the suction cups 2114 and tubes 2115. A inflatable and deflatable balloon 2118 is connected to and extends from the bottom of the base 2112, and may be filled with a variety of materials as described previously. As compared to the space filling device 1810 described with reference to FIGS. 18A and 18B, the space filling device 2110 illustrated in FIG. 21A utilizes a balloon 2118 having a larger surface area and different geometry, and more suction cups 2114 interconnected by tubes 2115. As shown in FIG. 21B, delivery catheter 1900 may be connected to space filling device 2110 in a similar manner as the connection to space filling device 1810 described previously. Further, the steps of deploying space filling device 2110 may be the same as described previously for space filling device 1810.
With reference to FIGS. 22A–22C, various design alternatives for the suction cups 1814/2114 are shown as top views and side views. In FIG. 22A, the suction cup 2200 includes a circular wall portion 2202 defining an interior with an open bottom and top. A pin 2204 extends through holes in the wall 2202 as well as the interior defined by circular wall 2202. With an open bottom and top, suction applied to the cup 2200 pulls both the heart wall (at least the epicardium) and the pericardium into the interior allowing the pin 2204 to pierce through both tissue layers.
In FIG. 22B, the suction cup 2210 includes a circular wall portion 2212 defining an interior. A cap 2216 covers the top portion of the wall 2212 to define a closed top portion and an open bottom potion of the cup 2210. A pin 2214 extends through holes in the wall 2212 as well as the interior defined by circular wall 2212. With an open bottom and a closed top, suction applied to the cup 2210 pulls the heart wall (at least the epicardium) into the interior while the cover 2216 prevents the pericardium from entering, thus allowing the pin 2214 to pierce through the heart wall but not the pericardium.
In FIG. 22B, the suction cup 2220 includes a circular wall portion 2222 defining an interior. A series of crossing wires 2226 cover the top portion of the wall 2222 to define a screened top portion and an open bottom potion of the cup 2220. The wall 2222 may be formed of a tubular structure with a highly elastic wire (e.g., NiTi) running therethrough, and the wires 2226 may be formed of a highly elastic material (e.g., NiTi) such that the entire cup 2220 may be collapsed into a delivery configuration small enough to fit into a delivery catheter and subsequently deployed into an expanded configuration as shown. A pin 2224 extends through holes in the wall 2222 as well as the interior defined by the wall 2222. With an open bottom and a screened top, suction applied to the cup 2220 pulls the heart wall (at least the epicardium) into the interior. Depending on the density of wires 2226 and the amount of suction applied, the pericardium may be selectively pulled into the interior, thus allowing the pin 2224 to pierce through the heart wall and optionally the pericardium.
With reference to FIG. 22D, an alternative implantation arrangement is shown. In this embodiment, three or more suction cups 2220 are attached to the heart wall and pericardium to isolate and hold the balloon 2218 therebetween. By connecting to both the epicardium and the heart wall in three or more locations, the balloon 2218 is constrained by the heart wall, the epicardium and the suction cup anchors 2220. This arrangement eliminates the need to interconnect the balloon 2218 and suction cups 2220 (e.g., by a base structure), and permits the suction cups and balloon to be separately delivered in a smaller profile enabling transluminal delivery through a catheter.
Conclusion
From the foregoing, it will be apparent to those skilled in the art that the present invention provides, in exemplary no-limiting embodiments, devices and methods for improving the function of a valve (e.g., mitral valve) by positioning a spacing filling device outside and adjacent the heart wall such that the device applies an inward force against the heart wall acting on the valve. The device may be remotely secured to the heart wall. A substantially equal and opposite force may be provided by securing the device to the heart wall, and/or a substantially equal and opposite outward force may be applied against anatomical structure outside the heart wall. Further, those skilled in the art will recognize that the present invention may be manifested in a variety of forms other than the specific embodiments described and contemplated herein. Accordingly, departures in form and detail may be made without departing from the scope and spirit of the present invention as described in the appended claims.

## Claims

1. A device for improving heart valve function, the device comprising:
a first anchor;
a second member anchor;
a flexible member configured to connect the first and second anchors, the flexible member being further configured to be positioned adjacent an external surface of a heart wall; and
at least one inflatable protrusion configured to be positioned in contact with an external surface of the heart wall such that the at least one protrusion exerts an inward force against the heart wall proximate a valve,
wherein the inward force is sufficient to alter valve function.

2. The device of claim 1, wherein the device is configured such that the device exerts a force substantially opposite to the inward force by securing the device to the heart wall.

3. The device of claim 2, wherein the force exerted substantially opposite the inward force is substantially equal to the inward force.

4. The device of claim 1, wherein the device is configured such that the device exerts a force substantially opposite to the inward force against anatomical structure outside the heart wall.

5. The device of claim 4, wherein the force exerted substantially opposite the inward force is substantially equal to the inward force.

6. The device of claim 1, wherein the protrusion is expandable.

7. The device of claim 6, wherein the protrusion defines an interior.

8. The device of claim 7, further comprising a coil disposed in the interior of the protrusion.

9. The device of claim 7, further comprising a foam disposed in the interior of the protrusion.

10. The device of claim 7, further comprising a sponge disposed in the interior of the protrusion.

11. The device of claim 7, further comprising a liquid disposed in the interior of the protrusion.

12. The device of claim 11, wherein the liquid is a curable liquid.

13. The device of claim 7, further comprising a mechanical reinforcement member disposed in the interior of the protrusion.

14. The device of claim 7, further comprising means for selectively adding or removing material from the interior.

15. The device of claim 1, wherein the protrusion includes a balloon.

16. The device of claim 14, wherein the means is transdermally accessible.

17. The device of claim 1, wherein the at least one protrusion comprises a plurality of protrusions.

18. The device of claim 17, wherein the plurality of protrusions form an integral structure.

19. The device of claim 17, wherein the plurality of protrusions are separate from each other.

20. The device of claim 17, wherein the plurality of protrusions are arranged so as to avoid cardiac veins and coronary arteries when positioned in contact with the heart wall.

21. The device of claim 1, wherein the at least one protrusion protrudes from the flexible member.

22. The device of claim 1, wherein the at least one protrusion is expandable between a relatively small delivery configuration and a relatively large deployed configuration.

23. The device of claim 1, wherein the device is configured to be delivered to the heart via a delivery catheter.

24. The device of claim 23, wherein the device is configured to be releasably connected to the delivery catheter.

25. The device of claim 1, wherein the at least one protrusion is configured to exert an inward force sufficient to draw leaflets of the valve together.

26. The device of claim 1, wherein the anchors are configured to secure the device to the heart.

27. A method for improving heart valve function, the method comprising:
providing a device comprising a first anchor, a second anchor, a flexible member connecting the first and second anchors, and at least one inflatable protrusion between the first and second anchors
positioning the flexible member adjacent an external surface of a heart wall; and
positioning the at least one inflatable protrusion in contact with an external surface of the heart wall such that the at least one inflatable protrusion exerts an inward force against the heart wall proximate a valve, wherein the inward force is sufficient to alter valve function.

28. The method of claim 27, further comprising positioning the device such that the device exerts a force substantially opposite to the inward force as a result of securing the device to the heart wall.

29. The method of claim 28, wherein the force exerted substantially opposite the inward force is substantially equal to the inward force.

30. The method of claim 27, further comprising positioning the device such that the device exerts a force substantially opposite to the inward force on anatomical structure external to the heart wall.

31. The method of claim 30, wherein the force exerted substantially opposite the inward force is substantially equal to the inward force.

32. The method of claim 27, wherein the inward force is sufficient to draw leaflets of the valve together.

33. The method of claim 32, wherein the valve leaflets define a line of coaptation and positioning the protrusion includes positioning the protrusion such that the inward force is exerted substantially orthogonal to the line of coaptation.

34. The method of claim 27, wherein the valve is a mitral valve.

35. The method of claim 27, further comprising adjusting a position of the device while observing the valve function.

36. The method of claim 27, wherein the inward force is exerted on an annulus of the valve.

37. The method of claim 27, wherein the inward force is sufficient to reposition papillary muscles of the valve.

38. The method of claim 27, further comprising positioning the device outside the epicardium of the heart.

39. The method of claim 38, further comprising positioning the device between the epicardium and the pericardium of the heart.

40. The method of claim 39, further comprising attaching the device to the epicardium.

41. The method of claim 40, further comprising maintaining the device free of the pericardium.

42. The method of claim 27, further comprising delivering the device to the heart via a surgical approach.

43. The method of claim 27, further comprising delivering the device to the heart via a subthoracic approach.

44. The method of claim 43, wherein the subthoracic approach includes a subxiphoid approach.

45. The method of claim 43, wherein the subthoracic approach includes a posterior approach.

46. The method of claim 27, further comprising delivering the device via a transluminal approach.

47. The method of claim 46, wherein the transluminal approach is via the superior or inferior vena cava, the right atrium, the coronary sinus, and a cardiac vein.

48. The method of claim 46, wherein the transluminal approach is via the superior or inferior vena cava, into the right atrium or right atrial appendage, through the right atrial wall and into the pericardial space.

49. The method of claim 46, wherein the transluminal approach is via the aorta, into the left ventricle, through the left ventricular wall, and into the pericardial space.

50. The method of claim 46, wherein the transluminal approach is via the azygos vein.

51. The method of claim 46, wherein the transluminal approach is via the esophagus.

52. The method of claim 27, wherein the inward force is exerted throughout the cardiac cycle.