Abstract:
Devices, systems and methods are provided for tissue approximation and repair at treatment sites, particularly in those procedures requiring minimally-invasive or endovascular access to remote tissue locations. Fixation devices are provided to fix tissue in approximation with the use of distal elements. In some embodiments, the fixation devices have at least two distal elements and an actuatable feature wherein actuation of the feature varies a dimension of the at least two distal elements. In other embodiments, the fixation devices have at least two pairs of distal elements wherein the pairs of distal elements are moveable to engage tissue between opposed pairs of distal elements. Systems are also provided having fixation devices and accessories.

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
     The present application is a continuation of U.S. patent application Ser. No. 10/975,555 filed Oct. 27, 2004 (now U.S. Pat. No. 7,811,296), which is a continuation in part of U.S. patent application Ser. No. 10/803,444 filed Mar. 17, 2004 (now U.S. Pat. No. 7,563,273), which is a continuation of U.S. patent application Ser. No. 09/894,463 filed Jun. 27, 2001 (now U.S. Pat. No. 6,752,813), which is a continuation in part of U.S. patent application Ser. No. 09/544,930 filed Apr. 7, 2000 (now U.S. Pat. No. 6,629,534), and which is a non-provisional of, and claims the benefit of U.S. Provisional Patent Application No. 60,128,690, filed Apr. 9, 1999. The entire contents of each of the above listed patent applications is incorporated herein by reference. 
    
    
     BACKGROUND OF THE INVENTION 
     1. Field of the Invention 
     The present invention relates generally to medical methods, devices, and systems. In particular, the present invention relates to methods, devices, and systems for the endovascular, percutaneous or minimally invasive surgical treatment of bodily tissues, such as tissue approximation or valve repair. More particularly, the present invention relates to repair of valves of the heart and venous valves. 
     Surgical repair of bodily tissues often involves tissue approximation and fastening of such tissues in the approximated arrangement. When repairing valves, tissue approximation includes coapting the leaflets of the valves in a therapeutic arrangement which may then be maintained by fastening or fixing the leaflets. Such coaptation can be used to treat regurgitation which most commonly occurs in the mitral valve. 
     Mitral valve regurgitation is characterized by retrograde flow from the left ventricle of a heart through an incompetent mitral valve into the left atrium. During a normal cycle of heart contraction (systole), the mitral valve acts as a check valve to prevent flow of oxygenated blood back into the left atrium. In this way, the oxygenated blood is pumped into the aorta through the aortic valve. Regurgitation of the valve can significantly decrease the pumping efficiency of the heart, placing the patient at risk of severe, progressive heart failure. 
     Mitral valve regurgitation can result from a number of different mechanical defects in the mitral valve or the left ventricular wall. The valve leaflets, the valve chordae which connect the leaflets to the papillary muscles, the papillary muscles or the left ventricular wall may be damaged or otherwise dysfunctional. Commonly, the valve annulus may be damaged, dilated, or weakened limiting the ability of the mitral valve to close adequately against the high pressures of the left ventricle. 
     The most common treatments for mitral valve regurgitation rely on valve replacement or repair including leaflet and annulus remodeling, the latter generally referred to as valve annuloplasty. A recent technique for mitral valve repair which relies on suturing adjacent segments of the opposed valve leaflets together is referred to as the “bow-tie” or “edge-to-edge” technique. While all these techniques can be very effective, they usually rely on open heart surgery where the patient&#39;s chest is opened, typically via a sternotomy, and the patient placed on cardiopulmonary bypass. The need to both open the chest and place the patient on bypass is traumatic and has associated high mortality and morbidity. 
     For these reasons, it would be desirable to provide alternative and additional methods, devices, and systems for performing the repair of mitral and other cardiac valves. Such methods, devices, and systems should preferably not require open chest access and be capable of being performed either endovascularly, i.e., using devices which are advanced to the heart from a point in the patient&#39;s vasculature remote from the heart or by a minimally invasive approach. Further, such devices and systems should provide features which allow repositioning and optional removal of a fixation device prior to fixation to ensure optimal placement. In addition, such devices and systems should provide features that assist in secure engagement of the targeted tissue (e.g. leaflet or other targeted structure) at the time of placement and over time (e.g. tissue in growth, maximal surface area of engagement). The methods, devices, and systems would also be useful for repair of tissues in the body other than heart valves. At least some of these objectives will be met by the inventions described hereinbelow. 
     2. Description of the Background Art 
     Minimally invasive and percutaneous techniques for coapting and modifying mitral valve leaflets to treat mitral valve regurgitation are described in PCT Publication Nos. WO 98/35638; WO 99/00059; WO 99/01377; and WO 00/03759. 
     Maisano et al. (1998) Eur. J. Cardiothorac. Surg. 13:240-246; Fucci et al. (1995) Eur. J. Cardiothorac. Surg. 9:621-627; and Umana et al. (1998) Ann. Thorac. Surg. 66:1640-1646, describe open surgical procedures for performing “edge-to-edge” or “bow-tie” mitral valve repair where edges of the opposed valve leaflets are sutured together to lessen regurgitation. Dec and Fuster (1994) N. Engl. J. Med. 331:1564-1575 and Alvarez et al. (1996) J. Thorac. Cardiovasc. Surg. 112:238-247 are review articles discussing the nature of and treatments for dilated cardiomyopathy. 
     Mitral valve annuloplasty is described in the following publications. Bach and Bolling (1996) Am. J. Cardiol. 78:966-969; Kameda et al. (1996) Ann. Thorac. Surg. 61:1829-1832; Bach and Bolling (1995) Am. Heart J. 129:1165-1170; and Bolling et al. (1995) 109:676-683. Linear segmental annuloplasty for mitral valve repair is described in Ricchi et al. (1997) Ann. Thorac. Surg. 63:1805-1806. Tricuspid valve annuloplasty is described in McCarthy and Cosgrove (1997) Ann. Thorac. Surg. 64:267-268; Tager et al. (1998) Am. J. Cardiol. 81:1013-1016; and Abe et al. (1989) Ann. Thorac. Surg. 48:670-676. 
     Percutaneous transluminal cardiac repair procedures are described in Park et al. (1978) Circulation 58:600-608; Uchida et al. (1991) Am. Heart J. 121: 1221-1224; and Ali Khan et al. (1991) Cathet. Cardiovasc. Diagn. 23:257-262. 
     Endovascular cardiac valve replacement is described in U.S. Pat. Nos. 5,840,081; 5,411,552; 5,554,185; 5,332,402; 4,994,077; and 4,056,854. See also U.S. Pat. No. 3,671,979 which describes a catheter for temporary placement of an artificial heart valve. 
     Other percutaneous and endovascular cardiac repair procedures are described in U.S. Pat. Nos. 4,917,089; 4,484,579; and 3,874,338; and PCT Publication No. WO 91/01689. 
     Thoracoscopic and other minimally invasive heart valve repair and replacement procedures are described in U.S. Pat. Nos. 5,855,614; 5,829,447; 5,823,956; 5,797,960; 5,769,812; and 5,718,725. 
     BRIEF SUMMARY OF THE INVENTION 
     The invention provides devices, systems and methods for tissue approximation and repair at treatment sites. The devices, systems and methods of the invention will find use in a variety of therapeutic procedures, including endovascular, minimally-invasive, and open surgical procedures, and can be used in various anatomical regions, including the abdomen, thorax, cardiovascular system, heart, intestinal tract, stomach, urinary tract, bladder, lung, and other organs, vessels, and tissues. The invention is particularly useful in those procedures requiring minimally-invasive or endovascular access to remote tissue locations. 
     In some embodiments, the devices, systems and methods of the invention are adapted for fixation of tissue at a treatment site. Exemplary tissue fixation applications include cardiac valve repair, septal defect repair, vascular ligation and clamping, laceration repair and wound closure, but the invention may find use in a wide variety of tissue approximation and repair procedures. In a particularly preferred embodiment, the devices, systems and methods of the invention are adapted for repair of cardiac valves, and particularly the mitral valve, as a therapy for regurgitation. The invention enables two or more valve leaflets to be coapted using an “edge-to-edge” or “bow-tie” technique to reduce regurgitation, yet does not require open surgery through the chest and heart wall as in conventional approaches. In addition, the position of the leaflets may vary in diseased mitral valves depending upon the type and degree of disease, such as calcification, prolapse or flail. These types of diseases can result in one leaflet being more mobile than the other (e.g. more difficult to capture), and therefore more difficult to grasp symmetrically in the same grasp with the other leaflet. The features of the present invention allow the fixation devices to be adapted to meet the challenges of unpredictable target tissue geometry, as well as providing a more robust grasp on the tissue once it is captured. 
     Using the devices, systems and methods of the invention, the mitral valve can be accessed from a remote surgical or vascular access point and the two valve leaflets may be coapted using endovascular or minimally invasive approaches. While less preferred, in some circumstances the invention may also find application in open surgical approaches as well. According to the invention, the mitral valve may be approached either from the atrial side (antegrade approach) or the ventricular side (retrograde approach), and either through blood vessels or through the heart wall. 
     The fixation devices of the present invention each have a pair of distal elements (or fixation elements). In the main embodiments, each distal element has a first end, a free end opposite the first end, an engagement surface therebetween for engaging tissue and a longitudinal axis extending between the first and free end. The first ends of the at least two distal elements are movably coupled together such that the at least two distal elements are moveable to engage tissue with the engagement surfaces. Thus, the first ends are coupled together so that the distal elements can move between at least an open and closed position to engage tissue. Preferably, the engagement surfaces are spaced apart in the open position and are closer together and generally face toward each other in the closed position. 
     Each distal element has a width measured perpendicular to its longitudinal axis and a length measured along its longitudinal axis. In one embodiment suitable for mitral valve repair, the fixed width across engagement surfaces (which determines the width of tissue engaged) is at least about 2 mm, usually 3-10 mm, and preferably about 4-6mm. In some situations, a wider engagement is desired wherein the engagement surfaces have a larger fixed width, for example about 2 cm. The engagement surfaces are typically configured to engage a length of tissue of about 4-10 mm, and preferably about 6-8 mm along the longitudinal axis. However, the size of the engagement surfaces may be varied in width and/or length, as will be described in later sections. 
     The fixation device is preferably delivered to a target location in a patient&#39;s body by a delivery catheter having an elongated shaft, a proximal end and a distal end, the delivery catheter being configured to be positioned at the target location from a remote access point such as a vascular puncture or cut-down or a surgical penetration. In an alternative embodiment, the target location is a valve in the heart. 
     Optionally, the fixation devices of the invention will further include at least one proximal element (or gripping element). Each proximal element and distal element will be movable relative to each other and configured to capture tissue between the proximal element and the engagement surface of the distal element. Preferably, the distal elements and proximal elements are independently movable but in some embodiments may be movable with the same mechanism. The proximal element may be preferably biased toward the engagement surface of the fixation element to provide a compressive force against tissue captured therebetween. 
     In a first aspect of the present invention, fixation devices are provided that include at least two distal elements and an actuatable feature attached to at least one of the at least two distal elements. Actuation of the feature varies a dimension of at least one of the at least two distal elements which varies the size of its engagement surface. For example, in some embodiments, the actuatable feature is configured so that actuation varies the width of the distal element. In some of these embodiments, the actuatable feature comprises at least one loop which is extendable laterally outwardly in a direction perpendicular to the longitudinal axis. Thus, extension of the at least one loop increases the size of the engagement surface of the distal element, specifically the width. In others of these embodiments, the actuatable feature comprises at least one flap which is extendable laterally outwardly in a direction perpendicular to the longitudinal axis. And in still others, the actuatable feature comprises at least one pontoon which is expandable laterally outwardly in a direction perpendicular to the longitudinal axis. The pontoon may be expanded by inflation or any suitable means. 
     In some embodiments, the actuatable feature is configured so that actuation varies the length of the distal element. In some of these embodiments, the actuatable feature comprises at least one loop which is extendable laterally outwardly from its free end along its longitudinal axis. Thus, extension of the at least one loop increases the size of the engagement surface of the distal element, specifically the length. In others of these embodiments, each of the distal elements comprises an elongate arm and the actuatable feature comprises an extension arm coupled with the elongate arm. The extension arm is extendable from the elongate arm to increase the length of the distal element. For example, in some instances the extension arm is coupled with the elongate arm by a cam such that rotation of the cam advances the extension arm along the longitudinal axis. Extension or retraction of the extension arm may be actuated by movement of the fixation device. For example, when each distal element is moveable from a closed position (wherein the engagement surfaces of the at least two distal elements are closer together) to an open position (wherein the engagement surfaces of the at least two distal elements are further apart), movement between the closed and open position may advance the extension arm of each distal element along its longitudinal axis. 
     In a second aspect of the present invention, fixation devices are provided that include two pairs of distal elements, wherein the pairs of distal elements are in an opposed orientation so that the engagement surfaces of one pair faces the engagement surfaces of the other pair, and wherein the pairs of distal elements are moveable to engage tissue with the opposed engagement surfaces of the two pairs of distal elements. Thus, the fixation device includes four distal elements, the distal elements functioning in pairs so that each pair of distal elements engages a valve leaflet (in the case of the tissue comprising a valve leaflet) rather than a single distal element engaging each valve leaflet. In some embodiments, the distal elements of at least one of the two pairs are alignable so their longitudinal axes are substantially parallel. Alternatively or in addition, the distal elements of at least one of the two pairs may be rotatable laterally outwardly to a splayed position wherein their longitudinal axes substantially form an angle. 
     In a third aspect of the present invention, accessories are provided which may be used with fixation devices of the present invention. Such accessories may provide benefits which are similar to increasing the width and/or length of the distal elements. Thus, such accessories may be used with fixation devices of fixed dimension or with fixation devices having distal elements of varying dimensions. 
     In some embodiments, the accessory comprises a support coupleable with the fixation device, the support having at least two planar sections, each planar section configured to mate with an engagement surface of a distal element when coupled. In some embodiments, wherein the tissue comprises a valve leaflet, the support is configured so that each planar section is positionable against an upstream surface of the valve leaflet while each distal element is positionable against a downstream surface of the valve leaflet. Typically the fixation device is released from a delivery catheter yet temporarily maintained by a tether. Thus, in some embodiments, the support is configured to be advancable along the tether to the fixation device. The tether may be removed from the fixation device while the support is coupled to the fixation device. Thus, the fixation device and support may be left behind to maintain fixation of the tissue. 
     In a fourth aspect of the present invention, a fixation device is provided having at least two distal elements wherein each of the at least two distal elements has a length along its longitudinal axis, and wherein the length of one of the at least two distal elements is longer than another of the at least two distal elements. In some embodiments, the fixation device has variable length distal elements, wherein each distal element is adjustable to a different length. In other embodiments, the fixation device has fixed length distal elements, wherein each distal element is formed to have a different length. And, in still further embodiments, the fixation device has both fixed and variable length distal elements. 
     Other aspects of the nature and advantages of the invention are set forth in the detailed description set forth below, taken in conjunction with the drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A-1C  illustrate grasping of the leaflets with a fixation device, inversion of the distal elements of the fixation device and removal of the fixation device, respectively. 
         FIG. 2  illustrates the position of the fixation device in a desired orientation relative to the leaflets. 
         FIG. 3  illustrates another embodiment of the fixation device of the present invention. 
         FIGS. 4A-4B ,  5 A- 5 B,  6 A- 6 B,  7 A- 7 B illustrate embodiments of a fixation device in various possible positions during introduction and placement of the device within the body to perform a therapeutic procedure. 
         FIGS. 8A-8B  illustrate an embodiment of distal elements having variable width wherein one or more loops are extendable laterally outwardly. 
         FIGS. 9A-9B  illustrate an embodiment of distal elements having variable width wherein one or more flaps are extendable laterally outwardly. 
         FIGS. 10A-10B  illustrate an embodiment of distal elements having variable width wherein one or more pontoons are expandable laterally outwardly. 
         FIGS. 11A-11B  provide a perspective view of a fixation device having distal elements which are capable of moving to a splayed position. 
         FIGS. 11C-11D  provide a side view of the fixation device of  FIGS. 11A-11B  plicating tissue of a leaflet. 
         FIGS. 12A-12B  provide a top view of a fixation device having distal elements which are capable of moving to a splayed position. 
         FIGS. 13A-13B  illustrate an embodiment of distal elements having variable length wherein one or more loops are extendable outwardly. 
         FIGS. 14A-14B ,  15  illustrate embodiments of distal elements having variable length wherein the distal elements include extension arms. 
         FIG. 16  illustrates an embodiment of the fixation device having distal elements of different lengths. 
         FIGS. 17A-17B  illustrate an embodiment of an accessory for use with fixation devices of the present invention. 
         FIGS. 18A-18B  illustrate an embodiment of distal elements which vary in length and width. 
         FIGS. 19A-19C ,  20 A- 20 C illustrate embodiments of a fixation device combining splaying and variable length distal elements. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     1. Fixation Device Overview. The present invention provides methods and devices for grasping, approximating and fixating tissues such as valve leaflets to treat cardiac valve regurgitation, particularly mitral valve regurgitation. 
     Grasping may be atraumatic which can provide a number of benefits. By atraumatic, it is meant that the devices and methods of the invention may be applied to the valve leaflets and then removed without causing any significant clinical impairment of leaflet structure or function. 
     The leaflets and valve continue to function substantially the same as before the invention was applied. Thus, some minor penetration or denting of the leaflets may occur using the invention while still meeting the definition of “atraumatic”. This enables the devices of the invention to be applied to a diseased valve and, if desired, removed or repositioned without having negatively affected valve function. In addition, it will be understood that in some cases it may be necessary or desirable to pierce or otherwise permanently affect the leaflets during either grasping, fixing or both. In some of these cases, grasping and fixation may be accomplished by a single device. Although a number of embodiments are provided to achieve these results, a general overview of the basic features will be presented herein. Such features are not intended to limit the scope of the invention and are presented with the aim of providing a basis for descriptions of individual embodiments presented later in the application. 
     The devices and methods of the invention rely upon the use of an interventional tool that is positioned near a desired treatment site and used to grasp the target tissue. In endovascular applications, the interventional tool is typically an interventional catheter. In surgical applications, the interventional tool is typically an interventional instrument. In some embodiments, fixation of the grasped tissue is accomplished by maintaining grasping with a portion of the interventional tool which is left behind as an implant. While the invention may have a variety of applications for tissue approximation and fixation throughout the body, it is particularly well adapted for the repair of valves, especially cardiac valves such as the mitral valve. Referring to  FIG. 1A , an interventional tool  10 , having a delivery device, such as a shaft  12 , and a fixation device  14 , is illustrated having approached the mitral valve MV from the atrial side and grasped the leaflets LF. The mitral valve may be accessed either surgically or by using endovascular techniques, and either by a retrograde approach through the ventricle or by an antegrade approach through the atrium, as described above. For illustration purposes, an antegrade approach is described. 
     The fixation device  14  is releasably attached to the shaft  12  of the interventional tool  10  at its distal end. When describing the devices of the invention herein, “proximal” shall mean the direction toward the end of the device to be manipulated by the user outside the patient&#39;s body, and “distal” shall mean the direction toward the working end of the device that is positioned at the treatment site and away from the user. With respect to the mitral valve, proximal shall refer to the atrial or upstream side of the valve leaflets and distal shall refer to the ventricular or downstream side of the valve leaflets. 
     The fixation device  14  typically comprises proximal elements  16  (or gripping elements) and distal elements  18  (or fixation elements) which protrude radially outward and are positionable on opposite sides of the leaflets LF as shown so as to capture or retain the leaflets therebetween. The proximal elements  16  may be comprised of cobalt chromium, nitinol or stainless steel, and the distal elements  18  are may be comprised of cobalt chromium or stainless steel, however any suitable materials may be used. The fixation device  14  is coupleable to the shaft  12  by a coupling mechanism  17 . The coupling mechanism  17  allows the fixation device  14  to detach and be left behind as an implant to hold the leaflets together in the coapted position. 
     In some situations, it may be desired to reposition or remove the fixation device  14  after the proximal elements  16 , distal elements  18 , or both have been deployed to capture the leaflets LF. Such repositioning or removal may be desired for a variety of reasons, such as to reapproach the valve in an attempt to achieve better valve function, more optimal positioning of the device  14  on the leaflets, better purchase on the leaflets, to detangle the device  14  from surrounding tissue such as chordae, to exchange the device  14  with one having a different design, or to abort the fixation procedure, to name a few. To facilitate repositioning or removal of the fixation device  14  the distal elements  18  are releasable and optionally invertible to a configuration suitable for withdrawal of the device  14  from the valve without tangling or interfering with or damaging the chordae, leaflets or other tissue.  FIG. 1B  illustrates inversion wherein the distal elements  18  are moveable in the direction of arrows  40  to an inverted position. Likewise, the proximal elements  16  may be raised, if desired. In the inverted position, the device  14  may be repositioned to a desired orientation wherein the distal elements may then be reverted to a grasping position against the leaflets as in  FIG. 1A . Alternatively, the fixation device  14  may be withdrawn (indicated by arrow  42 ) from the leaflets as shown in  FIG. 1C . Such inversion reduces trauma to the leaflets and minimizes any entanglement of the device with surrounding tissues. Once the device  14  has been withdrawn through the valve leaflets, the proximal and distal elements may be moved to a closed position or configuration suitable for removal from the body or for reinsertion through the mitral valve. 
       FIG. 2  illustrates the position of the fixation device  14  in a desired orientation in relation to the leaflets LF. This is a short-axis view of the mitral valve MV from the atrial side, therefore, the proximal elements  16  are shown in solid line and the distal elements  18  are shown in dashed line. The proximal and distal elements  16 ,  18  are positioned to be substantially perpendicular to the line of coaptation C. The device  14  may be moved roughly along the line of coaptation to the location of regurgitation. The leaflets LF are held in place so that during diastole, as shown in  FIG. 2 , the leaflets LF remain in position between the elements  16 ,  18  surrounded by openings O which result from the diastolic pressure gradient. Advantageously, leaflets LF are coapted such that their proximal or upstream surfaces are facing each other in a vertical orientation, parallel to the direction of blood flow through mitral valve MV. The upstream surfaces may be brought together so as to be in contact with one another or may be held slightly apart, but will preferably be maintained in the substantially vertical orientation in which the upstream surfaces face each other at the point of coaptation. This simulates the double orifice geometry of a standard surgical bow-tie repair. Color Doppler echo will show if the regurgitation of the valve has been reduced. If the resulting mitral flow pattern is satisfactory, the leaflets may be fixed together in this orientation. If the resulting color Doppler image shows insufficient improvement in mitral regurgitation, the interventional tool  10  may be repositioned. This may be repeated until an optimal result is produced wherein the leaflets LF are held in place. Once the leaflets are coapted in the desired arrangement, the fixation device  14  is then detached from the shaft  12  and left behind as an implant to hold the leaflets together in the coapted position. 
       FIG. 3  illustrates an embodiment of a fixation device  14 . Here, the fixation device  14  is shown coupled to a shaft  12  to form an interventional tool  10 . The fixation device  14  includes a coupling member  19  and a pair of opposed distal elements  18 . The distal elements  18  comprise elongate arms  53 , each arm having a proximal end  52  rotatably connected to the coupling member  19  and a free end  54 . The free ends  54  have a rounded shape to minimize interference with and trauma to surrounding tissue structures. Each free end  54  may define a curvature about two axes, one being a longitudinal axis  66  of arms  53 . Thus, engagement surfaces  50  have a cupped or concave shape to surface area in contact with tissue and to assist in grasping and holding the valve leaflets. This further allows arms  53  to nest around the shaft  12  in a closed position to minimize the profile of the device. Arms  53  may be at least partially cupped or curved inwardly about their longitudinal axes  66 . Also, each free end  54  may define a curvature about an axis  67  perpendicular to longitudinal axis  66  of arms  53 . This curvature is a reverse curvature along the most distal portion of the free end  54 . Likewise, the longitudinal edges of the free ends  54  may flare outwardly. Both the reverse curvature and flaring minimize trauma to the tissue engaged therewith. Arms  53  further include a plurality of openings to enhance grip and to promote tissue ingrowth following implantation. 
     The valve leaflets are grasped between the distal elements  18  and proximal elements  16 . In some embodiments, the proximal elements  16  are flexible, resilient, and cantilevered from coupling member  19 . The proximal elements are preferably resiliently biased toward the distal elements. Each proximal element  16  is shaped and positioned to be at least partially recessed within the concavity of the distal element  18  when no tissue is present. When the fixation device  14  is in the open position, the proximal elements  16  are shaped such that each proximal element  16  is separated from the engagement surface  50  near the proximal end  52  of arm  53  and slopes toward the engagement surface  50  near the free end  54  with the free end of the proximal element contacting engagement surface  50 , as illustrated in  FIG. 3 . This shape of the proximal elements  16  accommodates valve leaflets or other tissues of varying thicknesses. 
     Proximal elements  16  include a plurality of openings  63  and scalloped side edges  61  to increase grip on tissue. The proximal elements  16  optionally include frictional accessories, frictional features or grip-enhancing elements to assist in grasping and/or holding the leaflets. In some embodiments, the frictional accessories comprise barbs  60  having tapering pointed tips extending toward engagement surfaces  50 . It may be appreciated that any suitable frictional accessories may be used, such as prongs, windings, bands, barbs, grooves, channels, bumps, surface roughening, sintering, high-friction pads, coverings, coatings or a combination of these. Optionally, magnets may be present in the proximal and/or distal elements. It may be appreciated that the mating surfaces will be made from or will include material of opposite magnetic charge to cause attraction by magnetic force. For example, the proximal elements and distal elements may each include magnetic material of opposite charge so that tissue is held under constant compression between the proximal and distal elements to facilitate faster healing and ingrowth of tissue. Also, the magnetic force may be used to draw the proximal elements  16  toward the distal elements  18 , in addition to or alternatively to biasing of the proximal elements toward the distal elements. This may assist in deployment of the proximal elements  16 . In another example, the distal elements  18  each include magnetic material of opposite charge so that tissue positioned between the distal elements  18  is held therebetween by magnetic force. 
     The fixation device  14  also includes an actuation mechanism  58 . In this embodiment, the actuation mechanism  58  comprises two link members or legs  68 , each leg  68  having a first end  70  which is rotatably joined with one of the distal elements  18  at a riveted joint  76  and a second end  72  which is rotatably joined with a stud  74 . The legs  68  may be comprised of a rigid or semi-rigid metal or polymer such as Elgiloy®, cobalt chromium or stainless steel, however any suitable material may be used. While in the embodiment illustrated both legs  68  are pinned to stud  74  by a single rivet  78 , it may be appreciated, however, that each leg  68  may be individually attached to the stud  74  by a separate rivet or pin. The stud  74  is joinable with an actuator rod  64  (not shown) which extends through the shaft  12  and is axially extendable and retractable to move the stud  74  and therefore the legs  68  which rotate the distal elements  18  between closed, open and inverted positions. Likewise, immobilization of the stud  74  holds the legs  68  in place and therefore holds the distal elements  18  in a desired position. The stud  74  may also be locked in place by a locking feature. 
     In any of the embodiments of fixation device  14  disclosed herein, it may be desirable to provide some mobility or flexibility in distal elements  18  and/or proximal elements  16  in the closed position to enable these elements to move or flex with the opening or closing of the valve leaflets. This provides shock absorption and thereby reduces force on the leaflets and minimizes the possibility for tearing or other trauma to the leaflets. Such mobility or flexibility may be provided by using a flexible, resilient metal or polymer of appropriate thickness to construct the distal elements  18 . Also, the locking mechanism of the fixation device (described below) may be constructed of flexible materials to allow some slight movement of the proximal and distal elements even when locked. Further, the distal elements  18  can be connected to the coupling mechanism  19  or to actuation mechanism  58  by a mechanism that biases the distal element into the closed position (inwardly) but permits the arms to open slightly in response to forces exerted by the leaflets. For example, rather than being pinned at a single point, these components may be pinned through a slot that allowed a small amount of translation of the pin in response to forces against the arms. A spring is used to bias the pinned component toward one end of the slot. 
       FIGS. 4A-4B ,  5 A- 5 B,  6 A- 6 B,  7 A- 7 B illustrate embodiments of the fixation device  14  of  FIG. 3  in various possible positions during introduction and placement of the device  14  within the body to perform a therapeutic procedure.  FIG. 4A  illustrates an embodiment of an interventional tool  10  delivered through a catheter  86 . It may be appreciated that the interventional tool  10  may take the form of a catheter, and likewise, the catheter  86  may take the form of a guide catheter or sheath. However, in this example the terms interventional tool  10  and catheter  86  will be used. The interventional tool  10  comprises a fixation device  14  coupled to a shaft  12  and the fixation device  14  is shown in the closed position.  FIG. 4B  illustrates a similar embodiment of the fixation device of  FIG. 4A  in a larger view. In the closed position, the opposed pair of distal elements  18  are positioned so that the engagement surfaces  50  face each other. Each distal element  18  comprises an elongate arm  53  having a cupped or concave shape so that together the arms  53  surround the shaft  12  and optionally contact each other on opposite sides of the shaft. This provides a low profile for the fixation device  14  which is readily passable through the catheter  86  and through any anatomical structures, such as the mitral valve. In addition,  FIG. 4B  further includes an actuation mechanism  58 . In this embodiment, the actuation mechanism  58  comprises two legs  68  which are each movably coupled to a base  69 . The base  69  is joined with an actuator rod  64  which extends through the shaft  12  and is used to manipulate the fixation device  14 . In some embodiments, the actuator rod  64  attaches directly to the actuation mechanism  58 , particularly the base  69 . However, the actuator rod  64  may alternatively attach to a stud  74  which in turn is attached to the base  69 . In some embodiments, the stud  74  is threaded so that the actuator rod  64  attaches to the stud  74  by a screw-type action. However, the rod  64  and stud  74  may be joined by any mechanism which is releasable to allow the fixation device  14  to be detached from shaft  12 . 
       FIGS. 5A-5B  illustrate the fixation device  14  in the open position. In the open position, the distal elements  18  are rotated so that the engagement surfaces  50  face a first direction. Distal advancement of the stud  74  relative to coupling member  19  by action of the actuator rod  64  applies force to the distal elements  18  which begin to rotate around joints  76  due to freedom of movement in this direction. Such rotation and movement of the distal elements  18  radially outward causes rotation of the legs  68  about joints  80  so that the legs  68  are directly slightly outwards. The stud  74  may be advanced to any desired distance correlating to a desired separation of the distal elements  18 . In the open position, engagement surfaces  50  are disposed at an acute angle relative to shaft  12 , and are preferably at an angle of between 90 and 180 degrees relative to each other. In one embodiment, in the open position the free ends  54  of arms  53  have a span therebetween of about 10-20 mm, usually about 12-18 mm, and preferably about 14-16 mm. 
     Proximal elements  16  are typically biased outwardly toward arms  53 . The proximal elements  16  may be moved inwardly toward the shaft  12  and held against the shaft  12  with the aid of proximal element lines  90  which can be in the form of sutures, wires, nitinol wire, rods, cables, polymeric lines, or other suitable structures. The proximal element lines  90  may be connected with the proximal elements  16  by threading the lines  90  in a variety of ways. When the proximal elements  16  have a loop shape, as shown in  FIG. 5A , the line  90  may pass through the loop and double back. When the proximal elements  16  have an elongate solid shape, as shown in  FIG. 5B , the line  90  may pass through one or more of the openings  63  in the element  16 . Further, a line loop  48  may be present on a proximal element  16 , also illustrated in  FIG. 5B , through which a proximal element line  90  may pass and double back. Such a line loop  48  may be useful to reduce friction on proximal element line  90  or when the proximal elements  16  are solid or devoid of other loops or openings through which the proximal element lines  90  may attach. A proximal element line  90  may attach to the proximal elements  16  by detachable means which would allow a single line  90  to be attached to a proximal element  16  without doubling back and would allow the single line  90  to be detached directly from the proximal element  16  when desired. Examples of such detachable means include hooks, snares, clips or breakable couplings, to name a few. By applying sufficient tension to the proximal element line  90 , the detachable means may be detached from the proximal element  16  such as by breakage of the coupling. Other mechanisms for detachment may also be used. Similarly, a lock line  92  may be attached and detached from a locking mechanism by similar detachable means. 
     In the open position, the fixation device  14  can engage the tissue which is to be approximated or treated. This embodiment is adapted for repair of the mitral valve using an antegrade approach from the left atrium. The interventional tool  10  is advanced through the mitral valve from the left atrium to the left ventricle. The distal elements  18  are oriented to be perpendicular to the line of coaptation and then positioned so that the engagement surfaces  50  contact the ventricular surface of the valve leaflets, thereby grasping the leaflets. The proximal elements  16  remain on the atrial side of the valve leaflets so that the leaflets lie between the proximal and distal elements. In this embodiment, the proximal elements  16  have frictional accessories, such as barbs  60  which are directed toward the distal elements  18 . However, neither the proximal elements  16  nor the barbs  60  contact the leaflets at this time. 
     The interventional tool  10  may be repeatedly manipulated to reposition the fixation device  14  so that the leaflets are properly contacted or grasped at a desired location. Repositioning is achieved with the fixation device in the open position. In some instances, regurgitation may also be checked while the device  14  is in the open position. If regurgitation is not satisfactorily reduced, the device may be repositioned and regurgitation checked again until the desired results are achieved. 
     It may also be desired to invert the fixation device  14  to aid in repositioning or removal of the fixation device  14 .  FIGS. 6A-6B  illustrate the fixation device  14  in the inverted position. 
     By further advancement of stud  74  relative to coupling member  19 , the distal elements  18  are further rotated so that the engagement surfaces  50  face outwardly and free ends  54  point distally, with each arm  53  forming an obtuse angle relative to shaft  12 . The angle between arms  53  is preferably in the range of about 270 to 360 degrees. Further advancement of the stud  74  further rotates the distal elements  18  around joints  76 . This rotation and movement of the distal elements  18  radially outward causes rotation of the legs  68  about joints  80  so that the legs  68  are returned toward their initial position, generally parallel to each other. The stud  74  may be advanced to any desired distance correlating to a desired inversion of the distal elements  18 . Preferably, in the fully inverted position, the span between free ends  54  is no more than about 20 mm, usually less than about 16 mm, and preferably about 12-14 mm. In this illustration, the proximal elements  16  remain positioned against the shaft  12  by exerting tension on the proximal element lines  90 . Thus, a relatively large space may be created between the elements  16 ,  18  for repositioning. In addition, the inverted position allows withdrawal of the fixation device  14  through the valve while minimizing trauma to the leaflets. Engagement surfaces  50  provide an atraumatic surface for deflecting tissue as the fixation device is refracted proximally. It should be further noted that barbs  60  are angled slightly in the distal direction (away from the free ends of the proximal elements  16 ), reducing the risk that the barbs will catch on or lacerate tissue as the fixation device is withdrawn. 
     Once the fixation device  14  has been positioned in a desired location against the valve leaflets, the leaflets may then be captured between the proximal elements  16  and the distal elements  18 .  FIGS. 7A-7B  illustrate the fixation device  14  in such a position. Here, the proximal elements  16  are lowered toward the engagement surfaces  50  so that the leaflets are held therebetween. In  FIG. 7B , the proximal elements  16  are shown to include barbs  60  which may be used to provide atraumatic gripping of the leaflets. Alternatively, larger, more sharply pointed barbs or other penetration structures may be used to pierce the leaflets to more actively assist in holding them in place. This position is similar to the open position of  FIGS. 5A-5B , however the proximal elements  16  are now lowered toward arms  53  by releasing tension on proximal element lines  90  to compress the leaflet tissue therebetween. At any time, the proximal elements  16  may be raised and the distal elements  18  adjusted or inverted to reposition the fixation device  14 , if regurgitation is not sufficiently reduced. 
     After the leaflets have been captured between the proximal and distal elements  16 ,  18  in a desired arrangement, the distal elements  18  may be locked to hold the leaflets in this position or the fixation device  14  may be returned to or toward a closed position. 
     It may be appreciated that the fixation devices  14  of the present invention may have any or all of the above described functions and features. For example, the fixation devices  14  may or may not be moveable to an inverted position. Or, the fixation devices  14  may or may not include proximal elements  16 . Thus, the above described aspects of the fixation devices  14  are simply various embodiments and are not intended to limit the scope of the present invention. 
     2. Variable Width Distal Elements. The width of one or more distal elements  18  of a fixation device  14  may be varied to increase the surface area and therefore increase the area of contact with tissue to be fixated, such as a valve leaflet. In some embodiments, the width is increased once the leaflets have been grasped. In other embodiments, the width is increased prior to grasping of the leaflets. Although it is typically desired to increase the width of the distal elements  18  to increase purchase size and distribute fixation forces, in some instances the variable width distal elements  18  may be used to decrease the width, either prior to leaflet grasping or while the leaflets are grasped. 
       FIGS. 8A-8B  illustrate an embodiment of distal elements  18  having a variable width. In this embodiment, each distal element  18  has one or more loops  100  which are extendable laterally outward in a direction perpendicular to longitudinal axis  66 .  FIG. 8A  illustrates the loops  100  in a retracted position, wherein the distal elements  18  each have a width determined by the size of the distal element  18  itself. In this embodiment, the loops  100  are disposed on a surface of the distal elements  18  opposite the engagement surfaces  50  when in the retracted position. However, it may be appreciated that the loops  100  may be disposed on the engagement surfaces  50  or within the distal elements  18  themselves.  FIG. 8B  illustrates the loops  100  in an expanded position wherein the loops  100  extend laterally outward in a direction perpendicular to longitudinal axis  66 . Expansion may be active or passive. The loops  100  may be comprised of any suitable material including wire, polymer, shape-memory alloy, Nitinol™, suture, or fiber, to name a few. Further, it may be appreciated that any number of loops  100  may be present, the loops  100  may extend any distance and the loops  100  may expand on one side of a distal element and not the other. 
       FIGS. 9A-9B  illustrate another embodiment of a fixation device  14  having distal elements  18  of variable width; here, the fixation device  14  is shown grasping a leaflet LF. In this embodiment, each distal element  18  has one or more flaps  104  which are extendable laterally outward in a direction perpendicular to longitudinal axis  66 .  FIG. 9A  illustrates the flaps  104  in a retracted position wherein the flaps  104  are substantially disposed within the distal elements  18  themselves. It may be appreciated however that the flaps  104  may be folded or curved so that the flaps are substantially disposed on the engagement surfaces  50  or on a surface of the distal elements  18  opposite the engagement surfaces  50 .  FIG. 9B  illustrates the flaps  104  in an expanded position wherein the flaps  104  extend laterally outward in a direction perpendicular to longitudinal axis  66 . Expansion may be active or passive. The flaps  104  may be comprised of any suitable material including polymer, mesh, metal, shape-memory alloy or a combination of these, to name a few. Further, it may be appreciated that any number of flaps  104  may be present, the flaps  104  may extend any distance and the flaps  104  may expand on one side of a distal element and not the other. 
       FIGS. 10A-10B  illustrate yet another embodiment of a fixation device  14  having distal elements  18  of variable width. In this embodiment, each distal element  18  has one or pontoons  108  which are expandable laterally outward in a direction perpendicular to longitudinal axis  66 .  FIG. 10A  provides a perspective view of a fixation device  14  having expandable pontoons  108  wherein the pontoons  108  are in an expanded state.  FIG. 10B  provides a side view of the fixation device  14  of  FIG. 10B . Here, the increase in width of the distal element  18  due to the pontoon  108  may be readily seen. The pontoons  108  may be expanded by any means, such as by inflation with liquid or gas, such as by inflation with saline solution. Such expansion may be active or passive. The pontoons  108  may be comprised of any suitable material such as a flexible polymer or plastic. Further, it may be appreciated that any number of pontoons  108  may be present, the pontoons  108  may extend any distance and a pontoon  108  may expand on one side of a distal element and not the other. 
     3. Splayed Distal Elements. In some embodiments, the fixation device  14  includes additional distal elements  18  that assist in grasping of tissue, such as a valve leaflet. For example, the fixation device  14  may include four distal elements  18  wherein a pair of distal elements  18  grasp each side of the leaflet. The pairs of distal elements  18  may have any arrangement, however in some embodiments the distal elements  18  of each pair rotated laterally outwardly to a splayed position. This increases the area of contact with the tissue to be fixated and distributes the fixation forces across a broader portion of the tissue. Typically, the pairs of distal elements are splayed prior to grasping of the leaflets, however such splaying may be achieved after grasping. 
       FIGS. 11A-11B  provide a perspective view of an embodiment of a fixation device  14  having a first distal element  112 , a second distal element  114 , a third distal element  116  and a fourth distal element  118 . The distal elements  112 ,  114 ,  116 ,  118  are arranged in pairs so that the first and second distal elements  112 ,  114  are connected with one leg  68  and the third and fourth distal elements  116 ,  118  are connected with the other leg  68 ′ allowing the distal elements to grasp in pairs.  FIG. 11A  illustrates the fixation device  14  in a closed position wherein the distal elements  112 ,  114 ,  116 ,  118  are in substantially parallel alignment.  FIG. 11B  illustrates the fixation device  14  in an open position wherein the distal elements  112 ,  114 ,  116 ,  118  are splayed apart. Here, the first and second distal elements  114  are rotated laterally outwardly so that the free ends  54  are moved away from each other. Such splaying may be achieved as a result of opening the fixation device  14  or may be achieved separately from the opening and closing mechanism. In this embodiment, the fixation device  14  includes two proximal elements  16 , each proximal element  16  facing a pair of distal elements. It may be appreciated that any number of proximal elements  16 , if any, may be present, including a corresponding proximal element for each distal element. Finally, the distal elements  112 ,  114 ,  116 ,  118  may be splayed to separate the distal elements by any distance and the distance may be fixed or variable. Further, the distal elements  112 ,  114 ,  116 ,  118  may be returned to the substantially parallel alignment. 
       FIG. 11C  provides a side view of the fixation device  14  of  FIGS. 11A-11B  capturing valve leaflets LF in a coapted position. The fixation device  14  is shown in the splayed position wherein the distal elements  112 ,  114  are rotated laterally outwardly so that the free ends  54  are moved away from each other. It may be appreciated the proximal element  16  is disposed on the opposite side of the leaflet LF and therefore shielded from view. Return of the distal elements  112 ,  114  toward the substantially parallel alignment, as illustrated in  FIG. 11D , may capture tissue between the distal elements  112 ,  114 , plicating the leaflet LF as shown. Such plication may be desired for optimal treatment of the diseased valve. 
       FIGS. 12A-12B  provide a top view of another embodiment of a fixation device  14  having a first distal element  112 , a second distal element  114 , a third distal element  116  and a fourth distal element  118 .  FIG. 12A  illustrates the fixation device  14  in a closed position wherein the distal elements  112 ,  114 ,  116 ,  118  are in substantially parallel alignment.  FIG. 12B  illustrates the fixation device  14  in an open position wherein the distal elements  112 ,  114 ,  116 ,  118  are splayed apart. Here, the first and second distal elements  114  are rotated laterally outwardly so that the free ends  54  are moved away from each other. Again, such splaying may be achieved as a result of opening the fixation device  14  or may be achieved separately from the opening and closing mechanism. And, the distal elements  112 ,  114 ,  116 ,  118  may be splayed to separate the distal elements by any distance and the distance may be fixed or variable. Further, the distal elements  112 ,  114 ,  116 ,  118  may be returned to the substantially parallel alignment. Again, it may be appreciated that return of the distal elements toward the substantially parallel alignment may capture tissue between the distal elements, plicating the leaflet. 
     4. Variable Length Distal Elements. The length of one or more distal elements  18  of a fixation device  14  may be varied to increase the surface area and therefore increase the area of contact with tissue to be fixated, such as a valve leaflet. In some embodiments, the length is increased once the leaflets have been grasped. In other embodiments, the length is increased prior to grasping of the leaflets. Although it is typically desired to increase the length of the distal elements  18  to increase purchase size and distribute fixation forces, in some instances the variable length distal elements  18  may be used to decrease the length, either prior to leaflet grasping or while the leaflets are grasped. 
       FIGS. 13A-13B  illustrate an embodiment of distal elements  18  having a variable length. In this embodiment, each distal element  18  has one or more loops  100  which are extendable outwardly from the free ends  54  along longitudinal axis  66 .  FIG. 13A  illustrates the loops  100  in a refracted position, wherein the distal elements  18  each have a length determined substantially by the length of the distal element  18  itself. In this embodiment, the loops  100  are retracted within the distal elements  18  themselves. However, it may be appreciated that the loops  100  may be disposed on the engagement surfaces  50  or on a surface opposite the engagement surfaces  50 .  FIG. 13B  illustrates the loops  100  in an expanded position wherein the loops  100  extend outwardly along longitudinal axis  66 . Expansion may be active or passive. The loops  100  may be comprised of any suitable material including wire, polymer, shape-memory alloy, Nitinol™, suture, or fiber, to name a few. Further, it may be appreciated that any number of loops  100  may be present and the loops  100  may extend any distance. 
       FIGS. 14A-14B  illustrate another embodiment of a fixation device  14  having distal elements  18  of variable length. In this embodiment, the fixation device  14  includes a coupling member  19  and a pair of opposed distal elements  18 , wherein each distal element  18  is comprised of an elongate arm  53  which is coupled with an extension arm  130 . Each elongate arm  53  has a proximal end  52  rotatably connected to the coupling member  19  and a free end  54 . The extension arm  130  is coupled with the elongate arm  53  near the free end  54  to lengthen the distal element in the direction of a longitudinal axis  66 . Each elongate arm  53  is also coupled with a leg  68 , each leg  68  having a first end  70  which is rotatably joined with one of the distal elements  18  and a second end  72  which is rotatably joined with a base  69 . 
     In this embodiment, the extension arm  130  is coupled with the elongate arm  53  by a cam  132 . The leg  68  is joined with the arm  53  and cam  132  at a first joint  134  and the extension arm  130  is joined with the cam  132  at a second joint  136 . Rotation of the cam  132  in the direction of arrows  138 , advances the extension arm  130  along the longitudinal axis  66 .  FIG. 14B  shows the cams  132  rotated so that the extension arms  130  are extended in the direction of arrows  140 . The cams  132  may rotate due to motion of the fixation device  14  between an open and closed position, or rotation of the cams  132  may occur due to actuation of a mechanism. The extension arms  130  may be comprised of any suitable material, particularly a material similar to that of the elongate arms  53 . Further, it may be appreciated the extension arms  130  may have any length and may extend any distance. 
       FIG. 15  illustrates another embodiment of a fixation device  14  having distal elements  18  of variable length. In this embodiment, each distal element  18  comprises an elongate arm  53  coupled with an extension arm  130 . Each elongate arm  53  has a proximal end  52  rotatably connected to the coupling member  19  and a free end  54 . The extension arm  130  is coupled with the elongate arm  53  near the free end  54  to lengthen the distal element in the direction of a longitudinal axis  66 . Each elongate arm  53  is also coupled with a leg  68 , each leg  68  having a first end  70  which is rotatably joined with one of the distal elements  18  and a second end  72  which is rotatably joined with a base  69 . In this embodiment, each extension arm  130  is disposed within a corresponding elongate arm  53  and may be extended beyond the free end  54  by advancement out of the elongate arm  53 . Likewise, the extension arm  130  may be retracted back into the elongate arm  53 . In some embodiments, the extension arms  130  are extended by action of the fixation device  14  moving toward an open position and are retracted by action of the fixation device  14  moving toward a closed position. Extension and retraction may be active or passive and the extension arms  130  may be extended any distance. 
     5. Differing Length Distal Elements. In some instances, it may be desired to grasp or fix tissue or valve leaflets together with a fixation device  14  wherein the distal elements  18  are of differing length. This may be achieved with a fixation device  14  having variable length distal elements  18 , wherein each distal element  18  is adjusted to a different length. Or, this may be achieved with a fixation device  14  having distal elements  18  of fixed length, wherein each distal element  18  is formed to have a different length. An example of such a fixation device is illustrated in  FIG. 16 . As shown, the fixation device  14  includes two distal elements  18 , each joined with a coupling member  18  and a leg  68  wherein actuation of the legs  68  move the distal elements  18  between at least an open and closed position. In this example, one of the distal elements  18  is shown to be longer than the other. The fixation device  14  may also include proximal elements  14 . Proximal elements  16  may be of the same dimensions or one may be longer than the other to correspond with the distal elements  18  to which they mate. 
     6. Accessories. One or more accessories may be used with the fixation devices  14  of the present invention to increase purchase size and distribute fixation forces. Thus, such accessories may provide benefits similar to increasing the width and/or length of the distal elements. Thus, such accessories may be used with fixation devices of fixed dimension or with fixation devices having distal elements of varying dimension. 
       FIGS. 17A-17B  illustrate an embodiment of an accessory  150 . In this embodiment, the accessory  150  comprises a support  152  which is positioned to support the tissue which is being grasped by the fixation device  14 .  FIG. 17A  illustrates valve leaflets LF being grasped by a fixation device  14 . The fixation device  14  includes a pair of distal elements  18  which are joined with a coupling member  19  and moveable between at least an open and closed position by a pair of legs  68 . In this embodiment, engagement surfaces  50  of the distal elements  18  contact the downstream surfaces of the leaflets LF. In this embodiment, the support  152  has at least two planar sections, each planar section configured to mate with an engagement surface of a distal element  18  when coupled. Typically, the fixation device  14  is released from a delivery catheter, yet maintained by a tether  154 , to determine if regurgitation has been sufficiently reduced. If additional support is desired, the support  152  is advanced down the tether  154 , as depicted in  FIG. 17A , and positioned against the upstream surfaces of the leaflets, as depicted in  FIG. 17B . The support  152  is then attached to the fixation device  14  and the tether  154  removed. 
     7. Combinations. Any of the above described features and accessories may be present in any combination in a fixation device of the present invention. For example, a fixation device  14  may have distal elements  18  that vary in width and in length, either simultaneously or independently. Or, the fixation device may have distal elements  18  that are splayable and vary in length or width or length and width, all of which may occur simultaneously or independently. Or, in another example, the fixation device  14  may have one distal element  18  which is longer than the other wherein one or both distal elements  18  vary in width. Further, mechanisms related to each feature may be present in any combination. For example, a fixation device  14  may have one distal element  18  that varies in width by action of a flap  104  and another distal element  18  that varies in width by action of a pontoon  108 . Still further, a fixation device  14  may include some distal elements  18  which have one or more of the above described features and some distal elements  18  which do not. 
       FIGS. 18A-18B  illustrate an embodiment of a fixation device  14  combining the features presented in  FIGS. 8A-8B  and  FIGS. 13A-13B . In this embodiment, each distal element  18  has one or more loops  100  which are extendable laterally outward in a direction perpendicular to longitudinal axis  66  and extendable outward along longitudinal axis  66 .  FIG. 18A  illustrates the loops  100  in a retracted position, wherein the distal elements  18  each have a width and length substantially determined by the size of the distal element  18  itself. In this embodiment, some of the loops  100  are disposed on a surface of the distal elements  18  opposite the engagement surfaces  50  when in the retracted position. However, it may be appreciated that the loops  100  may be disposed on the engagement surfaces  50  or within the distal elements  18  themselves.  FIG. 18B  illustrates the loops  100  in an expanded position wherein the loops  100  extend laterally outward in a direction perpendicular to longitudinal axis  66  and outward along longitudinal axis  66 . Expansion may be active or passive. The loops  100  may be comprised of any suitable material including wire, polymer, shape-memory alloy, Nitinol™, suture, or fiber, to name a few. Further, it may be appreciated that any number of loops  100  may be present and the loops  100  may extend any distance. 
       FIGS. 19A-19C  illustrate an embodiment of a fixation device  14  combining splaying and variable length distal elements.  FIG. 19A  provides a perspective view of a fixation device  14  having four distal elements  18 . Each distal element  18  is connected with a coupling member  19  and a leg  68 , wherein actuation of the legs  68  move the distal elements  18  between at least an open and closed position.  FIG. 19B  provides a top view of the fixation device  14  of  FIG. 19A  in the open position illustrating the splaying of the distal elements  18 . In this embodiment, the distal elements  18  are fixed in a splayed position. When in the open position, the fixation device  14  can be positioned to grasp tissue, such as a valve leaflet. Transitioning to a closed position retracts the distal elements  18  as illustrated in  FIG. 19C . Similarly, as mentioned above, tissue may be captured or “pinched” between the distal elements  18 . Further, retraction of the distal elements may drag the tissue inwardly. Together, such actions may assist in gathering up the leaflet to tighten the plication while also providing a more secure grasp on the captured tissue. 
       FIGS. 20A-20C  also illustrates an embodiment of a fixation device  14  combining splaying and variable length distal elements.  FIG. 20A  provides a top view of the fixation device  14  having four distal elements  18 . Again, each distal element  18  is connected with a coupling member  19  and a leg  68 , wherein actuation of the legs  68  move the distal elements  18  between at least an open and closed position. In  FIG. 20A , the distal elements  18  are shown in a splayed arrangement. However, in this embodiment, the distal elements  18  are not fixed in the splayed arrangement.  FIG. 20B  illustrates the distal elements  18  rotating to a parallel arrangement. Thus, when in the open position, the distal elements  18  can move between a parallel arrangement and a splayed arrangement prior to grasping tissue. Transitioning to a closed position retracts the distal elements  18  as illustrated in  FIG. 20C . 
     Although the foregoing invention has been described in some detail by way of illustration and example, for purposes of clarity of understanding, it will be obvious that various alternatives, modifications and equivalents may be used and the above description should not be taken as limiting in scope of the invention which is defined by the appended claims.