Patent Publication Number: US-2020276017-A1

Title: Percutaneous delivery systems for anchoring an implant in a cardiac valve annulus

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application claims the benefit under 35 U.S.C. § 119(e) as a nonprovisional application of U.S. Prov. App. No. 62/803,952 filed on Feb. 11, 2019, the disclosure of the aforementioned priority applications is hereby incorporated by reference herein in its entirety. This application is related to U.S. application Ser. No. 15/851,557, filed Dec. 21, 2017, which in turn claims the benefit under 35 U.S.C § 119(e) as a nonprovisional of U.S. Prov. App. No. 62/437,898 filed on Dec. 22, 2016, U.S. Prov. App. No. 62/491,750 filed Apr. 28, 2017, and U.S. Prov. App. No. 62/549,215 filed Aug. 23, 2017. The disclosure of each of the aforementioned priority applications is hereby incorporated by reference herein in their entireties. This application is also related to U.S. application Ser. No. 15/293,111, filed Oct. 13, 2016, which in turn claims the benefit under 35 U.S.C. § 119(e) as a nonprovisional application of U.S. Prov. App. No. 62/241,687 filed on Oct. 14, 2015. This application is also related to U.S. patent application Ser. No. 14/628,114 filed on Feb. 20, 2015, which is in turn a continuation of U.S. patent application Ser. No. 13/650,998 filed Oct. 12, 2012, now issued as U.S. Pat. No. 8,961,597 on Feb. 24, 2015, which is a continuation of U.S. patent application Ser. No. 12/579,330 filed Oct. 14, 2009, now abandoned, which is a continuation-in-part of U.S. patent application Ser. No. 12/104,011 filed Apr. 16, 2008, and issued as U.S. Pat. No. 8,262,725 on Sep. 11, 2012. This application is related to U.S. Prov. App. No. 62/437,898 filed Dec. 22, 2016 and U.S. Prov. App. No. 62/491,750 filed Apr. 28, 2017. The disclosure of each of the aforementioned applications is hereby incorporated by reference herein in their entireties. 
    
    
     BACKGROUND 
     Field of the Invention 
     Embodiments of the present invention relate generally to treatment of mitral or tricuspid valve prolapse and mitral regurgitation, and more specifically, relate to the use of a transvalvular intraannular band to treat mitral valve prolapse and mitral regurgitation. 
     Description of the Related Art 
     The heart is a double (left and right side), self-adjusting muscular pump, the parts of which work in unison to propel blood to all parts of the body. The right side of the heart receives poorly oxygenated (“venous”) blood from the body from the superior vena cava and inferior vena cava and pumps it through the pulmonary artery to the lungs for oxygenation. The left side receives well-oxygenated (“arterial”) blood from the lungs through the pulmonary veins and pumps it into the aorta for distribution to the body. 
     The heart has four chambers, two on each side—the right and left atria, and the right and left ventricles. The atria are the blood-receiving chambers, which pump blood into the ventricles. A wall composed of membranous and muscular parts, called the interatrial septum, separates the right and left atria. The ventricles are the blood-discharging chambers. A wall composed of membranous and muscular parts, called the interventricular septum, separates the right and left ventricles. 
     The synchronous pumping actions of the left and right sides of the heart constitute the cardiac cycle. The cycle begins with a period of ventricular relaxation, called ventricular diastole. The cycle ends with a period of ventricular contraction, called ventricular systole. 
     The heart has four valves that ensure that blood does not flow in the wrong direction during the cardiac cycle; that is, to ensure that the blood does not back flow from the ventricles into the corresponding atria, or back flow from the arteries into the corresponding ventricles. The valve between the left atrium and the left ventricle is the mitral valve. The valve between the right atrium and the right ventricle is the tricuspid valve. The pulmonary valve is at the opening of the pulmonary artery. The aortic valve is at the opening of the aorta. 
     Various disease processes can impair the proper functioning of one or more of these valves. These include degenerative processes (e.g., Barlow&#39;s Disease, fibroelastic deficiency), inflammatory processes (e.g., Rheumatic Heart Disease) and infectious processes (e.g., endocarditis). In addition, damage to the ventricle from prior heart attacks (i.e., myocardial infarction secondary to coronary artery disease) or other heart diseases (e.g., cardiomyopathy) can distort the valve&#39;s geometry causing it to dysfunction. 
     The mitral valve is comprised of an anterior leaflet and a posterior leaflet. The bases of the leaflets are fixed to a circumferential partly fibrous structure, the annulus, preventing dehiscence of the valve. A subvalvular apparatus of chordae and papillary muscles prevents the valve from prolapsing into the left atrium. Mitral valve disease can be expressed as a complex variety of pathological lesions of either valve or subvalvular structures, but can also be related to the functional status of the valve. Functionally the mitral valve disease can be categorized into two anomalies, increased leaflet motion i.e. leaflet prolapse leading to regurgitation, or diminished leaflet motion i.e. restricted leaflet motion leading to obstruction and/or regurgitation of blood flow. 
     Leaflet prolapse is defined as when a portion of the leaflet overrides the plane of the orifice during ventricular contraction. The mitral regurgitation can also develop secondary to alteration in the annular ventricular apparatus and altered ventricular geometry, followed by incomplete leaflet coaptation. In ischemic heart failure this can be attributed to papillary or lateral wall muscle dysfunction, and in non-ischemic heart failure it can be ascribed to annular dilation and chordal tethering, all as a result of dysfunctional remodeling. 
     The predominant cause of dysfunction of the mitral valve is regurgitation which produces an ineffective cardiac pump function resulting in several deleterious conditions such as ventricular and atrial enlargement, pulmonary hypertension and heart-failure and ultimately death. 
     The main objective for the surgical correction is to restore normal function and not necessarily anatomical correction. This is accomplished by replacing the valve or by reconstructing the valve. Both of the procedures require the use of cardiopulmonary bypass and is a major surgical operation carrying a non-negligible early morbidity and mortality risk, and a postoperative rehabilitation for months with substantial postoperative pain. Historically, the surgical approach to patients with functional mitral regurgitation was mitral valve replacement, however with certain adverse consequences such as thromboembolic complications, the need for anticoagulation, insufficient durability of the valve, loss of ventricular function and geometry. 
     Reconstruction of the mitral valve is therefore the preferred treatment for the correction of mitral valve regurgitation and typically consists of a quadrangular resection of the posterior valve (valvuloplasty) in combination with a reduction of the mitral valve annulus (annuloplasty) by the means of suturing a ring onto the annulus. These procedures are surgically demanding and require a bloodless and well-exposed operating field for an optimal surgical result. The technique has virtually not been changed for more than three decades. 
     More recently, prolapse of the valve has been repaired by anchoring the free edge of the prolapsing leaflet to the corresponding free edge of the opposing leaflet and thereby restoring apposition but not necessarily coaptation. In this procedure a ring annuloplasty is also required to attain complete coaptation. 
     This method commonly referred to as an edge-to-edge or “Alfieri” repair also has certain drawbacks such as the creation of a double orifice valve and thereby reducing the effective orifice area. Several less invasive approaches related to the edge-to-edge technique has been suggested, for repairing mitral valve regurgitation by placing a clip through a catheter to suture the valve edges. However, it still remains to conduct an annuloplasty procedure, which has not yet been resolved by a catheter technique and therefore is to be performed by conventional surgery, which makes the method impractical. 
     Notwithstanding the presence of a variety of presently available surgical techniques and promising catheter based procedures for the future, there remains a need for a simple but effective device and corresponding surgical, minimally invasive or transvascular procedure to reduce mitral valve regurgitation. 
     SUMMARY OF THE INVENTION 
     In some embodiments, disclosed herein are methods of delivering a transvalvular intraannular implant. Also disclosed herein are transvalvular intraannular delivery systems. In some embodiments, disclosed herein are systems for delivering and anchoring an implant to a valve annulus. Also disclosed herein are methods for delivering and anchoring an implant to a valve annulus of a valve. 
     Further features and advantages of the present invention will become apparent to those of skill in the art in view of the detailed description of preferred embodiments which follows, when considered together with the attached drawings and claims. 
     Some embodiments of this invention are directed to a transvalvular intraannular band to treat mitral valve prolapse and mitral regurgitation. The terminology “transvalvular” as used herein encompasses “across”, “over”, or “through” the valve surfaces by any means, and “intraannular” provides an axial spatial reference to within the native valve annulus or an annular band that serves to function within the valve annulus. Axial with respect to the valve axis means along the axis of the valve and can describe position relative to the atrium, “supra”, or relative to the ventricle, “infra”. Specifically, it creates an axis through which a plane is pierced by the aforementioned axis, and encompasses an embodiment that is intraannular to address coaptation at the valvular plane or series of valvular planes created during each cardiac cycle, but does not obviate other salient features of the invention that may be clearly infraannular or supraannular during the cardiac cycle. Further, the terminology in the following descriptions may use “transannular band” or “band” and it means to include all features that may be infraannular, intraannular, or suprannular without or with stating each axially descriptive term. As well “offset” refers to directionally displaced from a frame of reference. 
     In some embodiments, disclosed herein is a method of delivering a transvalvular intraannular implant. The method includes the steps of providing a delivery catheter, the delivery catheter comprising an elongate body; a movable outer sheath; and a transvalvular intraannular implant having a longitudinal axis and comprising a valve leaflet support portion and an anchoring portion, the valve leaflet support portion at least partially longitudinally offset from the anchoring portion; percutaneously delivering the delivery catheter to the vicinity of a heart valve annulus; transforming the implant from a first radially reduced configuration to a second radially enlarged configuration; and positioning the implant in its second radially enlarged configuration within the heart valve annulus such that the implant is oriented in the valve annulus such that the longitudinal axis of the implant is oriented substantially transversely to a coaptive edge of a heart valve positioned within the valve annulus. The heart valve annulus can be, for example, a mitral, aortic, tricuspid, or pulmonary valve annulus. In some embodiments, transforming the implant from the first radially reduced configuration to the second radially enlarged configuration comprises retracting or pushing forward the movable outer sheath of the delivery catheter, exposing the implant. The delivery catheter can further include a self-expandable support structure, such as a ring or stent for example, operably connected to the transvalvular implant. Percutaneously delivering the delivery catheter to the vicinity of the valve annulus can include one or more of approaching the valve annulus from a supraannular location, infraannular location, cardiac septum, such as the intra-atrial or intra-ventricular septum, a vascular cut-down, or a thoracoscopic procedure. The anchoring portion of the implant can be secured to tissue of the valve annulus, such as passing a tissue anchor through the anchoring portion of the implant and tissue of the valve annulus. In some embodiments, providing a delivery catheter includes providing a control wire operably attached to the implant, and positioning the implant includes applying tension to the control wire to move the implant. The control wire can be detached from the implant after being properly positioned, in some embodiments. 
     Also disclosed herein is a transvalvular intraannular delivery system. The system includes a percutaneous delivery catheter comprising an elongate body; a movable outer sheath; and a transvalvular intraannular implant having a longitudinal axis and comprising a valve leaflet support portion and an anchoring portion, the valve leaflet support portion at least partially longitudinally offset from the anchoring portion, wherein the transvalvular implant is configured to be transformable from a first radially reduced configuration to a second radially enlarged configuration; wherein the transvalvular implant is configured to be housed within the percutaneous delivery catheter in its first radially reduced configuration, wherein the transvalvular implant is configured to be positioned in its second radially enlarged configuration within a heart valve annulus such that the implant is oriented in the valve annulus such that the longitudinal axis of the implant is oriented substantially transversely to a coaptive edge of a heart valve positioned within the valve annulus. The system can also include a control wire operably attached to the implant for positioning the implant within the heart valve annulus. In some embodiments, the system also includes at least one tissue anchor for attaching the implant to tissue of the valve annulus. In some embodiments, the system also includes a self-expandable support structure operably connected to the transvalvular implant, for securing the implant to tissue of the valve annulus. Also disclosed herein is a transvalvular intraannular band that can include an elongate body having a first end, a first anchoring portion located proximate the first end, a second end, a second anchoring portion located proximate the second end, and a central portion connected to the first end and the second end. In some embodiments, the central portion has a convex arcuate shape and can include a plurality of crossing struts encapsulated by a thermoplastic material, the crossing struts intersecting at an intersection zone, the central portion displaced transversely from the intraannular plane which includes the mitral valve annulus and is transverse to the direction of blood flow when the band is attached to the annulus. The central portion can extend generally along a second plane which is perpendicular to the intraannular plane, the second plane including the first end and the second end; wherein the first end and the second end are configured to be attached to the mitral valve annulus within the intraannular plane and the central portion is configured to be convex in the direction of the ventricle to support the mitral valve leaflets at a point displaced toward the ventricle from the intraannular plane. The first end and the second end can reside on a generally septal-lateral axis transverse to the coaptive edges of the mitral valve leaflets when the band is attached to the mitral valve annulus. In some embodiments, the band does, or does not, comprise an annuloplasty ring, stent-valve, or replacement valve leaflets. 
     In some embodiments, disclosed herein is a system for delivering and anchoring an implant to a valve annulus. The system can include an anchor catheter configured to deliver a subannular anchor to a valve annulus of a heart of a patient. The anchor catheter can include a portion configured to create a hole in the valve annulus through which the anchor catheter delivers the subannular anchor. In some embodiments, the subannular anchor comprises a first configuration in which the subannular anchor has a low profile to be delivered through the hole and a second configuration in which the subannular anchor is expanded. In some embodiments, the subannular anchor comprises a suture. The system can include a transvalvular band configured to be delivered by sliding the transvalvular band along the suture toward the valve annulus. In some embodiments, the transvalvular band includes a first anchoring portion and wherein the suture is configured to extend through the first anchoring portion. 
     In some embodiments, the system can include a locking clip configured to be delivered by sliding the locking clip along the suture toward the valve annulus. In some embodiments, the anchor catheter is configured to deliver a plurality of subannular anchors. In some embodiments, the anchor catheter is configured to deliver four subannular anchors. In some embodiments, the anchor catheter is configured to deliver two subannular anchors on each leaflet. In some embodiments, the subannular anchor has a star configuration in which a plurality of prongs fold outward. In some embodiments, the subannular anchor compresses with tension, wherein the anchor catheter applies tension to compress the subannular anchor in the first configuration. In some embodiments, the transvalvular band comprises the first anchoring portion and a second anchoring portion, and a central portion therebetween. In some embodiments, the central portion comprises a convex arcuate shape and comprises a plurality of crossing struts encapsulated by a material. In some embodiments, the transvalvular band comprises the first anchoring portion and a second anchoring portion, and a central portion therebetween, wherein each anchoring portion is configured to accept sutures connected to subannular anchors therethrough. In some embodiments, the system can include a trimming catheter, wherein the trimming catheter is configured to slide along the suture after the transvalvular band is delivered and trims the excess suture. In some embodiments, the system can include a catheter configured to allow transseptal access. In some embodiments, at least one catheter is steerable. In some embodiments, the system can include a means for suture management. In some embodiments, the anchor catheter further comprises a lumen for each suture. In some embodiments, the anchor catheter comprises four lumens, each lumen configured to receive a suture connected to a subannular anchor. In some embodiments, the anchor catheter comprises a sleeve for each suture. In some embodiments, the system can include four sleeves, each sleeve configured to receive a suture connected to a subannular anchor. In some embodiments, the anchor catheter is configured to apply energy to create the hole. 
     Also disclosed herein is a method for delivering and anchoring an implant to a valve annulus of a valve. The method can include percutaneously creating a hole in the valve annulus to deliver a subannular anchor. The method can include delivering a subannular anchor through the hole in the valve annulus in a low profile configuration and expanding the subannular anchor on the ventricular side of the annulus. In some embodiments, the subannular anchor comprises a suture extending to the upstream side of the annulus relative to a direction of blood flow. The method can include delivering a transvalvular band to the valve annulus by sliding the transvalvular band along the suture toward the valve annulus. 
     In some embodiments, the method can include delivering a locking clip by sliding the locking clip along the suture toward the valve annulus. In some embodiments, the locking clip slides freely along the suture in a first direction, but resists movement in a second direction, opposite the first direction. In some embodiments, the method can include delivering a plurality of subannular anchors. In some embodiments, the method can include delivering four subannular anchors. In some embodiments, the method can include delivering two subannular anchors on the posterior annulus and two subannular anchors on the anterior annulus. In some embodiments, the subannular anchor is reversible. In some embodiments, the method can include applying tension to compress the subannular anchor. In some embodiments, creating the hole in the valve annulus comprises applying energy to the valve annulus. In some embodiments, creating the hole in the valve annulus comprises mechanically puncturing the valve annulus. In some embodiments, the valve is a mitral valve. In some embodiments, the method can include creating a second hole in the valve annulus to deliver a second subannular anchor, and delivering the second subannular anchor through the second hole in the valve annulus, wherein the first hole and the second hole are spaced apart. 
     In some embodiments, disclosed herein is a method of using a subannular anchor to percutaneously anchor an implant in a valve annulus. The method can include providing a subannular anchor. In some embodiments, the subannular anchor comprises a first configuration in which the subannular anchor has a low profile and a second configuration in which the subannular anchor is expanded. In some embodiments, the subannular anchor comprises a suture. The method can include threading the suture of the subannular anchor through an anchoring portion of a transvalvular band. 
     In some embodiments, the method can include providing an anchor catheter configured to deliver the subannular anchor. In some embodiments, the anchor catheter is configured to apply energy to tissue. In some embodiments, the method can include providing a delivery catheter configured to deliver the transvalvular band to the valve annulus. In some embodiments, the method can include threading the suture through the delivery catheter after threading the suture through the anchoring portion of the transvalvular band. In some embodiments, the method can include compressing the transvalvular band after threading the suture through the anchoring portion of the transvalvular band. In some embodiments, the method can include threading the suture of the subannular anchor through a locking clip. In some embodiments, the method can include threading the suture through the delivery catheter after threading the suture the locking clip. In some embodiments, the method can include threading the suture through a locking clip after threading the suture through the anchoring portion of the transvalvular band. In some embodiments, the method can include providing a trimming catheter configured to trim the suture. 
     In some embodiments, disclosed herein is a method for treating mitral valve regurgitation. The method can include percutaneously delivering a first subannular anchor coupled to a first suture, wherein the first suture extends through the annulus. The method can include percutaneously delivering a second subannular anchor coupled to a second suture, wherein the second suture extends through the annulus. The method can include cinching the first suture and the second suture with a transvalvular implant. 
     In some embodiments, cinching comprises cinching the posterior annulus toward the anterior annulus. In some embodiments, cinching facilitates proper leaflet coaptation. In some embodiments, the first suture extends in a straight path through a pilot hole in the posterior annulus. In some embodiments, the second suture extends in a straight path through a pilot hole in the anterior annulus. In some embodiments, the method can include delivering a third subannular anchor coupled to a third suture, wherein the third suture extends through the annulus. In some embodiments, the method can include delivering a fourth subannular anchor coupled to a fourth suture, wherein the fourth suture extends through the annulus. In some embodiments, the first suture and the third suture are coupled to a first end of the transvalvular implant and the second suture and the fourth suture are coupled to a second end of the transvalvular implant. In some embodiments, the first suture and the third suture are coupled to the posterior annulus and the second suture and the fourth suture are coupled to the anterior annulus. In some embodiments, the method can include ablating tissue to create a pilot hole to deliver the first anchor subannularly. In some embodiments, the method can include sequentially delivering the first subannular anchor and the second subannular anchor. 
     In some embodiments, disclosed herein is a system for delivering and anchoring an implant to a valve annulus. The system can include an anchor catheter configured to deliver a subannular anchor to a valve annulus of a heart of a patient. In some embodiments, the anchor catheter can include a portion configured to create a hole in the valve annulus through which the anchor catheter delivers the subannular anchor. In some embodiments, the subannular anchor comprises a first configuration in which the subannular anchor has a low profile to be delivered through the hole and a second configuration in which the subannular anchor is expanded. In some embodiments, the subannular anchor comprises a suture. The system can include a transvalvular implant configured to be delivered by sliding the transvalvular implant along the suture toward the valve annulus. In some embodiments, the transvalvular implant includes a first anchoring portion. In some embodiments, the suture is configured to extend through the first anchoring portion. 
     In some embodiments, the system can include a locking clip configured to be delivered by sliding the locking clip along the suture toward the valve annulus. In some embodiments, the anchor catheter is configured to deliver a plurality of subannular anchors. In some embodiments, the anchor catheter is configured to deliver four subannular anchors. In some embodiments, the anchor catheter is configured to deliver two subannular anchors on each leaflet. In some embodiments, the subannular anchor has a star configuration in which a plurality of prongs fold outward. In some embodiments, the subannular anchor compresses with tension, wherein the anchor catheter applies tension to compress the subannular anchor in the first configuration. In some embodiments, the transvalvular implant comprises the first anchoring portion and a second anchoring portion, and a central portion therebetween, wherein the central portion comprises a convex arcuate shape and comprises a plurality of crossing struts encapsulated by a material. In some embodiments, the transvalvular implant comprises the first anchoring portion and a second anchoring portion, and a central portion therebetween, wherein each anchoring portion is configured to accept sutures connected to subannular anchors therethrough. In some embodiments, the system can include a trimming catheter, wherein the trimming catheter is configured to slide along the suture after the transvalvular implant is delivered and trims the excess suture. In some embodiments, the system can include a catheter configured to allow transseptal access. In some embodiments, at least one catheter is steerable. In some embodiments, the system can include a means for suture management. In some embodiments, the system can include a lumen for each suture. In some embodiments, the system can include four lumens, each lumen configured to receive a suture connected to a subannular anchor. In some embodiments, the system can include a sleeve for each suture. In some embodiments, the system can include four sleeves, each sleeve configured to receive a suture connected to a subannular anchor. In some embodiments, the anchor catheter is configured to apply energy to create the hole. In some embodiments, disclosed herein is a system for delivering and anchoring an implant to a valve annulus. The system can include a template catheter configured to deliver a subannular anchor to a valve annulus of a heart of a patient. In some embodiments, the template catheter includes a pathway through which a needle delivers the subannular anchor. The system can include an implant configured to be delivered to the valve annulus. In some embodiments, the implant includes a first anchoring portion aligned with the pathway. 
     In some embodiments, the subannular anchor comprises a first configuration in which the subannular anchor is compressed to be delivered through the first anchoring portion and a second configuration in which the subannular anchor is expanded. In some embodiments, the subannular anchor comprises a suture. In some embodiments, the system can include a clip configured to slide along the suture. In some embodiments, the template catheter is configured to deliver a plurality of subannular anchors. In some embodiments, the template catheter is configured to deliver four subannular anchors. In some embodiments, the template catheter comprises four separate pathways. In some embodiments, the template catheter comprises a guide tube forming the pathway. In some embodiments, the template catheter is removably coupled to the transvalvular band by a suture. In some embodiments, the template catheter is coupled to the transvalvular band by a slip knot. In some embodiments, template catheter comprises a template, wherein the template is asymmetric. 
     In some embodiments, disclosed herein is a method for delivering and anchoring an implant to a valve annulus of a valve. The method can include delivering the implant to the valve annulus, the implant removably coupled to a template catheter comprising a pathway. The method can include delivering a needle along the pathway and through the implant to a subannular space. The method can include deploying an anchor to the subannular space. 
     In some embodiments, the method can include deploying the anchor comprises deploying the anchor on a posterior side of the valve annulus. In some embodiments, the method can include deploying a second anchor on an anterior side of the valve annulus. In some embodiments, the method can include securing the subannular anchor with a clip. 
     In some embodiments, disclosed herein is an anchor. The anchor can include a first configuration in which the anchor is compressed to be delivered and a second configuration in which the anchor is expanded. 
     In some embodiments, the anchor comprises a star configuration in which a plurality of prongs fold outward. In some embodiments, the anchor comprises a plurality of longitudinal slots. In some embodiments, the anchor comprises one or more integral tabs. In some embodiments, the anchor comprises one or more rounded slots. In some embodiments, the anchor comprises one or more arrow shaped slots. In some embodiments, the anchor comprises one or more pointed slots. In some embodiments, the anchor comprises one or more curved slots. In some embodiments, the anchor comprises one or more flanges. In some embodiments, the anchor comprises one or more springs. In some embodiments, the anchor comprises two expandable portions. In some embodiments, the anchor comprises two expandable portions separated by a spring. In some embodiments, the anchor comprises a balloon. In some embodiments, the anchor comprises a balloon configured to be filled with a wire. In some embodiments, the anchor comprises a collapsible tube. In some embodiments, the anchor comprises a flexible structure. In some embodiments, the anchor comprises a clip configured to compress the anchor. In some embodiments, the anchor comprises a nitinol braid. In some embodiments, the anchor comprises a compressible sponge. In some embodiments, the anchor comprises a balloon with a permeable membrane. In some embodiments, the anchor comprises a balloon comprising an absorbable material. In some embodiments, the anchor comprises an absorbable sugar, protein, or salt. In some embodiments, the anchor comprises one or more flanges. In some embodiments, the anchor comprises one or more springs configured to be positioned within the annulus. In some embodiments, the anchor comprises one or more springs configured to be positioned above the annulus. In some embodiments, the anchor comprises a cinching suture. In some embodiments, the anchor comprises one or more springs configured to secure an implant. In some embodiments, the anchor comprises a laser cut tube. In some embodiments, the anchor comprises an elastic material. 
     In some embodiments, disclosed herein is a clip. The clip can include a first configuration in which the clip slides along a suture and a second configuration in which the clip remains fixed relative to the suture. 
     In some embodiments, the clip comprises a nitinol sheet. In some embodiments, the suture passes through a tube positioned through the clip in the first configuration, wherein the tube is removed in the second configuration. In some embodiments, the clip is configured to be positioned within an aperture of an implant. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a simplified cross-sectional view of the heart with a normal mitral valve during systole. The intraannular plane is illustrated relative to supraannular and infrannular. 
         FIG. 2  is a cross-sectional view of the heart with a normal mitral valve during diastole. The axis of the mitral valve is illustrated, and shown piercing the intraannular plane. 
         FIG. 3  is a bottom view of the normal mitral valve of  FIG. 1  during systole looking from the left atrium to the left ventricle. 
         FIG. 4  is a bottom view of the normal mitral valve of  FIG. 2  during diastole looking from the left atrium to the left ventricle. 
         FIG. 5  is a cross-sectional schematic view of the normal mitral valve of  FIG. 1  during systole, illustrating the depth of the coaption zone. 
         FIG. 6  is a cross-sectional schematic view of the normal mitral valve of  FIG. 2  during diastole. 
         FIG. 7  is a cross-sectional view of the heart during systole showing a mitral valve with a prolapsed anterior leaflet caused by the rupture of the chordae tendineae attached to the anterior leaflet. 
         FIG. 8  is a bottom view of the mitral valve of  FIG. 7  having a prolapsed anterior leaflet looking from the left atrium to the left ventricle. 
         FIG. 9  is a cross-sectional view of the heart during systole showing a mitral valve with a prolapsed posterior leaflet caused by the rupture of the chordae tendineae attached to the posterior leaflet. 
         FIG. 10  is a bottom view of the mitral valve of  FIG. 9  having a prolapsed posterior leaflet looking from the left atrium to the left ventricle. 
         FIG. 11  is a cross-sectional view of the heart during systole showing a mitral valve with anterior leaflet prolapse. 
         FIG. 11A  is a cross sectional view as in  FIG. 11 , showing posterior leaflet prolapse. 
         FIG. 11B  is a cross sectional view as in  FIG. 11 , showing bileaflet prolapse with mitral regurgitation. 
         FIG. 11C  illustrates a dilated mitral annulus with little or no coaption of both leaflets causing central mitral regurgitation in ischemic cardiomyopathy. 
         FIG. 12  is a top view of an embodiment of a transvalvular band. 
         FIG. 13  is a side view of the transvalvular band of  FIG. 12 . 
         FIG. 14  is a cross-sectional view of a transvalvular band with a triangular cross-section. 
         FIG. 15  is a cross-sectional view of a transvalvular band with an oblong cross-section. 
         FIG. 16  is a cross-sectional view of a transvalvular band with a circular cross-section. 
         FIG. 17  is a cross-sectional view of a transvalvular band with a rectangular cross-section. 
         FIG. 18  is a top view of another embodiment of a transvalvular band. 
         FIGS. 19A  and B show a perspective view of yet another embodiment of a transvalvular band, with a widened coaptive edge support portion. 
         FIGS. 20-23  are top views of other embodiments of a transvalvular band. 
         FIG. 23A  shows a central mitral transvalvular band with posterior annuloplasty ring. 
         FIG. 23B  shows an intraannular band formed from a length of wire. 
         FIGS. 24-27  are side views of other embodiments of a transvalvular band. 
         FIG. 28  is a cross-sectional view of a heart during systole with a transvalvular band implanted in the mitral annulus. 
         FIG. 29  is a bottom view of the mitral valve of  FIG. 28  during systole with a transvalvular band implanted in the mitral annulus looking from the left atrium to the left ventricle. 
         FIG. 30  is a cross-sectional view of a heart during diastole with mitral valve and a transvalvular band implanted in the mitral annulus. 
         FIG. 31  is a bottom view of the mitral valve of  FIG. 30  during diastole with a transvalvular band implanted in the mitral annulus looking from the left atrium to the left ventricle. 
         FIG. 32  is a cross-sectional schematic view of the mitral valve of  FIG. 28  during systole with a transvalvular band implanted in the mitral annulus. 
         FIG. 33  is a cross-sectional schematic view of the mitral valve of  FIG. 32  during systole without the transvalvular band implanted in the mitral annulus. 
         FIG. 34  is a cross-sectional schematic view of the mitral valve of  FIG. 30  during diastole with the transvalvular band implanted in the mitral annulus. 
         FIG. 35  is a cross-sectional schematic view of the mitral valve of  FIG. 34  during diastole without the transvalvular band implanted in the mitral annulus. 
         FIG. 36  is a bottom view of the mitral valve during systole with another embodiment of the transvalvular band implanted in the mitral annulus looking from the left atrium to the left ventricle. 
         FIG. 37  is a cross-sectional view of a transvalvular band with a transverse leaflet support. 
         FIG. 38  is a cross-sectional schematic view of the mitral valve treated with the transvalvular band of  FIG. 37  and an Alfieri type procedure. 
         FIG. 39  is a schematic cross-sectional view of the heart, showing a typical antegrade approach to the mitral valve by way of a transseptal crossing. 
         FIG. 40  is a cross sectional view as in  FIG. 39 , showing placement of a guidewire through the mitral valve. 
         FIG. 41  is a cross sectional view of the heart showing a typical retrograde approach to the mitral valve by way of a femoral artery access. 
         FIG. 42  shows a retrograde approach as in  FIG. 41 , with a guidewire placed across the mitral valve. 
         FIG. 43A  is a schematic view of the distal end of a percutaneous deployment catheter having a self-expandable implant positioned therein. 
         FIG. 43B  is a schematic view as in  FIG. 43A , with the implant partially deployed from the catheter. 
         FIG. 43C  is a schematic view of the deployment catheter showing the implant fully expanded at the deployment site, but still tethered to the deployment catheter. 
         FIG. 43D  is a side elevational view of the implant of  FIG. 43C . 
         FIG. 43E  is an end view taken along the line  43 E- 43 E of  FIG. 43D . 
         FIG. 44A  is a side elevational perspective view of an anchor deployment catheter in accordance with the present invention. 
         FIG. 44B  is a cross sectional view taken along the line  44 B- 44 B of  FIG. 44A . 
         FIG. 44C  is a cross sectional side view of the anchor deployment catheter of  FIG. 44A . 
         FIG. 45A  is a schematic plan view of a self-expandable transvalvular band in accordance with the present invention. 
         FIG. 45B  is a side elevational view of the transvalvular band of  FIG. 45A  shown in a reduced crossing profile (folded) configuration, and attached to three control wires. 
         FIG. 46A  is a cut-away perspective view of the distal end of a deployment catheter having a self-expandable implant contained therein. 
         FIG. 46B  is a deployment catheter as in  FIG. 46A , with the implant partially deployed. 
         FIG. 46C  is a view as in  FIG. 46B , showing the implant released from the deployment catheter, but connected to three control wires. 
         FIG. 46D  is a view as in  FIG. 46C  with a tissue anchor deployment catheter. 
         FIG. 46E  is a cross sectional view of a mitral valve, having an implant anchored in place and the deployment catheter removed. 
         FIG. 47A  is a side elevational view of the distal end of a deployment catheter, having an implant partially deployed therefrom. 
         FIG. 47B  is a schematic view of the catheter and implant of  FIG. 47A , during implantation at the mitral valve. 
         FIG. 47C  is a schematic view as in  FIG. 47B , with the tissue anchor deployment guides removed. 
         FIG. 47D  is a schematic view as in  FIG. 47C , with the implant configured to move coaption earlier in the cardiac cycle. 
         FIG. 47E  is a schematic view of the implant of  FIG. 47D , with the deployment catheter removed. 
         FIG. 48A  is schematic cross sectional view of a transapical deployment device positioned across the mitral valve. 
         FIG. 48B  is a schematic view of the device of  FIG. 48A , with tissue anchors engaged at the mitral valve annulus. 
         FIG. 48C  is a schematic view as in  FIG. 48B , with the deployment catheter withdrawn through the mitral valve. 
         FIG. 48D  is a schematic view as in  FIG. 48C , in an embodiment having a transventricular support. 
         FIGS. 49A through 49G  illustrate an implantation sequence for a transvalvular band at the mitral valve, via a transapical access. 
         FIG. 49H  shows an alternate end point, in which the transvalvular band is additionally provided with a transventricular truss and an epicardial anchor. 
         FIG. 50A  is a side elevational schematic view of the distal end of a deployment catheter, having a rolled up transvalvular band therein. 
         FIG. 50B  is an illustration as in  FIG. 50A , following distal deployment of the transvalvular band. 
         FIGS. 51A and 51B  illustrate top plan views and side views of a transvalvular band in accordance with the present invention. 
         FIG. 51C  illustrates a perspective view of one embodiment of a transvalvular band in a rolled-up configuration and mounted on a delivery mandrel. 
         FIG. 51D  illustrates a view of at least a non-linear portion of a strut of  FIG. 51B . 
         FIGS. 52A through 52C  illustrate a transvalvular band, with a “t-tag” deployment system and suture tensioning feature. 
         FIG. 52D  illustrates an embodiment of a plurality of tissue anchors looped together on a suture. 
         FIG. 53  is a side elevational perspective view of a transvalvular band in accordance with the present invention. 
         FIG. 54  is a schematic illustration of various suture lock configurations for use on transvalvular bands of the present invention. 
         FIG. 55  is a side elevational perspective view of a transvalvular band, having barbed tissue anchors thereon. 
         FIG. 56  is a side elevational perspective view of a transvalvular band in accordance with the present invention, having arcuate tissue anchors thereon. 
         FIGS. 56A-B  are graphs illustrating data regarding chordal physiologic force experiments.  FIGS. 57A-D  illustrate another embodiment of a transvalvular band. 
         FIGS. 57E-H  illustrate views of the underlying skeleton layer of the transvalvular band, according to some embodiments. 
         FIG. 58  is a simplified cross-sectional view of the heart. 
         FIGS. 59A-59C  are views of a catheter system, according to some embodiments. 
         FIG. 60  illustrates examples of access locations. 
         FIGS. 61A-61G  illustrates various features of the catheter system, according to some embodiments. 
         FIG. 62  is a side perspective view of an embodiment of a needle catheter. 
         FIG. 63A  is a side perspective view of an embodiment of a needle and an energy tip.  FIG. 63B  is a front perspective view of the needle and the energy tip of  FIG. 63A . 
         FIG. 63C  are various views of an alternative embodiment of a needle and an energy tip. 
         FIGS. 64A-64E  are various perspective views of the delivery of a retainer, according to some embodiments. 
         FIGS. 65A-65H  are various perspective views of the delivery of a transvalvular bridge, according to some embodiments. 
         FIG. 66A  is a front perspective view of a clip.  FIG. 66B  is a front perspective view of the clip of  FIG. 66A  and a suture, according to some embodiments. 
         FIG. 67A  is a side perspective view of a handle, according to some embodiments.  FIG. 67B  is a cross-sectional perspective view of the handle of  FIG. 67A . 
         FIGS. 68A-68B  are side perspective views of a steerable catheter, according to some embodiments.  FIGS. 68C-68D  are side perspective views of a steerable needle catheter.  FIG. 68E  is a perspective view of a needle catheter. 
         FIG. 69A-69B  are perspective views of a handle, according to some embodiments. 
         FIG. 70  is a simplified view of various access locations, according to some embodiments. 
         FIGS. 71-73  are simplified views of the heart and the location of the transvalvular band, according to some embodiments. 
         FIGS. 74-76  are views of the transvalvular band, according to some embodiments. 
         FIGS. 77-83  are views of an open procedure method, according to some embodiments. 
         FIGS. 84-86  are views of a minimally invasive surgery method, according to some embodiments. 
         FIGS. 87-91  are views of a transcatheter system, according to some embodiments. 
         FIGS. 92-93  are views of subannular anchoring, according to some embodiments. 
         FIGS. 94-96  are views of transcatheter surgery, according to some embodiments. 
         FIGS. 97A-97E  are views of a transcatheter system, according to some embodiments. 
         FIG. 98  is a view of the percutaneous insertion of the transcatheter system of  FIGS. 97A-97E . 
         FIGS. 99A-100B  are views of subannular anchoring and anchor placement, according to some embodiments. 
         FIG. 101  is a view of preliminary cinching, according to some embodiments. 
         FIGS. 102A-102D  are views of suture threading and insertion of the transvalvular bridge, according to some embodiments. 
         FIGS. 103A-103D  are views of an embodiment of a transvalvular bridge. 
         FIG. 104  is a schematic view of the threading of sutures, according to some embodiments. 
         FIG. 105  is a schematic view of the trimming of sutures, according to some embodiments. 
         FIGS. 106A-106E  are views of a transcatheter system, according to some embodiments. 
         FIGS. 107A-107C  are views of transseptal access, according to some embodiments. 
         FIGS. 108A-108C  are views of introduction of the transcatheter system, according to some embodiments. 
         FIGS. 109A-110B  are views of anchor deployment, according to some embodiments. 
         FIGS. 111A-111C  are views of cinching, according to some embodiments. 
         FIGS. 112A-112B  are schematic views of transducer positions and planes of the heart, according to some embodiments. 
         FIGS. 113A-113T  are schematic views of methods of use of a transcatheter system, according to some embodiments. 
         FIGS. 114-125  illustrate embodiments and features of a template catheter. 
         FIGS. 126-146  illustrate an embodiments and features of anchors and clips. 
     
    
    
     DETAILED DESCRIPTION 
       FIG. 1  illustrates a cross-sectional view of the heart  10  with a normal mitral valve  18  in systole. As illustrated, the heart  10  comprises the left atrium  12  which receives oxygenated blood from the pulmonary veins  14  and the left ventricle  16  which receives blood from the left atrium  12 . The mitral valve  18  is located between the left atrium  12  and left ventricle  16  and functions to regulate the flow of blood from the left atrium  12  to the left ventricle  16 . During ventricular diastole, the mitral valve  18  is open which allows blood to fill the left ventricle  16 . During ventricular systole, the left ventricle  16  contracts, which results in an increase in pressure inside the left ventricle  16 . The mitral valve  18  closes when the pressure inside the left ventricle  16  increases above the pressure within the left atrium  12 . The pressure within the left ventricle  16  continues increasing until the pressure within the left ventricle  16  exceeds the pressure within the aorta  20 , which causes the aortic valve  22  to open and blood to be ejected from the left ventricle and into the aorta  20 . 
     The mitral valve  18  comprises an anterior leaflet  24  and a posterior leaflet  26  that have base portions that are attached to a fibrous ring called the mitral valve annulus  28 . Each of the leaflets  24  and  26  has respective free edges  36  and  38 . Attached to the ventricular side of the leaflets  24  and  26  are relatively inelastic chordae tendineae  30 . The chordae tendineae  30  are anchored to papillary muscles  32  that extend from the intraventricular septum  34 . The chordae tendineae  30  and papillary muscle  32  function to prevent the leaflets  24  and  26  from prolapsing and enable proper coaptation of the leaflets  24  and  26  during mitral valve  18  closure. Also shown schematically is line  9  through the valve annulus  28  representing the intraannular plane. Arrow 8 points supraannularly, toward the left atrium  12 , while arrow 7 points infraannularly, toward the left ventricle  16 . 
       FIG. 2  illustrates a cross-sectional view of the heart  10  with a normal mitral valve  18  in diastole. After the left ventricle  16  has ejected the blood into the aorta, the left ventricle relaxes, which results in a drop in pressure within the left ventricle  16 . When the pressure in the left ventricle  16  drops below the pressure in the aorta  20 , the aortic valve  22  closes. The pressure within the left ventricle  16  continues dropping until the pressure in the left ventricle  16  is less than the pressure in the left atrium  12 , at which point the mitral valve  18  opens, as shown in  FIG. 2 . During the early filling phase, blood passively fills the left ventricle  16  and this accounts for most of the filling of the left ventricle  16  in an individual at rest. At the end of the filling phase, the left atrium  12  contracts and provides a final kick that ejects additional blood into the left ventricle. Also shown is intraannular plane  9  as described above, and line  6  representing the longitudinal axis  6  of the valve  18 . 
       FIG. 3  illustrates a bottom view of normal mitral valve  18  in systole, looking from the left atrium and to the left ventricle. As shown, the anterior leaflet  24  and posterior leaflet  26  are properly coapted, thereby forming a coaptive edge  40  that forms a seal that prevents retrograde flow of blood through the mitral valve  18 , which is known as mitral regurgitation.  FIG. 4  illustrates a bottom view of normal mitral valve  18  in diastole.  FIG. 5  provides a side cross-sectional view of a normal mitral valve  18  in systole. As shown in  FIG. 5 , the valve leaflets  24  and  26  do not normally cross the plane P defined by the annulus and the free edges  36  and  38  coapt together to form a coaptive edge  40 . 
       FIG. 5  also illustrates a coaption zone  41 . Preferably the depth of coaption (length of zone  41  in the direction of blood flow, in which the leaflets  24  and  26  are in contact) is at least about 2 mm or 5 mm, and is preferably within the range of from about 7 mm to about 10 mm for the mitral valve. 
     Thus, implantation of the devices in accordance with the present invention preferably achieves an increase in the depth of coaption. At increase of at least about 1 mm, preferably at least about 2 mm, and in some instances an increase of at least about 3 mm to 5 mm or more may be accomplished. 
     In addition to improving coaption depth, implantation of devices in accordance with the present invention preferably also increase the width of coaptation along the coaption plane. This may be accomplished, for example, by utilizing an implant having a widened portion for contacting the leaflets in the area of coaption such as is illustrated in connection with  FIGS. 19A and 19B  below. A further modification of the coaptive action of the leaflets which is accomplished in accordance with the present invention is to achieve early coaption. This is accomplished by the curvature or other elevation of the implant in the ventricle direction. This allows the present invention to achieve early coaption relative to the cardiac cycle, relative to the coaption point prior to implantation of devices in accordance with the present invention. 
       FIGS. 4 and 6  illustrate normal mitral valve  18  in diastole. As shown, the anterior leaflet  24  and posterior leaflet  26  are in a fully opened configuration which allows blood to flow from the left atrium to the left ventricle. 
       FIGS. 7 and 8  illustrate a heart  10  in systole where the anterior leaflet  24  of the mitral valve  18  is in prolapse. Anterior leaflet  24  prolapse can be caused by a variety of mechanisms. For example, as illustrated in  FIG. 7 , rupture  42  of a portion of the chordae tendineae  30  attached to the anterior leaflet  24  can cause the free edge  36  of the anterior leaflet  24  to invert during mitral valve  18  closure. As shown in  FIG. 8 , inversion 44 of the anterior leaflet  24  can prevent the mitral valve leaflets  24  and  26  from properly coapting and forming a seal. This situation where the free edge  36  of the anterior leaflet  24  crosses into the left atrium  12  during mitral valve  18  closure can lead to mitral regurgitation. 
     Similarly,  FIGS. 9 and 10  illustrate posterior leaflet  26  prolapse caused by a rupture of the chordae tendineae  30  attached to the posterior leaflet  26 . In this case, the posterior leaflet  26  can invert and cross into the left atrium  12  during mitral valve  18  closure. The inversion of the posterior leaflet  26  prevents the mitral valve leaflets  24  and  26  from properly coapting and forming a seal, which can lead to mitral regurgitation. 
     Mitral regurgitation can also be caused by an elongated valve leaflet  24  and  26 . For example, an elongated anterior leaflet  24 , as shown in  FIG. 11 , can prevent the valve leaflets  24  and  26  from properly coapting during mitral valve  18  closure. This can lead to excessive bulging of the anterior leaflet  24  into the left atrium  12  and misalignment of the free edges  36  and  38  during coaptation, which can lead to mitral regurgitation. 
     One embodiment of a transvalvular band  50  that would improve mitral valve leaflet  24  and  26  coaptation and prevent or reduce mitral regurgitation is illustrated in  FIGS. 12 and 13 .  FIG. 12  provides a top view of the transvalvular band  50  while  FIG. 13  provides a side view of the transvalvular band  50 . In this embodiment, the transvalvular band  50  comprises an elongate and curved structure with a first end  52 , a second end  54 , a central portion  64  located between the two ends  52  and  54 , and a length that is capable of extending across the annulus. The leaflet contact surface  56  is convex along the longitudinal axis, as best illustrated in  FIG. 13 . In other embodiments, the leaflet contact surface  56  can have a different shape and profile. For example, the contact surface  56  can be concave, straight, a combination of convex, concave and/or straight, or two concave or straight portions joined together at an apex. As illustrated in  FIG. 12 , the transvalvular band  50  can have a substantially constant width between the first end  52  and the second end  54 . The first end  52  has a first anchoring portion  58  and the second end  54  has a second anchoring portion  60 . 
     The anchoring portions  58  and  60  can have holes  62  for sutures that allow the transvalvular band  50  to be secured to the annulus. Alternatively, in other embodiments the anchoring portions  58  and  60  can have other means for securing the transvalvular band  50  to the annulus. For example, the anchoring portions  58  and  60  can be made of a membrane or other fabric-like material such as Dacron or ePTFE. Sutures can be threaded directly through the fabric without the need for distinct holes  62 . The fabric can be attached to the other portions of the transvalvular band  50  by a variety of techniques. For example, the fabric can be attached to the other portions of the transvalvular band  50  with the use of an adhesive, by suturing, by tying, by clamping or by fusing the parts together. Another non-limiting technique of securing the transvalvular band to the annulus is to coat a malleable metal basis material, which creates structure for securing a skeleton of the transvalvular band, with a polymer such as silicone and bonding a material, such as PET (i.e., Dacron) velour for comprehensive tissue ingrowth when desired. 
     The central portion of the transvalvular band  50  can have a variety of cross-sectional shapes, as illustrated in  FIGS. 14-17 . For example, the cross sectional shape can be substantially rectangular, circular, oblong or triangular. The edges of the transvalvular band  50  can be rounded or otherwise configured so that the transvalvular band  50  presents an atraumatic surface  51  to the valve leaflets. In some embodiments, the cross-section can be oriented in a particular fashion to enhance performance of the transvalvular band  50 . For example as shown in  FIG. 14 , a transvalvular band  50  with a triangular cross section can be designed so that a relatively larger surface  56  of the triangle contacts the valve leaflets while a lower profile leading edge  53  of the triangle opposite the surface  51  faces the left atrium. This configuration allows a larger surface area to make contact with and support the mitral valve leaflets, while also presenting a more streamlined shape that provides less resistance to blood flowing from the left atrium to the left ventricle. Decreasing the resistance to blood flow is desirable because it can reduce turbulence and reduce the impedance of the transvalvular band  50  on the filling of the left ventricle. Similarly, the transvalvular bands  50  with an oblong or rectangular cross-section can be oriented to either increase the surface area for contact with the valve leaflets, or be oriented to reduce the resistance to blood flow. 
     The dimensions of the transvalvular band  50  will vary, depending upon the specific configuration of the band  50  as well as the intended patient. In general, transvalvular band  50  will have an axial length from first end  52  to second end  54  within the range of from about 20 mm to about 32 mm. In one embodiment, intended for a typical male adult, the axial length of the transvalvular band  50  is about 24 mm to 26 mm. The width of the transvalvular band  50  in the central zone  64  may be varied depending upon the desired performance, as will be discussed herein. In general, the trailing surface  51  against which leaflets will seat is preferably large enough to minimize the risk of erosion resulting from repeated contact between the closed leaflets and the implant. The width of the leading edge  53  is preferably minimized, as discussed above, to minimize flow turbulence and flow obstruction. In general, widths of the surface  51  measured perpendicular to the flow of blood are presently contemplated to be less than about 5 mm, and often within the range of from about 5 mm to about 10 mm in the zone of coaptation. 
     In some embodiments as illustrated in  FIG. 18 , the central portion  64  of the transvalvular band  50  can be narrower in width, measured perpendicular to blood flow than the first and second anchoring portions  58  and  60 . By narrowing the central portion  64 , the resistance to blood flow can be reduced. However, narrowing the central portion  64  reduces the surface area of the leaflet contact surface  56  that supports the valve leaflets. 
     In the embodiment illustrated in  FIG. 18 , the narrowed central portion  64  is separated from the first anchoring portion  58  and second anchoring portion  60  by a first shoulder  57  and second shoulder  59 . The length of the central portion  64 , between first shoulder  57  and second shoulder  59  can be less than about 50% of the overall length of the device, or less than about 30% of the overall length of the device if it is desired to minimize the obstruction in the center of the flow path, while presenting a wider transverse surface for supporting the leaflets when the valve is closed. Alternatively, the length of the central zone  64  may be greater than 50%, and in some embodiments greater than 75% of the overall length of the implant. 
     In some embodiments as illustrated in  FIGS. 19A, 19B, 21 and 23 , a coaptive edge support portion  66  of the central portion  64  of the transvalvular band  50  can be wider than the adjacent portions of the transvalvular band  50 , leading up to and potentially including the first and second anchoring portions  58  and  60 . By increasing the width and surface area of the coaptive edge support portion  66 , more support can be provided to the valve leaflets at the coaptive edge. This increased support can increase the width of leaflet coaption. The other portions of the central portion  64  can remain narrow to reduce the resistance to blood flow. The support portion  66  can be located at a fixed position or adjustable along the transvalvular band so that its position can be optimized by the surgeon and then secured at a fixed point such as by suturing, or removed if deemed unnecessary. 
     In one implementation of the invention, the transvalvular band comprises a first component for primary reduction and a second component for fine adjustment. For example, the device illustrated in  FIG. 19A  may be provided with an adjustable (e.g. slidable) support portion  66 . The transvalvular band may be positioned across the annulus as has been described herein, and hemodynamic function of the valve may be evaluated. The support portion  66  may thereafter be adjusted along the length of the transvalvular band to treat residual leakage or otherwise optimize the functionality of the implant such as by increasing the zone of coaptation. The second component (e.g. support portion  66 ) may thereafter be fixed with respect to the transvalvular band such as by sutures, clips, adhesives, or other techniques known in the art. Alternatively, the second portion may be separate from and connectable to the transvalvular band such as stitching, clips, suturing or other technique known in the art. 
     In addition, the coaptive edge support portion  66  can be offset from the center of the transvalvular band  50 , to reflect the asymmetry between the anterior leaflet and the posterior leaflet. For example, the coaptive edge support portion  66  can be positioned closer to the first anchoring portion  58  than to the second anchoring portion  60 . In certain embodiments, the edge support portion  66  will be centered about a point which is within the range of from about 20% to about 45% of the overall length of the implant from the closest end. 
       FIG. 20  illustrates another embodiment of a transvalvular band  50  that is a modification of the transvalvular band  50  shown in  FIG. 18 . As illustrated in  FIG. 20 , the transvalvular band  50  has a narrow central portion  64  that provides relatively low resistance to blood flow. However, the first and second anchoring portions  58  and  60  extend further in a lateral direction, and can be arcuate to conform to the mitral valve annulus. These laterally extended anchoring portions  58  and  60  provide additional anchoring of the transvalvular band  50  and can help improve the stability of the device after implantation. The laterally extending anchoring portion  58  and  60  may be provided with any of a variety of structures for facilitating anchoring to the valve annulus. For example, they may be provided with a plurality of apertures  61 , for conventional stitching or to receive any of a variety of clips or tissue anchors. The anchoring portions may alternatively be provided with any of a variety of barbs or hooks, or may be provided with a fabric covering such as a Dacron sleeve to facilitate sewing. Further, in some embodiments, this sewing ring may have an elastomeric core upon which the Dacron is secured to provide a more compliant structure to hold the implant. Measured in the circumferential direction (transverse to the longitudinal axis of the implant  50 ) the laterally extending anchoring portions will have an arc length of greater than about 5 mm, and, in some embodiments, greater than about 1 cm. Arc lengths of at least about 2 cm, and, in some embodiments, at least about 3 cm may be utilized, depending upon the desired clinical performance. 
       FIG. 21  illustrates another embodiment of a transvalvular band  50  with the extended anchoring portions  58  and  60  and a wider, offset coaptive edge support portion  66 . This embodiment has the benefit of additional stability provided by the extended anchoring portions  58  and  60  and enhanced support of the coaptive edge. 
       FIGS. 22 and 23  illustrate another embodiment of a transvalvular band  50  which is combined with an annular ring  68 . The annular ring  68  can be used as both a support for the transvalvular band  50  and, if desired, also to help stabilize the size and shape of the mitral valve annulus itself. In some embodiments, the annular ring  68  can be used to reduce the size of the mitral valve annulus and to bring the mitral valve leaflets closer together. This can be accomplished by, for example, suturing the mitral valve annulus to an annular ring  68  of smaller diameter. In addition, the annular ring  68  provides additional support and stability to the transvalvular band  50 . The anchoring portions  58  and  60  of the transvalvular band  50  can be formed integrally with the annular ring  68 , or the anchoring portions  58  and  60  can be attached to the annular ring by a variety of means, such as suturing, bonding, adhesives, stapling and fusing.  FIG. 22  discloses an embodiment with a narrow central portion  64  while  FIG. 23  discloses an embodiment with a wider, offset coaptive edge support portion  66 . 
       FIG. 23A  illustrates a further implementation of the invention, adapted to treat ischemic mitral regurgitation with posterior annuloplasty. A transvalvular band  61  is provided for spanning the leaflet coaption plane as has been described herein. Any of the features described in connection with other transvalvular bands disclosed herein may be incorporated into the transvalvular band  61 . 
     An arcuate posterior annuloplasty support  63  is connected to the transvalvular band  61 , and adapted to extend for an arc length along the native annulus. In the illustrated embodiment, the support  63  extends through an arc of approximately 180°, extending from a first trigone attachment zone  65  to a second trigone attachment zone  67 . The attachment zones may be provided with sewing apertures, a fabric covering, or other structure for facilitating attachment to tissue. In general, the transvalvular band  61  will have dimensions similar to those described elsewhere herein. The transverse dimension from first trigone zone  65  to second trigone zone  67  may be varied depending upon the size of the native annulus, but will generally be within the range of from about 35 mm to about 45 mm. 
     Referring to  FIG. 23B , there is illustrated a transvalvular band in accordance with the present invention, formed from a single length or several lengths of flexible wire. The bend angles and orientation of the struts in the illustrated embodiment may be readily altered, to accommodate the desired axes of compression which may be desirable for a particular deployment procedure. 
     In general, the transvalvular band  71  comprises an elongate flexible wire  73  formed into a serpentine pattern, for providing a support for the valve leaflets as has been discussed herein. Although not illustrated in  FIG. 23B , the wire  73  may be formed such that it bows or inclines in the direction of the ventricle to achieve early closure as is discussed elsewhere herein. The wire  73  may extend into a first connection section  75  and a second connection section  77 . Each of the connection sections  75  and  77  may be provided with a plurality of eyelets  79 , to receive sutures for attaching the implant to the valve annulus. The implant may be formed from any of a variety of flexible materials, including various polymers described elsewhere herein as well as titanium, titanium alloy, Nitinol, stainless steel, elgiloy, MP35N, or other metals known in the art. This design has an advantage of providing a relatively large support footprint against the valve leaflets, while at the same time optimizing the area of open space to permit maximum blood flow therethrough. The design may be treated or coated with silicone or other suitable material to eliminate untoward effects such as thrombosis or corrosion. Treatments may be sequential and include more than one listed but not limited to electropolishing, harperization, tumbling, pickling, plating, encapsulation or physical vapor deposition of appropriate materials. 
       FIGS. 24-27  illustrate side views of transvalvular bands  50  with different inclinations. One of the objectives of the present invention is to not merely provide support to the leaflets during systole, but to elevate the plane of coaption in the direction of the ventricle, to cause early coaption (closure) relative to the cardiac cycle, as is discussed elsewhere herein. The variation in conditions, and other patient to patient variations may warrant production of the transvalvular band of the present invention in an array of sizes and/or configurations, so that clinical judgment may be exercised to select the appropriate implant for a given case. Alternatively, the transvalvular band may be provided in an adjustable form or a modular form so that an implant of the desired configuration can be constructed or modified intraoperatively at the clinical site. In a three segment embodiment, such as that illustrated in  FIGS. 24 through 27 , a central segment may be provided for positioning within the center of the flow path, or centered on the coaptive edges of the leaflets. First and second end portions may be connected to the central portion, for supporting the central portion relative to the tissue anchors. First and second end portions may be provided in a variety of lengths and curvatures, enabling construction of a relatively customized modular implant as may be desired for a particular patient. 
     For example,  FIG. 24  illustrates a transvalvular band  50  with a central portion  64  and two gently angled arm portions  70  and  72 . The first and second ends  52  and  54  are displaced from the central portion  64  by a height, h 1  and h 2 , respectively. In  FIG. 24 , h 1  and h 2  are about equal and can range from about 0 mm to about 10 mm. Preferably h 1  and h 2  will be at least about 2 mm and will often be at least about 4 mm or 6 mm or more, but generally no more than about 10 mm or 12 mm. 
       FIG. 25  illustrates a transvalvular band  50  with a central portion  64  and two sharply angled arm portions  70  and  72 . The first and second ends  52  and  54  are displaced from the central portion  64  by a height, h 1  and h 2 , respectively. In  FIG. 25 , h 1  and h 2  are about equal and can range from about 8 mm to about 12 mm.  FIG. 26  illustrates a transvalvular band  50  with a central portion  64 , a highly angled first arm  70  and a gently angled second arm  72 . The first and second ends  52  and  54  are displaced from the central portion  64  by a height, h 1  and h 2 , respectively. In  FIG. 26 , h 1  is greater than h 2 . The h 1  ranges from about 6 mm to about 10 mm, while h 2  ranges from about 2 mm to about 6 mm.  FIG. 27  illustrates a transvalvular band  50  with a central portion  64 , a gently angled first arm  70  and a highly angled second arm  72 . The first and second ends  52  and  54  are displaced from the central portion  64  by a height, h 1  and h 2 , respectively.  FIG. 27 , may be a mirror image of  FIG. 26 . 
     The transvalvular band  50  can be made of any of a variety of materials that are compatible with implantation within a patient&#39;s body and which has the requisite structural integrity to support the mitral valve leaflets. For example, suitable materials include titanium, titanium alloys, stainless steel, stainless steel alloys, nitinol, elgiloy, MP35N, other metals and alloys, ceramics, and polymers such as PTFE, polycarbonate, polypropylene, UHMWPE, HDPE, PEEK, PEBAX and the like. 
     In order to reduce the thrombogenicity of the transvalvular band  50 , the transvalvular band  50  can be provided with a smooth surface or appropriately micro-texture the surface in some embodiments, such as via a porous or microporous structure. Other factors such as surface chemistry, energy, morphology, macrofeatures, and general material properties matching the in situ needs can also be considered in tailoring the surface of the band. In addition, the transvalvular band  50  can be coated with a variety of substances to reduce thrombogenicity. For example, the transvalvular band  50  can be coated with a antithrombogenic agent such as heparin, a polymer such as PTFE, or a polymer conjugated with heparin or another antithrombogenic agent. Heparin coatings can be achieved in a variety of methods, one of which may be to coat or drip the prosthesis in TDMAC-heparin (Tridodecylmethylammonium heparinate). 
     As illustrated in  FIGS. 28-31 , the transvalvular band  50  is implanted in the plane of the mitral valve annulus  28  in a patient suffering from anterior leaflet  26  prolapse caused by the rupture  42  of the chordae tendineae  30  attached to the anterior leaflet  26 . Although a prolapsed anterior leaflet  26  is illustrated, it should be understood that the method described herein is also applicable for treating other types of prolapse, such as posterior leaflet prolapse and prolapse caused by elongated leaflets  24  and  26 . The transvalvular band  50  can be attached to the annulus  28  by a variety of techniques, such as sutures, anchors, barbs, stapes, self-expanding stents, or other techniques that are known or are apparent to those of skill in the art. 
     As best illustrated in  FIGS. 29 and 31 , the transvalvular band  50  is oriented in the annulus  28  so that the transvalvular band  50  is positioned approximately transversely to the coaptive edge  42  formed by the closure of the mitral valve leaflets  24  and  26 . The transvalvular band  50  can also be positioned over the prolapsed portion of the anterior leaflet  26  so that the transvalvular band  50  can directly support the prolapsed portion of the anterior leaflet  24  and keep the anterior leaflet  24  inferior to the plane of the mitral valve annulus  28 , i.e., elevated in the direction of the ventricle or of antegrade flow, thereby preventing or reducing prolapse and mitral regurgitation. 
       FIGS. 28 and 29  illustrate the effect of the transvalvular band  50  on the mitral valve  18  during systole. As shown, both the anterior leaflet  24  and the posterior leaflet  26  are supported by the transvalvular band during closure of the mitral valve  18 . The arcuate transvalvular band  50  functions to keep both leaflets  24  and  26  inferior to the plane of the annulus  28  and enables the leaflets  24  and  26  to form a coaptive edge  40 . Although a single transvalvular band  50  has been illustrated, in some embodiments, multiple transvalvular bands  50  such as two or three or more can be implanted across the annulus  28  to provide additional support to the mitral valve leaflets  24  and  26 . 
       FIGS. 30 and 31  illustrate the effect of the transvalvular band  50  on the mitral valve  18  during diastole. During diastole, the mitral valve  18  opens so that blood can fill the left ventricle  16  from the left atrium  12 . As best illustrated in  FIG. 31 , the transvalvular band  50  obstructs only a small portion of the mitral valve  18  opening, and therefore, does not cause excessive resistance to blood flow. 
       FIGS. 32-35  are cross-sectional side views of the mitral valve  18  with and without the support of the transvalvular band  50 . During systole, the mitral valve  18  closes. Without the transvalvular band  50 , the anterior leaflet  24  crosses the plane P defined by the mitral valve annulus  28  and prolapse, which leads to mitral regurgitation, as shown in  FIG. 33 . However, by implanting the transvalvular band  50  in the annulus  28  such that the arcuate transvalvular band  50  arches towards the left ventricle and the central portion  64  is displaced from the plane P, the anterior leaflet  24  is prevented from prolapsing above the plane P thus eliminating or reducing retrograde flow (shown in  FIG. 33 ). The leaflets  24  and  26  rest upon the transvalvular band  50  and the pressure exerted by the blood upon the distal portion of the leaflets  24  and  26  form the coaptive edge  40 . As illustrated in  FIGS. 34 and 35 , the performance of the mitral valve  18  during diastole is not substantially affected by the transvalvular band  50 . 
     Although the method of implanting and positioning the transvalvular band  50  has been illustrated with one embodiment of the transvalvular band  50 , other embodiments as described above can also be used. For example,  FIG. 36  illustrates a transvalvular band  50  with a wider, offset coaptive edge support portion  66  that has been implanted in the mitral valve annulus. As shown, the coaptive edge support  66  is offset so that it positioned to support the coaptive edge of the mitral valve  18 . In addition, the transvalvular band  50  can be used in conjunction with other devices and procedures, such as a separate or integrally attached annular or annuloplasty ring described above. In addition, the transvalvular band  50  can be used in conjunction with the Alfieri procedure, where the tips of the mitral valve leaflets  24  and  26  are sutured  74  together, as shown in  FIG. 38 . 
     Referring to  FIG. 37 , there is illustrated a perspective view of a transvalvular band  50  having a transverse projection or support  51  extending in the direction of the ventricle or in the direction of diastolic blood flow, which could be considered antegrade. The support  51  has a width W, which may be at least about 3 mm, and in some embodiments, at least about 5 mm, and in other embodiments at least about 1.0 cm. The projection  51  may be utilized without an Alfieri stitch, so that the leaflets of the mitral valve close against opposing side walls  53  and  55  of the projection  51 . The projection  51  thus helps center the closure of the leaflets, as well as controlling the width of coaption. In addition, the band  50  is illustrated as convex in the direction of the ventricle, to accomplish early closure as has been discussed herein. 
     The transvalvular band in accordance with the present invention can be implanted via an open surgical procedure, via thoracotomy (e.g. transapically) or alternatively, via a percutaneous procedure using a translumenally implantable embodiment. In the translumenally implantable embodiment, one or more transvalvular bands can be attached to a self-expandable support structure, such as a self-expandable ring or self-expandable stent having a relatively short axial length relative to its expanded diameter. The transvalvular band and the compressed self-expandable support structure are loaded into a catheter with a retractable outer sheath which is inserted percutaneously and advanced translumenally into or across the mitral valve. The retractable outer sheath can be retracted to allow the self-expandable support structure to expand adjacent or against the annulus, thereby positioning the one or more transvalvular bands in about the plane of the mitral annulus. Each transvalvular band can be characterized by a longitudinal axis, and the transvalvular band is oriented in the mitral valve such that the longitudinal axis of the transvalvular band in oriented substantially transversely to the coaptive edge of the mitral valve. 
     By “percutaneous” it is meant that a location of the vasculature remote from the heart is accessed through the skin, such as using needle access through, for example, the Seldinger technique. However, it may also include using a surgical cut down procedure or a minimally invasive procedure. The ability to percutaneously access the remote vasculature is well-known and described in the patent and medical literature. 
     Depending on the point of vascular access, the approach to the mitral valve may be antegrade and require entry into the left atrium via the pulmonary vein or by crossing the interatrial septum. Alternatively, approach to the mitral valve can be retrograde where the left ventricle is entered through the aortic valve. Once percutaneous access is achieved, the interventional tools and supporting catheter(s) will be advanced to the heart intravascularly where they may be positioned adjacent the target cardiac valve in a variety of manners, as described elsewhere herein. While the methods will preferably be percutaneous and intravascular, many of the implants and catheters described herein will, of course, also be useful for performing open surgical techniques where the heart is beating or stopped and the heart valve accessed through the myocardial tissue. Many of the devices will also find use in minimally invasive procedures where access is achieved thorascopically and where the heart will usually be stopped but in some instances could remain beating. 
     A typical antegrade approach to the mitral valve is depicted in  FIG. 39 . The mitral valve MV may be accessed by a standard approach from the inferior vena cava IVC or superior vena cava SVC, through the right atrium RA, across the interatrial septum IAS and into the left atrium LA above the mitral valve MV. As shown, a catheter  120  having a needle  122  may be advanced from the inferior vena cava IVC into the right atrium RA. Once the catheter  120  reaches the interatrial septum IAS, the needle  122  may be advanced so that it penetrates through the septum at the fossa ovalis FO or the foramen ovale into the left atrium LA. At this point, a guidewire may be advanced out of the needle  122  and the catheter  120  withdrawn. 
     As shown in  FIG. 40 , access through the interatrial septum IAS will usually be maintained by the placement of a guide catheter  125 , typically over a guidewire  124  which has been placed as described above. The guide catheter  125  affords subsequent access to permit introduction of the tool(s) which will be used for performing the valve or tissue modification, as described in more detail below. 
     A typical retrograde approach to the mitral valve is depicted in  FIG. 41 . Here the mitral valve MV may be accessed by an approach from the aortic arch AA, across the aortic valve AV, and into the left ventricle below the mitral valve MV. The aortic arch AA may be accessed through a conventional femoral artery access route, as well as through more direct approaches via the brachial artery, axillary artery, or a radial or carotid artery. As shown in  FIG. 42 , such access may be achieved with the use of a guidewire  128 . Once in place, a guide catheter  126  may be tracked over the guidewire  128 . The guide catheter  126  affords subsequent access to permit introduction of the tool(s) which will be used for performing the valve modification, as described in more detail below. 
     In some cases, access routes to the mitral valve may be established in both antegrade and retrograde approach directions. This may be useful when, for instance, grasping is performed with the use of specific devices introduced through one route and fixation is achieved with the use of separate devices introduced through another route. In one possible situation, the transvalvular band may be introduced via a retrograde approach. While the transvalvular band is held in place, a fixation tool may be introduced via an antegrade approach to fix the transvalvular band in place. The access pathways for the transvalvular band and fixation tool may alternatively be reversed. Thus, a variety of access routes may be used individually or in combination with the methods and devices of the present invention. 
     Referring to  FIG. 43A , there is illustrated a schematic view of a percutaneously deliverable implant in accordance with one aspect of the present invention. The deployment system includes a deployment catheter  200 , only a distal end of which is illustrated herein. Deployment catheter  200  is configured in accordance with known technology for accessing the mitral valve, utilizing conventional dimensions and the materials known to those of skill in the art. In general, the deployment catheter  200  comprises an elongate flexible tubular body  202  extending between a proximal end (not illustrated) and a distal end  204 . The proximal end is provided with a proximal manifold, including access portals such as luer connectors in communication with each functional lumen in the catheter  200 . 
     The distal end  204  is provided with a distally facing opening  208 , which is in communication with the proximal end via a central lumen  206 . 
     Positioned within the central lumen  206  is a collapsed implant  210 . Implant  210  is transformable between a first, radially reduced configuration such as for positioning within the deployment catheter  200  and a second, radially enlarged configuration (see  FIG. 43C ) for positioning at the treatment site. Transformation of the implant from the first configuration to the second configuration may be accomplished under positive force, such as via balloon dilatation. Alternatively, as illustrated herein, transformation is accomplished by self-expansion of the implant  210  in response to removal of the constraint provided by the tubular body  202 . 
     In general, the implant  210  comprises a frame or anchor component  212  and a leaflet support component  214 . Leaflet support component  214  may comprise any of a variety of structures similar to those described previously herein as the annular band, configured or reconfigured such that the annular band may be radially reduced for positioning within a deployment catheter and subsequently radially enlarged for spanning the mitral valve. The implant  210  additionally comprises an anchor component, for anchoring the leaflet support  214  at the treatment site. In the illustrated embodiment, anchor  212  is schematically illustrated as a zigzag wire or filament structure, which is radially expansible following removal of the constraint. However, any of a variety of configurations may be utilized for the anchor  212 . 
     Referring to  FIG. 43B , the outer tubular flexible body  202  is shown partially retracted from the implant, permitting the implant to begin to radially expand.  FIG. 43C  illustrates further retraction of the tubular body  202 , to fully release the anchor  212  at the deployment site. As illustrated, anchor  212  radially expands within the left atrium. The leaflet support  214  extends approximately transversely to the coaptive edge of the mitral valve leaflets, and is convex or inclined in the direction of the mitral valve to advance the coaptation of the mitral valve leaflets in the direction of the ventricle as has been described elsewhere herein. 
     As seen in  FIG. 43A , the implant  210  is controlled by at least one control line  216 . Control line  216  extends throughout the length of the deployment catheter  200 , and to at least one control on or near the proximal manifold. This enables proximal retraction of the flexible body  202  with respect to the implant  210 , and control of implant  210  prior to final detachment from the deployment system. 
     Referring to  FIG. 43C , at least a first control wire  216 , a second control wire  218 , and a third control wire  220  are illustrated connected to the anchor  212 . Control wires  216 ,  218  and  220  enable manipulation of the implant into its final desired position, and, if necessary, proximal retraction of the implant back within the deployment catheter should the decision be made to remove the implant prior to final detachment. 
     Prior to final detachment of the implant  210 , additional anchoring structures may be engaged to retain the implant at its desired implanted location. For example, anchor  212  may be provided with any of a variety of tissue anchors or barbs, for engaging the mitral valve annulus or the base of the leaflets or other adjacent anatomical structures. Alternatively, separate tissue anchors may be advanced through the deployment catheter  200 , and utilized to secure the anchor  212  to the adjacent tissue. Suitable anchors are preferably enlargeable from a first, reduced cross sectional configuration for traveling through the deployment catheter  200  and piercing tissue, to a second, enlarged configuration for resisting removal from the tissue. In the embodiment illustrated in  FIG. 43C , no secondary anchoring structures are illustrated for simplicity. 
     Once the position of the implant  210  has been verified and found acceptable, and the determination of whether to introduce secondary anchoring structures has been made, the control wires  216 ,  218  and  220  are detached from the anchor  212 , and the deployment catheter  200  is removed from the patient. Detachment of the control wires from the implant  210  may be accomplished in any of a variety of ways, such as by electrolytic detachment, detachment by thermal elevation of a softenable or meltable link, mechanical detachment such as by rotating the control wire such that a threaded end of the control wire is threadably disengaged from the anchor  212 , or other detachment techniques depending upon the desired functionality and profile of the system. 
     Referring to  FIG. 43D , there is illustrated a side elevational view of the implant  210  in an unconstrained (e.g., bench top) expanded configuration. The anchor  210  comprises a plurality of struts  222 , which are joined at a first end by a plurality of apices  224  and a second end by a plurality of apices  226  to produce a zigzag structure sometimes referred to as a “Z stent” configuration. This configuration is convenient and well understood in the intravascular implant arts, although any wide variety of structures may be utilized. For example, zigzag wire patterns, woven wire patterns, or sinusoidal wire patterns may be utilized. Laser cut wall patterns such as from tubing stock may also be utilized, and may be provided with any of a wide variety of complex wall patterns. In general, nickel titanium alloys such as any of a variety of nitinol alloys are preferred. However, depending upon the wall pattern, stainless steel, elgiloy, certain polymers or other materials may also be utilized. Heat treatment may be required to anneal and shape set an alloy such as Nitinol. Other alloys may require only annealing to relieve stresses incurred during prior processing. 
     Referring to  FIG. 43E , there is illustrated an end view of the implant shown in  FIG. 43D  to show the transverse configuration of the transvalvular band portion of the implant. In this illustration, the transvalvular band comprises a plurality of struts  230  which are connected to the anchor  212  at junctions  232 . Struts  230  may in turn be divided into a bifurcated section  234  or other configuration to increase the effective footprint of the transvalvular band measured along the coaptive edge of the valve, while minimizing obstruction to blood flow therethrough. The coaptive edge of the valve, as implanted, will preferably be approximately aligned with the transverse axis  236  illustrated in  FIG. 43E  of the band, as implanted. The axis of coaption of the mitral valve is preferably parallel to axis  236  in the implanted configuration, but may be within about 45°, preferably within about 20°, and most preferably within about 10° of the axis  236 . 
     Referring to  FIGS. 44A and 44B , there is illustrated an anchor deployment catheter which may be utilized to provide either primary or secondary anchoring of the anchor structure  212  to adjacent tissue. Anchor deployment catheter  250  comprises an elongate flexible tubular body  252 , configured to access the vicinity of the mitral valve. Tubular body  252  extends between a proximal end  254  and a distal end  256 . Distal end  256  is provided with a distal opening  258 , enabling access to a central lumen  260 . An elongate flexible core wire  262  extends from the proximal end  254  throughout most of the length of the lumen  260  to a distal surface  264 . See  FIG. 44C . The proximal end of the core wire  262  is provided with a control  266  that enables axial reciprocal movement of the core wire  262  within the central lumen  260 . 
     A tissue anchor  268  may be positioned within the distal end of the delivery catheter  250 . In use, manipulation of the control  266 , such as by distal axial advance relative to the tubular body  252 , distally, axially advances the core wire  262  to expel the anchor  268  through the distal opening  258 . Distal opening  258  is preferably provided with a bevel or angled cut to provide a sharpened distal tip  270 . This enables distal axial advance of the distal tip  270  into tissue at a desired site, so that the control  266  may be manipulated to deploy all or a portion of the anchor  268  into the target tissue. 
     Any of a variety of tissue anchors  268  may be utilized, depending upon the desired configuration of the implant and the implant anchor interface. In the illustrated embodiment, the anchor  268  is configured as a double “t-tag” anchor. A first tissue engaging element  272  is connected to a second implant engaging element  274  by a filament  276 . In use, the distal tip  270  is positioned within the tissue of the mitral valve annulus. Control  266  is manipulated to deploy the first element  272  beneath the surface of the tissue. The tubular body  252  is thereafter proximally retracted, enabling the second element  274  to engage the implant and retain it against the adjacent tissue. 
     The anchor delivery catheter  250  may be advanced through the deployment catheter  200 , and/or along a guide such as a guidewire or support wire. In the illustrated embodiment, the anchor deployment catheter  250  is provided with a guide lumen  278  allowing the anchor delivery catheter to track along a guidewire. Guide lumen  278  is defined by a tubular wall  280 . Tubular wall  280  may extend the entire length of the anchor delivery catheter  250 , such as by forming the catheter body as a dual lumen extrusion. Alternatively, tubular wall  280  may be provided with an axial length that is short relative to the overall length of the catheter, such as no more than about 3 cm and preferably no more than about 2 cm in length. This allows the anchor delivery catheter to ride along a guidewire in a monorail or rapid exchange manner as will be illustrated below. 
     Referring to  FIGS. 45A and 45B , there is illustrated an implant configured for use with the anchor delivery catheter described above. In general, the implant comprises a first leaflet support  292  and a second leaflet support  294 , separated by a flexible connection  296 . Flexible connection  296  permits the implant  290  to be folded within a deployment catheter, and later expanded in a manner that permits the implant  290  to function as a transvalvular band as described. The implant  290  may be manufactured in any of a variety of ways, such as using a wire frame or by laser cutting from sheet stock as will be appreciated by those of skill in the art. 
     In the illustrated embodiment, a first and second flexible connection  296  reside in a plane configured to be substantially parallel to the axis of coaption the as implanted orientation. The lateral edges of the each of the first leaflet support  292  and second leaflet support  294  are provided with at least one and preferably two or three eyes  298 , fabric patches, or other anchor attachment structure, for receiving a tissue anchor. 
     Referring to  FIG. 45B , the implant of  FIG. 45A  is illustrated in a partially collapsed configuration, flexed about the flexible connection  296 . In addition, control wires  300 ,  302  and  304  are illustrated releasably connected to the implant  290 . Control wires  300 ,  302  and  304  may be utilized to advance the implant  290  from the deployment catheter such as catheter  200  described above, and manipulate the implant until the anchors have been fully deployed. Thereafter, control wires  300 ,  302  and  304  may be removed such as by electrolytic detachment, melting a polymeric link, unscrewing a threaded connection, or other detachment mechanism depending upon the desired functionality of the device. 
     Referring to  FIGS. 46A through 46E , there is illustrated a sequence of deploying an implant at the mitral valve from an antegrade direction. The implant  290  may be similar to that illustrated in  FIGS. 45A and 45B , or have wall patterns or characteristics of other implants disclosed elsewhere herein. In general, the implant  290  is deployed from the catheter  200  in the sequence illustrated in  FIGS. 46A through 46C . The surrounding anatomy has been eliminated for simplicity. 
     Referring to  FIG. 46D , the anchor delivery catheter  250  is advanced onto the proximal end of one of the control wires  300 , such that the control wire  300  is axially moveably positioned within guide lumen  278 . This enables the anchor delivery catheter  250  to be advanced along the control wire  300  in a monorail or rapid exchange configuration as is understood in the catheter arts. Anchor delivery catheter  250  is advanced along the control wire  300  until the distal tip  270  advances through the eye  298  or fabric tab or other attachment structure, and into the adjacent tissue of the base of the mitral valve leaflet or mitral valve annulus. The control  266  is manipulated such as by distal advance to advance the first anchor element  272  out of the distal opening  258  and into the tissue as illustrated in  FIG. 46D . 
     The anchor delivery catheter  250  is thereafter proximally withdrawn to position the distal opening  258  on the device proximal side of the eye  298 , and the core wire  262  is further distally advanced to deploy the second anchor element  274  from the distal opening  258  of the anchor delivery catheter  250 . Anchor delivery catheter  250  may thereafter be proximally withdrawn from the patient. Either the same or a different anchor delivery catheter  250  may thereafter be advanced along the third control wire  304 , enabling deployment of another tissue anchor as is illustrated in  FIG. 46E . 
     The implant  290  is illustrated in  FIG. 46E  as having a central portion inclined in the direction of the ventricle to support the leaflets as has been discussed elsewhere herein. This configuration may be retained by the inherent bias built into the structure and materials of the implant  290 . Alternatively, the configuration of inclining in the direction of the ventricle may be retained by active intervention such as by providing a mechanical interlock, in situ heat weld with capacitive discharge/electrolytic weld, application of a clip or other locking structure by way of control wire  302  or simply by the mechanical forces attributable to the mitral valve annulus, which prohibit lateral expansion of the device sufficient for the flexible connection  296  to invert in the direction of the atrium. Alternatively, an implantable control wire (not illustrated) may be introduced, to connect the implant  290  such as in the vicinity of the flexible connection  296  to the opposing wall of the ventricle, as will be described in connection with a transapical implementation of the invention described below. 
     A further implementation of the invention is illustrated in connection with  FIGS. 47A through 47E . Referring to  FIG. 47A , the first control line  300  and third control line  304  have been replaced by a first guide tube  310  and a second guide tube  312 . First guide tube  310  and second guide tube  312  each has the double function of controlling deployment of the implant, as well as enabling introduction of a tissue anchor therethrough. This avoids the use of a separate tissue anchor deployment catheter such as that described above. 
     As illustrated in  FIG. 47B , once the implant is provisionally positioned in the vicinity of the mitral valve, a first tissue anchor  314  is deployed through the first guide tube  310 . A second tissue anchor  316  is deployed through the second guide tube  312 . The tissue anchors may comprise “T” tag type constructions, pigtail or corkscrew constructions, or any of a variety of other soft tissue anchors known in the art. In general, tissue anchors utilized for the present purpose are preferably transformable from a first, reduced cross-sectional configuration to a second, radially enlarged cross-sectional configuration to enable deployment through a small needle or tube and then provide a relatively higher resistance to pull out. Radial enlargement may be accomplished by angular movement of a portion of the anchor, or by physical expansion in a radial direction. 
     Referring to  FIG. 47C , the first guide tube  310  and second guide tube  312  have been removed following deployment of the tissue anchors. The guide tubes may be removed using any of a variety of detachment techniques disclosed elsewhere herein. Either before or after removal of the guide tubes, distal pressure on either the tubular body  202  or the control wire  302  inverts the implant from the configuration shown in  FIG. 47C  to the final configuration shown in  FIGS. 47D  and E. The inverted configuration of  FIGS. 47D  and E may be retained by the mechanical bias imparted through the anchoring to the mitral valve annulus, or using techniques described elsewhere herein. The control wire  300  is thereafter detached from the implant, as illustrated in  FIG. 47E . 
     Any of a variety of the implants of the present invention may alternatively be introduced across the ventricle, such as in a transapical approach. The retrograde approach to the mitral valve will necessitate certain modifications to both the implant and the deployment system, as will be appreciated by those of skill in the art in view of the disclosure herein. 
     For example, a transventricular approach is illustrated in  FIGS. 48A through 48D . A deployment catheter  320  is introduced into the ventricle, and retrograde through the mitral valve to position the distal opening  208  within the atrium. An implant is carried within the deployment catheter  320 , as has been described elsewhere herein. In general, the implant comprises a first leaflet support  292  and a second leaflet support  294  separated by a flexible zone or pivot point. 
     In the retrograde implementation of the invention, the first and second leaflet supports are flexible or pivotable with respect to the longitudinal axis of the control wire  300 , such that they may be moved between a first configuration in which there are substantially parallel with the axis of the control wire  300 , and a second position, as illustrated in  FIGS. 48A through 48D , in which they are inclined radially outwardly from the longitudinal axis of the control wire  300  in the device proximal direction. The implant may thus reside within the deployment catheter  320  when the first leaflet support  292  and second leaflet support  294  are in the first, reduced crossing profile configuration, with each of the tissue anchors  314  and  316  pointing in a device proximal direction. In this embodiment, the tissue anchor  314  may be permanently affixed to or integral with the first leaflet support  292  and the second anchor  316  may be similarly carried by the second leaflet support  294 . 
     Once the distal end of the deployment catheter  320  has been positioned within the atrium, the control wire  300  may be distally advanced to advance the anchors  314  and  316  beyond the distal opening  208 . This releases the implant and allows the angle between the first and second leaflet supports to be increased, so that the tissue anchors  314  and  316  may be aimed at the desired tissue anchor target sites. Proximal retraction on the control wire  300  may be utilized to seat the tissue anchors within the target tissue, as illustrated in  FIG. 48B . 
     Further proximal traction on the control wire  300  may be utilized to invert the implant into the configuration illustrated in  FIG. 48C . At that point, the control wire  300  may be severed from the implant as has been discussed elsewhere herein. Alternatively, the deployment catheter  320  may be proximally retracted leaving the control wire  300  secured to the implant, and a second portion of the control wire may be secured to a tissue anchor  322  within or on the epicardial surface of the ventricle. Anchor  322  may comprise any of a variety of structures, such as a pledget, button, or other structure that provides a footprint against the epicardial surface to resist retraction of the control wire  300  into the ventricle. The control wire  300  may thereafter be severed proximally of its securement to the anchor  322 , leaving the control wire  300  and anchor  322  in position to span the ventricle and retain the configuration of the implant as illustrated in  FIG. 48D . 
     In all the foregoing embodiments, the final configuration of the implant within the mitral valve is illustrated in a highly schematic form, and the angle and degree of inclination into the direction of the ventricle may be significantly greater than that illustrated herein depending upon the desired clinical performance. The transvalvular band inclination can be highly advantageous in some embodiments in providing clinical benefit as it facilitates “physiologic coaptation” in a preferred manner as its surface mimics the three dimensional feature created by the leaflets as they would have coapted in a healthy native valve. 
     Referring to  FIGS. 49A through 49H , there is illustrated a transapical approach to the mitral valve, and deployment of a transvalvular band in accordance with the present invention. As illustrated in  FIG. 49A , a deployment catheter  320  has been introduced such as via thoracotomy, and advanced retrograde through the mitral valve. A transvalvular band  324  has been deployed distally from the catheter  320 , and is illustrated in  FIG. 49A  in an expanded configuration within the left atrium. Expansion of the transvalvular band  324  from a reduced cross-sectional profile for positioning within the catheter  320  to the enlarged cross-sectional profile illustrated in  FIG. 49A  may be accomplished either under mechanical force, such as by dilatation of an inflatable balloon or other mechanical mechanism. Preferably, however, transvalvular band  324  is self-expandable so that it converts from the reduced profile to the enlarged profile automatically upon deployment from the distal end of the catheter  320 . 
     In the illustrated embodiment, the transvalvular band  324  comprises an arcuate central portion  325 , which is convex in the direction of the ventricle. See  FIGS. 49A and 49B . The transvalvular band  324  is provided with a first attachment structure  326  and a second attachment structure  328 . Attachment structures  326  and  328  may comprise any of a variety of structures disclosed herein, such as tissue anchors, including hooks or barbs. In one implementation of the invention, the first attachment structure  326 , and second attachment structure  328  each comprise a target for receiving an anchor as will be disclosed below. Suitable targets for the present purpose include woven or non-woven fabrics, polymers, or other materials or constructions which permit a needle or sharpened anchor to penetrate therethrough, as will be discussed. In one implementation of the invention, each of the attachment structures comprises a Dacron mesh, having a frame for supporting the mesh and securing the mesh to the transvalvular band  324 . 
     Referring to  FIG. 49B , there is illustrated a perspective view of the transvalvular band  324  illustrated in  FIG. 49A . The transvalvular band  324  comprises a central section  325 , convex in the direction of the ventricle for affecting leaflet closure as has been described herein. Central section  325  is formed by a frame  327 , which comprises at least one strut  329  extending between the first attachment structure  326  and second attachment structure  328 . In the illustrated embodiment, three struts extend generally parallel to each other, defining at least two elongate openings therebetween. One or two or four or more transverse elements  331  may be provided, such as to enhance structural integrity of the construct. At least a first control wire  300  and, optionally a second or third or fourth control wire  300  is releasably attached to the transvalvular band  324 , to enable manipulation of the band into position as shown in  FIG. 49C . Control wire  300  is releasably connected to the transvalvular band  324  at a connection point  301 . The connection at point  301  may be established by threadable engagement, an electrolytically detachable link or weld, or other detachment mechanism. Electrolytically detachable deployment systems are known, among other places, in the neurovascular embolic coil and stent arts, and suitable systems are disclosed in U.S. Pat. No. 5,976,131 to Guglielmi, et al.; U.S. Pat. No. 6,168,618 to Frantzen; and U.S. Pat. No. 6,468,266 to Bashiri, et al., the disclosures of which are hereby incorporated in their entireties herein by reference 
     The first attachment structure  326  comprises a support  333  carried by the frame  327 . In the illustrated embodiment, support  333  comprises an enclosed loop, having a central opening filled or covered by a mesh  337 . The support  333  may alternatively comprise any of a variety of structures, such as a single linear element, sinusoidal or zigzag pattern, depending upon the desired performance. In the illustrated embodiment, the support  333  is conveniently provided in the form of a loop, to facilitate holding mesh  337  in a generally planar configuration, and support the mesh so that it may be punctured by an anchor, suture or other retention structure. A second support  335  is similarly provided with a mesh  337 , to facilitate attachment. The mesh  337  may conveniently be a layer or pad of Dacron or other material, such as an integration of a silicone core with a Dacron jacket, which facilitates both piercing by an attachment structure, as well as tissue in-growth for long term retention. The first support  333  and second support  335  may comprise a radio opaque material, or be provided with radio opaque markers to enable aiming the anchor deployment system into the mesh  337  under fluoroscopic visualization. 
     Once the transvalvular band  324  has been brought into the position illustrated in  FIG. 49C , the first attachment structure  326  and second attachment structure  328  may be secured to the adjacent tissue using any of a variety of clips, staples, barbs, sutures, or other structure which may be conveniently pierced through the mesh  337  and/or looped around the first and second supports  333 ,  335 . The retention element may be approached from either the side of the left atrium, the ventricle, or epicardially, such as by way of a minimally invasive puncture on the chest wall. In the implementation of the method described below, the example of advancing the retention elements from the left ventricle will be described. 
     Referring to  FIG. 49C , proximal traction on the catheter  320  and on the control wire  300 , pulls the transvalvular band  324  snuggly against the left atrial side of the mitral valve, such that the first attachment structure  326  and second attachment structure  328  are seated against the valve annulus. 
     Referring to  FIG. 49D , a first anchor guide  330  and a second anchor guide  332  have been distally advanced from the distal end of the catheter  320 . Anchor guides  330  and  332  may be alternatively associated with or carried by the catheter  320  in a variety of ways. For example, the first and second anchor guides  330  and  332 , may be pivotably carried by the catheter  320 , such that they may be inclined radially outwardly from the longitudinal axis of the catheter in the distal direction. 
     In the illustrated embodiment, the first and second anchor guides comprise a wire or tube for directing an anchor as will be discussed. The wire or tube of the anchor guide may comprise any of a variety of materials, such as nickel titanium alloys (e.g. nitinol) which may be preset to assume a position similar to that illustrated in  FIG. 49D  upon distal advance from the catheter  320 . The first and second anchor guides may be provided with radio-opaque markers, or may be constructed from a radio-opaque material, to permit fluoroscopic guidance. In the illustrated embodiment, the first and second anchor guides are in the form of tubes, for axially slidably receiving a tissue anchor and tissue anchor deployment structures therein. 
     Referring to  FIG. 49E , a retention element in the form of a first anchor  334  is illustrated as having been distally advanced from the first anchor guide  330 , through the tissue in the vicinity of the mitral valve annulus, and through the first attachment structure  326 . Penetration of the first anchor  334  through the first attachment structure  326  may be accomplished while providing proximal traction on the control wire  300 . 
     The first anchor  334  is provided with at least one and preferably two or four or more transverse elements  336  to resist proximal retraction of the first anchor  334  back through the opening formed in the first attachment structure  326 . The transverse element or surface  336  may be provided on any of a variety of structures, such as an umbrella-type structure, t-tag, barbs, or other anchoring configuration which can pass in a first direction through an opening formed in the first attachment structure  326 , but resist retraction in a second, opposite direction, back through the first attachment structure  326 . 
     The transverse element  336  is carried by a filament  338 , which extends through the adjacent myocardial tissue. Filament  338  may comprise any of a variety of materials, such as a monofilament or multi-filament structure made from polypropylene, any of a variety of other known suture materials such as polyethylene, or metals such as stainless steel, nitinol, and others known in the art. The filament  338  may be a mono-filament structure or a multi-filament structure which may be braided or woven, depending upon the desired clinical performance. At least a second, similar anchor  340  is introduced on the opposing side of the mitral valve. 
     Referring to  FIG. 49F , a second transverse element  342  is shown secured to or carried by the ventricular end of the filament  338 , to provide a secure anchoring through the tissue wall for the transvalvular band. A similar structure is provided on the opposing side of the mitral valve. Although only a first and second anchoring systems has been described above, additional anchoring systems, such as a total of four or six or eight or more, typically in even numbers to produce bilateral symmetry, may be used. The number and configuration of tissue anchors will depend upon the configuration of the transvalvular band, as will be apparent to those of skill in the art in view of the disclosure herein. 
     As shown in  FIG. 49F , the anchors have been fully deployed and the first anchor guide  330  and second anchor guide  332  have been proximally retracted into the catheter  320 . 
     Referring to  FIG. 49G , the control wire  300  may thereafter be detached from the transvalvular band and removed. Detachment of control wire  300  may be accomplished in any of a variety of ways, as has been described elsewhere herein. 
     Alternatively, the control wire  300  may be left in place as is illustrated in  FIG. 49H . Control wire  300  is secured to an epicardial anchor  322 , to provide a transventricular truss, as has been described. 
     Referring to  FIGS. 50A and 50B , there is illustrated a side elevational schematic view of the distal end of a deployment catheter  360  which may be adapted for use in either the transapical delivery of  FIGS. 49A-49H , or any other delivery mode described herein. In the illustrated embodiment, the deployment catheter  360  includes an elongate tubular body having a central lumen  362 , opening at a distal end  364 . Carried within the central lumen  362  is a transvalvular band  366 , in a rolled-up configuration. Transvalvular band  366  is maintained in a rolled-up configuration by the constraint imposed by the deployment catheter  360 . However, upon distal advance of the push element  368  to deploy the transvalvular band  366  beyond the distal end  364 , as illustrated in  FIG. 50B , the transvalvular band  366  unrolls under its natural bias into a predetermined configuration for implantation across the mitral valve. 
     One configuration for the transvalvular band is shown rolled out in plan view in  FIG. 51A . However, any of a variety of alternative transvalvular band configurations disclosed herein can be utilized with the catheter of  FIGS. 50A and 50B . 
     Referring to  FIG. 51A , there is illustrated a transvalvular band  366  having a central portion  368  for spanning the coaptive edges of the mitral valve. A first attachment zone  370  and a second attachment zone  372  are provided on opposing ends of the central portion  368 . 
     The central portion comprises at least a first strut  374  for spanning the mitral valve as has been discussed. In the illustrated embodiment, a second strut  376  and a third strut  378  are provided, spaced apart to increase the width of the contact footprint with the valve leaflet but permit blood flow therethrough. A first end of each of the struts  374 ,  376 , and  378  are connected at the first attachment zone  370 , and the second ends of the three struts are connected at the second attachment zone  372 . 
     The first and second attachment zones may be provided with a reinforcing element  382 , to facilitate long term attachment. Apertures  380  are illustrated, which may be provided to allow manual suturing when the transvalvular band  366  is intended for use in an open surgical procedure. Alternatively, apertures  380  may be configured for attachment using an anchor deployment catheter when intended for use in a translumenal or transapical deployment. Each of the first, second and third ribs may be provided with a central core, such as a nitinol or stainless steel wire or ribbon, and an outer coating such as a polycarbonate urethane with or without copolymers like silicone, silicone coating, or a fabric such as PET, ePTFE, polyethylene, or a hybrid of, for example, the aforementioned materials impregnated silicone coating, to reduce the risk of abrasion of the mitral valve leaflets A close-up view of circled zone  51 D of  FIG. 51A  is illustrated in  FIG. 51D . 
       FIG. 51D  illustrates one embodiment of a fatigue-resistant terminal portion of a proximal and/or distal end of one, two, or more of the struts  374 ,  376 ,  378  illustrated in  FIG. 51D . The terminal portion  51 D may have a non-linear portion  378 ′ and a head portion  379 . The non-linear portion could be a coil with a helical, zig-zag, or any other generally non-linear shape to advantageously provide increased fatigue resistance for the struts. In some embodiments, at least a portion of the terminal portion  51 D is embedded in an elastomer such as silicone, polycarbonate, urethane, or the like to further improve fatigue tolerance. In some embodiments, the terminal portion  51 D may have a straight-line length that is less than 20%, 15%, 10%, 5%, or less of the strut. In some embodiments, the terminal portion  51 D may have a straight-line length that is at least about 5%, 10%, 15%, 20%, 25%, or more of the length of the strut, or could even cover the entire length of one, two, or more struts  374 ,  376 ,  378  from first attachment zone  370  to second attachment zone  372  (e.g., a strut without a linear portion). Head portion  379  is operably connected to non-linear portion  378 ′ and the portions may be integrally formed. The head portion  379  could be spherical, ovoid, square, rectangular, triangular, or a variety of other shapes. Head portion  379  is in turn operably connected to first attachment zone  370  and/or second attachment zone  372 . In some embodiments, the head portion  379  is not attached to an attachment zone but rather terminates as a free end of one or more of the struts  374 ,  376 ,  378 . 
       FIG. 51B  is a side elevational view of the transvalvular band  366  of  FIG. 51A , shown in a flat configuration. However, as has been discussed elsewhere herein, the transvalvular band will typically be provided with a curvature such that it advances the mitral valve leaflets in the direction of the ventricle and provides for physiologic coaptation. 
       FIG. 51C  illustrates a perspective view of a transannular band  366  in a rolled-up configuration for delivery, similar to that illustrated in  FIG. 50B . The band can be rolled in a variety of ways, such as capturing the band  366  at or near the center (near  363 ) and rolling it such that both ends are drawn inward as shown. In some embodiments, the band could be rolled up like a scroll, or folded into a “V”, “W”, or a variety of other shapes. In some embodiments, at least a portion of the band  366  resides within one or more slots  363  or movable jaw-like elements on the distal end  363  of a mandrel  367  or other elongate body within a delivery catheter. Actuation of the jaw-like elements to release the band  366 , distal movement of a pusher tube, retraction of the mandrel  367  relative to another catheter, or other mechanism can be employed to deploy the band  366 . In some embodiments, turning the mandrel a desired distance, such as about 90 degrees, can help facilitate unfurling of the band  366  for deployment. 
     Referring to  FIGS. 52A-52C , there is illustrated a transvalvular band in accordance with the present invention having a tissue attachment system which may be adapted for either percutaneous or open surgical use. The transvalvular band comprises a central zone  368  carrying a first attachment zone  370  and a second attachment zone  372  as has been described. 
     A tissue anchor  390 , such as a “t-tag” anchor includes a transverse element  392  and an elongate flexible suture  394 . As used herein, the term “suture” is not limited to its normal definition, but also includes any of a wide variety of elongate flexible filaments, including polymeric, metal, combinations of both as well as monofilament and multifilament structures. Multifilament structures may be braided, woven, or otherwise configured, depending upon the desired performance. 
     The suture  394  is illustrated to extend through a first guide  396  in the second attachment zone  372 . For simplicity, only a single anchoring system will be disclosed herein. However, it should be appreciated that the anchoring system may be utilized on both ends of the central zone  368 , and more than one, such as two or three or more, anchors  390  may be utilized on each attachment zone. 
     The suture  394  is illustrated as extending through first guide  396 , and then through a lock  398  which will be described below. The free end  402  of the suture  394  is further advanced through a second guide  400 . Depending upon the intended use of the system, the free end  402  may extend proximally throughout the length of the deployment catheter, where it may be manipulated such as by proximal traction in order to tighten the second attachment zone  372  with respect to the transverse element  392 . Thereafter, the free end  402  may be severed in the vicinity of the second attachment zone  372  or elsewhere. 
     Referring to  FIG. 52C , details of the lock  398  may be seen. In general, the lock  398  includes an aperture  404  through which the suture  394  may extend. An engaging element  406  is exposed to the interior of the aperture, for permitting the suture to advance in a first direction through the aperture  404  but resist movement of the suture  394  in an opposite direction through the aperture  404 . In the illustrated embodiment, the engaging element  406  is a sharpened point or spike configured to mechanically pierce or engage the suture  394 . 
     The foregoing structure permits the free end  402  to be proximally withdrawn away from the second attachment zone  372  in a manner that draws the transverse element  392  closer to the second attachment zone  372 . However, traction on the transverse element  392  causes the suture  394  to engage the engaging element  406 , and prevents the transverse element  392  from pulling away from the second attachment zone  372 . 
     Referring to  FIG. 52D , illustrated is a suture  394  which can be looped through one, two, or more transverse elements  392  of anchors. The suture  394  looped through the anchor can function as a pulley, where appropriate traction on the suture  394  can tighten the anchors into place. Having a plurality of anchors as shown connected on one loop, such as, for example, 2, 3, 4, 5, or more anchors, can advantageously allow one cinching maneuver to tighten all of the anchors at once. 
     Referring back to  FIG. 52A , an anchor deployment tool  408  is illustrated. Deployment tool  408  may comprise an elongate flexible wire having a proximal end  410  and a distal end  412 . The deployment tool  408  may extend throughout the length of a percutaneous translumenal catheter, with the proximal end  410  exposed or attached to a control to allow axial reciprocal movement of the deployment tool  408 . The distal end  412  is releasably positioned within an aperture  414  on a first end of the transverse element  392 . A second end of the transverse element  392  is provided with a sharpened point  416 . 
     In use, distal axial advance of the deployment tool  408  is utilized to drive the transverse element  392  into a target tissue, to a desired depth. Once the desired depth has been achieved, proximal retraction on the deployment tool  408  proximally retracts the distal end  412  out of the aperture  414 , allowing removal of the deployment tool  408  but leaving the transverse element  392  behind within the target tissue. Proximal traction on the free end  402  of the suture  394  enables tightening of the transvalvular band with respect to the transverse element  392 . Once a desired level of tightening has been achieved, releasing the free end  402  allows engaging element  406  to lock the suture  394  against further release, thereby holding the transvalvular band into position. 
     Although the lock  398  is illustrated as an enclosed aperture, alternative lock embodiments may involve access from a lateral edge of the implant. This permits side-loading of the suture into the lock, which may in some instances be desired over an enclosed aperture which requires end loading of the suture through the aperture. A variety of alternative side-loading lock configurations is illustrated in  FIG. 53 . 
     Referring to  FIG. 54 , there is illustrated a perspective view of an alternate transvalvular band in accordance with the present invention. In this embodiment, the central section  368  is provided with an asymmetrical curvature, to provide asymmetrical support to the mitral valve leaflets. Along the width or central portion of the transvalvular band, this provides a contour mimicking the three-dimensional shape of the coapted mitral valve in a healthy native valve, and provides a physiologic analog thereby promoting correct anatomy during coaptation. 
       FIGS. 55 and 56  illustrate alternative transvalvular bands in accordance with the present invention. In these embodiments, the attachment zones are provided with tissue anchors configured to pierce the tissue of the valve annulus. In general, the tissue anchors each comprise a pointed end, for penetrating tissue and a retention structure for resisting removal of the tissue anchor from the tissue. The retention element in  FIG. 55  is in the form of a first or second barb or shoulder, as will be understood by those skilled in the art. The retention feature of the transvalvular band illustrated in  FIG. 56  comprises an arcuate configuration for the tissue-piercing structure. Compression from the closure of the valve leaflets against the convex side of the central zone will tend to impart a circumferential force on the tissue anchors, advancing the distal point further in the direction of its own arcuate path. This construction tends to allow the natural forces of closure of the mitral valve to increase the retention of the tissue anchor within the adjacent tissue. In some embodiments, the barbs can be used as a primary anchor that can be crimped or otherwise secured in place. In other embodiment, the barbs could act as positioning features, to temporarily hold the band in place while verifying the position. The band could then be anchored in a secondary step, such as using a crimp, staple, suture, or other anchor as described herein. In some embodiments, the barbs can be self-locking upon penetration through tissue. 
     In some embodiments, disclosed is a transvalvular band that provides resistance to coaptation in the same manner as the chordae provides resistance to coaptation in a continuously nonlinear fashion, like a viscoelastic response. This band could have a configuration such as described and illustrated above, and could have material properties or additional features to provide non-linear resistance to coaptation. Such embodiments could retain a curvature mimicking the natural three dimensional surface of the coapted mitral valve yet could displace in the retrograde direction up to the anatomically correct plane of coaption when appropriate. The direction of displacement, for example, with respect to the mitral valve is better described in the atrial direction during systole to provide a cushioned impact for the valve leaflets as opposed to the leaflets striking a ridged implant structure and remodeling in a potentially deleterious fashion such as fibrosis or thinning around impact edges.  FIG. 56A  is reproduced from Nielsen et al, Circulation 2003; 108:486-491 , Influence of Anterior Mitral Leaflet Second - Order Chordae Tendineae on Left Ventricular Systolic Function , which is hereby incorporated by reference in its entirety, illustrating a bilinear relationship between LV pressure and chordal tension during isovolumic contraction, a decrease in chordal tension despite high LV pressure during ejection, and an almost linear decline during isovolumic relaxation.  FIG. 56B  is reproduced from Nielsen et al, J Thorac Cardiovasc Surg 2005; 129:525-31 , Imbalanced chordal force distribution causes acute ischemic mitral regurgitation: Mechanistic insights from chordae tendineae force measurements in pigs , which is incorporated by reference in its entirety. These figures demonstrate that chordae force with respect to time increases and then decays in a non-linear manner during systole. A band mimicking this performance could benefit the valvular surface as it returns its coaptive forces to a near normal state. In some embodiments, a band could cushion or physiologically reduce or prevent physical stress caused by repetitive contact with the coaptive leaflet surfaces. The band could accomplish this by virtue of construction such as chambered struts that may or may not be filled with a media such as a fluid. These chambers would be enclosed and impermeable or substantially impermeable to blood or blood component penetration within a lifetime. Another method of cushioned coaption would be a device that allows some flexing during coaption. This flexibility could be designed based upon strut material, thickness, width, inferior and superior cross-section such as a ripple, or encapsulation material such as an elastomer or elastomeric foam. The foam material could be sealed by an exterior polymer of equal overall flexibility. Additional embodiments would be coils (such as illustrated in  FIG. 51D  above) or coils within coils to produce unique nonlinear displacement signatures or tubes such as Nitinol laser cut tubes that could optionally be filled with a polymer. Yet another embodiment would include struts that loop towards the ventricle crossing itself. This loop would also create this nonlinear resistance to coaption by its spring force. In other embodiments, the band can proceed down to the chordae and devices can be adapted to shorten or augment the chordae to achieve natural physiology. Devices of this manner can be, for example, crimped bands with elastomer bodies between the crimped bands. The elastomeric bodies would replicate the deficient portion of the chordae to mimic the correct force curve during coaptation. This may provide enough benefit in some grades of the disease so as to provide palliative care or resolve it. 
       FIGS. 57A-D  illustrate another embodiment of a transvalvular band  500 , which can also be referred to herein as a transvalvular bridge, e.g., a mitral bridge.  FIG. 57A  is a perspective view of a transvalvular bridge  500  according to some embodiments of the invention. The transvalvular bridge  500  can include a first attachment structure  504  at a first end of the bridge  500  and a second attachment structure  526  at a second end of the bridge  500 , both attachment structures  504 ,  526  of which can include a variety of structures as discussed elsewhere herein for anchoring to the valve annulus. As illustrated, the attachment structures  504 ,  526  can have one or more layers  515  of a velour material such as a Dacron mesh and having a underlying frame for supporting the mesh and securing the mesh to the transvalvular band  500 . The velour could be 6111 Polyester Double Velour Fabric in some embodiments. The mesh material can advantageously promote tissue ingrowth in some embodiments. The attachment structures  504 ,  526  can also include one or a plurality of apertures  508  which can be configured to allow for suturing therethrough, to attach the transvalvular bridge  500  to the valve annulus. 
     Still referring to  FIG. 57A , the transvalvular bridge  500  can also include an arcuate central portion  502  which can be generally convex in the direction of the ventricle. As illustrated, the central portion  502  can include a plurality of struts  516  that cross and form a generally “X” shape at intersection zone or junction  518 . The struts  516  can be made of any appropriate material, such as a metal, e.g., a shape memory metal such as Nitinol. The struts  516  as well as the spaces  514  in between the struts  516  can be treated or coated, e.g., encapsulated with silicone or another appropriate material as described elsewhere herein, in order to eliminate untoward effects such as thrombosis or corrosion. 
       FIG. 57B  is a top view of the transvalvular bridge  500  of  FIG. 57A . As shown, the central portion  502  spans between the first attachment portion  504  and the second attachment portion  526 , and can have a transverse width laterally that is substantially the same as that of the attachment portions  504 ,  526 , but can become narrower toward the center toward intersection zone  518 . In some embodiments, the width C in the central intersection zone  518  (measured perpendicular to blood flow) is between about 20% and about 80%, such as between about 25% and about 50%, or about 20%, 25%, 30%, 35%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% of the width of the central portion  502  just proximate to the attachment portions  504 ,  526 , and can gradually narrow toward the center as illustrated. In some embodiments, the width C in the central intersection zone  518  can be between about 4 mm and about 7 mm, such as between about 5 mm and about 6 mm, or about 5 mm, about 5.2 mm, about 5.4 mm, about 5.6 mm, about 5.8 mm, or about 6 mm, or ranges incorporating any of the foregoing values. By narrowing the central portion  502 , the resistance to blood flow can advantageously be reduced. 
       FIG. 57C  is a side view of the transvalvular bridge  500  illustrated and described in connection with  FIGS. 57A-B . In some embodiments, the thickness T 2  of the central portion  502  can be defined by the strut  516  and the encapsulation layer  514  surrounding the strut. In some embodiments, the thickness T 1  of the attachment portions  504 ,  526  can be defined by the ends of the struts  516 , an encapsulation layer  514  surrounding the strut  516 , and/or the velour material layer(s)  515  as previously described. The attachment portions  504 ,  526  can have a relatively greater thickness than the thickness of the central portion  502 . In some embodiments, the attachment portions  504 ,  526  can have a thickness that is between about 25% and about 75% greater than that of the central portion  502 , such as between about 40% and about 60% greater, or about 25%, 30%, 40%, 45%, 50%, 55%, 60%, 65%, 70%, or 75% greater than the thickness of the central portion  502 . In some embodiments, the central portion  502  can have a thickness T 1  of between about 0.5 mm and about 1.0 mm, such as about 0.6 mm, 0.7 mm, or 0.8 mm, or ranges incorporating any of the foregoing values. In some embodiments, the attachment portions  504 ,  526  can have a thickness of between about 0.8 mm and about 1.3 mm, such as about 0.9 mm, 1.0 mm, 1.05 mm, 1.07 mm, 1.1 mm, or 1.2 mm, or ranges incorporating any of the foregoing values. 
     Still referring to  FIG. 57C , the transvalvular bridge  500  can have an entire axial length A in some embodiments of between about 15 mm and about 40 mm, such as between about 20 mm and about 32 mm depending on the patient&#39;s anatomy. The central portion  502  of the transvalvular bridge  500  can have an axial length in some embodiments of between about 8 mm and about 24 mm, such as between about 12 mm and about 20 mm in some embodiments. 
       FIG. 57D  illustrates an end view of the transvalvular bridge  500  illustrated and described in connection with  FIGS. 57A-C  above, showing the struts  516 , silicone encapsulation layer  514 , and attachment portion  514 . In some embodiments, the width W of the attachment structures  504 ,  526  can be between about 10 mm and about 20 mm, and about 15 mm in some embodiments. 
       FIGS. 57E-H  illustrate views of the underlying skeleton layer  560  of the transvalvular bridge  500 , and can be formed of a shape set Nitinol skeleton that can be convex in the direction of the ventricle as previously described.  FIG. 57E  is a perspective view of the shape memory skeleton  560  of the transvalvular bridge  500 , which can include struts  516  that cross at intersection zone  518  as previously described. The lateral ends of the skeleton  560  can include rings  509  defining apertures  508  that can be utilized for suturing as previously described. The skeleton layer  560  contribution to the central portion  502  of the transvalvular band  500  can include lateral curved transition zone  521  of the struts  516 , which has a first curvature; which is in turn connected to medial curved transition zone  522  of the strut  516  which has a second curvature different from the first curvature; and the intersection zone  518  which includes the vertex of the arcuate central portion  502 .  FIG. 57F  is a top view of the skeleton layer  560  of  FIG. 57E . As illustrated, in some embodiments the lateral curved transition zones  521  of the struts  516  can, while configured to slope downwardly as shown, can run substantially parallel to the longitudinal axis of the skeleton  560  (and that of the transvalvular bridge  500 ), while the medial curved transition zone  522  can be oblique to the longitudinal axis of the skeleton  560  and the transvalvular bridge  500 . In some embodiments, the axial length CC of the skeleton layer  560  can be between about 13 mm and about 25 mm, and the width BB of each strut  516  can be between about 1 mm and about 2 mm, such as between about 1.3 mm and about 2.0 mm.  FIG. 57G  is a side view, and  FIG. 57H  is an end view of the shape set Nitinol skeleton of  FIGS. 57E-F . 
     As described above, the mitral valve and supporting structures are composed of the valve annulus, two leaflets, chordae tendineae, and papillary muscles. The anterior and posterior leaflets, oriented in the septal-lateral direction, provide for closing the valve opening during systole. During systole, the annulus and valvular surface create a saddle shape optimizing forces during closure by arching. The chordae and papillary muscles work together to limit the leaflet coaptation to the intraannular plane. 
     Qualitative Motion and Load on the Mitral Bridge: The mitral valve has a saddle shape. As the saddle gets deeper, the commissures drop, and the anteroposterior diameter contracts. This contraction results in a compressive load on the transvalvular bridge. During this contraction, the pressure behind the leaflets causes them to contact the transvalvular bridge strut. In some embodiments, the mitral bridge is configured to withstand a total circumferential or compressive force applied to the Mitral Bridge of at about or at least about 0.35N, 0.40N, 0.45N, 0.50N, or about 0.368N per cardiac cycle in some embodiments. In some embodiments, the Mitral Bridge can be configured to tolerate a septal-lateral displacement of about or at least about 0.4 mm, 0.5 mm, or 0.6 mm during the cardiac cycle. As such, the mitral bridge can be configured to withstand load in cyclic fatigue without damage allowing long term function; maintain an AP diameter or septal-lateral diameter for early coaptation eliminating regurgitation; and/or maintain an AP diameter facilitating LV remodeling. 
     Quantitative Leaflet Loads: The force acting on a papillary muscle can be, in some embodiments, between 3.97 and 6.42 N dependent upon systolic pressure typically ranging between 120 and 200 mmHg. There are two papillary muscles. If both muscles were not functioning, the load acting on the mitral valve leaflets would be 13 N. The force transferred to the mitral bridge can be calculated by using the ratio of the total orifice area to the area of the mitral bridge strut. The orifice and MB strut areas are typically 1000 mm 2  and 100 mm 2 , respectively. The resulting load on the MB strut is about 1.3 N. This is the load that the mitral bridge would see if the chordate and papillary muscles were not absorbing any load. Therefore, in some embodiments, the mitral bridge can be configured to withstand a leaflet load of between about 1N and about 2N, or about or at least about 1.2N, 1.3N, 1.4N, or 1.5N to withstand loads without damage, allowing for long-term function. 
     Quantitative Motion on the Mitral Bridge: Based upon a six month Chronic Porcine Study of the mitral bridge, the echo analysis of that study showed no perceptible displacement of device from the Septal-Lateral (SL) plane. However, in some embodiments the mitral bridge can be configured to tolerate a displacement of about 0.5 mm in compression and tension. The average force to displace a device ±0.5 mm is between about 0.80N and about 0.85N, such as about 0.8358N in tension; and between about 0.60N and about 0.70N, such as about 0.63808N in compression. The forces found are over double the circumferential forces. The mitral bridge can be configured, when implanted, to withstand such forces and continue to stably function to improve valve coaptation without being damaged, displaced, or substantially displaced as noted above. The mitral bridge can thus be configured to tolerate, in some embodiments, a tension force of about or at least about 0.75N, 0.80N, 0.85N, 0.90N, 0.95N, 1.00N, or more. The mitral bridge can thus be configured to tolerate, in some embodiments, a compression force of about or at least about 0.55N, 0.60N, 0.65N, 0.70N, 0.75N, 0.80N, or more. 
       FIGS. 58-70  illustrate a system of delivery catheters  600  configured for use with the mitral devices described herein. While the system of delivery catheters  600  is described herein for use with the transvalvular bridge  500 , any of the mitral devices described herein can be used with the devices and methods described herein. Referring back to  FIG. 57A , the transvalvular bridge  500  comprises the first attachment structure  504  at the first end of the bridge  500  and the second attachment structure  526  at the second end of the bridge  500 . The arcuate central portion  502  permits the transvalvular bridge  500  to be folded or otherwise compressed for delivery within a deployment catheter, and later expanded in a manner that permits the transvalvular bridge  500  to function as described. The attachment structures  504 ,  526  can include one or a plurality of apertures  508  which can be configured to allow for suturing therethrough, to attach the transvalvular bridge  500  to the valve annulus. In the illustrated embodiment, each of the attachment structures  504 ,  526  comprises two apertures  508 . 
       FIG. 58  illustrates features of the anatomy of the heart. A system of cardiovascular catheters  600  is used to percutaneously deliver the transvalvular bridge  500  to the mitral valve for the repair of the mitral valve. The transvalvular bridge  500  can be securely attached to the mitral valve annulus at four points, that is P 1 , P 3 , A 1 , and A 3 . Locations A 1  and A 3  can be located on the anterior leaflet. Locations P 1  and P 3  can be located on the posterior leaflet. The locations P 1 , P 3 , A 1 , and A 3  can correspond to the apertures  508  in the attachment structures  504 ,  526  of the transvalvular bridge  500 . The transvalvular bridge  500  can be secured to provide coaptation of the mitral valve leaflets. The coaptation can be observable via various visualization techniques. 
       FIGS. 59A-59C  illustrate features of the cardiovascular catheters  600 . The cardiovascular catheters  600  described herein are intended for transcatheter implantation of the transvalvular bridge  500 . This method is in contrast to an open-surgical implantation. An overview of the transcatheter implantation of the transvalvular bridge  500  can include one or more of the following steps. The patient can be anesthetized. An introducer catheter  602  can be introduced through the femoral vein. The introducer catheter  602  can be any commercially available introducer catheter. The method can include the step of inserting the introducer catheter  602 . Imaging can be used throughout the procedure to ensure proper positioning. Imaging techniques can include fluoroscopy and 2D/3D/4D TTE imaging modalities. In some methods of use, a guide catheter  604  can be positioned in the right ventricle. In some methods of use, the guide catheter  604  can be positioned in the right atrium. The guide catheter  604  can be 12 F but other dimensions are contemplated. A septal needle  606  can be inserted through the guide catheter  604 . The septal needle  606  can puncture through the atrial septum. The puncture can be located at the 12 o&#39;clock position, proximate the fossa ovalis. The guide catheter  604  can allow for subsequent dilation and advancement of the guide catheter  604 . The guide catheter  604  can be advanced into the left atrium. 
     The needle catheter  610  can be delivered through the guide catheter  604 . The needle catheter  610  can include multiple components, as described herein. The needle catheter  610  can be positioned to deliver a retainer  612 . The position for delivery may be located at approximately P 3 . The needle catheter  610  can deliver the retainer  612  via sub-annular puncture. The needle catheter  610  can deliver the retainer  612  via a pressure or force. The needle catheter  610  can deliver the retainer  612  by applying electrical energy to create a hole. The hole can be created in the annulus. The hole can be created in a leaflet. One or more holes can be created. The needle catheter  610  or a portion thereof can be pushed through the hole. The retainer  612  can be positioned and delivered by being pushed from the needle catheter  610 . The retainer  612  can be deployed. The needle catheter  610  can be withdrawn. A suture tail of the retainer  612  can be left exteriorized through the venous access. The process can be repeated to deploy one or more additional retainers  612 . The additional retainers  612  can be placed at approximately P 1 , A 1  and A 3 . In some methods of use, two or more retainers  612  are deployed simultaneously. In some methods of use, two or more holes are created simultaneously. 
     The transvalvular bridge  500  can be loaded into a deployment catheter  614 . The transvalvular bridge  500  can be crimped to fit within the deployment catheter  614 . The deployment catheter  614  can be delivered near the annulus. The transvalvular bridge  500  can be deployed. A dilator  616  can be delivered through the deployment catheter  614 . The dilator  616  can allow for suture management and cinching. 
     The transvalvular bridge  500  can be secured by advancing a clip  620 . The clip  620  can be advanced via a pusher  622 . The clip  620  can be advanced toward the transvalvular bridge  500 . The pusher  622  can extend through the deployment catheter  614 . The suture can be trimmed via a trimming catheter  624 . The trimming catheter  624  can extend through the deployment catheter  614 . The implantation of the transvalvular bridge  500  can be viewed through imaging techniques. The cardiovascular catheters  600  can be withdrawn. The incision can be closed. 
     In some embodiments, one or more catheter can be transseptal (TS) catheters. The transseptal catheters can include catheters delivered via the atrial septum. The transseptal catheters can include the introducer catheter  602 . The introducer catheter  602  can be a transfemoral introducer. The transseptal catheters can include the guide catheter  604 . The transseptal catheters can include needle catheter  610 . The transseptal catheters can include the deployment catheter  614 . The transseptal catheters can include the dilator  616 . The one or more transseptal catheters can deploy on the atrial side of the mitral valve (in other words, upstream in the direction of blood flow of a cardiac valve). 
     In some embodiments, the system  600  can include one or more transapical (TA) catheters. The transapical catheters can include an introducer  702 . The transapical catheters can include a guide catheter  704 . The transapical catheters can include an anvil delivery catheter  706 . The transapical catheters can include a cinching catheter  708 . The one or more transapical catheters can deploy on the ventricular side of the mitral valve (in other words, downstream in the direction of blood flow of a cardiac valve). The one or more transseptal catheters and the one or more transapical catheters can deploy on opposite sides of the annulus. The deployment of the system  600  can be considered a hybrid approach. 
       FIG. 60  illustrates the locations of insertion for the one or more transseptal catheters and the one or more transapical catheters. The method can include one or more of the following steps. The introducer catheter  602  can be inserted through a transfermoral approach. The introducer catheter  602  can be inserted through a transseptal approach. The introducer  702  can be inserted through a transapical approach. The guide catheter  604  can be inserted through a transfermoral approach. The guide catheter  604  can be inserted through a transseptal approach. The guide catheter  704  can be inserted through a transapical approach. The deployment catheter  614  can be inserted through a transseptal approach. The anvil delivery catheter  706  can be inserted through a transapical approach. The needle catheter  610  can be inserted through a transseptal approach. The cinching catheter  708  can be inserted through a transapical approach. The dilator  616  can be inserted through a transseptal approach. 
     The deployment of the sutures can be through a transseptal approach. The suture retrieval can be through a transapical approach. The suture count and management can be through a transapical approach. The cinching can be through a transapical approach. The deployment of the transvalvular bridge  500  can be through a transseptal approach. The knotting can be through a transapical approach. The suture can be cut through a transapical approach. The withdrawal of the one or more catheters can be through a transseptal approach. The withdrawal of the one or more catheters can be through a transapical approach. The closure can be through a transapical approach and/or through a transseptal approach. 
     In some embodiments, the delivery is through a singular location. The method can include delivery of the one or more transseptal catheters. The introducer catheter  602  can be inserted at described herein. The guide catheter  604  can be inserted as described herein. In the atrium, the needle catheter  610  can be deployed. In the atrium, the deployment catheter  614  can be deployed. In the subvalvular region, the anvil delivery catheter  706  can be deployed. In the subvalvular region, the cinching catheter  708  can be deployed. The anvil delivery catheter  706  can be inserted transaortically. The anvil delivery catheter  706  can be inserted through a transmitral approach via transseptal access. 
       FIGS. 61A-61G  illustrates an example of the hybrid approach.  FIG. 61A  shows an embodiment of transseptal (TS) catheters. The guide catheter  604  is shown as a sheath. The deployment catheter  614  extend through the guide catheter  604  to the atrium to deploy the transvalvular bridge  500 . The needle catheter  610  can extend through the guide catheter  604  to the atrium. Referring to  FIG. 61B , the needle catheter  610  can deploy one or more needles  628 . In the illustrated embodiment, the needle catheter  610  deploys three needles  628 . In some embodiments, three retainers  612  are deployed by the three needles  628 . In some embodiments, six retainers  612  are deployed (e.g., two sets of three retainers  612 ). In some embodiments, the needle catheter  610  deploys six needles  628 . The six needles  628  can correspond to six retainers  612 . 
     The deployment catheter  614  can include a port  640 . The port  640  can allow deployment of the transvalvular bridge  500 . The transvalvular bridge  500  can exit the deployment catheter  614  through the port  640 . The port  640  can be located on a side surface of the deployment catheter  614 . The retainers  612  can be coupled to the transvalvular bridge  500  prior to deployment of the transvalvular bridge  500 . In some embodiments, a suture  654  of the retainer  612  extends through an aperture  508  of the transvalvular bridge  500 . In some embodiments, two or more sutures corresponding to two or more retainers are coupled to the transvalvular bridge  500  prior to deployment. 
     The one or more needles  628  can be designed to interact with an anvil  710 . The anvil  710  can be delivered to a sub annular location via the anvil delivery catheter  706 . The anvil  710  can include one or more slots  712 . In some embodiments, the number of slots  712  can correspond to the number of needles  628 . In the illustrated embodiment, the anvil  710  includes three slots  712 . The slot  712  can be sized and shaped to accept the needle  628  therethrough. The needle  628  can extend through the anvil  710  in a direction transverse to the longitudinal axis  714  of the anvil  710 . 
     The anvil  710  is designed to be deployed to support the annulus. The anvil  710  can have a first configuration wherein the longitudinal axis  714  of the anvil  710  is generally parallel to a longitudinal axis of the anvil delivery catheter  706 . The longitudinal axis  714  of the anvil  710  can be coaxial with the longitudinal axis of the anvil delivery catheter  706 . The first configuration can be a low profile configuration. The anvil  710  can be deployed within the left ventricle. The anvil  710  can be pivoted. The anvil  710  can have a second configuration wherein the longitudinal axis  714  of the anvil  710  is generally perpendicular to a longitudinal axis of the anvil delivery catheter  706 . The anvil  710  can lie against the annulus. The anvil  710  can support the annulus. The slot  712  of the anvil  710  can be in position to accept the needle  628 . The second configuration can be a deployed configuration. The anvil  710  can include a lock  716 . The lock  716  can maintain the position of the anvil  710  in the second configuration. The lock  716  can maintain the position of the anvil  710  relative to a control arm  718 . The anvil  710  can be hinged relative to the control arm  718 . In some embodiments, the control arm  718  is rigid. In some embodiments, the control arm  718  is flexible. The angle between the anvil  710  and the control arm  718  can be approximately ninety degrees. Other configurations are contemplated (e.g., 30 degrees, 40 degrees, 50 degrees, 60 degrees, 70 degrees, 80 degrees, 90 degrees, 100 degrees, 110 degrees, 120 degrees, etc.). The anvil  710  can lock at 290 degrees. 
     As described herein, the retainer  612  can be loaded into the needle  628 . The retainer  612  can include a pledget  652 . The retainer  612  can include the suture  654 . The needle can deliver the retainer  612  through the slot  712  in the anvil  710 . The retainer  612  can be considered an uncrimped suture tag. The retainer  612  can include a suture pinch point. 
       FIG. 61C  illustrates the trajectory of the needle  628 . In some embodiments, the one or more needles  628  extend along a straight path through the needle catheter  610 . In some embodiments, the one or more needles  628  extend in a straight path from the needle catheter  610 . The trajectory of the needle  628  can be linear. In some embodiments, the one or more needles  628  extend along a non-linear, curved or helical path through the needle catheter  610 . In some embodiments, the one or more needles  628  extend in non-linear path from the needle catheter  610 . The trajectory of the needle  628  can be non-linear. As described herein, the needle catheter  610  can be steerable. The needle catheter  610  can curve. The curvature of the needle catheter  610  can align the trajectory of the one or more needles  628  with the slots  712  in the anvil  710 . In some embodiments, two or more needles  628  are designed to be simultaneously inserted into two or more slots  712 . In some embodiments, two or more needles  628  are designed to deliver retainers  712  simultaneously through two or more slots  712 . 
       FIGS. 61D and 61E  illustrates a method of using the anvil  710 . The anvil  710  can be moved into position relative to the annulus. The anvil  710  can be pivoted relative to the control arm  718 . The anvil  710  can be locked relative to the control arm  718 . In the locked configuration, the anvil  710  supports a larger cross-section of the annulus. The needle  628  can be aligned with the slot  712  of the anvil  710 . The retainer  612  can be disposed within the needle  628 . The suture  654  of the retainer  612  can be coupled to the transvalvular bridge  500 . The suture  654  can span from the needle catheter  610  to the transvalvular bridge  500 . A plunger  656  can be disposed within the needle catheter  610 . The anvil  710  can be held in position via the lock  716  during delivery of the retainers  612 . 
     The needle  628  can be advanced to puncture the annulus, as described herein. The needle  628  can be advanced such that the needle  628  burns a hole in the annulus, as described herein. The needle  628  can be advanced through the slot  712  of the anvil  710 . The needle  628  can deliver the retainer  612  through the annulus. The plunger  656  can be advanced to push the retainer  612  through the needle  628 . The plunger  656  can cause the retainer  612  to enter the left ventricle. The retainer  612  can be subannular. The suture  654  of the retainer  612  can span from the retainer  612  to the transvalvular bridge  500 . The suture  654  of the retainer  612  can span the annulus from the left ventricle to the left atrium. 
       FIG. 61F  illustrates the cinching catheter  708 . The transvalvular bridge  500  can be deployed and positioned relative to the annulus. As described herein, the transvalvular bridge  500  can be coupled to the suture  654  of the retainer  612 . The suture  654  can extend through the annulus from the pledget  652 . The anvil  710  can separate the pledget  652  from the annulus after the retainer  612  is deployed. The anvil  710  can be retracted into the anvil delivery catheter  706 . The anvil  710  causes the pledget  652  to move toward the anvil delivery catheter  706 . The cinching catheter  708  can cause the anvil delivery catheter  706  to move inward. In the illustrated embodiment, the cinching catheter  708  controls two anvil delivery catheters  706 . The cinching catheter  708  can cause the two anvil delivery catheters  706  to move toward each other. The cinching catheter  708  can cause the two anvil delivery catheters  706  to become more linear or straighter. The cinching catheter  708  can cause the transvalvular bridge  500  to be cinched. The cinching catheter  708  can cause the transvalvular bridge  500  to be cinched. The cinching catheter  708  can cause the attachment structures  504 ,  526  of the transvalvular bridge  500  to move toward each other. 
       FIG. 61G  illustrates a method. The method can include one or more of the following steps. The method can include the step of holding all of the sutures  654 . The anvil  710  can enable one or more retainers  612  to be held. In the illustrated embodiment, three retainers  612  are held by the anvil  710 . The method can include withdrawal of the anvil  710 . The anvil  710  can be retracted into the anvil delivery catheter  706 . The method can include withdrawal of the anvil delivery catheter  706 . The anvil delivery catheter  706  can be withdrawn into the cinching catheter  708 . The method can include removal of the pledget  652  or tag. The pledget  652  can be removed while the suture  654  is held in position. In some methods of use, the suture  654  is held in tension from the ventricular side of the annulus. In some methods of use, the suture  654  is held in tension from the atrial side of the annulus. The method can include loading a suture fastening system such as a COR-KNOT device (LSI Solutions, Inc., Victor, N.Y.). The method can include loading a pledget. The method can including cinching. The cinching can apply tension to the transvalvular bridge  500 . The cinching can apply tension to the pledget  652 . The cinching can apply tension to the suture  654 . The cinching can apply tension to the anvil  712 . The cinching can move one or more components of the system into position. The method can include deploying the suture fastening system. 
       FIG. 62  illustrates the needle catheter  610 . The needle catheter  610  can include the needle  628 . The illustrated embodiment includes two needles  628  but other configurations are contemplated (e.g., one needle, two needles, three needles, four needles, five needles, six needles, etc.). The two needles  628  can be similar or identical. The two needles  628  can be oriented to be a mirror image. The needle  628  can be designed for puncturing the annulus. The needle  628  can include a sharpened tip  630 . The sharpened tip  630  can be any design to allow for puncture. In the illustrated embodiment, the sharpened tip  630  is tapered from an inside surface to an outside surface. The needle  628  can be cylindrical. The needle  628  can include a lumen  632 . In some embodiments, the transvalvular bridge  500  can be disposed within the needle catheter  610 . In some embodiments, the transvalvular bridge  500  can be designed to span the distance from between the needles  628 . In some embodiments, the transvalvular bridge  500  can be designed to be deployed by advancing through the end of the needles  628 . 
     The needle catheter  610  can use fluid pressure to deliver the needle  628 . In some methods of use, the needle catheter  610  can allow for hydraulic or compressed air delivery of the needle  628 . The needle catheter  610  can include a flexible pressure vessel  634 . The flexible pressure vessel  634  can include a fluid chamber. The fluid can be gas or liquid. The fluid can be air. The flexible pressure vessel  634  can be flexible to enable the needle catheter  610  to flex or turn. The flexible pressure vessel  634  can allow components to apply a pressure or force on other components within the needle catheter  610 . The needle catheter  610  can include a pressure plate  636  for an internal pusher or plunger. The pressure plate  636  allows a pressure or force to be applied to the internal pusher or plunger. For instance, a pressure or force can be applied to move the retainer  612 . For instance, a pressure or force can be applied to move the transvalvular bridge  500 . The needle catheter  610  can include a pressure plate  638  for the needle  628 . The pressure plate  638  can allow a pressure or force to be applied to the needle  628 . For instance, a pressure or force can be applied for sub-annular puncture. The needle catheter  610  can include a catheter port  640 . The catheter port  640  can allow the flexible pressure vessel  634  to be filled with fluid. 
       FIGS. 63A and 63B  illustrate perspective views of the needle  628 . The needle  628  can include an energy tip  644 . The energy tip  644  can delivery energy such as RF energy to the tissue. The energy tip  644  can be an electrode. The energy tip  644  can be coupled to the needle  628 . The energy tip  644  can be integrally formed with the needle  628 . The energy tip  644  can be located within a detent  646  of the needle  628 . The detent  646  can enable the energy tip  644  to be partially or entirely disposed within the detent  646 . The detent  646  can change the cross-sectional shape of the lumen  632  as shown in  FIG. 60B . The energy tip  644  can be designed to burn through the annulus. The energy tip  644  can be designed to the puncture through the annulus. The energy tip  644  can be located at the distalmost edge of the needle  628 . The energy tip  644  can protrude past the distalmost edge of the needle  628  such that the energy tip  644  is the first to contact the annulus. The needle  628  can include a slot  648 . 
       FIG. 63C  illustrate various additional views of the needle  628 . Referring to  FIG. 60C , the energy tip  644  can be a sleeve. The energy tip  644  can partially surround the needle  628 . The energy tip  644  can be coupled to an energy source (not shown). The energy source can supply the energy tip  644  with energy such as electrical energy. The energy tip  644  can convert the electric energy to RF energy. The energy tip  644  can enable RF heating. The energy tip  644  can enable the application of a high-frequency or radiofrequency electric current to biological tissue such as the annulus. The energy tip  644  can allow the tissue to be cut. The energy tip  644  can also coagulate blood or blood vessels or cauterize the tissue. The needle catheter  610  can include a sheath (not shown) which covers the needles  628  during delivery. The sheath can cover the energy tip  644 . 
     In some methods of use, the user locates the position and uses low force for penetration of the needle  628 . In some methods of use, the energy tip  644  can be a guide for the incising needle  628 . The energy tip  644  can be collinear with the needle  628 . The initial penetration can be with the energy tip  644 . The secondary penetration can be with the needle  628 . The energy tip  644  can be co-linear with the needle catheter  610 . The energy tip  644  can be co-axial with the needle catheter  610 . In some embodiments, suction is used to locate and provide puncture counterforce. 
       FIGS. 64A and 64B  illustrate the deployment of the retainer  612 . The retainer  612  can include the pledget  652 . The pledget  652  can be cylindrical or any shape known in the art (rectangular, square, oval, elliptical, etc.). The pledget  652  can be shaped to be disposed within the lumen  632  of the needle  628 . The pledget  652  can be formed from a plastic or polymer materials. The pledget  652  can comprise polytetrafluorethylene (PTFE). The pledget  652  can be sterile and non-absorbable. The retainer  612  can include the suture  654 . The pledget  652  can be coupled the suture  654 . The suture  654  can be formed from a plastic or polymer materials. The suture  654  can comprise polyethylene terephthalate (PET). The suture  654  can be any size known in the art. In the illustrated embodiments, the suture  654  is size 2 (2-0). The retainer  612  can secure the transvalvular bridge  500  in the annulus. The retainer  612  can be used to replicate open implants. The retainer  612  can be disposed within the needle catheter  610 . The retainer  612  can be a self-locking slice for single column. The retainer  612  can be double locked by the clip  620 . The retainer  612  can hold the transvalvular bridge  500  in place. The retainer  612  can hold greater than the suture strength in the annulus. 
     Referring to  FIG. 64A , the retainer  612  can be loaded into the lumen  632  of the needle  628 . The suture  654  can be attached to the pledget  652  before being loaded into the needle  628 . The retainer  612  can be disposed in a first orientation. In the first orientation, the pledget  652  of the retainer  612  can have a longitudinal axis aligned with the longitudinal axis of the lumen  632  of the needle  628 . The suture  654  can extend from the distal end of the needle  628 . The suture  654  can extend through the slot  648  of the needle  628 . The suture  654  can extend toward the proximal end of the needle  628 . The suture  654  can be held within the needle catheter  610  during delivery. The retainer  612  can be disposed in the needle  628  during delivery through the annulus. 
     In the first orientation, the pledget  652  of the retainer  612  can have a longitudinal axis aligned with the longitudinal axis of the hole created by the needle  628 . As described herein, the energy tip  644  can burn a hole in the annulus. The needle  628  can enlarge the hole created by the energy tip. The needle  628  can puncture the annulus. The needle  628  can be delivered through the hole. The retainer  612  can be delivered through the hole created by the energy tip  644 . The retainer  612  can be delivered through the hole created by the needle  628 . 
     Referring to  FIG. 64B , the retainer  612  can be deployed. The needle catheter  610  can include the plunger  656 . The plunger  656  can be advanced along the lumen  632  of the needle  628 . The plunger can push the retainer  612  out of the needle  628 . The pledget  652  of the retainer  612  can be plunged out of the needle  628 . The pledget  652  can be disposed on the other side of the annulus. The suture  654  of the retainer  612  can span the annulus. The retainer  612  can be disposed in a second orientation. In the second orientation, the pledget  652  of the retainer  612  has a longitudinal axis not aligned with the longitudinal axis of the lumen  632  of the needle  628 . In some methods of use, the longitudinal axis of the pledget  652  is ninety degrees from the longitudinal axis of the lumen  632  of the needle  628 . In some methods of use, the longitudinal axis of the pledget  652  is transverse to the longitudinal axis of the lumen  632  of the needle  628 . In some methods of use, the pledget  652  is rotated during deployment. The needle catheter  610  can be withdrawn after deployment of the retainer  612 . Referring back to  FIG. 60 , the pressure plate  636  allows a pressure or force to be applied to the plunger  656 . The pressure plate  636  can enable the plunger  656  to deploy the retainer  612 . 
     Referring to  FIG. 62 , the needle catheter  610  can deliver two retainers  612 . In some methods of use, the needle catheter  610  can be moved to another location. The needle catheter  610  can deliver two additional retainers  612 . In some methods of use, the needle catheter  610  can deliver four retainers  612 . The needle catheter  610  can create the number of holes corresponding to the number of apertures  508  of the transvalvular bridge  500 . In the illustrated embodiment, the needle catheter  610  can create four holes corresponding to the four apertures  508  of the transvalvular bridge  500 . After the retainers  612  are deployed, four sutures  654  can span the annulus. 
       FIG. 64C-64E  show a single needle catheter  658 . The single needle catheter  658  can include any of the features of needle catheter  610 . The single needle catheter  658  can include the needle  628 . The needle  628  can include the sharpened tip  630 . The needle  628  can include the lumen  632 . The single needle catheter  658  can include the energy tip  644 . The needle  628  can include the detent  646 . Referring to  FIG. 64D , the single needle catheter  658  can be designed to deliver the retainer  612 . The single needle catheter  658  can deliver one retainer  612 . The single needle catheter  658  can include the plunger  656 . The plunger  656  can extend through the lumen  632  of the needle  628  to deploy the retainer  612 .  FIG. 64E  shows various components decoupled. 
       FIG. 65A-65G  illustrate the deployment of the transvalvular bridge  500 . The transvalvular bridge  500  can be deployed via the deployment catheter  614 . In some embodiments, the transvalvular bridge  500  can include an asymmetric feature to wrap the transvalvular bridge  500  around with a sheath. The transvalvular bridge  500  can be cinched to reduce diameter. The transvalvular bridge  500  can be folded within the deployment catheter  614  such that an inner diameter of the deployment catheter  614  is available for passage of other devices. The output of crimping creates a capsule encompassing the transvalvular bridge  500 . The transvalvular bridge  500  can be deployed with the use of the dilator  616 . The transvalvular bridge  500  can be unsheathed from the deployment catheter  614 . The transvalvular bridge  500  can be deployed such as by unrolling the transvalvular bridge  500 . Referring to  FIG. 65A , the dilator  616  can move the transvalvular bridge  500  toward the annulus. The dilator  616  can maintain the position of the one or more sutures  654  relative to the transvalvular bridge  500 . The dilator  616  can function to allow for suture management. The dilator  616  can function to cinch the sutures  654 . The dilator  616  can also function to cinch the transvalvular bridge  500 . 
     Referring to  FIG. 65B , the deployment catheter  614  can be moved away from the transvalvular bridge  500 . The dilator  616  can be partially withdrawn into the deployment catheter  614 . The deployment catheter  614  can include a plurality of pushers  622 . Each pusher  622  can include a lumen  660 . In some embodiments, each retainer  612  can include a single suture  654 . In some embodiments, each retainer  612  can include two or more sutures  654 . Prior to delivery of the transvalvular bridge  500 , each suture  654  can be passed through a lumen  660  of the pusher  622 . The pusher  622  can extend along a length of the suture  654 . The deployment catheter  614  can include the one or more pushers  622 . In the illustrated embodiment, the dilator  616  can include four pushers  622  for the four sutures  654 . The number of pushers  622  can correspond to the number of retainers  612  deployed. The number of pushers  622  can correspond to the number of sutures  654  deployed. 
     Referring to  FIG. 65C , the pusher  622  can be moved toward the transvalvular bridge  500 . In some methods of use, two or more pusher  622  can move simultaneously. In some methods of use, one or more pushers  622  are moved independently of another pusher  622 . The one or more pushers  622  are moved toward the transvalvular bridge  500  as shown in  FIG. 65D . The pusher  622  can be flexible to be deflected outward when moved toward the transvalvular bridge  500 . The pusher  622  can follow the path of the suture  654  disposed within the lumen  660 . As the pusher  622  is moved toward the transvalvular bridge  500 , the suture  654  can be managed. The suture  654  can straighten. The suture  654  can be detangled. The pusher  622  can cinch the suture  654 . The one or more pushers  622  can move the transvalvular bridge  500  into position. The one or more pushers  622  can move the transvalvular bridge  500  against the annulus. The one or more pushers  622  can move the transvalvular bridge  500  such that the apertures  508  align with holes created by the needle catheter  610 . The one or more pushers  622  can move the transvalvular bridge  500  such that the apertures  508  align with P 1 , P 3 , A 1 , and A 3  described herein. 
     In some embodiments, each suture  654  can include a single clip  620 . Prior to delivery of the transvalvular bridge  500 , each suture  654  can be passed through the clip  620 . Prior to delivery of the transvalvular bridge  500 , each suture  654  can be passed through the clip  620  prior to passing the suture  654  through the lumen  660  of the pusher  622 . The clip  620  can be disposed on the suture  654 . Referring back to  FIGS. 65B and 65C , the clip  620  can be disposed between the transvalvular bridge  500  and the end of the pusher  622 . The number of clips  620  can correspond to the number of sutures  654 . In the illustrated embodiment, four clips  620  are deployed. 
     Referring to  FIG. 65D , the pusher  622  can advance the clip  620 . As the pusher  622  is advanced toward the transvalvular bridge  500 , the clip  620  can be advanced toward the transvalvular bridge  500 . The clip  620  can be located near a distal end of the pusher  622  as the pusher  622  is advanced. Referring to  FIG. 65E , the clip  620  can be pushed against the transvalvular bridge  500 . The pusher  622  can be withdrawn.  FIGS. 65F-65G  show various other perspective views of deploying the transvalvular bridge  500 . 
       FIGS. 66A and 66B  illustrates the clip  620 . The clip  620  can include any cross-sectional shape including circular, oval, elliptical or other rounded configuration. The round edges may reduce trauma to the surrounding tissue. Other cross-sectional shapes are contemplated include triangular, square, rectangular, or other polygonal shape. The clip  620  can include a first aperture  662 . The first aperture  662  can be circular, oval, elliptical or other rounded configuration. 
     The clip  620  can include a second aperture  664 . The second aperture  664  can include a rounded portion  668 . The rounded portion  668  can be semi-circular, semi-oval, semi-elliptical or other rounded configuration. The rounded portion  668  can be approximately half of a circle. The rounded portion  668  can be approximately half of the second aperture  664 . The second aperture  664  can include a catch portion  670 . The catch portion  670  can include a protrusion  672 . The protrusion  672  can extend inward from the second aperture  664 . The protrusion  672  can be any cross-sectional shape such as triangular, square, rectangular, or other polygonal shape. In the illustrated embodiment, the protrusion  672  is triangular. The catch portion  670  can be approximately half of the second aperture  664 . 
     The clip  620  can include a third aperture  674 . The third aperture  674  can include a rounded portion  676 . The rounded portion  676  can be semi-circular, semi-oval, semi-elliptical or other rounded configuration. The rounded portion  676  can be approximately half of a circle. The rounded portion  676  can be approximately half of the third aperture  674 . The third aperture  674  can include a catch portion  678 . The catch portion  678  can include a protrusion  680 . The protrusion  680  can extend inward from the third aperture  674 . The protrusion  680  can be any cross-sectional shape such as triangular, square, rectangular, or other polygonal shape. In the illustrated embodiment, the protrusion  680  is triangular. The catch portion  678  can be approximately half of the third aperture  674 . The second aperture  664  and the third aperture  674  can be similar. The second aperture  664  and the third aperture  674  can be identical. The second aperture  664  and the third aperture  674  can be oriented such that the protrusion  672  of the second aperture  664  is coaxial with the protrusion  680  of the third aperture  674 . 
     Referring to  FIG. 66B , the suture  654  can be passed through the first aperture  662 , the second aperture  664 , and the third aperture  674 . The suture  654  can be passed through the first aperture  662 , the second aperture  664 , and the third aperture  674  sequentially. The suture  654  can be passed through the first aperture  662 , then through the second aperture  664 , and then through the third aperture  674 . The suture  654  can pass over the clip  620  between the first aperture  662  and the second aperture  664 . The suture  654  can pass under the clip  620  between the second aperture  664  and the third aperture  674 . 
     The suture  654  can be passed through the clip  620  in a first direction  1 D. The suture  654  slides through the first aperture  662 . The suture  654  slides through the rounded portion  668  of the second aperture  664 . The suture  654  slides through the rounded portion  676  of the third aperture  674 . The first direction can move the clip  620  toward the transvalvular bridge  500 . 
     The suture  654  can be limited or prevented from passing through the clip  620  in a second direction  2 D. As the suture  654  is pulled in the second direction, the protrusion  672  of the second aperture  664  can embed within the suture  654 . As the suture  654  is pulled in the second direction, the protrusion  680  of the third aperture  674  can embed within the suture  654 . The second direction can move the clip  620  away from the transvalvular bridge  500 . 
     The clip  620  can be a one direction push and lock device. The clip  620  can allow travel of the suture  654  through the clip  620  in the first direction. The clip  620  can limit travel of the suture  654  through the clip  620  in the second, opposite direction. The clip  620  can be manufacture from a rigid material such as a metal. In the illustrated embodiment, the clip  620  comprises 316 stainless steel. The clip  620  can have a high tensile force. The clip  620  can break above the suture strength. The clip  620  can fit within the deployment catheter  614 . 
       FIGS. 67A and 67B  illustrate a handle  684 . The handle  684  can be any shape to facilitate grip by the user. The handle  684  can be designed to fit within the hand of the user. The handle  684  can be designed for use by the right hand, the left hand, or either the left hand or the right hand of the user. The handle  684  includes a wheel  686 . The wheel  686  can be actuated by a finger of the hand of the user. The wheel  686  can be actuated by the thumb. As the wheel  686  is turned, the wheel  686  can actuate one or more gears  688  within the handle  684 . The gears  688  can cause an action such as the twisting or turning motion of a catheter attached thereto. 
     Referring to  FIG. 67B , the handle  684  can include an insert  690 . The insert  690  can couple to the handle  684 . The insert  690  can couple to a catheter. In some embodiments, the handle  684  can accept two or more inserts. In some embodiments, the handle  684  can be designed to couple to two or more catheters. Each catheter described herein can be designed to couple with an insert. The handle  684  can be considered a universal handle. The handle  684  can couple to each catheter described herein. 
     Referring to  FIG. 67B , the handle  684  is shown in cross-section. The insert  690  can include multiple pieces  690 A,  690 B,  690 C,  690 D. The piece  690 A can have a mirror image piece  690 C. The piece  690 B can have a mirror image piece  690 D. The insert  690  can include a lumen  692 . The lumen  692  can be formed from the piece  690 A and the corresponding mirror image piece  690 C. The lumen  692  can be formed from the piece  690 B and the corresponding mirror image piece  690 D. The lumen  692  can be sized to accept a catheter therewithin. 
       FIGS. 68A and 68B  illustrate a steerable catheter  800 . The steerable catheter  800  can be used with the handle  684 . The steerable catheter  800  can be bi-direction. The steerable catheter  800  can move in at least two directions. The steerable catheter  800  can include a steering wire  802 . In the illustrated embodiment, the steerable catheter  800  includes two steering wires  802 . The steering wires  802  can be disposed 180 degrees from each other. The steering wire  802  can allow the steerable catheter  800  to collapse along steering wire  802 . The steering wire  802  can cause the tip to flex or turn. The steerable catheter  800  can turn in two directions due to the two steering wires  802 . Each steering wire  802  can include a steering wire attachment  804 . The steering wire attachment  804  can couple the steering wire  802  to the steerable catheter  800 . The steerable catheter  800  can include a distal end  806 . The distal end  806  can be considered steerable. The user can actuate the steering wire  802  to cause the distal end  806  to turn. 
     The steerable catheter  800  can include a dog bone pattern. The steerable catheter  800  can include a plurality of ribs  808 . The rib  808  can include two ends and a narrower middle section disposed therebetween. The ribs  808  can enable the steerable catheter  800  to flex. As the steerable catheter  800  is flexed, the space between adjacent ribs  808  becomes smaller. In some embodiments, the narrower middle section of two adjacent ribs  808  can touch. The design of the ribs  808  can impact the ability of the steerable catheter  800  to flex or rotate. The design of the ribs  808  can impact the radius of curvature of the steerable catheter  800 . 
       FIGS. 68C and 68D  depict a steerable needle catheter  810 . Any of the catheters described herein can include one or more features of the steerable catheter  800 . The steerable needle catheter  810  can be bi-direction. The steerable needle catheter  810  can move in at least two directions. The steerable needle catheter  810  can include the steering wire  802 . The steering wire  802  can allow the steerable needle catheter  810  to collapse along steering wire  802 . The steering wire  802  can cause the tip to flex or turn. The steering wire  802  can be coupled to the steerable needle catheter  810 . The steerable needle catheter  810  can include a dog bone pattern. The steerable needle catheter  810  can include a plurality of ribs  808 . 
     The steerable needle catheter  810  can include a radius of curvature R. In some embodiments, the steerable needle catheter  810  can allow the steerable needle catheter  810  to turn up to 180 degrees from the direction of travel. In some embodiments, the steerable needle catheter  810  can turn up to ninety degrees from the direction of travel. The ribs  808  can occur along a portion of the length of the steerable needle catheter  810 . The ribs  808  can allow the portion of the steerable needle catheter  810  to curve. The steerable needle catheter  810  can be bi-directional. The steerable needle catheter  810  can include the single needle catheter  658  as described herein. The needle  628  can protrude from the sheath  812 . The needle  628  can be sharpened. The needle  628  can be collinear with the steerable needle catheter  810 . The energy tip  644  can be collinear with the steerable needle catheter  810 . The steerable needle catheter  810  can facilitate immediate deployment. The single needle catheter  658  with the needle  628  is shown in  FIG. 68E . 
       FIGS. 69A and 69B  illustrate embodiments of a handle  814 . The handle  814  can be designed to interact with any catheter described herein. The handle  814  can be designed to interact with the steerable needle catheter  810 . The handle  814  can be any shape to facilitate grip by the user. The handle  814  can be designed to fit within the hand of the user. The handle  814  can be designed for use by the right hand, the left hand, or either the left hand or the right hand of the user. 
     The handle  814  can allow one or more functions. The handle  814  can include a user interface  816  to control the sheath  812 . The sheath  812  can cover any of the catheters described herein. The sheath  812  can cover the needle  628 . The handle  810  can include a user interface  818  to deploy. The user interface  818  can deploy any catheter or any catheter component described herein. In some embodiments, the user interface  818  can apply a force for the needle  628  to puncture the annulus. In some embodiments, the user interface  818  can apply a force for the energy tip  644  to apply energy to the annulus. The handle  818  can include a user interface  820  to articulate. The user interface  820  can articulate any catheter or any catheter component described herein. The user interface  820  can articulate the steerable needle catheter  810 . The user interface  820  can cause the steerable needle catheter  810  to turn. Each of the user interfaces  816 ,  818 ,  820  can be a button, slide, wheel, or other device to enable movement as described herein. Each of the user interfaces  816 ,  818 ,  820  can be the same or similar to another user interface. In the illustrated embodiment, the user interfaces  816 ,  818 ,  820  are slides. The handle  814  can be durable and ergonomic. 
       FIG. 70  shows various access locations. The systems and methods described herein can be used for any access location. The procedure approach and delivery system can be trans-femoral, trans-femoral and trans-apical, trans-apical, trans-apical and trans-atrial, trans-atrial, trans-subclavian, trans-subclavian and trans-apical, or any other approach known in the art. 
     Advantages can include any of the following. The systems and methods described herein can replicate open procedures. The systems and methods described herein can replicate open procedures related to the placement of the transvalvular bridge  500 . The systems and methods described herein can replicate open procedures end-securement. The systems and methods described herein can guarantee suture placement. The systems and methods described herein can show the user, such as a surgeon, the suture count prior to first knot. The systems and methods described herein can provide positional identification of the sutures by valve nomenclature. The systems and methods described herein can be used with the devices described herein. The systems and methods described herein can be used with the transvalvular bridge  500 . The systems and methods described herein can be conducted on a beating heart. The systems and methods described herein can be echogenic. The systems and methods described herein can prevent or limit occlusions. The systems and methods described herein can prevent or limit leaflet damage. The systems and methods described herein can prevent or limit chordae damage. The systems and methods described herein can allow for complete bail out until first suture is knotted. The systems and methods described herein can allow for complete identification and count of all catheter delivery components. The systems and methods described herein can allow for complete identification and count of all suture tail cuts. The systems and methods described herein can allow for hydraulic or compressed air delivery of the one or more needle  628 . The systems and methods described herein can include a flexible pressure vessel and needles. The systems and methods described herein can include a flexible deployment of retaining system. The systems and methods described herein can allow for percutaneous securement by knot or ferrule locking device. The systems and methods described herein can allow for trans-apical and trans-septal hybrid delivery. The systems and methods described herein can allow for trans-septal and trans-aortic hybrid delivery. 
     The systems and methods described herein can have simple designs. One or more of the needle catheter  610 , the deployment catheter  614 , and the trimming catheter  624  can have a simple design. One or more of the needle catheter  610 , the deployment catheter  614 , and the trimming catheter  624  can include a single lumen. One or more of the needle catheter  610 , the deployment catheter  614 , and the trimming catheter  624  can include embedded catheter features. The needle catheter  610  can include a built in plunger  656 . The deployment catheter  614  can include a built in pusher  622 . 
     The method can include the step of inserting a sub-annular retainer  612 . The method can include the step of inserting the energy tip  644  through the tissue of the heart. In some methods of use, the energy tip  644  is inserted through the annulus. In some methods of use, the energy tip  644  is inserted through the anterior leaflet. In some methods of use, the energy tip  644  is inserted through the posterior leaflet. The method can include the step of holding the energy tip  644  in position. The method can include the step of guiding the energy tip. The method can include the step of following the energy tip  644  with the needle catheter  610 . The method can include the step of intraluminal deployment of the pledget  652 . The pledget  652  can be coupled to the suture  654 . The method can include the step of cinching the suture  654 . 
     The method can include the step of positioning the mitral device. The mitral device can be any device described herein. In some methods of use, the method can include the step of positioning transvalvular bridge  500 . The method can include the step of sliding the transvalvular bridge  500  out of the deployment catheter  614 . The deployment catheter  614  can be a single lumen catheter. The method can include the step of parachuting the transvalvular bridge  500  down with the dilator  616 . The method can include the step of moving the transvalvular bridge  500  toward the annulus. The method can include the step of cinching the suture  654 . 
     The method can include the step of securely clipping the mitral device. The method can include the step of deploying the clip  620 . The method can include the step of moving the clip  620  with a pusher  622 . The method can include the step of securing the clip  620 . The clip  620  can be a self-locking clip. The method can include the step of trimming the suture  654 . 
       FIGS. 71-73  illustrates the transvalvular bridge  500  positioned within the heart. The transvalvular bridge  500  can include the first attachment structure  504  at a first end of the bridge  500  and the second attachment structure  526  at a second end of the bridge  500 . The transvalvular band  500  serves both surgical and interventional markets. The same transvalvular band  500  can be used for both markets. The design of the transvalvular band  500  is shown in  FIGS. 74-76 . Systems and methods including tools and transcatheter systems are shown in  FIGS. 77-96 . 
     Mitral Regurgitation (MR) occurs when one of the four valves in the heart, the mitral valve, does not close properly, allowing blood to leak backwards. Mitral Regurgitation is the most common form of valvular heart disease. There are two types of Mitral Regurgitation: Functional Mitral Regurgitation (FMR) and Degenerative Mitral Regurgitation (DMR). The transvalvular bridge  500  can be used for Functional Mitral Regurgitation (FMR). The transvalvular bridge  500  can be used for Degenerative Mitral Regurgitation (DMR). Mitral Regurgitation may lead to shortness of breath and eventually heart failure. Mitral Regurgitation affects about 5% of the US population. Some estimates suggest 2.8M people suffer from Mitral Regurgitation in the US. Approximately 80,000 mitral valve surgeries are performed per year. Some estimates suggest that 41% are in need of intervention. Some estimates suggest that 41% are in need of intervention, either due to Functional Mitral Regurgitation (FMR) or Degenerative Mitral Regurgitation (DMR). Some estimates suggest a 5% conversion to percutaneous treatment for Mitral Regurgitation. There may be a need for a less invasive technology. 
     For annuloplasty rings, the procedure can be invasive, requiring open heart surgery. The procedure may require cardiopulmonary bypass. The procedure may require anticoagulants. There are disadvantages or limitations to current devices and procedures. The annuloplasty ring may not be optimal for anatomy. The annuloplasty ring flattens the annulus from a natural saddle shape. The annuloplasty ring may affect outcome. The limitations include that the procedure, and subsequent outcome, can be surgeon technique dependent. 
     For clips, a guide catheter is inserted through the femoral vein at the groin and is guided into the mitral valve. The clip delivery system delivers and deploys the implant. The clip holds and fastens the leaflets of the valve together. In this procedure, usually two clips are delivered. There are disadvantages or limitations to current devices and procedures. The large size of the catheter can be problematic. The entire length procedure is technically demanding. The long-term durability of the results of the device is unknown. The device cannot be used in patients with severe pathology of the mitral valve. 
     The transvalvular band  500  can overcome limitations of other devices. The transvalvular band  500  can be optimal for the anatomy. The transvalvular band  500  does not flatten the annulus in some embodiments, but rather conforms to the natural saddle shape. The transvalvular band  500  is not surgeon technique dependent in some cases. The shape of the transvalvular band  500  can be determined prior to surgery, for instance by selecting the transvalvular band  500  from a plurality of bands. In some methods of use, the transvalvular band  500  can be implanted in an open procedure. In some methods of use, the transvalvular band  500  can be implanted in a minimally invasive procedure. In some methods of use, the transvalvular band  500  can be implemented without cardiopulmonary bypass. In some methods of use, the transvalvular band  500  can be implemented without anticoagulants. In some methods of use, the transvalvular band  500  can be implemented with a plurality of anchor locations. In some methods of use, the transvalvular band  500  can be implemented with four anchor locations. In some methods of use, the transvalvular band  500  can be implemented with a plurality of spaced apart anchor locations. In some methods of use, the transvalvular band  500  can be implemented with a small, reduced diameter catheter system. In some methods of use, the transvalvular band  500  can be implemented with a short, non-technically demanding procedure. In some methods of use, the transvalvular band  500  can have long-term durability. In some methods of use, the transvalvular band  500  can be implemented in patients with severe pathology of the mitral valve. In some methods of use, the transvalvular band  500  implantation is simple and effective. In some methods of use, the transvalvular band  500  implantation is an alternative to annuloplasty in mitral valve repair. 
     The transvalvular band  500  can be a unique technology developed for the treatment of mitral valve regurgitation. The transvalvular band  500  in some cases can be configured to act as a transannular bridge in the septolateral dimension. The transvalvular band  500  can be configured to reduce annular dimensions back to normal and physiological needs. The unique design of the transvalvular band  500  in some embodiments allows it to be used in either a surgical (open-sternotomy or MIS) or transcatheter approach. 
       FIG. 71  illustrates the location of a transvalvular band  500  implanted in the heart. The transvalvular band  500  is positioned to span the mitral valve.  FIG. 72  illustrates the transvalvular band  500  in the septolateral dimension.  FIG. 73  illustrates the transvalvular band  500  illustrates another view of the position of the transvalvular band  500 . The position of the transvalvular band  500  avoids the circumflex (Cx) coronary artery. The position of the transvalvular band  500  avoids the atrioventricular (AV) node. The position of the transvalvular band  500  avoids the aortic leaflets. 
     The design of the transvalvular band  500  according to some embodiments is shown in  FIGS. 74-76 . The transvalvular bridge  500  can include the first attachment structure  504  at a first end of the bridge  500  and the second attachment structure  526  at a second end of the bridge  500 . In some embodiments, the first attachment structure  504  is a polyethylene terephthalate (PET) anchoring pad. In some embodiments, the second attachment structure  526  is a PET anchoring pad. In some embodiments, the first attachment structure  504  and the second attachment structure  526  can be similar or identical in shape. In some embodiments, the first attachment structure  504  and the second attachment structure  526  can be similar or identical in material.  FIG. 74  shows the bottom view of the transvalvular band  500 .  FIG. 75  shows the top or annular view of the transvalvular band  500 .  FIG. 76  shows the perspective view of the transvalvular band  500 . 
     The transvalvular bridge  500  can also include an arcuate central portion  502  which can be curved downward. The transvalvular bridge  500  is concave when implanted. The transvalvular bridge  500  can include a plurality of struts  516 . The struts  516  can provide structural support to the transvalvular bridge  500 . In some embodiments, the struts  516  form a generally X shape. The arcuate central portion  502  can be formed of silicon. The arcuate central portion  502  can be formed of Nitinol. In some embodiments, the arcuate central portion  502  can comprise a covering formed silicon with the struts  516  formed of Nitinol. The transvalvular bridge  500  can include infra-annular curvature. The transvalvular bridge  500  can include a silicon-nitinol bridge between the first and second attachment structures  504 ,  526 . The transvalvular bridge  500  can be a silicone-Nitinol bridge. In some embodiments, the transvalvular bridge  500  can be a single piece. In some embodiments, the transvalvular bridge  500  can be multiple pieces coupled together. In some embodiments, the transvalvular bridge  500  can have no moving parts. 
     In some embodiments, the transvalvular bridge  500  can be in a plurality of sizes, for instance, 22 mm, 24 mm, 26 mm, 28 mm, 30 mm, or ranges incorporating any of the foregoing values. Other sizes are contemplated including 10 mm, 12 mm, 14 mm, 16 mm, 18 mm, 20 mm, 21 mm, 23 mm, 25 mm, 27 mm, 29 mm, 31 mm, 32 mm, 34 mm, 36 mm, 38 mm, 40 mm, or ranges incorporating any of the foregoing values. In some embodiments, two or more sizes of the transvalvular bridge  500  are provided. In some embodiments, five sizes of the transvalvular bridge  500  are provided. The transvalvular bridge  500  can include a centered infra-annular curvature. The transvalvular bridge  500  can be symmetric. The transvalvular bridge  500  can have one axis of symmetry. The transvalvular bridge  500  can have two axes of symmetry. The transvalvular bridge  500  can have three axes of symmetry. The transvalvular bridge  500  can have a plurality of axes of symmetry. 
     The transvalvular bridge  500  can form a continuous infra-annular curvature. The midpoint or vertex of the transvalvular bridge  500  can be centered. The midpoint or vertex of the transvalvular bridge  500  can be centered between the first and second attachment structures  504 ,  526 . 
     In some methods of use, the transvalvular bridge  500  reduces the septolateral dimension. In some methods of use, the transvalvular bridge  500  reduces the distance between PPM and leaflet. In some methods of use, the transvalvular bridge  500  maintains the saddle shape of the annulus. In some methods of use, the transvalvular bridge  500  ensures early coaptation of leaflets. In some methods of use, the transvalvular bridge  500  is compliant to annular displacement. In some methods of use, the transvalvular bridge  500  is durable. In some embodiments, the transvalvular bridge  500  can withstand 400 million cycles. In some embodiments, the transvalvular bridge  500  can withstand 600 million cycles. In some embodiments, the transvalvular bridge  500  can withstand 1 billion cycles. In some embodiments, the transvalvular bridge  500  can withstand cycles with a displacement of 0.5 mm. In some embodiments, the transvalvular bridge  500  can withstand cycles with a displacement of −0.5 mm. 
       FIGS. 77-78  illustrate a transvalvular bridge  500  on a holder  850  with a holding suture  852 . The holder  850  can include a flat region designed to abut the transvalvular bridge  500 . The holder  850  can span the distance between the first and second attachment structures  504 ,  526 . The holding suture  852  can couple the transvalvular bridge  500  to the holder  850 . The holder  850  can be used to position the transvalvular bridge  500  relative to the heart. In some methods of use, removal or release of the holding suture  852  can allow the holder  850  to move away from the transvalvular bridge  500 . In some methods of use, the holding suture  852  can extend through the attachment structures  504 ,  526 . In some methods of use, the holding suture  852  can extend through one or more of the plurality of apertures  508  of the attachment structures  504 ,  526 . 
       FIG. 77-83  illustrate an open procedure.  FIG. 77  illustrates the position of the transvalvular bridge  500  on a holder  850 .  FIG. 78-79  illustrates the surgeon positioning the transvalvular bridge  500 . The holder  850  facilitates placement of the transvalvular bridge  500 . In some methods of use, the tissue is retracted to provide access to the mitral valve.  FIG. 80  illustrates the position of the sutures  654  or other sutures described herein extending from the transvalvular bridge  500 . As described herein, the retainer  612  can be loaded into the needle  628 . The retainer  612  can include a pledget  652  and the suture  654 .  FIG. 81  illustrates the position of the transvalvular bridge  500  relative to the mitral valve. The surgeon moves the transvalvular bridge  500  toward the mitral valve until the transvalvular bridge  500  spans the mitral valve. The holder  850  can be removed.  FIG. 82  illustrates the position of the transvalvular bridge  500 . The transvalvular bridge  500  can be secured by advancing a clip  620 . The clip  620  can be pushed along the suture  654  as described herein.  FIG. 83  illustrates the position of the transvalvular bridge  500  after the transvalvular bridge  500  is secured. 
       FIGS. 84-86  illustrate a minimally invasive surgical procedure.  FIG. 84  illustrates a mini thoracotomy. The transvalvular bridge  500  can be delivered.  FIG. 85  illustrates the transvalvular bridge  500  being inserted into the annulus.  FIG. 86  illustrates transvalvular bridge  500  anchoring. The surgeon can ensure delivery of the transvalvular bridge  500  by viewing a display  854 . The display  854  shows the positioning of the transvalvular bridge  500  during the minimally invasive surgical procedure. 
     In some methods of use, the transvalvular bridge  500  is placed between midpoints of A 2 -P 2 . In some methods of use, the transvalvular bridge  500  is placed at the annular level. In some methods of use, the attachment structures  504 ,  526  of the transvalvular bridge  500  are placed level with the annulus. In some methods of use, the transvalvular bridge  500  is placed with standard sutures. In some methods of use, the transvalvular bridge  500  is placed with suture  654  as described herein. In some methods of use, the transvalvular bridge  500  has rapid implantation. In some methods of use, the transvalvular bridge  500  is available in a plurality of sizes. In some methods of use, the transvalvular bridge  500  is in the range of 22 to 30 mm. In some methods of use, the transvalvular bridge  500  can achieve direct, non-planar septolateral dimension reduction. In some methods of use, the transvalvular bridge  500  can restore the annular saddle shape. In some methods of use, the transvalvular bridge  500  can facilitate preservation of leaflet curvature. In some methods of use, the transvalvular bridge  500  can facilitate preservation of annular function. In some methods of use, the transvalvular bridge  500  can promotes early coaptation. In some methods of use, the transvalvular bridge  500  can retrain the leaflet (prolapse) below the annular plane. 
     In some embodiments, the septolateral dimension is reduced by 10 percent. In some embodiments, the septolateral dimension is reduced by 15 percent. In some embodiments, the septolateral dimension is reduced by 20 percent. In some embodiments, the septolateral dimension is reduced by 25 percent. In some embodiments, the septolateral dimension is reduced by 30 percent. In some embodiments, the septolateral dimension is reduced an average of about 25 percent. In some embodiments, the septolateral dimension is reduced about 5 mm. In some embodiments, the septolateral dimension is reduced about 10 mm. In some embodiments, the septolateral dimension is reduced about 15 mm. In some embodiments, the septolateral dimension is reduced about 20 mm. In some embodiments, the septolateral dimension is reduced an average of about 10 mm. In some embodiments, the copatation height increases 2 mm. In some embodiments, the copatation height increases 3 mm. In some embodiments, the copatation height increases 4 mm. In some embodiments, the copatation height increases 5 mm. In some embodiments, the copatation height increases 6 mm. In some embodiments, the copatation height increases an average of about 4.5 mm. In some embodiments, the mean gradient increase 0.2 mm Hg. In some embodiments, the mean gradient increase 0.4 mm Hg. In some embodiments, the mean gradient increase 0.6 mm Hg. In some embodiments, the mean gradient increase 0.8 mm Hg. In some embodiments, the mean gradient increase 1.0 mm Hg. In some embodiments, the mean gradient increase an average of about 0.7 mm Hg. In a baseline study, about 60% of patients had moderate-severe mitral regurgitation before implantation. In a baseline study, about 40% of patients had—severe mitral regurgitation before implantation. After implantation about 60% of patients had no regurgitation and about 40% had mild regurgitation. Some estimates suggest that over 50% of patients with annuloplasty rings have moderate or severe regurgitation at two years. 
     The same transvalvular bridge  500  used in open or MIS surgery can be mounted in catheter for trans-septal delivery. The delivery, positioning, and anchoring can be optimized for trans-septal delivery and implantation. 
       FIG. 87  illustrates a transcatheter system  900 . The transcatheter system can deliver the transvalvular bridge  500  or any implant described herein. The transcatheter system  900  can include any of the features of the system of delivery catheters  600  described herein. The transcatheter system  900  can include any number of primary catheters. In some embodiments, the transcatheter system  900  can include four primary catheters. The transcatheter system  900  can include a pipeline catheter  902 . The transcatheter system  900  can include a sheath &amp; needle catheter  904 . The transcatheter system  900  can include a delivery catheter &amp; suture management catheter  906 . The transcatheter system  900  can include a trimming catheter  908 . 
     The transcatheter system  900  can include one or more catheters that include a single lumen. The transcatheter system  900  can include one or more catheters that include a plurality of lumens. The transcatheter system  900  can include embedded catheter features. For instance, the clip pushers described herein can be built into the delivery catheter &amp; suture management catheter  906 . The transcatheter system  900  can reduce complexity. The transcatheter system  900  can enable rapid progress and easy prototypes. The transcatheter system  900  can replicate open procedure. The transcatheter system  900  can allow delivery while the heart is beating. The transcatheter system  900  can deliver the transvalvular bridge  500  without cardiopulmonary bypass. 
       FIG. 88  illustrates the pipeline catheter  902 , according to some embodiments. The pipeline catheter  902  can function as a guide and can be the primary conduit. The pipeline catheter  902  can have any size outer diameter and length. In some embodiments, the pipeline catheter  902  has an outer diameter of 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, 26 Fr, 28 Fr, 30 Fr, 32 Fr, 34 Fr, or ranges incorporating any of the foregoing values, between 20-30 Fr, about 24 Fr, etc. In some embodiments, the pipeline catheter  902  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, or ranges incorporating any of the foregoing values, between 90-110 cm, about 100 cm, etc. The pipeline catheter  902  can have a single lumen. The pipeline catheter  902  can be steerable. For instance, a handle of the pipeline catheter  902  can control a flexible tip. The pipeline catheter  902  can be a 90° Bi-directional catheter. The pipeline catheter  902  can be axially stiff. The pipeline catheter  902  can hold a septal position. The pipeline catheter  902  can be an ultra-flexible dilator. In some embodiments, the pipeline catheter  902  can have a reduced outer diameter during delivery. In some embodiments, the pipeline catheter  902  can have a reduced outer diameter compared to other delivery catheters. 
       FIG. 89A  illustrates a sheath &amp; needle catheter  904 . The sheath &amp; needle catheter  904  can include a sheath  910  and a needle  912 . The sheath  910  and the needle  912  are separated in  FIG. 89A .  FIG. 89B  illustrate the distal end of the sheath &amp; needle catheter  904 . The needle  912  is disposed within the sheath  910  in  FIG. 89B . The sheath  910  can have LA steering. The sheath  910  can have any size outer diameter and length. In some embodiments, the sheath  910  has an outer diameter of 2 Fr, 4 Fr, 6 Fr, 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 10-20 Fr, about 8 Fr, etc. In some embodiments, the sheath  910  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, or ranges incorporating any of the foregoing values, between 100-120 cm, about 110 cm, etc. The sheath  910  can be steerable. The sheath  910  can be a 180° Bi-directional catheter. The sheath  910  can have any bend radius. In some embodiments, the sheath  910  has bend radius of 8 mm, 8.5 mm, 9 mm, 9.5 mm, 10 mm, 10.5 mm, 11 mm, 11.5 mm, 12 mm, 12.5 mm, 13 mm, 13.5 mm, 14 mm, 14.5 mm, 15 mm, 15.5 mm, 16 mm, 16.5 mm, 17 mm, or ranges incorporating any of the foregoing values, between 10-15 mm, about 12.5 mm, etc. 
     The needle  912  is designed to be disposed within the sheath  910 . The needle  912  can include a needle and a needle sheath. The needle  912  can function for burn and retainer delivery. In some embodiments, the needle  912  has an outer diameter of 1 Fr, 2 Fr, 3 Fr, 4 Fr, 5 Fr, 6 Fr, 7 Fr, 8 Fr, 9 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 1-10 Fr, about 5 Fr, etc. In some embodiments, the needle  912  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, 140 cm, 150 cm, or ranges incorporating any of the foregoing values, between 110-130 cm, about 120 cm, etc. The needle  912  can be axially stiff. The needle  912  can be a RF needle. The needle  912  can be designed to deliver RF energy to burn a hole in the annulus, as described herein. The needle  912  can facilitate flexible pusher deployment.  FIG. 89B  illustrates the coaxial sheath &amp; needle catheter  904 . 
       FIG. 90A  illustrates the delivery catheter &amp; suture management catheter  906 . The delivery catheter &amp; suture management catheter  906  can function for deployment of the transvalvular bridge  500  or any implant described herein. The delivery catheter &amp; suture management catheter  906  can function for suture management and cinching. In some embodiments, the delivery catheter &amp; suture management catheter  906  has an outer diameter of 1 Fr, 2 Fr, 3 Fr, 4 Fr, 5 Fr, 6 Fr, 7 Fr, 8 Fr, 9 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 1-10 Fr, about 8 Fr, etc. In some embodiments, the delivery catheter &amp; suture management catheter  906  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, 140 cm, 150 cm, or ranges incorporating any of the foregoing values, between 110-130 cm, about 120 cm, etc. The delivery catheter &amp; suture management catheter  906  can be steerable. The delivery catheter &amp; suture management catheter  906  can be a 180° Bi-directional catheter. The delivery catheter &amp; suture management catheter  906  can have any bend radius. In some embodiments, the sheath  910  has bend radius of 8 mm, 8.5 mm, 9 mm, 9.5 mm, 10 mm, 10.5 mm, 11 mm, 11.5 mm, 12 mm, 12.5 mm, 13 mm, 13.5 mm, 14 mm, 14.5 mm, 15 mm, 15.5 mm, 16 mm, 16.5 mm, 17 mm, or ranges incorporating any of the foregoing values, between 10-15 mm, about 12.5 mm, etc. The delivery catheter &amp; suture management catheter  906  can detangle from each other. The delivery catheter &amp; suture management catheter  906  can function to detangle or prevent tangles of the suture  654  or any suture described herein. The delivery catheter &amp; suture management catheter  906  can function to be pushable. The delivery catheter &amp; suture management catheter  906  can push the clips as described herein.  FIG. 90B  illustrates the distal end of the delivery catheter &amp; suture management catheter  906 . The delivery catheter &amp; suture management catheter  906  can include four ports  914 . The number of ports  914  can correspond to the number of apertures  508  of the transvalvular bridge  500 . The number  914  of ports can correspond to the number of pushers  622 . 
       FIG. 91  illustrates the sheath &amp; needle catheter  904  with the sheath  910  and the needle  912 . The needle  912  can include a needle  916  and a needle sheath  918 . The needle  916  can be deliver thermal energy, such as RF energy. The needle  916  can burn a hole through the annulus, as described herein. The needle  916  can carry a subannular anchor  920 . The subannular anchor  920  can anchor the transvalvular bridge  500  or any implant described herein. The subannular anchor  920  can have a star design. The subannular anchor  920  can have a holding strength of 10 N, 12 N, 14 N, 16 N, 18 N, 20 N, 22 N, 24 N, 26 N, 28 N, 30 N, 32 N, 34 N, 36 N, 38 N, 40 N, or ranges incorporating any of the foregoing values, between 15-30 N, between 20-26 N, etc. The subannular anchor  920  flattens with tension. The subannular anchor  920  can have a compressed outer diameter. The subannular anchor  920  compressed outer diameter can be 0.2 mm, 0.4 mm, 0.6 mm, 0.8 mm, 1.0 mm, 1.2 mm, 1.4 mm, 1.6 mm, 1.8 mm, 2.0 mm. 2.1 mm, 2.2 mm, or ranges incorporating any of the foregoing values, between 1 mm and 1.5 mm, about 1.2 mm, etc. The subannular anchor  920  can have an expanded diameter. The subannular anchor  920  expanded outer diameter can be 4.5 mm, 5 mm, 5.5 mm, 6 mm, 6.5 mm, 7 mm, 7.5 mm, 8 mm, 8.5 mm, 9 mm, or ranges incorporating any of the foregoing values, between 6 mm and 7 mm, about 6.5 mm, etc. 
     In some embodiments, the subannular anchor  920  can be cylindrical or substantially cylindrical when compressed. In some embodiments, the subannular anchor  920  can have a longer length when compressed or under tension. In some embodiments, the subannular anchor  920  can have a pre-formed shaped. In some embodiments, the subannular anchor  920  can assume the pre-formed shaped when the tension is released. In some embodiments, the subannular anchor  920  can assume the pre-formed shaped when a constraint is removed. In some embodiments, the subannular anchor  920  comprises a shape memory material. In some embodiments, the subannular anchor  920  comprises Nitinol. In some embodiments, the subannular anchor  920  can comprise a plurality of struts  922 . In some embodiments, the subannular anchor  920  can comprise four struts  922 . In some embodiments, the subannular anchor  920  can comprise equally spaced or unequally spaced struts  922 . In some embodiments, the struts  922  can bend outward during expansion. 
     In some embodiments, the subannular anchor  920  is reversible. The subannular anchor  920  can be compressed. The subannular anchor  920  can be deployed such that the subannular anchor  920  has the expanded outer diameter. If desired by the surgeon, tension can be applied to the subannular anchor  920 . The subannular anchor  920  can be compressed to a smaller outer diameter. The subannular anchor  920  can be repositioned and redeployed. The subannular anchor  920  facilitates reversibility. The subannular anchor  920  can be reversible (e.g., removable) even after placement of the transvalvular band  500 . 
       FIG. 92  illustrates deployment of the subannular anchor  920 . The needle  916  can create holes within tissue. In some methods of use, the needle  916  can pass through the apertures  508  of the transvalvular band  500 . The needle  916  punctures the underlying tissue. In some methods of use, the needle  916  applies RF energy as described herein. The subannular anchor  920  is passed through the apertures  508  of the transvalvular band  500  and the underlying tissue. The subannular anchor  920  can be in a compressed configuration during delivery such that the outer diameter of the subannular anchor  920  is reduced. The subannular anchor  920  can be carried by the needle  916  through the annulus. The subannular anchor  920  can be deployed. In some methods of use, the subannular anchor  920  is released from tension. The struts  922  of the subannular anchor  920  expand. The subannular anchor  920  can be positioned on the ventricular side of the annulus. The subannular anchor  920  can be positioned in the left ventricle. The deployed subannular anchor  920  are shown in  FIG. 92 . 
     The subannular anchor  920  can be connected to the suture  654  or other sutures described herein. The clips  620  can be delivered via the delivery catheter &amp; suture management catheter  906 . The clips  620  can be pushed along the suture  654 . In some embodiments, the clip  620  can be pushed against the transvalvular band  500 . In some embodiments, the suture  654  can be pulled as the clip  620  is pushed against the transvalvular band  500 . In some embodiments, the suture  654  can be pulled to position the subannular anchor  920  against the tissue. In some embodiments, as the subannular anchor  920  is pulled against the tissue the subannular anchor  920  flattens horizontally against the tissue. In some embodiments, as the subannular anchor  920  is pulled against the tissue the subannular anchor  920  embeds in the tissue.  FIG. 93  illustrates the position of the transvalvular band  500  and the clips  620 . 
       FIGS. 94-96  illustrate the transcatheter system  900 .  FIG. 94  illustrates a fluoroscopic image of the heart. The pipeline catheter  902  or other guide catheter is through the septal wall. The dilator is across the left atrium. The Transesophageal Echo (TEE) probe is also shown.  FIG. 94-96  shows successful deployment of the transvalvular band  500 . 
       FIGS. 97A-97E  are views of an embodiment of a transcatheter system  1000 . The catheters of transcatheter system  1000  can include any of the features of catheters described herein.  FIG. 97A  illustrates a guide catheter  1002 . The guide catheter  1002  can provide a transseptal conduit to the left atrium.  FIG. 97B  illustrates a steering catheter  1004 . In some embodiments, the steering catheter  1004  can be steerable to the annulus. In some embodiments, the steering catheter  1004  can be steerable to the mitral annulus.  FIG. 97C  illustrates an anchor catheter  1006 . The anchor catheter  1006  can deliver one or more of the subannular anchor.  FIGS. 97A-97C  illustrate the three catheters to place the anchors in some embodiments. The three catheters are the guide catheter  1002 , the steering catheter  1004 , and the anchor catheter  1006 .  FIG. 97D  illustrates a delivery catheter  1008 . The delivery catheter  1008  can deliver and secure the transvalvular band  500 . The transvalvular band  500  can be considered a mitral bridge.  FIG. 97E  illustrates a trimming catheter  1010 . The trimming catheter  1010  can cut and secure the sutures.  FIGS. 97D-97E  illustrates the two catheters to deliver and secure the transvalvular band  500  in some embodiments. The transcatheter system  1000  can have the advantage of replicating an open procedure. The transcatheter system  1000  can allow for delivery of the transvalvular band  500  to a beating heart. The transcatheter system  1000  can be proven to have beating heart delivery success. 
     The catheters of the transcatheter system  1000  can be utilized in one or more methods. In some embodiments, the five catheters can be utilized in any number of the following steps. The steps can include 1) transseptally place guide catheter  1002 , 2) insert steering catheter  1004  with anchor catheter  1006  inside, 3) position the steering catheter  1004  and deliver anchors, 4) insert delivery catheter  1008 , deploy transvalvular band  500 , and cinch, and 5) insert trimming catheter  1010  and cut sutures. The method can include transseptal puncture with transseptal needles. After puncture, the user can transseptally place the guide catheter  1002 . The guide catheter  1002  can provide a conduit to the left atrium. In some embodiments, the user can insert the steering catheter  1004  through the guide catheter  1002 . The steering catheter  1004  can be steerable to the annulus. In some embodiments, the anchor catheter  1006  can be disposed inside the steering catheter  1004  during positioning of the steering catheter  1004 . The user can position the steering catheter  1004  and thereby position the anchor catheter  1006 . The user can deliver four anchors via the anchor catheter  1006 . The user can deliver a plurality of anchors sequentially. The user can deliver a plurality of anchors simultaneously. The anchor catheter  1006  can deliver the anchors subannularly. The anchor catheter  1006  can puncture the annulus to deliver the anchor. The user can insert the delivery catheter  1008 . The delivery catheter  1008  can deliver the transvalvular band  500 . The user can deploy the transvalvular band  500 , for instance, by unrolling the transvalvular band  500 . The transvalvular band  500  can be guided by the sutures extending from the subannular anchors. The delivery catheter  1008  can secure the transvalvular band  500 . The user can cinch the sutures to position the transvalvular band  500 . The user can insert the trimming catheter  1010 . The user can cut the sutures via the trimming catheter  1010 . The catheters of the transcatheter system  1000  can be withdrawn. 
       FIG. 98  illustrates the percutaneous delivery of the transcatheter system  1000 . The transcatheter system  1000  can be inserted in a sequence for anchor and implant placement. The general transseptal steps can include placing an introducer in the right femoral vein. The introducer can be 26 Fr, or any other size to permit access (e.g., 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, 28 Fr, 30 Fr, 32 Fr, or ranges incorporating any of the foregoing values, between 20-30 Fr, between 25-27 Fr, etc.). The general transseptal steps can include transseptal puncture with a transseptal needle system via right atrium. The general transseptal steps can include placing a guidewire through the mitral valve into the left ventricle. The general transseptal steps can include removing transseptal needle system. The general transseptal steps can include leaving the guidewire in place. 
     The method can include anchor placement. The guide catheter  1002 , the steering catheter  1004 , and/or the anchor catheter  1006  can be utilized for anchor placement. The method can include transseptally placing the guide catheter  1002  over the guidewire. This step can include angling to an appropriate angle such as about 90°. This step can include removing a dilator. This step can include removing the guidewire. The method can include inserting the steering catheter  1004  into the guide catheter  1002 . The steering catheter  1004  can include the anchor catheter  1006  disposed within the steering catheter  1004 . The steering catheter  1004  can be advanced through the guide catheter  1002  until the tip of the steering catheter  1004  can be visualized, such as through transesophageal echocardiography (TEE) and/or fluoroscopy. The steering catheter  1004  can be advanced beyond the guide catheter  1002 . In some embodiments, the steering catheter  1004  can be advanced about 5 cm beyond the guide catheter  1002 . The method can include positioning the steering catheter  1004  to deliver the anchor catheter  1006 . In some embodiments, the anchors are delivered separately. In some embodiments, the steering catheter  1004  can be moved to deliver each anchor. In some embodiments, the anchor catheter  1006  can be moved to deliver each anchor. The anchor can include features of any anchor described herein. 
       FIGS. 99-100  are views of subannular anchoring and anchor placement according to some embodiments.  FIG. 99A  illustrates the positions of the annulus. The steering catheter  1004  can be positioned at a desired location, e.g., the 5 o&#39;clock position on annulus. The anchor catheter  1006  can be pushed against the annulus. The anchor catheter  1006  can include a RF needle, microwave tip, ultrasonic tool, or the like to ablate a tissue pathway through the annulus. The anchor catheter  1006  can create a passage through the annulus. The anchor catheter  1006  can advance an anchor subannularly. In some embodiments, the anchor catheter  1006  can advance an anchor subannularly about 5-10 mm. Referring to  FIG. 99B , the anchor catheter  1006  can deploy the anchor  1012 . The anchor  1012  can be deployed by linearly advancing a pusher. After the anchor is deployed, the pusher and the RF needle can be withdrawn. The anchor catheter  1006  can be withdrawn. The anchor catheter  1006  can be repositioned. The steering catheter  1004  can be positioned at the 7 o&#39;clock position on annulus. The anchor catheter  1006  can be positioned against the annulus and the RF needle can burn through the annulus. The anchor catheter  1006  can advance an anchor  1012  subannularly and deploy the anchor  1012 . The pusher, the RF needle can be withdrawn from the 7 o&#39;clock position. The steering catheter  1004  can positioned at the 11 o&#39;clock position on annulus. The anchor catheter  1006  can positioned against the annulus and the RF needle can create a hole through the annulus. The anchor catheter  1006  can advance an anchor  1012  subannularly and deploy the anchor  1012 . The pusher, the RF needle can be withdrawn from the 11 o&#39;clock position. The steering catheter  1004  can positioned at the 1 o&#39;clock position on annulus. The anchor catheter  1006  can be positioned against the annulus and the RF needle burns through the annulus. The anchor catheter  1006  can advance an anchor  1012  subannularly and deploy the anchor  1012 . The pusher, the RF needle can be withdrawn from the 1 o&#39;clock position. The anchors can be deployed in any order. The anchors can be deployed at the 5 o&#39;clock, 7 o&#39;clock, 11 o&#39;clock, and 1 o&#39;clock position on the annulus, or other clock positions. In some embodiments, a first anchor is spaced apart about 180 degrees circumferentially on the annulus with respect to a second anchor, and a third anchor is spaced apart about 180 degrees circumferentially on the annulus with respect to a fourth anchor, each anchor spaced apart from each other. In some embodiments, a first anchor and a third anchor (and/or a second anchor and a fourth anchor) can be spaced circumferentially about 60 degrees apart, such as between about 45 degrees and about 75 degrees apart. Two anchors can be deployed on the anterior annulus. Two anchors can be deployed on the posterior annulus. The anchor deployment can be symmetrical. The anchor deployment can enable the transvalvular band  500  to span the valve. Other positions are contemplated, as well as more or less than four anchors. 
       FIG. 99B  illustrates the anchors deployed at the 5 o&#39;clock, 7 o&#39;clock, 11 o&#39;clock, and 1 o&#39;clock positions, according to some embodiments. The 5 o&#39;clock and 7 o&#39;clock positions can include the posterior anchors under the annulus. The 11 o&#39;clock and 1 o&#39;clock positions can include the anterior anchors under the annulus. In some embodiments, two or more anchors are delivered simultaneously. In some embodiments, two or more anchors are delivered sequentially. In some embodiments, four anchors are delivered. Each anchor  1012  can include a suture  1014 , such that four anchors  1012  include four sutures  1014 . In some methods of use, the four sutures  1014  can pass outside the body, extracorporeal, through the guide catheter  1002 . The sutures  1014  can extend from the anchors  1012  and through the transcatheter system  1000 . The sutures  1014  can remain outside of the body of the patient during the procedure. After the anchors  1012  are delivered, the sutures  1014  can be preliminary cinched for sizing of the transvalvular band  500 .  FIGS. 100A-100B  illustrate anchor placement according to some embodiments.  FIG. 100A  illustrates two deployed sutures  1014  connected to deployed anchors, the steering catheter  1004 , and the anchor catheter  1006 . The deployed sutures  1014  can extend through the steering catheter  1004  and outside the body of the patient. The anchor catheter  1006  can be in position to deliver another anchor  1012 .  FIG. 100B  illustrates a deployed anchor  1012 , according to some embodiments. 
       FIG. 101  is a view of preliminary cinching according to some embodiments. The four anchors  1012  can be deployed such that the four corresponding sutures extend through the annulus. The sutures can extend from the anchor to the steering catheter  1004 . According to some embodiments, the sutures  1014  can be cinched together before delivery of the transvalvular band  500 . In some embodiments, the preliminary cinching can allow for sizing of the transvalvular band  500 .  FIG. 101  is a view of the left ventricle. In some embodiments, the steering catheter  1004  can cinch the sutures  1014  by movement of the steering catheter  1004 , such as movement toward the annulus. 
     The method can include delivery of the transvalvular band  500  or any other implant described herein, according to some embodiments. The delivery catheter  1008  and/or the trimming catheter  1010  can be utilized for delivery and securing of the transvalvular band  500 . The method can include any of the following: inserting the delivery catheter  1008 , deploying the transvalvular band  500 , and cinching. The transvalvular band  500  can be threaded onto the four extracorporeal sutures  1014 . Each suture  1014  can be threaded through an aperture  508  on the transvalvular band  500 . As described herein, the four extracorporeal sutures  1014  can be coupled to the deployed subannular anchors  1012 . Each suture can have a free end which can be threaded through the transvalvular band  500 . In some methods of use, locking clips  1016  can be threaded onto the sutures  1014  after the transvalvular band  500  is threaded, such that a locking clip  1016  can be threaded onto each suture  1014 . In some methods of use, the four sutures  1014  can be threaded through the distal end of the delivery catheter  1008  after the four sutures are threaded through the transvalvular band  500 . The free ends of the four sutures  1014  can be pulled out the proximal end of the delivery catheter  1008 . The transvalvular band  500  can be loaded into the guide catheter  1002  after being threaded onto the sutures  1014 . In some embodiments, the transvalvular band  500  can be rolled or compressed to fit within the guide catheter  1002 . The delivery catheter  1008  can be configured to push the transvalvular band  500  down the lumen of the guide catheter  1002 . The delivery catheter  1008  can be configured to push the transvalvular band  500  along the sutures  1014 . The delivery catheter  1008  can be configured to push the transvalvular band  500  through the distal end of guide catheter  1002 . The delivery catheter  1008  can deliver the transvalvular band  500 . In some embodiments, the transvalvular band  500  can unroll or expand within the heart of the patient. The transvalvular band  500  can be deployed into the left atrium. The delivery catheter  1008  can be configured to push the transvalvular band  500  along the sutures and toward the annulus. The transvalvular band  500  can be cinched into position on the annulus. The transvalvular band  500  can span the valve from the anterior leaflet to the posterior leaflet. Each locking clip  1016  can be advanced along the corresponding suture  1014  by a clip pusher. The locking clips  1016  can be secured to the transvalvular band  500  by advancing the clip pushers. The transvalvular band  500  can be pushed against the annulus and secured by the locking clips  1016 . The delivery catheter  1008  can be removed after the transvalvular band  500  is secured. 
     The method can include trimming the sutures  1014  according to some embodiments. The suture  1014  can be fed into the trimming catheter  1010 . The trimming catheter  1010  can be inserted into the guide catheter  1002 . The trimming catheter  1010  can be advanced to the surface of the transvalvular band  500  and the locking clip  1016 . The trimming catheter  1010  can be configured to cut the suture  1014 . In some embodiments, the trimming catheter  1010  can be removed after trimming a suture  1014 . Another suture can be fed into the trimming catheter  1010 , and the trimming catheter  1010  can be inserted into the guide catheter  1002 . The trimming catheter can be advanced toward the transvalvular band  500  and cut the corresponding suture  1014 . The sequence can be repeated for all four sutures  1014 . In some embodiments, after the sutures  1014  are trimmed, the guide catheter  1002  can be removed. The transvalvular band  500  can be implanted and secured.  FIG. 71  illustrates the transvalvular band  500  with the locking clips securing the transvalvular band  500  according to some embodiments. 
       FIGS. 102A-102D  are views of suture threading and insertion of the transvalvular bridge  500  according to some embodiments.  FIG. 102A  illustrates sutures  1014  threaded through the transvalvular band  500  according to some embodiments. Each suture  1014  can be threaded through an aperture  508  of the transvalvular band  500 .  FIG. 102B  illustrates the sutures  1014  threaded into the delivery catheter  1008  according to some embodiments.  FIG. 102C  illustrates the transvalvular band  500  prior to loading in the guide catheter  1002  according to some embodiments.  FIG. 102D  illustrates pushing the transvalvular band  500  down the guide catheter  1002  according to some embodiments. 
       FIGS. 103A-103D  are views of the transvalvular band  500  according to some embodiments. The transvalvular band  500  can be considered a bridge. In some embodiments, the transvalvular band  500  can be rolled to fit within the guide catheter  1002 . The transvalvular band  500  can be rolled as shown in  FIG. 103A . The transvalvular band  500  can be deployed by being pushed from the guide catheter  1002  as shown in  FIG. 103B-103D . The transvalvular band  500  can fit within the inner diameter of the guide catheter  1002 . In some embodiments, the transvalvular band  500  can fit within a 16 Fr inner diameter catheter. Other configurations are completed (e.g., fits within catheters of about, less than about, or more than about 10 Fr inner diameter, 12 Fr inner diameter, 14 Fr inner diameter, 18 Fr inner diameter, 20 Fr inner diameter, 22 Fr inner diameter, or ranges incorporating any of the foregoing values etc.). The transvalvular band  500  can be resilient to being rolled. In some embodiments, the transvalvular band  500  was tested after deployment, including 5 roll ups and deployment, and 750 million cycles. The transvalvular band  500  can be considered durable and showed no signs of damage or wear during the aforementioned test. 
       FIG. 104  is a schematic view of the threading of sutures  1014  according to some embodiments. The anchors  1012  can be deployed in situ. Each anchor  1012  can be connected to a suture  1014 . The anchors can be placed subannularly. In some embodiments, the sutures  1014  can extend through the annulus. The sutures  1014  can extend from the anchors  1012  in situ and through the guide catheter  1002 . The sutures  1014  can extend from the guide catheter  1002  and through the transvalvular band  500 . The sutures  1014  can extend from the transvalvular band  500  through the locking clips  1016 . The sutures  1014  can be threaded through the transvalvular band  500  and the locking clips  1016 . The threaded and crimped transvalvular band  500  can pass through the guide catheter  1002  as described herein. The sutures  1014  can extend from the locking clips  1016  through the delivery catheter  1008 . The sutures  1014  can have free ends extending from the delivery catheter  1008 . The sutures  1014  can extend out of the proximal end of the delivery catheter  1008 . The sutures ends can be extracorporeal. The arrows show an example of the suture threading direction. The suture  1014  can be attached to an anchor  1012  which is subannularly placed. The suture  1014  can be passed through the guide catheter  1002 . The suture  1014  can be threaded through the transvalvular band  500  and locking clips  1016 . The threaded and crimped transvalvular band  500  according to some embodiments is shown in  FIG. 104 . The threaded and crimped transvalvular band  500  is sized to fit within the guide catheter  1002 . The suture  1014  can pass through the delivery catheter  1008  and out the proximal end of the delivery catheter  1008 . 
       FIG. 105  is a schematic view of the trimming of sutures  1014 , according to some embodiments. The anchors  1012  can be deployed in situ. Each anchor  1012  can be connected to a suture  1014 . The sutures  1014  can extend from anchors  1012 , through the transvalvular band  500 , and through the locking clips  1016 . The sutures  1014  can be threaded through the transvalvular band  500  and the locking clips  1016 . The transvalvular band  500  can be positioned adjacent to the annulus and the locking clips  1016  can be secured. The sutures  1014  can extend from the locking clips  1016  and through the guide catheter  1002 . The sutures  1014  can extend from the guide catheter  1002  to the trimming catheter  1010 . The trimming catheter  1010  can be threaded onto each suture  1014 . The suture  1014  is fed into the trimming catheter  1010 . The trimming catheter  1010  can be advanced through the guide catheter  1002 . The trimming catheter  1010  can be moved toward the transvalvular band  500  and locking clips  1016 . The trimming catheter  1010  can be designed to stop at the surface of the transvalvular band  500  and locking clips  1016 . The trimming catheter  1010  can cut the suture  1014 . The sequence can be repeated three more times until each suture  1014  is trimmed. The red arrows show an example of the suture threading direction. The suture  1014  can be attached to an anchor  1012  which is subannularly placed. The suture  1014  can be threaded through the transvalvular band  500  and locking clips  1016 . The suture  1014  can be passed through the guide catheter  1002 . The suture  1014  passes through the trimming catheter  1010 . The green arrows show the direction of the trimming catheter  1010 . The suture  1014  is fed into the trimming catheter  1010 . The trimming catheter  1010  can be advanced through the guide catheter  1002 . The trimming catheter  1010  can stop at the surface of the transvalvular band  500  and the locking clip  1016 . The trimming catheter  1010  can cut the suture  1014 . The sequence can be repeated. 
       FIGS. 106A-106E  are views of a transcatheter system according to some embodiments.  FIG. 106A  illustrates the guide catheter  1002  according to some embodiments. The guide catheter  1002  can have any size outer diameter and length. The guide catheter  1002  can have a 24 Fr outer diameter. The guide catheter  1002  can have a 100 cm length. In some embodiments, the guide catheter  1002  has an outer diameter of 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, 26 Fr, 28 Fr, 30 Fr, 32 Fr, 34 Fr, or ranges incorporating any of the foregoing values, between 20-30 Fr, about 24 Fr, etc. In some embodiments, the guide catheter  1002  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, or ranges incorporating any of the foregoing values, between 90-110 cm, about 100 cm, etc. The guide catheter  1002  can have a single lumen. The guide catheter  1002  can be steerable. For instance, a handle of the guide catheter  1002  can control a flexible tip. The guide catheter  1002  can be a 90° Bi-directional catheter. 
       FIGS. 106B-106C  illustrates the steering catheter  1004  according to some embodiments. The steering catheter  1004  can provide left atrium steering. The steering catheter  1004  can have any size outer diameter and length. The steering catheter  1004  can have a 12 Fr outer diameter. The steering catheter  1004  can have a 110 cm length. In some embodiments, the steering catheter  1004  has an outer diameter of 2 Fr, 4 Fr, 6 Fr, 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 10-20 Fr, about 8 Fr, etc. In some embodiments, the steering catheter  1004  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, or ranges incorporating any of the foregoing values, between 100-120 cm, about 110 cm, etc. The steering catheter  1004  can be a 180° Bi-directional catheter. The steering catheter  1004  can have any bend radius. The steering catheter  1004  can have a 12.5 bend radius. In some embodiments, the steering catheter  1004  can have a bend radius of 8 mm, 8.5 mm, 9 mm, 9.5 mm, 10 mm, 10.5 mm, 11 mm, 11.5 mm, 12 mm, 12.5 mm, 13 mm, 13.5 mm, 14 mm, 14.5 mm, 15 mm, 15.5 mm, 16 mm, 16.5 mm, 17 mm, or ranges incorporating any of the foregoing values, between 10-15 mm, about 12.5 mm, etc. 
       FIGS. 106B-106C  illustrates the anchor catheter  1006  according to some embodiments. The anchor catheter  1006  can be sized to be disposed within the steering catheter  1004 . The anchor catheter  1006  can have any size outer diameter and length. The anchor catheter  1006  can have a 5.3 Fr outer diameter. The anchor catheter  1006  can have a 120 cm length. In some embodiments, the anchor catheter  1006  can have an outer diameter of 1 Fr, 2 Fr, 3 Fr, 4 Fr, 5 Fr, 6 Fr, 7 Fr, 8 Fr, 9 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 1-10 Fr, about 5 Fr, etc. In some embodiments, the anchor catheter  1006  can have a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, 140 cm, 150 cm, or ranges incorporating any of the foregoing values, between 110-130 cm, about 120 cm, etc. The anchor catheter  1006  can be designed to provide a passage in the annulus. The anchor catheter  1006  can be designed to deliver RF energy to burn a hole in the annulus. The anchor catheter  1006  can be designed for anchor delivery through the annulus. The anchor catheter  1006  can provide pusher deployment of the anchor.  FIG. 106C  illustrates the distal end of the steering catheter  1004  and the anchor catheter  1006  according to some embodiments. The anchor  1012  can include a star design. The anchor  1012  can include, e.g., between about 10N and about 26 N of holding strength. The anchor  1012  can flatten with tension. The anchor  1012  can be inserted through the annulus in the flattened configuration. The anchor  1012  can be deployed by releasing the tension.  FIG. 106C  illustrates the steering catheter  1008  with the anchor catheter  1006  disposed within according to some embodiments. The anchor  1012  is shown in the illustrated embodiment in the deployed state according to some embodiments. In the compressed or flattened state, the anchor can have a 1 mm outer diameter. In the expanded or deployed state, the anchor can have a 6 mm outer diameter. Other configurations are completed, such as a flattened or compressed state having 0.5 mm outer diameter, 1.5 mm outer diameter, 2 mm outer diameter, 2.5 mm outer diameter, 3 mm outer diameter, 3.5 mm outer diameter, etc. Other configurations are completed, such as an expanded or deployed state having 4.5 mm outer diameter, 5 mm outer diameter, 5.5 mm outer diameter, 6.5 mm outer diameter, 7 mm outer diameter, 7.5 mm outer diameter, or ranges incorporating any of the foregoing values, etc. The anchor catheter  1006  can include an RF needle  1018 . The RF needle  1018  can be disposed in the center of the anchor  1012 . The anchor  1012  can deploy relative to the RF needle  1018 . The RF needle  1018  can slide or be withdrawn relative to the anchor  1012 . In some embodiments, the anchor catheter  1006  can include a pusher configured to push the anchor  1012  relative to the RF needle  1018 . The anchor  1012  can be reversible. The anchor  1012  can transition from the compressed to expanded state, and vice versa. The anchor  1012  can be compressed after placement of the transvalvular bridge  500 . The anchor  1012  can be compressed to remove the anchor  1012 . The anchor  1012  can be compressed to remove the transvalvular bridge  500 . 
       FIG. 106D  illustrates a delivery catheter  1008  according to some embodiments. The delivery catheter  1008  can function for deployment of the transvalvular bridge  500  or any implant described herein. The delivery catheter  1008  can function for suture management and/or cinching. The delivery catheter  1008  can have any size outer diameter and length. The delivery catheter  1008  can have a 12 Fr outer diameter. The delivery catheter  1008  can have a 120 cm length. In some embodiments, the delivery catheter  1008  has an outer diameter of 1 Fr, 2 Fr, 3 Fr, 4 Fr, 5 Fr, 6 Fr, 7 Fr, 8 Fr, 9 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 1-10 Fr, about 8 Fr, etc. In some embodiments, the delivery catheter  1008  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, 140 cm, 150 cm, or ranges incorporating any of the foregoing values, between 110-130 cm, about 120 cm, etc. The delivery catheter  1008  can be steerable. The delivery catheter  1008  can be a 180° Bi-directional catheter. The delivery catheter  1008  can have any bend radius. The delivery catheter  1008  can have a 12.5 bend radius. In some embodiments, the delivery catheter  1008  can have a bend radius of 8 mm, 8.5 mm, 9 mm, 9.5 mm, 10 mm, 10.5 mm, 11 mm, 11.5 mm, 12 mm, 12.5 mm, 13 mm, 13.5 mm, 14 mm, 14.5 mm, 15 mm, 15.5 mm, 16 mm, 16.5 mm, 17 mm, or ranges incorporating any of the foregoing values, between 10-15 mm, about 12.5 mm, etc. The delivery catheter  1008  can function detangle the sutures. The delivery catheter  1008  can function to detangle or prevent tangles of any suture described herein. The delivery catheter  1008  can include four ports  1020  to manage the sutures  1014 , e.g., one port per suture. Each suture  1014  can be threaded through a port  1020  of the delivery catheter  1008 . The number of ports  1020  can correspond to the number of apertures  508  of the transvalvular bridge  500 . The number of ports  1020  can correspond to the number of sutures  1014 . The delivery catheter  1008  can function to push or move one or more components. The delivery catheter  1008  can push the locking clips  1016  toward the transvalvular band  500 . The delivery catheter  1008  can include one or more pushers to advance the locking clips  1016  toward the transvalvular band  500  as described herein. 
       FIG. 106E  illustrates the trimming catheter  1010  according to some embodiments. The trimming catheter  1010  can function to cut the sutures  1014  to a desired length. The trimming catheter  1010  can have any size outer diameter and length. The trimming catheter  1010  can have a 12 Fr outer diameter. The trimming catheter  1010  can have a 120 cm length. In some embodiments, the trimming catheter  1010  has an outer diameter of 1 Fr, 2 Fr, 3 Fr, 4 Fr, 5 Fr, 6 Fr, 7 Fr, 8 Fr, 9 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, 18 Fr, 20 Fr, 22 Fr, 24 Fr, or ranges incorporating any of the foregoing values, between 1-10 Fr, about 8 Fr, etc. In some embodiments, the trimming catheter  1010  has a length of 70 cm, 80 cm, 90 cm, 100 cm, 110 cm, 120 cm, 130 cm, 140 cm, 150 cm, or ranges incorporating any of the foregoing values, between 110-130 cm, about 120 cm, etc. The trimming catheter  1010  can be guided over a suture  1014 . The trimming catheter  1010  can pass through the guide catheter  1002 . The trimming catheter  1010  can provide a repeatable post-cut length of the suture. The trimming catheter  1010  can cut the suture to be approximately 5 to 7 mm. Other lengths are contemplated, e.g., 1 mm, 2 mm, 3 mm, 4 mm, 5 mm, 6 mm, 7 mm, 8 mm, 9 mm, 10 mm, 11 mm, 12 mm, 13 mm, 14 mm, 15 mm, or ranges incorporating any of the foregoing values, etc. The trimming catheter  1010  can include a single cutting port for suture. The trimming catheter  1010  can be designed to cut one suture at a time, or a plurality of sutures simultaneously. 
       FIGS. 107A-107C  are views of transseptal access according to some embodiments.  FIG. 107A  illustrates the general steps of transseptal access according to some embodiments. The introducer can be placed in the right femoral vein or another access point.  FIG. 107B  illustrates transseptal puncture with a dilator inserted through the atrial septum according to some embodiments.  FIG. 107C  is a view of the posterior leaflet after transseptal access according to some embodiments. 
       FIGS. 108A-108C  are views of introduction of the transcatheter system  1000  according to some embodiments.  FIG. 108A  illustrate an introducer according to some embodiments. As described herein, the introducer can be a 24 Fr introducer catheter. The guide catheter  1002  can be inserted into the introducer.  FIGS. 108B-108C  illustrate the steering catheter  1004  and the anchor catheter  1006  according to some embodiments. The posterior leaflet and the anterior leaflet are also identified. 
       FIGS. 109A-110B  are views of anchor deployment according to some embodiments.  FIG. 109A  illustrates the guide catheter  1002  and the steering catheter  1004  according to some embodiments.  FIG. 109B  illustrates two sutures  1014  deployed according to some embodiments.  FIG. 109C  illustrates another view of the two deployed sutures  1014 , which are coupled to subannular anchors  1012 .  FIG. 109D  illustrates a view of three deployed sutures  1014 . The posterior leaflet and the anterior leaflet are also identified.  FIG. 110A  illustrate the steering catheter  1004  and the anchor catheter  1006  according to some embodiments. The deployed sutures  1014  are shown. The anchor catheter  1006  is illustrated deploying the last of the four anchors according to some embodiments.  FIG. 110B  illustrates another view of the anchor  1012 . The aortic valve is shown. The anchor  1012  can be pushed through the annulus after the RF needle creates a passage. The anchor  1012  can be in a compressed state when the anchor  1012  is passed through the annulus. The anchor  1012  can be deployed by releasing the tension on the anchor  1012 . Other configurations are contemplated such as a shape memory material to deploy the anchor or a mechanical force to deploy the anchor. The enlarged outer diameter of the deployed anchor  1012  can prevent or limit the anchor  1012  from passing back through the annulus. 
       FIGS. 111A-111C  are views of cinching according to some embodiments.  FIG. 111A  illustrates four deployed sutures  1014  according to some embodiments. The sutures  1014  can be coupled to subannular anchors  1012 .  FIG. 111B  illustrates the steering catheter  1004 , the sutures  1014 , and the anchor  1012  connected to one of the sutures  1014 .  FIG. 111C  illustrates the fully cinched sutures  1014  according to some embodiments. The posterior leaflet and the anterior leaflet are also identified. The aortic valve is shown. 
       FIG. 112A  is a schematic view of transducer positions according to some embodiments.  FIG. 112B  shows the 3D echo full volume image at one transducer position. The heart has three planes: the long axis or sagittal plane, the short axis or transverse plane, and the four-chamber or oblique coronal plane. The transducer positions can provide various views of the heart. 
     Advantages can include any of the following related to the placement and coaxial nature of the one or more catheters. The transcatheter system  1000  can provide catheters configured to be disposed within one another. As described herein, the guide catheter  1002  can provide a transseptal conduit to the left atrium. The guide catheter  1002  can have an inner diameter sized to accept one or more other catheters. For instance, the guide catheter  1002  can accept the steering catheter  1004  therethrough. The guide catheter  1002  can accept the anchor catheter  1006  therethrough. In some embodiments, the guide catheter  1002  can accept the steering catheter  1004  therethrough, and the steering catheter  1004  can accept the anchor catheter  1006  therethrough. In some embodiments, the steering catheter  1004  and the anchor catheter  1006  can be removed after one or more anchors are installed. In some methods of use, the steering catheter  1004  and the anchor catheter  1006  can be removed after four anchors are installed. The guide catheter  1002  can remain in place as a transseptal conduit to the left atrium after the steering catheter  1004  and the anchor catheter  1006  are removed. The guide catheter  1002  can accept the delivery catheter  1008  therethrough. In some embodiments, the delivery catheter  1008  can be removed after the transvalvular band  500  is positioned. In some embodiments, the delivery catheter  1008  can be removed after the transvalvular band  500  is secured by the locking clips  1016 . The guide catheter  1002  can remain in place as a transseptal conduit to the left atrium after the delivery catheter  1008  is removed. The guide catheter  1002  can accept the trimming catheter  1010  therethrough. In some embodiments, the trimming catheter  1010  can be removed after cutting each suture  1014 . In some embodiments, the trimming catheter  1010  can be removed after cutting a plurality of sutures  1014 . The guide catheter  1002  can be removed after the sutures  1014  are cut. 
     Also, advantages can include any of the following related to the function of the one or more catheters. The transcatheter system  1000  can provide the following functions or purposes related to anchor delivery. The guide catheter  1002  can be designed to provide a conduit to the left atrium. In some embodiments, an introducer and/or dilator can puncture the atrial septum. The guide catheter  1002  can be positioned to provide access to the valve. The steering catheter  1004  can be designed to be steerable to the annulus. The steering catheter  1004  can include a bend radius allowing the tip to position near the annulus. The steering catheter  1004  can guide the anchor catheter  1006  to various locations on the annulus. The steering catheter  1004  can position the anchor catheter  1006  at the 5 o&#39;clock position to deliver an anchor  1012 . The steering catheter  1004  can position the anchor catheter  1006  at the 7 o&#39;clock position to deliver an anchor  1012 . The steering catheter  1004  can position the anchor catheter  1006  at the 11 o&#39;clock position to deliver an anchor  1012 . The steering catheter  1004  can position the anchor catheter  1006  at the 1 o&#39;clock position to deliver an anchor  1012 . The steering catheter  1004  can position the anchor catheter  1006  at any position on the annulus to deliver an anchor  1012 . The steering catheter  1004  can position the anchor catheter  1006  at two positions on the posterior leaflet or posterior annulus to deliver two anchors  1012 . The steering catheter  1004  can position the anchor catheter  1006  at two positions on the anterior leaflet or anterior annulus to deliver two anchors  1012 . The steering catheter  1004  can position the anchor catheter  1006  at four positions on the annulus to deliver four anchors  1012 . 
     Furthermore, advantages can include any of the following related to the function of one or more catheters. The transcatheter system  1000  can provide the following functions or purposes related to implant delivery. The delivery catheter  1008  can deliver the transvalvular band  500 . The delivery catheter  1008  can slide the transvalvular band  500  along the sutures  1014  which are attached to the subannular anchors  1012 . The guide catheter  1002  can be sized to accept the transvalvular band  500  in a collapsed configuration. The delivery catheter  1008  can be designed to separate the four sutures  1014 . The delivery catheter  1008  can be designed to limit or prevent tangles of the sutures  1014  within the guide catheter  1002 . The delivery catheter  1008  can be designed to facilitate sliding of the transvalvular band  500  along the sutures  1014 . The delivery catheter  1008  can be designed to facilitate sliding of the transvalvular band  500  along the sutures  1014  and toward the annulus. The delivery catheter  1008  can be designed to facilitate sliding of the locking clips  1016  toward the transvalvular band  500  along the sutures  1014 . The delivery catheter  1008  can be designed to accommodate a clip pusher on each suture  1014  to push the locking clip  1016  along the suture  1014 . The delivery catheter  1008  can be designed to position the transvalvular band  500  relative to the annulus. The delivery catheter  1008  can be designed to secure the transvalvular band  500  relative to the annulus. The trimming catheter  1010  can be designed to trim the sutures  1014  after the transvalvular band  500  is secured. The trimming catheter  1010  can be designed to trim one suture  1014  at a time. The trimming catheter  1010  can be designed to slide along the suture toward the locking clip  1016  and the transvalvular band  500 . The trimming catheter  1010  can be designed to cut the suture close or substantially close to the locking clip  1016 . 
     Moreover, advantages can include any of the following related to surgical technique and procedure management. The transcatheter system  1000  can provide an intuitive and easy system to deliver the transvalvular band  500 . Each catheter can be utilized in a step of a method. In some methods of use, the heart can be accessed via a transseptal puncture with one or more transseptal needles. The first step, according to some embodiments, can include transseptally placing the guide catheter  1002 . The second step according to some embodiments, can include inserting the steering catheter  1004  with the anchor catheter  1006  inside. The third step according to some embodiments, can include positioning the steering catheter  1004  and delivering the anchors  1012 . The fourth step according to some embodiments, can include inserting the delivery catheter to deploy the transvalvular band  500  and cinch. The fifth step according to some embodiments, can include inserting the trimming catheter  1010  to cut the sutures  1014 . 
     In some embodiments, advantages can include any of the following related to anchor delivery. Each anchor  1012  can be attached to a suture  1014 . Each anchor  1012  can be attached to a suture  1014  prior to delivery to the annulus. The sutures  1014  can be firmly and rigidly attached to the anchors  1012 . In some embodiments, the suture  1014  can extend from the distal end of the anchor  1012  to the proximal end of the anchor  1012 . In some embodiments, the suture  1014  can extend from the distal end of the anchor  1012  and through the anchor catheter  1006 . In some embodiments, the anchor catheter  1006  can be designed to deliver a single anchor  1012 . The anchor catheter  1006  can be designed to manage the suture  1014  attached to the single anchor  1012 . The suture  1014  can extend from the anchor  1012  to the proximal end of the transcatheter system  1000 . The suture  1014  can extend from the anchor  1012  to outside the body of the patient. In some embodiments, the anchor catheter  1006  can be steerable. In some embodiments, the steering catheter  1004  can be designed to steer and position the anchor catheter  1006 . In some embodiments, the anchor catheter  1006  can deliver a second anchor  1012 . In some embodiments, the anchor catheter  1006  can deliver all four anchors  1012 . In some embodiments, the anchor catheter  1006  can be removed after delivery of an anchor  1012 . In some embodiments, the anchor catheter  1006  can be reloaded with another anchor  1012  after delivery of an anchor  1012 . In some embodiments, a second anchor catheter  1006  can be inserted into the steering catheter  1004  to deliver the second anchor  1012 . The anchor catheter  1006  can be designed to manage one or more sutures  1014  extending therethrough. In some embodiments, the anchor catheter  1006  can include one or more channels or grooves to accommodate the suture  1014 . 
     Still further, advantages can include any of the following related to the one or more anchors. The anchor  1012  can have a compressed configuration in which the anchor  1012  has a smaller outer diameter. In some embodiments, the anchor catheter  1006  can apply tension to the anchor  1012  to collapse the anchor  1012 . The anchor  1012  can have an expanded configuration in which the anchor  1012  has a larger outer diameter. In some embodiments, the anchor catheter  1006  can release tension to the anchor  1012  to expand the anchor  1012 . In some embodiments, the anchor catheter  1006  can remove a constraint on the anchor  1012  to expand the anchor  1012 . In some embodiments, the anchor catheter  1006  is configured to push the anchor  1012  from the distal end of the anchor catheter  1006  to expand the anchor  1012 . In some embodiments, the anchor catheter  1006  can include a mechanism to expand the anchor  1012 . The mechanism can move the distal end and the proximal end of the anchor  1012  toward each other. In some embodiments, the anchor  1012  can be reversible. The anchor  1012  can expand and compress and expand again. In some embodiments, the anchor  1012  can be irreversible. The anchor  1012  cannot compresses again after expansion. The transcatheter system  1000  can provide a compact system combining a suture  1014  and an anchor  1012 . The suture  1014  and the anchor  1012  can be rigidly coupled. The suture  1014  and the anchor  1012  can be rigidly coupled prior to subannular delivery. The suture  1014  and the anchor  1012  can be rigidly coupled to withstand anchor deployment. The suture  1014  and the anchor  1012  can be rigidly coupled during the life cycle of the transvalvular band  500 . 
     Advantages can additionally include any of the following related to subannular anchoring. In some embodiments, the anchor catheter  1006  can include a mechanism to create a passageway in the annulus. In some embodiments, the mechanism can be the RF needle  1018 . The RF needle  1018  can apply energy to the annulus to burn a hole through the annulus. The RF needle  1018  can extend through the anchor  1012 . The RF needle  1018  can be centrally placed. The RF needle  1018  can create a passageway having a diameter equal to the outer diameter of the compressed anchor  1012 . The RF needle  1018  can create a passageway having a diameter larger than the outer diameter of the compressed anchor  1012 . The RF needle  1018  can create a passageway having a diameter smaller than the outer diameter of the expanded anchor  1012 . Other mechanisms are contemplated. The mechanism can include a punch. The punch can create the passageway. The punch can be sharpened or blunt. The mechanism can include the application of heat, light, or energy. The number of anchors  1012  can correspond to the transvalvular band  500 . The transvalvular band  500  can be secured by any number of anchors. In some embodiments, the transvalvular band  500  can be designed to be secured with four anchors  1012 . The user therefore can know the suture count prior to surgery based on the selected transvalvular band  500 . 
     Also, advantages can include any of the following related to securing the implant. In some embodiments, the transcatheter system  1000  can provide knotless securement. The locking clips  1016  can be designed to slide along the suture  1014 . The locking clips  1016  can slide after subannular anchoring. The locking clips  1016  can slide after the transvalvular band  500  is deployed. In some embodiments, the locking clips  1016  can be pushed by clip pushers along the sutures  1014 . The clip pushers can be designed to manage the sutures  1014 . Each clip pusher can surround a suture  1014  to prevent or limit tangles of the suture  1014 . The transcatheter system  1000  can provide implant delivery that is reversible. In some embodiments, the transvalvular band  500  can be removable until the locking clips  1014  are secured. In some embodiments, the anchors  1012  can be removable until the locking clips  1014  are secured. 
     Advantages can further include any of the following related to suture management. The anchor catheter  1006  can be designed to manage the attached suture  1014  during delivery of the anchor  1012 . The four sutures  1014  can extend outside of the body after subannular deployment of the anchors  1012 . The transvalvular band  500  can include one or more apertures  508 . The number of apertures  508  can correspond to the number of sutures  1014 . The sutures  1014  can be threaded through the apertures  508  as shown in  FIG. 102A . In some embodiments, the sutures  1014  can be threaded through the apertures  508  after subannular anchoring. In some embodiments, the sutures  1014  can be threaded through the apertures  508  outside the body of the patient. The sutures  1014  can be threaded through the ports  1020  in the delivery catheter  1008 . The ports  1020  can be channels or grooves to facilitate separation of the sutures  1014 . In some embodiments, the sutures  1014  can be threaded through the ports  1020  in the delivery catheter  1008  after threading the sutures  1014  through the transvalvular band  500 . In some embodiments, the sutures  1014  can be threaded through the ports  1020  in the delivery catheter  1008  after subannular anchoring. In some embodiments, the sutures  1014  can be threaded through the ports  1020  in the delivery catheter  1008  outside the body of the patient. The delivery catheter  1008  can prevent or reduce tangles of the sutures during delivery of the transvalvular band  500 . The transvalvular band  500  can slide along the sutures  1014  within the guide catheter  1002 . The locking clips  1016  can slide along the sutures  1014  within the guide catheter  1002 . The trimming catheter  1010  can slide along each suture  1014  after the transvalvular band  500  is positioned and secured. The trimming catheter  1010  can include one port designed to accept one suture  1014 . The trimming catheter  1010  can be designed to manage the suture  1014  as the trimming catheter  1010  slides along the suture  1014 . In some embodiments, suture management relates to the sutures themselves. In some embodiments, two or more sutures  1014  can be the same or similar. In some embodiments, two or sutures  1014  can be different. The sutures  1014  can include an identifier (e.g., color, label, markings, etc.) For instance, the suture  1014  can include an identifier related to the annular position of the associated anchor  1012 . 
     In addition, advantages can include any of the following related to implant delivery including, but not limited to, implant delivery to a beating heart. The transcatheter system  1000  can replicate an open procedure. The transcatheter system  1000  can be delivered percutaneously. The transcatheter system  1000  can be delivered in a minimally invasive manner. The transcatheter system  1000  can be inserted through transseptal access. The transcatheter system  1000  can allow for processes to be completed outside of the body of the patient. The sutures  1014  can extend outside of the body of the patient after subannular anchoring of the anchors  1012 . The transcatheter system  1000  can allow for the sutures  1014  to be threaded through the transvalvular band  500  outside of the body of the patient after subannular anchoring. The transcatheter system  1000  can allow for the sutures  1014  to be threaded through the delivery catheter  1008  outside of the body of the patient after subannular anchoring. The transcatheter system  1000  can allow for the sutures  1014  to be threaded through the trimming catheter  1010  outside of the body of the patient after subannular anchoring. The transcatheter system  1000  can allow retrieval of the sutures tails outside of the body of the patient after subannular anchoring. The heart valve can be, for example, a mitral, aortic, tricuspid, or pulmonary valve. The heart valve annulus can be, for example, a mitral, aortic, tricuspid, or pulmonary valve annulus. The transcatheter system  1000  can be utilized in any valve of the human body. 
     The transcatheter systems and methods include many distinguishing features over the prior art, including but not limited to those disclosed herein. In some embodiments, the transvalvular bridge is not or does not include an annuloplasty ring. In some embodiments, the transvalvular bridge does not comprise an enclosed or ring-like shape. As known in the art, the annuloplasty ring may not be optimal for anatomy. The annuloplasty ring can flatten the annulus from its natural saddle shape. Further, for an annuloplasty ring, the procedure, and subsequent outcome, can be dependent on surgical technique. 
     In some embodiments, the transvalvular bridge can be an elongate structure. In some embodiments, the transvalvular bridge can be shaped to span across the valve instead of encircle or partially encircle the valve. In some embodiments, the transvalvular bridge can be shaped to cinch the valve together. In some embodiments, the transvalvular bridge can cinch the leaflets toward each other to close the valve. In some embodiments, the transvalvular bridge can be designed to span across the leaflets. The transvalvular bridge can include an elongate body having a first end, a second end, and a central portion connected to the first end and the second end. In some embodiments, the central portion can have a convex arcuate shape which is configured to be displaced downward from the first end and the second end. 
     In some embodiments, the valve is not replaced. In some embodiments, the leaflets are not replaced or rendered non-functional. In some embodiments, the transvalvular bridge can be considered a leaflet support, rather than a valve replacement. In some embodiments, the transvalvular bridge is not designed to keep the valve open. In some embodiments, the transvalvular bridge is not designed to keep the leaflets separated. In some embodiments, the transvalvular bridge can allow for normal coaptation of the leaflets which are supported by the transvalvular bridge. In some embodiments, the transvalvular bridge can at least partially close or cinch the valve together to increase the contact between the leaflets. 
     In some embodiments, the delivery systems and methods can allow optimal placement of the transvalvular bridge based on guided sutures which are anchored subannularly. In some embodiments, the first end and the second end can be delivered along sutures to the mitral valve annulus. In some embodiments, the delivery systems and methods can include templates for optimal spacing between two sutures. In some embodiments, the delivery systems and methods can include templates for optimal spacing between four sutures. In some embodiments, two anchors can be positioned on the posterior annulus. In some embodiments, the spacing between the two anchors on the posterior annulus can correspond with the spacing of two apertures on the first end of the transvalvular bridge. In some embodiments, two anchors can be positioned on the anterior annulus. In some embodiments, the spacing between the two anchors on the anterior annulus can correspond with the spacing of two apertures on the second of the transvalvular bridge. In some embodiments, the systems and methods can include a guide to position the anchor catheter. In some embodiments, the anchors are delivered sequentially such that the single anchor catheter is repeatedly positioned at the anchor location. In some embodiments, two or more anchors are delivered simultaneously. 
     In some embodiments, the suture can extend linearly or substantially linearly from the anchor. In some embodiments, the suture can extend linearly or substantially linearly through the hole or other opening in tissue, such as the annulus. In some embodiments, the suture can extend linearly or substantially linearly through the transvalvular bridge. In some embodiments, the suture can form a linear path from the anchor positioned under the annulus and through the transvalvular bridge positioned over the annulus. 
     In some embodiments, the transvalvular bridge can be anchored to the annulus. In some embodiments, the transvalvular bridge is not anchored to the commissures, but rather a non-commissure part of the annulus. However, the implant can be anchored to the commissures in some embodiments. In some embodiments, the transvalvular bridge is not anchored to a natural orifice. In some embodiments, the transvalvular bridge can be anchored via an artificially created orifice in the annulus. In some embodiments, the annulus provides a robust tissue for anchoring. The annulus can be described as a fibrous ring attached to the posterior and anterior leaflet. The annulus can provide sufficient strength to prevent the anchors from backing out or tearing through the annulus when tension is applied to the sutures. The annulus can be described as saddle shaped and the annulus can be described as changing shape during the cardiac cycle. In some embodiments, the transvalvular bridge can be shaped to match the saddle shape of the annulus and provide support during the cardiac cycle. 
     In some embodiments, the transvalvular bridge can be designed to cinch the posterior annulus and the anterior annulus. In some embodiments, the transvalvular bridge can bring the leaflets toward each other. In some embodiments, the transvalvular bridge can cinch the leaflets to provide support. In some embodiments, the transvalvular bridge can cinch the leaflets to change the shape of the leaflets. In some embodiments, the transvalvular bridge can cinch the leaflets to encourage more contact at coaptation points or a larger coaptation zone. 
     In some embodiments, the transvalvular bridge can be reversibly anchored. In some embodiments, the subannular anchors can be adapted to be compressed to be delivered through the hole. In some embodiments, the subannular anchors can assume a larger diameter shape on the underside of the annulus. In some embodiments, the subannular anchors can change configuration with the application of tension to the subannular anchors. In some embodiments, each subannular anchor can be retrieved through the hole in the annulus. In some embodiments, each subannular anchor can be retrieved after the sutures are cinched. In some embodiments, each subannular anchor can be retrieved after the transvalvular bridge is deployed. In some embodiments, each subannular anchor can be retrieved after the locking clips are advanced. In some embodiments, each subannular anchor can be retrieved until the sutures are trimmed. In some embodiments, each subannular anchor can be retrieved after complete implantation of the transvalvular bridge. 
     In some embodiments, the sutures connected to subannular anchors can function as a guide member for the transvalvular bridge. In some embodiments, the system can include a plurality of guide members, including at least one guide member for each end of the transvalvular bridge. In some embodiments, the system can include two guide members for each end of the transvalvular bridge. In some embodiments, the sutures described herein are distinct sutures. In some embodiments, each subannular anchor can include only one suture. In some embodiments, the suture can be threaded through the transvalvular bridge. In some embodiments, the suture can form a straight path through the transvalvular bridge. In some embodiments, the suture is not woven through the transvalvular bridge. 
     In some embodiments, the suture does not form a U-shaped configuration. In some embodiments, the suture does not include two free ends. In some embodiments, one end of the suture can be fixed to the anchor and one end of the suture can be free. In some embodiments, the suture does not form a loop. In some embodiments, the suture does not form a looped portion. In some embodiments, the suture is not stitched through the annulus. In some embodiments, the suture has only one free end. In some embodiments, the suture is connected to the subannular anchor at a fixed end. In some embodiments, the suture can form a single path from the anchor through the body of the patient. In some embodiments, the suture can form a straight path through the annulus. In some embodiments, the suture can form a straight path through the hole in the annulus. In some embodiments, the suture has a diameter between about 0.02 mm and about 0.8 mm (e.g., 0.02 mm, 0.03 mm, 0.05 mm, 0.07 mm, 0.1 mm, 0.15 mm. 0.2 mm, 0.3 mm, 0.35 mm, 0.4 mm, 0.5 mm, 0.6 mm, 0.7 mm, 0.8 mm, or ranges incorporating any of the foregoing values). 
     In some embodiments, the procedure can begin with anchoring. In some embodiments, the subannular anchors can be advanced toward the annulus of the valve. In some embodiments, the subannular anchors are not positioned near the first and second commissures of the valve. In some embodiments, the anchors can be advanced into the left atrium toward the annulus. In some embodiments, the anchors can be advanced from the left atrium to the left ventricle, through the annulus. In some embodiments, the anchors are not advanced from the left ventricle toward the left atrium. 
     In some embodiments, a hole can be created in the annulus to pass the compressed anchor therethrough. In some embodiments, the hole can be created with the application of energy to ablate the annulus. In some embodiments, the hole can include smooth edges. In some embodiments, the hole can be stretched/dilated to accept a larger diameter catheter therethrough. In some embodiments, the method of creating the hole can prevent tearing of the annulus. In some embodiments, the hole can be a smaller diameter than the anchor catheter. In some embodiments, the anchor catheter can include features such as a tapper or dilator which increases the diameter of the hole, or is not configured to dilate the aperture. In some embodiments, the anchor catheter can reversibly stretch the hole to allow delivery of the anchor. In some embodiments, the hole can retain its original diameter when the anchor catheter is removed. In some embodiments, the deployed anchor can have a larger diameter than the hole. In some embodiments, the deployed anchor can have a cross-section which is larger than the hole (e.g., twice the diameter, three times the diameter, four times the diameter, five times the diameter, or ranges incorporating any of the foregoing values). 
     In some embodiments, the subannular anchor, or a surface thereof can rest against the underside of the annulus. In some embodiments, the subannular anchor can maintain its position against the underside of the annulus while the suture is cinched. In some embodiments, the system can include four anchors. In some embodiments, the system can include two anchors on the posterior annulus and two anchors on the anterior annulus. In some embodiments, the suture can pass through the annulus only once. In some embodiments, the suture is not looped through the annulus in a sewing pattern. In some embodiments, the subannular anchor can be expanded on the ventricular side of the annulus. In some embodiments, the suture can extend from the ventricular side of annulus and through the hole in the annulus. In some embodiments, the holes and sutures can be in a one-to-one correspondence. In some embodiments, each suture can have a separate hole through the annulus. In some embodiments, the suture can extend to the atrial side of the annulus. In some embodiments, the sutures can be flexible. In some embodiments, the sutures can be pulled taut to be semi-rigid. In some embodiments, the semi-rigid sutures can provide a guide for the advancement of the delivery catheter along the sutures. In some embodiments, the semi-rigid sutures can provide a guide for advancement of the transvalvular bridge. In some embodiments, the semi-rigid sutures can provide a guide for advancement of the locking clips. 
     In some embodiments, the transvalvular bridge does not include ventricular attachment. In some embodiments, the transvalvular bridge can extend along the plane of the annulus. In some embodiments, the transvalvular bridge can be similar to the saddle shape of the valve. In some embodiments, the convex central portion does not extend beyond the point of coaptation or coapatation zone of the leaflets. In some embodiments, the convex central portion does not interfere with natural coaptation. 
     Access to the annulus can be provided in various ways according to some embodiments. In some embodiments, the systems can be advanced through the vasculature toward the annulus using any known point of enter to the left atrium. In some embodiments, the catheters described herein can be introduced via the femoral vein, to an inferior vena cava, to the right atrium, and then to the left atrium. The catheters can be delivered transseptally. The catheters can be delivered through the fossa ovalis. In some embodiments, the catheters can be introduced via the basilic vein, to the subclavian vein, to the superior vena cava, to the right atrium, and to the left atrium. In some embodiments, the catheters can be introduced via the external jugular vein, to the subclavian vein, to the superior vena cava, to the right atrium, and to the left atrium. Access can be provided by dilators, if needed, according to some embodiments. Access can be provided by one or more sheaths, according to some embodiments. Access can be provided by one or more steerable catheters, according to some embodiments. Access can be provided by one or more catheters or needles configured to puncture the septum to create access, according to some embodiments. 
     In some embodiments, the anchors can be guided into position by the anchor catheter. In some embodiments, the anchor catheter can be guided into position by the template catheter. In some embodiments, the template catheter can ensure spacing between the anchors appropriate for the corresponding band. In some embodiments, the surgeon can position the anchor catheter at spaced locations along the annulus. In some embodiments, two anchors can be positioned on the posterior annulus and two anchors can be positioned on the anterior annulus. In some embodiments, two anchors can be positioned adjacent to the posterior leaflet and two anchors can be positioned adjacent to the anterior leaflet. In some methods, one set of anchors is parallel to another set of anchors. 
     In some embodiments, the anchors can comprise a shape memory material such as Nitinol or other springy metals. In some embodiments, the anchors can comprise a flexible material allowing the anchors to assume a compressed and expanded shape. In some embodiments, the anchors can comprise one or more radially expandable prongs that can be reversibly expanded and compressed. In some embodiments, the anchors can be coupled and carried by the anchor catheter through the hole in the annulus. The anchors can be held under tension to assume a compressed shape. Other configurations are contemplated such as a sheath or other constraining structure. 
     In some embodiments, the anchors can be advanced through the hole and pushed distally to the ventricle. In some embodiments, once on the ventricular side of the annulus, the anchor catheter can release tension on the subannular anchor allowing the anchor to expand such that the anchor cannot fit through the hole. In some embodiments, as the tension is released from the anchors, the anchors can expand. In some embodiments, the struts of the anchors can radially expand and longitudinally compress. In some embodiments, the anchor can expand to a star shape. The expanded subannular anchor can create a larger cross-sectional shape than the hole. The expanded subannular anchor can create a larger surface area than the anchors when compressed. In some embodiments, the anchor catheter can retract after placement of the anchor. In some embodiments, the anchors can be reversible. The anchor can be compressed and pulled back through the hole. In some embodiments, the anchor can compress under the influence of tension and can be extracted through the hole. In some embodiments, the anchor catheter can apply tension to the anchor to compress the anchor. 
     In some embodiments, the suture can be anchored to the ventricular side of the annulus. The suture can extend from the subannular anchor and through the catheter system. The free end of the suture can be external to the patient. The extracorporeal sutures can be easily managed. Once trimmed, the extracorporeal sutures can be pulled to retrieve the sutures from the left atrium. In some embodiments, the surgeon can retrieve all four sutures and maintain the suture count. 
     The annulus can provide a robust tissue for anchoring the suture. The tissue in the area of the annulus can be thicker than other tissues of the heart. The tissue can be continuous, without any natural orifices or weaknesses. The anchor can be passed through an artificial hole created in the annulus. In some embodiments, the hole can be perfectly circular, oval, or other geometries. In some embodiments, the hole can be cauterized such as by the application of heat or energy. In some embodiments, the hole can be punched. In some embodiments, the hole can be created in a way to prevent any areas for stress cracks or tears. 
     In some embodiments, after placement of the anchors, the transvalvular bridge can advanced toward the annulus. The transvalvular bridge can be advanced along the sutures after the subannular anchors are expanded. The transvalvular bridge can be pushed distally by one or more guides or by the delivery catheter itself. The transvalvular bridge can be advanced in a compressed configuration. The transvalvular bridge can be rolled to a compressed configuration but still be able to slide along the suture. The transvalvular bridge can be expanded within the left atrium of the heart. The transvalvular bridge can be expanded when approaching the annulus. In some embodiments, as the transvalvular bridge is expanded from the delivery catheter, the transvalvular bridge can assume a pre-set shape. The central portion can curve downward from the first end and the second end. The transvalvular bridge can assume a convex shape. In some embodiments, the transvalvular bridge can be expanded by removal of a constraint. In some embodiments, the transvalvular bridge can be expanded by removal of a tubular covering or sheath. In some embodiments, the transvalvular bridge can be expanded by being pushed distally. 
     In some embodiments, the transvalvular bridge can include two or more apertures for slidable delivery along the sutures. In some embodiments, the transvalvular bridge can be preloaded on the sutures. The manufacturer can thread the sutures through the transvalvular bridge. In some embodiments, the surgeon can thread the sutures through the apertures of the transvalvular bridge. The sutures can be threaded through the transvalvular bridge outside the body of the patient. In some embodiments, each suture can correspond to a single aperture in the transvalvular bridge. In some embodiments, prior to delivery of the transvalvular bridge, the sutures can be threaded through the transvalvular bridge such that the transvalvular bridge can slide along the sutures toward the annulus. The transvalvular bridge can provide support to the valve. The transvalvular bridge can be positioned to allow natural coaptation. In some embodiments, the transvalvular bridge does not force the valve open. In some embodiments, the transvalvular bridge does not extend into the ventricle. In some embodiments, the transvalvular bridge does not comprise a stent. 
     In some embodiments, the locking clips can slide along the sutures. The locking clips can be pushed distally toward the annulus. The locking clips can be designed to be positioned against the transvalvular bridge. In some embodiments, the sutures can allow the surgeon to accurately position the locking clips relative to the transvalvular bridge. In some embodiments, the surgeon can be provided with tactile feedback when the locking clip is secured by abutting the locking clips against the transvalvular bridge. The locking clips can be unidirectional to allow distal movement but prevent proximal movement of the locking clip. 
       FIGS. 113A-113T  are schematic views of methods of use of a transcatheter system according to some embodiments. The systems and methods can revolutionize the treatment of mitral or other valve regurgitation. In a simple procedure, surgeons can treat mitral valve regurgitation in vivo, as an alternative to open heart surgery. The catheter system can be introduced via the femoral vein or other access point and delivered to the heart. The catheter system can be delivered using a transseptal puncture. In some embodiments, a guide wire can be positioned to the left atrium. The guide catheter can be navigated into the heart along the guide wire. The guide catheter can gain access to the mitral valve. 
       FIGS. 113A-113T  are views of a transcatheter system  1100  and methods of use according to some embodiments. The catheters of transcatheter system  1100  can include any of the features of catheters described herein.  FIG. 113A  illustrates a guide catheter  1102 . The guide catheter  1102  can provide a transseptal conduit to, for example, the left atrium. The transcatheter system  1100  can include a guide wire  1104 . The guide wire  1104  can span between the right atrium and the left atrium. The guide wire  1104  can extend from the left atrium, through the valve annulus and toward the left ventricle. While some embodiments are described in the context of a mitral bridge, other implants that span the annulus can be utilized, and the method adapted to other valve annuli including the tricuspid, aortic, and/or pulmonic valve annuli depending on the desired clinical result. 
     The guide catheter  1102  can be placed in the left atrium through the transseptal access. In some embodiments, a template catheter  1106  can be utilized after the guide catheter  1102  is placed. The template catheter  1106  can be delivered in a compressed configuration in  FIG. 113A . The template catheter  1106  can be deployed in the left atrium to direct the system appropriately to the mitral valve. 
       FIG. 113B  illustrates the template catheter  1106  being deployed according to some embodiments. The template catheter  1106  can slide along the guide wire  1104  toward the mitral valve. The template catheter  1106  can include one or more struts  1008 . In some embodiments, the number of struts  1108  can correspond to the number of anchors, as described herein. The template catheter  1106  can be steered toward the mitral valve along the guide wire  1104 . 
       FIG. 113C  illustrates the deployed template catheter  1106  according to some embodiments. The struts  1108  can assume an enlarged cross-section. The struts  1108  can radially expand. The struts  1108  can axially shorten. The struts  1108  can fold outward as shown. In some embodiments, each strut can comprise a pair of apertures  1110  through which an anchor catheter conduit  1112  passes. In the illustrated embodiment, the template catheter  1106  can include four struts  1108  with four corresponding anchor catheter conduits  1112 . In some embodiments, each strut  1108  can support one, two, or more anchor catheter conduit  1112 . Other configurations are contemplated (e.g., one strut  1108  supports two anchor catheter conduits  1112 , one strut  1108  supports three anchor catheter conduits  1112 , one strut  1108  supports four anchor catheter conduits  1112 , etc.). The anchor catheter conduit  1112  can be a flexible tube. The anchor catheter conduit  1112  can be an enclosed channel or partially enclosed channel. 
       FIG. 113D  illustrates the deployed template catheter  1106  being moved toward the mitral valve according to some embodiments. The template catheter  1106  can be positioned across the anterior and posterior leaflets. The template catheter  1106  can provide the appropriate spacing for the anchors via anchor catheter conduits  1112 . The template catheter  1106  can be rotated relative to the guide wire  1104  to position the anchor catheter conduits  1112 . The anchor catheter conduits  1112  can be positioned at or near the 5 o&#39;clock, 7 o&#39;clock, 11 o&#39;clock, and 1 o&#39;clock positions. In some embodiments, two anchors can be spaced apart from another two anchors along an axis of symmetry. The 5 o&#39;clock and 7 o&#39;clock positions can be the locations of the anchors on the posterior annulus. The 11 o&#39;clock and 1 o&#39;clock positions can be the locations of the anchors on the anterior annulus. Other positions are contemplated (e.g., 1 o&#39;clock, 2 o&#39;clock, 3 o&#39;clock, 4 o&#39;clock, 5 o&#39;clock, 6 o&#39;clock, 7 o&#39;clock, 8 o&#39;clock, 9 o&#39;clock, 10 o&#39;clock, 11 o&#39;clock, 12 o&#39;clock, or any range including two or more values).  FIG. 113E  illustrates the position of the template catheter  1106  against the leaflets and the annulus, according to some embodiments. A portion of the template catheter  1106  can extend toward the left ventricle and between the leaflets. The struts  1108 , or a portion thereof, can be positioned against the annulus. The anchor catheter conduits  1112  can extend in an appropriate direction such as downward toward the annulus. 
       FIG. 113F  illustrates an anchor catheter  1116  according to some embodiments. The anchor catheter  1116  can be sized to pass through the anchor catheter conduit  1112  toward the annulus. As described herein, the strut  1108  can include the pair of apertures  1110 . The pair of apertures  1110  can provide a passageway to the annulus. The pair of apertures  1110  can allow the anchor catheter  1116  to create a hole in the annulus. The anchor catheter  1116  can be passed through the anchor catheter conduit  1112  to deliver an anchor subannularly. The anchor catheter  1116  can use a radio frequency wire system or other electromagnetic, mechanical, or other source of energy to ablate a small pilot hole in the annulus. The anchor catheter  1116  can apply energy to the annulus as shown in  FIG. 113F . In some embodiments, the hole created by the anchor catheter  116  can be smaller in diameter than the anchor catheter  1116 . In some embodiments, the hole can reversibly stretch to allow passage of the anchor catheter  1116 . 
       FIG. 113G  illustrates an anchor catheter  1116  extending through the pilot hole on the ventricular side of the annulus according to some embodiments. The anchor catheter  1116  can carry the anchor  1118  through the pilot hole in a compressed configuration. The anchor  1118  can be axially elongated in the compressed state. The distal tip of the anchor catheter  1116  can include a wire  1120  used to create the hole. In some embodiments, the anchor catheter  1116  can include a punch to create a hole.  FIG. 113H  illustrates the deployed anchor  1118  on the ventricular side of the annulus according to some embodiments. The anchor catheter  1116  can be retracted through the pilot hole. The anchor  1118  can include a tether, such as a suture extending from the anchor  1118 . The suture  1122  can extend through the anchor catheter  1116 . In some embodiments, as the anchor catheter  1116  is retracted, the suture  1122  can remain extending from the anchor  1118 , through the pilot hole, and to the left atrium as described herein. The suture  1122  can extend through the catheter system and extend external to the patient. 
       FIG. 113I  illustrates the plurality of anchors  1118  deployed in a similar manner according to some embodiments. Four or a different number of anchors  1118  can be used to secure the mitral bridge. The plurality of anchors, e.g., four anchors, can be delivered subannularly. In some embodiments, the subannular anchors  1118  can be placed through the pilot holes under the annulus with minimal pressure. In some embodiments, the anchors  1118  can be delivered sequentially such that the anchor catheter  1116  can be removed from one anchor catheter conduit  1112  after anchor delivery, and can be inserted into a second anchor catheter conduit  1112  for delivery of a second anchor, until all four anchors  1118  are sequentially delivered. In other embodiments, two or more of the anchors can be delivered simultaneously.  FIG. 113I  illustrates a portion of the template catheter  1106  extending between the leaflets and along the guide wire  1104  according to some embodiments. In some embodiments, the anchors can be removed after being deployed. The anchors  1118  can be compressed and retrieved from the annulus. The template catheter  1106  can be redeployed. The anchor catheter  1116  can create one or more additional holes for the subannular anchors. 
       FIG. 113I  shows the four sutures  1122  extending from the four anchors  1118  according to some embodiments. In some embodiments, after all four anchors  1118  are delivered, the template catheter  1106  can be removed.  FIG. 113I  shows the removal of the template catheter  1106  according to some embodiments. The template catheter  1106  can be compressed for passage through the guide catheter  1102 . In some embodiments, the template catheter  1106  including the anchor catheter conduit  1112  can provide suture management. Each suture  1122  can extend through the anchor catheter conduit  1112  such that the sutures  1122  are prevented from tangling or tangling is reduced. In some embodiments, the sutures  1122  can extend through separate lumens. In some embodiments, the template catheter  1106  can be retracted by sliding along the guide wire  1104 . In some embodiments, the guide wire  1104  can remain in position after the template catheter  1106  is removed. 
       FIG. 113K  illustrates the cinching of the annulus according to some embodiments.  FIG. 113L  illustrates further cinching of the annulus according to some embodiments. In some embodiments, with the anchors  1118  in place subannularly and the sutures extending through the annulus, the annulus can be cinched, in other words, the opposing sides of the annulus can be brought closer together along part of the annulus. The cinching can confirm securement of the subannular anchors  1118 . The cinching can position the anchors  1118  against the annulus. The cinching can reduce any slack in the sutures  1122 . The cinching can confirm the correct mitral bridge size. The cinching can confirm the desired spacing or length between the pair of sutures associated with the posterior leaflet and the pair of sutures associated with the anterior leaflet. The length of the implant, e.g., mitral bridge, can be selected to maintain the cinched position of the annulus. In some embodiments, the guide catheter  1102  can be brought toward the annulus to cinch the sutures  1122 . In some embodiments, as the guide catheter  1102  moves toward the annulus, the sutures  1122  can be moved toward each other. In some embodiments, tension is applied to the sutures  1122  to cinch the sutures  1122 . The sutures  1122  can be connected to the annulus via the subannular anchors  1118  in order to move the annulus. The cinching can increase the engagement between the posterior and anterior leaflet to enhance coaptation, as described herein. 
       FIG. 113M  illustrates the mitral bridge  1130  which can be as described elsewhere herein and can include any of the features of any implant described herein including a transvalvular band  500 . The mitral bridge  1130  can be deployed after the anchors are deployed. The mitral bridge  1130  can be guided into place through the guide catheter  1102  via the sutures  1122  which are permanently attached to the subannular anchors. The mitral bridge  1130  can include apertures  1132  through which the sutures  1122  can pass. In some embodiments, each aperture  1132  can be designed to accept one suture  1122 . The first end of the mitral bridge  1130  can include two apertures  1132  designed to accept two sutures  1122 . The mitral bridge  1130  can be compressed for delivery through the guide catheter  1102 .  FIG. 113N  illustrates the mitral bridge  1130  deployed in the left atrium according to some embodiments. The mitral bridge  1130  can slide along the anchored sutures  1122  toward the annulus. The second end of the mitral bridge  1130  can include two apertures  1132  designed to accept two sutures  1122 . The four apertures  1132  can correspond to the four sutures  1122 . The four apertures  1132  can provide suture management to prevent the sutures  1122  from being tangled during delivery. 
       FIG. 113O  illustrates a delivery catheter  1134  according to some embodiments. The delivery catheter  1134  can move the mitral bridge  1132  toward the annulus. Once positioned, the mitral bridge  1130  can be used in conjunction with the anchored sutures  1122  to cinch the posterior annulus toward the anterior annulus to facilitate proper leaflet coaptation. The delivery catheter  1134  can move locking clips  1136  toward the annulus. Each locking clip  1136  can slide along the corresponding suture  1122  during delivery. The locking clips  1136  can secure the mitral bridge  1130 . The suture  1122  can be threaded through the locking clip  1136  to allow for unidirectional movement. The locking clip  1136  can allow movement of the locking clip  1136  toward the annulus but prevent or limit movement of the locking clip  1136  away from the annulus. In some embodiments, the mitral bridge  1130  and the locking clips  1136  can be simultaneously delivered. In some embodiments, the mitral bridge  1130  can be delivered first and the locking clips  1136  can be delivered after. In some embodiments, the locking clips  1136  can be sequentially delivered. The delivery catheter  1134  can be removed as shown in  FIG. 113P  according to some embodiments. 
       FIG. 113Q  illustrates the deployed mitral bridge  1130  according to some embodiments. The mitral bridge  1130  can be sized to maintain the position of the sutures  1122 . The mitral bridge  1130  can be sized to cinch the sutures  1122  and therefore the annulus.  FIG. 113R  illustrates a trimming catheter  1138  according to some embodiments. The trimming catheter  1138  can slide along the suture  1122  toward the annulus.  FIG. 113R  illustrates a trimming catheter  1138  trimming the suture  1122  according to some embodiments.  FIG. 113R  illustrates the deployed mitral bridge  1130  according to some embodiments. In some embodiments, all four sutures  1122  can be sequentially trimmed by the trimming catheter  1138 . The trimming catheter  1138  can allow the suture  1128  to be retrieved by pulling the suture from the body of the patient. 
     Disclosed herein are methods of percutaneous transcatheter delivery of embodiments of a transvalvular band, which can also be referred to herein as a transvalvular bridge or a mitral bridge. The transvalvular bridge can be delivered to the valve for repair of regurgitation or prolapse. The transvalvular bridge can be delivered to the mitral valve to repair of mitral regurgitation. 
     The systems and methods can include various features or advantages. The systems and methods can replicate an open procedure. The systems and methods can replicate an open procedure end-securement. The systems and methods can guarantee suture placement. The systems and methods can show a surgeon the suture count prior to securing the first locking device. The systems and methods can provide positional identification of the sutures by valve nomenclature. The systems and methods can include no new implantable device technology. The systems and methods can be conducted on beating heart. The systems and methods can be echogenic. The systems and methods can prevent or limit occlusions. The systems and methods can prevent or limit leaflet damage. The systems and methods can prevent or limit chordae damage. The systems and methods can allow for complete bail out or reversal until first suture knotted. The systems and methods can allow for complete identification and count of all catheter delivery components and suture-tail cuts. The systems and methods can allow for a RF wire pilot hole through annulus. The systems and methods can allow for a low pressure delivery of one or more anchors. The systems and methods can allow for flexible deployment of a retaining system. The systems and methods can allow for percutaneous securement by knot or ferrule locking device The systems and methods can allow for transseptal delivery. The systems and methods can allow for over the wire delivery. The systems and methods can allow for one placement that enables delivery of four individual anchors via four individual anchor catheters. The systems and methods can allow for use of a template catheter. The systems and methods can allow for single catheter delivery which is repeated four times to secure the transvalvular bridge with subannular or intramuscular anchors, retaining clips, and suture cutting. The systems and methods can allow for one or more catheters that secure the transvalvular bridge with subannular or intramuscular anchors, secure via retaining clips, and cut the suture. One or more of these functions can be separated into differentiated catheters. The systems and methods can allow for one placement that enables delivery in situ of the transvalvular bridge at the distal end of the catheter or the slight proximal delivery of the transvalvular bridge. 
     The methods can include transseptally placing a guide catheter. The methods can include inserting a template catheter to land in the AP position. The methods can include sequentially advancing steering catheters to the annulus and deliver one or more anchors, e.g., four anchors. The methods can include deploying the transvalvular bridge. The methods can include cinching the transvalvular bridge. The methods can include deploying the one or more retaining clips, e.g., deploying one retaining clip for each suture. The methods can include inserting a trimming catheter. The methods can include cutting the excess suture. 
     The template catheters and methods described herein can include various features or advantages. In some embodiments, the transvalvular bridge is located distally already in situ. In some embodiments, the template catheters and methods can eliminate suture management issues. 
     From an end user point, the template catheter and transvalvular bridge can be packaged as one item. In some embodiments, the template catheter and transvalvular bridge can be packaged with the transvalvular bridge pre-sutured to the template in the deployed state. The transvalvular bridge velour can include pre-punched holes that are big enough to allow the whole needle to pass through. The transvalvular bridge velour can facilitate entry of compressed anchor therethorugh. The transvalvular bridge velour can include 0.080″ holes in some embodiments. 
     Before surgery, the template can be retracted into a closed position in a steerable sheath. In the closed position, the transvalvular bridge can be loose on length of suture, for example, about 1.5 inches of suture. The transvalvular bridge can be free to be rolled up and inserted into a guide sheath or guide catheter. Once inserted into the heart, the template catheter can be steered into position. The template catheter can be used to push the transvalvular bridge into the atrium. 
     Once in the atrium the template can be deployed. In deployment, transvalvular bridge can be held tight against the template. The template can be footprint of the template catheter. 
     Once the template catheter is in position on either the posterior or anterior side, the needles can be deployed via lumens. The needles can be 0.075″ needles in some embodiments. The needles pass through the lumens, through the template, through pre-punched holes in the transvalvular bridge velour, and finally through the annulus. 
     The needles can deliver the anchors. The anchors can be deployed. 
     The retaining clips can be included in the anchor catheter along with suture trimming capability. This combined function of the anchor catheter can eliminate a catheter and pusher. 
     In some methods, two options are available for the next step. In some methods, the surgeon can drop retaining clips on atrial side, pull anterior/posterior side of annulus across, and burn reaming anchor holes, using the template catheter to cinch. In some methods, the surgeon can reposition the template catheter for opposing side anchors, burn and deploy anchors, cinch, then systematically drop retaining clips for all 4 positions, using the sutures to cinch. 
     The suture retaining the transvalvular bridge to the template can be clipped, freeing template from transvalvular bridge and surgery is completed. The template catheter can be removed. 
     The template catheter can be a 0.120″ nitinol tube, laser cut, and shape set. The template can be free to rotate and could sit centrally in a current 0.124″ inner diameter steerable catheter. A coil can be attached to the end of the template, so the template catheter can be controlled distally, e.g., rotate, push and/or pull for deployment and/or retraction. On the 0.125″ inner diameter shaft, 0.183″ outer diameter shaft, four lumens can be attached for the needles and two small lumens can be attached for the template and transvalvular bridge retaining sutures. 
     The total outer diameter can be about 0.260″. The template catheter and the steerable catheter can utilize a guide sheath of around 0.270″ID (˜25 French OD). 
     The benefit of this approach can include better or smaller anchor and clip systems. The benefit of this approach can include a change in the lumen diameter. In some embodiments, all sizes can shrink. The benefit of this approach can include a suture-less anchoring system. In some embodiments, a rivet can crimp the atrial side, or the anchor can be a double anchor concept. 
       FIG. 114  illustrates an embodiment of a transvalvular band  500 . The transvalvular band  500  can also include an arcuate central portion  502  which can be generally convex in the direction of the ventricle. As illustrated, the central portion  502  can include a plurality of struts  516  that cross and form a generally “X” shape at intersection zone or junction. Other designs of the transvalvular band  500  are contemplated. The transvalvular band  500  can have any shape including circular, oval, elliptical, semi-circular, semi-oval, semi-elliptical, spherical, ovoid, square, rectangular, triangular, or a variety of other shapes. For example, the cross sectional shape can be substantially rectangular, circular, oblong, triangular, or a variety of other shapes. The edges of the transvalvular band  500  can be rounded or otherwise configured so that the transvalvular band  500  presents an atraumatic surface to the valve leaflets. The transvalvular band  500  can have any shape to perform the functions described herein. The transvalvular band  500  can be considered a mitral bridge. The transvalvular band  500  can include a first attachment structure  504  at a first end of the band  500 . The transvalvular band  500  can include a second attachment structure  526  at a second end of the band  500 . Both attachment structures  504 ,  526  can include a variety of structures as discussed elsewhere herein for anchoring to the valve annulus. As illustrated, the attachment structures  504 ,  526  can have one or more layers of a velour material such as a Dacron mesh and having an underlying frame for supporting the mesh and securing the mesh to the transvalvular band  500 . The attachment structures  504 ,  526  can also include one or a plurality of apertures  508  which can be configured to allow for suturing therethrough, to attach the transvalvular band  500  to the valve annulus. The attachment structures  504 ,  526  can be any surface to allow a needle to create a hole therethough. 
     The transvalvular band  500  can be pushed into the atrium ahead of a template catheter  1200 . The transvalvular band  500  can be secured through a central suture  1202  on both sides of a template  1204 . The deployed template  1204  is illustrated in  FIG. 114 . The deployed template  1204  can be asymmetrical. The template  1204  can include a first end  1206  and a second end  1208 . In some embodiments, the first end  1206  can include enclosed anchor guides  1210 . The enclosed anchor guides  1210  can be guide socks or tubes. In some embodiments, the second end  1208  can include partially enclosed anchor guides  1212 . The enclosed anchor guides  1212  can be guide socks or tubes. In some embodiments, the first end  1206  can include guides  1210  for two anchors and the second end can include guides  1212  for two anchors, wherein the transvalvular band  500  includes four apertures  508 . Other configurations are contemplated including each guide  1210 ,  1212  designed to allow passage for one anchor, two anchors, three anchors, four anchors, five anchors, six anchors, or any ranges of the forgoing values. In some methods of use,  FIG. 114  shows Step  1  with the mitral bridge or transvalvular band  500  pushed into the atrium ahead of the template catheter  1200 . It is secured through a central suture on both sides to the template catheter  1200 . 
       FIG. 115  illustrates the transvalvular band  500  and the template catheter  1200 . The transvalvular band  500  can be secured to the template  1204 . In some methods, the transvalvular band  500  is secured using a slip knot or other mechanism. The suture can be looped through the template  1204 . In some methods, the suture loop is pulled tight. The system can include four guide lumens  1214  or guide socks. The guide lumens  1214  can extend toward the anchor guides of the first end  1206  and the second end  1208  of the template  1204 . The anchor guides  1210 ,  1212  of the first end  1206  and the second end  1208  align with the apertures  508  of the transvalvular band  500  when the template is secured. The guide lumen  1214  can direct a needle through the guide lumen  1214 , through an anchor guide  1210 ,  1212  and through an aperture  508  of the transvalvular band  500 . In some embodiments, the needles are deployed one at time. 
       FIG. 115  illustrates the template  1204  in a compressed configuration. The template catheter  1200  can be formed of a 0.120″ outer diameter tube. The template catheter  1200  can be laser cut. The template  1204  can be cut asymmetrically to reduce the diameter. The second end  1208  can be proximal to the first end  1206 . The second end  1208  can curve and fit within the profile of the tube. The first end  1206  can curve and fit within the profile of the tube. The template catheter  1200  can have a 0.120″ outer diameter, but other diameters are contemplated. The template catheter  1200  can be disposed in a steering catheter  1220 . The steering catheter  1220  can have a 0.124″ inner diameter and a 0.190″ outer diameter, but other diameters are contemplated. In some methods of use,  FIG. 115  shows Step  2  to secure the mitral bridge or transvalvular band  500  to the guide template  1204 , using slip knot or other mechanism. The suture loop is pulled tight. In some embodiments, the template catheter  1200  can have an 0.120″ outer diameter and the steering catheter  1220  can have a 0.124″ inner diameter and a 0.190″ in outer diameter. Other diameters are contemplated that allow the template catheter  1200  to extend through the steering catheter  1220 . The suture can have a slip knot. The template catheter  1200  can have four guide socks or tubes. The needles can be deployed one at a time. The central template catheter  1200  can be formed from a 0.120″ tube, laser cut asymmetrically for template  1204  to reduce the diameter. 
       FIG. 116  illustrates the transvalvular band  500  being positioned. In some methods, the transvalvular band  500  is positioned on a posterior side. In some methods, needles are deployed for P 1  and P 3 . The needles are guided by guide lumens  1214  or guide socks. The transvalvular band  500  has pre-punched apertures  508  to fit the needles and anchors  1012  through. In other embodiments, the needles form apertures in the transvalvular band  500 . Embodiments of a needle of an anchor catheter and anchors are illustrated in U.S. application Ser. No. 15/851,557, which is incorporated by reference in its entirety. In some embodiments, the anchor sutures at the P 1  and P 3  side are loosened and the template  1204  is repositioned to deploy anchors on an anterior side. In some methods, needles are deployed for P 2  and P 4 . The needles are guided by guide lumens  1214  or guide socks. In some methods, anchors and clips are deployed on an atrial anterior side. In some embodiments, the sutures are cinched. In some embodiments, anchors and clips are deployed on an atrial posterior side. In some methods of use,  FIG. 116  shows Step  3  to position the bridge or transvalvular band  500  on posterior side, deploy needles and anchors for P 1  and P 3 . The needles are guided by socks and the mitral bridge or transvalvular band  500  has pre-punched holes to fit needles and anchors through. In some methods of use,  FIG. 116  shows Step  4  to loosen anchor sutures at the P 1  and P 3  side, reposition template and deploy anchors on the anterior side. In some methods of use,  FIG. 116  shows Step  5  to deploy anchors and clips on atrial anterior side, cinch an deploy anchors and clips on posterior side. Four guide socks are shown. The needles can be deployed one at a time. The retaining suture is also shown. 
       FIG. 117  illustrates the bendability and/or compressibility of the guide lumens  1214  and the template  1204 . The guide lumens  1214  and the template  1204  can be compressed for delivery. The guide lumens  1214  and the template  1204  can be compressed within a delivery catheter. In some embodiments, the template  1204  is compressed within the steerable catheter for delivery. In some embodiments, guide lumens  1214  are compressed outside of the steerable catheter  1220  for delivery. In some embodiments, guide lumens  1214  are compressed within a larger guide catheter for delivery. The template  1204  can have a neutral, compressed shaped. The template  1204  can have a neutral, expanded shape. The template  1204  can have a nesting configuration to allow easy compressibility, see  FIG. 115 . 
       FIG. 118  illustrates the guide lumens  1214  and the template  1204  in a deployed configuration. The guide lumens  1214  and the template  1204  can be expanded within the heart valve. The guide lumens  1214  can be formed of a thin flexible structure. The guide lumens  1214  can be enclosed. The guide lumens  1214  can be woven. Each guide lumens  1214  can form a tube or sock. The guide lumens  1214  can prevent the needles or corresponding anchoring structures from tangling. The guide lumens  1214  can effectively guide the respective needle toward the respective aperture  508 . The guide lumens  1214  can be straight. The guide lumens  1214  can be curved. The guide lumens  1214  can be compressible for delivery. The guide lumens  1214  can extend the length of the template catheter  1200 . 
       FIG. 119  illustrates the guide lumens  1214  and a needle  1222  in a deployed configuration. The needle  1222  can extend through the guide lumens  1214 . The needle  1222  can extend through a partially enclosed anchor guide  1212  of the second end  1208  of the template  1204 . In some embodiments, the needle  1222  is inserted sequentially through each guide lumen  1214 . In some embodiments, a single needle is utilized for two or more guide lumens. In some embodiments, a single needle is utilized for each guide lumen. In some embodiments, two needles are utilized for two guide lumens, and each needle is inserted in a respective guide lumen. In some embodiments, two needles are utilized for two guide lumens on the same side of the template. In some embodiments, two needles are utilized for two guide lumens on opposite sides of the template. In some embodiments, two or more needles  1222  are inserted simultaneously through each guide lumen  1214 . In some embodiments, two needles are utilized for two guide lumens and each needle is inserted independently. In some embodiments, two needles are utilized for two guide lumens and each needle is inserted simultaneously. In some embodiments, two or more needles  1222  are inserted independently through each guide lumen  1214 . In some embodiments, the needle  1222  is inserted sequentially through each anchor guide  1210 ,  1212 . In some embodiments, two or more needles  1222  are inserted simultaneously through each anchor guide  1210 ,  1212 . In some embodiments, two or more needles  1222  are inserted independently through each anchor guide  1210 ,  1212 .  FIG. 120  illustrates another view of the needle  1222 . The needles  1222  can deliver anchors to a target site. The anchor can be within a lumen of the needle  1222 . The anchor can be expandable once removed from the needle  1222 . The anchor can be passed through the aperture  508  in one direction, but resist passing through the aperture  508  in a second, opposite direction. The anchor can have any shape described herein. The anchor can have any shape to anchor the band to the tissue. 
       FIG. 121  illustrates the deployed template catheter  1200  and the guide lumens  1214  on the left.  FIG. 121  illustrates the deployed template catheter  1200 , the guide lumens  1214 , and the transvalvular band  500  on the right. The suture  1202  can be tightened to bring the template  1204  adjacent to transvalvular band  500 . The suture  1202  can be tightened to bring the template  1204  toward the transvalvular band  500 . The suture  1202  can be tightened to bring transvalvular band  500  toward the template  1204 . The suture  1202  can cinch the components together. The suture  1202  can be tightened to align the anchor guide  1210 ,  1212  of the template  1204  with the apertures  508  of the transvalvular band  500 .  FIG. 122  illustrates another view of the template catheter  1200 , the guide lumens  1214 , and the transvalvular band  500 .  FIG. 123  illustrates yet another view of the template catheter  1200 , the guide lumens  1214 , and the transvalvular band  500 . The sutures  1202  can ensure that the template  1204  abuts the transvalvular band  500  when tension is applied to the suture  1202 . The transvalvular band  500  and the template  1204  can be effectively coupled relative to each other when the suture is tightened. The transvalvular band  500  and the template  1204  can form a unitary structure when the suture is tightened. The movement of the template  1204  can cause corresponding movement of the transvalvular band  500  when the suture is tightened. The transvalvular band  500  and the template  1204  can form a continuous path to guide the anchor into position when the suture is tightened. 
       FIG. 124  illustrates the system including the sutures  1202 . The proximal end of the system can allow for controlled deployment of the template catheter  1200 . The proximal end of the template catheter  1200  can be moved to cause corresponding movement of a distal end of the template catheter  1200 . The proximal end of the system can allow for controlled deployment of the guide lumens  1214 . In some embodiments, the guide lumens  1214  can extend the length of the template catheter  1200 . In some embodiments, the guide lumens  1214  can extend to the proximal end. In some embodiments, the needle  1222  can be inserted into the guide lumen  1214  at the proximal end. The needle  1222  can be guided toward the anchoring site by the guide lumens  1214 . The proximal end of the system can allow for controlled deployment of the needle  1222 . The proximal end of the needle  1222  can be moved to cause corresponding movement of a distal end of the needle  1222 . 
       FIG. 125  illustrates the guide lumens  1214 . The guide lumens  1214  can have any shape along the length of the guide lumens  1214 . The guide lumens  1214  can extend less than the total length of the template catheter  1200 . In some embodiments, the guide lumens  1214  are coupled near the distal end. In some embodiments, the guide lumens  1214  are coupled to each other. In some embodiments, the guide lumens  1214  are coupled to the template catheter  1200 . In some embodiments, the guide lumens  1214  can curve toward the anchor guides  1210 ,  1212  of the template  1204 . In some embodiments, the guide lumens  1214  can have one or more curved portions. In some embodiments, the guide lumens  1214  can have one or more straight portions. In some embodiments, the guide lumens  1214  are coupled to the template  1204 . In some embodiments, the guide lumens  1214  are integrally formed with the template  1204 . In some embodiments, the guide lumens  1214  are monolithically formed with the template  1204 . In some embodiments, the guide lumens  1214  are bonded with the template  1204  such as through the use of an adhesive or weld. In some embodiments, the guide lumens  1214  laterally expand when the template  1204  laterally expands. In some embodiments, the guide lumens  1214  are permanently coupled to the template  1204 . 
       FIG. 125  also illustrates all four anchors  1012  deployed. In some methods, the anchors  1012  are inserted sequentially. In some methods, the anchors  1012  are inserted on a posterior side then an anterior side. In some methods, the anchors  1012  are inserted and deployed independently. The anchors  1012  can be designed to pass through the anchor guide  1210 ,  1212  and the aperture  508  prior to being deployed. The anchors  1012  can be designed to pass through the transvalvular band  500  prior to being deployed. The anchors  1012  can be expanded. The anchors  1021  can be expanded by axial force. The anchors  1021  can be expanded after passing through the apertures  508  in the transvalvular band  500 . In some embodiments, the anchors  1012  are subannular anchors. 
       FIGS. 126-46  illustrate various anchor and clip embodiments. The anchor can be utilized with the template catheter  1200  described herein. The anchor can be used with any delivery system. The anchor can be utilized with the transvalvular band  500  described herein. The anchor can be utilized with any implant. In some embodiments, the anchor is configured to expand in a subannular space. In some embodiments, a clip is utilized. The clip can slide relative to a suture coupled to the anchor. The clip can slide toward the anchor. The clip can be utilized with the template catheter  1200  described herein. The clip can be used with any delivery system. The clip can be utilized with the transvalvular band  500  described herein. The clip can be utilized with any implant. These embodiments can be used with or without any of the systems described herein. 
       FIGS. 126-127  illustrate a serpentine clip  1300 . The suture  1302  is passed through the bottom of the clip and through a hypotube  1304 . The serpentine clip  1300  can include a Nitinol sheet. The serpentine clip  1300  can be folded various times. The serpentine clip  1300  can include an opening therethrough for the hypotube  1304 . When the hypotube  1304  is removed, the serpentine clip  1300  returns to its shape-set configuration. The serpentine clip  1300  can crimp down the suture in the shape-set configuration. In some embodiments, the serpentine clip  1300  does not have to be loaded by the surgeon. The serpentine clip  1300  can be loaded onto the catheter during assembly. In some embodiments, the serpentine clip  1300  can be loaded onto the suture  1302  coupled to the anchor  1012 . The hypotube  1304  can allow the serpentine clip  1300  along the suture  1302  toward the transvalvular band  500 . The hypotube  1304  can be removed allowing the serpentine clip  1300  to cinch the suture  1302 . The serpentine clip  1300  can prevent the transvalvular band  500  from pulling away from the annulus. The serpentine clip  1300  can prevent the reversibility of the anchors  1012 . The serpentine clip  1300  comprises a Nitinol or other shape memory material. The clip can be a nitinol sheet. The material is folded over itself. The suture is passed through the bottom of the clip and through the hypotube. When the hypotube is removed, the Nitinol returns to its shapeset configuration and crimps down on the suture. The clip does not have to be loaded by the surgeon. The clip can be loaded on the catheter during catheter assembly. 
       FIGS. 128-130  illustrate a rivet anchor  1310  and clip  1312 . The rivet anchor  1310  can include a distal portion that is similar to the anchor  1012 . The rivet anchor  1310  can include longitudinally extending slots. The rivet anchor  1310  can include a star design when deployed, see  FIG. 125 . The rivet anchor  1310  can include, e.g., between about 10N and about 26 N of holding strength (e.g., 10 N, 12 N, 14 N, 16 N, 18 N, 20 N, 22 N, 24 N, 26 N, or any range of the foregoing values). The rivet anchor  1310  can flatten with tension. The rivet anchor  1310  can be inserted through the aperture  508  and the annulus in the flattened configuration. The rivet anchor  1310  can be deployed by releasing the tension. The rivet anchor  1310  can be laterally expandable. The rivet anchor  1310  can be formed of a shape memory material. The rivet anchor  1310  can be made of shape-set Nitinol material. The rivet anchor  1310  can be laser cut to include the cut-outs. The rivet anchor  1310  can be made of a tube. The rivet anchor  1310  can be the same size as the anchor  1012 . The clips  1312  can be disk shaped. The clips  1312  can fit into the apertures  508 . The clips  1312  can apply a tension or force to deploy the rivet anchor  1310 . The clips  1312  can slide over the rivet anchor  1310  until the proper cinching is achieved. In some embodiments, the clips  1312  are moveable. The clip  1312  can slide downward over the rivet anchor  1310 . In some embodiments, the clips  1312  can be embedded into the transvalvular band  500 . In some embodiments, the clips  1312  can be added after the transvalvular band  500  is in place. The rivet anchor  1310  can include tabs  1314 . The tabs  1314  can be shape-set outward. The clip is simple and can be slid over the anchor until the correct cinching is achieved. The clips can be embedded into the mitral bridge or added after the bridge is in place. The bottom of the anchor can be the same as the anchor design shown in  FIG. 115 . The anchor can be made of laser cut and shapeset nitinol tube. The anchor can be same size as the apertures  508 , or similarly sized. The tabs can be shapeset outward. 
       FIG. 131  illustrates various features that can be included in the rivet anchor  1310  or any anchor described herein. The features can be cut-outs in a tube. The features can include one or more points. The features can be staggered. The features can include one or more tabs. The tabs can be rectangular. The tabs can prevent backing out of the clip  1312 . The tabs can prevent backing out of the anchor. The feature can include one or more star designs. The star design can be formed by strips of material that bend to laterally expand. The feature can include a helically cut-out. The helical cut-out can increase flexibility of the anchor. The feature can include two star designs which are coaxial along the length of the anchor. In some embodiments, one star design can be a sub-annular anchor and the other star design can retain the clip. In some embodiments, both star designs are subannular anchors. Other configurations are contemplated. 
       FIG. 132  illustrates an anchor  1320 . The anchor  1320  can include an enclosed cavity or balloon  1322 . The balloon  1322  can be filled with a wire  1324 . The wire  1324  can inflate or enlarge the balloon  1322 . The anchor  1320  can be compressed prior to introduction of the wire  1324 . The wire  1324  can fill the cavity to enlarge the anchor  1320 .  FIG. 132  shows anchor concepts including a balloon and a rivet filled with wire. The balloon can be inflated with the wire. The balloon can be any cavity. The balloon can be any partially enclosed or fully enclosed space. The balloon can be inflated by any means. The balloon can be filled with a liquid. The balloon can be filled with a gas. The balloon can be filled with a solid. The balloon can be filled with a suture. The balloon can be inflated or expanded. The balloon can change from a flexible structure to a more rigid structure. The balloon can change density. The balloon can change thickness. 
       FIG. 133  illustrates an anchor. The anchor can be in the shape of a tube  1328 . The tube  1328  can be flexible, such as a silicon tube. The tube  1328  can be enclosed or partially enclosed. The tube  1328  can be compressed. The tube  1328  can be cylindrical or conical. The tube  1328  can include a suture  1330  extending therethrough. The suture  1330  can be affixed at one end of the tube  1328 . The suture  1330  can be affixed at a distal end. The anchor can include a clip  1332  which can be passed along the suture  1330 . The suture  1330  and the clip  1332  can compress the tube  1328  as the clip  1332  is slid distally. The clip  1332  can have any shape. The clip  1332  can be larger than the proximal opening in the tube  1328 . The clip  1332  can apply a force to the tube to compress the tube  1328 .  FIG. 133  illustrates other anchor concepts. The anchor includes a conical silicon tube and a suture affixed to distal side. The compressed conical silicon tube is shown. 
       FIGS. 134-135  illustrate an anchor. The anchor can be in the shape of a tube  1338 . The tube  1338  can be flexible, such as a silicon tube. The tube  1338  can be enclosed or partially enclosed. The tube  1338  can be compressed. The tube  1338  can act as a silicon rivet. The tube  1338  can be cylindrical or conical. The tube  1338  can include a suture  1340  extending therethrough. The suture  1340  can be affixed at one end of the tube  1338 . The suture  1340  can be affixed at a distal end. The anchor can include a clip  1342  which can be passed along the suture  1340 . The suture  1340  and the clip  1342  can compress the tube  1338  as the clip  1342  is slid distally. The anchor can include a needle tube  1344 . The needle tube  1344  can pass through the clip  1342  and the tube  1338  toward the end of the tube  1338 . The suture can be coupled to the end of the tube  1338  with a ball  1346  or other securing structure. The suture  1340  can pass through the needle tube  1344 . The anchor can include a rigid section or stopper  1346 . The stopper  1346  can provide stop for the clip  1342  and the ball  1346  to rest against in a compressed configuration. The needle tube  1344  can be removed in the compressed configuration.  FIG. 134  illustrates other anchor concepts. The anchor includes a rigid section or stopper and a needle tube.  FIG. 135  shows a compressed conical silicon tube. The needle tube is removed. 
       FIGS. 136-137  illustrate an anchor. The anchor can be in the shape of a braid  1348 . The braid  1348  can be a coated nitinol braid. The braid  1348  can be shape-set to form a cavity or balloon. The braid  1348  can be a nitinol braid with an ePTFE coating. The anchor can include a suture  1350 . The braid  1348  can be a stent-like structure. The anchor can be the form of a compressible trap.  FIG. 136  shows the nitinol braid, the ePTFE coating, and the suture. In some embodiments, the suture is threaded along a path through the nitinol braid. The braid can be compressed similar to an inverted finger trap. The braid can capture the suture along a torturous path. 
       FIG. 138  illustrates an anchor as a compressible sponge  1352 . The sponge  1352  can be in the form of a cellulous sponge or biocompatible fabric. The sponge  1352  can be compressed to a paper thin thickness and used as a pledget. The compressible sponge  1352  can double in thickness when wet. In some embodiments, the compressible sponge  1352  is biocompatible. In some embodiments, the compressible sponge  1352  is not biocompatible.  FIG. 138  shows a compressed sponge as anchor. 
       FIG. 139  illustrates an anchor as a balloon  1354 . The balloon  1354  can be made from a membrane. The balloon  1354  can be made of a porous or permeable membrane. The balloon  1354  can be formed of silicon. The balloon  1354  can be formed of any material. The balloon  1354  can be filled with any material including a dry sugar, protein or salt based substance. The balloon  1354  can be filled with a material designed to absorb liquid, for instance, blood from the blood stream. The balloon  1354  can be filled with a material designed to fill up or create bulk when exposed within the heart of the patient.  FIG. 139  illustrates an unfilled membrane of the balloon  1354  on the left. The balloon  1354  can be lined with a sugar based material or any other material that absorbs liquid.  FIG. 139  illustrates a filled membrane of the balloon  1354  on the right. The porous membrane allows liquid to pass through, allowing the balloon  1354  to fill. The porous membrane fills due to internal salt or sugar concentration drawing liquid from blood flow concentration. The balloon can act as an artificial cell wall. The balloon  1354  can be filled with any biocompatible material.  FIG. 139  shows a balloon  1354  made from a porous silicon membrane. The balloon  1354  can be filled with a dry sugar, protein or salt based substance. The balloon  1354  absorbs in water from blood stream to fill up or create bulk. The unfilled balloon membrane is shown on the left. The balloon  1354  can be lined with sugar based material. The porous membrane fills due to internal salt/sugar concentration drawing in water from blood low concertation. The balloon  1354  can be any cavity. The balloon  1354  can be any partially enclosed or fully enclosed space. The balloon  1354  can be permeable. The balloon  1354  can be porous. The balloon  1354  can allow liquid to pass through. The balloon  1354  can allow liquid to pass through in only one direction. The balloon  1354  can be inflated or expanded by any means. The balloon  1354  can be filled with a liquid. The balloon  1354  can be filled with a gas. The balloon  1354  can be filled with a solid. The balloon  1354  can be filled a liquid interacting with a solid within the balloon. The balloon  1354  can be inflated or expanded. The balloon  1354  can change from a flexible structure to a more rigid structure. The balloon  1354  can change density. The balloon  1354  can change thickness. The balloon  1354  can function as reverse Gore-Tex or an artificial cell wall. The balloon  1354  can allow liquid to pass through. The balloon  1354  can include any substance. The balloon  1354  can include a silica gel. The balloon  1354  can include a sodium polyacrylate. The balloon can include any non-toxic material. 
       FIG. 140  illustrates an anchor. The anchor can be considered a ball and spread anchor.  FIG. 140  illustrates the deactivated state on the left and the activated state on the right. The anchor can include a tube  1358 . The anchor can include a ball  1360 . While a ball is shown, the anchor can include any feature that allows splaying of the tube. The anchor can include a suture  1362 . The ball  1360  can be coupled to the end of the suture  1362 . The suture can extend through the tube  1358 . In the activated state, the ball can be pulled toward an end of the tube  1358  thereby splaying the tube  1358 . The tube can be formed of plastic, e.g., Pebax, PEEK, etc.). The tube  1358  can include a plurality of vertical slits to allow splaying. By using the ball  1360  anchored to suture  1362  and placing the suture  1362  through the tube  1358 , the anchor activates when the suture  1362  is pulled. The contact area between the anchor and annulus increases when the anchor activates.  FIG. 140  shows two side views. The deactivated state is on the left and the activated state is on the right. The deactivated state can be in the form of a tube  1358 . The tube  1358  can comprise any plastic. The activated state can include a plurality of flanges or arms formed in the tube  1358 . The tube  1358  can have a plurality of slots extending from the distal end toward the proximal end. The slots extend partially along the length of the tube  1358 . The slots can be longitudinal. As tension is applied by the ball  1360 , the tubing between the slots flares outward. The suture can be a 2-0 suture.  FIG. 140  shows two front views. The deactivated state is on the left and the activated state is on the right. The deactivated state shows the low profile configuration. The diameter of the ball  1360  and the tube  1358  can be similar. The activated state shows the flanges flared outward. The diameter is larger in the activated state than the deactivated state. 
       FIG. 141  illustrates an anchor. The anchor can be considered a spring retainer. The anchor can be in the form a tube  1366 . The tube  1366  can be laser cut to form a pattern of cut-outs in the tube. The anchor can be manufactured by laser cutting a single 0.038″×0.048″ nitinol tubing. The tube  1366  can include two anchoring portion which can include the star design as described herein. In other embodiments, the tube  1366  includes one anchoring portion. In some embodiments, the anchor is utilized with a clip. In other embodiments, the anchor is utilized without a clip with the second anchoring portion acting as a clip. The two anchoring portion  1368 ,  1370  can be shape-set to their largest outer diameter. The two anchoring portions can be compressed such as by lengthening the tube  1366 . The two anchoring portions can be compressed for delivery. The tube  1366  can include a spring in between the two anchoring portions. The spring can be formed from a helical cut-out. The anchor can include a suture  1372  attached to a lower anchor hole  1374  and an upper anchor hole  1376  to increase the pullout force of the anchor when implanted. The suture  1372  can be positioned to enable the anchor to take shape of a tube for delivery. In some embodiments, the transvalvular band  500  and annulus are placed between the two anchoring portions during delivery. The spring can add flexibility to the anchor. The spring can along the anchor to lengthen or compress. The spring can change lengths depending on the thickness of the annulus. In some embodiments, one anchoring portion is placed on either side of the annulus. The spring can lengthen for thicker annuluses in order to properly position the anchoring portions.  FIG. 141  shows two retainers. The retainers are a star designed formed from compressing a tube with slots. The anchor can include a 2-0 suture. The anchor can include a spring at the location of the mitral bridge and annulus, in use. Other uses are contemplated, see  FIG. 143 . 
       FIG. 142  illustrates an anchor. The anchor can be considered a retainer with a retention clip. The anchor can be in the form a tube  1378 . The tube  1378  can be laser cut to form a pattern of cut-outs in the tube. The tube  1378  can include longitudinal slots  1380  to form an anchoring portion. The tube  1378  can include a retention clip cutout  1382 . By combining the anchor with the retention clip, the anchor would have the ability to have a larger contact area with the transvalvular band  500 . The anchor can function as the retention clip and retainer. 
       FIG. 143-146  illustrates an anchor. The anchor can be considered a tensioner. In some embodiments, two anchors are deployed. The anchor can include a spring  1384 . The anchor can include a suture  1386 . The anchor can include two anchoring portions  1388 ,  1390 . The two anchoring portions can include the star design as described herein. On each side of the transvalvular band  500 , when implanted, the anchor can include of two anchoring portions  1388 ,  1390  joined by a single suture  1386  with a spring  1384  in the middle. The spring  1384  can ensure tension on the suture  1386 , which ultimately positions the anchor in an expanded state that increases the pullout force of the transvalvular band  500 . The anchor can be formed from a single tube as described herein.  FIG. 143  illustrates one configuration.  FIG. 143  shows a 2-0 suture anchored to both retainers. The spring passes above the transvalvular band  500 . The anchor is utilized to span between two adjacent apertures  508 . The anchor utilizes two anchoring portions. The two anchoring portions can be passed through the two apertures  508 , respectively. The two anchoring portions can include the star shaped design or any other anchoring design described herein. The anchoring portions can be any subannular anchor. 
     The spring  1384  consistently places tension on the suture  1386 . The spring  1384  is responsible for clamping the annulus between the transvalvular band  500  and anchoring portions  1388 ,  1390 . Releasing the tension on the suture  1386  may result in an ability to reposition and cinch the valve. To release tension on the suture  1384  and to cinch the valve, another suture could be used. The spring  1384  can be threaded with a single suture prior deployment. The suture  1386  can be a size 2-0 or any other compatible size.  FIG. 144  illustrates the threading of the suture  1386  prior to deployment. In some embodiments, a secondary suture is provided. The secondary suture can be a cinching suture. The cinching suture can pass through the spring. The cinching suture can pass through the spring only. The cinching suture can tighten the spring. In some embodiments, the cinching suture can bring the two anchoring portions toward each other. In some embodiments, the cinching suture can cinch the spring toward the band  500 . In some embodiments, the spring acts as a clip once cinched. 
       FIG. 145  illustrates two anchors joined by a cinching suture  1392 . The cinching suture  1392  is looped through the first spring  1384  and then looped through the second spring  1384 . Both ends of the cinching suture  1392  can be pulled by the user to cinch the valve. After releasing the cinching suture  1392 , the transvalvular band  500  can be maintained in a cinched position because the spring  1384  will then clamp down on the annulus and maintain tension with the anchors&#39; suture  1386 . The cinching suture  1392  would then be removed from the entire implantation by pulling one end of the cinching suture  1392  until removal. In some embodiments, a secondary suture is provided. The secondary suture can be a cinching suture. The cinching suture can pass through the spring of a first anchor and pass through a spring of a second anchor. The cinching suture can pass through the spring only. The cinching suture can tighten the spring. In some embodiments, the cinching suture can bring the two sides of the band toward each other. In some embodiments, the cinching suture can bring the two anchoring portions on the same side toward each other. In some embodiments, the cinching suture can cinch each spring toward the band  500 . In some embodiments, each spring acts as a clip once cinched. 
       FIG. 146  illustrates alternative designs of the spring  1384 . These designs can replace the design shown in  FIGS. 143-145  for a variety of reasons including ease of use, or delivery. These designs can function the same as the spring  1384 . The spring  1384  can be formed from a laser cut tube. The spring  1384  can be formed of an elastic material that holds the suture with friction.  FIG. 146  shows a laser cut tube that acts similar as the spring.  FIG. 146  shows an elastic material. The suture can be held in place by any force. 
     In some embodiments, the systems and methods can allow deployment of a mitral bridge without open heart surgery. In some embodiments, the systems and methods can facilitate septal-lateral annular cinching. In some embodiments, the systems and methods can be used to close dilated valves. In some embodiments, the systems and methods can promote coapation early in the systolic phase. In some embodiments, the systems and methods can restore the natural biomechanics of the mitral or other valve. In some embodiments, the systems and methods can promote a healthy valve saddle shape. In some embodiments, the systems and methods can promote cardiac muscle alignment. 
     Any of a wide variety of specific tissue anchor constructions may be utilized in combination with the transvalvular band of the present invention. In addition, a variety of features have been described as illustrative in connection with a variety of implementations of the invention. Any of the features described above, may be recombined with any other of the embodiments disclosed herein, without departing from the present invention, as should be apparent to those of skill in the art. In some embodiments, the transvalvular band does not include a complete or partial annuloplasty ring, stent-valve, or partial or complete replacement valve or replacement valve leaflets and/or does not affect or substantially affect the size and/or shape of the valve annulus when operably attached to the valve annulus. 
     While the foregoing detailed description has set forth several exemplary embodiments of the apparatus and methods of the present invention, it should be understood that the above description is illustrative only and is not limiting of the disclosed invention. It will be appreciated that the specific dimensions and configurations disclosed can differ from those described above, and that the methods described can be used within any biological conduit within the body. 
     Various other modifications, adaptations, and alternative designs are of course possible in light of the above teachings. Therefore, it should be understood at this time that within the scope of the appended claims the invention may be practiced otherwise than as specifically described herein. It is contemplated that various combinations or subcombinations of the specific features and aspects of the embodiments disclosed above may be made and still fall within one or more of the inventions. Further, the disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with an embodiment can be used in all other embodiments set forth herein. Accordingly, it should be understood that various features and aspects of the disclosed embodiments can be combined with or substituted for one another in order to form varying modes of the disclosed inventions. Thus, it is intended that the scope of the present inventions herein disclosed should not be limited by the particular disclosed embodiments described above. Moreover, while the invention is susceptible to various modifications, and alternative forms, specific examples thereof have been shown in the drawings and are herein described in detail. It should be understood, however, that the invention is not to be limited to the particular forms or methods disclosed, but to the contrary, the invention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the various embodiments described and the appended claims. Any methods disclosed herein need not be performed in the order recited. The methods disclosed herein include certain actions taken by a practitioner; however, they can also include any third-party instruction of those actions, either expressly or by implication. For example, actions such as “attaching a transvalvular bridge to the mitral valve annulus” includes “instructing the attaching of a transvalvular bridge to the mitral valve annulus.” The ranges disclosed herein also encompass any and all overlap, sub-ranges, and combinations thereof. Language such as “up to,” “at least,” “greater than,” “less than,” “between,” and the like includes the number recited. Numbers preceded by a term such as “approximately”, “about”, and “substantially” as used herein include the recited numbers (e.g., about 10%=10%), and also represent an amount close to the stated amount that still performs a desired function or achieves a desired result. For example, the terms “approximately”, “about”, and “substantially” may refer to an amount that is within less than 10% of, within less than 5% of, within less than 1% of, within less than 0.1% of, and within less than 0.01% of the stated amount.