Patent Publication Number: US-2023157824-A1

Title: Ringless web for repair of heart valves

Description:
FIELD OF THE INVENTION 
     The present invention relates to minimally invasive repair of a heart valve. More particularly, the present invention relates to ringless webs for insertion into a beating heart of a patient to repair a heart valve. 
     BACKGROUND OF THE INVENTION 
     Various types of surgical procedures are currently performed to investigate, diagnose, and treat diseases of the heart. Such procedures include repair and replacement of mitral, aortic, and other heart valves, repair of atrial and ventricular septal defects, pulmonary thrombectomy, treatment of aneurysms, electrophysiological mapping and ablation of the myocardium, and other procedures in which interventional devices are introduced into the interior of the heart or vessels of the heart. 
     Of particular interest are intracardiac procedures for surgical treatment of heart valves, especially the mitral and aortic valves. Tens of thousands of patients are diagnosed with aortic and mitral valve disease each year. Various surgical techniques may be used to repair a diseased or damaged valve, including annuloplasty (contracting the valve annulus), quadrangular resection (narrowing the valve leaflets), commissurotomy (cutting the valve commissures to separate the valve leaflets), shortening mitral or tricuspid valve chordae tendonae, reattachment of severed mitral or tricuspid valve chordae tendonae or papillary muscle tissue, and decalcification of valve and annulus tissue. Alternatively, the valve may be replaced by excising the valve leaflets of the natural valve and securing a replacement valve in the valve position, usually by suturing the replacement valve to the natural valve annulus. Various types of 25 replacement valves are in current use, including mechanical and biological prostheses, homografts, and allografts. Valve replacement, however, can present a number of difficulties including that the invasiveness of the procedure can lead to long recovery times and that the irregular shape of the valve annulus can cause difficulty in properly fixing and orienting the replacement valve, which can lead to leaks and other problems. Therefore, in situations where 30 patients can adequately be treating by repairing, rather than replacing, the valve, it is generally preferable to do so. The mitral and tricuspid valves inside the human heart include an orifice (annulus), two (for the mitral) or three (for the tricuspid) leaflets and a subvalvular apparatus. The subvalvular apparatus includes multiple chordae tendinae, which connect the mobile valve leaflets to muscular structures (papillary muscles) inside the ventricles. Rupture or elongation of the chordae tendinae, commonly known as degenerative mitral valve regurgitation (DMR), results in partial or generalized leaflet prolapse, which causes mitral (or tricuspid) valve regurgitation. Patients can also suffer from functional mitral valve regurgitation (FMR), in which the chordae, leaflets, and papillary muscles are healthy, but the leaflets still do not properly coapt, causing blood to flow back into the atrium. FMR generally results from left ventricular dilation, which displaces the papillary muscles and stretches the valve annulus. 
     A number of approaches and devices have been employed to treat leaflet prolapse and/or mitral valve regurgitation. One commonly used technique to surgically correct mitral valve regurgitation is the implantation of artificial chordae (usually 4-0 or 5-0 Gore-Tex sutures) between the prolapsing segment of the leaflet of the valve and the papillary muscle. Another technique involves coapting leaflets together with a clip device and/or suture to prevent leaflet prolapse. Other repair devices, such as spacers and balloons, have been used to provide device assisted leaflet coaptation to prevent mitral valve regurgitation. However, to date, no specific technique for valve repair has achieved general, broad acceptance in the field as the preferred repair method. 
     Recent cardiac surgery publications acknowledge the improved patient outcomes delivered with mitral valve repair as compared to mitral valve replacement. One of the factors cited for improved outcomes with mitral valve repair is the preservation of the native mitral valve anatomy. While multiple new technologies are being developed, these technologies are directed towards a target patient population that is very high risk having FMR. It would therefore be desirable to provide for improved valve repair that can be used for patients suffering from DMR as well as patients suffering from FMR. 
     SUMMARY OF THE INVENTION 
     A ringless web is configured to repair heart valve function in patients suffering from degenerative mitral valve regurgitation (DMR) or functional mitral valve regurgitation (FMR). In accordance with various embodiments, a ringless web can be anchored at one or more locations below the valve plane in the ventricle, such as at a papillary muscle, and one or more locations above the valve plane, such as in the valve annulus. A tensioning mechanism connecting the ringless web to one or more of the anchors can be used to adjust a tension of the web such that web restrains the leaflet to prevent prolapse by restricting leaflet motion to the coaptation zone and/or promotes natural coaptation of the valve leaflets. 
     In one embodiment, a ringless web is configured to be chronically implanted into a beating heart of a patient to repair heart valve function. Ringless web can include a web for chronic implantation in the beating heart that is shaped and sized to correspond to at least one valve in the heart. One or more ventricular anchors can be operably connected to the web and configured to be anchored in ventricular tissue in the heart. One or more atrial anchors can be operably connected to the web and configured to be anchored in atrial tissue in the heart. In some embodiments, a tensioning mechanism can be operably connected to one or more of the ventricular anchors and/or one or more of the atrial anchors. The tensioning mechanism can be configured to enable selective adjustment of a tension of the web with respect to the corresponding anchor such that the web is positioned across a plane of the at least one valve to repair valve function. In various embodiments, the web can be formed by, for example, an array, a net or a mesh. 
     Various embodiments of systems, devices and methods have been described herein. These embodiments are given only by way of example and are not intended to limit the scope of the present invention. It should be appreciated, moreover, that the various features of the embodiments that have been described may be combined in various ways to produce numerous additional embodiments. Moreover, while various materials, dimensions, shapes, implantation locations, etc. have been described for use with disclosed embodiments, others besides those disclosed may be utilized without exceeding the scope of the invention. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The invention may be more completely understood in consideration of the following detailed description of various embodiments of the invention in connection with the accompanying drawings, in which: 
         FIG.  1    is a schematic cross-sectional view of a heart; 
         FIG.  2    is a schematic top plan view of a mitral valve; 
         FIG.  3 A  is a schematic cross-sectional view of a heart with a normal mitral valve; 
         FIG.  3 B  is a partial schematic cross-sectional view of a heart with an abnormal mitral valve; 
         FIG.  4 A  is a ringless web according to an embodiment of the present invention; 
         FIG.  4 B  is a side view of the ringless web of  FIG.  4 A ; 
         FIGS.  5 A and  5 B  are schematic representations of the ringless web of  FIGS.  4 A and  4 B  deployed in the heart. 
         FIG.  6    is a schematic representation of a ringless web according to an embodiment of the present invention deployed in the heart. 
         FIGS.  7 A- 7 C  depict an anchor system for a ringless web according to an embodiment of the present invention. 
         FIGS.  8 A- 8 C  depict an anchor system for a ringless with according to an embodiment of the present invention. 
         FIGS.  9 A- 9 C  depict an anchor system for a ringless web according to an embodiment of the present invention. 
         FIGS.  10 A- 10 C  depict an anchor for a ringless web according to an embodiment of the present invention. 
         FIG.  11    is a schematic representation of a heart valve repair device according to an embodiment of the present invention deployed in the heart. 
         FIG.  12    is flow-chart depicting a procedure for positioning a ringless web in the heart according to an embodiment of the present invention. 
         FIGS.  13 A- 13 C  depict a heart valve repair device according to an alternative embodiment. 
     
    
    
     While the invention is amenable to various modifications and alternative forms, specifics thereof have been shown by way of example in the drawings and will be described in detail. It should be understood, however, that the intentions is not to limit the invention to the particular embodiments described. On the contrary, the intention is to cover all modifications, equivalents, and alternatives falling within the spirit and scope of the invention. 
     DETAILED DESCRIPTION 
     A mitral valve is schematically depicted in  FIGS.  1 - 3 B . Situated between the left atrium and left ventricle, the mitral valve consists of two flaps of tissue, or leaflets (a posterior leaflet and an anterior leaflet). The mitral valve annulus forms a ring around the valve leaflets, thereby connecting the leaflets to the heart muscle. Papillary muscles are located at the base of the left ventricle. Tendon-like cords called chordae tendineae anchor the mitral valve leaflets to the papillary muscles. Normal chordae tendineae prevent the leaflets from prolapsing, or inverting, into the left atrium, as depicted in  FIG.  3 A . 
     Under normal cardiac conditions, the left atrium contracts and forces blood through the mitral valve and into the left ventricle. As the left ventricle contracts, hemodynamic pressure forces the mitral valve shut and blood is pumped through the aortic valve into the aorta. For the mitral valve to shut properly, the valvular edges of the valve leaflets must form a non-prolapsing seal, or coaptation, that prevents the backflow of blood during left ventricular contraction. 
     A properly functioning mitral valve opens and closes fully. When the mitral valve fails to fully close, as depicted in  FIG.  3 B , blood from the left ventricle is able to flow backward into the left atrium instead of flowing forward into the aorta. This backflow of blood through the heart valve is called regurgitation. The regurgitation of blood through the heart due to the failure of the mitral valve to close properly (coapt) is the condition known as mitral valve regurgitation (MR). A common symptom of mitral valve regurgitation is congestion of blood within the lungs. 
     When blood regurgitates from the left ventricle into the left atrium, such as due to MR, less blood is pumped into the aorta and throughout the body. In an attempt to pump adequate blood to meet the blood needs of the body, the left ventricle tends to increase in size over time to compensate for this reduced blood flow. Ventricular enlargement, in turn, often leads to compromised contractions of the heart, thereby exacerbating the congestion of blood within the lungs. If left untreated, severe MR can eventually lead to serious cardiac arrhythmia and/or congestive heart failure (CHF). 
     Mitral valve regurgitation can be caused by any number of conditions, including mitral valve prolapse (a condition in which the leaflets and chordae tendineae of the mitral valve are weakened resulting in prolapse of the valve leaflets, improper closure of the mitral valve, and the backflow of blood within the heart with each contraction of the left ventricle), damaged chords (wherein the chordae tendineae become stretched or ruptured, causing substantial leakage through the mitral valve), ventricular enlargement (FMR), rheumatic fever (the infection can cause the valve leaflets to thicken, limiting the valve&#39;s ability to open, or cause scarring of the leaflets, leading to regurgitation), endocarditis (an infection inside the heart), deterioration of the mitral valve with age, prior heart attack (causing damage to the area of the heart muscle that supports the mitral valve), and a variety of congenital heart defects. As MR becomes exacerbated over time, however, the condition can become more severe, resulting in life-threatening complications, including atrial fibrillation (an irregular heart rhythm in which the atria beat chaotically and rapidly, causing blood clots to develop and break loose and potentially result in a stroke), heart arrhythmias, and congestive heart failure (occurring when the heart becomes unable to pump sufficient blood to meet the body&#39;s needs due to the strain on the right side of the heart caused by fluid and pressure build-up in the lungs). 
     The present application describes various devices that can be implanted into the beating heart of a patient in a minimally invasive manner to treat mitral valve regurgitation as described above. Embodiments of the devices described herein can be used to restrain a prolapsing leaflet to prevent leaflet prolapse in patients suffering from DMR and to promote and retrain natural leaflet coaptation in FMR patients with a minimal device form factor that respects the native valve. In various embodiments, the implantable devices may be adaptable to treat both simple and complex repair requirements including small to large prolapsing or flail segments of primary MR patients (DMR) on either the posterior or anterior leaflets of secondary MR (FMR) patients, as will be described herein. 
       FIGS.  4 A and  4 B  depict one embodiment of a ringless web  100  for treating leaflet prolapse by restraining the leaflet and/or promoting natural coaptation of leaflets according to an embodiment of the present invention. In this embodiment, ringless web  100  comprises an array  102  of intersecting members or struts and multiple anchors that can include one or more atrial anchors  104  and one or more ventricular anchors  106 . Array  102  is positioned within the heart to repair the valve and anchors  104  are utilized to maintain the array  102  in the proper position for repair. Web  100  is ringless in that it is secured above the valve plane without being attached to a ring or partial ring seated above the valve plane. Rather, ringless web  100  is anchored in discrete locations above the valve plane via atrial anchors and sutures, as will be described in more detail herein. 
     As shown in  FIGS.  4 A and  4 B , one embodiment of array  102  can comprise a pair of ventricular struts  108  to extend from anchor points in the atrium above the valve plane, through the coaptation zone of the leaflets and down to anchor points in the left ventricle. Array  102  can also include one or more cross struts, which, in the depicted embodiment, include an upper valve plane strut  110 , a lower valve plane strut  112 , and an atrial strut  114 . In some embodiments, array can further include leaflet struts  116 . In some embodiments, a solid biomaterial can be disposed between the upper valve plane strut  110  and lower valve plane strut  112 . 
     The various members or struts of array  102  can be sutures. In various embodiments, struts can be comprised of expanded polytetrafluoroehtylene material or other material suitable for use in the human body. In some embodiments, struts that support the loads applied to the web caused by movement of the leaflets can be comprised of a braided suture material, such as, for example, one or more of the ventricular struts  108 , valve plane struts  110 ,  112 , and atrial strut  114 . Other struts that contact the leaflets or other valve tissue, such as leaflet struts  116 , can be formed of a single suture strand. In some embodiments, struts such as leaflet struts  116  that contact the leaflet or other tissue can have a non-uniform cross-section, such as ovoid, with the portion of the cross-section of greater size positioned to contact the leaflet to distribute the force imparted on the leaflet by the struts to minimize possible damage to the leaflet. 
       FIGS.  5 A  and SB schematically depict ringless web  100  deployed in the heart adjacent a valve leaflet  10 , papillary muscles  14 , and natural chordae tendinae  12  extending between the valve leaflet  10  and the papillary muscles  14 . Leaflet  10  could be either the anterior leaflet or posterior leaflet of the mitral valve, for example. Web  100  can interact with leaflet  10  to restrain the leaflet and restrict leaflet motion to the coaptation zone during systole to prevent the leaflet from prolapsing, which is particularly advantageous in patients suffering from DMR. Atrial anchors  104  are situated in a region above the valve plane in or adjacent to the annulus of the valve. Anchors  104  can be positioned in, for example, the valve annulus, the heart wall adjacent the annulus, or a leaflet adjacent the annulus. Atrial strut  114  can provide support to the web between the atrial anchor  104  points. Ventricular struts  108  extend from the atrial anchors  104 , through the valve plane and down into the ventricle where they are anchored with ventricular anchors  106  somewhere in or adjacent to the ventricular wall, such as at the papillary muscles  14 . Typically, ventricular anchors  106  are anchored somewhere below a midpoint of the ventricle. In the depicted embodiment, there are two atrial anchors  104  and two ventricular anchors  106 , though it should be understood that greater or fewer atrial and/or ventricular anchors can be employed and the numbers of the respective anchors need not be the same. Similarly, the figures depict an embodiment with a pair of ventricular struts  108  that provide redundant support for web, but greater or fewer such struts could be utilized. 
     As discussed herein, anchoring of the described webs refers to utilization of multiple distinct points of attachment to the wall or muscular structure of the interior chambers of the heart, or, in some embodiments, to a valve leaflet. In some embodiments, one or more anchors are separate devices that are pre-attached to web  100 . In other embodiments, one or more anchors can be advanced into the body and utilized to anchor web  100  following deployment of web in the heart. In further embodiments, one or more anchors can be unitarily formed as a single construct with web. Combinations of these embodiments are also contemplated. 
     As shown in  FIGS.  5 A and  5 B , upper valve plane strut  110  can be positioned above the valve plane and lower valve plane strut  112  can be positioned below the valve plane to offer support on the leaflet and on sub-valvular structure such as the chordae tendinae, respectively, to reduce the load on the ringless web  100  at the atrial anchors  104 . Portions of web  100  are 30 therefore positioned both above and below the valve plane. In some embodiments, the region  111  between the valve plane struts  110 ,  112  that is in the coaptation zone of the leaflets can include a solid biomaterial positioned therein to increase the surface area for leaflet coaptation, which is particularly useful for patients suffering from functional mitral valve regurgitation. In some such embodiments, the use of web  100  in valve to prevent regurgitation ultimately retrains and reshapes the valve such that the valve leaflets and annulus naturally revert to a more natural configuration to obtain proper coaptation over time. In such embodiments, the biomaterial can be a bioabsorbable material that is absorbed into the body over time. Suitable biomaterials can include, for example, bovine pericardium and CardioCel®. Leaflet struts  116  can be positioned  5  to overlay the leaflet to prevent leaflet prolapse. 
       FIG.  6    depicts a ringless web  200  according to another embodiment of the present invention deployed in the heart. Ringless web  200  includes a body  202  configured as a dense mesh or net material as opposed to an array of members or struts as described with respect to repair device  100 . Similarly to the embodiment described above incorporating a solid biomaterial, web  200  can advantageously be employed to treat patients suffering from FMR. In such cases, the web, which in some embodiments can include or be formed of a bioabsorbable material, can retrain and reshape the valve such that the valve leaflets and annulus naturally revert to a more natural configuration to obtain proper coaptation over time. 
     Similarly to the previous embodiment, body  202  is positioned within the heart with one or more atrial anchors  204  positioned in or near the valve annulus  16  and one or more ventricular anchors  206  seating in, for example, a papillary muscle  14 . Each anchor can be attached to body  202  with one or more sutures  208 . Body  202  is positioned to extend across the valve plane  210  through the coaptation zone to provide additional surface area for leaflet coaptation. 
     As exemplified in the embodiments described herein, ringless webs according to embodiments of the present invention can comprise a variety of different configurations having a variety of different porosities. A “web” as described herein describes a flexible material having a combination of solid material and open space therein and capable of conforming to aspects of the native valve tissue. For example, webs can comprise an array, a net or a mesh, which have decreasing amounts of porosity. In one embodiment, an array can be considered a web having 70-90% open space, a net can 30-75% open space and a mesh can have 10%-30% open space. 
       FIGS.  7 A- 7 C  depict one embodiment of an anchoring system  305  that can be used with the various ringless web embodiments of the present invention. Anchoring system  305  can be used to implant either atrial anchors or ventricular anchors as described herein. Each of the various embodiments of anchoring systems discussed herein can be used interchangeably such that different anchor embodiments can be used for atrial anchors than for ventricular anchors, as well as using atrial anchors that differ from each other and/or ventricular anchors that differ from each other. In one embodiment, anchoring system  305  implants a ventricular anchor  306  into a papillary muscle. Anchoring systems as described herein can include embodiments in which the anchors are independent of the web repair device with an interconnect existing between the web device and the anchors. Alternatively, anchoring systems can be configured such that the anchors are integrated into and unitary with the web repair device. 
     Anchoring system  305  includes a soft tissue anchor  306  that can include an anchor portion  330  configured as a corkscrew shape having a sharp distal tip  332  and a head  334 . A connector  335  can be attached to head  334  of anchor. In some embodiments, connector  335  can be formed by a loop of suture material. Connector  335  can connect anchor  306  to a tensioning suture  336  that can be looped through the connector  335  and carried by a tensioning catheter  338  as shown in  FIG.  7 A . Tensioning suture  336  can extend from anchor  306  towards a ringless web  300  and be connected thereto, by, for example, being tied by a surgeon with a knot onto a connecting element such as a ring  339 . Tensioning catheter includes a longitudinal opening  340  that enables the tension of tensioning suture  336  to be adjusted after anchor portion  330  has been driven into soft tissue, with head  334  and connector  335  extending from tissue. In this manner, when an anchor  306  is implanted into soft tissue, such as a papillary muscle, tensioning suture  336  can be used to adjust the tension with which the anchor carries a ringless web  300  to ensure proper repair. Proper leaflet function with repair device in place at a given tension can be confirmed via, e.g., an ultrasonic imaging system, prior to tying off the tensioning suture. In other embodiments, ringless webs, anchors, and connecting sutures as described herein can be pre-sized to provide proper valve function or can be conformable to the valve such that tensioning of web with respect to anchors is not required. 
       FIGS.  8 A- 8 C  depict another embodiment of an anchoring system  405  that can be used with the various ringless web embodiments of the present invention. Anchoring system  405  can be used to implant either an atrial anchor or a ventricular anchor as described herein. In one embodiment, anchoring system  405  implants an atrial anchor into annular tissue  16 . 
     Anchoring system  405  can include a delivery catheter  438  that delivers an anchor  404  to the target tissue  16 . Anchor  404  can include a head  434  and one or more barbs  430  configured to penetrate tissue  16  and retain anchor  404  on tissue  16 . A suture  436  can extend from anchor  404  to connect anchor  404  to a ringless web. In operation, delivery catheter  438  is used to forcibly drive barbs  430  of anchor  404  into tissue  16 . The delivery catheter  438  is then withdrawn, leaving the anchor  404  in place, with suture  436  attaching the anchor  404  to the  30  ringless web and barbs  430  retaining the anchor  404  in the tissue  16 . Although depicted as including a single suture  436 , in other embodiments anchor  404  can include a connector and tensioning suture as discussed above to enable selective tensioning of a ringless web with respect to anchor  404 . 
       FIGS.  9 A- 9 C  depict another embodiment of an anchoring system  505  that can be used with the various ringless web embodiments of the present invention. As with the above embodiments, anchoring system  505  can be used to implant either an atrial anchor or a ventricular anchor as described herein. In one embodiment, anchoring system  505  implants an atrial anchor  504  into a leaflet  10  near the valve annulus  16 . In one embodiment, the anchor can be inserted near the edge of a valve leaflet  10  approximately three millimeters from the annulus  16 . Alternatively, an atrial anchoring system  505  could implant an atrial anchor  504  into the annulus  16 . 
     Anchoring system  505  can include a delivery catheter  538  that delivers an anchor  504  to the target tissue  10 . Anchor  504  can initially be configured in a generally L-shaped configuration with a first leg  530   a  and a second leg  530   b . This allows delivery catheter  538  used to forcibly drive anchor  504  into and/or through tissue  10 . The delivery catheter  538  is then withdrawn, and when tension is applied to suture  536  the anchor  504  bends around the junction between legs  530   a ,  530   b  to convert to a linear configuration that embeds the anchor  504  in, or on the opposite side of, tissue  10 . Although depicted as including a single suture  536 , as with the previous embodiment in other embodiments anchor  504  can include a connector and tensioning suture as discussed above to enable selective tensioning of a ringless web with respect to anchor. 
       FIGS.  10 A- 1    OC depict another embodiment of an anchor  806  that can be used with any of the embodiments of the present invention, and in particular can be used as a ventricular anchor in place of the corkscrew anchor  306  described with respect to  FIGS.  7 A- 7 C . Anchor  806  includes a pair of grasping prongs  830  extending from a body  834 . A catheter  838  can be used to deliver the anchor  806  to the anchor site, e.g., the papillary muscle, and can actuate the prongs to grasp the tissue  14 . When it is determined that the prongs  830  have an adequate grasp on the tissue  14 , they can be locked into place and the catheter withdrawn. Anchor  806  can include a connector  835  at a proximal end thereof that can receive a tensioning suture used to tension a ringless web with respect to the anchor  806  as described above. 
       FIG.  11    schematically depicts a ringless web  600  in a final deployed position in a mitral valve of the heart according to an embodiment of the present invention. Ringless web  600  is anchored with atrial anchors  604  in or adjacent the valve annulus  16 . The body  602  extends through the coaptation zone  18  between the anterior valve leaflet  11  and the posterior valve leaflet  13 . The body is anchored via sutures  608  connected to ventricular anchors  606  seated in the papillary muscles  14  adjacent the natural chordae  12 . Alternatively, body  602  could be anchored to the ventricular wall. By being positioned in this manner and properly tensioned as described herein, body  602  aids in promoting natural leaflet coaptation and/or prevents leaflet prolapse as discussed above. It should be noted that although ringless web  600  is depicted as including a solid body similar to the embodiment described with respect to  FIG.  6   , a device comprising an array of struts such as described with respect to  FIGS.  4 A- 5 B  or other configuration as described above would attain a similar final position according to embodiments of the present invention. 
       FIG.  12    depicts a flowchart of one embodiment of procedural steps  800  taken to deploy a ringless web in the heart according to embodiments of the present invention. After the left side of the heart has been accessed, the ventricular anchors, for example, first and second ventricular anchors are sequentially inserted into heart tissue in the left ventricle at step  802 . In some embodiments, a first anchor is inserted into a papillary muscle on a first side of the ventricle and a second anchor is inserted into a papillary muscle on a generally opposing side of the ventricle. At step  804 , the web is positioned across the valve plane such that it is partially in the left atrium and partially in the left ventricle. The atrial anchors, for example, first and second atrial anchors, can then be seated in atrial tissue above the valve plane, such as in the valve annulus at step  806 . With all four anchors in place and the web extending across the valve, at step  808  the tension placed on web from the sutures extending from one or both of the atrial and ventricular anchors can be adjusted. An ultrasound or other imaging system can then be used to confirm proper heart function and leaflet interaction with the web at the set tension at step  810 . When proper heart function is confirmed, the tension can be fixed, such as by tying off the sutures connecting the one or more anchors to the web at step  812 . In other embodiments, ringless web may not require tensioning. For example, web and sutures could be pre-sized for proper valve function or conformable to the valve such that the described tensioning steps are not utilized. A similar procedure as described above could be conducted to deploy a ringless web in other valves or regions of the heart. 
       FIGS.  13 A- 13 C  depict a heart valve repair device  700  according to an alternative embodiment. Device  700  includes a generally clamshell shaped body comprising a frame  702 , which is depicted in  FIG.  11 A  in a generally open position and in  FIG.  11 B  in a partially closed, deployed position. A coaptation material  704  can be carried by frame  702 . In various embodiments, coaptation material  704  can include, for example, a net structure, a mesh material, an array of individual strand elements, such as sutures, or some combination thereof. When deployed in the heart, an upper portion  706  of the frame  702  sits in the annulus of the valve, with the frame extending through one of the commissures of the valve and around a portion of the valve inferior to the valve plane due to the partially-closed clamshell shape of the frame  702 . This causes the coaptation material to overlap a prolapsing segment of either the anterior or posterior leaflet of, e.g., the mitral valve, depending on the manner in which the device  700  is positioned. In some embodiments, the portion of the body located inferior to the valve plane is positioned between the natural chordae of the valve and the ventricular wall. Alternatively, this portion of the frame can be positioned below the coaptation zone of the leaflets, generally in front of the native chordae. In some embodiments, particularly for patients suffering from functional mitral valve regurgitation, the coaptation material could be dense mesh that generally resembles a solid material to increase the surface area for coaptation. 
     The values noted above are example embodiments and should not be read as limiting the scope of this invention other than as expressly claimed. Those skilled in the art will recognize that the above values may be adjusted to practice the invention as necessary depending on the physical characteristics of the patient. 
     Although specifically described with respect to the mitral valve, it should be understood the devices described herein could be used to treat any other malfunctioning valve, such as the tricuspid and aortic valves. Further, although not specifically described herein, it should be understood that the devices described in the present application could be implanted into the beating heart of the patient via various access approaches known in the art, including transapical approaches (through the apex of the left ventricle) and transvascular approaches, such as transfemorally (through the femoral vein). One example of a transapical access approach that could be employed with ringless webs as described herein is described in U.S. Pat. No. 9,044,221, which is hereby incorporated by reference herein. One example of a transvascular access approach that could be employed with ringless webs as described herein is described in U.S. Patent Publication No. 2013/0035757, which is hereby incorporated by reference herein. This versatility in access approach enables the access site for the procedure to be tailored to the needs of the patient. 
     Various embodiments of systems, devices, and methods have been described herein. These embodiments are given only by way of example and are not intended to limit the scope of the present invention. It should be appreciated, moreover, that the various features of the embodiments that have been described may be combined in various ways to produce numerous additional embodiments. Moreover, while various materials, dimensions, shapes, implantation locations. etc. have been described for use with disclosed embodiments, others besides those disclosed may be utilized without exceeding the scope of the invention.