Patent Publication Number: US-10327743-B2

Title: Device and methods for endoscopic annuloplasty

Description:
REFERENCE TO PRIORITY DOCUMENT 
     This application claims priority of U.S. Provisional Patent Application Ser. No. 60/674,931 entitled “DEVICE AND METHODS FOR ENDOSCOPIC ANNULOPLASTY”, filed Apr. 25, 2005. Priority of the aforementioned filing dates is hereby claimed, and the disclosure of the Provisional Patent Application is hereby incorporated by reference in their entirety. 
     This application is a continuation-in-part of U.S. application Ser. No. 10/820,581 now abandoned entitled “METHODS AND APPARATUS FOR CARDIAC VALUE REPAIR”, filed Apr. 7, 2004, which is a continuation of U.S. patent application Ser. No. 10/635,776 now U.S. Pat. No. 7,704,269, filed Aug. 5, 2003, which is a continuation of U.S. patent application Ser. No. 09/544,930, filed Apr. 7, 2000, now U.S. Pat. No. 6,629,534, which claimed the benefit under 35 U.S.C. 119(e) of U.S. Provisional Patent Application No. 60/128,690, filed on Apr. 9, 1999 under 37 CFR 1.78(a). The full disclosures of the aforementioned applications are incorporated herein by reference. 
    
    
     BACKGROUND 
     The present disclosure relates generally to medical methods, devices, and systems. In particular, the present disclosure relates to methods, devices, and systems for the endovascular or minimally invasive surgical repair of the atrioventricular valves of the heart, particularly the mitral valve. 
     Mitral valve regurgitation is characterized by retrograde flow from the left ventricle of a heart through an incompetent mitral valve into the left atrium. During a normal cycle of heart contraction (systole), the mitral valve acts as a check valve to prevent flow of oxygenated blood back into the left atrium. In this way, the oxygenated blood is pumped into the aorta through the aortic valve. Regurgitation of the valve can significantly decrease the pumping efficiency of the heart, placing the patient at risk of severe, progressive heart failure. 
     Mitral valve regurgitation can result from a number of different mechanical defects in the mitral valve. The valve leaflets, the valve chordae which connect the leaflets to the papillary muscles, or the papillary muscles themselves may be damaged or otherwise dysfunctional. Commonly, the valve annulus may be damaged, dilated, or weakened limiting the ability of the mitral valve to close adequately against the high pressures of the left ventricle. 
     The most common treatments for mitral valve regurgitation rely on valve replacement or strengthening of the valve annulus by implanting a mechanical support ring or other structure. The latter is generally referred to as valve annuloplasty. A recent technique for mitral valve repair which relies on suturing adjacent segments of the opposed valve leaflets together is referred to as the “bow-tie” or “edge-to-edge” technique. While all these techniques can be very effective, they usually rely on open heart surgery where the patient&#39;s chest is opened, typically via a sternotomy, and the patient placed on cardiopulmonary bypass. The need to both open the chest and place the patient on bypass is traumatic and has associated morbidity. 
     For these reasons, it would be desirable to provide alternative and additional methods, devices, and systems for performing the repair of mitral and other cardiac valves, including the tricuspid valve which is the other atrioventricular valve. Such methods, devices, and systems should preferably not require open chest access and be capable of being performed endovascularly, i.e., using devices which are advanced to the heart from a point in the patient&#39;s vasculature remote from the heart. Still more preferably, the methods, devices, and systems should not require that the heart be bypassed, although the methods, devices, and systems should be useful with patients who are bypassed and/or whose heart may be temporarily stopped by drugs or other techniques. 
     SUMMARY 
     The present disclosure provides methods, devices, and systems for the endovascular repair of cardiac valves, particularly the atrioventricular valves which inhibit back flow of blood from a heart ventricle during contraction (systole), most particularly the mitral valve between the left atrium and the left ventricle. By “endovascular,” it is meant that the procedure(s) are performed with interventional tools, guides, and supporting catheters and other equipment introduced to the heart chambers from the patient&#39;s arterial or venous vasculature remote from the heart. The interventional tools and other equipment may be introduced percutaneously, i.e., through an access sheath, or may be introduced via a surgical cut down, and then advanced from the remote access site through the vasculature until they reach the heart. Thus, the procedures will generally not require penetrations made directly through the exterior heart muscle, i.e., myocardium, although there may be some instances where penetrations will be made interior to the heart, e.g., through the interatrial septum to provide for a desired access route. While the procedures will usually be percutaneous and intravascular, many of the tools will find use in minimally invasive and open surgical procedures as well that includes a surgical incision or port access through the heart wall. In particular, the tools for capturing the valve leaflets prior to attachment can find use in virtually any type of procedure for modifying cardiac valve function. 
     The atrioventricular valves are located at the junctions of the atria and their respective ventricles. The atrioventricular valve between the right atrium and the right ventricle has three valve leaflets (cusps) and is referred to as the tricuspid or right atrioventricular valve. The atrioventricular valve between the left atrium and the left ventricle is a bicuspid valve having only two leaflets (cusps) and is generally referred to as the mitral valve. In both cases, the valve leaflets are connected to the base of the atrial chamber in a region referred to as the valve annulus, and the valve leaflets extend generally downwardly from the annulus into the associated ventricle. In this way, the valve leaflets open during diastole when the heart atria fill with blood, allowing the blood to pass into the ventricle. During systole, however, the valve leaflets are pushed together and closed to prevent back flow of blood into the atria. The lower ends of the valve leaflets are connected through tendon-like tissue structures called the chordae, which in turn are connected at their lower ends to the papillary muscles. Interventions described herein may be directed at any one of the leaflets, chordae, annulus, or papillary muscles, or combinations thereof. It will be the general purpose of such interventions to modify the manner in which the valve leaflets coapt or close during systole so that back flow or regurgitation is minimized or prevented. While the procedures will be most useful with the atrioventricular valves, at least some of the tools described hereinafter may be useful in the repair of other cardiac valves, including the aortic valve. 
     The methods described herein will usually comprise accessing a patient&#39;s vasculature at a location remote from the heart, advancing an interventional tool through the vasculature to a ventricle and/or atrium, and engaging the tool against a tissue structure which forms or supports the atrioventricular valve. By engaging the tool against the tissue structure, the tissue structure is modified in a manner that reduces valve leakage or regurgitation during ventricular systole. The tissue structure may be any of one or more of the group consisting of the valve leaflets, chordae, the valve annulus, and the papillary muscles, atrial wall, ventricular wall or adjacent structures. Optionally, the interventional tool will be oriented relative to the atrioventricular valve and/or tissue structure prior to engaging the tool against the tissue structure. The interventional tool may be self-orienting (e.g., pre-shaped) or may include active mechanisms to steer, adjust, or otherwise position the tool. Alternatively, orientation of the interventional tool may be accomplished in whole or in part using a separate guide catheter, where the guide catheter may be pre-shaped and/or include active steering or other positioning means such as those devices set forth in U.S. patent application Ser. No. 10/441,753 filed May 19, 2003, Ser. No. 10/441,508 filed May 19, 2003 and Ser. No. 10/441,687 filed May 19, 2003, all of which are expressly incorporated by reference herein. In all cases, it will usually be desirable to confirm the position prior to engaging the valve leaflets or other tissue structures. Such orienting step may comprise positioning the tool relative to a line of coaptation in the atrioventricular valve, e.g., engaging positioning elements in the valve commissures and confirming the desired location using a variety of imaging means such as MRI, intracardiac echocardiography (ICE), transesophageal echo (TEE), fluoroscopy, endoscopy, intravascular ultrasound (IVUS) and the like. 
     In a first aspect, the tissue structure comprises the valve leaflets and the engaging step comprises attaching one or more opposed points on or along the valve leaflets together. In the case of the bicuspid mitral valve, the attachment points may be located at or near the center of each leaflet, creating a generally symmetric structure with two openings, i.e., between the attachment point(s) and each of the two commissures. Alternatively, the attachment points may be close to each of the commissures. Both will effectively reduce the area in which the valve can open. In the case of the tricuspid valve, any two of the three leaflets can be partially or totally closed together or all three may be partially closed together. 
     In both cases, the attachment of the valve leaflets may be performed in a variety of ways, including suturing, clipping, stapling, riveting, gluing, fusing, or the like. While each of these approaches may differ significantly in the protocols and devices used for performing them, the end result will be the same, i.e., improved ability of the atrioventricular valve to close against the elevated pressures within the ventricle during systole. In order to improve apposition of the valve leaflets, it may be preferred to attach the leaflets at a point spaced inwardly from the free edge of the leaflet. Usually, the attachment point within the valve leaflet will be located from 1 mm to 4 mm inward from the free edge. 
     It will frequently be desirable to stabilize the interventional tool relative to the valve leaflets and other heart tissue structures at least some points during the interventional procedure. In a broad sense, such stabilization is intended primarily to couple motion of the interventional tool to the motion of the heart so that the tool may then engage the valve leaflets or other target tissue structures with minimum differential motion. The stabilization may be achieved either through the interventional tool or through a guide catheter or other platform which is used to deliver the interventional tool. In both cases, stabilization will usually be achieved by engaging a tissue structure of the heart, such as the interatrial septum, the atrial wall, the valve annulus, the valve chordae, the papillary muscles, or the like. For antegrade approaches, immobilization of either the guide catheter, the interventional tool, or both relative to the valve annulus or valve commissures will be particularly effective. For retrograde approaches, immobilization against the papillary muscles, the chordae, or the valve leaflets themselves may be particularly effective. Stabilization should be distinguished from valve capture which is usually performed after the interventional tool and/or guide catheter have been stabilized within the heart. Thus, the methods may comprise up to four separate steps or phases prior to valve affixation. First, the interventional tool and/or guide catheter may be positioned, either actively or passively. Second, the interventional tool and/or guide catheter may be stabilized within the heart. Next, the interventional tool may be used to capture the valve leaflets. Then, prior to affixation, the valve leaflets may be positioned and, if necessary, repositioned in order to determine that a particular coaptation and affixation are capable of inhibiting the valve regurgitation. Finally, once adequate regurgitation inhibition has been confirmed, the valve leaflets may be affixed in any of the manners described below. 
     In a particular approach, the interventional tool may be stabilized by mechanically fixing the shape of the tool after the tool has been advanced to a position proximate the atrioventricular valve. For example, the interventional tool can comprise a plurality of linked elements which can be locked into place, e.g., a “goose-neck” device. Such mechanically lockable devices may be used by themselves or in conjunction with any of the other stabilization devices described herein. 
     When attaching portions of the valve leaflets together, it will frequently be desirable to temporarily capture the valve leaflets before implementing the final attachment step. For example, the leaflets can be captured using forceps or other graspers introduced as part of or separately from the interventional tool. After capturing the valve leaflets, flow through the valve can be observed by conventional cardiac imaging techniques, such as trans-esophegeal echocardiography (TEE), intracardiac echocardiography (ICE) or other ultrasonic imaging technique, fluoroscopy, angioscopy, catheter based magnetic resonance imaging (MRI), computed tomography (CT) and the like. By thus observing the flow through the valves, and more importantly whether or not back flow or regurgitation continues or has been sufficiently inhibited, the desired attachment configuration for the leaflets can be determined. If continued regurgitation is observed, the valve leaflets may be repositioned and the presence or absence of regurgitation again determined. Such repositioning steps may be continued until a position is identified in which the regurgitation is sufficiently inhibited. Additionally, other considerations, such as position of the attachment within the leaflet, stress placed on the leaflet, and other factors can be visualized before deciding on the final attachment point(s). In a preferred example, the valve leaflets may be coapted by a grasping instrument which also has a fixation mechanism, such as stapling, suturing, clipping or riveting as previously described, so that once a desirable attachment configuration is temporarily achieved, the final attachment can be made using the same instrument. Grasping of the valve leaflets can be accomplished using articulated graspers, vacuum-assisted graspers, grasping pins, or other temporary attachment modes as described in more detail below. After the leaflets are in the desired configuration, they may be permanently secured together by any of the techniques described above. 
     In a second aspect, the tissue structure comprises the chordae and the engaging step comprises linking opposed chordae together, i.e., chordae attached to different valve leaflets. Usually, the chordae will be partially gathered or coupled together using a suture or other loop structure. In some instances it may be desirable to closely tie the chordae together at one or more locations. 
     In a third aspect, the tissue structure comprises the chordae and the engaging step comprises applying energy to shorten the chordae. Particular forms of heat energy, most particularly radiofrequency energy, have been found to be able to modify and shrink collagen so that supporting chordae may be tightened. By applying energy to shorten one or more of the chordae attaching either or both (or all three in the case of the tricuspid valve) valve leaflets, the flow through the atrioventricular valve can be modified and regurgitation minimized. In one aspect, the chordae will be initially grasped or captured and manipulated to temporarily apply tension to the valve leaflets. The effect of such temporary shortening can then be visually assessed and, if a desired improvement in valve performance is observed, energy can be applied to shorten the chordae. In many cases, however, it may be preferable to apply a clip, ring, suture loop, or other mechanical element to permanently twist, plicate, or otherwise shorten the chordae, as described elsewhere herein. 
     In a fourth aspect, the tissue structure comprises the valve annulus and the engaging step comprises circumferentially tightening or shortening the annulus. In a preferred technique, the annulus will be strengthened by positioning and attaching a supporting structure over the annulus in a manner broadly analogous to the open surgical placement of an annuloplasty ring. Alternatively, the annulus can be tightened by surgical plication techniques, or in some instances by shrinking tissue within the annulus by applying radiofrequency energy as generally described above in connection with shortening of the chordae. 
     In a fifth aspect, the tissue structure comprises the papillary muscles and the engaging step comprises capturing and drawing opposed points or portions of the papillary muscles together. This approach is similar in many respects to capture of the chordae, and will generally comprise suturing or otherwise forming a linkage between the opposed portions of the papillary muscles. As with the chordae, it will generally not be desirable to fully close the papillary muscles together, although in some instances such an approach may also find use. 
     In all the aspects of the method described above, the heart will usually remain beating while the interventional tool is engaged against the tissue structure. When the heart is beating, however, it may be desirable to temporarily stop valve action during at least a portion of the procedure, particularly to facilitate grasping of the valve leaflets when such a technique is being employed. The valve action can be slowed temporarily by decreasing the heart rate with intravenous infusion of a beta blocker, such as esmolol, or can be completely stopped for a brief time, e.g., five to ten seconds, by infusion of a drug, such as adenosine. Alternatively, the valve action can be stopped by temporarily raising the pressure in the associated ventricle to a pressure above that in the atrium during diastole. While the heart will continue to beat, the motion of the valve leaflets opening and closing will be stopped to facilitate grasping. As a further alternative, it will be possible to mechanically restrain the leaflets directly or by capturing the chordae, as described in more detail below. While such an approach may be effective for some purposes, the difficulty in capturing the valve leaflets initially may still be present. 
     While the methods described herein are particularly desirable since they permit interventions to occur without stopping the heart, they may also be used with patients undergoing cardiopulmonary bypass. Such cardiopulmonary bypass can be achieved by any presently available technique, including both conventional systems and recently developed endovascular bypass systems, such as those available from Heartport, Inc., Redwood City, Calif. 
     During the procedures performed while the heart is beating, it will often be desirable to stabilize the interventional tool against one or more cardiac structures prior to grasping the leaflets with the interventional tool. Such stabilization will lessen the relative motion between the tool and the structure. Stabilization mechanisms may be separate from or integral with any part of the system or device, including but not limited to guidewires, guiding catheters and interventional tools. Likewise, the stabilization mechanisms may provide one or more additional functions in the tissue modification procedure, such as steering, orientation assessment, grasping, coaptation, adjustment and fixation. Therefore, many components in the system may have dual purposes. 
     Coaptation may be performed by a number of methods, such as capturing the leaflets or by releasably capturing the chordae attached to each leaflet. An exemplary capture device will comprise a snare, or a pair of snares, which are advanced through the chordae to capture or entangle individual chordae. This snare or snares may then be tightened to draw the chordae partially together and limit valve motion, at least partially. After such coaptation is achieved, the valve leaflets, chordae, papillary muscles, or annulus may then be engaged and modified, e.g., the leaflets may be attached, using a separate interventional tool, as described above and elsewhere herein. Alternatively, it will be possible to form a permanent link, bridge, or capture of the chordae if the temporary coaptation appears sufficient to repair valve function. In some instances, it may be sufficient to simply detach the snare or other capture mechanism and leave it in place permanently. In other instances, it will be possible to exchange the snare for a more permanent attachment structure, such as a suture loop or metallic coil. For example, once the snare is in place, if the valve function is acceptably repaired, the snare may be drawn out from the chordae through the placement catheter, where the snare pulls a length of suture in the manner of a needle passing through tissue. The suture can then be tied or otherwise fastened to form a permanent capture loop for the chordae. Alternatively, a separate attachment structure, such as a metal coil, barb, malecot, or the like, may be advanced around the snared chordae to effect permanent capture, where a structure will be detached and left in place. 
     The methods described above may be performed using either antegrade or retrograde endovascular access through the vasculature. The following description will describe both antegrade and retrograde access approaches for gaining access to the mitral valve. Mitral valve access is generally more difficult than tricuspid valve access. In a retrograde approach, the interventional tool, optional guiding catheter, and any other supporting devices, will be introduced through distal arterial vasculature and over the aortic arch and into the left ventricle through the aortic valve. Typically, the aortic arch or via a brachial approach will be approached through a conventional femoral artery access route, but could also be approached through the brachial artery, axillary artery, or a carotid artery. When entering the left ventricle, the interventional tool will generally be directed downwardly and away from the mitral valve structure. Thus, the interventional tool will usually be curved or turned so that it approaches the mitral valve from below, usually through the chordae toward the valve annulus. For example, the interventional tool can enter the left ventricle through the aortic valve and then be deflected or otherwise steered to turn 90° to directly approach the mitral valve and chordae. Steering of the tool can be accomplished by deflecting a supporting catheter using pull wires, pre-formed curved catheters, or the like. In some instances, the papillary muscles could be more directly accessed since they generally lie below the aortic valve and inline with the tool as it enters the left ventricle. 
     Often, it will be desirable to position the interventional tool toward the target tissue structure using a preformed and/or steerable guide catheter. In a retrograde approach, the guide catheter may be placed from an access point, e.g., the femoral artery at the patient&#39;s groin, so that it passes over the aortic arch, through the aortic valve, and into the left ventricle where it will form an access path to the target tissue structure. When the tissue structure is the chordae or valve leaflets, the guide catheter will usually have to be curved or be everted or turned backward so that it can turn the interventional tool around. Additionally, it may be desirable to provide for stabilization of the distal end of the guide catheter. Stabilization may be provided by extendible elements, wires, cages, balloons, or other structures which engage the valve annulus, chordae or ventricular wall portions. Alternatively, two or more stabilizing extensions may be provided to project forwardly from the guide catheter and seat in the valve commissures to position and hold the guide catheter in place. Such extendible elements may also be used to stabilize guidewires, interventional tools and other types of catheter systems. Specific stabilization structures will be described in more detail below. 
     Access for an antegrade endovascular approach will be through the inferior vena cava or superior vena cava into the right atrium. Such antegrade access may, in itself, be sufficient to perform procedures on the tricuspid valve from the top of the valve. Such procedures, however, will not be described in detail herein. To access the mitral valve, it will be necessary to pass from the right atrium into the left atrium, typically by passing the tool through the interatrial septum. The interatrial septum may be endovascularly penetrated by conventional techniques, typically using a Brockenbrough needle, as described in the valvuloplasty literature. Once the interatrial septum has been penetrated, the interventional tool may be passed into the left atrium so that it approaches the mitral valve from the top. Such an approach will require that the access path turn downward, typically through an angle in the range from 0° to 120°. 
     The superior vena cava may be accessed through a variety of conventional peripheral access sites, such as the internal jugular vein, while the inferior vena cava may be accessed through the femoral vein. Such access may be performed percutaneously or by surgical cut down techniques. 
     As with the retrograde arterial approach, the antegrade venous approach may utilize placement of a guide catheter. With the use of a guidewire, the guide catheter will be configured to pass from the initial access location, through either the superior vena cava or inferior vena cava into the right atrium. The guide catheter will then be adapted to pass through an interatrial penetration and into the left atrium, where it will be pre-shaped or deflected to approach the mitral valve from the top. The guidewire, guide catheter and/or the interventional catheter which carries the interventional tool may be steerable and may optionally have stabilizing elements. For example, in this specific embodiment, the guide catheter may have two or more laterally extensible steering wires and/or a plurality of stabilizing arms which project forwardly and seat around the valve annulus or commissures to hold the guide catheter in place. The interventional tool may then be deployed through the guide catheter to perform the desired valve repair technique. 
     Systems described herein comprise a guide catheter configured to pass from the remote vasculature of a patient to a position within the heart adjacent to a target atrioventricular or other cardiac valve. The systems further comprise an interventional catheter configured to pass through the guide catheter and to engage the atrioventricular or other cardiac valve and/or associated cardiac structures and an interventional tool on the interventional catheter adapted to modify the atrioventricular or other cardiac valve leaflets, valve annulus, valve chordae or papillary muscles to reduce regurgitation. In particular, the guide catheter can be configured for either an antegrade or retrograde approach to the mitral valve, as described above. The guide catheter may further comprise a stabilizing element for engaging tissue within the heart to reduce relative movement between the guide catheter and the tissue while the heart remains beating. The structure can be any of the cages, wires, or the like, which have previously been described in connection with the method. Additionally, the interventional catheter may also comprise a stabilizing element for engaging a tissue structure within the heart to reduce relative motion between the interventional catheter and the tissue. The stabilizing element can also be an expansible cage, steering wires, or the like and may include vacuum and/or surface finishes to enhancing coupling. Specific interventional tools include suturing devices, stapling devices, clip-applying devices, radiofrequency electrodes, surgical adhesive applicators, annuloplasty rings, and the like. 
     Both the interventional tool and the guide catheter may employ stabilizing mechanisms intended to engage a tissue structure within the heart to reduce relative movement between the interventional tool and/or guide catheter relative to the heart, and in particular relative to the atrioventricular valve. The stabilization mechanisms in both cases may be the same. Typically, the stabilization mechanisms will be adapted to engage at least one tissue structure selected from the group consisting of the interatrial septum, the atrial wall, the valve annulus, the valve commissures, the valve chordae, and the papillary muscles. For example, the stabilizing mechanism may comprise one or more extensible wires which are deployable radially outwardly to engage the tissue structure, such as the valve commissures. Alternatively, the stabilizing mechanism could comprise an expansible cage that can be deployed to occupy all or at least a major portion of the atrium above the atrioventricular valve. As a still further alternative, the stabilizing mechanism could be a pair of inflatable balloons which are spaced-apart and adapted to engage the interatrial septum when the interventional tool and/or guide catheter are passed therethrough. 
     In further specific aspects, the interventional tool may comprise a valve leaflet capture device intended for temporarily holding the valve leaflets prior to modification, e.g., affixation. For example, the valve leaflet capture device may comprise a pair of extensible elements which may be advanced from a distal end of the interventional tool to engage and capture the two mitral valve leaflets or three aortic valve leaflets. The particular capture tools may grasp the leaflets by pinching, partially or fully penetrating or piercing, and/or suctioning the leaflets. The tools may comprise jawed devices, looped devices, coiled devices or pronged devices, or vacuum devices to grasp and hold the leaflets. 
     The present disclosure further provides methods for grasping an atrioventricular or other cardiac valve, particularly the mitral valve, to facilitate subsequent intervention or for other purposes. The grasping method comprises capturing chordae attached to at least one leaflet of the valve while the heart is beating. Capture of the chordae from beneath the valve can modify leaflet movement and improve valve function, optionally closing portions of opposed valve leaflets against each other. Usually, chordae attached to valve leaflets (or possibly three valve leaflets in the case of tricuspid valves) are captured simultaneously. For example, one or more snares, such as helical coils, can be advanced into the chordae to capture and immobilize portions thereof. Alternatively, a loop element can be advanced through the valve chordae and tightened in order to modify valve function. In some instances, capture of the chordae can be made permanent and will be sufficient to treat the underlying regurgitation. In other cases, capture of the chordae will be primarily for leaflet coaptation, and the leaflets will be affixed by a subsequent interventional step. Preferably, the subsequent interventional step is performed while the chordae remain captured. The chordae can then be released after the leaflets or other tissue structures have been modified. 
     The present disclosure still further provides a chordae capture catheter comprising a catheter body having a proximal end and a distal end. Means are provided at or near the distal end of the catheter body for capturing the chordae. A first exemplary means comprises one or more coils which are extensible from the distal end of the catheter and which engage and entangle the chordae when they are advanced therein. A second exemplary capture means comprises a loop element which is extensible from the distal end of the catheter and which is pre-formed to pass through the chordae on one or both, preferably both valve leaflets in order to draw the chordae together and modify valve function. 
     A further method according to the present disclosure for grasping an atrioventricular or other cardiac valve leaflets comprises capturing two valve leaflets separately and preferably sequentially. Such capture is effected by a leaflet capture catheter having at least three grasping jaws or prongs. A first valve leaflet is captured between a first pair of prongs, and second valve leaflet is captured between a second pair of prongs. Optionally, the two prong pairs can have a common center prong, typically where the center prong is fixed (immobile) and the two outer prongs pivot in order to provide a pair of adjacent jaw-type graspers. By separately and sequentially grasping the two leaflets, the leaflets can be held in a preferred apposition and the improvement in valve function observed. Alternatively, the leaflets may be grasped simultaneously. If the improvement is adequate, the valves can be permanently affixed in a separate step. Optionally, the leaflet capture catheter can include a device for fixing the valves, e.g., it can carry a clip which can be applied on to the valves as the capture catheter is withdrawn. 
     The present disclosure still further provides leaflet capture catheters suited for performing the method just described. The catheters comprise a catheter body having a proximal end and a distal end. A leaflet grasper is provided at or near the distal end of the catheter body and includes at least three prongs wherein at least two of the three prongs are pivotable so that they may be separately actuated to separately capture individual leaflets or simultaneously actuated to capture the leaflets together. Optionally, the catheters further comprise means for affixing the valve leaflets after they have been captured, preferably comprising a clip-applier. 
     The present disclosure further includes leaflet capture catheters and tools which utilize a vacuum for grasping the valve leaflets and manipulating the post leaflets into a desired apposition. Usually, the catheter will have at least two vacuum channels at a distal end where the channels are preferably separately positionable and independently actuable. In that way, at least two valve leaflets can be separately captured and positioned while the base catheter remains stationary. The catheter may be positioned in an antegrade or retrograde manner with the tool entering between the valve leaflets and optionally between the chordae. The tool and/or catheter may optionally further include modification devices, such as suture appliers, clip appliers, staplers, rivet appliers, adhesive applicators, heating elements for shortening the chordae, and others of the specific interventional tools described hereinafter. Likewise, the present disclosure further includes catheters and tools which include lumens for monitoring pressures within the chambers of the heart, and/or infusion of radiopaque contrast solution. 
     The present disclosure further includes a method of modifying a heart valve of a patient. The method comprises advancing a catheter through the patient&#39;s vasculature into the heart from a vascular access point remote from the heart. The catheter has at least one structure releasably coupled thereto. The method further comprises deploying the structure from the catheter into a gutter on a ventricular side of annulus of the heart valve, the structure adapted to modify the annulus so as to reduce regurgitation in the heart valve; and, in combination with deploying the structure, holding leaflets of the heart valve together so as to reduce regurgitation in the heart valve. 
     The present disclosure further includes a method of modifying a heart valve of a patient. The method comprises advancing a catheter through the patient&#39;s vasculature into the heart from a vascular access point remote from the hear. The catheter has an annuloplasty device releasably coupled thereto. The method further comprises performing an intervention on a gutter on a ventricular side of the heart valve to modify an annulus of the heart valve and reduce regurgitation in the heart valve; and in combination with performing an intervention, modifying a spatial relationship between a first valve leaflet and a second valve leaflet of the heart valve so as to reduce regurgitation in the heart valve. 
     The details of one or more embodiments are set forth in the accompanying drawings and the description below. Other features and advantages will be apparent from the description and drawings, and from the claims. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  is a schematic illustration of the left ventricle of a heart showing blood flow during systole with arrows. 
         FIG. 2  is a schematic illustration of the left ventricle of a heart having prolapsed leaflets in the mitral valve. 
         FIG. 3  is a schematic illustration of a heart in a patient suffering from cardiomyopathy where the heart is dilated and the leaflets do not meet. 
         FIG. 3A  shows normal closure of the leaflets, while  FIG. 3B  shows abnormal closure in the dilated heart. 
         FIG. 4  illustrates mitral valve regurgitation in the left ventricle of a heart having impaired papillary muscles. 
         FIG. 5  is a schematic illustration showing direct attachment of opposed valve leaflets to reduce valve regurgitation. 
         FIG. 6  is a schematic illustration showing attachment of valve chordae to treat valve regurgitation. 
         FIGS. 7-8  show exemplary antegrade approaches to the mitral valve from the venous vasculature. 
         FIGS. 9-10  show exemplary retrograde approaches to the mitral valve through the aortic valve and arterial vasculature. 
         FIGS. 11-14  illustrate the use of adjustment wires for steering capability. 
         FIGS. 15A-15D  illustrate the use of pre-shaped mandrels to steer a component or structure. 
         FIGS. 16-20, 21A-21C, and 22A-22B  depict various orientation assessment tools. 
         FIG. 23  is a schematic illustration of an interatrial septum stabilization device. 
         FIG. 24  is a schematic illustration of a catheter shaft designed to provide stabilization against a structure, such as the interatrial septum, or for flexible adjustment and locking stability in various positions. 
         FIG. 25  is a schematic illustration of an atrial stabilization device. 
         FIGS. 26-29  illustrate stabilization mechanisms which utilize coupling to the valve annulus. 
         FIGS. 30, and 31A-31D  illustrate stabilization mechanisms which utilize coupling with the valve commissures and/or leaflets. 
         FIGS. 32A and 32B  illustrate mitral valve stabilization using snares for capturing the valve chordae. 
         FIGS. 33A and 33B  illustrate an antegrade approach for snaring valve chordae and optionally suturing the chordae together to treat valve regurgitation. 
         FIG. 34  illustrates an antegrade approach for snaring valve chordae to stabilize the mitral valve. 
         FIGS. 35 and 35A  illustrate a snaring catheter particularly intended for capturing valve chordae from a retrograde approach. 
         FIGS. 36A and 36B  illustrate use of the catheter  FIG. 35  for snaring valve chordae. 
         FIGS. 37 and 38  illustrate a catheter similar to that shown in  FIGS. 35 and 35A , except that it includes a working channel for introducing interventional catheters and tools to treat the mitral or other atrioventricular valve. 
         FIGS. 39A and 39B  illustrate a coil which can be implanted within the valve chordae to stabilize the mitral valve. 
         FIG. 40  illustrates placement of the coil of  FIGS. 39A and 39B  from a retrograde approach. 
         FIGS. 41A-41B, 42A-42B and 43  illustrate valve leaflet grasping devices which utilizes a pinching method. 
         FIGS. 44A-44D  are schematic illustrations of an atrial-ventricular valve leaflet grasping device which utilizes a pinching method. 
         FIGS. 45A-45B  are schematic illustrations of a grasping device which utilizes rollers in a pinching method. 
         FIGS. 46A-46B  are schematic illustrations of a grasping device which utilizes a pair of opposing coils in a pinching method. 
         FIGS. 47A-D  illustrate a pronged valve leaflet device which utilizes a pinching, partially penetrating or piercing method. 
         FIG. 48  illustrates a vacuum-assisted stabilization catheter for use in the methods described herein. 
         FIG. 49  illustrates an embodiment of a valve suturing device. 
         FIGS. 49A-49C  illustrate an additional embodiment of a valve suturing device. 
         FIG. 50  illustrates a further embodiment of a valve suturing device. 
         FIG. 51  illustrates use of the catheter for capturing and suturing opposed mitral valve leaflets. 
         FIG. 52  illustrates the mitral valve leaflets which have been secured as shown in  FIG. 51 . 
         FIGS. 53 and 54  illustrate an alternative anchor which can be used with the suturing devices. 
         FIGS. 55A-55B  illustrate the use of an expansible anchor in fixation. 
         FIGS. 56 and 57  illustrate yet another suturing device. 
         FIG. 58  illustrates use of the suturing device of  FIGS. 56 and 57  to place sutures between valve leaflets of the mitral valve. 
         FIG. 59  illustrates yet another embodiment of a suturing device. 
         FIG. 60  illustrates use of the device of  FIG. 59  and suturing opposed mitral valve leaflets. 
         FIGS. 61A and 61B  illustrate a stapling device which can be used to staple opposed leaflets of an atrioventricular valve. 
         FIGS. 62A-D  are schematic illustrations of fixation devices. 
         FIG. 63  illustrates an alternative two part fixation stapling device. 
         FIG. 64  illustrates use of the stapling device of  FIG. 63  for stapling opposed valve leaflets of a mitral valve. 
         FIG. 65A-65C  are schematic illustrations of coiled fixation devices. 
         FIG. 66  illustrates use of a self-securing anchor for attaching opposed surfaces on the leaflets of the mitral valve. 
         FIGS. 66A-66B  are schematic illustrations of penetrating fixation devices. 
         FIGS. 67 and 68  are schematic illustrations of penetrating fixation devices with barb-like distal ends. 
         FIGS. 69A-C  and  70 A-B are schematic illustrations of clips used as fixation devices. 
         FIGS. 71, and 72A-72B  are schematic illustrations of clips involving the use of graspers in the fixation mechanism. 
         FIGS. 73A-73C  illustrate a three-jaw clip-applier. 
         FIG. 74  illustrates a clip which has been applied by the clip-applier of  FIGS. 73A-73C . 
         FIG. 75  illustrates a device for applying radiofrequency energy to shorten valve chordae. 
         FIGS. 76, and 77A-77B  illustrates devices used to plicate and shorten valve chordae. 
         FIG. 78  illustrates a first exemplary approach for placing an annuloplasty ring. 
         FIGS. 79 and 80  illustrate a second exemplary approach for placing an annuloplasty ring. 
         FIG. 81  illustrates a method for placing an anchored filament about a mitral valve annulus that can be used to tighten the annulus. 
         FIG. 82  illustrates a method for placing multiple sutures about a mitral valve annulus, where the individual suture plicate and tighten the annulus. 
         FIGS. 83-85  illustrate an embodiment of an atrial device for valve tissue modification. 
         FIGS. 86, and 87A-87C  illustrate an embodiment of an atrial-ventricular device for valve tissue modification. 
         FIGS. 88-89 , and  FIGS. 90A-90B  illustrate an embodiment of a ventricular device for valve tissue modification. 
         FIG. 91  shows a cutaway representation of the left ventricle. 
         FIGS. 92A and 92B  shows an annuloplasty device for positioning in a gutter of the left ventricle. 
         FIG. 93  shows a cutaway representation of the left ventricle with the annuloplasty device positioned in the gutter. 
         FIG. 94  is a cross-sectional view of the heart showing the mitral valve, valve leaflets, annulus, and coronary sinus. 
     
    
    
     DETAILED DESCRIPTION 
     I. Cardiac Physiology 
     The left ventricle LV of a normal heart H in systole is illustrated in  FIG. 1 . The left ventricle LV is contracting and blood flows outwardly through the tricuspid (aortic) valve AV in the direction of the arrows. Back flow of blood or “regurgitation” through the mitral valve MV is prevented since the mitral valve is configured as a “check valve” which prevents back flow when pressure in the left ventricle is higher than that in the left atrium LA. The mitral valve MV comprises a pair of leaflets having free edges FE which meet evenly to close, as illustrated in  FIG. 1 . The opposite ends of the leaflets LF are attached to the surrounding heart structure along an annular region referred to as the annulus AN. The free edges FE of the leaflets LF are secured to the lower portions of the left ventricle LV through chordae tendineae CT (referred to hereinafter as the chordae) which include plurality of branching tendons secured over the lower surfaces of each of the valve leaflets LF. The chordae CT in turn, are attached to the papillary muscles PM which extend upwardly from the lower portions of the left ventricle and interventricular septum IVS. 
     Referring now to  FIGS. 2-4 , a number of structural defects in the heart can cause mitral valve regurgitation. Ruptured chordae RCT, as shown in  FIG. 2 , can cause a valve leaflet LF 2  to prolapse since inadequate tension is transmitted to the leaflet via the chordae. While the other leaflet LF 1  maintains a normal profile, the two valve leaflets do not properly meet and leakage from the left ventricle LV into the left atrium LA will occur, as shown by the arrow. 
     Regurgitation also occurs in the patients suffering from cardiomyopathy where the heart is dilated and the increased size prevents the valve leaflets LF from meeting properly, as shown in  FIG. 3 . The enlargement of the heart causes the mitral annulus to become enlarged, making it impossible for the free edges FE to meet during systole. The free edges of the anterior and posterior leaflets normally meet along a line of coaptation C as shown in  FIG. 3A , but a significant gap G can be left in patients suffering from cardiomyopathy, as shown in  FIG. 3B . 
     Mitral valve regurgitation can also occur in patients who have suffered ischemic heart disease where the functioning of the papillary muscles PM is impaired, as illustrated in  FIG. 4 . As the left ventricle LV contracts during systole, the papillary muscles PM do not contract sufficiently to effect proper closure. The leaflets LF 1  and LF 2  then prolapse, as illustrated. Leakage again occurs from the left ventricle LV to the left atrium LA, as shown by the arrow. 
     II. Interventional Approaches 
     The described methods and devices treat cardiac valve regurgitation, particularly mitral valve regurgitation, by intervention at various locations. First, as shown in  FIG. 5 , the valve leaflets LF may be directly attached or coupled to each other by a structure S or other means. Typical structures include suture, staples, clips, pins, or other closure devices of a type commonly used in attaching opposed tissue surfaces. Alternatively, the opposed surfaces on the valve leaflets could be attached using adhesives, fusion energy, including radiofrequency current, laser energy, microwave, ultrasonic energy, or the like. A variety of specific techniques for valve leaflet attachment will be described hereinafter. 
     A second and often preferred interventional point will be in the chordae, as shown in  FIG. 6 . There, an attachment structure S is shown to couple individual chordae or tendons which are attached to each of the two leaflets LF. A variety of specific structures can be utilized, such as snares, staples, sutures, coils, clips, snaps, rivets, adhesives, and the like. Opposed chordae will usually also be attached directly, optionally employing any of the same structures listed above. Alternatively, opposed chordae may be indirectly tied or coupled together by a structure which links or couples their movement, but which does not physically attach chordae from each of the valve leaflets directly together. In addition to attaching the chordae, chordal intervention can include shortening the chordae, e.g., by applying energy to shrink the collagen therein, or may utilize mechanical plication devices, such as clips, to physically shorten the chordae. 
     A third interventional point is the annulus AN (shown in  FIG. 1 ) of the mitral valve AV. An annuloplasty device, such as a ring or a partial ring, can be positioned on the annulus to strengthen or re-shape the annulus. The atrial side of the annulus has a smooth, sloping surface around the circumference of the mitral valve. However, it can be difficult to secure an annuloplasty device to the smooth surface of the atrial side of the annulus. The ventricular side of the annulus has a concave, annular “gutter” around the valve. The gutter provides a location in which an annuloplasty device can be located and held while it is fastened to tissue. Thus, percutaneous annuloplasty could be more readily attainable by delivering an annuloplasty ring to the ventricular side rather than the atrial side of the valve, as described more fully below. 
     III. Access to the Mitral Valve 
     Access to the mitral valve or other atrioventricular valve will preferably be accomplished through the patient&#39;s vasculature in a “percutaneous” manner. By “percutaneous” it is meant that a location of the vasculature remote from the heart is accessed through the skin, typically using a surgical cut down procedure or a minimally invasive procedure, such as using needle access through, for example, the Seldinger technique. 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 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 tools described herein will, of course, also be useful for performing open surgical techniques where the heart is stopped and the heart valve accessed through the myocardial tissue. Many of the tools 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  FIGS. 7 and 8 . The mitral valve MV may be accessed by an 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 in  FIG. 7 , a catheter  10  having a needle  12  may be advanced from the inferior vena cava IVC into the right atrium RA. Once the catheter  10  reaches the anterior side of the interatrial septum IAS, the needle  12  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 exchanged for the needle  12  and the catheter  10  withdrawn. 
     As shown in  FIG. 8 , access through the interatrial septum IAS will usually be maintained by the placement of a guide catheter  14 , typically over a guidewire  16  which has been placed as described above. The guide catheter  14  affords subsequent access to permit introduction of the interventional tool(s) which will be used for performing the valve or tissue modification, as described in more detail below. 
     The antegrade approach to the mitral valve, as just described, is advantageous in a number of respects. For example, the use of the antegrade approach will usually allow for more precise and effective centering and stabilization of the guide catheter and/or interventional tool. Precise positioning, of course, facilitates accuracy in the tissue modification, particularly affixation of the valve leaflets or chordae. The antegrade approach also reduces the risk of damaging the subvalvular apparatus during catheter and interventional tool introduction and manipulation. Additionally, the antegrade approach eliminates the risks associated with crossing the aortic valve. This is particularly relevant to patients with prosthetic aortic valves which cannot be crossed. When employing chordal fixation, the tools can be placed very close to the free edge of the leaflet since they will be removed in a direction away from the chordae which are being fixed. Additionally, an antegrade approach allows more direct access to the valve leaflets unimpeded by presence of the chordae. 
     A typical retrograde approach to the mitral valve is depicted in  FIG. 9 . Here the mitral valve MV may be accessed by an approach from the aortic arch M, 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. Such access may be achieved with the use of a guidewire  42 . Once in place, a guide catheter  40  may be tracked over the guidewire  42 . The guide catheter  40  affords subsequent access to permit introduction of the interventional tool(s) which will be used for performing the valve or tissue modification, as described in more detail below. 
     In some instances, a retrograde arterial approach to the mitral valve will be preferred due to its advantages. Use of the retrograde approach will eliminate the need for a trans-septal puncture. The retrograde approach is also more commonly used by cardiologists and thus has the advantage of familiarity. Additionally, the retrograde approach provides more direct access to the chordae. 
     The interventional tool(s) used for performing the valve or tissue modifications may be specifically designed for the approach or they may be interchangeable. For example, tools may be specifically designed for an antegrade or retrograde approach, or they may be designed to be used with either approach. In any case, tools may be used in any appropriate fashion to achieve a desired result. However, for the sake of clarity, a nomenclature has been developed to describe the common usage of such tools. Tools which perform the modification procedure while primarily residing primarily in the atrium are referred to as “atrial” tools. These utilize an antegrade approach. Tools which perform the modification procedure while primarily residing in the ventricle are referred to as “ventricular” tools, and likewise utilize a retrograde approach. Tools which cross over the valve to perform the modification procedure, residing in both the atrium and the ventricle, are referred to as “atrial-ventricular” tools, and may utilize either an antegrade or retrograde approach. 
     IV. Orientation Steering 
     Approaching the desired valve or tissue structure for effective treatment, as described above, requires proper orientation of the catheters, tools and devices used throughout the procedure. Such orientation may be accomplished by gross steering of the device to the desired location and then refined steering of the device components to achieve a desired result. 
     Gross steering may be accomplished by a number of methods. First, a steerable guidewire may be used to introduce a guide catheter, interventional tool and/or treatment device into the proper position. The guide catheter may be introduced, for example, using a surgical cut down or Seldinger access to the femoral artery in the patient&#39;s groin. After placing a guidewire, the guide catheter may be introduced over the guidewire to the desired position. Alternatively, a shorter and differently shaped guide catheter could be introduced through the other routes described above. 
     Second, a guide catheter may be pre-shaped to provide a desired orientation relative to the mitral valve. For example, as shown in  FIGS. 9 and 10 , guide catheter  40  may have a pre-shaped J-tip which is configured so that it turns toward the mitral valve MV after it is placed over the aortic arch AA and through the aortic valve AV. As shown in  FIG. 9 , the guide catheter  40  may be configured to extend down into the left ventricle LV and to evert so that the orientation of an interventional tool or catheter is more closely aligned with the axis of the mitral valve MV. The guide catheter  40  of  FIG. 10  orients an interventional catheter (not shown) in a lateral direction relative to the access of the mitral valve MV. Each of the guide catheters  40  shown in  FIGS. 9 and 10  may find use under different circumstances. For example, the guide catheter  40  of  FIG. 10  might be particularly suited for introducing tools which modify the chordae CT, while the catheter  40  of  FIG. 9  may be more useful for engaging tools against the valve leaflets. As shown in  FIG. 9 , a guidewire  42  may be positioned from the tip of the guide catheter  40  directly through the opening of the mitral valve MV. Interventional tools can then be directed over the guidewire  42  to form the particular procedures described hereinafter. Likewise, the interventional tool itself may be pre-shaped to provide a desired orientation. 
     Third, the guidewire, guide catheter or interventional tool may be actively deflected, e.g., having push/pull wires which permit selective deflection of the distal end in 1, 2, 3, or 4 directions depending on the number of pull wires, having shape memory nitinol, or having balloons, wires, wire cages or similar mesh structures to direct the device away from a cardiac structure and therefore into a desired position, to name a few. 
     Either of the guide catheters  40  shown in  FIG. 9 or 10  may be provided with steering capabilities. For example, two or more adjustment wires  46  may be provided at the distal tip of the guide catheter  40  as shown in  FIG. 11 . These adjustment wires may be active or passive, and may be positioned within the valve commissures to enhance alignment of the guide catheter with the mitral valve MV. As shown in  FIGS. 12A and 12B , the adjustment wires  46  may be positioned in the medial commissure MVC and lateral commissure LVC, and the guide catheter  40  may thus be moved from a central location, as shown in  FIG. 12A  to a more medial position, as shown in  FIG. 12B . The catheter could of course also be moved in the lateral direction (not shown). The ability to position the guide catheter will be of great benefit in performing the specific interventions and valve modifications described hereinafter. It will be appreciated that similar steering mechanisms could be provided on an interventional catheter introduced through the guide catheter, and in some instances it may be most desirable to provide the guidewire, the guide catheter, and the interventional catheter with steering and positioning capabilities. 
     Steering wires  50  on a guide catheter  40  may also be provided to engage opposed surfaces within the left ventricle LV, as shown in  FIG. 13 . By providing such a steering capability, the distal tip of the guide catheter  40  can be moved further downward from the mitral valve. Catheter  40  of  FIG. 13  would be particularly useful in combination with an interventional catheter which itself has steering capabilities which engage portions of the mitral valve, such as the valve commissures as described above. 
     As shown in  FIG. 14 , the guidewire  52  may have laterally deflectable steering elements  54  which may be positioned in, for example, the valve commissures as described previously. This way, the guidewire  52  may be positioned toward the medial or lateral sides of the mitral valve MV, and an interventional catheter  56  introduced over the guidewire to a desired target structure within or surrounding the mitral valve MV. Providing such a steerable and positionable guidewire, it is particularly advantageous when it is desired to position the tip of an interventional catheter  56  at a region well below the opening of the mitral valve. That is, neither the guide catheter nor the interventional catheter have to be advanced fully to the opening of the mitral valve, leaving them free to be positioned elsewhere. 
     In some instances, it will be desirable to introduce interventional tools sequentially or simultaneously from both the antegrade and retrograde directions. While it will be possible to separately introduce guiding catheters and guidewires by the approaches described above, in at least some instances it may be preferable to pass a single guidewire between the vena cava and the right atrium, crossing the interatrial septum as previously described. The guidewire may then pass in an antegrade direction through the aortic valve, through the ascending and descending aorta, and then percutaneously out of the vasculature at a location remote from the heart, such as the femoral artery. 
     Location of a single guidewire in this manner provides a continuous “rail” through the heart, allowing placement of separate devices in both an antegrade and retrograde direction. Additionally, any interaction or cooperation between the devices is facilitated since they will necessarily advance toward one another in an alignment which is controlled and assured by the guidewire, e.g., when fully advanced any two devices will necessarily meet. Thus, one device would extend inward from the venous side of the heart in an anterior antegrade direction to the mitral valve, and a second device would enter through the arterial side of the heart in a retrograde direction. The two devices would then be precisely located relative to each other as they approach and optionally meet at or near the mitral valve. In a particular example, a stabilizing catheter could be introduced in a retrograde direction to approach the chordae and underside of the mitral valve leaflets to provide for temporary stabilization and/or leaflet coaptation, as generally described above. A catheter carrying a fixation device could then be advanced in an antegrade direction to approach the valve leaflets from above. The second device could then be separately actuated to affix the valve leaflets once the proper temporary stabilization has been achieved with the first device. 
     Fourth, the guidewire, guide catheter or interventional tool may be positioned with the use of a floating balloon. This may be most useful for use with an antegrade approach. The distal balloon of a balloon tipped guidewire or balloon tipped floppy catheter may be inflated and floated antegrade through the mitral valve. If the heart is slowly beating, blood will be flowing from the left atrium, through the mitral valve to the left ventricle. A floating balloon may be carried along this flow trajectory, carrying the guidewire or catheter with it. The balloon may then be deflated and newly placed guidewire or catheter may be utilized as desired. 
     Fifth, a hollow guidewire, guide catheter or interventional or other tool may be positioned with the use of a rigid, pre-shaped mandrel or insertable member. As shown in  FIGS. 15A-D , the mandrel  600  may be comprised of wire, metal, plastic or any suitable material that may be formed to hold a desired shape  601 , such as a bend or bump. The mandrel  600  may then be inserted into a lumen in a flexible structure  602  to be positioned. Such a structure may be a hollow guidewire, guide catheter, interventional tool or any other tool or component of a structure. As the shape  601  is advanced, the flexible structure  602  conforms to the shape  601  as it is passed through. This may be utilized to position a structure or component of a structure in a desired location for later steps in the procedure. 
     It may be appreciated that any of the devices, systems and methods used for gross steering may be also be applied to refined steering of the device or device components to achieve a desired result. In particular, it may be desired to independently or dependently manipulate components of the interventional tools throughout the procedure. Such steering may allow urging of the components relative to the leaflets, annulus, atrial wall or other specific cardiac structures. This may be achieved with any of the devices or methods described above. 
     V. Orientation Assessment 
     Proper orientation of the systems and devices is necessary for performing the valve or tissue modification. Both the orientation of the devices and the components of the devices, in relation to cardiac structures and to each other, are of concern. Cardiac structures to which orientation is desired may include the atrial walls, interatrial septum, valve annulus, valve leaflets, valve commissures, valve chordae, papillary muscles and ventricle walls, to name a few. Assessment of the orientation of the components and devices may be achieved by a number of mechanisms and methodologies. 
     First, orientation may be assessed by tactile feedback. Introduction and manipulation of the devices and components may allow them to contact cardiac structures or other devices. Such contact may guide the devices into proper position and relevant orientation. For example, it may be possible to tactilely sense the force of the distal end of a guidewire, catheter or interventional tool against the leaflets, commissures, annulus, chordae, papillary muscles, ventricular walls, and/or atrial walls, to name a few. The force may be translated along its length to its proximal end to provide feedback to the physician or operator. Similarly, sensors may be used to achieve a similar result. Additionally, the catheter or tool may have a lumen to allow for pressure monitoring. This may provide feedback throughout the procedure which may indicate the presence and level of mitral regurgitation. 
     Second, orientation may be assessed by visualization of the devices and components themselves. The components or the overall system may be modified for enhanced echogenic and/or fluoroscopic visibility. Echogenicity of a material in a blood medium is dependent on the difference in acoustic impedance (product of velocity of sound and density of the medium through which the sound wave is traveling) between the material and blood. Therefore, a thin polymer coating on the components or the overall system may provide modulation of the acoustic impedance at the interface of the component and blood, thereby improving echovisibility. Likewise, microscopic air bubbles trapped on the surface or embedded within the coating may also improve echovisibility. Similarly, fluoroscopic visibility may be improved with radiopaque coatings, radiopaque marker bands, or the like. Additionally, a lumen within the catheter or tool may be provided to inject radiopaque contrast solution to improve fluoroscopic visibility or surrounding tissues. In any case, such coatings, markings and fluids may provide visualization of the devices and components themselves or any structures or elements used throughout the treatment procedure. Similarly, angioscopic vision may be used to access the orientation throughout the procedure. 
     Third, one or more orientation elements may be used to assess orientation of the components and/or systems in relation to cardiac structures, specifically the target valve. Thus, orientation elements may be any structure or feature that provides information as to the orientation of the component, device or system described herein. The elements may be separate from or integral with any part of the system or device. They may be removably or fixedly mounted on the guidewire, guide catheter, interventional tool and/or other device. Likewise, the elements may be components or parts of components of the device which provide one or more additional functions in the tissue modification procedure, such as stabilization, grasping, coaptation, adjustment or fixation. Further the elements may be atrial, ventricular or atrial-ventricular devices such that they may or may not cross the valve in the orientation assessment process. In addition, such elements may be used to steer and/or orient the components and systems prior to or simultaneous with assessment. 
     Orientation elements may be in the form of propellers, wings, petals, arms, loops, and the like. One or more of these elements may be present, typically extending radially from a central shaft. When two elements are present, they are commonly placed 120 to 180 degrees apart around the central shaft; more than two elements are typically arranged in a radial pattern around the central shaft. In the preferred embodiments, the orientation elements are typically placed either perpendicular to the line of coaptation or following the line of coaptation. This may provide the most useful reference, however many other placement orientations may be used. 
     Examples of orientation elements placed perpendicular to the line of coaptation are depicted in  FIGS. 16 and 17 .  FIG. 16  is a short axis view of the mitral valve MV with an orientation element  612  shown having a pair of orientation structures  613  arranged 180 degrees apart around a central shaft  614 . The orientation element  612  is shown perpendicular to the line of coaptation C. Such positioning of the element  612  may indicate that the device is in its desired orientation, specific components are in a desired orientation, or devices or components may be oriented in relation to the positioned element which may be more visible than other parts of the device. 
       FIG. 17  is a long axis view of the mitral valve MV. Here, a guidewire  615  with a pair of orientation propellers  616  is shown inserted through the mitral valve MV via a retrograde approach. Visualization of the propellers  616  may allow repositioning of the guidewire  615  until the propellers are perpendicular to the line of coaptation C. At this point, a guide catheter, interventional or other tool may be tracked over the catheter in the desired orientation. Such tracking may be facilitated with the use of a keyed, notched, oval or similar lumen for guidance. Similarly, such orientation propellers  616  may be mounted on a guide catheter with a keyed lumen for guided insertion of interventional tools. 
     Examples of orientation elements placed along the line of coaptation are depicted in  FIGS. 18 and 19 .  FIG. 18  is a long axis view of an orientation element  620  inserted into the valve opening along the line of coaptation C. An end view shown in  FIG. 19  illustrates the penetration of the element  620  through the valve opening and the valve leaflets LF sealing against the element  620 . In addition, portions of the orientation element  620  may contact the commissures CM at each end of the valve opening for support and/or for reference. Using the position of the orientation element  620  as a reference, the location of a variety of cardiac structures, particularly the valve leaflets LF, are known. In addition, if the position of specific components of the device are known in relation to the orientation elements  620 , such relation may be used to infer the relation of those components to the cardiac structures. For example, if the orientation elements are known to be perpendicular to the graspers, positioning of the orientation elements in the manner described above would ensure that the graspers would be aligned perpendicular to the line of coaptation C or in a desirable location to grasp the valve leaflets LF. 
     In this example, the orientation element  620  is shown as an inflatable bladder coaxially attached to a distal central shaft  621 . Such a bladder may be comprised of a compliant or noncompliant material, such as PET, PUR, Silicone, Chronoprene, or the like. The bladder material itself may be echo or fluorogenic, or it may be filled with an echo or fluorogenic liquid or suitable medium, such as carbon dioxide or agitated saline. In its inflated state, it is preferred that the bladder is wide or thick enough to so that the endview of the bladder is visible in a short axis view of the mitral valve, as shown in  FIG. 19 , and that the bladder is long or high enough so that the anterior and posterior leaflets may seal against the bladder in systole. 
     In addition, as shown in  FIG. 20 , the bladder  625  may be supported by a frame  626 . The frame  626  may be comprised of any suitable material, such as nitinol, stainless steel, plastic or any combination thereof, of any consistent or variable flexibility, and any cross-sectional shape, such as round wire, hollow tube or flat ribbon. This material may be echo or fluorogenic or treated for such effects. In addition, the shape of the frame  626  may be of any suitable symmetrical or nonsymmetrical geometry, including but not limited to triangular, rectangular, circular, oblong, and single or multi-humped. A rectangular geometry is depicted in  FIG. 20 . In addition, the frame  626  may be expandable as shown in  FIGS. 21A-C . In the collapsed state,  FIG. 21A , the bladder  625  and enclosed frame  626  may be inserted through a lumen in a guide catheter or interventional tool. When appropriately positioned, the frame  626  may be gradually expanded,  FIG. 21B , to a desired geometry,  FIG. 21C . It may be appreciated that the orientation element may function without inflation of the bladder  625  or with just the frame  625  and no bladder. 
     Fourth, orientation may be assessed by visualization of flow patterns resulting from system or component position with respect to cardiac structures. As mentioned, the heart may be slowly beating throughout the tissue modification procedure. As the heart beats, blood may be flowing from the left atrium, through the mitral valve, to the left ventricle. Visualization of these flow patterns using Color Doppler Echocardiography may allow inferences as to how systems or components are positioned. For example, as shown in  FIG. 22A , if a thin planar structure  650  is inserted in the valve opening with its long axis perpendicular to the line of coaptation C, a higher level of regurgitation may result due to blood flow through the unsealed portions  651 . If the structure  650  is inserted with its long axis along the line of coaptation C, as shown in  FIG. 22B , a lower level of regurgitation may result due to more adequate sealing of the valve leaflets LF against the structure  650 . Thus, such a structure  650  or similarly designed device may be used as an orientation element. 
     VI. Stabilization 
     Before a valve or tissue modification or intervention is performed, it will usually be desirable to temporarily stabilize the interventional tool in relation to the a cardiac structure. By “stabilization” it is meant that the interventional tool will be somehow coupled to a cardiac structure so that any existing relative motion between the tool and the structure is lessened. Cardiac structures which may be utilized for coupling include the atrial walls, interatrial septum, valve annulus, valve leaflets, valve commissures, valve chordae, papillary muscles and ventricle walls, to name a few. Such stabilization is performed in order to facilitate a subsequent intervention. For example, an access catheter may be mechanically coupled to the valve or tissue surrounding the valve, such as the annulus or the chordae, and the interventional tool deployed from the catheter to perform a desired intervention, such as suturing, stapling, snaring, annuloplasty, RF tissue modification, or the like. The stabilization will usually be terminated after the particular valve modification is completed, but in some instances the stabilization could be terminated and redeployed multiple times at various points throughout the procedure. 
     The stabilization mechanisms may be separate from or integral with any part of the system or device. They may be removably or fixedly mounted on the guidewire, guide catheter, interventional tool and/or other device. Likewise, the elements may be components or parts of components of the device which provide one or more additional functions in the tissue modification procedure, such as steering, orientation assessment, grasping, coaptation, adjustment or fixation. Further the mechanisms may be atrial, ventricular or atrial-ventricular devices such that they may or may not cross the valve in the stabilization process. In particular, such mechanisms may be used to steer and/or orient the components and systems prior to or simultaneous with stabilization. 
     In the preferred embodiments, three general categories of stabilization mechanisms may be formed for descriptive purposes: 1) stabilization against the atrial septum, atrial walls or ventricle walls, 2) stabilization against the valve, and 3) stabilization against the chordae or papillary muscles. Stabilization against the atrial septum may be useful when approaching antegrade with atrial or atrial-ventricular devices. As previously described, an antegrade approach involves crossing from the right atrium RA to the left atrium LA by penetrating the interatrial septum IAS. This may be accomplished with a needle bearing catheter, which may then be exchanged for an introducer, guide catheter or similar catheter. Interventional tools may be introduced through this catheter for tissue modification treatment. To prevent movement of the catheter in an axial direction, a stabilization mechanism may be used to engage and lock the catheter to the interatrial septum. A preferred embodiment is shown in  FIG. 23 , which depicts a catheter shaft  660  having a distal balloon  661  and a proximal balloon  662  inflated on opposite sides of the interarterial septum IAS. Inflation of the balloons  661 ,  662  against the septum couples the shaft  660  to the septum and stabilizes the system. It may be appreciated that a number of components, such as disks, cages, balls, mesh, or other structures, may be used in place of one or more of the balloons to achieve a similar result. 
     Stabilization against the atrial septum may also be achieved by forming an introducer or guide catheter which is rigid through the interatrial septum and left atrium. Typically, such introducers or guide catheters are flexible along their length to facilitate introduction through the tortuous paths of the vascular system. In an antegrade approach as described, the catheter may be inserted through the interatrial septum with its distal end suspended in the left atrium. In the case of a flexible catheter, movements at the septum may not be translated linearly to the catheter tip. Therefore, there may be relative movement between the distal end and the portion passing through the septum. This may be reduced by coupling the distal end to the portion passing through the septum. In a preferred embodiment, the catheter shaft between and including the distal end and the portion passing through the septum may be made rigid. Referring to  FIG. 24 , the catheter shaft  670  may be comprised of stacked elements  671 . The elements  671  may be domed disks or collar segments with domed ends which are mechanically coupled by a structure  672 . The structure  672  may connect the centers of the elements  671 , as shown, in a flexible manner so that the shaft  670  may be shaped in any desired geometry suitable for use in the tissue modification treatment. Once a desired shape is formed, the structure  672  may be rigidified to hold the shape. Such rigidity may allow any movement of the interatrial septum to be translated to the distal end of the catheter shaft, thus coupling the catheter to the movements of the heart. This may improve stabilization of the devices and systems used in the tissue modification treatment. It may be appreciated that a variably rigid shaft as described may be utilized for coupling to any cardiac feature and may be used with or as part of any device component or device in the procedure. Thus, the feature may be utilized to lock any device component, catheter or tool into place once it has been manipulated into a desired shape. This may be useful in a variety of situations in addition to those mentioned above. 
     Stabilization against the valve may be most useful when approaching antegrade with atrial or atrial-ventricular devices, however it may also be useful when approaching retrograde with ventricular or atrial-ventricular devices. When approaching antegrade, stabilization may be most easily achieved by coupling one or more components of the device to the atrial walls, valve annulus, valve leaflets, and/or valve commissures. 
     Coupling to the atrial walls may be accomplished by a number of stabilization mechanisms. In each embodiment, structures such as wires, ribbons, mesh, cages or balloons extend outwardly from the device, contacting and applying radial force to the atrial walls. Such contact may couple the movements of the atrium with the device for stabilization. A preferred embodiment is shown in  FIG. 25 . Here, flexible wires  680  bend out radially from the catheter shaft  681  with curved portions contacting the atrial walls AW. It may be appreciated that any number of wire patterns or means of extending from the shaft may be utilized, as mentioned above. 
     Coupling to the valve annulus may also be accomplished by a number of stabilization mechanisms, many of which include simultaneous coupling to other valve features, such as the leaflets and/or commissures. In preferred embodiments, such stabilization mechanisms may be comprised of loops, rings, wings, petals, arms, and the like. Coupling can be enhanced by varying surface friction and/or combining structures with vacuum. One or more of these mechanisms may be present, typically extending radially from a central shaft. When two elements are present, they are commonly placed 90 to 180 degrees, preferably 120 to 180 degrees, apart around the central shaft. More than two elements are typically arranged in a radial pattern around the central shaft. Structure, size, angle and arrangement may be adjustable to fit individual patient anatomy. 
     Examples of such embodiments are shown in  FIGS. 26-29 . Referring to  FIG. 26 , a guide catheter  14  may have deployable adjustment wires  20  to serve as a stabilization mechanism. The wires  20  are typically attached at one end to the distal tip of the guide catheter  14  and may be advanced at their other ends so that they selectively deploy from the guide catheter to engage the mitral valve MV. The adjustment wires  20  may act to stabilize or anchor the guide catheter relative to the mitral valve MV by coupling to the valve annulus, leaflets or commissures. 
     Similarly, the guide catheter  14  may have any number of stabilization elements, as illustrated in  FIGS. 27-29 . As shown in  FIG. 27 , the stabilization elements may be comprised of a number of petals  22  arranged around the distal tip of the catheter  14 . Similarly, the stabilization element may be a single large loop  25 , as depicted in  FIG. 28 . Alternatively, the interventional catheter  30  may have a plurality of stabilizing arms  34  ( FIG. 29 ) which both position and anchor the distal tip of the interventional catheter  30  relative to the valve annulus. Usually, at least three stabilizing arms will be utilized, with four being illustrated, however any number may be used. The stabilizing arms  34  may be pre-shaped, resilient metal rods (for example, formed from nitinol or other shape memory or superelastic alloy), ribbons, tubes, polymers or composites thereof that may be selectively extended from the tip of the interventional catheter  30  to engage the valve annulus. The interventional catheter  30  of  FIG. 29  is shown with a separately extendable interventional tool  36  which performs the desired valve or tissue modification, as described in more detail below. Such stabilization elements may preferably engage the annulus located about the mitral valve MV and apply forward pressure against the annulus to maintain contact and provide axial stabilization. 
     Stabilization may also be achieved by applying radial pressure to the commissures. As shown in  FIG. 30 , a pair of stabilization elements  32  may extend radially from a guide catheter  14  or interventional tool  30  to contact the commissures. The distance between the elements  32  may be equal to or slightly greater than the distance between the commissures to apply radial force against the commissures. The stabilization elements  32  may be comprised of any suitable material, such as nitinol, stainless steel, plastic or any combination thereof, of any consistent or variable flexibility, and any cross-sectional shape, such as round wire, flat ribbon or hollow tube. As shown in  FIGS. 31A-31D , the shape of the stabilization element may be of any suitable symmetrical or nonsymmetrical geometry, including but limited to triangular ( FIG. 31A ), rectangular ( FIG. 31B ), circular, oblong, double-humped ( FIG. 31C ) or single-humped ( FIG. 31D ). It may be appreciated that such stabilization mechanisms may also serve in orientation assessment, particularly as the frame  626  ( FIG. 20 ) previously described. Thus, they may be echo or fluorogenic or treated for such effects. In addition, it may be appreciated that such stabilization elements may be passive, i.e., pre-sized and shaped to fit the patient anatomy so that they engage the valve annulus without adjustment, or may be active so that they can be used to steer the guide catheter as previously described. 
     A number of stabilization mechanisms apply both radial and axial pressure to the valve for stabilization. For example, the double-humped element, shown in  FIG. 31C , has a superior hump  700  which may protrude into the left atrium, contacting the superior aspect of the annulus and possibly the left atrial wall, and an inferior hump  701  which may protrude into the left ventricle, contacting the inferior aspect of the annulus and possibly the left ventricle wall or chordal tissue. The superior hump  700  may apply a downward axial force on the annulus and the inferior hump  701  may apply an upward axial force. The waist  702  between the humps may be dimensioned or adjustably sized to fit between the commissures and to apply a radial force on the commissures. Similarly, a single-humped element, shown in  FIG. 31D , may provide similar stabilization without the added support from the protruding inferior hump. Additionally, this design may be easier to position in the mitral valve. 
     The last general category of stabilization mechanisms for descriptive purposes is stabilization against the chordae. Stabilization against the chordae may be most useful when approaching retrograde with ventricular or atrial-ventricular devices. Coupling to the chordae may be useful in stabilization for tissue modification to the valve, the chordae, the annulus or a combination of these. When modifying the valve, the contact with the valve structures (typically grasping of the valve leaflets) may still be necessary. However, when modifying the chordae, additional contact (such as grasping the chordae) may not be necessary since the stabilization methods may include this step. Therefore, stabilization against the chordae will be discussed in Section VIII Grasping. 
     VII. Immobilization 
     Immobilization refers to substantially retarding or diminishing the motion of the cardiac structures or intermittently or temporarily stopping the cardiac cycle. This may be accomplished with a variety of methodologies. First, drugs may be injected to temporarily slow or stop the cardiac cycle. Such drugs may include but are not limited to esmolol, adenosine, isofluorane and transarrest mixture, with or without electrical pacing. Likewise, induced atrial fibrillation may interrupt the cardiac cycle. 
     Mechanical immobilization of the valve can be effected in a variety of ways. Most simply, valve action can be diminished or stopped by raising the pressure in the associated ventricle to a pressure above that in the atrium during diastole. For example, a suitable liquid can be infused into the ventricle to raise the intraventricular pressure, or the aortic valve could be temporarily incapacitated allowing aortic regurgitation and raising the ventricular diastolic pressure. Alternatively, interventional tools and/or catheters carrying such tools may simply be mechanically stabilized against the valve, valve annulus, valve commissures, ventricular wall, atrial wall, generally as described above. 
     Mechanical valve immobilization will usually involve more interaction with the valve than simple stabilization. Immobilization will usually involve either capture and immobilization of either or both valve leaflets (or all three valve leaflets in the case of a tricuspid valve) or capture and immobilization of the chordae. For example, balloons or mesh cages may be used and placed under one or both leaflets to hold them partially closed. By temporarily immobilizing or adjusting the valve action, such as changing the point of coaptation, it is possible to see if a particular modification will be sufficient to treat the regurgitation. For example, by temporarily grasping the valve leaflets at a particular point and holding the leaflets together, it can be determined whether a permanent suturing, stapling, or other affixation at that point will achieve a sufficient reduction in regurgitation. When the heart is beating, valve regurgitation can be examined in real time via conventional imaging techniques, such as TEE. If the temporary valve modification appears sufficient, it can then be made permanent using any one of a variety of interventional techniques. 
     VII. Grasping 
     Valve or tissue modifications or interventions most commonly require grasping a portion of the valve or tissue to be modified. Such grasping may be useful in adjusting tissues (such as coapting valve leaflets) for appropriate modification, checking the positioning of the tissues for improved biological function, and stabilizing or immobilizing the tissue for the modification procedure. As previously described, such grasping may also be useful to stabilize another tissue which will be modified in the procedure, such as the grasping the chordae to stabilize the valve for valve modification. Since the most common procedures may involve valve modification or chordal modification, grasping of these cardiac structures will be discussed. However, it may be appreciated that described grasping devices, systems and methods may apply to any cardiac or other structure. 
     A. Chordal Grasping 
     Grasping of the chordae may involve capturing and anchoring the chordae, as illustrated in  FIGS. 32-40 . As shown in particular in  FIGS. 32A and 32B , a guide catheter  40  can deploy a first capture coil  60  and a second capture coil  62  through a pair of deployment catheters  64  and  66 , respectively. The coils will be positioned while visualizing so that the first coil  60  captures chordae attached to a first valve leaflet LF and coil  62  captures chordae attached to a second valve leaflet LF. The capture coils will typically be elastic wires, preferably composed of a superelastic material such as nitinol, which are delivered through the deployment catheters in a straightened configuration. When they are advanced out of the deployment catheters, the capture coils will assume a helical or other configuration that can be advanced into and entangle the chordae. 
     The coils  60  and  62  may then be brought together laterally preferably coapt the leaflets LF together by advancing a retaining ring  68  which is secured at the distal end of a deployment wire  70 , as illustrated in  FIG. 32B . The leaflets are thus brought together and immobilized for a subsequent intervention. Alternatively, if immobilization via the coils  60  and  62  is sufficient in itself, it will be possible to make the deployment permanent. It is a particular advantage of the temporary immobilization that the valve action can be examined via the real time imaging techniques to see if regurgitation has been adequately addressed. If it hasn&#39;t, the coils can be redeployed or the relative positions of the two coils  60  and  62  can be changed until an adequate pair has been effected. 
     It will be appreciated that if a subsequent interventional step is required, it can be made from either an antegrade or retrograde approach. A variety of specific interventional techniques are described in detail hereinbelow. 
     An antegrade approach for deploying a single chordae snare  74  and optionally securing a suture loop about the captured chordae is illustrated in  FIGS. 33A and 33B . A guide catheter  14  deployed over the leaflets LF of the mitral valve MV may be deployed as described previously. A pair of deployment catheters  76  and  78  are advanced from the distal end of the guide catheter  14  and observed in real time via any of the imaging techniques described previously. The pre-shaped snare  74  is advanced out of the first deployment catheter  76  and is advanced through both of the chordae CT, as illustrated in  FIG. 33A . A capture loop  80  is advanced from the second deployment catheter  78  and positioned so that it lies in the path of the pre-shaped snare  74  as it is advanced through the chordae CT. After a capture tip  82  passes through the capture loop  80 , the loop can be tightened to secure to the capture tip  82  and draw the tip into the second deployment catheter  78 . The capture tip  82  is attached to an end of a length of suture  84  ( FIG. 33B ) which runs back through a lumen in the snare  74 . In this way, the suture may be pulled into the second deployment catheter  78 , while the snare  74  is withdrawn back into the first deployment catheter  76 , leaving only the suture in place grasping both the chordae. By then tying or otherwise securing the suture together into a permanent loop through the chordae, the coaptation of the valve leaflets LF can be modified in a desired way. As with the previous embodiments, a particular advantage of this approach is that the valve coaptation can first be viewed using the real time imaging capability to assure that valve regurgitation is adequately addressed before making the chordae capture permanent. 
     An alternative technique for deploying suture to capture chordae CT is illustrated in  FIG. 34 . First deployment catheter  90  (positioned through a guide catheter which is not shown) is positioned through the opening between valve leaflets LF. A balloon  93  at the distal end of chordae snare  92  is extended through the chordae, as described previously. The balloon  93  is inflated and floated through the mitral valve during regurgitation. The balloon will pass through the previously deployed capture snare  95 . Alternatively, the chordae snare  92  could be shaped so that it will encircle the chordae and then pass outwardly through the valve opening and into the previously deployed capture snare  95 . 
     A chordae stabilization catheter  100  which is particularly suited for a retrograde approach is illustrated in  FIG. 35 . The catheter  100  includes a catheter body  102  having a pair of lumens  104  and  106  extending from a proximal end (not shown) to a distal end which is illustrated in  FIG. 35A . The main lumen  104  extends fully to the distal tip of the catheter body  102  and a chordal snare  108  is slidably received in the lumen. The snare  108  has a loop pre-formed over its distal end so that, when extended from the catheter  100 , it will assume the shape shown in  FIG. 35 . The loop has a diameter generally in the range from 3 mm to 20 mm and is shaped so that it will evert backwardly into a secondary loop formed by a capture snare  112 . The capture snare  112  is disposed in the secondary lumen  106  and emerges from an opening  114  space proximally from the distal end of the catheter  100 . The distal tip of the capture snare  112  is fixed at an anchor point  116  in the distal tip of the catheter body  102 . Thus, by extending and retracting the capture snare  112 , the capture loop can be moved between the position shown in full line and broken line. 
     Referring now to  FIGS. 36A and 36B , use of the catheter  100  for capturing and stabilizing chordae CT will be described. The catheter  100  is introduced in a retrograde direction (although antegrade would also be possible), typically through a guide catheter  40  as generally described above. Under direct (e.g., fluoroscopic) observation, the distal end of the catheter  100  will be guided to a position generally within the chordae CT, as illustrated in  FIG. 36A . The chordae snare  108  will then be extended from the distal tip so that it passes through and becomes entangled with the chordae CT attached to both of the leaflets LF. The distal tip of the chordal snare  108  will eventually pass through the loop defined by the capture snare  112 , also as illustrated in  FIG. 36A . The capture snare will then be tightened to hold the distal tip of the chordae snare  108 , and the chordae snare then retracted so that the loop of the snare which passes through the chordae will be tightened, generally as shown in  FIG. 36B . Generally, the catheter  100  will not be intended for permanently affixing the chordae CT. Instead, immobilization of the valve leaflets LF will be intended to facilitate a subsequent treatment step, as described hereinafter. Use of the retrograde approach for immobilizing the chordae CT will be particularly advantageous when used with antegrade interventions. 
     The catheter of  FIG. 35  could, however, be modified to facilitate performance of retrograde interventions while the chordae are stabilized. As shown in  FIG. 37 , the catheter  120  includes a catheter body  122  which is generally the same as that shown for catheter  100  in  FIG. 35  (with common components being given identical reference numbers), except that a third working lumen  124  is provided. The working lumen  124  can be used to deliver and position a wide variety of interventional tools for performing at least most of the specific interventions described elsewhere in this application. The catheter  120  will, of course, be particularly useful for performing interventions which rely on retrograde stabilization of the chordae CT of the type provided by the catheter. For example, the lumen  124  may be used to position an RF energy delivery tool for heating the chordae to cause shrinkage, as described in more detail below. Alternatively, the working lumen  124  could be used to position a chordae stabilization coil  130 , generally as described in  FIGS. 39A and 39B . The coil is typically a helical filament having a secondary helical structure comprising, for example, three major loops. The coil may comprise an inner element composed of a shape memory material, such as nitinol, inserted into an outer coil  132  made of a radiopaque material, such as a platinum alloy. The shape memory coil  134  is formed into a “stacked coil” configuration (with no space between adjacent windings of the coil) and then programmed so that it will assume the stacked coil configuration at a temperature slightly above body temperature. The coil assembly  130  is formed by heat treating the platinum  132  to a diameter D 1  and length L 1 , as shown in  FIG. 39A . The shape memory coil  134  is then stretched to a near linear configuration and inserted into the platinum coil  132 , and the two are coupled at the end. Upon heating, the shape memory coil contracts back into its tightly stacked coil shape, compressing the platinum coil  132 , and causing the entire assembly  130  to assume a smaller diameter D 2  and length L 2 , as shown in  FIG. 39B . The coil  130  may be delivered using a pusher catheter through the working lumen  124  so that it deploys within and entangles the chordae CT, as shown in  FIG. 40 . The pusher catheter (not shown) could be configured similarly to embolic coil delivery catheters, such as those described in U.S. Pat. Nos. 5,226,911; 5,234,437; 5,250,071; 5,261,916; 5,312,415; 5,350,397; and 5,690,671, the full disclosures of which are incorporated herein by reference. 
     B. Valve Leaflet Grasping 
     Valve leaflet grasping may be accomplished using a number of methods, most commonly the following three: 1) pinching, 2) partially or fully penetrating or piercing, and 3) the use of suction or vacuum. Pinching involves grasping the surface or edge of the leaflet without penetrating the tissue. This may be accomplished by an antegrade or retrograde approach using atrial, ventricular or atrial-ventricular devices. It may be appreciated that although the following embodiments are examples which are described relative to a specific approach (antegrade or retrograde), each device or component may be used or adapted to be used in all approaches. 
     In preferred embodiments, depicted in  FIGS. 41-43 , pinching of the valve leaflets LF can be achieved, for example, by using a grasping catheter introduced in a retrograde direction to temporarily capture the free ends of the valve leaflets LF. It may be possible to use a simple two-jaw tool at the distal end of a catheter to capture both opposed leaflets. Such a two-jaw tool  710  is depicted in its open position in  FIG. 41A . In this position, opposing jaws  711  may be positioned on opposite sides of the free ends of the valve leaflets LF. In its closed position, depicted in  FIG. 41B , the leaflets may be drawn together and pinched to immobilize the valve. Although this may be adequate, it may be preferred to use a three-jaw capture tool as shown in  FIGS. 42-43 . The catheter  140  can be delivered through a guide catheter generally as described above. The catheter includes a tool  142  at its distal end. Tool  142 , as best shown in  FIG. 42B , includes a fixed center jaw  144  and a pair of pivotable outer jaws  146  and  148 . The jaws  146  and  148  may be independently opened to a “capture” position as shown in broken line in  FIG. 42B . Actuation of the jaws  146  and  148  may be achieved in a variety of conventional manners, including pull wires, push wires, inflatable balloons, heat memory alloy motors, and the like. By independently opening and closing the capture jaws  146  and  148  against the fixed jaw  144 , the valve leaflets LF can be captured independently. 
     As shown in  FIG. 42A , a first leaflet LF can first be captured. The catheter  140  can then be manipulated and positioned, typically under real time imaging, to capture the second leaflet LF, as shown in  FIG. 43 . It will be appreciated that independent capture of the leaflets greatly facilitates the procedure. Use of a single pair of capture jaws requires that the leaflets be captured at the instant when they are properly opposed. In the case of prolapsed valves, such an instance may never occur. Once captured and immobilized, as shown in  FIG. 43 , the valve leaflets can then be modified in any one of a variety of ways, as described elsewhere in the application. 
     Additional embodiments, depicted in  FIGS. 44-46 , involve pinching of the valve leaflets LF by using a grasping catheter introduced in an antegrade direction to temporarily capture the surfaces or the free ends of the valve leaflets LF. Referring to  FIGS. 44A-44D , the valve leaflets LF may be pinched between a superior loop  720  and an inferior loop  721 . In a preferred embodiment, the grasper is comprised of a nitinol flat ribbon heat set in the shape of double loops  720 ,  721 . The ribbon may be mounted on a series of three coaxial shafts, an interior shaft  725 , a central shaft  726  and an exterior shaft  727 . The distal end of the ribbon may be attached to the distal end  730  of the interior shaft  725 , a midportion of the ribbon may be attached to the distal end  731  of the central shaft  726 , and the proximal end of the ribbon may be attached to the distal end  732  of the exterior shaft  727 . One or more ribbons may be mounted on the coaxial shafts; in this example, two ribbons are shown 180 degrees apart. When extended, as shown in  FIG. 44A , the grasper may be pulled flat against the shafts  725 ,  726 ,  727  for ease of insertion through a guide catheter or tool and into a desired position between the valve leaflets LF. When the central shaft  726  is retracted or the exterior shaft  727  advanced, as shown in  FIG. 44B , the superior loops  720  may extend radially from the shafts. The superior loops  720  may rest on the superior surface of the valve leaflets LF in the atrium, as shown in  FIG. 44D . In this position, the superior loops  720  may aid in orientation assessment, as the superior loops may be echo or fluorogenic and may be easily visible in relation to the cardiac structures or other devices or components. When positioned in a desired location, the interior shaft  725  may then be retracted, as shown in  FIG. 44C , to extend the inferior loops  721  radially from the shafts. The inferior loops  721  may be in contact with the inferior surface of the valve leaflets LF in the ventricle. Thus, the valve leaflets LF may be pinched between the inferior loop  721  and superior loop  720 . It may also be appreciated that the inferior loops  721  may be deployed prior to the superior loops  720 . 
     Referring to  FIGS. 45A-45B , the valve leaflets LF may be pinched between a superior roller  750  and an inferior roller  751 . As shown in  FIG. 45A , the rollers  750 ,  751  may be mounted on a shaft  755  and connected by a pull actuation wire  756 . The rollers  750 ,  751  may be serrated or surface treated in a directional pattern to facilitate grasping of the valve leaflets LF. To grasp a leaflet LF, the rollers  750 ,  751  may be placed against the surface or free edge of the leaflet LF. Pulling of the actuation wire  756  may rotate the superior roller  750  and inferior roller  751  toward each other. This may draw the leaflet LF between the rollers  750 ,  751 , as shown in  FIG. 45B . Thus, the leaflets LF may be individually grasped for treatment. 
     Referring to  FIGS. 46A-46B , the valve leaflets LF may be pinched between a pair of flat coils  770 . In a preferred embodiment, each coil  770  may be comprised of nitinol flat ribbon heat set in the shape of a coil. As shown in  FIG. 46A , the coils  770  may be linked together with opposing curvature by a clip  772 . Movement of the clip  772  along the coils  770  may uncurl the coils  770  to a straightened configuration. As shown in  FIG. 46B , this may also be accomplished by a catheter shaft  773  placed over the coils  770 . In the straightened position, the coils  770  may be inserted between the valve leaflets LF in an atrial-ventricular position so that the distal ends  775  of the coils  770  are in the ventricle. As the shaft  773  or clip  772  is retracted, the coils  770  may begin curling radially beneath the valve leaflets LF and upwardly so that the distal ends  775  of the coils  770  contact the inferior surface of the valve leaflets LF. Similarly, if the coils  770  continue curling, a portion of the flat ribbon proximal to the distal end  775  may contact the valve leaflet. In this manner, the leaflets may be grasped for treatment. Such a grasping device may also serve as a fixation device with the pair of coils  770  left in place, as will be described in a later portion of the application. 
     A valve or tissue structure may also be grasped by atraumatic partial or full penetration or piercing. This may be accomplished with a variety of grasping mechanisms. Preferred embodiments include one or more prongs extending from an interventional tool in an arrangement to grasp a specific structure. Specifically, three opposing prongs may extend from a grasping sheath with distal ends configured to pinch, partially penetrate or pierce. Such ends may be pointed or may be soft, as in the case of rounded, urethane coated or solder coated ends. Referring to  FIG. 47A , the opposing prongs  800  may be retracted into a grasping sheath  801  to hold the prongs  800  in a closed configuration. It may be preferred to orient the device to a desired position in this configuration. When the target tissue has been located, the prongs  800  may be extended to grasp the tissue structure, as shown in  FIG. 47B . This may be accomplished by either extending the prongs  800  axially or retracting the grasping sheath  801 . The target tissue may be pinched, partially penetrated or pierced with the prongs  800  in this configuration, or such action may be facilitated by closing or partially closing the prongs  800  as previously depicted in  FIG. 47A . Alternatively, the prongs  800  may be attached to or integral with a prong-tipped tube  802 , as shown in  FIG. 47C . Such a design may be more conducive to the insertion of tools or fixation devices for further treatment steps, such as tissue modification. Tools or devices may be inserted through a lumen in the prong-tipped tube  802 , depicted by arrows  804 , for use at or near the grasping location. Similarly, tools or fixation devices may be inserted through a lumen in a hollow prong  806 , as depicted in  FIG. 47D . Here, one or more prongs  806  may be hollow, and the remaining prongs  808  may be comprised of solid wire or a suitable material. Tools or devices may be inserted through a lumen in the hollow prong  806 , depicted by arrows  810 , for use at or near the grasping location. Prongs, hollow or solid, may be made from stainless steel, NiTi, plastic or other suitable material. Additionally, they may be coated or coiled to enhance visibility. Likewise, the geometries of the prongs may be varied to facilitate grasping of the desired amount of tissue. And, the distal tip sharpness and surface finish can be varied to establish the amount, if any, of piercing. 
     In addition to directly engaging the valve leaflets to effect stabilization and/or immobilization with the grasper devices described above, the devices and methods may also employ a catheter or other tool having vacuum or suction applicators to temporarily capture the valve leaflets. As shown in  FIG. 48 , a catheter  812  comprises a shaft having a pair of vacuum applicator rods  813  and  814 . Usually, the vacuum applicator rods  813  and  814  will comprise separate shafts which may be axially translated relative to the main shaft of the catheter. Further optionally, the shafts could be articulated or otherwise manipulable so that they can be independently positioned relative to the valve leaflets or other tissue structures once the catheter  812  is in place. The vacuum applicators have one or more apertures to permit contact and adherence to tissue when the applicators are attached to external vacuum sources. Usually, the shaft will be placed across the valve, either in an antegrade or retrograde fashion, and the applicators positioned to grasp and manipulate the valve leaflets. Optionally, the catheter  812  may comprise additional stabilizing and/or steering wires of the type previously described. For example, a steering wire  815  (and optionally a second steering wire on the opposite side) may be provided for engaging against the valve commissures to permit positioning of the catheter with respect to the valve leaflets. The vacuum applicators would further be independently positionable to engage the valves in the desired fashion. Using this catheter, the leaflets can be grasped and the competency of the valve evaluated using the methods described previously. The valve adjustment can then be effected using any of the interventional approaches described herein. Further, it may be appreciated that in each embodiment, timing of grasping may be facilitated by the use of gating with the patient&#39;s EKG, pressure waves of the cardiac cycle, audio heart sounds, electronic pressure or contact sensors on the graspers. 
     VIII. Coaptation, Adjustment and Evaluation 
     Once the valve leaflets, chordae or tissue structure is grasped by an interventional tool, the tissue may be manipulated to achieve a desired result, such as improvement in valve function. Such manipulation may occur during the grasping step, or it may require a separate step following grasping. In the case of leaflet modification, valve leaflets may be coapted or brought together and held in a preferred apposition. The valve function may then be evaluated for indications of improved valve function, such as reduced regurgitation. If further improvement is desired, the valve leaflets may be additionally manipulated or adjusted. Adjustment should primarily occur in a superior/inferior (up/down) motion in order to bring the leaflets to a final positioning where regurgitation is minimized. During adjustment, one or both leaflets may be released and recaptured with new positioning. After the final evaluation, the valve leaflets may be fixated in the desired position by an appropriate fixation device. In the case of chordae shortening or other tissue modification, similar steps may be taken. 
     IX. Tissue Modifications 
     Repair of atrioventricular or other cardiac valves is effected by modifying the valve or a supporting tissue structure in some way to affect blood flow through the valve during a phase of the cardiac cycle, for example to permit blood flow through the valve during diastole when the associated ventricle is filling with blood but which inhibits or prevents blood regurgitation back through the valve during systole. A number of techniques for modifying the valve closure by capturing or grasping the chordae attached to each valve leaflet have been described above. These techniques are often used just for valve grasping and/or coaptation and adjustment prior to a separate valve modification step, but they may also be made permanent to provide the final valve modification. Other techniques for more directly modifying the leaflets or other supporting structures of the atrioventricular valves will be described in this section. These techniques may be utilized either with or without the valve grasping and/or coaptation and adjustment techniques described above. For purposes of simplicity, however, the following methods will generally be described without specifically illustrating such grasping, coapting and adjustment approaches, focusing primarily on the methods and devices involved with fixation. In addition, it may be appreciated that although the following embodiments are examples which are described relative to a specific approach (antegrade or retrograde), each device or component may be used or adapted to be used in all approaches. Further, although devices and methods are described for fixating specific tissues, such as valve leaflets or chordae, such devices and methods may be used for any cardiovascular tissues and the like. 
     A. Fixation of Valve Leaflets 
     Suture can be delivered through the valve leaflets and then tied in a manner analogous to an open surgical procedure. In one embodiment, a suturing tool  200 , shown in  FIG. 49 , may be positioned at the distal end of an interventional catheter. The interventional catheter will usually be advanced in an antegrade direction (i.e., from above the mitral valve), either directly through a guiding catheter or through a working lumen in a stabilization catheter. The tool  200  carries a length of suture  202  attached to a pair of needles  204  at either end thereof. The suture may be comprised of conventional suture material or of wire, typically stainless steel, nitinol or other material. The needles are held on a reciprocating shaft  206  disposed within a lumen of a retrieval sheath  208 . The tool  200  can be positioned to capture the opposed free ends of the mitral valve leaflets LF, generally as shown in  FIG. 49 . The needles can then be advanced through the leaflets LF by drawing the shaft  206  toward the sheath  208  so that the needles  204  penetrate the leaflet and are captured in needle receptacles  210  formed in the sheath  208 . The sheath can then be withdrawn. A knot can be tied in the suture, and the knot then advanced through the associated catheter to tighten over the valve leaflets. The tool  200  can carry two, three, four, or even more lengths of suture which may be simultaneously or sequentially introduced into the valve leaflets in order to permit multiple suture loops to be placed. The resulting tied suture loops will be similar to the “bow tie” sutures placed in open surgical procedures which have been described in the medical literature as described above. 
     The need to place and draw long lengths of suture through the valve leaflets can, however, be deleterious to the fragile leaflet structures. Thus, alternative needle and suture devices which rely on mechanical fasteners in relatively short suture lengths may be preferred. In one embodiment, a hollow suturing coil  1300 , shown in  FIG. 49A , may be positioned at or near the distal end of an interventional catheter. The suturing coil  1300  may be comprised of any material of sufficient rigidity to pierce and penetrate through valve leaflets LF, such as stainless steel, various shape memory or superelastic materials, metal alloys and various polymers, to name a few. The hollow suturing coil  1300  may contain a suture  1302  comprised of conventional suture material or of wire, typically stainless steel, nitinol or other material. The suture  1302  may be secured at the tip  1304  of the coil  1300  with a toggle rod  1305 . After the valve leaflets LF have been grasped and coapted, the suturing coil  1300  may be advanced in a corkscrew fashion through the valve leaflets LF, as shown in  FIG. 49A . Though such advancement is shown from above, advancement may be made from any direction through any number and configuration of valve leaflet layers. When advancing, the sharpened tip  1304  of the coil  1300  may pierce through the leaflets LF any number of times. It may be appreciated that such corkscrew piercing may be made through the middle portions of the leaflets such that a pierce is made at each half-rotation, or the piercings may be made along the edges of the leaflets such that a pierce is made at each full-rotation, to name a few. 
     Once the coil  1300  has advanced to a desired location, the toggle rod  1305  may be secured against a leaflet LF to hold the suture  1302  in place. At this point, the coil  1300  may be removed by retracting the coil  1300  in a reverse corkscrew fashion, as depicted in  FIG. 49B , leaving the suture  1302  behind. Since the coil  1300  may be much larger in diameter than the thickness of the leaflets (to aid in placement), the suture  1302  may be loose-fitting and the valve leaflets LF insufficiently modified. The suture  1302  may then be tightened, as shown in  FIG. 49C , so that the suture  1302  holds the leaflets LF together in a desired configuration. This may be aided by the use of a soft-tipped catheter  1306  which may be advanced to contact the surfaces of the leaflets LF when tightening to prevent the leaflets LF from prolapsing. Once the suture  1302  is sufficiently tight, a restrictive collar  1308  may be deployed from the catheter  1306  or another device to secure and terminate the suture  1302 . Such a restrictive collar  1308  may be comprised of any suitable material, such as heat-shrink tubing, nitinol shape-memory or superelastic coil or the like. Thus, this embodiment eliminates the need for needle passers and needle receivers providing a simplified method of valve leaflet fixation. 
     Alternatively, referring to  FIGS. 50 and 51 , a short length of suture  220  may be positioned using a curved needle  222  which can be extended from the distal tip  224  of an interventional catheter  225 . The needle  222  is formed from an elastic material, such as a shape memory alloy, and may be constrained in a generally straightened configuration within the catheter  224 . When extended, as shown in  FIG. 50 , it assumes a curved shape so that it may be advanced through the atrioventricular or other cardiac valve leaflets LF, as shown in  FIG. 51 . A distal anchor  226  is secured to the distal end of the suture  220  while a slideable, locking anchor  228  is placed over a portion of the suture located proximally to the distal anchor  226  as shown in  FIG. 50 . The catheter  225  may be advanced to the valve leaflets LF in a retrograde approach, as shown in  FIG. 51 , using a guide catheter  40 , as generally described above. The distal end  224  of the catheter  225  is positioned adjacent to the underside of a valve leaflet, and the needle  222  then advanced outwardly from the distal tip so that it passes through both valve leaflets. 
     In order to assure that the valve leaflets are in a proper orientation prior to needle advancement, the valve leaflets may be coapted and observed using any of the techniques described previously. After the needle has been advanced through the leaflets LF, a deployment sleeve  230  is advanced to release the slideable anchoring catheter  228  from the needle and advance it toward an underside of the valve leaflet LF. As the anchor  228  approaches the valve leaflet, tension on the suture  220  will pull the distal anchor  226  from the needle. The deployment sleeve  230  can be advanced sufficiently to draw the two anchors  226  and  228  together on opposite sides of the valve leaflets, as seen in  FIG. 52 . The suture can then be tied off or, alternatively, locked in place using a mechanical lock  232 . If the suture is comprised of a malleable wire, as previously described, the wire may be twisted together. In either case, the suture is then severed and the catheter  225  withdrawn. 
     The anchors  226  and  228  shown in  FIG. 50  are generally oval shaped and have a length dimension which is greater than the width of the needle used to introduce them. Thus, when pulled laterally, they can seal against the opposed surfaces of the two valve leaflets. In some instances, however, it will be desirable to have anchors which are capable of expanding to a much larger dimension to assure that they do not pull through the relatively fragile tissue of the leaflets. An exemplary expansible anchor  240  is shown in its collapsed configuration within a needle  242  in  FIG. 53  and its expanded configuration in  FIG. 54 . The anchor  240  is connected to a length of suture  244  and could be used with a similar slideable, expansible anchor (not shown) analogous to the non-expansible anchor  228  of  FIG. 50 . 
     Additional expansible anchors may be seen in  FIGS. 55A and 55B . In this embodiment, the anchor is comprised of an expanding randomly oriented wire coil. The coil is made from a shape memory nitinol wire that is annealed (heat set) in a straight configuration and then coiled. As shown in  FIG. 55A , different sections  820 ,  821  of the coil may be processed to have different properties by varying the diameter and tension in the coil along its length. When the coil is heated to a specified level (T 1 ), such as with RF energy, a designated portion  821  of the coil will become a randomly oriented mass of wire  824  with self-locking struts to prevent disentanglement. When the coil is heated to a different specified level (T 2 ), a different designated portion of the coil  825  will become randomly oriented. As each portion of the coil  824 ,  825  expands and changes shape, a full entanglement of the coils is allowed to occur, effectively compressing and fixing the two halves  824 ,  825  of each coil together. The coil may be introduced through the valve leaflets LF with the use of a shape memory, super elastic or heat/current activated needle introducer  826 . Once the valve leaflets LF are pierced, an anchor  824  may be activated and deployed distally. The introducer  826  may then be retracted to the proximal side of the second leaflet LF 2  and the second anchor (not shown) may be deployed in the same manner. The amount of tension between the anchors  824 ,  825  may be affected with the shape memory or super elastic properties of the expanding anchor. It may be appreciated that the heat activated expanding coil may alternatively take other forms, such as a wire mesh, for example. Additional expansible anchors may be in the form of inflatable chambers filled with a liquid that may optionally partially or fully solidify. 
     Yet another form of detachable anchor attached to a length of suture is illustrated in  FIGS. 56 and 57 .  FIG. 56  is a front view, while  FIG. 57  is a side view of the same structure. A self-penetrating anchor  260  attached to a length of suture  262  is carried on a pair of rods  264 . The rods are mounted within an open lumen of a deployment catheter  266 . The anchor  260  can pivot on a detent structure  268  formed between the distal ends of the deployment rods  264 . The anchor has a sharpened distal tip  270  which permits the anchor to be directly penetrated through the valve leaflet tissue when the rods are extended from the catheter  266 . 
     Referring now to  FIG. 57 , the catheter  266  may be deployed over the leaflets LF of the mitral valve MV in an antegrade direction through a guide catheter  14  as generally described above. The catheter  266  can be used to deliver a pair of the anchors  260  sequentially. As shown in  FIG. 58 , a first anchor  260   a  has been deployed through a first leaflet and a second anchor  260   b  has just been placed through the second leaflet. The anchors  260   a  and  260   b  are deployed by pushing them through the leaflet tissue while the sharpened tip  270  remains generally in a distal or forward direction. After passing through the tissue, the anchor  260   a / 260   b  can be turned, either by pulling back on the deployment rods  264  or by pulling backwardly on the suture  262 . The two ends of suture  262  can then either be tied or fastened using a mechanical fastener in order to draw the opposed leaflets into proper apposition. 
     Referring now to  FIGS. 59 and 60 , a deployment catheter  290  having a needle  280  with sharpened distal tip  282  can be used to place suture loops in individual valve leaflets. A needle  280  is carried on a pair of actuator rods  284  with a length of suture  286  attached to the needle. The needle  280  is first passed through the leaflet in a generally axial orientation with respect to the catheter  290 . After passing through the leaflet from a guide catheter  14 , as shown in  FIG. 60 , the needle is canted at an angle from 20° to 30° and passed back through the leaflet at a different position. A locking groove  288  on the needle is captured on a bar  292  in the distal end of the catheter  290 . The needle  280  may thus be detached from the rods  284  to pull suture  286  in a loop back through the leaflet. This way, loops of suture may be placed successively through both leaflets LF of a mitral valve MV, as shown in  FIG. 60 . The suture loops may then be tied off, connected with fasteners, fused together using RF, microwave or ultrasound energy, or otherwise secured to close the valves together in a desired apposition. 
     In addition to sutures and suture-based devices, as just described, opposed points on the valve leaflets and/or chordae can be attached with a variety of staples and tissue-penetrating fasteners. The staples and other fasteners can be delivered through guide catheters, generally as described above, and may be positioned during or after valve grasping, coaptation and adjustment, also as described above. 
     Referring now to  FIGS. 61A and 61B , staple applying catheter  300  is schematically illustrated. Typically, the leaflets LF of a mitral or other atrioventricular valve will first be accessed by any of the techniques described above. The catheter  300  will then be introduced in a retrograde fashion, for example, as illustrated previously. A staple  302  is held in an open position at the distal tip of the catheter  300  and has a generally W-shaped profile with two recesses for receiving each of the leaflets LF, as shown in  FIG. 61A . After proper positioning is confirmed visually, the staple  302  may be closed over the leaflets so that the tips penetrate opposed points on each leaflet by pulling on an actuator cord  304 , as shown in  FIG. 61B . The actuator cord can then be detached and the catheter  300  withdrawn, leaving the staple  302  in place to hold the leaflets together. Optionally, additional clips can be placed in a like manner to further strengthen the affixation of the leaflets. As described, the clip is a malleable clip which undergoes plastic deformation for emplacement. Alternatively, the clip could be formed of an elastic material, such as a shape memory alloy, and held in its open position as shown in  FIG. 61A . The clip could then be placed by releasing it to return to its memory (closed) configuration, as shown in  FIG. 61B . Other actuation mechanisms could also be used, such as the use of heat to induce a shape change in a heat memory alloy staple. 
     In addition, two part snaps, rivets and staples may be used to hold leaflets in place by locking together. This may be achieved by a number of device designs. Preferred embodiments involve two disks  850 , pledgets, or the like, placed on opposite sides of tissues or leaflets LF to be bound together, as shown in  FIG. 62A . Typically a shaft  852 , pin or needle may pierce the leaflets LF and connect the two disks  850 . The disks  850  may then be snapped or joined together by interlocking one or both disks  850  to the shaft  852  and/or portions of the shaft  852  to each other. Such a fixation device may be introduced through a lumen of a specialized catheter  854 , introducer or component of an interventional tool, as shown in  FIG. 62B . The disks  850  may be solid and/or rigid requiring placement on each side of the tissue, or the disks  850  may be flexible, collapsible and/or inflatable such that they may be inserted through the tissue for placement on the other side of the tissue. Preferred embodiments also involve two disks  855 , pledgets, or the like, which are placed between tissues or leaflets LF to be bound together, as shown in  FIG. 62C . Here, the disks  855  have penetrating prongs  856  at each end to pierce and grasp tissue. When the disks  855  are snapped or joined together by interlocking one or both disks  855  to a shaft  858 , shown in  FIG. 62D , and/or portions of the shaft  858  to each other, the leaflets LF may be bound together. 
     An additional embodiment of a two part rivet-like stapling mechanism is illustrated in  FIG. 63 . A stapling mechanism  322  at the distal end of a catheter  320  comprises a first jaw  324  which carries a fastener  326  and a second jaw  328  which carries a retaining ring  330 . The fastener has a collapsible cone  332  at its distal end so that it may be forced into an aperture  334  in the retaining ring  330 . The jaws  324  and  328  are pivotally mounted within the distal end  340  of the catheter so that they may be opened and closed to grasp the free ends of the valve leaflets therebetween. The closing of the jaws  324  and  328 , however, does not lock the fastener  326  into the retaining ring  330 . Thus, the valve leaflets can be temporarily grasped and the improvement in valve regurgitation visually assessed. If the improvement is sufficient, the fastener  332  can be driven into the tissue and locked in the retaining ring  330 . If the improvement is not sufficient, the jaws can be repositioned on the valve leaflets one or more additional times until an adequate or optimized repositioning of the leaflets is obtained. The fastener  332  can be driven into the retaining ring in a variety of ways. In the illustrated embodiment, a cam device  342  is slidably mounted behind an inclined surface  344  on the rear of the fastener  326 . By drawing the cam actuator  342  downwardly using draw cord  348 , the rivet can be driven through the valve leaflets and into the retaining ring  330 , as illustrated in  FIG. 64 . 
     In addition to rivets, snaps, pins and the like, coils may be used in a similar manner to fix valve leaflets in a desirable arrangement, as shown in  FIG. 65A . Coils  900  may be comprised of a superelastic material and pre-shaped in a coil configuration for engagement with the leaflets. The coil  900  may be advanced from an introducer sheath  902  to deploy the coil  900  in an orientation that will approximate the leaflets in compression. Alternatively, the coil  900  may be comprised of a heat or current activated shape memory material As depicted in  FIG. 65B , the coil  900  may be straightened in its initial configuration for ease of piercing and advancing through the leaflets LF. When positioned, the material may be activated by heat or current to assume a shape memory coil configuration corresponding with  FIG. 65A . Again, the coils may be oriented to approximate the leaflets in compression. To achieve maximum leaflet compression at the coaptation points, a super elastic or shape memory coil  900  may be delivered in a manner that places the coil in an inverted orientation across the leaflets, as illustrated in  FIG. 65C . This may be accomplished with the use of a specialized delivery system  904 . When released from the delivery system  904 , the distal end  905  of the coil produces a compressive force as the coil attempts to achieve a non-inverted orientation. 
     As a further alternative, a cinch-type fastener  360  may be positioned in a loop through opposed valve leaflets LF, as shown in  FIG. 66 . The fastener  360  could be advanced from either a retrograde or antegrade direction, but the antegrade direction is illustrated for convenience. A positioning catheter  362  can be introduced through a guide catheter  14  which has been previously positioned by any of the techniques described above. After advancing the cinch-type fastener  360  through the leaflets, for example by pushing a pre-shaped fastener  360  through the leaflets so that it returns to the distal tip of the placement catheter  360 , a fastening collar  364  may then be advanced to tighten the fastener loop  360  until the leaflets are positioned in a desired fashion. Alternatively, the fastener  360  may be twisted to constrict the open loop. Typically, the fastener  360  has chevrons or other one-way surface features so that the locking column may be advanced and will remain in place without loosening over time, or in the case of twisting, untwisting over time. The fastener  360  is then released and, if desired, additional fasteners positioned in a like manner. The fastening collar  364  may alternatively be used to secure the sutures shown previously in  FIG. 49 . The collar  364  may be crimped onto the sutures  202  or locked in place by the use of a combination of one-way surface features on the collar  364  and sutures  202 . 
     Further, a variety of penetrating and non-penetrating clips, barbs, grappling hooks, and the like, may be used to fasten valve leaflets in a desired configuration. As previously described as a means to grasp the free ends of the valve leaflets in a pinching manner, a pair of flat coils may also be used as a fixation device. As previously shown and described in relation to  FIG. 46A , the coils  770  may be linked together with opposing curvature by a clip  772 . When inserted as shown in  FIG. 46B , the coils  770  may be permanently joined in this orientation and may remain as a permanent implant. Alternatively, the coils  910  may pierce the leaflets LF to hold them in place as shown in  FIGS. 66A and 66B . During placement, the coil  910  may be inserted through a delivery catheter  911  in a straight configuration and pierce the leaflets LF in this form, allowing the free distal end  912  of the coil  910  to curl after it has penetrated the leaflets LF, as shown in  FIG. 66A . The proximal end may then curl after it disengages from the delivery catheter  911  to remain as an implant as shown in  FIG. 66B . 
     Likewise, a variety of barb-like structures may be used in a similar fashion to fasten valve leaflets in a desired configuration. Referring to  FIG. 67 , a shaft  920  with one or several curved barb-like distal ends  922  may be positioned so that the distal ends partially or fully penetrate each leaflet LF to be fixed. The shaft  920  may be a shape memory or super elastic wire. By activating the shaft  920  with heat or current, in the case of a shape memory material, or allowing the shaft  920  to assume its pre-configured shape, in the case of a super elastic material, several barbs  922  may be approximated to coapt the leaflets in the desired position. On the other hand, several discontinuous barbs  922  may be tensioned and coapted using a crimping or coupling and trimming system. Similarly, as shown in  FIG. 68 , a shaft  924  with expanding barb-like distal ends  926  may be positioned so that the distal ends  926  penetrate each leaflet LF to be fixed. Here, however, the distal ends  926  may be comprised of one or more struts  927  which expand to further prevent retraction of the shaft  924 . Such expansion may be achieved by activation of the shaft  924  with heat or current or allowing the device to assume its pre-configured shape. In addition to end  926  expansion, the shaft  924  may be approximated to coapt the leaflets or several discontinuous shafts may be tensioned and coapted using a crimping or coupling and trimming system. 
     In addition to fixation, clips may be used to draw leaflets together in a suitable coaptation configuration. While temporarily holding two or more leaflets in a desired configuration, such as with grasping tools, a clip may be deployed to maintain the desired position or to further manipulate the leaflets. For example, a clip  940  may be mounted on a delivery catheter or interventional tool  942 , as shown in  FIG. 69A . It may then be positioned in a desired location to hold the leaflets LF, as shown in  FIG. 69B . In the deployed and activated state, depicted in  FIG. 69C , the clip  940  may tend to pinch inwardly, pulling the leaflets together, as indicated by arrows  944 . This may be achieved by activation of super elastic or shape memory material. Alternatively, referring to  FIGS. 70A and 70B , the clip  945  may pinch inwardly, indicated by arrows  944 , by manual crimping of the spine  946  or interlocking of the piercing legs  948 . When positioned appropriately between the valve leaflets LF, as shown in  FIG. 70B , the leaflets may be drawn together by crimping the spine  946  of the clip  945  with the use of a removable actuator  950 . As the actuator  950  passes over the spine  946 , the spine  946  may be plastically deformed to a new configuration. Or, as the actuator  950  passes over the spine  946 , the proximal ends of the piercing legs  948  may become interlocked. In either case, inward movement of the clip  945  may be controlled by passing the actuator  950  only over portions of the spine  946  in which such pinching is desired. Therefore, a single clip may provide variable inward forces. 
     Inward forces may also be applied by components of an interventional tool, such as a by graspers. Graspers, as previously described, are devices which grasp and hold tissues (such as coapting valve leaflets) for appropriate modification, such as fixation. Thus, graspers are most likely in place while a fixation device is deployed and positioned. Referring to  FIG. 71 , an embodiment of graspers  960  is shown holding the leaflets LF on opposite sides of a deployed clip  962 . Inward force may be applied to the clip  962  by moving or applying force to the graspers  960  in an inward direction, as depicted by arrows. In a further embodiment, the graspers may serve as a grasping device and as an implantable fixation device. Referring to  FIG. 72A , an embodiment of graspers  960  is shown coapting and holding the leaflets LF together. The graspers  960  may then be joined by a coupling device  964  and detached for implantation, as shown in  FIG. 72B . 
     Because of the fragility of the tissue in the valve leaflets, it will sometimes be preferred to utilize methods or devices which do not completely pierce or penetrate the tissue. For example, leaflets may be fused together in a desired coaptation position by applying laser, RF, microwave or ultrasonic energy at specified coaptation points. In addition or alternatively, external clips which are partially penetrating or non-penetrating may be used. A variety of deformable and elastic clips can be utilized, and clips will usually be deployed in a retrograde fashion so that an opening in the clip can be placed over the undersides of the adjacent valve leaflets. 
     A preferred clip-applying catheter  380  in is depicted in  FIGS. 73A, 73B, and 73C . The catheter  380  has a three-jaw clip-applying device  382  at its distal end. The three-jaw structure allows the clip-applier to be used as a three-jaw grasping device before final deployment of the clip. Such grasping has been described earlier with reference to  FIGS. 42A, 42B, and 43  above. A center jaw  384  of the device has a tubular structure and allows the catheter to be introduced over a guidewire  386 , where the guidewire may be placed through the atrioventricular valve prior to catheter positioning. A clip  388  has a V-shaped structure and is normally closed so that a force is required to open the distal ends of the clip. Jaws  390  and  392  hold the clip and can open the clip by selectively opening either jaw, with jaw  392  shown in open in broken line in  FIG. 73A . Thus, jaw  392  may be opened first to capture a free end of a first valve leaflet. With the catheter  380  thus attached to just the first valve leaflet, the catheter can be repositioned so that the other jaw  390  can be opened and used to capture the second valve leaflet. After the valve leaflets are captured and held in a proper orientation, valve improvement can be confirmed by visual observation. If improvement is sufficient, the clip can be detached from the catheter and left in place, as shown in  FIG. 74 . 
     B. Shortening of the Chordae 
     In addition to suturing, fastening, and otherwise physically attaching portions of the valve leaflets and/or chordae together, valve leaflet closure can be improved by shrinking portions of either or both of the chordae attached to the two valve leaflets. An exemplary catheter  400  having an energy-applying coil  402  at its distal end is shown in  FIG. 75 . Such energy may be in the form of radiofrequency (RF), microwave, ultrasound, laser, heat or current. The catheter  400  may be deployed in either an antegrade or retrograde direction, with retrograde generally being preferred to facilitate access to the chordae. One or more chordae CT are captured within the coil and RF energy, for example, applied from a conventional power supply. Application of the RF energy to the chordae, which are composed of collagen and other normal tissue constituents, over a length L will cause shrinkage of the tissue to a length which is shorter than the original length L. Similarly, such application of energy to the chordae may also be achieved with the use of an energy applying chordal snare or similar device. By applying such shortening of the chordae, valve conditions, such as prolapsed valves can be effectively treated. 
     In addition to the use of energy for shortening chordae, the chordae can be plicated using mechanical plication devices  420 , as illustrated in  FIG. 76 . Each of the devices  420  comprise a cap piece  422  and a receptacle  424 . A receptacle has a channel  426  which receives a pin  428  on the cap piece  422 . There is sufficient clearance between the pin  428  and channel  426  so that a portion of the chordae CT can be captured and folded therein by placing the cap into the receptacle. Each plication device  420  will thus shorten a portion of the chordae by a predetermined amount. Multiple devices can be used to achieve a desired overall shortening of the chordae. The devices can be placed using jaw-type devices and shortening can be visually observed by any of the techniques described above. Alternatively, chordae may be mechanically plicated with the use of suture loops. Referring to  FIG. 77A , a suture  980  may penetrate the chordae CT at a first location  982  and then penetrate the chordae CT again at a second location  984  forming a loop. By pulling closed the loop, as shown in  FIG. 77B , the effective length of the chordae CT is reduced. The suture loop may then be fixed and trimmed for implantation. This may be repeated along a chordae to form multiple individual or continuous loops, and/or it may be repeated on along more than one chordae. Similarly, such plication may also be achieved with the use of a shape memory or super elastic wire coil which may penetrate a chordae at one or more points and draw the tissue together upon activation. 
     C. Annuloplasty 
     The intravascular approaches described herein can also be used to place annuloplasty devices, such as supporting rings and other devices, around the atrioventricular valve annulus, including the mitral valve annulus AN (shown in  FIG. 1 ). Such annuloplasty devices can provide support which is analogous to that provided by annuloplasty rings implanted in open surgical procedures. 
     As mentioned, annuloplasty device can be positioned on either the atrial side or the ventricular side of the annulus. An advantage to positioning the annuloplasty device on the ventricular side of the annulus is that the device can be positioned within an annular gutter G that is located immediately adjacent the ventricular side of the mitral valve MV. The gutter G is shown in the cutaway representation of the left ventricle LV in  FIG. 91 . As mentioned, the gutter G has a concave shape, which provides a geometrically-supportive location in which the annuloplasty device can be securely nested during and after deployment of the device. The rounded, concave shape of the gutter G provides an increased amount of contact area between the wall of the left ventricle and an annuloplasty device positioned in the gutter. 
     The annuloplasty device can have a variety of configurations. For example, with reference to  FIGS. 92A and 92B , the annuloplasty device  1090  can be shaped as a ring ( FIG. 92A ) or as a partial ring ( FIG. 92B ). The annuloplasty device  1090  can be equipped with any of a variety of securing or retaining structures for securing the device to the heart, including hooks, barbs, prongs, adhesive fasteners, bendable legs, etc. In addition, secondary attachment devices or materials can be coupled to the annuloplasty device  1090 , such as, for example, staples or adhesive, for permanently or temporarily securing the device to the annulus. 
       FIG. 78  shows another exemplary annuloplasty device comprised of an annuloplasty ring  500 . The annuloplasty ring  500  includes an outer ring having radially-extending spokes  504 , which can be used to open the outer ring. The annuloplasty ring can be deployed using a catheter  502  positioned through a guide catheter  14 , as described more fully below. The ring can be secured in place using sutures, staples, tissue adhesives, or other conventional techniques. The catheter  502  may then be removed, together with the deployment spokes  504 , leaving the ring permanently in place. One or more of the spokes can be attached to one or more clips that coapt the valve flaps. The spokes can be stiff or the spokes can be sutures or other flexible material to allow free or limited movement of the clips. Alternatively, rigid or flexible members in the form of sutures or pins/posts could extend upwardly from the annuloplasty device and penetrate through the annulus tissue to the left atrium where members fasten to the atrial side of the clip in tension. This could help to anchor the annuloplasty device in place and could partially or totally immobilize the clip, should that be desirable. 
     Magnets can also be used to secure the annuloplasty device  1090  to the heart. This is described in more detail with reference to  FIG. 93 , which shows the annuloplasty device positioned in the gutter G. A pair of magnets  9310   a  and  9310   b  sandwich at least a portion of the annuloplasty device therebetween. The magnet  9310   a  is located on a ventricular side of the mitral valve and the magnet  9310   b  is located on the atrial side of the mitral valve. The magnets are of opposite polarity such that they exert an attractive force on one another to force the device against the wall of the gutter G and retain the annuloplasty device in the gutter G. Alternately, the magnet  9310   a  can be replaced with magnetic material that is integrally formed within the annuloplasty device. The atrial magnet  9310   b  can be left in place permanently or it can be removed once annuloplasty device is permanently secured either through fixation devices of through tissue growth. 
     In an exemplary embodiment, the annuloplasty device is configured to be-reshaped after placement in the annulus. For example, the annuloplasty device can be malleable such that it can be reformed into a desired shape after placement of the device by using an endovascular grasping/shaping tool. In another embodiment, a pull wire spans the circumference of the device. The pull wire has a grasping means, such as a loop, handle, snare, etc. After the annuloplasty device has been deployed, the end of the pull wire is grasped and pulled by a catheter so as to cause the wire to constrict the device into a smaller diameter or to re-shape the device in a predetermined manner. 
     The pull wire can alternatively extend from the annuloplasty device to an extra-cardiac location, either in the chest cavity or in a peripheral vessel for later access. The pull wire can be left in a subcutaneous location like a pacing lead to facilitate easy access. The pull wire and/or the annuloplasty device can be coated with agents to prevent endothelialization, tissue encapsulation, and infection. 
     In another approach, the annuloplasty device is formed at least partially of a thermal shape memory material that changes shape upon heating. A source of heat, such as an electrical lead through which current could be delivered, can be coupled to the annuloplasty device at a desired time to cause the device to change shape. Alternatively, the annuloplasty device could have a mechanism that is remotely controllable (from outside the body) so that it can be transitioned to the desired shape at any time during or after the procedure without further intervention. For example, the device could have magnetic components to allow the shape to be controlled via MRI steering technology. Other remotely controllable mechanisms are also possible. 
     In another approach of a re-shapeable annuloplasty device, the device has one or more articulating joints with one-way locking or ratchet mechanisms in each joint that allow the device to be shaped (e.g. by pulling a wire attached to one end) from straight into a curved or bent shape. The annuloplasty device can then be locked into the re-shaped configuration with any desired degree of curvature or angle. 
     The annuloplasty device can be resiliently flexible such that it can be compressed into a state of reduced size that would fit through the lumen of a guide or delivery catheter. In the reduced-size state, the annuloplasty device can comprise a flattened ring in a straightened configuration. When released from the guide catheter, the annuloplasty device resiliently returns to a predetermined shape, such as the ring or partial ring shown in  FIGS. 92A and 92B . Thus, an elastic annuloplasty ring can be delivered through the guide catheter in a collapsed fashion, deployed to open over the annulus, and then stitched or stapled in place using appropriate catheters. 
     Rather than being comprised of a single ring or partial ring structure, the annuloplasty device can comprise of a plurality of structures that collectively re-shape the annulus when positioned therein. For example, a plurality of attachment members, such as staples or clips, can be positioned in an annular formation around the entire circumference of the annulus or along a portion of the annulus. Each attachment member is attached to the annulus in such a manner that it re-shapes a local portion of the tissue. The plurality of attachment members collectively re-shape a global area of the annulus. 
     The plurality of anchors approach is shown in  FIG. 81 , which shows a plurality of anchors comprised of as staples  540  about the annulus of the mitral valve, such as in the gutter described above. A suture  542  or other filament can then be placed through the anchors  540  and tightened in a “purse string” fashion. The suture filament can then be tied off to maintain the desired tightening and enforcement of the valve annulus. 
     As yet a further alternative, the valve annulus can be plicated by positioning a plurality of staples about the annulus, as shown in  FIG. 82 . Here, each staple  560  plicates or shortens a small peripheral segment of the annulus. A staple applying catheter  562  may have the same general structures described above in connection with  FIGS. 61A and 61B . 
     In an embodiment, a period of time elapses after placement of the annuloplasty device in the annulus. The annuloplasty device is then re-shaped after passage of the period of time. During the time period, the tissue around the annulus forms scar tissue where the annuloplasty device has been attached. In this regard, the annuloplasty device can be covered with a suitable material, such as Dacron, that promotes tissue healing and growth. The scar tissue strengthens the attachment between the tissue and the annuloplasty device and reduces the likelihood of injury to the tissue or detachment from the tissue during reshaping. The amount of the time period can vary. In one embodiment, the annuloplasty device is deployed in the annulus and the annuloplasty device is re-shaped after a time period of four to twenty four weeks has elapsed. 
     The annuloplasty device can be delivered to the annulus in a variety of manners and using various devices. The annuloplasty device can be delivered using an antegrade approach or a retrograde approach. As discussed above with reference to  FIG. 9 , in the retrograde approach, the annuloplasty device is introduced by deploying a delivery device through distal arterial vasculature and over the aortic arch and into the left ventricle through the aortic valve. As discussed above, a guidewire  42  can be used to provide initial access to the left ventricle. A guide catheter  40  is then tracked over the guidewire  42  to the left ventricle. 
     An interior lumen of the guide catheter  40  provides subsequent access to the left ventricle for a delivery catheter that holds the annuloplasty device at its tip. When entering through the left ventricle, the delivery catheter may be required to curve or turn such that it approaches the gutter of the mitral valve annulus from below. In this regard, the delivery catheter may have a predetermined shape that facilitates such an approach. The delivery catheter can also have a deflectable distal tip that can be deflected (such as via a pull wire) so that the distal tip angles outwardly and upwardly toward the gutter region of the annulus. The delivery catheter then deploys the annuloplasty device in the gutter region and the annuloplasty device is secured in place. A second catheter can also be deployed to the gutter to secure the annuloplasty in place while the delivery catheter temporarily holds the annuloplasty device in position. It should be appreciated that the delivery devices and methods for approaching the mitral valve annulus described above can be used in delivering the annuloplasty device. 
     In the antegrade approach, the device is introduced through the inferior vena cava IVC or superior vena cava SVC into the right atrium RA, as described above with reference to  FIGS. 7 and 8 . The interatrial septum IAS is then penetrated such as using a catheter  10  having a needle  12 , as shown in  FIG. 7 . As shown in  FIG. 8 , access through the interatrial septum IAS can be maintained by the placement of a guide catheter  14 , typically over a guidewire  16 . The guide catheter  14  permits introduction to the left atrium LA of a delivery device having the annuloplasty device at a distal end. The delivery device is passed downward through the mitral valve MV such that it approaches the gutter region from below the mitral valve MV. As discussed above, the delivery catheter can be preshaped to facilitate such an approach or it can be equipped with a mechanism that enables the distal region of the delivery catheter to be deflected toward the gutter region. 
     Alternatively, an annuloplasty ring  520  can be delivered on a balloon catheter  522  as shown in  FIGS. 79 and 80 . The ring  520  can be formed from a deformable material, and the balloon  520  inflated within the valve annulus to expand and deploy the ring, as shown in  FIG. 80 . The balloon catheter may be placed directly over a guidewire  524 , but will more usually be positioned using a combination of a guide catheter and guidewire. Once the ring  520  is deployed, it can be sutured, stapled, glued, or otherwise affixed around the valve annulus. 
     In an alternative approach that can be used in place of or in combination with deployment of the annuloplasty device, annulus remodeling is accomplished by applying RF energy to the gutter region of the annulus to shrink or otherwise change the annulus shape. A catheter having one or more RF electrodes at a distal tip is inserted through the guide catheter to the gutter region of the annulus. The RF electrodes are energized to deliver energy delivered to the annulus or to the surrounding tissue for remodeling. The catheter can include a suction port for applying suction to the heart tissue near the annulus to stabilize the device. Again the catheter would be steerable by means of pull wires or the like. 
     Placement of the annuloplasty device can be combined with any of the other procedures described herein. For example, chordal grasping and/or valve leaflet grasping can be employed in combination with deployment of the annuloplasty device. The annuloplasty device delivery catheter can include grasping arms at a distal end to grasp the valve leaflets during delivery of the annuloplasty device. 
     Placement of the annuloplasty device can also be combined with temporary or permanent tissue modifications, such as fixation of the valve leaflets or shortening of the chordae, which tissue modifications are described in detail above. With respect to valve leaflet fixation, the delivery catheter that is used to deliver the annuloplasty device can be combined with a suturing tool  200  (shown in  FIG. 49 ) or variations of the suturing tool described herein. The staple applying catheter  300  (shown in  FIGS. 61 a  and 61 b   ) can also be used to deliver the annuloplasty device. The stapling mechanism catheter  320  (shown in  FIG. 63 ) can be equipped with a separate lumen for delivery of the annuloplasty device. Pursuant to a method of delivery, one of the catheters described herein is used to apply a clip or staple to the leaflets or to suture the leaflets. Before or after coaptation of the leaflets, the annuloplasty device is deployed in the gutter G of the mitral valve annulus AN. It should be appreciated that any of the delivery or interventional devices described herein can be modified for use with the annuloplasty device. 
     D. Annuloplasty via the Coronary Sinus 
       FIG. 94  is a cross-sectional view of the heart showing the mitral valve MV, valve leaflets LF, annulus AN, and coronary sinus CS. The coronary sinus CS is positioned adjacent the mitral valve MV. Because the coronary sinus substantially encircles the mitral valve annulus AN, a re-shaping of the coronary sinus CS will results in a re-shaping of the annulus AN. A device of predetermined shape can be implanted into the coronary sinus CS and allowed to heal in place so as to form scar tissue adjacent the device. The shape of the device is then subsequently changed to also re-shape the coronary sinus CAS and the adjacent annulus AN in a desired manner. The scar tissue strengthens the tissue to provide a strong attachment to the device and also reduce the risk of injury. 
     X. Device Embodiments 
     The following three device embodiments depict complete device designs utilizing a variety of the specific components described above and/or new component designs to accomplish similar objectives. 
     A. Atrial Device 
     Referring to  FIG. 83 , the atrial device  1000  is comprised of a catheter shaft  1002  having a distal end  1004  and a proximal end  1006 . The catheter shaft  1002  is comprised of, among others, a conduit  1008 , a coaxial outer sheath  1010 , and a central guidewire lumen  1011 . Toward the distal end  1004 , a pair of stabilizers  1012  having a single-hump shape (previously illustrated in  FIG. 31D ) are fixedly mounted on the outer sheath  1010  at their proximal end  1014  and fixedly attached or hinged to extenders  1016  at their distal end  1018 . The stabilizers  1012  are shown in an outwardly bowed position, however they may be inwardly collapsed by either extending the extenders  1016  or retracting the outer sheath  1010 . Bowing may be achieved by the reverse process. 
     Referring to  FIG. 84 , the atrial device  1000  may be used with a typical antegrade approach to the mitral valve MV. As previously described and depicted in  FIGS. 7 and 8 , such an antegrade approach may involve penetrating the interatrial septum IAS and maintaining such access with a guide catheter  14 . The guide catheter  14  permits introduction of the atrial device  1000  to the left atrium LA and mitral valve MV. To allow passage of the device  1000  through the guide catheter  14 , the stabilizers  1012  must be in a collapsed position as shown. In addition, graspers, described below, may be fully retracted to avoid damage to cardiac structures. Thus, they are not visible in  FIG. 84 . 
     Referring to  FIG. 85 , the atrial device  1000  may be stabilized against the mitral valve MV. The stabilizers  1012  may be inserted through the mitral valve MV and may be aligned with the line of coaptation C between the valve leaflets LF 1 , LF 2 . To minimize mitral valve regurgitation (MVR) due to insertion of the device  1000 , the stabilizers  1012  may be located approximately 120 degrees apart. This angle may be fixed or adjustably variable. The single-humped shape of the stabilizers  1012  may allow the inferior portion  1030  to pass within the valve and apply radial pressure to the commissures CM and the superior portion  1032  (or hump) to rest upon and apply axial pressure to the commissures CM. 
     Referring again to  FIG. 83 , a pair of graspers, comprised of grasping sheaths  1020  and three opposing prongs  1021  configured to partially or fully penetrate or pierce, are shown extended from the conduit  1008  in the plane bisecting the angle of the stabilizers  1012  (i.e. approaches the middle of the leaflets). This angle may be fixed or variable. When not in use, however, the graspers may be fully retracted within the conduit  1008 . Tension from lateral steering wires  1022  cause the graspers to deflect away from each other and approximate the most desirable angle for grasping. Amount of deflection may be controlled from the proximal end of the device by the steering wires  1022 . When the graspers are positioned in a desired location as shown in  FIG. 85 , the prongs  1021  may be deployed and opened by either retraction of the grasping sheath  1020  or advancement of the prongs  1021  beyond the grasping sheath  1020 . Retraction of the sheath  1020  does not significantly affect the position of the graspers, thus enabling the user to contact the valve leaflets LF 1 , LF 2  with the prongs  1021  housed within the sheath  1020  and then to initiate grasping the leaflets at the contacted location by retracting the grasping sheaths  1020 . The opposing prongs  1021  may be closed to grasp (pinch, partially penetrate or pierce) the leaflet tissue by advancing the grasping sheaths  1020  or retracting the prongs  1021  within the sheaths  1020 . 
     After both leaflets have been grasped, tension in the steering wires  1022  is released and the conduit  1008  is advanced over the grasping sheaths  1020 . Such advancement draws the sheaths  1020 , and grasped leaflets, together for coaptation. After coaptation, the mitral valve regurgitation is evaluated to determine if the locations which are grasped are appropriate for fixation. If the grasping points are not appropriate, the leaflets may be released and regrasped individually or simultaneously by the above described methods. If the grasping points are appropriate, the preferred embodiment allows for exchange of the guidewire, located in the guidewire lumen  1011 , for a fixation device. The fixation device may use, for example, staples, sutures, clips, rivets, coils, fusing devices, zippers, snares, clamps, hooks, chordal fixation or shortening devices to repair the mitral valve regurgitation. Specifically, the fixation device may be the hollow suturing coil  1300  shown previously in  FIGS. 49A-C . As shown in  FIG. 84A , the hollow suturing coil  1300  containing suture  1302  (not shown) may be deployed through the guidewire lumen  1011  in a coiled configuration. The coil  1300  may expand or change shape once it is deployed from the lumen  1011 , providing the coil  1300  is comprised of a suitable shape memory or superelastic material. Similarly, as shown in  FIG. 84B , the suturing coil  1300  may be deployed through the guidewire lumen  1011  in a straightened configuration such that it coils and/or expands or changes shape once it is deployed from the lumen  1011 . 
     The above described components may be manipulated and controlled by a handle  1026  connected to the proximal end  1006  of the catheter shaft  1002 , as shown in  FIG. 83 . The handle  1026  permits independent control of the components, including but not limited to retraction and extension of extenders  1016 , deployment of stabilizers  1012 , adjustment and locking of outer sheath  1010 , translation and deflection of grasping sheaths  1020 , stopping and locking of grasping sheaths  1020  and axial sliding of the conduit  1008 . In addition, the device may be readily adapted to approach the mitral valve trans-atrially for a minimally invasive surgical (MIS) procedure, with either beating or stopped heart. 
     B. Atrial-Ventricular Device 
     Referring to  FIG. 86 , the atrial-ventricular device  1100  is comprised of a catheter shaft  1102  having a distal end  1104  and a proximal end  1106 . The catheter shaft  1102  is comprised of, among others, a conduit  1108 , a coaxial outer sheath  1110 , a central lumen  1111  through which a double-jaw grasper  1113  may be inserted, and a central guidewire lumen  1105 . Toward the distal end  1104 , a pair of stabilizers  1112  having a triangular shape (previously illustrated in  FIG. 31A ) are fixedly mounted on the outer sheath  1110  at their proximal end  1114  and fixedly attached to extenders  1116  at their distal end  1118 . The stabilizers  1112  are shown in an outwardly bowed position, however they may be inwardly collapsed by either extending the extenders  1116  or retracting the outer sheath  1110 . Bowing may be achieved by the reverse process. The double-jaw grasper  1113  is comprised of two articulating jaw arms  1120  which may be opened and closed against the central shaft  1122  (movement depicted by arrows) either independently or in tandem. The grasper  1113  is shown in the open position in  FIG. 86 . The surfaces of the jaw arms  1120  and central shaft  1122  may be toothed, as shown, or may have differing surface textures for varying degrees of friction. 
     Referring to  FIGS. 87A-C , the atrial-ventricular device  1100  may be used with a typical antegrade approach to the mitral valve MV, as previously described and depicted in  FIGS. 7 and 8 . However, the double-jaw grasper  1113  extends through the valve such that the leaflets L 1 , L 2  are grasped from below. Thus; the device  1100  is termed “atrial-ventricular.” 
     Referring to  FIG. 87A , the atrial device  1100  may be stabilized against the mitral valve MV. The stabilizers  1112  may be positioned on the superior surface of the valve leaflets LF 1 , LF 2  at a 90 degree angle to the line of coaptation. The grasper  1113  may be advanced in its closed position from the conduit  1108  between the leaflets LF 1 , LF 2  until the jaw arms  1120  are fully below the leaflets in the ventricle. At this point, the grasper  1113  may be opened and retracted so that the jaw arms  1120  engage the inferior surface of the leaflets LF 1 , LF 2 . In this manner, the leaflets are secured between the stabilizers  1112  and the jaw arms  1120 . This action allows for leaflets of many different shapes and orientations to be secured. Cardiomyopathic valves are often enlarged and distorted so that they coapt irregularly. Such irregularity creates difficulty in mechanically coapting such valves for tissue modification. The action of the grasper  1113  overcomes much of these difficulties. 
     Referring to  FIG. 87B , the grasper  1113  will gradually close, drawing the leaflets LF 1 , LF 2  together while maintaining a secure hold on the leaflets between the jaw arms  1120  and the stabilizers  1112 . This may be accomplished by number of methods. For example, the stabilizers  1112  may be gradually collapsed by either extending the extenders  1116  or retracting the outer sheath  1110 . As the stabilizers  1112  collapse, the jaw arms  1120  may collapse due to spring loading to gradually close the grasper  1113 . Alternatively, the jaw arms  1120  may be actuated to close against the central shaft  1122  applying force to the stabilizers  1112  causing them to collapse. In either case, such action allows the stabilizers  1112  to simultaneously vertically retract and withdraw from the leaflets as the leaflets are clamped between the jaw arms  1120  and the central shaft  1122 . In this manner, the leaflets are effectively “transferred” to the grasper  1113 . Referring to  FIG. 87C , once the collapsed stabilizers  1112  are completely withdrawn, the leaflets LF 1 , LF 2  are held in vertical opposition by the grasper  1113  in a more natural coaptation geometry. At this point the leaflets may be adjusted and fixated. Fixation may be achieved with an external element or the grasper  1113  may be left in place as a fixation device. 
     The above described components may be manipulated and controlled by a handle  1126  connected to the proximal end  1106  of the catheter shaft  1102 , as shown in  FIG. 86 . The handle  1026  permits independent control of the components described above. 
     C. Ventricular Device 
     Referring to  FIG. 88 , the ventricular device  1200  is comprised of a catheter shaft  1202  having a distal end  1204  and a proximal end  1206 . The distal end  1204  is comprised of a joining coil  1208 , an upper jaw  1210 , a lower jaw  1212 , an actuator  1214  and a central lumen  1216  through which a guidewire  1218  or other wires may be inserted. The upper jaw  1210  may open and close (depicted by arrows) against the lower jaw  1212  by action of the actuator  1214 . The upper jaw  1210  is shown in the open position. These components may be manipulated and controlled by a handle  1226  connected to the proximal end  1206  of the catheter shaft  1202  as shown. 
     Referring to  FIG. 89 , the ventricular device  1200  may be used with a typical retrograde approach to the mitral valve MV, as previously described and depicted in  FIG. 9 . 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 LV below the mitral valve MV. Such access may be maintained with a guide catheter  40  through which the ventricular device  1200  may be introduced. The ventricular device  1200  may be inserted through the guide catheter  40  with the upper jaw  1210  in the closed position. After it exits the guide catheter  40  just below the aortic valve AV, the device  1200  may be advanced toward the mitral valve MV. The catheter shaft  1202  may be pre-shaped to provide favorable curvature in positioning the distal end  1204  beneath the valve leaflets ALF, PLF. Additionally, two mandrels with favorable shapes may be advanced into a lumen in the catheter shaft  1202 . By changing the location of the mandrels with respect to each other and to the catheter shaft  1202 , the general curvature of the shaft  1202  may be altered in-situ. 
     It is desired to position the distal end  1204  of the device  1200  beneath the mitral valve leaflets ALF, PLF with the upper jaw  1210  in the open configuration. The lower jaw  1212  is to be proximal to the anterior leaflet ALF and the upper jaw  1210  is to be distal of the posterior leaflet PLF, as shown in  FIG. 89 , such that the leaflets may be secured between the jaws  1210 ,  1212 . To achieve such positioning, the device  1200  may be required to flex at an extreme angle in the region of the joining coil  1208 . Therefore, the joining coil  1208  is designed to provide such flexibility. 
     To aid in positioning the device  1200 , a balloon wire  1250  may be used. The balloon wire  1250  may first be inserted through the aortic valve AV, advanced down to the apex of the ventricle and then back upwards towards the mitral valve MV behind the posterior leaflet PLF. Once positioned, the balloon  1252  may be inflated to assist in holding the position stationary. A cuff wire  1260  may then be inserted through the aortic valve AV. The cuff wire  1260  may track along the balloon wire  1250  by means of a locking ring  1262 . The cuff wire  1260  may track down to the apex of the ventricle and then back upwards toward the mitral valve MV. Once the cuff wire  1260  is advanced to a desirable position, the locking ring  1262  may be actuated to lock the cuff wire  1260  to the balloon wire  1250 . A typical means of actuation is by inflation of the locking ring.  1262 . The ventricular device  1200  may then be tracked over the cuff wire  1260  to the desired position, as shown in  FIG. 89 . The balloon, or balloon wire  1250 , may also be used to walk or urge the posterior leaflet towards the center of the valve to facilitate grasping. 
     Once positioned, the upper jaw  1210  may be closed against the lower jaw  1212  such that the leaflets are grasped between them. It is often desirable to adjust or manipulate the leaflets once they are grasped. Manipulation should occur only in a superior/inferior (up/down) motion in order to bring the leaflets to a final position where regurgitation is minimized. The lower jaw  1212  may be fitted with a travel mechanism for extending or retracting the jaw  1212 . This would move one leaflet up or down with respect to the other leaflet. Once the leaflets are sufficiently adjusted, fixation may occur in any manner previously described. In a preferred embodiment, fixation may achieved through the lower jaw  1212 , as depicted in  FIGS. 90A and 90B . As shown in  FIG. 90A , a cutout  1270  may be present in the lower jaw  1212  accessing a lumen  1272  which extends through the catheter shaft  1202  and lower jaw  1212 ; such a lumen may also serve as the guidewire lumen  1216 . When the upper jaw  1210  is closed against the lower jaw  1212 , the valve leaflets LF may be captured between the jaws. As shown a side-view,  FIG. 90B , the captured leaflets LF may protrude into through the cutout  1270  into the lumen  1272 . A fixation device  1274  may then be inserted through the lumen  1272  (in the direction of the arrow) and may affix the leaflets LF together. It may be appreciated that such a method of fixation may be used in a number of devices involving jaw-type graspers, such as the atrial ventricular device  1100  depicted in  FIG. 86 . 
     Although the forgoing devices and methods have been described in some detail by way of illustration and example, for purposes of clarity of understanding, it will be obvious that various alternatives, modifications and equivalents may be used and the above description should not be taken as limiting in scope.