Patent Publication Number: US-2021186699-A1

Title: Method and apparatus for transvascular implantation of neo chordae tendinae

Description:
INCORPORATION BY REFERENCE TO ANY PRIORITY APPLICATIONS 
     This application is a continuation-in-part of U.S. application Ser. No. 15/638,176, filed Jun. 29, 2017, which claims priority to U.S. Provisional Application 62/441,031, filed on Dec. 30, 2016, the entirety of each of these applications is hereby incorporated by reference herein for all purposes. Any and all applications for which a foreign or domestic priority claim is identified in the Application Data Sheet as filed with the present application are hereby incorporated by reference under 37 CFR 1.57. 
    
    
     BACKGROUND 
     Field 
     The disclosure relates generally to mitral valve repair devices and techniques, and in particular, to transvascular methods and devices for chordae tendinae replacement to reduce mitral regurgitation. 
     Description of the Related Art 
     The heart includes four heart valves, which allow blood to pass through the four chambers of the heart in one direction. The four valves are the tricuspid, mitral, pulmonary and aortic valves. The four chambers are the right and left atria (upper chambers) and right and left ventricle (lower chambers). 
     The mitral valve is formed by two leaflets, which are known as the anterior leaflet and the posterior leaflet, which open and close in response to pressure placed on the leaflets by the pumping of the heart. There are several problems that can develop or occur with respect to the mitral valve. Such problems include mitral valve regurgitation (MR), in which the mitral valve leaflets do not close properly, which can cause leakage of the mitral valve. Severe mitral regurgitation can adversely affect cardiac function and compromise a patient&#39;s quality of life and life-span. 
     Several techniques have been developed, for correcting mitral valve regurgitation. These include heart transplant, valve replacement or repair, chordae tendinea shortening or replacement and mitral annular repair also known as annuloplasty, depending upon the stage and underlying etiology. 
     As it relates to chordae tendinea replacement or repair, certain surgical and trans apical approaches have been proposed. Despite those efforts, however, there remains a need for a transvascular approach for chordae tendinea replacement or repair, to reduce or eliminate MR. 
     SUMMARY OF THE INVENTION 
     There is provided in accordance with one aspect of the present disclosure, a method of transvascular prosthetic chordae tendinea implantation. The method can comprise the steps of advancing a catheter into the left atrium, through the mitral valve, and into the left ventricle, and deploying a ventricular anchor from the catheter and into a wall of the left ventricle, leaving a ventricular suture attached to the ventricular anchor and extending proximally through the catheter. A leaflet anchor is deployed to secure a mitral valve leaflet to a leaflet suture, with the leaflet suture extending proximally through the catheter. The leaflet suture is secured to the ventricular suture to limit a range of travel of the leaflet in the direction of the left atrium. 
     The deploying a leaflet anchor step may comprise securing the leaflet anchor to the leaflet within the range of from about 3 mm to about 10 mm from a leaflet coaptive edge. The deploying a ventricular anchor step may comprise attaching the anchor to the ventricular septum or the ventricle wall, preferably spaced apart from the apex. The deploying a ventricular anchor step may comprise advancing an anchor driver through the mitral valve, rotating the driver to secure the ventricular anchor, and proximally retracting the anchor driver to expose the ventricular suture carried by the ventricular anchor. 
     The deploying a leaflet anchor step may comprise positioning a needle guide in contact with the leaflet and advancing a needle from the needle guide and through the leaflet. The method may further comprise deflecting a distal portion of the needle guide through an angle of at least about 160 degrees to position a distal end of the needle guide against the ventricle side of the leaflet. The needle guide may comprise a slotted tube and deflecting the needle guide may be accomplished by proximally retracting a pull wire. 
     The securing step may comprise applying a suture lock to the ventricular suture and the leaflet suture. The method may further comprise applying tension to the leaflet suture prior to the securing step, to improve leaflet function. The method may further comprise applying sufficient tension to the leaflet suture to pull the limit of leaflet travel during systole to approximately to the level of the annulus. The securing step may comprise engaging a knot to secure the leaflet suture and the ventricular suture. The method may additionally comprise the step of cutting the leaflet suture and the ventricular suture proximally of the suture lock or knot, leaving the leaflet suture and the ventricular suture to function as a native chordae. 
     The method may additionally comprise the initial step of identifying a patient including at least three characteristics selected from the group consisting of: the patient has been diagnosed with primary or degenerative mitral regurgitation; the patient has been diagnosed with secondary or functional Mitral Regurgitation; the patient has been diagnosed with Mixomotous Mitral Regurgitation; the patient has been diagnosed with a flail leaflet, ruptured chordae, or leaflet prolapse; the patient has Mitral regurgitation grade 1 or more; the patient has annular diameter from A2 leaflet to P2 leaflet at least 5 mm less than sum of length of P2+A2 leaflet; the patient has annular diameter from A2 to P2 leaflet of at least 10 mm; and the patient has an access vessel diameter of at least 2 mm. 
     The patient may additionally have at least one characteristic selected from the group consisting of: the patient has been evaluated by a heart team including at least one cardiac surgeon and determined not to be an appropriate candidate for conventional open surgical repair; the patient has STS predicted operative mortality (STS Score) of 2 or greater; the patient was offered and refused open surgical repair; the patient is age between 18 and 90; the patient will not accept blood transfusion; the patient has had prior open chest surgery; and the patient has an ejection fraction of at least 10 percent. 
     In accordance with a further aspect of the present disclosure, there is provided a method of increasing mitral valve leaflet coaptive area during systole. The method comprises the steps of securing at least a first ventricular tension element to a wall of the ventricle and securing at least a first leaflet tension element to a mitral valve leaflet. The leaflet tension element is proximally retracted to move the limit of travel of the leaflet during systole in the direction of the ventricle, thereby increasing mitral valve leaflet coaptive area during systole. The leaflet tension element is thereafter secured to the ventricular tension element. 
     The ventricular tension element may comprise a neo papillary muscle having a distal end facing the ventricular anchor, and a proximal end approximately at the height of the top of the native papillary muscle, and the securing step may comprise securing the leaflet tension element to the ventricular tension element at the proximal end of the neo papillary muscle. The neo papillary muscle may comprise an elongate, atraumatic body, and may comprise ePTFE. 
     The securing a leaflet tension element step may comprise advancing a needle guide having a distal end through the mitral valve and into the left ventricle, and deflecting the needle guide through an angle of at least 160 degrees to place the distal end into contact with the leaflet during diastole. The method may further comprise advancing a leaflet anchor deployment needle out of the distal end of the needle guide and through the leaflet, and deploying an anchor from the needle. The deploying an anchor step may comprise deploying an anchor from a first, reduced cross section within the deployment needle, to a second, enlarged cross section for seating against the atrial side of the leaflet. The deploying an anchor step may comprise deploying a pledget. 
     The proximally retracting the leaflet tension element step may comprise positioning an aperture in the left ventricle, with at least the leaflet tension element extending through the aperture, and proximally retracting the leaflet tension element with the aperture functioning as a fulcrum so that the tension element draws the leaflet in the direction of the ventricle. The fulcrum may comprise a distal opening of a catheter and the proximally retracting step may comprise proximally retracting the leaflet tension element through the catheter. The method may further comprise securing a second leaflet tension element to the leaflet and to the ventricular tension element. 
     In accordance with a further aspect of the present disclosure, there is provided an assembled in situ mitral valve leaflet restraint. The restraint comprises an elongate, flexible neo papillary muscle, having a proximal end and a distal end, and a helical tissue anchor attached to the distal end of the neo papillary muscle. An elongate, flexible neo chordae extends proximally from the neo papillary muscle, and a leaflet anchor is attached to a proximal end of the neo chordae. The leaflet anchor is enlargeable from a first reduced cross section for advancing through the leaflet, to a second, enlarged cross section for contacting an atrial side of the leaflet. The neo chordae may be attached to a suture extending distally through the neo papillary muscle to the helical tissue anchor. 
     The helical anchor may comprise a laser cut hypotube. The helical anchor may comprise one or two or more coiled round wires. The neo chordae may comprise a suture extending from a proximal end of the neo papillary muscle to the leaflet anchor. The suture may extend through the neo papillary muscle to the helical tissue anchor. 
     The neo chordae may comprises a first component extending proximally from the neo papillary muscle and a second component extending distally from the leaflet anchor. A proximal portion of the first component and a distal portion of the second component can be joined together by a locking device. The locking device can have a locked configuration and an unlocked configuration. The locking device may be configured to be advanced over the first component and the second component when in an unlocked configuration and to fixedly clamp the first component and the second component when in a locked configuration. 
     The leaflet anchor may comprise a pledget. The pledget can be configured to be collapsed by pulling a suture coupled to the pledget so that the pledget assumes the second, enlarged cross section when collapsed. A suture may be threaded through at least two, at least three, or more than three apertures in the pledget. The apertures may be substantially collinear. The leaflet anchor may comprises a T tag bar. The T tag bar may include a bar rotatably coupled to a suture such that rotation of the bar enlarges the leaflet anchor from the first reduced cross section to the second, enlarged cross section. The leaflet anchor may comprise a hub. The hub can include a plurality of flexible radially extending spokes. The spokes may be configured to bend into alignment along a longitudinal axis so as to be confined within a delivery needle. The spokes may be biased to expand radially outward when unconfined to enlarge the leaflet anchor from the first reduced cross section to the second, enlarged cross section. 
     The helical anchor may comprises a hub configured for receiving and frictionally securing a suture. The helical anchor may comprise a loop for securing the neo papillary muscle to the helical anchor. The neo papillary muscle may comprise a soft ribbon. 
     In accordance with a further aspect of the present disclosure, a neo chordae tendinae deployment system can include an elongate, flexible tubular body, having a proximal end and a distal end. A helical ventricular anchor can be positioned within the tubular body, having a rotational driver extending proximally through the tubular body. A radially enlargeable leaflet anchor within the tubular body, having a suture extending proximally through the tubular body. 
     In accordance with a further aspect of the present disclosure, there is provided a neo chordae tendinae deployment system. The deployment system comprises a catheter having a proximal end and a distal end; a helical anchor within the catheter; and a radially enlargeable leaflet anchor within the catheter. The helical anchor has a driver configured to rotate the helical anchor and extending proximally through the catheter. The leaflet anchor has a suture extending proximally through the catheter. 
     The radially enlargeable leaflet anchor may comprise a pledget. The pledget may be transformable from an elongate strip configuration to a radially enlarged, axially shortened configuration by proximal retraction of the suture. The radially enlargeable leaflet anchor may comprise the suture inserted between two sheets of material. The radially enlargeable leaflet anchor may comprise a deflectable deployment tube carried within the catheter. 
     A distal deflection zone of the deployment tube can be deflectable through an angle of at least about 160 degrees in response to manipulation of a proximal deflection control. The distal deflection zone may be within about 1.5 cm from a distal end of the deployment tube. The distal deflection zone may be deflectable to form a curve having a best fit radius of no more than about 1.5 cm. The deflectable deployment tube may comprise a slotted deflection tube. 
     The neo chordae tendinae deployment system can be configured to deploy the helical anchor in a distal direction, and to deploy the radially enlargeable anchor in a proximal direction. The enlargeable leaflet anchor can be sequentially inserted into the catheter after the helical anchor and driver have been removed from the catheter. The enlargeable leaflet anchor and the helical anchor and driver can be preloaded within the catheter. 
     In accordance with a further aspect of the present disclosure, there is provided a leaflet anchor delivery system. The leaflet anchor delivery system comprises a delivery shaft and a tissue piercing element. The delivery shaft has a distal portion, a proximal portion, and a deflection zone positioned at a distal portion of the delivery shaft. The tissue piercing element is configured to be advanced through the distal end of the delivery shaft. The deflection zone is configured for positioning the distal end of the delivery shaft on the ventricular side of the leaflet with the proximal portion of the delivery shaft extending into the left atrium. The deflection zone may comprise a flex tube. The flex tube when deflected can have a best fit radius of curvature of less than about 2 cm. 
     In accordance with a further aspect of the present disclosure, there is provided a pledget for anchoring to a heart leaflet. The pledget comprises two flat sheets comprising substantially overlapping areas; a suture positioned between the two flat sheets; and one or more apertures extending through the two flat sheets. The suture has a proximal end and a distal end. The proximal end extends from a first side of the two flat sheets. The one or more apertures extending through the two flat sheets are sized to receive the suture. The two flat sheets are joined together over portions of the overlapping areas on both sides of the suture. 
     The suture may be at least partially flattened between the two sheets. The one or more apertures may extend through the flattened suture. The distal end of the suture may extend to a second side of the two flat sheets, opposite the first side. The suture may extend between the two flat sheets along a substantially straight line. The suture may extend between the two flat sheets along a zig-zag or undulating direction. The two flat sheets may comprise expanded polytetrafluoroethylene. At least one of the two flat sheets may be at least partially sintered. 
     A proximal end of the suture extending from the first side of the two flat sheets can be threaded through the one or more apertures. The pledget may comprise a collapsed configuration in which the two flat sheets are folded over at least once to form a radially enlarged cross section. The radially enlarged cross section may extend around the suture as it passes through the one or more apertures. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  illustrates the mitral valve annulus with a suture attached as delivered via catheter. 
         FIG. 2  illustrates the distal anchor being delivered via catheter and attached to a suture further connected to the mitral annulus. 
         FIG. 3  illustrates the distal anchor being rotated into the apex of the heart with suture lines attached for later attachment to the mitral leaflet or the mitral annulus. 
         FIG. 4  illustrates the distal anchor rotated into the apex of the heart with suture lines attached to the mitral leaflet or the mitral annulus. 
         FIG. 5  illustrates the distal anchor attached and projected above the apex of the heart approximately the same height as the top of the papillary muscles. 
         FIG. 6  illustrates the distal anchor attached and projected above the apex of the heart approximately the same height as the top of the papillary muscles and attached to the mitral annulus and or mitral leaflet. 
         FIG. 7  illustrates the distal anchor attached and projected above the apex of the heart approximately the same height as the top of the papillary muscles and attached to a loop suture traversing through the catheter. 
         FIG. 8  illustrates a catheter delivered suture loop pierced through the mitral leaflet with a strain relief on the ventricular side of the mitral leaflet and a distal anchor in the bottom of the left ventricle with the final suture tension adjustment being held with a suture lock advanced over the suture tails. 
         FIG. 9  illustrates a catheter delivered suture line pierced through the mitral leaflet with a strain relief on the ventricular side of the mitral leaflet and a suture lock being advanced to the atrial side of the mitral leaflet to secure the suture tail before cutting of the suture. 
         FIG. 10  illustrates a catheter delivered suture line pierced through the mitral leaflet with a strain relief on the ventricular side of the mitral leaflet and a suture lock advanced to the atrial side of the mitral leaflet to secure the suture tail. The other end of the suture tail extends from the catheter handle through the catheter traversing about the distal anchor located in the bottom of the left ventricle for tensioning of the suture. A second suture lock is advanced over the final suture tail once the suture tension is adjusted by the user. 
         FIG. 11  illustrates a catheter delivered suture loop pierced through the mitral leaflet with a strain relief on the ventricular side of the mitral leaflet in a looped configuration about the strain relief and a distal anchor in the bottom of the left ventricle with the final suture tension adjustment being held with a suture lock advanced over the suture tails. Holding the leaflet steady and counteracting the piercing force of the strain relief is illustrated a cryo-catheter sticking to the mitral leaflet. 
         FIG. 12  illustrates a catheter delivered suture loop pierced through the mitral leaflet with a strain relief to be delivered on the ventricular side of the mitral leaflet in a looped configuration about the strain relief and a distal anchor in the bottom of the left ventricle with the final suture tension adjustment being held with a suture lock advanced over the suture tails. Holding the leaflet steady and counteracting the piercing force of the strain relief is illustrated a cryo-catheter sticking to the mitral leaflet. 
         FIG. 13  illustrates a view from the atrial side showing where the mitral annulus is pierced and where the distal anchor is located with respect to the native papillary muscles. 
         FIG. 14  illustrates a view from the atrial side showing where the mitral annulus is pierced and where the distal anchor is located with respect to the native papillary muscles. 
         FIG. 15  illustrates a variety of anchors for attachment into the apex of the left ventricle including coiled round wire and laser cut hypo-tube with vertical risers adjusting the connection point closer to the height of the papillary muscles to better simulate the correct angle and match the new chordal connections. 
         FIG. 16  illustrates a trans-septal catheter delivering an anchor in the apex of the left ventricle with a plurality of replacement chords attached and extending out the handle of the catheter. 
         FIG. 17  illustrates a trans-septal catheter delivering a piercing tool through the mitral leaflet to deliver a strain relief anchor connected to a suture loop. 
         FIG. 18  illustrates a trans-septal catheter delivering a suture loop through the mitral leaflet piercing through the leaflet with the suture loop. 
         FIG. 19  illustrates a trans-septal catheter delivering the strain relief to the ventricle side of the mitral leaflet exposing it for delivery through or with the piercing tool 
         FIG. 20  illustrates a trans-septal catheter delivering the strain relief and the piercing tool being withdrawn for the mitral leaflet. 
         FIG. 21  illustrates a trans-septal catheter delivering the strain relief with the connection to the distal anchor and the suture loop extending back out the catheter handle. 
         FIG. 22  illustrates a trans-septal catheter delivering a suture lock to the distal anchor being advanced over the suture tail while tension is applied from the proximal end of the suture back our the catheter handle to adjust the position and tension of the final implant suture connected now to the mitral leaflet and the distal apex anchor. 
         FIG. 23  illustrates a final suture loop anchoring the distal apex anchor to the mitral leaflet noting the mitral anchor can be single sided flange or a single side as shown in the unexploded view. 
         FIG. 24  illustrates a continuous loop anchor delivered in its final position with a distal apex anchor and a strain relief element on the mitral leaflet. 
         FIG. 25  illustrates an example of a distal apex anchor constructed of a stainless tube and a silicone anchor plug//to limit the suture movement before delivery of the suture lock for final positioning. The materials can be varied and changed to accommodate size and material enhancements. 
         FIG. 26  illustrates a catheter penetrating the septum from the right atrial and the left atrium. 
         FIG. 27  illustrates an anchor being rotated into the left ventricle. 
         FIG. 28  illustrates the distal apical anchor in place with the suture lines attached and extending back through the catheter and an extension arm exposed to capture the mitral leaflet with a needle to be fired when properly positioned on the leaflet. 
         FIG. 29  illustrates the extension arm in contact with the mitral leaflet and the needle connected to a suture loop penetrating the leaflet to expose a suture loop on the atrial side of the mitral leaflet. 
         FIG. 30  illustrates the suture loop exposed on the atrial side of the leaflet penetrating through the mitral leaflet to accept a loop-snare for capture of the suture loop and retrieval back through the catheter. 
         FIG. 31  illustrates the suture loop closed around the suture loop and the suture being withdrawn proximally through the catheter. 
         FIG. 32  illustrates the catheter to deliver a suture lock to the backside of the mitral leaflet as the suture is looped around the pathway including the distal apical anchor 
         FIG. 33  illustrates a second catheter to contain the suture ends to deliver a suture lock over both leaflets locking the suture together after proper tensioning of the two ends. 
         FIG. 34  illustrates the final position of the suture locks in position above and below the mitral leaflet and the suture ends cut to leave a final implant of a distal apical anchor connected to the mitral leaflet. 
         FIG. 35A  illustrates attachment of a neo papillary muscle within the left ventricle. 
         FIG. 35B  illustrates a steerable leaflet puncture catheter advancing through the mitral valve. 
         FIG. 35C  illustrates the steerable leaflet puncture catheter deflected through an angle of at least about 180°. 
         FIGS. 35D through 35G  illustrate puncturing the leaflet and deployment of a collapsible pledget type leaflet anchor. 
         FIG. 35H  illustrates a ventricle suture and a leaflet suture extending proximally through the deployment catheter. 
         FIGS. 35I-1 through 35I-4  illustrate deployment of a T tag type leaflet anchor. 
         FIGS. 35J-1 through 35J-3  illustrate deployment of a radially expandable tissue anchor. 
         FIG. 35K  schematically illustrates a fulcrum positioned at about the proximal end of the neo papillary muscle. 
         FIG. 35L  illustrates verifying mitral valve function prior to removal of the deployment system. 
         FIG. 35M  illustrates the attachment of the leaflet suture to the ventricle suture following desired tensioning. 
         FIG. 35N  illustrates severing of the leaflet suture and ventricle sutures, leaving the neo cord construct in place. 
         FIG. 35O  illustrates a distal, steerable portion of a leaflet puncture catheter, having a compound deflected configuration. 
         FIG. 36A  is a picture of a looped papillary muscle in a configuration it is first captured in. 
         FIG. 36B  shows the looped papillary pulled up onto the chords in an area where a cutting step is preferably performed. 
         FIG. 37  illustrates one embodiment of a chordae cutting tool. 
         FIG. 38A  depicts the installation of a helical anchor near the apex of the left ventricle via a ventricular anchor delivery subsystem. 
         FIG. 38B  depicts positioning a leaflet anchor delivery subsystem on the ventricular side of the leaflet using a distal flex tube. 
         FIG. 38C  depicts piercing the leaflet using a needle disposed at the distal end of the ventricular leaflet delivery subsystem. 
         FIG. 38D  depicts advancing a pledget leaflet anchor through the needle in a reduced radial cross section conformation. 
         FIG. 38E  depicts the pledget leaflet anchor expanding to an expanded radial cross section conformation. 
         FIG. 38F  depicts the pledget leaflet anchor being folded into a collapsed configuration for anchoring the suture against the atrial side of the leaflet. 
         FIG. 38G  depicts advancing a suture lock via a suture lock delivery subsystem over the leaflet anchor suture and ventricular anchor suture to connect the leaflet anchor to the ventricular anchor. 
         FIG. 38H  depicts the suture lock in locked position after the tension has been adjusted with the suture tails having been severed. 
         FIG. 39A  depicts a perspective view of a distal end of the ventricular anchor delivery subsystem. 
         FIG. 39B  depicts a perspective view of a proximal end of the ventricular anchor delivery subsystem. 
         FIG. 39C  depicts a partially exploded view of a distal end of the ventricular anchor delivery subsystem. 
         FIG. 40A  depicts a perspective view of a distal end of the leaflet anchor delivery subsystem. 
         FIG. 40B  depicts a perspective view of a proximal end of the leaflet anchor delivery subsystem. 
         FIG. 40C  depicts an exploded view of the distal end of the leaflet anchor delivery subsystem. 
         FIG. 40D  depicts a perspective view of a flex tube of the leaflet anchor delivery subsystem. 
         FIG. 40E  depicts a side view of a transition region of the flex tube of the leaflet anchor delivery subsystem. 
         FIG. 40F  depicts an orthogonal side view from that depicted in  FIG. 40E  of the transition region of the flex tube of the leaflet anchor delivery subsystem. 
         FIG. 41A  depicts a perspective view of a distal end of the suture lock delivery subsystem. 
         FIG. 41B  depicts a perspective view of a proximal end of the suture lock delivery subsystem. 
         FIG. 41C  depicts a partially exploded view of the distal end of the suture lock delivery subsystem. 
         FIG. 41D  depicts a perspective view of a distal end of a cutting assembly. 
         FIG. 41E  depicts a side view of a cutting assembly portion of the suture lock delivery subsystem in a configuration where the cutting head is not advanced for holding the sutures prior to being severed. 
         FIG. 41F  depicts a side view of a cutting assembly portion of the suture lock delivery subsystem in a configuration where the cutting head is advanced for severing the sutures. 
         FIG. 41G  depicts a side view of a suture lock and a distal end of a torque driver configured to engage the suture lock. 
         FIG. 41H  depicts a proximal end view of the suture lock. 
         FIG. 41I  depicts a distal end view of the suture lock. 
         FIG. 42  schematically illustrates a neo chordae construct implanted between two papillary muscles such that the neo chordae construct can be aligned substantially parallel to the native chordae. 
         FIG. 43A  schematically depicts a pledget formed by integrating a distal end of a suture between two flat sheets of the pledget. 
         FIG. 43B  schematically depicts a cross section of the pledget in  FIG. 43A . 
         FIG. 43C  schematically depicts the pledget in  FIG. 43C  including apertures through which the suture tail can be threaded back through to form a collapsible anchor. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     An embodiment to attach a ruptured or flail chord could include a catheter delivered through the femoral vein and traversed up into the inferior vena cava (IVC) and trans-septal to the left atrium where an attachment is made to the mitral annulus. This attachment could be a single suture loop through the mitral annular tissue or an anchor inserted into the annulus either rotated, pierced into or threaded to the local tissue where the mitral leaflet meets the atrial tissue at or near the mitral annulus. The anchor could be constructed of a coiled-wire anchor which would be rotated into the tissue with a suture receiver for chordal replacement or a pre-attached chordal affixed to the anchor. 
     A connection to the mitral annulus can provide a secure and positive attachment point as a stable anchor through a piercing, hook or corkscrew anchoring device. To this attachment point a chord can be connected to drape over the mitral valve leaflet and further attached or anchored into the apex of the left ventricle. It could also be pierced through the anterior or posterior mitral leaflets at any position. The chord can be made of round, flat PTFE, PE or nylon as conventionally used in surgery for chordal repair. 
     In some embodiments, the chord may serve as a neochord or prosthetic chord. The chord may be a standard suture in certain embodiments. In some embodiments, one or more additional prosthetic elements may be secured over the chord. For example, tubular structures may be advanced (e.g., slid) over the cord through the delivery device. The structures may be configured to self-position themselves as appropriately along the length of the chord or the structures may be secured to the chord along at an appropriate position (e.g., by placing locking members proximally and/or distally of the structure). Any suitable locking members may be used to position structures in place. Locking members may be crimpable, may comprise mechanical locking mechanisms, and/or may frictionally engage the chord require a threshold amount of force to be advanced over the chord. Any suitable type of locking member may be used. Locking members may be similar to suture locks described elsewhere herein. In some embodiments, locking members may be configured to be advanced distally and proximally over the chord. In some embodiments, locking members may be configured to advance in only one direction (e.g., distally over the chord). In some embodiments, additional prosthetic structures may be secured at a proximal end, distal end, or intermittently along the length of the chord. The chord may attach to a proximal or distal end of the prosthetic structure. For example, two chords may be used, one attached to a proximal end of the structure and one attached to a distal end of the structure. In some embodiments, the chord may connect to the structure, for example at a proximal and/or distal end (e.g., inserted through or wrapped around a loop on the structure), and run parallel along the length of the structure. The prosthetic structure may be configured for contact with one or more physiological tissues (e.g., for interfacing with the leaflet) and/or may be configured to replicate the mechanical/structural properties of physiological structures (e.g., the papillary muscle). 
     Anchoring to the annulus can provide an attachment point which is positive and immobile with respect to the mitral leaflets which are difficult to capture with a ruptured chord due to the movement at each heartbeat. This movement can be halted with a grasping of the flail leaflet by a mechanical gripper tool, suction tube or a cryo-catheter to freeze-grab the leaflet as will described in more detail below in relation to certain illustrated embodiments. As the upper anchor is positively attached to the mitral annulus it can be draped over the mitral leaflet and between the existing chords to limit the location laterally with respect to the leaflet. Locating the leaflet between existing chords provides the artificial chord a positive anchor at the upper anchor point, a secured angular location passing through the existing chords and another positive location at the apex of the left ventricle. The replacement chord can be a single suture strand or a plurality of chords traversing up and down the pathway as described above allowing the load to be carried by a plurality of chords. 
     The lower apical anchor that can be located in the left ventricle can be secured via a rotational screw or plug to hold the chord positively. The anchor could be short in height and close to the base of the apex or have an extended length to better match the native papillary muscles of about 20-22 millimeters above the apex of the left ventricle. In some embodiments, the anchor extend about less than 5 mm, 5 mm, 10 mm, 15 mm, 20 mm, 25 mm, 30 mm, 35 mm, 40 mm,  45 , mm, 50 mm, or more than 50 mm above the apex and/or a range between the afore-mentioned values. A single chord or plurality of chords could be attached to one or more anchors at the base of the left ventricle. The anchor could be constructed of an implantable grade of stainless steel, Nitinol or other metallic material that would be visible on fluoroscopy or a polymeric material such as PEEK, PTFE or other implantable materials. These polymers could be doped with a radiopaque marker for visibility if needed. 
     An embodiment for the anchoring system could comprise of the apical tissue anchor which couples or attaches to the left ventricle, a riser which projects the attachment from the apical tissue anchor and could be constructed from a monolithic material or a combination of materials including polymers and metallic components. The construction could be rigid throughout or have flexible joints to allow movement or an elastic zone or zones for controlled motion and flexibility. It could be constructed of a round crossing profile or any other profile including a varying shape longitudinally. The diameter could be about 6 to 24 French (2 to 8 millimeters) and length about 20 to 40 millimeters and delivered via steerable catheter with or without a guidewire generally along the central axis. Once the upper leaflet anchor is attached to the mitral annulus or leaflet and draped over the mitral leaflets and further coupled to the lower anchor a tension force would allow for an adjustment via real time imaging/monitoring (e.g., under live echo) while monitoring the leaflet motions and regurgitant flow reduction. The final step could be to tension, lock and disconnect the chord from the delivery system. A tension of the chord would apply tension to the connected mitral valve leaflet strain relief and a locking device such as a Cor-Knot from LSI Solutions could be advanced down the chord and lastly the suture tail could be cut. 
     According to one embodiment (see  FIGS. 1-7 ), the steps of the replacement chord delivery could include:
         1. Trans-venous, trans-femoral entry of the delivery catheter  100     2. Catheter  100  advancement to the right atrium  10     3. Trans-septal advancement  12  of catheter  100  into the left atrium  14     4. Catheter  100  advancement to the mitral annulus  16  for the strain relief anchor  18  positioning and delivery   5. Positioning of a grasping tool of the mitral leaflet   6. Strain relief anchor  18  attachment to the mitral annulus  16     7. Replacement Chord  22  advancement over the mitral valve  25  and between the existing chords  17     8. Chord  22  advancement to the apex  20  of the left ventricle and distal attachment into the apex  20     9. Tensioning of the chord  22  while monitoring the mitral valve leaflet motion       

     Alternatively, in certain embodiments (see e.g.,  FIGS. 26-34 ), the delivery could be in a somewhat opposite order:
         1. Trans-femoral entry of the delivery catheter  100     2. Catheter  100  advancement to the right atrium  10     3. Trans-septal advancement  12  of Catheter  100  into the left atrium  14     4. Advancement of the delivery catheter  100  through the mitral valve  24  to the apex  20  of the left ventricle   5. Delivery of the distal ventricular anchor (e.g., rotational anchor  32 ) into the apex  20     6. A withdrawal of the delivery catheter  100  to expose the lower apex anchor  30     7. Pulling the delivery catheter  100  proximal to expose the new chord suture line  22  or lines  22     8. Over each new chord  22  a mitral leaflet strain relief can be delivered through the mitral leaflet and on the ventricular side of the leaflet   9. An advancement of a suture lock  26  over the suture tail  28  to lock the position of the suture to the position of the strain relief anchor   10. A cutting of the suture tail at the mitral leaflet anchor   11. An advancement of a suture lock  26  over the suture tail from the catheter handle to the mitral leaflet anchor   12. An advancement of a suture lock  26  over the suture tail from the catheter handle to the distal apex anchor locking the tension as applied from the distal most suture tail outside the catheter handle   13. A cutting of the suture tail at the distal apex anchor       

     Some of the steps of these methods may be optional. Additional steps may be included where appropriate. Furthermore, the steps may be rearranged into any feasible order. 
     An embodiment according to  FIGS. 1-7  will now be described with additional detail.  FIG. 1  illustrates the mitral valve annulus  16  with the suture  22  attached as delivered via the catheter  100 .  FIG. 2  illustrates the distal anchor  32  being delivered via the catheter  100  and attached to the suture  22  further connected to the mitral annulus  16 .  FIG. 3  illustrates the distal anchor  32  being rotated into the apex  20  of the heart with suture lines  22  attached for later attachment to the mitral leaflet  24  or the mitral annulus  16 .  FIG. 4  illustrates the distal anchor  32  rotated into the apex  20  of the heart with suture lines  22  attached to the mitral leaflet  24  or the mitral annulus  17 .  FIG. 5  illustrates the distal anchor  32  attached and projected above the apex  20  of the heart approximately the same height as the top of the papillary muscles. The anchor  32  can include a riser  70  connected to a connection point  72  having a length of about 20-40 mm in certain embodiments. The riser  70  may be of a same or different material, diameter, stiffness, etc. as the remainder of the anchor  32 . The riser  70  may be in longitudinal alignment with the remainder of the anchor  32  or may be positioned at an angle to the remainder of the anchor  32 . The riser  70  may be rigidly fixed or integrated to the remainder of the anchor  32 , coupled in an articulable manner (e.g., joint/socket), or flexibly joined (e.g., interconnecting loops). The tension placed on the anchor  32  upon installation of the neo chordae may determine or alter the orientation of the riser  70  with respect to the heart and/or remainder of the anchor  32 .  FIG. 6  illustrates the distal anchor  32  attached and projected above the apex  20  of the heart approximately the same height as the top of the papillary muscles. The distal anchor  32  may be attached via one or more suture lines to the mitral annulus  16  and or mitral leaflet  24 .  FIG. 7  illustrates the distal anchor  32  attached and projected above the apex  20  of the heart approximately the same height as the top of the papillary muscles and attached to a suture  33  in a form of a loop traversing through the catheter  100 . 
       FIG. 8  illustrates an embodiment in which a catheter delivered suture  50  in a form of a loop can be pierced through the mitral leaflet  24  with a strain relief  52  on the ventricular side of the mitral leaflet  24  and a distal anchor  32  in the bottom of the left ventricle with the final suture tension adjustment being held with a suture lock  54  advanced over the suture tails  56 . The single suture loop  50  may join the distal anchor  32  to the strain relief  52 , directly to the distal anchor, and/or to another leaflet anchor. More than one loop may also be used. In some embodiments, the suture  50  may pass through a loop structure in the distal anchor  32  and/or the strain relief  52  such that it effectively doubles back on itself. In some embodiments, the suture  50  may pass through a channel in the distal anchor  32  and/or strain relief  52  such that a proximal end of the suture  50  enters at one opening and a distal end of the suture  50  exits at another opening. The openings may be positioned on the same side of the distal anchor  32  and/or strain relief  52 . The openings may be positioned on opposite sides of the distal anchor  32  and/or strain relief  52 . The relative length of the suture tails  56  extending from the distal anchor  32  and the strain relief  52  may determine the effective final positioning of the suture lock  56 . For example, by minimizing the length of the suture tail  56  extending from the strain relief  52 , the suture lock  54  may be effectively positioned on the atrial side of the mitral leaflet  24 , such as directly over the strain relief  52 . By minimizing the length of the suture tail  56  extending from the proximal end of the distal anchor  32 , the suture lock  54  may be effectively positioned just above the distal anchor  32 . The suture lock  54  may be any suitable type of suture locking mechanism, including those described elsewhere herein. The strain relief  52  may comprise an expandable conformation, such that the strain relief  52  is inserted through the leaflet  24  in a collapsed conformation (e.g., a reduced cross-section conformation) and expanded (e.g., to an expanded cross-section conformation) on the ventricular side of the leaflet  24 . The strain relief  52  may be self-expanding. In some embodiments, the strain relief  52  may be a pledget as described elsewhere herein. The strain relief  52  may be inserted via a needle or other suitable implement for piercing the leaflet  24  tissue, such as those described elsewhere herein. The strain relief  52  may be stored inside and advanced through an internal lumen of the needle. The needle may constrain the strain relief  52  in a collapsed conformation. The strain relief  52  may be inserted through the leaflet  24  with the suture  50  pre-loaded (e.g., looped through the strain relief) such that both the proximal end and distal end of the suture  50  extending from the strain relief remain extending through the puncture through the leaflet  24  when the strain relief  52  is installed. The suture lock  54  can prevent the suture tails  56  from advancing or retracting through the suture lock  54 , thereby, holding the suture chords in a state of tension after the suture lock  54  engaged, allowing the tails  56  to be severed proximal to the suture lock  54 . The tails  56  of the suture  50  may be severed directly adjacent to the suture lock  54  or proximally distant to the suture lock  54  allowing a length of the tails  56  to freely extend from the suture lock  54 . The strain relief  52  and the distal anchor may be loaded onto the suture loop  50  outside of the body and sequentially installed through the catheter  100  in any order. 
       FIG. 9  illustrates an embodiment in which a catheter delivered suture line or loop  60  can be pierced through the mitral leaflet  24  with a strain relief  52  on the ventricular side of the mitral leaflet  24 . The strain relief  52  may be inserted as described with respect to  FIG. 8 . In this embodiment, a suture lock  62  can be advanced to the atrial side of the mitral leaflet  24  to secure the suture tail before cutting of the suture  60 . The suture lock  62  can be advanced along only one tail of the suture  60 , such that it does not secure the suture tail extending from the distal anchor  32 , only the tail extending from the strain relief  52 . The suture lock  62  can be configured (e.g., size and/or shaped) to prevent the suture lock from being pulled through the puncture in the mitral leaflet  24  when under tension. The suture tail extending from the distal anchor  32  may be secured as described with respect to  FIG. 10 . 
       FIG. 10  illustrates an embodiment in which a catheter delivered suture line  60  can be pierced through the mitral leaflet  25  with a strain relief  52  on the ventricular side of the mitral leaflet  25  and a suture lock  62  advanced to the atrial side of the mitral leaflet to secure the suture tail, as described with respect to  FIG. 9 . The other end of the suture tail extends from the catheter handle through the catheter  100  traversing about the distal anchor  32  located in the bottom of the left ventricle for tensioning of the suture. A second suture lock  63  can be advanced over the final suture tail and locked in position on the final suture tail once the suture tension is adjusted by the user. The second suture lock  62  may be configured (e.g., sized and/or shaped) to prevent the suture lock  62  from being pulled through the distal anchor  32  when under tension. 
       FIG. 11  illustrates an embodiment in which a catheter delivered suture loop  60  can be pierced with a piercing element  27  (e.g., a needle) through the mitral leaflet  24  with a strain relief  52  on the ventricular side of the mitral leaflet  24  in a looped configuration about the strain relief  52  and a distal anchor  32  in the bottom of the left ventricle with the final suture tension adjustment being held with a suture lock advanced over the suture tails. The configuration of this embodiment may be similar to that illustrated in  FIGS. 8-10 . Holding the leaflet steady and counteracting the piercing force of the strain relief can be accomplished using a cryo-catheter  70  sticking to the mitral leaflet  24 . The cryo-catheter  70  can be delivered through the same catheter  100  or through a separate catheter. The cryo-catheter may transiently apply a cooling effect to the mitral leaflet  24  causing tissue of the leaflet  24  to temporarily adhere to the catheter. Other retention devices may be used as well, alone or in combination, including suction devices, tissue-grasping devices, additional piercing devices, etc. Providing a retention force to the leaflet  24  may advantageously assist in applying a counter force to the leaflet during insertion of the piercing element  27 . 
       FIG. 12  illustrates a catheter delivered suture loop  60  pierced through the mitral leaflet  24  with a strain relief to be delivered on the ventricular side of the mitral leaflet in a looped configuration about the strain relief and a distal anchor  32  in the bottom of the left ventricle with the final suture tension adjustment being held with a suture lock advanced over the suture tails. Holding the leaflet steady and counteracting the piercing force of the strain relief is illustrated a cryo-catheter  70  sticking to the mitral leaflet. The embodiment illustrated in  FIG. 12  may be similar to the embodiment illustrated in  FIG. 11 , with the piercing element  27  retracted from the tissue. 
       FIGS. 13 and 14  illustrates a views from the atrial side showing where according to certain embodiments the mitral annulus  16  is pierced and where the distal anchor  32  is located with respect to the native papillary muscles. In some embodiments, either the anterior or posterior leaflet or the annular tissue adjacent thereto may be pierced. The positioning of the piercing and installation of a strain relief or leaflet anchor may be used to affect the amount of tension exerted on the leaflet. 
       FIG. 15  illustrates a variety of anchors embodiments  32   a ,  32   b ,  32   c ,  32   d , for attachment into the apex of the left ventricle including coiled round wire  32   a ,  32   b ,  32   c  and laser cut hypo-tube  32   d  with vertical risers  70  adjusting the connection point  72  closer to the height of the papillary muscles to better simulate the correct angle and match the new chordal connections. Anchor  32   a  comprises a single helical coil extending around the outside of a longitudinally aligned pointed shaft. In some embodiments, the shaft may be excluded. Anchor  32   b  comprises two helical coils, having substantially the same pitches, extending in opposite directions. In some embodiments, a pointed shaft, such as in  32   a , may extend between the coils. Anchor  32   c  includes a single helical coil that reduces in its outer diameter from the proximal end of the coil to the distal end of the coil. Anchor  32   d  includes a single coil formed from the laser cut hypotube. In some embodiments, the connection point  72  may be a single closed loop. Sutures may be looped through or otherwise attached to the loop. In some embodiments, other types of connections to the suture or other type of chord may be used. The anchor  32   c  includes a riser  70  in the form of a strut and the connection point  72  that can receive the suture  60 , which can be secured within the connection point  72  by a silicone plug  74 . Any suitable material may be used for the plug. The connection point  72  may have a channel configured (e.g., sized and shaped) for receiving the plug  74 . The connector may include one or more apertures extending through a sidewall of the channel for allowing a suture to pass through. The plug  74  may frictionally engage the channel. The one or more sutures may extend through the channel and through an aperture in the sidewall as shown in  FIG. 15 . The suture may freely slide through the aperture during installation when the plug  74  is absent, allowing adjustment of the length of the suture and the tension in the suture. The plug  74  may be inserted into the channel and form a tight frictional fit with the channel. The plug  74  may frictionally secure the one or more sutures between an outer surface of the plug  74  and an inner surface of the sidewall, thereby effectively locking the suture in place with respect to the anchor  32   c . The plug  74  may be installed after adjusting the length and tension of the one or more sutures. In other embodiments, the suture may extend through a loop a distal end of the channel, allowing the suture to slide there through. Proximal and distal ends of the suture may extend through the proximal opening of the channel. The plug  74  may frictionally secure the suture as described above and preventing further sliding of the suture with respect to the anchor  32   d . The various features of the anchors  32   a - 32   d  disclosed herein may be employed in any suitable combination. 
       FIGS. 16-22  illustrate another method according to certain embodiments. 
       FIG. 16  illustrates a trans-septal catheter delivering an anchor  32  in the apex  20  of the left ventricle with a plurality of replacement chords  22  attached and extending out the handle of the catheter  100 .  FIG. 17  illustrates the trans-septal catheter  100  of  FIG. 16  delivering a piercing tool  80  through the mitral leaflet  24  to deliver a strain relief anchor connected to a suture loop  60 .  FIG. 18  illustrates the trans-septal catheter  100  delivering a suture loop  60  through the mitral leaflet  24  piercing through the leaflet  24  with the suture loop  60 .  FIG. 19  illustrates the trans-septal catheter  100  delivering the strain relief  52  to the ventricle side of the mitral leaflet  24  exposing it for delivery through or with the piercing tool  80 . In some embodiments, the strain relief  52  may self-expand upon exposure, as described elsewhere herein.  FIG. 20  illustrates the trans-septal catheter delivering the strain relief  52  and the piercing tool  80  being withdrawn from the mitral leaflet  24 .  FIG. 20  shows an embodiment in which two strain reliefs are positioned on opposite sides of the mitral leaflet  24 . The leaflet may be sandwiched between atrial-side and ventricular-side strain reliefs. The atrial-side strain relief may be advanced over the suture after the ventricular-side strain relief  52  is positioned in place and tension applied to the suture to put the ventricular-side strain relief  52  into flush contact with the leaflet  24 . The atrial side strain relief may be configured to be locked or secured to the suture to prevent slack from generating between the strain reliefs, which could interfere with the contact between the strain reliefs and the leaflet  24  tissue and take pressure off of the strain reliefs. In some embodiments, a suture lock may be advanced behind the atrial-side strain relief and force the atrial-side strain relief into flush contact with the leaflet  24  tissue. In some instances, using dual strain reliefs may reduce the strain on the puncture point through the leaflet  24  and mitigate any damage to the leaflet  24  tissue.  FIG. 21  illustrates the trans-septal catheter  100  delivering the strain relief  52  with the connection to the distal anchor  32  and the suture loop  60  extending back out the catheter handle  FIG. 22  illustrates the trans-septal catheter delivering a suture lock  62  to the distal anchor  32 . The suture lock  22  is being advanced over the suture tail while tension is applied from the proximal end of the suture back out through the catheter handle to adjust the position and tension of the final implant suture, which is connected now to the mitral leaflet  24  and the distal apex anchor  32 . 
       FIG. 23  illustrates an embodiment in its final position, in which a continuous suture loop anchors the distal apex anchor  32  to a strain relief element  52  on the mitral leaflet  24 . In some embodiments, the continuous loop may be formed by applying suture locks to tails of the looped suture. Any other suitable means for forming a continuous loop suture may be used as well. In some embodiments, the mitral leaflet anchor or strain relief element  52  can be double-sided (e.g., comprise a double-sided flange  52   b ), as shown in the exploded view, or a singlesided flange  52   a  as shown in the unexploded view. The double-sided flange  52   b  may comprise expandable elements (e.g., expandable flanges) configured to be positioned on opposite sides of the mitral leaflet tissue. In some embodiments, the two opposing flanges may be fixedly coupled to each other through an intermediate element that traverses the leaflet  24  puncture. The flanges may comprises a plurality of strain relief elements (e.g., flexible/deformable loops) configured to distribute the strain across a larger surface area of the leaflet  24 . 
       FIG. 24  illustrates an embodiment in which a continuous loop  90  is delivered in its final position with a distal apex anchor  32  and a strain relief element  52  on the mitral leaflet  24 . The embodiment may be similar to that illustrated in  FIG. 23 . 
       FIG. 25  illustrates an example of a distal apex anchor  32  constructed of a stainless steel tube  73  and a silicone anchor plug  72  configured to limit the suture movement before delivery of the suture lock  62  for final positioning. In some embodiments, the plug  72  may be used as a temporary suture lock. In other embodiments, the plug may serve as a temporary suture lock in addition to or alternatively to suture lock  62 , which is advanced over the suture. Where the plug  72  is temporarily used, it may be removed prior to completion of the implant installation. The materials can be varied and changed to accommodate size and/or material enhancements. In some implementations, the anchor  32  may be the same or similar to the anchor  32   c  illustrated in  FIG. 15 . 
       FIGS. 26-34  illustrate an embodiment in which order of the placement distal apex anchor  32  can be modified. As shown,  FIG. 26  shows a catheter  100  penetrating the septum  12  from the right atrial and the left atrium  14 . 
       FIG. 27  illustrates an anchor  32  being rotated into the apex of the left ventricle. The anchor  32  may be rotated clockwise or counterclockwise depending on the configuration of the anchor. The anchor  32  may be rotated by a delivery instrument (e.g., a rotational driver) that can be inserted through the catheter  100 , as described elsewhere herein. In addition, while the illustrated embodiment shows the anchor  32  being rotated into the apex of the left ventricle in modified embodiments the anchor  32  can be secured to other locations within the left ventricle. For example, as will be described in more detail below, embodiments of the methods and devices described herein can also be utilized in arrangements in which the anchor  32  is positioned in left ventricle between the papillary muscles. Such an arrangement can advantageously align the suture extending the anchor  32  and the mitral leaflet  24  with one or more of the chordae tendinae extending from the anchored mitral valve leaflet  24 . 
       FIG. 28  illustrates the distal apical anchor  32  in place with the suture lines  22  attached and extending back through the catheter  100  to a proximal end of the delivery device outside of the body. The suture can be looped through the anchor  32  as described elsewhere herein. An extension arm  94  of the catheter  100  can be exposed on a lateral side of the catheter, somewhat proximal to the distal end of the catheter  100 . The extension arm  94  may be angled to extend in a proximal direction from the side of the catheter  100 . The extension arm may be configured to capture the mitral leaflet  24 , such as on the ventricular side of the leaflet  24 . The extension arm  94  may have a pointed tip or may comprise a needle or allow passage of a needle through the catheter  100  and the extension arm  94 . The leaflet  24  may be engaged with a needle configured to be fired when properly positioned on the leaflet  24 . In some embodiments the extension arm may be formed on a separate catheter which is configured to extend through and be independently distally advanceable and proximally retractable through the catheter  100 . 
       FIG. 29  illustrates the extension arm  94  in contact with the mitral leaflet  24  and the needle  96  connected to a suture loop  60  penetrating the leaflet  24  to expose a suture loop  60  on the atrial side of the mitral leaflet  24 . In some embodiments, the suture loop may be formed from one tail of the suture extending through the distal anchor  32 . The other end may extend proximally through the delivery catheter to a proximal end of the delivery catheter  100  and outside the body. In some embodiments, the suture loop  60  may be a ring through which the suture is looped. In some embodiments, the suture loop  60  may be a loop in the suture which is engaged with the needle  96 , and the needle  96  may be configured to retain the suture loop  60  and prevent the suture loop from being retracted proximally through the needle  96 . In some embodiments, a continuous suture may be threaded through the distal anchor  32  such that four strands extend from the distal anchor  32 , two of which extend through to the proximal end of the catheter  100  and two of which extend to form the suture loop  60 . 
       FIG. 30  illustrates the suture loop  60  exposed on the atrial side of the leaflet penetrating through the mitral leaflet to accept a loop-snare  99  for capture of the suture loop  60  and retrieval back through the catheter  100 . The loop snare may be delivered through another opening the catheter  100 , which is positioned proximally of the extension arm  94 . The extension arm  94  and loop snare opening may be positioned on the same lateral side of the catheter  100 . The loop snare  99  may be configured to be contracted around the suture loop  60  such that the loop snare  99  may retain the suture loop  60  and retract it proximally into the catheter  100  through the loop snare opening (advancing the suture loop distally through the extension arm  94 ). 
       FIG. 31  illustrates the suture loop snare  99  closed around the suture loop  60  and the suture being withdrawn proximally through the catheter  100 .  FIG. 32  illustrates the catheter  100  delivering a suture lock  62  to the backside of the mitral leaflet as the suture is looped around the pathway including the distal apical anchor  32 . The suture lock  62  and distal anchor  32  may be configured such that the suture lock  62  may freely pass through the connecting point of the distal anchor  32  to reach the ventricular side of the leaflet  24 . For example, the suture lock  62  may be configured to pass through a loop in the distal anchor  32 . The extension arm  94  may be retracted prior to or during this step, such that the leaflet  24  is no longer captured by the extension arm  94 . In some embodiments, as described elsewhere herein, the extension arm may be formed as part of an internal catheter that is advanced through catheter  100  and can subsequently be withdrawn through catheter  100 . 
       FIG. 33  illustrates a second catheter  101  to contain the suture ends to deliver a suture lock over both leaflets locking the suture together after proper tensioning of the two ends. Catheter  100  may be withdrawn bringing the suture loop  60  outside of the body, where it may be aligned with the other end of the suture. The second suture lock may be applied over the suture ends and subsequently delivered into the body using the second catheter  101   FIG. 34  illustrates the final position of the suture locks  62  in position above and below the mitral leaflet  35  and the suture ends cut to leave a final implant of a distal apical anchor connected to the mitral leaflet  24 . The second suture lock  62  may be positioned in alternative positions as well relative to the leaflet  24 , depending on the length of the suture between the two suture locks. Positioning two suture locks on opposite sides of the leaflet  24  may allow the suture locks to serve as strain reliefs. In some embodiments, the first suture lock  62  positioned on the ventricular side of the leaflet  24  may be omitted. 
     Chordal end termination and suture locking configurations and devices can include one or more of knots, pledgets or other termination techniques to reduce the focal stress at the attachment points. Piercing through annular tissue and leaflets can be achieved via sharpened needle insertion and can be driven via a steerable catheter and core shaft to push, locate and drive the needle through the mitral leaflet. These procedures may be guided under fluoroscopy, echo guidance, or any other suitable visualization or monitoring procedure. Leaflet location and isolation can be achieved by a mechanical technique of grasping or pinching the leaflet or by suction or freeze-grabbing with a cryo-catheter. These techniques would include a cryo-catheter used in ablation procedures to freeze the focal tissue as described, for example, with reference to  FIG. 12 . These cryoablation-catheters used for atrial fibrillation often attach themselves to the mitral leaflets accidentally and need to be deactivated to release the attached leaflets. This same cryo attachment could be used to locate and isolate the leaflet in question for a reinstallation of the repair. The cryo catheter uses a gaseous exchange (NO or Argon) to drop the temperature of the tip of the catheter, and can reach temperatures as low as minus 75 degrees Celsius. 
     The lower apical anchor construction could consist of a coiled distal section to rotate into the apex of the left ventricle with a round or flat wire construction or a laser cut tube emulating a cork screw similar to a wine cork as described for example in  FIG. 6  and  FIG. 15 . A variable pitch in the screw will allow for a more secure attachment into the surrounding tissue. Another device for tissue securement could include a swaging or ovalization of the screw anchor to achieve the same securement. The attachment to the anchor riser could be pinned, welded, or joined though other mechanical devices. Alternatively it could be constructed of the same material and laser cut from the same tube of stainless steel, Nitinol or other implantable material. At the proximal most end could be a loop or tube to receive the replacement chord such as illustrated in the connection  72  of  FIG. 15  or a plurality replacement chords could be preloaded ready for delivery and extending out the handle of the catheter. 
     In another embodiment, the distal anchor could be delivered to the apex of the left ventricle with a plurality of replacement chords looped to the anchor and the extending back to most proximal handle section of the catheter. This would allow for a delivery of multiple anchors to a single point of origin extending vertically from the apex of the left ventricle and the free ends of the replacement chord would be extended back out of the delivery catheter for access and advancement of other tools for locking and cutting. Over these free ends a delivery piercing element or tube can be advanced to the mitral leaflet to pierce through and deliver a pledget or restraining element through the leaflet and to the back side (ventricular side) of the leaflet. This could secure a loop and restraining element to hold the loop from being pulled through the leaflet and acting as a strain relief element. Over the same free end of the replacement chord can be delivered a locking element to hold the position of the chord and pledget securely to the leaflet position. Once delivered, this free end can be cut. Finding and holding the leaflet can be achieved by the cryo-catheter to hold the leaflet from the atrial side or a gripping tool to grasp the leaflet from the free edge could also be used. Once the first piercing and pledget is delivered, the other free end can now be tensioned around the distal apex anchor and a second locking element can be delivered to hold the position relative to the end of the apex anchor. The chord or suture anchor can be secured by an interference fit to the distal apex anchor and/or to the other chord line running up to the mitral leaflet. It is important to note the drawings illustrate the delivery and installation of the mitral leaflet anchor to the posterior leaflet but anchors and replacement chords could also be delivered to the anterior leaflet or any position on the mitral leaflet including the free margin, coaptation zone, or annulus. 
     Another method would be to place the distal rotational anchor in the left ventricle that is connected to a continuous loop of suture similar to a rubber band. One end would be secured to the distal anchor and the other end would pierce the mitral valve leaflet and be connected to a strain relief element to distribute the force on the ventricular side of the mitral leaflet, so as to prevent from pulling the replacement chord through the leaflet or tearing the leaflet. The strain relief element could be a laser cut tube that expands from a small configuration to a larger configuration once passed through the leaflet either through a compressive axial force or it could be constructed of a shape memory metal like Nitinol, where it is pre-set to a shape where the delivery diameter is small and the delivered diameter expands to a larger state. The delivered diameter could be about 0.5 millimeters expanding into about 2-3 millimeters in diameter and have a length of about 2 to 5 millimeters at delivery shortening to about 1-2 millimeters. It could also be constructed of shape memory metal and set to a round shape similar to an Amplatz device or a simple or complex suture knot located on the ventricular side of the leaflet. Another configuration could be a wound looped Nitinol wire that would look like a daisy with Nitinol wire peddles. This device could also be used to adjust the final length of the loop chord by winding or coiling the loop end passed through the leaflet. For example, the number of times the suture or chord is wound around the device could incrementally decrease the free length of the suture or chord. This winding mechanism could also be located at the distal coil anchor located in the left ventricle. The adjustment could be actuated during delivery to adjust the chord length and/or post-procedure where the adjustment is accessed and either shortened or lengthened. A rotational ratcheted drive coupled to a drive shaft or wire could be rotated external to the body by coupling and decoupling when adjustment is needed. The drive shaft could be a round wire constructed of stainless or Nitinol where a hex coupling interface between the drive shaft and winding mechanism could be used to engage and disengage the two elements. The two elements could be delivered in a mated configuration with one another for actuation and could later couple by using a loop snare to grasp the winding mechanism and couple the drive shaft engaging the hex drive device. The winding mechanism could utilize a simple rotational spool with a cog-style stop for anti-rotation or a friction resistance to hold the tensioned position. Alternatively, designing the distal coil anchor to accept an inner matching pitch adjustment screw, which would be coupled to the chord and allow for the outer body of the distal anchor to be driven into the apical tissue and secondarily a rotation of the inner matching pitch screw would allow for a tensioning of the chord by shortening the relative distance between the two screw elements. The simplest configuration would be a coil inside another coil where they both have right or left-hand threading and would couple with one another to provide a rotational motion into a translational or axial motion. Locking the two coils together post-adjustment would provide for a positive location of the chord length between the leaflet and the distal anchor system. 
     Patient Selection 
     In an embodiment, the method of treating a patient begins with selecting an appropriate patient. The methods, apparatuses, and systems, disclosed herein, however, are not limited to application only on preferable or otherwise appropriate patients. Preferably, the patient includes at least one three or five of the following characteristics from a first group:
         Diagnosed with primary or degenerative mitral regurgitation.   Diagnosed with secondary or functional Mitral Regurgitation.   Diagnosed with Mixomotous Mitral Regurgitation.   Diagnosed with a flail leaflet, ruptured chordae, or leaflet prolapse.   Mitral regurgitation grade 1 or more; 2 or more; 3 or more or; 4 or more.   Annular diameter from A2 leaflet to P2 leaflet at least 5, 10, 15, 20, 30, 50 mm less than sum of length of P2+A2 leaflet. Similar mathematical relationships that ensure adequate redundant coaptation after repair, so as to create a durable repair, may also be used.   Annular diameter from A2 to P2 leaflet 10 to 50 mm, or preferably 24 to 36 mm, or most preferably 26 to 33 mm.   Access vessel diameter at least 2-10 mm diameter.
 
Preferably the patient has at least 1, 3, or 5 of the following characteristics from a second group:
   Evaluated by a heart team including at least one, and preferably two, cardiac surgeons and determined not to be an appropriate candidate for conventional open surgical repair.   STS predicted operative mortality (Society of Thoracic Surgeons&#39; Score or STS Score) of 2-20 or greater.   Patient was offered and refused open surgical repair.   Age between 18 and 90, or preferably between 35 and 85 more preferably between 40 and 85.   Patient will not accept blood transfusion.   Prior open chest surgery   Ejection fraction of at least 10-60 percent       

     For some embodiments of the device, it is preferable the patient is substantially free from the following conditions (the third group):
         Moderate or severe COPD   Hypercoagulative disorder   Systemic degenerative collagen disease (i.e. Marfans syndrome)   Prior septal infarction affecting the anchor area   Ventricular septal defect   Known allergy to contrast media   Prior mitral valve replacement       

     In one embodiment the patient selected may meet at least 1, 2, or 3 criteria from the first group and at least 1, 2, or 3 criteria from the second group. In one embodiment, the patient selected may meet at least 1, 2, or 3 criteria from the first group and at least 1, 2, or 3 criteria from the second group and does not meet at least 1, 2, or 3 conditions from the third group. 
     Patients can be screened using echocardiographic imaging and/or CT imaging. MRI imaging is also possible. Preferably, a contrast gated cardiac CT with at least 32, 64, or 128 slices is obtained prior to the procedure and used for patient selection and/or case planning. Using imaging software, the annular diameter can be measured from the hinge point of A2 to hinge point of P2 leaflet, and the free length of the leaflet can be measured. These measurements can be compared to ensure that after the procedure is completed, sufficient redundant coaptation will be present to produce a durable repair. In one embodiment, the annular dimension may be reduced using another device or method such as a trans-catheter annuloplasty device, to create a small enough annular diameter. 
     Imaging 
     The present disclosure has the potential to allow excellent real time assessment and adjustment of suture placement and tension during the procedure. Some embodiments of the imaging method offer significant advantages in visualization even compared to what is available during open cardiac surgery. 
     Optimizing Tension 
     During open surgical mitral valve repair, the heart is stopped, flaccid and deflated, such that the surgeon has to estimate the movement of the dynamic structure based on his or her experience. The surgeon&#39;s initial assessment step involves filling the ventricle with saline to push the mitral leaflets into a closed position and visually assessing areas of leakage, prolapse and/or inadequate coaptation. 
     This assessment may be limited because it is not performed on a beating heart, but the sutures are tied off and secured based on this assessment, then the atrium is closed the heart is reanimated, and the final echo assessment or other monitoring procedure on the beating heart is performed. If an issue is identified, the surgeon may need to stop the heart again, reopen the atrium, and modify the previously completed repair. Because the sutures are knotted and trimmed they cannot simply be re-tensioned and so are typically replaced or additional artificial chords added. In some embodiments of the present disclosure, real time echocardiographic assessment is possible as the suture tensions are being adjusted individually. 
     In one embodiment, the method for implanting the artificial chords includes the following steps: First, securing one end of a plurality of artificial chords to a leaflet of the mitral valve or annulus of the surrounding tissue and the other end to an anchor point mechanically connected to the left ventricle; Second, adjusting the tension of the artificial chords while viewing an echocardiographic image other other image of the mitral valve. 
     In some embodiments of the method described above, the echocardiographic image includes color Doppler assessment of velocity and or flow. In some embodiments, the echocardiographic image includes real time 3D or 4D echo. In some embodiments, the color flow Doppler and 3D images are fused or combined. In some embodiments, the Echo probe is placed through the patient&#39;s esophagus. In some embodiments, the echo probe is a surface probe on the patient&#39;s chest, and in some embodiments, the echo probe is within the patient&#39;s vascular system. 
     In some embodiments at least 1, 2, 3, 4, or 5 of the functions below are confirmed under echocardiography as the artificial chords are being tensioned. In another embodiment, the functions below are confirmed after the artificial chords are tensioned, but before the chords are permanently disconnected from the delivery system, where this may allow simplified re-tensioning if necessary.
         Free from Systolic anterior leaflet motion causing obstruction or restriction of Left Ventricular Outflow Tract   Mitral valve gradient   Appearance of regurgitant jets   Velocity of regurgitant jest   Length of regurgitant jets   MR grade   A minimum leaflet coaptation distance of at least 3, 5, 9, 12, or 15 mm is achieved throughout the line of coaptation   Degree of leaflet prolapse or measurement of the height that a portion of the mitral leaflet moves above the plane of the mitral valve   Areas of “smoke” or stasis within the atrium ventricle or atrial appendage   Shunting between left and right ventricles, especially at ancho locations or other turns septal sections       

     Additionally, during the assessment period after initial tensioning of the sutures and before disconnecting the sutures from the delivery system, or before trimming off excess suture, while suture tension is easily read adjustable, at least 1, 2, 3, 4, or 5 of the following are assessed:
         Blood pressure   Cardiac output   ACT Actual clotting time   EKG electrocardiogram   Cardiac enzymes ckmb and troponin   Patency of coronary arteries   Fluoroscopic evaluation of ventricular shunt potentially from anchor or trans ventricular access.   Floroscopic appearance of ventricular anchor   Flouroscopic position of delivery system   Atrial pressure or wedge pressure   Oxygen content of patient&#39;s blood       

     After the assessment step is completed based on the information obtained from the measurements, the physician or team may decide to make the results permanent or to readjust the tension, add additional repair components, or abort the procedure. In some embodiments the physician also has the option to remove the entire implant. In other embodiments, the physician has the option to remove the artificial chord portion of the implant but the ventricular anchor remains implanted. In some embodiments, the assessment step is further augmented by including a stress echo component where drugs such as pressure regulators are given to the patient to adjust the heart rate, cardiac output and ventricular pressure to further assess how the repair functions in different hemodynamic conditions. 
     Monitoring 
     During the procedure, the patient is preferably under conscious sedation. This can make Trans Esophageal Echocardiography more challenging, but minimizes anesthesia risk and allows patients to go home more quickly. With general anesthesia or conscious sedation during the procedure, standard cath lab monitoring procedures should be performed including arterial pressure, EkG, ACT, blood gasses, etc. Additionally, wedge pressure or left atrial pressure may be useful for this procedure. For this procedure, careful monitoring of arterial pressure provides an early indicator of damage to the mitral valve apparatus, entanglement of the device in chordae, and/or damage to the septal wall. Measuring left atrial pressure may provide a simple quantifiable measure of improvement in mitral function without the challenges associated with getting the appropriate echocardiographic view. 
     Access 
     A blood vessel is accessed through conventional methods standard in interventional cardiology. Preferably, the vessel is a vein. In one embodiment, the vessel is the femoral vein. In another embodiment, the vessel is the radial brachial or subclavian vein. Access may be by cut-down or percutaneous needle stick. In some embodiments, the vessel is prepared for closure by pre-insertion of a vascular closure device, such as Percolse or Prostar (Abbot Vascular) 
     A guidewire may be advanced, optionally using a guide catheter, through a valve into the right ventricle. The device of the present disclosure can be advanced over the guidewire to a position near the apex of the ventricle. 
     A sharp curve may be created at the tip of the device. The curve can be oriented so that the exit lumen points towards the septal wall of the heart. The radius of curvature of the fully curved system is preferably less than about 3-30 mm, and the curvature is preferably positioned less than about 5-50 mm from the tip of the system. 
     In one embodiment, this curve is created using a steerable catheter. Certain embodiments of a steerable catheter incorporates a pull wire that when pulled creates the inner radius of the catheter. Some embodiments also include a coil, a braid, and/or an axial reinforcement. 
     In another embodiment, the curve is created using coaxial sheaths with different shapes. For example, an outer sheath substantially straight or with a large radius of curvature near its tip combined with an inner sheath with a small radius of curvature at its distal tip may be used. By advancing the inner sheath out of the outer sheath, the tip of the catheter creates the desired curve. By advancing the more curved sheath further, a greater curved angle is obtained. 
     In some embodiment, the sheaths have different relative stiffnesses at different points in their length. In certain embodiments, the outer sheath is curved to access the apex of the ventricle and stabilize through the vena cava. The shape that enables this may be about 7 to 50 cm back from the distal tip of the sheath. The inner sheath can be substantially more flexible (e.g., less than about 30, 50, 70, or 90% the bending stiffness by ASTM three point bend test) than the outer sheath in the range at about 7 to 55 cm from its distal tip. This enables the inner sheath to move relative to the outer sheath without substantially changing the orientation of the outer sheath in the heart and vena cava. The distal portion of the inner sheath is preferably stiffer than the previously described section, and stiff enough that as it is extended out of the outer sheath, it assumes its approximate shape despite contact with the structures of the heart. 
     The device may be oriented so that the exit of the catheter is near the right ventricular apex, pointing into the septal wall, and, preferably, upwards towards the mitral valve. The position of the sheath can be confirmed by imaging. A four chamber echocardiaographic view may be used in some embodiments. A short axis mitral view may be used in other embodiments. Fluoroscopic imaging can be used in some embodiments. Depending on the location of the area in need of repair, the desired puncture site can be selected and the appropriate angle based on the planned orientation of the replacement chords. 
     In some embodiments, a puncture higher up, closer to the papillary muscle insertions, and away from the ventricular apex is preferred. This location provides the benefit that as the heart remodels and the ventricular volume is reduced to more normal physiological levels, the tension in the chords will change less than with a near apical attachment. 
     A needle and/or dilator may be advanced through the sheath or sheaths and through the septal wall of the heart. In some embodiments, a needle and dilator are used together. Both the needle and dilator can be pre-shaped with curvature near their distal tip to ensure the needle stays within the left ventricle and avoids the mitral valve apparatus. Presence of the needle in the left ventricle may be confirmed with echocardiography, fluoroscopy, and/or by the presence of red (oxygenated) pulsatile blood at the proximal end of the needle. 
     After ventricular access is gained, a guidewire can be advanced across the septum. In some embodiments, the guidewire is further advanced across the mitral valve into the atrium, and, in some embodiments, is advanced further into a pulmonary vein. The wire can be confirmed not to be tangled in the mitral apparatus using echocardiography and/or wire manipulation. In some embodiments, a device such as a balloon or sheath is advanced over the wire to confirm that the wire does not pass through the chordal structure. 
     Ventricular Anchor 
     The present disclosure include several embodiments of ventricular anchors. 
     In one embodiment, the ventricular anchor is similar to an Amplatz septal occluder (ST Jude Medical) consisting of a braided section that expands on both sides of the septal wall. 
     In another embodiment, the anchor is a barbed stent-like structure intended to be deployed within the ventricular wall. The stent structure may be self-expanding or mechanically expandable (i.e. balloon expandable) and may include barbed anchors similar to those found on stent grafts such as Endurant (Medtronic) 
     In another embodiment, the anchor is a flanged covered stent where the right ventricular side opens into a substantially flat configuration oriented in a plane substantially perpendicular to the axis of the stent. 
     In another embodiment, the flange is constructed from a ring around the circumference of the flange and the flange itself a layer of fabric. The flange can be collapsed into an elliptical shape and delivered through the lumen. The ring may be constructed from nitinol titanium stainless steel or a cobalt chrome alloy. A fabric lumen can extend through the center of the flange and into the trans-septal puncture. After chord implantation, tension to snug the flange against the septal wall is provided through the chords, in some embodiments. During the procedure, a portion of the delivery system can be used to push the flange against the septal wall. In other embodiments, the fabric sleeve incorporates and anchors such as a stent or a barb to stabilize it within the septal wall. 
     The ventricular anchor may be deployed over a guidewire. After the anchor is deployed, the chord delivery anchors and their delivery system can be delivered through the ventricular anchor and over the guidewire. 
     Positioning 
     Identifying the correct place to place the new chords can be performed substantially using echocardiography. The area of a regurgitant jet or a leaflet prolapse or flail can be identified using 2D or 3D echo and/or color flow Doppler. Preferably, a combination of these imaging modalities is used. 
     The device to deliver the chords may be advanced across the septal puncture. In some embodiments, the same steerable or shapeable system used to create the septal puncture is advanced across the puncture. In other embodiments, it is a separate device that can pass through the other sheaths. 
     The position of the distal tip of the device can be oriented relative to the mitral structure as follows. The device may be biased more anteriorly by increasing the curvature of the system where it passes into the left ventricle through the septum. The device may be biased more posteriorly by decreasing the curvature of the system where it passes into the left ventricle through the septum. The device may be biased from commissure to commissure by rotating the curved portion that passes through the sheath. The device may be biased atrially by extending, or ventricularly by retracting, the distal portion of the device. 
     Primary 
     To replace primary chords, the chords located near the free edge of the leaflet, several methods of engaging the mitral leaflet are possible. The bulky knot system used by Harpoon Medical may be used in one embodiment. The looped suture used by Neochord Inc. may be used in another embodiment. Both these methods appear to work well in early clinical experience. The preferred embodiments intend to replicate the clinically proven suture tissue interfaces that have been developed in the open surgical experience. 
     Another embodiment may use a bifurcated catheter. One side of the catheter engages under the leaflet, and this side can be pushed on to help identify the area of the leaflet where the suture will pass. The other side passes into the atrium. A needle or pair of needles puncture the leaflet from the first side of the catheter and a snare captures the needles or the suture from the needles from the second side of the catheter. In some embodiments, a loop end of the suture is passed over the snare such that when the needle end of the suture is pulled back through it forms a girth hitch. In other embodiments, the loop end of the suture is twisted and doubled over twice forming a knot known a prusik or double girth hitch. 
     Secondary 
     To replace secondary chords, those that are located farther back from the free edge of the leaflet, some of the devices and methods described to replace primary chords may need adaptation. The bulky knot anchoring method can be appropriate for replacing secondary chords without modification. 
     The bifurcated catheter method can be appropriate for replacing secondary chords with a minor adaptation to allow the snare side to puncture the leaflet. 
     Resect Like 
     During mitral valve repair surgeons often resect some of the leaflet tissue. A similar effect can be created using the bifurcated catheter system described above. By placing suture through a section of leaflet and gathering the tissue together as the suture is tightened a similar effect can be achieved. The suture can be noted close to the leaflet to only resect, or extended and used as a new chord as well. 
     Partially Annuloplasty 
     In some cases, it may be desirable to use the dual puncture method into the annulus close to the hinge point of the leaflet to create a result similar to a surgical suture annuloplasty. In some embodiments, a series of suture loops are created, encircling the entire annulus. In some embodiments, suture loops are created only in a safe area away from the aortic valve, coronary arteries, and conduction pathways. In some embodiments, the suture loops are created in the areas where the heart is most likely to dilate (i.e. in an area of prior infarct) or in an area near the mitral commissures. 
     Assessment 
     After one or more repair sutures are placed into the mitral structure, the result may be assessed. Tension is applied selectively on each artificial chord until the desired leaflet motion is achieved. Preferably, a target coaptation height is achieved by echocardiography. In some embodiments, as too much and too little tension are balanced, the sutures are slightly over tensioned to allow some remodeling to occur. 
     Knotting 
     In one embodiment the sutures are knotted on the right ventricular side of the anchor using a crimpable knot large enough to prevent the crimped knot from passing through an opening in the anchor. 
     In another embodiment, the artificial cords are crimped directly to a suture-sewn or tied to the anchor. 
     Suture Adjustment 
     In some embodiments, the artificial chord tension can be adjusted in a similar procedure. In some embodiments, this can be achieved entirely from the right ventricle without re-crossing the septum. In one embodiment, the crimpable knots are snared, pulled away from their base and twisted. The twisting motion of the suture of pair of sutures forming the artificial chord effectively shortens it. In another embodiment, the crimp knot is snared and pulled and an additional crimp knot placed over it. 
     Multiple Systems 
     In some embodiments, it is possible to attach up to 1 to about 10 artificial chords to a single septal anchor. In some embodiments, more than one ventricular anchor is used, either to optimize the direction of pull of the chords, or to minimize the load on the septal anchor. 
     Alternative Methods 
     For some patient anatomies, it may be necessary or desirable to anchor the chords to a different area of the left ventricle rather than the septal wall. In one embodiment the anchoring location is at the papillary muscle. Preferably, the suture attachment to the papillary muscle or ventricular wall is made by creating a figure-eight suture, as is commonly done by surgeons during open chordal replacement. This type of anchor can be placed by a trans-catheter method through the trans-septal ventricular puncture described above, or can be placed through a more conventional atrial trans-septal puncture. One embodiment of the system, as adapted to suture to papillary muscles, is a simple change to the bifurcated leaflet suturing system where the needle and snare ends are curved inward towards each other so that when actuated they can place a suture through a papilay muscle. In another embodiment, the ventricular anchor is a cork screw shaped anchor similar to an Aptos Endovascular staple (Medtronic Inc) or any of the configurations used to secure pacemaker leads. 
     Bailout 
     In some embodiments, the ventricular anchor is retrievable. One example is a recapturable self-expanding stent, or an Amplatz like device. 
     In some embodiments, artificial chords are retrievable through a hemodynamic assessment period. In one embodiment, this is achieved by pulling both ends of the suture for assessment, prior to engaging the girth hitch for permanent implantation 
     Concomitant Repair Rings Alfieri 
     In some embodiments, the procedure is performed in conjunction with another mitral valve repair procedure. This simulates the multiple techniques typically used by surgeons. There are several devices in clinical use that simulate annuloplasty rings such as cardiac dimension coronary sinus based approaches, Mitralign and Valtech suture based approaches, etc. Additionally, Mitraclip (Abbott) simulates an Alfieri stitch, a seldom used surgical technique that creates two orifices. 
     Device 
     Certain embodiments of the device include and outer sheath that is curved to engage the shape of the vena cava and right ventricle. The proximal end of the outer sheath is connected to the handle of the delivery system. Within the outer sheath is a conventional dilator for gaining vascular access. Once the right ventricle has been accessed, the dilator is changed out for a special trans-ventricular dilator, with a relatively flexible proximal portion and a stiffer sharply curved distal portion with a short tapered radio opaque tip. The handle can include a provision to lock to the dilator, preventing both axial and rotational movement. The internal diameter (ID) of the dilator allows clearance for a long flexible, preferably hollow needle. In some embodiments the needle is curved. The needle can be configured to allow the needle tip to be advanced through the distal tip of the dilator and precisely place the trans-ventricular puncture. In some embodiments, the needle is sized to accommodate a 0.009, 0.014, 0.018, or 0.035 inch diameter guidewire. In other embodiments, the dilator is advanced through the puncture and over the needle and the needle is withdrawn. In some embodiments, the needle is integral to the dilator and can be retracted within the dilator or extended a limited length past the tip of the dilator. In some embodiments, the length may be about 2 to 20 mm. In other embodiments, the length may be about 4 to 40 mm. In some embodiments, the length maybe less than about 2 mm or greater than about 40 mm. 
     One exemplary application of the foregoing is discussed below, in connection with  FIGS. 35A through 35O . Referring to  FIG. 35A , a catheter  100  (also referred to herein as an elongate, flexible tubular body) having a distal end and a proximal end. The distal end of catheter  100  has entered the left atrium  102  via conventional techniques. The catheter  100  is advanced through the mitral valve  104  to the vicinity of the apex  112  of left ventricle  106 . A tissue anchor  108 , such as a helical tissue anchor  110 , is rotated into the muscular wall by an anchor driver (not shown), which can be in the form of a rotational driver (not shown) advanced distally through catheter  100 . In certain embodiments, the anchor driver or rotational deriver can extend proximally through the catheter  100 . After anchoring the tissue anchor  108 , the catheter  100  and/or anchor driver is proximally retracted to leave the anchor  110  secured to the wall, and attached to an anchor suture  114  which extends proximally throughout the length of the catheter  100 . A distal portion of the anchor suture  114  may carry a neo papillary muscle  116  which may comprise a soft ribbon or body  118 , optionally approximating the size of a mitral papillary muscle. The neo papillary muscle  116  may comprise a substantially larger diameter compared to the suture  114 . The suture  114  may be configured to extend through the neo papillary muscle  116  (e.g., through a central channel) or may be affixed at a proximal end of the neo papillary muscle, as described elsewhere herein. In certain embodiments, the neo papillary muscle replacement  118  can be formed of soft PTFE material. 
     Preferably the anchor  108  is attached at a point that is offset from the thin tissue of the apex  112 , and is instead implanted in the generally thicker adjacent wall of the ventricle. Positioning the anchor is preferably also such that the longitudinal axis of the implanted neo chord construct is aligned approximately parallel to or concentric with the original path of the native chord. In such arrangements, the tissue anchor  108  can be positioned in left ventricle between the papillary muscles. As noted and described herein, the tissue anchor can be in the form of a helical ventricular anchor. 
     Referring to  FIG. 35B , a steerable leaflet capture catheter  120  can be advanced distally beyond the catheter  100 , through the mitral valve  104  and into the left ventricle  106 . The steerable catheter  120  may be delivered through the catheter  100 . Alternatively the steerable catheter  120  may be delivered alongside catheter  100 . In certain embodiments, the steerable leaflet capture catheter  120  can be positioned within the catheter  100  along the driver (e.g., rotational driver) coupled to the tissue anchor (e.g., a helical ventricular anchor). In certain embodiments, the driver (e.g., rotational driver) coupled to the tissue anchor (e.g., a helical ventricular anchor) can be inserted through the catheter  100  and after deployment removed or partially removed from the catheter  100 . The steerable leaflet capture catheter  120  can be then be advanced through the catheter  100  to the target site. 
     A distal portion of leaflet capture catheter  120  can be provided with a deflection zone  122 . Deflection zone  122  may comprise any of a variety of deflection mechanisms. For example, a plurality of transverse slots  124  may be spaced apart along a first side of the catheter  120 . A second, opposing side  126  of the catheter may comprise an axially incompressible spine. Proximal retraction of one or more pull wires (not shown) may cause axial collapse of the slots  124 , thereby deflecting the catheter as shown, for example, in  FIG. 35C . The slots  124  may be specifically configured to allow the types and ranges of motions suited for the insertion of the leaflet anchor. 
     Preferably, the deflection zone  122  may be deflected throughout an angle of at least about 160° and preferably at least about 180° or about 190° or more in a simple or compound curve, and have a best fit radius of curvature of less than about 2 cm, and in one embodiment, less than 1.5 and, preferably, less than about 1 cm in an embodimetn. In one implementation, the shortest linear distance D between the distal tip  128  and the catheter shaft is within the range of from about 0.5 cm and about 1.5 cm and optimally approximately 1 cm, to position the leaflet anchor a desired setback from the leaflet coaptive edge. 
     The steerable leaflet capture catheter  120  may be advanced through the mitral valve  104  and deflected as illustrated in  FIG. 35C  to position distal tip  128  in contact with a ventricular side  130  of a flail leaflet  132 . 
     As illustrated in  FIG. 35D , a control on a proximal manifold may be manipulated to advance a needle  134  out of the distal end  128  and through the flail leaflet  132 . Puncture of leaflet  132  by needle  134  may be accomplished during diastole, when the leaflet  132  is biased in the direction of the left ventricle  106 . 
     The catheter  120  and/or needle  134  may be utilized to deploy any of a variety of tissue anchors to secure a suture to leaflet  132 . In certain embodiments as described herein, the tissue anchor is radially enlargeable leaflet anchor coupled to a suture which can extend proximally through the catheter  100 . In the illustrated embodiment, a pledget  136  carried by a leaflet anchor suture  138  is deployed from the needle  134  on the atrium side of the leaflet  132 . The pledget is in the form of an elongate ribbon, having a proximal end and a distal end. The distal end is secured with respect to the leaflet anchor suture  138 . The leaflet anchor suture  138  may be threaded through one or two or four or more apertures in the elongated ribbon. As seen in  FIGS. 35E through 35G , proximal retraction on the leaflet anchor suture  138  causes the ribbon to fold and collapse axially, thereby forming a mass of sufficient transverse area, such that proximal tension on the leaflet suture is insufficient to pull the resulting pledget through the leaflet. Accordingly, in certain arrangements, the pledget  136  is transformable from an elongate strip configuration to a radially enlarged, axially shortened configuration by proximal retraction of the suture  138 . 
     The leaflet capture catheter  120  may be thereafter proximally retracted, leaving the construct as illustrated in  FIG. 35H . 
     Any of a variety of leaflet anchors may be utilized, generally sharing the characteristic of being laterally enlargeable from a low crossing profile for crossing the leaflet, to a larger transverse profile for resisting retraction back through the leaflet. Lateral enlargement may be accomplished by tilting a T anchor or by active deformation by a control wire or elastic deformation following release from a constraint. 
       FIGS. 35I-1 through 35I-4  illustrate deployment of a T tag type anchor through the flail leaflet  132 . An anchor element such as a single T tag bar  140  secured to suture  138  may be distally advanced through the needle  134  by a push wire  142 . Push wire  142  may be provided with a distal pushing platform  144 , which may be provided with a cut out  146  for accommodating suture  138 . As the bar  140  exits the needle  134 , it will rotate about the suture attachment point and seat against the atrium side of the leaflet  132  upon proximal traction on leaflet suture  138 . The bar  140  may comprise a single element as illustrated, or an “X” or multi strut construct, depending upon desired performance characteristics. 
     An alternative leaflet anchor is illustrated in the sequence of  FIGS. 35J-1 through 35J-3 . The tissue anchor comprises a hub  150  secured to the suture  138 . Hub  150  carries a plurality of spokes  152  which are enlargeable transversely from a low profile linear configuration when constrained within needle  134 , to an expanded configuration illustrated in  FIG. 35J-3  for resisting proximal retraction through the leaflet  132 . At least two, and preferably four, or six, or more spokes or struts  152  may be provided, extending radially outwardly from the hub  150  in the deployed configuration, for providing a footprint against the leaflet. The struts may be inclined radially outwardly in the proximal direction to provide a force damper allowing hub  150  to be transiently drawn closer to leaflet  132  in response to tension spikes, such as when the leaflet  132  reaches the limit of travel during systole imposed by the implanted neo chord. The spokes  152  and hub  150  may be laser cut from a NiTi tube and adhesively bonded, crimped, or otherwise attached to the leaflet suture  138 . 
     Referring to  FIG. 35K , a fulcrum  154  may be positioned at about the distal end of the neo chord and proximal end of the neo papillary muscle. The fulcrum  154  may provide a point at which length and/or tension between the leaflet anchor  136  and the distal anchor  110  can be adjusted. At least the leaflet suture  138  passes across the fulcrum, so that proximal retraction on the leaflet suture  138  pulls the atrium direction limit of travel of the flail leaflet in the direction of the ventricle. The fulcrum  154  may be the edge of a distal opening of a lumen of an adjustment catheter which is advanced distally over the leaflet suture and potentially also the ventricle anchor suture. The fulcrum may alternatively comprise an eye or loop on the distal end of a fulcrum support such as a hypo tube or support wire. Alternatively, the fulcrum  154  may be on a suture lock, through which both of the anchor suture and leaflet suture may pass. 
     Prior to engaging the suture lock, the leaflet suture may be slowly proximally retracted to progressively limit prolapse of the flail leaflet into the left atrium. Mitral regurgitation can be observed via fluoroscopic imaging, and the leaflet suture can be retracted until mitral regurgitation (MR) has been eliminated or sufficiently minimized. 
     Referring to  FIG. 35L , the catheter  100  maybe advanced distally to induce slack in the anchor suture and leaflet suture, thereby minimizing any influence of the catheter  100  on leaflet function. This enables the physician to evaluate the effect on mitral regurgitation at the current tension level on the leaflet suture. The leaflet suture may be retracted or advanced to further adjust the leaflet range of travel, as desired. 
     Once the desired cardiac function has been achieved, the suture lock may be engaged, using known techniques or techniques disclosed elsewhere herein, to fix the maximum distance between the tissue anchor  108  and the leaflet anchor, as shown in  FIG. 35  M. Alternatively, if the adjustment catheter was utilized as the fulcrum, a suture lock or knot may be advanced distally through the catheter into position in the vicinity of the distal end of the neo cord and the proximal end of the neo papillary muscle, and secured prior to retracting the adjustment catheter. 
     Referring to  FIG. 35N , the leaflet suture  138  and anchor suture  114  may be severed proximally of the suture lock, using known techniques or techniques described elsewhere herein, and the catheter  100  may be withdrawn from the patient. This leaves a neo cord and neo papillary muscle construct in place within the left ventricle. 
     Referring to  FIG. 35O , there is illustrated a distal deflection zone  122  on a modified leaflet capture catheter  120 . As with the deflection zone illustrated in  FIG. 35C , the implementation of  FIG. 35O  includes a plurality of axially compressible slots  124  opposing a non-collapsible spine  126 . Upon proximal retraction of a pull wire, this construct produces a primary concavity  150 . As has been discussed, the shortest distance D at maximum flexion of the deflection zone  122  may generally be in the range of from about 0.5 to about 1.5 cm. 
     Depending upon the desired performance, there may be provided a secondary concavity  152  operable by axially collapsing the second plurality of slots  154 . Flexion of the secondary concavity  152  may be accomplished by proximal retraction of a second pull wire. Alternatively, the primary concavity  150  and secondary concavity  152  may be simultaneously flexed by pulling a single pull wire. 
     In the illustrated embodiment, the secondary concavity  152  is concave in the same plane as, and in an opposite direction from the primary concavity  150 . Alternatively, the second concavity  152  can be concave in the same direction as the primary concavity  150 . In either configuration, the primary concavity may reside in a first plane, and the secondary concavity  152  may reside in a second plane rotationally offset from the first plane, depending upon the desired performance. Additional details of compound curvature catheter shafts can be seen in U.S. Patent Publication No. 2014/0243877, the disclosure of which is hereby incorporated in its entirety herein by reference. 
     With reference now to  FIGS. 36A-37 , in some embodiments, rather than treating pure degenerative mitral regurgitation, embodiments of the method and devices disclosed here can also be used to treat a subset of patients with functional mitral regurgitation, where the patients have a tethered leaflet type of defect. In this anatomy, there is adequate length of the mitral valve leaflets for the leaflets to close and seal against leak, but the leaflets are not able to move up to the plane of the mitral annulus because the chordae are too short. This type of anatomy typically occurs because the annulus dilates and or the ventricle enlarges, while the chordae remain approximately the same length. Treatment of these patients can be performed by cutting all or a portion of the native chords as a step during the procedure. 
     In an embodiment, the chord cutting step is performed as the initial step, prior to the device implantation steps. This can prevent the possibility of accidental damage to the implant, but can create a condition of severe regurgitation during the procedure. Alternatively, the native chords can be cut at any point during the implantation of prosthetic chords, or after the other steps of implantation of the prosthetic chords is complete. Cutting as a final step can create the disadvantage that it may not be feasible to assess the exact result until after the chords have been implanted. The implanted device may be the same or similar to one of the embodiments disclosed herein. 
     In certain embodiments, the native chordae may be cut after placing the initial leaflet and ventricular anchors, but prior to final tensioning. In certain embodiments, this is achieved by first, prior to chord implantation, isolating the native chords by passing a guidewire around each papillary muscle, snaring the end of the wire and then advancing a sheath over the wire, in this way creating a snug loop around the papillary muscles. These loops can remain intact during the normal implantation of the ventricular and leaflet anchors. Once the ventricular and leaflet anchors are in place, using one of the devices and methods described here, and preferably partially tensioned, the native chords are cut. This can be achieved by manipulating the loops around the papillary muscles such that they move up past the papillary heads to the base of the chordae and cutting them. In one embodiment, the guidewire is simply pulled into the guide creating a cutting action. In another embodiment, a blade type tool that fits within the guide and has lumens for the guidewires is provided. By pulling both ends of the guidewire, the chordae are pulled against the blade and cut. Many other tissue cutting devices have been described in the art and would be applicable to the devices and method described here. After the native chordae are cut, the tension on the implant is adjusted. If the result is satisfactory it can be made permanent by locking the suture lock and cutting the suture tails as described in this application or by similar methods. If the result is not satisfactory, additional chordae may be added or other mitral repair procedures may be performed in conjunction. 
     Looping the papillary muscle instead of looping the chordae directly can ensure that all the chordae are captured, because all the normal chordae attach to the heads of the papillary muscles. Cutting using a looped guidewire is one method of cutting the native chordae but other methods and apparatuses can be used such as various types of transvascular suture cutters. 
     With reference now to  FIGS. 36A-37 ,  FIG. 36A  is a picture of a looped papillary muscle  200  in the configuration it is first captured in.  FIG. 36B  shows the looped papillary  200  pulled up onto the chords  202  in the area where the cutting step is preferably performed.  FIG. 37  illustrates one embodiment of the chordae cutting tool  210 . The illustrated embodiment contains two lumens  212 ,  214 , one for each end of a looped guidewire  216 , a cutting edge  218  and an element  220  to protect the cutting edge  218  from contacting the sheath  210  and other portions of the device and patient that are not intended to be cut. The guidewire may be delivered through a first lumen  212  and a snare delivered through the second lumen  214  to snare the guidewire, after looping around the papillary muscle. The snare may withdraw the guidewire into the second lumen  214 . As noted above, cutting using a looped guidewire is one method of cutting the native chordae but other methods and apparatuses can be used such as various types of transvascular suture cutters. 
     In some embodiments, the procedures described herein may be performed via specialized delivery systems and devices. The delivery systems may comprise multiple subcomponents configured for performing various steps of the procedure. In some implementations, a neo chordae tendinae deployment system, comprising an elongate, flexible tubular body such as catheter  100 , may be used to access the heart of the patient (e.g., the left atrium). Multiple subsystems may be introduced into the heart via the delivery catheter  100 . The subsystems may comprise catheters of smaller diameter than the internal lumen of the delivery catheter  100  such that they are configured to be inserted through the delivery catheter  100 . In some implementations, some or all of the various subsystems may occupy the delivery catheter  100  simultaneously in order to perform the operations described elsewhere herein. In some implementations, some or all of the various subsystems may occupy the delivery catheter  100  in subsequent fashion in order to perform the operations described elsewhere herein. For example, the delivery system may comprise a ventricular anchor delivery system  300 , a leaflet anchor delivery system  330 , and/or a suture lock delivery system  370 , as described elsewhere herein.  FIGS. 38A-38H  schematically illustrate a method of implanting a neo chordae tendinae via a delivery system comprising subsystems for ventricular anchor delivery, leaflet anchor delivery, and suture lock delivery. The procedure illustrated in  FIGS. 38A-38H  may be the same or substantially the same as that illustrated in  FIGS. 35A-35O . In some embodiments, the neo chordae tendinae (or prosthetic chordae tendinae) comprises a suture, as illustrated in  FIGS. 38A-38H . In other embodiments, the neo chordae tendinae may be another flexible element. The flexible element may be attached to a suture at its proximal end and/or its distal end for coupling to the ventricular anchor and/or the leaflet anchor. 
       FIG. 38A  depicts the installation of a helical anchor  302  near the apex  112  of the left ventricle  196 . While the helical anchor  302  is shown positioned near the apex  112  in the following figures, the anchor  302  can be attached at a point that is offset from the thin tissue of the apex, and can be instead implanted in the generally thicker adjacent wall of the ventricle, such as between the two papillary muscles. Positioning the anchor is preferably also such that the longitudinal axis of the implanted neo chord construct is aligned approximately parallel to or concentric with the original path of the native chord. In such arrangements, the tissue anchor  302  can be positioned in left ventricle between the papillary muscles as shown, for example, in see  FIG. 42 . In addition, while a helical anchor is illustrated the anchor can have a different structure for engaging tissue of the heart and thus as explained above other structures can be use instead of a helical structure including various piercing or hook structures for engaging tissue. 
     The helical anchor  302  may be delivered by a ventricular anchor delivery subsystem  300 .  FIGS. 39A-39C  illustrate various views of the ventricular anchor delivery subsystem  300  and its components.  FIG. 39A  depicts a perspective view of a distal end of the subsystem  300 .  FIG. 39B  depicts a perspective view of a proximal end of the subsystem  300 .  FIG. 39C  depicts a partially exploded view of a distal end of the subsystem  300 . The subsystem  300  may be delivered through the delivery catheter  100 . The delivery catheter  100  may access the left atrium through conventional techniques, such as through an atrial trans-septal puncture. The delivery catheter  100  may be maintained in a substantially constant location throughout the procedure as various subsystems are placed and removed from the delivery catheter  100 . For instance, the distal end of the delivery catheter  100  may be positioned in the left atrium. In other implementations, the distal end of the delivery catheter  100  may be positioned in the left ventricle throughout the duration of the procedure. 
     As shown in  FIGS. 39A and 39C , the ventricular anchor delivery subsystem  300  may comprise an outer sheath  304 , a guide shaft  305 , a driver  309  (comprising shaft  307  and head  306 ), an anchor hub  308 , and an anchor. The anchor may be a helical anchor  302  and the drive  309  can be configured to rotate the anchor  302  such that the driver  309  is configured to rotate the helical anchor  302 . The helical anchor  302  may comprise an inner diameter configured to be received over the outer diameter of an anchor hub  308 . The helical anchor  302  may be securely fixed secured to the anchor hub  308  by an interference fit or other frictional engagement. The anchor hub  308  may be left implanted along with the helical anchor  302 . The anchor hub  308  may comprise a lumen positioned substantially along a central axis of the anchor hub  308  for receiving a suture  311  (not shown) and attaching the suture  311  to the helical anchor  302 . In some embodiments, the suture  311  may comprise an attachment element (e.g. a knot or a washer) with a diameter sized to prevent the suture  311  from being pulled proximally through the anchor hub  308  lumen. For example, the suture  311  may be knotted on a distal side of the lumen. In some embodiments, the suture  311  may be tied to the anchor hub  308  (e.g., passed through the lumen, wrapped around the outer surface, and tied to itself). The helical anchor  302  may comprise a distal section of windings and a proximal section of windings. The proximal section of windings may be spaced closer together than the distal section of windings and may be configured for securing the helical anchor  302  to the anchor hub  308 . The distal section of windings may be spaced further apart than the proximal section of windings and may be configured for insertion into the ventricular tissue. The anchor hub  308  may comprise an enlarged cross-section at its proximal end configured to abut the helical anchor  302  and/or prevent the helical anchor  302  from advancing proximally over the proximal end of the anchor hub  308 . Other helical anchors, such as those described elsewhere herein, may be configured to be used with the ventricular anchor delivery subsystem  300  described herein as well. 
     The proximal face of the helical anchor  308  may comprise a recess for receiving an extending portion  306 ′ of the driver head  306 . The recess may be non-circular (e.g., oblong or polygonal) such that it is configured to transfer torque from the driver  309  to the anchor hub  308  upon rotation of the driver  309 . The recess may be positioned around the central lumen of the anchor hub  308 . In other embodiments, the anchor hub  308  may comprise an extending portion and the driver  306  may have a recess. The driver head  306  may be generally cylindrical. The driver head  306  may be fixedly coupled to a drive shaft  307 . The driver  309  may comprise a central lumen through the driver head  306  and drive shaft  307  configured to receive the suture  311 . The central lumen of the driver  309  may be configured to be aligned with the central lumen of the anchor hub  308 . The drive shaft  307  may be received within a guide shaft  305 . The diameter of the driver head  306  may be larger than the inner diameter of the guide shaft  305 . The outer sheath  304  may be sized to receive the guide shaft  305  as well as the driver head  306 , the anchor hub  308 , and the helical anchor  302 . 
     The outer sheath  304  may be delivered into the left ventricle and proximal to the ventricular attachment site via the delivery catheter  100 . In some embodiments, the outer sheath  304  may be delivered without a delivery catheter. In some implementations, the helical anchor  308  may be concealed within the outer sheath  304  until the outer sheath  304  is positioned proximal to the ventricular attachment site then pushed distally through the outer sheath  304  so that the helical anchor  302  is exposed. The helical anchor  302  may be placed into contact with the ventricular tissue. Rotation of the drive shaft  307  may cause the driver head  306 , the anchor hub  308 , and the helical anchor  302  to rotate thereby screwing the ventricular anchor  302  into the ventricular tissue. Rotation of the driver  309  may axially advance the driver  309 , anchor hub  308 , and helical screw  302  in a distal direction with respect to the outer sheath  304 . The drive shaft  307  may be rotated manually by a user using a drive handle  312 , as shown in  FIG. 39B . The proximal end of the ventricular anchor delivery subsystem  300 , as illustrated in  FIG. 39B , may comprise first and second hemostasis valves  314 ,  316 . The first hemostasis valve  314  may be positioned distal to the drive handle  312  and may provide access to the guide shaft  305 . The second hemostasis valve  316  may be positioned proximal to the drive handle  312  and may provide access to the central lumen of the driver. The ventricular anchor suture  311  may extend through the second hemostasis valve  316 . 
     In some embodiments, the ventricular delivery subsystem  300  may include a shield or guard  303  (shown in  FIG. 38A ) positioned around the distal end of the outer sheath  304 . Guard  303  may comprise a tubular wall attached to or advanceable out of the tubular sheath  304 , having an open distal end. The guard  303  may be enlargeable from a first, reduced cross section for transluminal navigation, to a second, enlarged cross section for permitting rotation of the anchor therein. 
     The guard  303  may have an increasing diameter in the distal direction such that the inner diameter of the guard  303  is larger at the distal end of the guard  303  than the outer diameter at the distal end of the outer sheath  304 . The expanded diameter of the guard  303  may provide sufficient space for rotation of the helical anchor  302  without contacting an inner surface of the guard  303 . The guard  303  may be placed into contact with the ventricular tissue or positioned in close proximity to the ventricular tissue during installation of the helical anchor  302 . The guard  303  may advantageously prevent chordae or other tissue adjacent to the helical anchor  302  from getting caught up in the windings of the helical anchor  302  during rotational insertion of the helical anchor  302 . Once the helical anchor  302  is inserted into the ventricular tissue an adequate depth, the driver  309  may be withdrawn from the anchor hub  308  such that the helical anchor  302  is disengaged from the remainder of the ventricular anchor delivery subsystem  300 . 
     In some implementations, the inserting portion  306 ′ of the driver head  306  and the recess of the anchor hub  308  may have a frictional engagement that transiently holds the two components together. The frictional engagement may be overcome upon proximal retraction of the driver by a counter force from the ventricular tissue once the helical anchor  302  is inserted. In some implementations, proximal tension on the suture  311  may provide an engagement force between the proximal hub  308  and the driver head  306 , which can be released upon retraction of the driver  309 . The driver head  306  may be proximally withdrawn into the outer sheath  304  before the outer sheath  304  is withdrawn into the delivery catheter  100 . 
     The non-implanted components of the ventricular anchor delivery subsystem  300  may be removed from the delivery catheter  100  and subsequent subsystems may be placed in the delivery catheter  100  for completing implantation of the neo chordae. In a modified embodiment, the the ventricular anchor delivery subsystem  300  and subsequent subsystems such as the leaflet anchor delivery subsystem  330  may be positioned within the delivery catheter  100  at the same time and in certain arrangement the tissue and leaflet anchors can both be preloaded into the delivery catheter. In alternative embodiments, the implantation of the ventricular anchor may be performed in a different order (e.g., after the implantation of the leaflet anchor). The ventricular anchor delivery components may be proximally retracted over a proximal end of the suture  311 , which may remain extending through the delivery catheter  100  to the ventricular anchor  302 .  FIGS. 38A-38H  depict installation of a neo chordae without a neo papillary muscle  116 , as depicted, for example, in  FIG. 35A . However, the procedure may also be performed in combination with a neo papillary muscle  116 . The neo papillary muscle  116  may be advanced over the suture  311 , for example, after installation of the ventricular anchor  302 . In some embodiments the neo papillary muscle may be coupled to the anchor hub  308 . 
       FIGS. 38B-38F  depict various steps comprising the installation of the leaflet anchor via a leaflet anchor delivery subsystem  330 . The leaflet anchor may be delivered after the installation of the ventricular anchor. The leaflet anchor delivery subsystem  330  may be delivered through the delivery catheter  100  alongside the ventricular anchor suture  311  which remains connected to the ventricular anchor  302 . In some embodiments, the leaflet anchor may be delivered prior to the installation of the ventricular anchor  302 . The leaflet delivery subsystem  330  may alternatively be delivered through the ventricle wall such as transapically into the left ventricle, or transseptally from the right ventricle to the left ventricle. 
       FIGS. 40A-40F  illustrate various views of the leaflet anchor delivery subsystem  330  and its components.  FIG. 40A  depicts a perspective view of a distal end of the subsystem  330 .  FIG. 40B  depicts a perspective view of a proximal end of the subsystem  330 .  FIG. 40C  depicts an exploded view of the distal end of the subsystem  330 .  FIG. 40D  depicts a perspective view of a flex tube  332 .  FIGS. 40E and 40F  depict different side views of a transition region of the flex tube  332 . 
     As shown in  FIGS. 40A and 40C , the leaflet anchor delivery subsystem  330  may comprise a delivery shaft  334 . A deflectable flex tube  332  may be coupled to the distal end of the delivery shaft  334 .  FIG. 40D  depicts one implementation of the flex tube  332 . The deflectable flex tube  332  may form a deflection zone  122  as described elsewhere herein. The deflectable flex tube  332  may be configured to be steerable by an operator as described elsewhere herein, such as by proximal retraction of one or two or more pull wires (not shown) along various sides of the flex tube  332 . The operator may control the flexion of the flex tube via a knob  352  or lever or other actuation mechanism positioned on a handle  350  at the proximal end of the leaflet anchor delivery subsystem  330 , as shown in  FIG. 40B . 
     As shown in  FIG. 40D , the flex tube may comprise transverse slots. The transverse slots may be positioned at various lengths of the flex tube  332  substantially opposite a side of the flex tube  332  comprising no apertures or slot to form a relatively stiff or axially incompressible spine. The axial spacing of the transverse slots, the axial width of the transverse slots, the shape of the transverse slots, the circumferential orientation of the transverse slots, and/or the circumferential length of the transverse slots may affect the degree of flexibility and/or the direction the flex tube  332  is prone to flex at a local area or generally along the overall length of the flex tube  332 . 
     The flex tube  332  may comprise two or more sections along the length of the flex tube  332  having different patterns of transverse slots and/or different flexing properties. For example, the flex tube  332  depicted in  FIG. 40D  comprises a proximal section and a distal section having different patterns of transverse slots.  FIGS. 40E and 40F  show close up side views of the flex tube  332  near the transition between the proximal section and the distal section. The views in  FIGS. 40E and 40F  are approximately 90 degrees rotationally offset from each other with respect to the longitudinal axis of the flex tube  332 . 
     The flex tube  332  may be used to steer or guide the distal end of the leaflet anchor delivery subsystem  330  to the leaflet. The flex tube  332  may be especially advantageous for positioning the distal end on the ventricular side of the leaflet when the subsystem is delivered to the heart from the right atrium. As shown in  FIG. 38B , the distal end of the leaflet anchor delivery subsystem  330  may be deflected (e.g., at least approximately 180 degrees) such that proximal retraction of the subsystem exerts pressure on the ventricular surface of the leaflet. The radius or best fit radius of curvatures of the deflected flex tube  332  is generally less than about 2 cm, and preferably less than about 1.5 cm or 1.0 cm. 
     A flexible jacket  333  may surround the flex tube  332  and the delivery shaft  334 . An internal flexible shaft  336  terminating at a distal end with a needle point may extend through the delivery shaft  334  and the flex tube  333 . The internal flexible shaft  336  may comprise a braided tube or catheter which is flexible enough to conform to the shape of the flex tube  332 . A needle tip  338  may be coupled to the distal end of the internal flexible shaft  336 . The proximal end of the internal flexible shaft  336  may be connected to a needle handle  354 , as shown in  FIG. 40B . The needle handle  354  may comprise a hemostasis valve  356 . The leaflet suture  344  may be inserted through valve  356 . Valve  356  may be a touhy. The needle handle  354  may include additional ports  358  for accessing the lumen of the internal flexible shaft  336 . The needle handle  354  may be positioned proximally to the handle  350  such that the internal flexible shaft  336  extends through the handle  350  and into the lumen of the delivery shaft  334 . The handle  350  may comprise a hemostasis valve for receiving the internal flexible shaft  336  and sealing the internal components of the handle, including the opening to the delivery shaft  334 , from the ambient environment. The needle  338  may be extendable and retractable by extending the needle handle  354  toward the handle  350  or retracting the needle handle  354  from the handle  350 , respectively. 
     Exertion of pressure on the leaflet when the needle tip  338  is extended distally beyond the flex tube  332  and the flexible jacket  333  may cause the needle tip  338  to puncture the leaflet such that the needle tip  338  may extend through to the opposite side (e.g., the atrial side) of the leaflet, as shown in  FIG. 38C . This pressure may be exerted by extending the needle tip  338  and/or retracting the entire delivery device  330  in a proximal direction with the needle tip  338  in an extended position. 
       FIGS. 38D-38F  depict the deployment of the leaflet anchor. The leaflet anchor may be a pledget  340  similar to those described elsewhere herein. The pledget  340  may be coupled or attached to the distal end of a suture  344 . The pledget may comprise a soft and/or flexible material such as a fabric. The suture  344  may extend through the internal flexible shaft  336 . The pledget  340  may be folded or compressed in a conformation comprising a reduced radial cross section such that it may be disposed within the internal flexible shaft  336  for delivery, as shown in  FIGS. 38D and 40A . The pledget  340  may expand to assume a larger radial cross section upon deployment from the distal end of the needle tip  338 , as shown in  FIG. 38E . In some embodiments, the pledget  340  may be pushed through the internal flexible shaft  336  via a push wire or release wire (not shown), similar to that illustrated in  FIG. 35E . Upon delivery through the needle tip  338 , proximal retraction of the leaflet suture  344  may cause the leaflet anchor to assume an axially collapsed, radially enlarged conformation which prevents the leaflet anchor from being retracted through the puncture in the leaflet and thereby anchors the leaflet suture  344  to the leaflet, as shown in  FIG. 38F . 
       FIG. 40C  schematically depicts a pledget  340  connected to the distal end of a leaflet suture  344 . The pledget  340  may comprise two wings  341 ,  342 , which may be rolled/folded (e.g., both in a clockwise or counterclockwise direction) around a longitudinal axis of the pledget  340  to form a reduced cross section conformation. In some embodiments, the leaflet suture  344  may be integrally formed with the pledget  340  as described elsewhere herein ( FIGS. 43A-43C ). In order to produce a foldable or collapsible configuration, the proximal end of the suture  344  extending from the pledget  340  may be threaded back through one or more apertures (e.g., two apertures, three apertures, four apertures, etc.) formed in the pledget  340 , as shown in  FIG. 38E . In some embodiments, the apertures may be aligned along a center of the pledget  340 . The apertures may extend through the pledget  340  and through the portion of the embedded portion of the suture  344  which is integral with the pledget  340 . The embedded portion of the suture  344  may be at least partially flatted within the pledget  340 . In some embodiments, the apertures may be place substantially near the center of the pledget (e.g., immediately to the left or right of the embedded suture  344  or alternating between the left and right side of the suture  344 ). When deployed the suture  344  may be effectively joined to a distal end of the pledget  340  (e.g., the suture  344  may loop back to where it inserts between the pledget sheets). The pledget  340  may be formed such that the wings  341 ,  342  are approximately the same size or they may be formed to be different sizes. Upon proximal retraction of the leaflet suture  344 , the pledget  340  may be folded to assume an accordion-like conformation, as depicted in  FIG. 38F . The pledget  340  may assume a conformation comprising a substantially planar surface which is approximately perpendicular to the longitudinal axis of the leaflet suture  344 . This conformation may facilitate anchoring the suture  344  in the leaflet. Upon anchoring the leaflet suture  344  in the leaflet, the leaflet anchor delivery subsystem  340  may be withdrawn from the delivery catheter  100 . The leaflet anchor delivery components may be proximally retracted over a proximal end of the suture  344 , which may remain extending through the delivery catheter  100  to the leaflet anchor  340 , alongside the ventricular anchor suture  311 . 
     The ventricular anchor suture  311  and the leaflet anchor suture  344  may be coupled together in a tensioned fashion to form the neo chordae implant or to join two sections of the neo chordae implant together, such that the neo chordae extends between the ventricular anchor  302  and the leaflet anchor  340 . The overall length of the neo chordae may be modulated such that an appropriate tension is applied to the leaflet, with the tension maintained by the ventricular anchor  302 . The sutures  311 ,  344  may remain extending through the delivery catheter  100  to a location outside the body. In some embodiments, the proximal ends of the suture  311 ,  344  may be fed into a handle or proximal portion of a suture lock delivery system  370  during placement of the suture lock and cutting of the sutures  311 ,  344 . In some embodiments, the proximal ends may remain free or coupled or secured by other means. 
       FIGS. 41A-41I  illustrate various views of the suture lock delivery subsystem  370  and its components.  FIG. 41A  depicts a perspective view of a distal end of the subsystem  370 .  FIG. 41B  depicts a perspective view of a proximal end of the subsystem  370 .  FIG. 41C  depicts a partially exploded view of the distal end of the subsystem  370 .  FIG. 41D  depicts a perspective view of a distal end of a cutting assembly.  FIGS. 41E and 41F  depict side views of a cutting assembly portion of the subsystem  370 .  FIG. 41G  depicts a side view of a suture lock  376  and a distal end of a torque driver  388  configured to engage the suture lock  376 .  FIGS. 41H and 41I  depict a proximal end view and a distal end view, respectively, of the suture lock  376 . 
     The suture lock delivery subsystem  370  may be configured to advance (e.g., slide) a suture lock  376  over both the sutures  311 ,  344  (or even additional sutures) securing them together. The sutures  311 ,  344  may each be proximally retracted to tension the sutures  311 ,  344  and modulate the length of each suture  311 ,  344  between the suture lock  376  and the respective tissue anchors  302 ,  340 . Once the tension and length of the neo chordae implant is optimized, the suture lock  376  may be locked to fix the length of the sutures  311 ,  344  such that the sutures  311 ,  344  can no longer move with respect to the suture lock  376 . The sutures  311 ,  344  may then be severed at a point proximal to the suture lock  376 . The suture  311 ,  344  may be cut by the same suture lock delivery subsystem  370  which delivered the suture lock  376 . In other embodiments, a separate cutting device may be inserted into the delivery catheter  100  after the suture lock has been locked in place. 
       FIG. 38G  depicts the advancement of suture lock  376  over the ventricular anchor suture  311  and the leaflet suture  344 . The suture lock delivery subsystem  370  may be advanced through the delivery catheter  100  and may push a suture lock  376  along the distal direction of the sutures  311 ,  344 , bringing proximal portions of the sutures  311 ,  344  into close proximity at the distal end of the suture lock  376 . The suture lock  376  may be advanced along the sutures by a retainer catheter  373 . The distal end of the retainer catheter  373  may be coupled to a retainer element  377  ( FIG. 41C ). The retainer element may comprise a flange  371  or other mechanical feature configured to engage the suture lock  376 . For example, the flange  371  may be inserted into a recess at a proximal end of the suture lock  376 . In some embodiments, rotation of the retainer catheter  373  and/or translation substantially perpendicular to the axial direction of the retainer catheter  373  may be used to disengage the retainer catheter  373  from the suture lock  376 . The sutures  311 ,  344  may extend from their respective tissue anchors to pass through the suture lock  376 , entering from a distal channel  395  in a distal face of the suture lock  376 , shown in  FIG. 41I , and exiting at a proximal channel  394  in a proximal face of the suture lock  376 , shown in  FIG. 41H . The sutures  311 ,  344  may extend through a channel in a cutter head  375  proximal to the suture lock  376  and along the outside of the retainer catheter  373  and through the delivery catheter  100 . The cutter head  375  may be coupled to the distal end of a cutter catheter  372 . The retainer catheter  373  may extend through an internal lumen of the cutter catheter  372  such that the two catheters  372 ,  373  may be extendable or retractable relative to one another. 
     Once the sutures  311 ,  344  are locked (fixedly secured) within the suture lock  376 , the proximal ends of the suture  311 ,  344  may be cut adjacent to the proximal face of the suture lock. The sutures  311 ,  344  may be cut by advancing the cutter catheter  372  coupled to the cutter head  375  toward the proximal face of the suture lock  376 . As schematically illustrated in  FIGS. 41E-41F , as the cutter head  375  advances along the retainer catheter  373  toward the retainer element  377 , the cutter head brings the sutures  311 ,  344  into close proximity to a cutting blade  379  positioned on the retainer element  377 . The cutter head  375  is configured to advance over the retainer element  377  in such a fashion that the channel in the cutter head  375  retaining the sutures  311 ,  344  becomes increasingly spatially occupied by the blade  379 . As the blade  379  is forced into the channel of the cutter head  375 , the blade  379  shears the sutures  311 ,  344 . Application of proximal tension to the sutures  311 ,  344  may facilitate the cutting of the sutures  311 ,  344 . In other embodiments, different actuations (e.g., rotation of a cutting catheter) can be configured to sever the sutures  311 ,  344 . In some implementations, more than two sutures may be employed and may be locked within the suture lock  376  and severed by the suture lock delivery subsystem  370  in the same fashion. In some embodiments, advancement of the cutter head  375  over the retainer element  377  may facilitate the disengagement of the retainer catheter  373  from the suture lock  376 . For example, the cutter head  375  may advance to a distal position where it is configured to stabilize the suture lock  376 , allowing the retainer catheter  373  to be axially and/or rotationally disengaged from the suture lock  376 . 
       FIG. 41G  illustrates a side view of an example of a suture lock  376  (shown with its outer casing/shell removed). The sutures may pass through the suture lock  376  from a distal end to a proximal end as described elsewhere herein. The suture lock  376  may comprise a screw  382  configured to distally advance or proximally retract a push wedge  384 , depending on the direction of rotation of the screw. The screw  382  may be rotated by a torque shaft  388 . The torque shaft  388  may comprise a driver head configured to mate with recess  381  (e.g., a polygonal recess or other non-circular shaped recess, as shown in  FIG. 41H ) positioned at the proximal end of the suture lock  376  such that rotation of the torque shaft  388  causes rotation of the screw  382 . The torque shaft  388  may extend through an internal lumen of the retainer catheter  373 . The torque shaft  388  may be rotated at its proximal end by a knob  398  or other actuation mechanism positioned at a proximal end of the subsystem handle  396 . The handle  396  may include a hemostasis valve  397 . In some implementations, the sutures  311 ,  344  may pass through the hemostasis valve  397 . 
     Advancement of the push wedge  384  by the torque shaft  388  may cause a ramp or angled surface  386  to gradually compress one or more springs, such as spring pins  388 . Compression of the one or more springs  388  may force a clamp  390  downward on the sutures  311 ,  344 , compressing the sutures  311 ,  344  between two opposing surfaces. In some embodiments, the clamp  390  and the opposing surface  392  may have notched surfaces configured to mate with each other at discrete increments. The mated notched surfaces may provide enhanced retention of the sutures  311 ,  344  between the opposing surfaces such that they cannot be withdrawn, either proximally or distally, from the suture lock  376 . In some embodiments, the tightening may be reversible by rotating the torque shaft in an opposite direction. 
     Once the suture lock is properly positioned over the sutures  311 ,  344  and locked into place, the sutures  311 ,  344  may be severed as described elsewhere herein.  FIG. 38H  depicts the retraction of the suture lock delivery subsystem  370  after the sutures  311 ,  344  have been cut. Once the suture lock delivery subsystem  370  has been removed from the delivery catheter  100 , the delivery catheter  100  may be withdrawn from the body. 
       FIG. 42  schematically illustrates a helical anchor  110  implanted in a portion of the ventricle comprising relatively thick tissue, between two of the papillary muscles. As described elsewhere herein, the implanted neo chord construct, the optional neo papillary muscle, and/or the helical anchor may be aligned along a longitudinal axis substantially parallel to or concentric with the original path of the native chord and/or the path of the surrounding native chordae. In certain embodiments, the implanted neo chord construct, the optional neo papillary muscle, and/or the helical anchor aligned along a longitudinal axis that is within 5 degrees, 10 degrees, or 15 degrees of being parallel with the original path of the native chord and/or the path of the surrounding native chorda. 
       FIGS. 43A-43C  schematically depict an example of a pledget as described elsewhere herein, in particular with reference to  FIGS. 38E and 38F .  FIG. 43A  schematically depicts a pledget  340  formed by affixing a distal end (shown in dashed lines) of the suture  344  between two flat sheets, such that the sheets for left and right wings  341 ,  342 .  FIG. 43B  shows a cross-section of the pledget  340  along the axis of B-B illustrated in  FIG. 43A . In some embodiments, the suture  344  may be inserted between two sheets (e.g., substantially down the middle of the sheets) and pressed and/or laminated to join the three components together (e.g., under heat and/or pressure). At least one of the layers may be partially sintered. The suture  344  may be flattened and/or densified to improve resistance to suture tear out. The sheets may be flat polytetrafluoroethylene (PTFE) sheets (e.g., thin uncured expanded PTFE (ePTFE) sheets) or any other suitable material. In some implementations, the leaflet suture  344  may be disposed between the sheets in alternative configurations, such as a zig-zag or s-shaped configuration.  FIG. 43C  shows the pledget  340  of  FIG. 43A  comprising a plurality of apertures  343  through which the proximal tail end of the suture  344  may be threaded through. In some embodiments, one or more apertures  343  may be formed through the pledget, in various configurations, to form a collapsible structure, as described elsewhere herein, which is configured to anchor the suture  344  against the mitral leaflet.  FIG. 43C  shows apertures  343  alternating around opposing sides of the suture  344 . In some embodiments, the apertures  343  may be formed on the same side of the suture  344  (e.g., in wing  341  or wing  342 ). In some embodiments, the apertures  343  may be formed through the suture  344 . The apertures  343  may be aligned along a center of the pledget  340 . The apertures  343  may be aligned along the length of the suture  344  (e.g., may form a straight line). The suture  344  may be at least partially flattened between the two opposing sheets, which may facilitate the placement of apertures  343  through the suture  344 . Various combinations of apertures  343 , including the positioning described above, may be used. 
     Although this disclosure describes certain embodiments and examples, many aspects of the above-described systems and methods may be combined differently and/or modified to form still further embodiments or acceptable examples. All such modifications and variations are intended to be included herein within the scope of this disclosure. Indeed, a wide variety of designs and approaches are possible and are within the scope of this disclosure. 
     Also, although there may be some embodiments within the scope of this disclosure that are not expressly recited above or elsewhere herein, this disclosure contemplates and includes all embodiments within the scope of what this disclosure shows and describes. Further, this disclosure contemplates and includes embodiments comprising any combination of any structure, material, step, or other feature disclosed anywhere herein with any other structure, material, step, or other feature disclosed anywhere herein. 
     Furthermore, certain features that are described in this disclosure in the context of separate implementations can also be implemented in combination in a single implementation. Conversely, various features that are described in the context of a single implementation can also be implemented in multiple implementations separately or in any suitable subcombination. Moreover, although features may be described above as acting in certain combinations, one or more features from a claimed combination can, in some cases, be excised from the combination, and the combination may be claimed as a subcombination or variation of a sub combination. 
     For purposes of this disclosure, certain aspects, advantages, and features are described herein. Not necessarily all such aspects, advantages, and features may be achieved in accordance with any particular embodiment. Those skilled in the art will recognize that the disclosure may be embodied or carried out in a manner that achieves one advantage or a group of advantages as taught herein without necessarily achieving other advantages as may be taught or suggested herein. 
     The disclosure herein of any particular feature, aspect, method, property, characteristic, quality, attribute, element, or the like in connection with various embodiments can be used in all other embodiments set forth herein. Also, any methods described herein may be practiced using any device suitable for performing the recited steps. 
     Moreover, while components and operations may be depicted in the drawings or described in the specification in a particular arrangement or order, such components and operations need not be arranged and performed in the particular arrangement and order shown, nor in sequential order, nor include all of the components and operations, to achieve desirable results. Other components and operations that are not depicted or described can be incorporated in the embodiments and examples. For example, one or more additional operations can be performed before, after, simultaneously, or between any of the described operations. Further, the operations may be rearranged or reordered in other implementations. Also, the separation of various system components in the implementations described above should not be understood as requiring such separation in all implementations, and it should be understood that the described components and systems can generally be integrated together in a single product or packaged into multiple products. 
     In summary, various illustrative embodiments and examples are described herein. Although the systems and methods have been disclosed in the context of those embodiments and examples, this disclosure extends beyond the specifically disclosed embodiments to other alternative embodiments and/or other uses of the embodiments, as well as to certain modifications and equivalents thereof. This disclosure expressly contemplates that various features and aspects of the disclosed embodiments can be combined with, or substituted for, one another. Accordingly, the scope of this disclosure should not be limited by the particular disclosed embodiments described above, but should be determined only by a fair reading of the claims that follow as well as their full scope of equivalents.