US 20040167539 A1
A novel approach to mitral or tricuspid valve repair involves the performance of an edge-to-edge fastening/securing of opposing heart valve leaflets through a catheter entering the heart. Thus, a device is introduced including a leaflet fastener applicator through a cardiac catheter or other suitable catheter. The leaflet fastener applicator and cardiac catheter can be formed into a kit. A gripper can be used to hold the heart valve leaflets while they are fastened.
1. A kit comprising a cardiac catheter and a leaflet fastener applicator, said cardiac catheter having suitable dimensions for deployment and insertion into a human heart in the vicinity of the mitral or tricuspid valve, said leaflet fastener applicator having a size allowing insertion through said cardiac catheter and being capable of holding portions of opposing heart valve leaflets.
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11. A method of repairing a valve of a beating heart, said method comprising:
a) inserting the distal end of a catheter into the heart to provide access to said valve; and
b) fastening together portions of leaflets of said valve using a leaflet fastener applicator inserted through said catheter.
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21. A device comprising a catheter and a leaflet fastener applicator, said catheter having a proximal end, a distal end and suitable dimensions for insertion into a heart, said leaflet fastener applicator passing through said catheter such that an actuating element projects from said proximal end of said catheter while a fastening element projects from said distal end of said catheter.
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25. A heart valve leaflet fastener comprising two pairs of arms, each pair having a suitable size for fastening heart valve leaflets and said two pairs of arms capable of fastening two adjacent leaflets.
26. The heart valve leaflet fastener of
27. The heart valve leaflet fastener of
28. A heart valve gripper/fastener applicator comprising a gripper and a fastener applicator wherein said gripper and said fastener applicator extend from a single shaft.
29. The gripper/fastener of
30. The gripper/fastener of
31. A heart valve leaflet fastener applicator comprising two opposing jaws, one of said jaws having a site for holding a tack and the second of said jaws having a site for holding a cap.
32. The heart valve leaflet fastener applicator of
33. A gripper comprising a plunger that slides over an inner shaft and arms having suitable dimensions for gripping heart valve leaflets, said plunger slides such that interaction of heart valve leaflets with said plunger directs said leaflets toward said arms.
34. The gripper of
35. A fastener applicator comprising a first shaft, a first portion of a button clip having a sharp projection for piercing a heart valve leaflet, a second shaft that slides over said first shaft, and a second portion of said button clip having an opening to engage the projection of said first portion of said button clip, said second portion of said button clip sliding over said first shaft and not over said second shaft such that second shaft can direct said second portion toward said first portion.
 The invention relates to the repair of mitral and tricuspid valves exhibiting valve regurgitation. More particularly, the invention relates to apparatus and methods suitable for a less invasive repair of a mitral or tricuspid heart valve.
 Mitral regurgitation, i.e., backward leakage of blood at the mitral heart valve, results in reduced pumping efficiency. Furthermore, compensatory mechanisms such as hypertrophy and dilation of the ventricle suggest early treatment to prevent progressive deterioration of ventricular function. Diagnosis of mitral regurgitation can be performed using visualization with transesophageal echocardiography or by echocardiodiography. In particular, defective leaflet coaptation and the site and direction of the regurgitant flow can be examined to evaluate likely modes of failure.
 Mitral valve prolapse, i.e., myxomatous degeneration of mitral valve leaflets, is the most common cause of mitral regurgitation in North America. Rheumatic heart disease was the most common cause of mitral regurgitation in the U.S.A. thirty years ago and is still the most common cause of mitral regurgitation in developing countries. Chronic rheumatic heart disease results in retraction, deformity and rigidity of one or both mitral valve cusps as well as structural abnormalities in the commissures, chordae tendinae and papillary muscles. Ischemic mitral regurgitation (IMR), i.e., anemia of the valve tissue due to reduced arterial blood flow feeding the valve tissue, is the second most common cause of mitral valve regurgitation. Studies suggest that annular irregularities and posterior papillary muscle fibrosis with scarring of the underlying ventricular wall may be associated with IMR.
 Many cases of mitral regurgitation can be repaired by modifications of the original valve in a procedure generally referred to as valvuloplasty. These repair procedures typically involve a full sternotomy and quadrangular resection of the anterior leaflet, while on cardiopulmonary bypass. Repairs can also involve reattachment of chordae tendinae, which tether the valve leaflets, or removal of leaflet tissue to correct misshapen or enlarged valve leaflets. In some cases, the base of the valve is secured using an annuloplasty ring. Valves that are heavily calcified or significantly compromised by disease may need to be replaced.
 As an alternative to these repair techniques, an edge-to-edge suturing of the anterior and posterior mitral valve leaflets can be performed. Commonly referred to as a “bow-tie” repair, edge-to-edge suturing ensures leaflet coaptation without performing a quadrangular resection of the anterior leaflet. The bow-tie repair generally involves the use of a centrally located suture, although a suture can be placed close to a commissure, or multiple sutures can be used to complete the repair. A centrally placed suture creates a double orifice valve, which resembles a bow-tie.
 The bow-tie repair procedure has been applied using invasive procedures by placing the patient on extracorporeal circulation. An incision is made to provide access into the left atrium of the heart. Following suturing, the atrium is closed. Such repairs can result in a significant decrease in mitral regurgitation along with a corresponding increase in the ejection fraction.
 In a first aspect, the invention relates to a kit including a cardiac catheter and a leaflet fastener applicator. The cardiac catheter generally has suitable dimensions for deployment and insertion into a human heart in the vicinity of the mitral or tricuspid valve. The leaflet fastener applicator generally has a size allowing insertion through the cardiac catheter and is capable of holding portions of opposing heart valve leaflets.
 In another aspect, the invention relates to a method of repairing the mitral or tricuspid valve of a beating heart, the method including:
 a) inserting the distal end of a catheter into the heart to provide access to the valve; and
 b) fastening together portions of leaflets of the valve using a leaflet fastener applicator inserted through the catheter.
 In another aspect, the invention relates to a device including a catheter and a leaflet fastener applicator. The catheter has a proximal end, a distal end and suitable dimensions for insertion into a heart. The leaflet fastener applicator passes through the catheter such that an actuating element projects from the proximal end of the catheter while a fastening element projects from the distal end of the catheter.
 In another aspect, the invention relates to a heart valve leaflet fastener including two pairs of arms. Each pair of arms is of a suitable size for fastening heart valve leaflets together. The two pairs of arms are capable of fastening two adjacent leaflets.
 In another aspect, the invention relates to a heart valve gripper/fastener applicator including a gripper and a fastener applicator wherein the gripper and the fastener applicator extend from a single shaft.
 In another aspect, the invention relates to a heart valve leaflet fastener applicator including two opposing jaws. One of the jaws has a site for holding a tack, and the second jaw has a site for holding a cap.
 In another aspect, the invention relates to a gripper including a plunger that slides over an inner shaft, and arms having suitable dimensions for gripping heart valve leaflets. The plunger slides such that the interaction of heart valve leaflets with the plunger directs the leaflets toward the arms.
 In another aspect, the invention relates to a fastener applicator including a first shaft, a first portion of a button clip having a sharp projection for piercing a heart valve leaflet, a second shaft that slides over the first shaft, and a second portion of the button clip having an opening to engage the projection of the first portion of the button clip. The second portion of the button clip slides over the first shaft and not over the second shaft such that the second shaft can direct the second portion toward the first portion.
FIG. 1 is a side view of one embodiment of a cardiac catheter.
FIG. 2 is a perspective view of the proximal end of the cardiac catheter of FIG. 1.
FIG. 3 is a side view of a suture knot securing two leaflets together.
FIG. 4 is a side view of a knot pusher.
FIG. 5 is a perspective view of sutured heart valve leaflets being secured with a suture clip with a portion of a cardiac catheter cut away to expose structure within the catheter.
FIG. 6 is a perspective view of endoscopic scissors being used to cut a suture.
FIG. 7 is a perspective view of heart valve leaflets secured with attached wires that have suture attached at one end.
FIG. 8 is a side view of heart valve leaflets each pierced by a barbed needle where the barbed needles are attached to each other with suture.
FIG. 9 is an enlarged view of a barbed needle of FIG. 8.
FIG. 10 is a side view of a push rod useful for the deployment of the barbed needles of FIG. 8.
FIG. 11 is a side view of barbed needles with flexible wire attached to the needle.
FIG. 12 is a side view of heart valve leaflets with the barbed needles of FIG. 11 piercing the heart valve leaflets and a push rod gripping the suture connecting the two barbed needles.
FIG. 13A is a side view of a fastener with a corresponding applicator inserted between two heart valve leaflets prior to deployment.
FIG. 13B is a side view of the fastener and applicator of FIG. 13A with arms extended on either side of the heart valve leaflets.
FIG. 13C is a side view of the fastener and applicator of FIG. 13 A where the arms are being pushed together to grab the leaflets.
FIG. 13D is a side view of the fastener and applicator reaching a locked position where the leaflets are held firmly in place.
FIG. 13E is a side view of the leaflets secured in place by the fastener of FIG. 13A after the applicator is removed.
FIG. 13F is a sectional view of the engagement mechanism used to secure and detach the fastener of FIG. 13A from the applicator used to deploy the fastener.
FIG. 14A is a perspective view of a gripper/fastener with spring loaded arms being deployed from a cardiac catheter with a portion of the cardiac catheter cut away to expose structure within the catheter.
FIG. 14B is a perspective view of the gripper/fastener of FIG. 14A with two spring loaded arms being free of the cardiac catheter with a portion of the cardiac catheter cut away to expose structure within the catheter.
FIG. 14C is a perspective view of the spring loaded fastener of FIG. 14A deployed holding heart valve leaflets following release of the deployment device with a portion of the cardiac catheter cut away to expose structure within the catheter.
FIG. 14D is a perspective view of an alternative embodiment of the arms of the spring loaded fastener where the arms are curved.
FIG. 15 is a side view of a needle fastener with a suction based gripper.
FIG. 16 is side view of a gripper mounted adjacent a fastener applicator being directed toward heart valve leaflets.
FIG. 17 is an enlarged perspective view of the gripper and fastener applicator of FIG. 16.
FIG. 18A is a sectional side view of the gripper of FIG. 17.
FIG. 18B is an exploded side view of an alternative embodiment of the gripper of FIG. 18A, the alternative embodiment being based on a cam, where the rod and moveable jaw have been removed from the remainder of the gripper.
FIG. 18C is a side view of the embodiment shown in FIG. 18B.
FIG. 18D is a view down the end of the shaft from the proximal end toward the jaws, where the ball of the cam is shown in both an open and closed position.
 Fiqs. 19A-C are sectional views of the fastener applicator of FIG. 17 where the section in FIG. 19B is taken at a right angle relative to the sections in FIGS. 19A and 19C. Hidden structures are shown with phantom lines.
FIG. 19D is a side view of the tack and cap of FIG. 19A secured together, shown in phantom.
FIG. 20 is a side view of a gripper with a plunger used to direct the leaflets to gripper arms.
FIG. 21 is a side view of an alternative embodiment of a gripper with spring loaded arms and a balloon plunger that directs the leaflets to the spring loaded arms.
FIG. 22 is a side view of hooks used as gripper elements.
FIG. 23 is a side view of a spring fastener with a suction based gripper.
FIG. 24 is a side view of heart valve leaflets secured with a spring fastener of FIG. 23.
FIG. 25 is a perspective view of a portion of a clip button held by a deployment device, the clip button being useful for fastening heart valve leaflets.
FIG. 25A is a perspective view of the tip of a first applicator.
FIG. 26 is a perspective view of the clip button of FIG. 25 and associated deployment devices, with the two portions of the clip button aligned.
FIG. 27 is a front view of a first portion of the clip button of FIG. 26.
FIG. 28 is a side view of the first portion of the clip button of FIG. 26.
FIG. 29 is a side view of the second portion of the clip button of FIG. 26.
FIG. 30 is a rear view of the second portion of the clip button of FIG. 26.
FIG. 31 is a side view of the second portion of the clip button of FIG. 26 rotated 90 degrees relative to the view in FIG. 29.
FIG. 32 is a side view of the two portions of the clip button of FIG. 26 fastened together.
FIG. 33 is a sectional side view of a spring loaded ring in a loaded position.
FIG. 34 is a sectional side view of the spring loaded ring of FIG. 33 in an extended position.
FIG. 35 is a side view of a crimp ring in an uncrimped position.
FIG. 36 is a side view of the crimp ring of FIG. 35 following crimping.
FIG. 37 is a perspective view of a ring fastener being positioned with an applicator toward heart valve leaflets, where a portion of the cardiac catheter is cut away to permit the visibility of structure within the catheter.
FIG. 38 is a perspective view of the applicator of FIG. 37 following deployment of the ring fastener.
FIG. 39 is a side view of one embodiment of an automatic suture device positioned near heart valve leaflets.
FIG. 40 is a side view of the automatic suture device of FIG. 39 gripping the heart valve leaflets with needles.
FIG. 41 is a sectional view of one of the needles of the automatic suture device of FIG. 39.
FIG. 42 is sectional view of the automatic suture device of FIG. 39 with an ultrasonic welder positioned for placement at its ultimate welding position.
FIG. 43 is a side view of an alternative embodiment of an automatic suture device.
FIG. 44 is a perspective view of the automatic suture device of FIG. 43.
 Methods have been developed for performing less invasive mitral valve repairs. While the discussion focuses on the repair of mitral heart valves, the repair approaches can be used for the repair of tricuspid valves using straightforward modification of the described procedures and instruments. In particular, the repairs can be performed on a beating heart such that the patient does not have to be placed on cardiopulmonary bypass.
 Access into the heart for mitral valve repair is obtained by securing a passageway from the exterior of the body into the body and into the heart to provide access into the left atrium or left ventricle. With suitable instruments inserted through the passageway, the mitral leaflets are grabbed, and the edges of the leaflets are secured together. The gripping and securing or fastening procedures can be performed simultaneously in some embodiments of the invention, or they can be performed separately. A suitable method of visualization may be used to guide the manipulations. Manipulations to the mitral valve can be conducted under ultrasound or fluoroscopy to show correct placement of the devices and of the repair and to verify effectiveness of the repair.
 One approach to introduce the instruments into the heart involves the direct introduction of a passageway through the wall of the heart. To introduce the passageway or a cardiac catheter into the body, a small incision is made in the chest. Instruments generally used to position catheters can be used to guide the cardiac catheter to the heart and into the heart wall, as described further below. Use of properly selected instruments for the introduction of the cardiac catheter reduces the amount of trauma to the heart. Upon completion of the mitral valve repair, the instruments are removed through the cardiac catheter, the cardiac catheter is removed, and the incision in the heart wall is repaired, for example, with suture.
 Alternatively, the instruments can be introduced into the heart by a vascular approach. In these approaches, a catheter is introduced into an artery or vein and directed into the heart. These vascular approaches are described further below.
 Suitable gripping and fastening instruments have appropriate dimensions to fit through the cardiac catheter into the heart. In general, the instruments have a tubular section or shaft between a distal end and a proximal end. The tubular section may be flexible. The distal end of the instrument is inserted through the cardiac catheter into the heart. The gripping and/or securing/fastening elements are located at the distal end of the instrument. One or more actuating elements are located at the proximal end.
 In some embodiments, a single element performs the gripping and fastening functions. In other words, a fastening element grips the tissue during the fastening process such that a separately identifiable gripping element is not present. For example, suture can be placed through each leaflet such that tightening of the suture draws the two portions of the leaflets together.
 Alternatively, the gripping and fastening elements can be distinct, separate instruments. For certain embodiments, functionally distinct gripping and fastening elements can be integrated into a single instrument such that a single tubular section is needed. Alternatively, the distinct gripping and fastening elements can be located on separate instruments, each having a separate tubular section. If the gripping and fastening elements are located on separate instruments, the tubular sections of the instruments can have suitable dimensions such that the two tubular sections can be inserted simultaneously through a single cardiac catheter. Alternatively, one or more additional cardiac catheters can be introduced into the heart to provide separate instrument passageways for the gripping and fastening instruments and any other instruments used to facilitate the procedure. Also, one or more additional cardiac catheters can be used to provide a means of direct visualization.
 The mitral valve repair device generally includes a gripper/fastener applicator instrument, and may include a cardiac catheter or other suitable catheter. The cardiac catheter generally has an elongated tubular section and proximal and distal ends each with an opening. For example, the cardiac catheter can be a catheter introducer used for standard intravascular placement or a similar instrument. An embodiment of a cardiac catheter 126 is displayed in FIG. 1. Proximal end 102 includes opening 104, as shown in FIG. 2, through which a gripper/fastener applicator instrument is introduced. Proximal end 102 preferably includes a hemostasis valve 106 to prevent blood from flowing out of the cardiac catheter. Standard designs used in the catheter art can be used for the hemostasis valve.
 Tubular section 108 of cardiac catheter 100 preferably is flexible so that it can be guided through the body to the desired location. Generally, tubular section 108 has a length from about 4 cm to about 15 cm and a diameter from about3 mm (9 French (F)) to about 10 mm (30 F), more preferably from about 3 mm (9 F) to about 8 mm (24 F). However, tubular section 108 can be selected to have a suitable length appropriate for the specific procedure used. Tubular section 108 preferably has a tapered end 110 to assist with introduction of cardiac catheter 100 into the heart.
 The gripper/fastener applicator instrument can have one functional element that accomplishes both the gripping and fastening operations simultaneously (e.g., FIG. 19), or two functional elements with one element performing the gripping and a second performing the fastening (e.g., FIG. 17). Two functional elements can be integrated together on a single instrument, or they can operate together as two separate instruments through the cardiac catheter(s). One or more cardiac catheters can be used, as needed or desired. Specific embodiments are described below.
 A first type of gripper/fastener applicator has one functional device that accomplishes both gripping and fastening functions. Several embodiments of the first type of gripper/fastener applicator can be based on attachment of suture that is tied off to secure. the leaflets together.
 Referring to FIG. 3, sutures 120 placed through the respective valve leaflets 122, 124 can be tied outside of the body. Sutures 120 can be positioned using a needle or needles that are passed through leaflets and withdrawn through cardiac catheter 126. A knot pusher 130 (FIG. 4) can be used to push a knot tied outside of the body to the leaflets such that the knot pulls the leaflets together. Variations on the design of the needle and the knot pusher can be used to accomplish the same purposes. Alternatively, rather than tying a knot, a suture clip 132 can be used to fasten sutures 120, as shown in FIG. 5. Suture clip 132 is pushed into place up to leaflets 122, 124 with a clip pusher 134. Suture clip 132 is shaped such that suture can be fed through clip 132 only in one direction. Once sutures 120 are tied or clipped, suture 120 can be cut with endoscopic scissors 136, as shown in FIG. 6, or other similar device.
 Another suture based gripper/fastener embodiment is depicted in FIG. 7. Instead of passing suture through each leaflet, the suture 150 can be secured to the edge of leaflets 122, 124 with a piece of wire 152 at one end of suture 150. Wire 152 can be sharpened spiral or coiled wire, such as a pacemaker lead. Wire 152 can be crimped on the edge of a particular leaflet 122, 124. As described above, the suture can be tied outside the heart, the knot can be pushed to the leaflets, and the suture 150 can be cut.
 Another embodiment of a single element gripper/fastener applicator involves the use of barbed needles. Referring to FIG. 8, a barbed needle 200 penetrates each leaflet 122, 124. If the repair requires further securing of the leaflets, additional needles may be deployed. Barbed needles 200 are connected to each other by suture 206. Each needle 200 can include a plurality of barbs 208 (FIG. 9). Barbed needles 200 can be deployed individually with a push rod 210 (FIG. 10). Push rod 210 generally has releasable jaws 212 for holding barbed needles 200 during deployment. Jaws 212 are activated by lever 214 at the handle end 216 of push rod 210. Alternatively, suitable push rods or other mechanical trigger actuators, such as spring activated mechanisms, can be used to deploy barbed needles 200.
 In order to use a short enough piece of suture 206 to hold the leaflets closed while having enough flexibility to deploy barbed needles 200, the embodiment in FIG. 8 can be modified as shown in FIG. 11. Each barbed needle 222 has a wire 224 extending from needle 222. Suture 226 connects the two wires 224. Barbed needles 222 can be deployed in the same way as depicted in FIG. 8. Referring to FIG. 12, push rod 210 with jaws 212 or a similar device can be passed into the heart through cardiac catheter 126 to grab suture 226. Push rod 210 is rotated to wind suture 226 and ultimately to wind wires 224. The winding of wires 224 draws barbed needles 222 closer together, resulting in leaflets 122, 124 being drawn closer together. Wires 224 preferably are made of material, such as stainless steel, which is malleable enough that they can be wound together with forces transmitted through the suture yet resilient enough that the wires do not unwind from the load transmitted by leaflets 122, 124.
 Alternatively, suture can be connected directly to each barbed needle and looped around the other needle. Pulling each suture then draws each barb to the other. Additional knots can be pushed down from outside the body through cardiac catheter 126 to secure the two sutures together.
 In other embodiments of a single element gripper/fastener applicator, a gripping/fastener applicator device is deployed and later released using an applicator. For example, referring to FIG. 13A, a deploying wand 250 is inserted through cardiac catheter 126. Outer sleeve 254 holds gripper arms 256, 258, 260, 262 in place against inner core 264. Deploying wand 250 is inserted between leaflets 122, 124. Referring to FIG. 13B, outer sleeve 254 is pulled away from gripper arms 256, 258, 260, 262 to permit gripper arms to extend once the outer sleeve 254 no longer holds them in place.
 With gripper arms 256, 258, 260, 262 extending on both side of leaflets 122, 124, inner core 264 is pulled inward and outer sleeve 254 is pushed outward in the direction of arrow 266 (FIG. 13C), such that arms are being pushed together to grab the leaflets. Referring to FIG. 13D, gripper arms 256, 258, 260, 262 hold leaflets 122, 124 in place. The position of gripper arms 256, 258, 260, 262 along inner core 264 is locked in place by stops 270. Gripper arms 256, 258, 260, 262 are extended beyond an equilibrium position such that restorative forces tend to pull gripper arms toward inner core 264. Referring to FIG. 13E, end 272 of inner core 264, while gripping and fastening leaflets 122, 124, is released from the remaining portions of inner core 264 by disengaging a locking mechanism thereby securing the leaflets with the fastening device. Inner core 264 is removed through cardiac catheter 126. The locking mechanism can have any of a variety of conventional structures, so as to grip and fasten leaflets 122, 124. One embodiment of a suitable locking mechanism is depicted in FIG. 13F. Pivoting latches 280 lock into flanges 282. Wires 284 can be used to release latches 280 from flanges 282. Gripper arms 256, 258, 260, 262 generally have a length from about 2 mm to about 10 mm. Inner core 264 generally has a diameter from about 1 mm to about 8 mm.
 A similar embodiment of the invention is depicted in FIG. 14. In single element gripper/fastener applicator 300, arms 302, 304, 306, 308 are spring loaded. As arms 302, 304, 306, 308 are pushed free of the end 310 of cardiac catheter 126., they extend due to the spring loading feature. In FIG. 14B, gripper/fastener applicator 300 is depicted with arms 302, 306 extended. Arms 302, 306 have pointed tips 314, 316 that can pierce leaflets 122, 124. As depicted in FIG. 14C, once arms 304, 308 are free of the cardiac catheter 126, arms 304, 308 extend on one side of the leaflets to grasp leaflets 122, 124 along with arms 302, 306, which extend on the other side of leaflets 122, 124. Arms 304, 308 have clasps 322, 324 that engage pointed tips 314, 316 such that arms 302, 304, 306, 308 firmly grasp leaflets 122, 124 therebetween. Grasper/fastener applicator 300 is released from applicator 326 by rotating knob 328 such that knob 328 passes through passageway 330 within base 332. In an alternative embodiment, arms 302, 304, 306, 308 are curved as depicted in FIG. 14D.
 The second type of gripper/fastener applicator has two distinct elements, a gripper element and a fastener applicator element. The gripper element and the fastener applicator element can be located at the respective distal ends of two distinct shafts. For certain embodiments the gripper element and the fastener applicator elements can be integrated on a single shaft and may be adapted to move relative to one another as appropriate for the procedure that is being performed, i.e., gripping or fastening. In this way, a single shaft can be guided through the cardiac catheter.
 An embodiment of a distinct gripper and a fastener applicator integrated onto a single shaft is depicted in FIG. 15. Gripper/fastener applicator 340 has a spiral needle 342, which spirals around inner catheter 344. The first step involves applying suction through an internal lumen of inner catheter 344 by way of openings 346 to grasp and position a leaflet against inner catheter 344. Once the leaflets are grasped by suction, spiral needle 342 is advanced and rotated. Rotation of outer sleeve 343 results in the passage of spiral needle 342 through leaflets 122, 124. Spiral needle 342 is mounted on outer sleeve 343 that rotates around inner catheter 344. The outer sleeve can be threaded to provide appropriate pitch and number of rotations. To hold the leaflets in place, spiral needle 342 is disengaged from outer sleeve 343 by disengaging a clamp or the like at the end 345 of outer sleeve 343. If desired, the needle can be crimped to ensure permanent attachment. The suction based gripper of FIG. 15 can be used also with other types of fasteners.
 Referring to FIGS. 16-17, device 400 includes a gripper 402 and a fastener applicator 404 that extend from a shaft 406. Gripper 402 and fastener applicator 404 can be adjacent each other, as shown in FIG. 17. Alternatively, gripper 402 and fastener applicator 404 may move relative to each other by sliding in a tube, track, or similar mechanisms. The relative position of gripper 402 and fastener applicator 404 can be reversed. In FIG. 17, with fastener applicator 404 in a distal withdrawn position, gripper 402 can grab leaflets 122, 124. Then, fastener applicator 404 can be opened in the withdrawn position and slid forward to apply a tack on captured leaflet edges. Therefore, gripper 402 preferably is oriented relative to leaflets 122, 124 as shown in FIG. 16.
 One embodiment of gripper 402 is depicted in FIG. 18A. In this embodiment, claw gripper 412 has opposing jaws 414, 416, which meet at serrated edges 418, 420 in a closed orientation. Serrated edges 418, 420 assist with the gripping of the leaflets 122, 124. The extension of rod 422 alters the relative position of jaws 414, 416 by moving a lever 424. Rod 422 extends through shaft 406 to the distal end of shaft 406 such that a physician can manipulate rod 422 outside of the patient. The length of jaws 414, 416 should be appropriate for the jaws to reach leaflets 122, 124 at the maximum anticipated spacing between leaflets 122, 124. If desired, grippers 412 can be used with a shaft separate from a shaft holding a fastener applicator element. Grippers 412 are designed to grip leaflets 122, 124 as depicted in FIGS. 16, 17 and 18.
 As an alternative to the lever mechanism shown in FIG. 18A, a cam can be used to rotate the jaw, as depicted in FIGS. 18B-D. In particular, jaw 411 rotates around pivot 413. Rotation of rod 415 causes ball 417 to change position relative to the position of rod 415. Ball 417 fits into track 419 in the end of jaw 411. Also, ball 417 fits into a notch in an off center position in the end of rod 415 such that rotation of rod 415 moves ball 417 up or down. Lowering of the ball results in the opening of jaw 411 relative to jaw 421. Rod 415 is rotated using lever 423, as shown in FIG. 18D. Generally a half rotation of rod 415 results in motion of jaw 411 from a closed position to its open. position.
 As depicted in FIG. 17, fastener applicator 404 applies a fastener, such as a tack. Further details about fastener applicator 404 can be seen in FIG. 19. Fastener applicator 404 holds tack 424 and cap 426 in separate housings for deployment. When jaws 428, 430 are opened by the movement of lever 432 in the direction shown by the arrow 431 in FIG. 19A, rod 434 slides tack 424 within track 436 to a position aligning cap 426 with tack 424, as shown in FIGS. 19B and 19C. Jaws 428, 430 rotate relative to each other by way of lever arm 438 or other mechanical link, such as a cam. When jaws 428, 430 subsequently are closed, tack 424 engages cap 426, as shown in FIG. 19D, thereby fastening leaflets 122, 124. Jaws 428, 430 can be opened to release tack 424 and fastened leaflets 122, 124.
 While the above grippers and fastener applicators can be used for an atrial or ventricular approach, other designs for the gripper are particularly adapted for gripping leaflets from an atrial approach. Referring to FIG. 20, gripper 438 includes graspers 440 used to grasp each leaflet 122, 124. To push the leaflets toward graspers 440, plunger 446 includes two or more arms 450, 452. In an alternative embodiment depicted in FIG. 21, a balloon plunger 454 is used. Balloon plunger 454 is deflated for delivery and removal of the instrument through cardiac catheter 126 and inflated within the heart for use to guide the leaflets to the graspers 440.
 With either embodiment of the plunger, shaft 456 can be pulled to draw spring loaded graspers 440 toward plunger 446 or 454 to grip leaflets 122, 124 within grasper 440. Alternatively, plunger 446 or 454 can push leaflets 122, 124 toward graspers 440. In any case, as plunger 446 or 454 reaches a certain position relative to graspers 440 so that graspers 440 are within reach of leaflets 122, 124, shaft 456 is pulled back to retract graspers 440, which clasp leaflets 122, 124 between graspers 440 and grasper tube 441. Once leaflets 122, 124 are clasped, plunger 446, 454 can be removed. After leaflets 122, 124 are fastened, graspers 440 can be released by extending shaft 456 such that gripper 438 can be withdrawn. Graspers 440 should be less than about 10 mm in length. Graspers 440 can be curved.
 Another approach to grasping the leaflets from the atrial side is depicted in FIG. 22. Hooks 470, 472 are deployed through cardiac catheter 126 to grab leaflets 122, 124. Hooks 470, 472 preferably have sharp tips 480, 482 without barbs. With leaflets 122, 124 held in place, a variety of fasteners, as described throughout, can be used to fasten leaflets 122, 124. Once leaflets 122, 124 are fastened securely, hooks 470, 472 can be released and removed by pushing hooks 470, 472 to release the respective leaflets 122, 124 and rotating hooks 470, 472 such that they do not grab leaflets 122, 124 when withdrawn.
 Once one embodiment of grasper is holding the leaflets, another type of grasper generally can be substituted for that grasper to hold the leaflets. A wider variety of graspers are suitable for grasping already held leaflets. In this way, a fastener applicator can be used with a more appropriate grasper, if desired. Furthermore, multiple grippers can be used to grasp the leaflets to be fastened. For instance, a hook as shown in FIG. 22 can be used to grab one leaflet while jaws such as shown in FIGS. 18A-D can be used to grab the other leaflet. As another example, two sets of jaws can be used, each grabbing one leaflet.
 With respect to fastener applicators, a spring fastener embodiment is depicted in FIGS. 23-24. Leaflets 122, 124 are drawn into cavities 500, 502 with suction similar to that applied by the device in FIG. 15. Vacuum is applied by way of lumen 504. Spring 506 is pushed and rotated using rotating shaft 508. End 510 of spring 506 catches a leaflet such that rotating the spring 506 causes spring 506 to spiral through leaflets 122, 124 as shown in FIG. 24, fastening leaflets 122, 124 together. After spring 506 is placed through the leaflets, vacuum is released and lumen 504 is withdrawn.
 Referring to FIGS. 25-32, another embodiment of a fastener applicator uses a fastener clip button 540 which includes a first portion 542 and a second portion 544. Referring to FIGS. 27 and 28, first portion 542 includes spikes 546 extending from a first surface 548 of base 550. Base 550 has notches 552 at the edge of second surface 554 at a position rotated 90 degrees relative to spikes 546. The center of base 550 has an opening 556 with wings 558 oriented toward notches 552. Second surface 554 includes indentations 560 adjacent opening 556 oriented toward spikes 546.
 Referring to FIGS. 29-31, second portion 544 includes perforations 566 which have a diameter equal to or slightly smaller than spikes 546. Tabs 568 extend from first surface 570 of base 572. Tabs 568 include lips 574 that can engage notches 552. Base 572 includes an opening 578 with wings 580. Base 572 is slightly noncircular to allow for tabs 568.
FIG. 32 displays first portion 542 engaged with second portion 544. When portions 542, 544 are engaged, spikes 546 engage perforations 566 and tabs 568 engage notches 552. The leaflets are positioned in the separation between base 550 and base 572.
 Referring to FIG. 25, to deploy clip button 540, first portion 542 is positioned with first applicator 580. First applicator 580 includes a central core 582 with a knob 584 at the end of the central core 582, as shown in FIG. 25A. Knob 584 engages indentations 560 when first portion is positioned on first applicator 580, and can pass through wings 558 when oriented accordingly for removal of first applicator 580. First applicator 580 also includes tubular portion 588, which slides over central core 582. When knob 584 engages indentations 560 and tubular portion 588 engages first surface 548, first portion 542 is held firmly by first applicator 580. Preferably, first portion 542 is placed in position near the leaflets prior to grasping of the leaflets by a gripper. Once grasped, the leaflets can be pierced with spikes 546 of first portion 542.
 After spikes 546 are inserted through the leaflets, tubular portion 588 can be removed through cardiac catheter 126. Then, second applicator 590 can be slid over central core 582, as shown in FIG. 26. Second applicator 590 is used to engage second portion 544 with first portion 542. Second applicator 590 can push second portion 544 into place, or, alternatively, second applicator 590 can hold second portion 544 using a fastener such as threads or a clamp, as first portion 542 is pulled against it. After second portion 544 engages first portion 542, second applicator 590 is removed through cardiac catheter 126. Central core 582 is removed by first rotating knob 584 such that knob 584 passes through wings 558 and 580. Clip button 540 remains fastened to the mitral valves leaflets.
 Another embodiment of a fastener uses a deformable ring. Different variations of the ring are available. A first embodiment of a spring loaded ring is depicted in FIGS. 33 and 34. Spring loaded ring 600 has a first spike 632 at the end of crescent portion 604. Second spike 606 is initially located in cavity 608 within crescent portion 604. Spring 610 is located between second spike 606 and surface 612. A button lock 614 holds second spike 606 within crescent portion 604 until deployment of spring loaded ring 600. When the lock 614 is released, first spike 602 and second spike 606 pierce the leaflets and secure them together. Alternative embodiments of the spring loaded ring can employ dual springs with a spike being propelled by each spring. If desired, the spikes can be retractable such that the ring is used to hold the leaflets while another fastening approach is used to secure the leaflets.
 Referring to FIGS. 35 and 36, crimp ring 630 includes points 632, 634 and handles 636, 638. Between handles 636, 638 is a notch 641. Notch 640 provides a weak location for bending points 632, 634 toward each other, as shown in FIG. 36. Crimp ring 630 is placed near the grasped leaflet. Then, handles 636, 638 are rotated away from each other to place the crimp ring 630 in the closed crimped position shown in FIG. 36 with points 632, 634 piercing respective leaflets.
 Rings such as spring loaded ring 600 and crimp ring 630 can be applied with an applicator 640, as depicted in FIGS. 37 and 38. Ring 642 is brought up to leaflets 122, 124 and deformed to pierce leaflets 122, 124. Applicator 641 can include lever arms 650 and/or other implements to assist with deployment of rings 600 or 630. For example, for spring loaded ring 600, either lever arms 650 or another implement releases lock 614. For crimp ring 630, lever arms 650 hold handles 636, 638 and rotate handles to crimp the ring to bring points 632, 634 toward each other.
 An automatic suture device can be used as a fastener. One embodiment of an automatic suture device is described in U.S. Pat. No. 5,417,700, to Egan, incorporated herein by reference. Referring to FIGS. 39-42, suture device 658 includes hollow needles 660, 662, which can rotate to pierce leaflets 122, 124. Suture 664 (FIG. 42) is threaded through channel 666 (FIG. 41) within hollow needles 660, 662. Suture 664 can be secured with an ultrasonic weld formed between weld anvil 668 and welding horn 670. Suture 664 can be pulled tight prior to welding.
 An alternative embodiment of an automatic suture device is shown in FIGS. 43 and 44. The suture device 700 includes a curved needle 702. Needle 702 has a point 704 and a blunt end 706. Needle 702 lies within slot 708. Suture 710 is threaded through channel 712. Suture 710 exits channel 712, crosses to the opposite opening into slot 708, circumscribes slot 708 and attaches to needle 702 at blunt end 706.
 Suture 710 is pulled, which rotates needle 702, impaling leaflets 122, 124 with point 704. Needle 702 is rotated about 360 degrees such that needle 702 has passed through leaflets 122, 124. Following complete rotation of needle 702, suture 710 is threaded through leaflets 122, 124. Withdrawal of suture device 700 through the catheter introducer pulls suture 710 through leaflets 122, 124. Suture 710 can be tied, as described above with respect to FIG. 3, to secure leaflets 122, 124. Alternatively, a suture clip 132 can be used to secure suture 710, as shown in FIG. 5.
 All of the devices described above can be constructed from standard biocompatible materials including a variety of metals, such as stainless steel and titanium, and polymers, such as polysulfone. The materials can be selected as appropriate for a particular application. Furthermore, the fasteners can be coated with a surface modifier such as polytetrafluoroethylene (PTFE), i.e., Teflon®, or an antimicrobial coating, such as silver metal or a silver compound. Antimicrobial metal coatings are further described in copending and commonly assigned U.S. patent application Ser. No. 08/974,992 to Ogle et al., entitled “Medical Article with Adhered Antimicrobial Metal,” incorporated herein by reference.
 Surgical Procedure
 In preferred embodiments of the procedure, the repairs are performed on a beating heart. Alternatively, the heart can be stopped during the procedure. Cardioplegia, i.e., stopped cardiac contraction, can be induced by certain chemicals such as cold potassium-containing solutions that are introduced into the myocardium. The chemical induction of cardioplegia requires the isolation of the heart and ascending aorta from the rest of the patient's vascular system. Procedures using cardioplegia are less desirable since they require cardiopulmonary bypass, which increases patient risk factors.
 For cardiac catheter based embodiments, one or more access points are used along the patient's chest, generally positioned between adjacent ribs. The access points provide access to the heart. Incisions are made to initiate the access points. Trocar sheaths, such as those used for the performance of laparoscopic procedures, can facilitate use of the access points as described in published PCT application WO 94/18881 to Stanford Surgical Technologies, Inc., incorporated herein by reference. Alternatively, soft tissue retractors, such as those used in pediatric open chest procedures can be utilized to facilitate use of the access points. Suitable location of the access point(s) can be determined based on the approach appropriate for the gripper/fastener applicator to be used.
 Once the heart is accessed, a guide wire can be inserted through the wall of the heart either near the apex of the heart into the left ventricle or near the top of the heart into the left atrium. A dilator can be slid over the guide wire to expand the opening into the heart. Suitable guidewires and dilators are available from Daig Corp., Minnetonka, Minn. A cardiac catheter with a hemostasis valve, described above, is deployed over the dilator. The cardiac catheter provides access. into the heart to deliver the repair device or devices.
 Alternatively, a cardiac catheter can be inserted through an incision in the wall of the heart at the desired location. As during normal cannulation, a purse string suture can be applied at the point where the cardiac catheter enters the heart to reduce any bleeding. The suture can be applied, for example, using a piece of suture with a needle on both ends. The needles can be manipulated using forceps or the like. After the desired stitching is performed, the needles can be cut off using endoscopic scissors. Additional cardiac catheters can be placed near or into the heart, as desired.
 Once the cardiac catheter is in place, the gripper/fastener instruments can be directed at the mitral or tricuspid valve to perform the repair. All of the instruments are designed such that the appropriate manipulations by the appropriate health care professional are performed at the proximal end of the cardiac catheter.
 Following completion of the bow-tie repair, the cardiac catheter is removed. The procedures used to deploy the cardiac catheter preferably minimize the damage to the heart muscle by separating the tissue without significantly tearing the tissue. Nevertheless, stitches or staples can be used to close the incision at the point where the cardiac catheter was inserted. Once access to the heart has been closed, the incision providing access into the chest cavity is closed.
 Alternatively, a less invasive, percutaneous vascular approach can be used. There are two, alternative, percutaneous vascular approaches to positioning the catheter for the medical procedure. One is to introduce the catheter into the femoral artery by a standard introducer sheath and advance it up the aorta, across the aortic valve into the left ventricle and then position its tip under the mitral annulus. This is commonly referred to as the “retrograde” approach.
 The other approach, commonly referred to as the transseptal approach, is to introduce a transseptal sheath apparatus, a long single plane curve introducer, into the right femoral vein and advance it through the inferior vena cava into the right atrium. A puncture is then made through the fossa ovalis in the intraatrial septum, and the apparatus is advanced into the left atrium where the trocar and dilator of the apparatus is removed, leaving the sheath in position in the left atrium. Once the valve is accessed, the repair can be completed as described above.
 Edge-to-edge mitral valve repair provides a simple and effective repair technique relative to complex and surgically demanding approaches of chordal shortening, resectioning, chordal transposition or artificial chordae replacement. The edge-to-edge repair is particularly effective with severe isolated mitral regurgitation or in association with coronary artery bypass surgery. The present approach provides the benefits of the edge-to-edge repair without the trauma of open heart surgery and cardiopulmonary bypass. Thus, the procedure can be accomplished concomitant with coronary artery bypass graft (CABG) or as a stand alone outpatient procedure in a cardiac catheterization laboratory. The advantages include reduced cost, hospitalization and patient recovery times. With minimal trauma to the patient, it may be desirable to perform the repair earlier before the disease has progressed to a serious level. Thus, more repair procedures may be performed, preventing further progression of the disease, obviating the need for more serious invasive procedures.
 The instruments described above may be distributed in the form of a kit. Generally, the kit includes a fastener applicator and a suitable cardiac catheter or other catheter for a vascular approach. The kit may also include a suitable gripper for use with the fastener applicator. Alternatively, the kit may include only a fastener (fastener applicator) and/or a gripper. The kit preferably includes instructions for the performance of mitral and/or tricuspid valve repair. In particular, the instructions can describe the particular use of the fastener applicator and/or the grippers.
 Although the present invention has been described with reference to preferred embodiments, workers skilled in the art will recognize that changes may be made in form and detail without departing from the spirit and scope of the invention.