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1. WO2021038559 - POINTE DE CANAL D'ANCRAGE

Note: Texte fondé sur des processus automatiques de reconnaissance optique de caractères. Seule la version PDF a une valeur juridique

[ EN ]

ANCHOR CHANNEL TIP

CROSS-REFERENCE TO RELATED APPLICATIONS

[0001] This application claims the benefit of U.S. Provisional Patent Application No.

62/894,517, filed August 30, 2019, which is incorporated by reference herein for all purposes.

BACKGROUND

[0002] Annuloplasty structures comprising a flexible material through which anchors are delivered tend to twist and warp as a result of passage of the anchor through the material of the annuloplasty structure. It is therefore often advantageous to provide devices and techniques to facilitate deployment of the tissue anchor through the flexible material of the annuloplasty structure while minimizing or eliminating twisting or warping of the flexible material during deployment of the anchor.

SUMMARY OF THE INVENTION

[0003] This summary is meant to provide some examples and is not intended to be limiting of the scope of the invention in any way. For example, any feature included in an example of this summary is not required by the claims, unless the claims explicitly recite the features. Also, the features described can be combined in a variety of ways. Various features and steps as described elsewhere in this disclosure can be included in the examples summarized here.

[0004] A tubular structure is used to advance toward a tissue site of a subject an anchor driver used to drive a tissue anchor into tissue of a subject. The tubular structure has a distal end portion comprising an implant-gripping element that is configured to temporarily grip material (e.g., flexible material) of an annuloplasty structure, in accordance with some applications of the present invention.

[0005] For some applications of the present invention, the implant-gripping element comprises a plurality of teeth which reversibly grip the material of the annuloplasty structure during deploying, or driving, a tissue anchor through material of the annuloplasty structure so as to anchor the annuloplasty structure to tissue of the subject.

[0006] For some applications of the present invention, the implant-gripping element comprises a deformable element which changes its structural configuration as a tissue anchor is passed with respect to and engages the deformable element. This is advantageous because the tubular structure is able to move freely within a lumen of the annuloplasty structure and only engage

and grip the annuloplasty structure once the desired location of tissue has been reached and it has been determined that in this location, a tissue anchor be driven into tissue.

[0007] There is therefore provided, in accordance with an application of the present invention, a system and/or apparatus, for use with a tissue anchor, the system/apparatus including an implant, dimensioned to be advanced into a body of a subject and an anchor-delivery tool. The anchor delivery tool can include an anchor-delivery channel, shaped to define a lumen therethrough, the lumen having a diameter, and the channel being dimensioned to be moveable within a lumen of the implant. The anchor-delivery tool can also include an implant-gripping element disposed at a distal end portion of the anchor-delivery channel. The implant-gripping element can be configured to reversibly grip an inner wall of the implant during implantation of the tissue anchor via the anchor-delivery channel.

[0008] In an application, the implant-gripping element includes a radiopaque material.

[0009] In an application, the implant includes a flexible material, and the flexible material of the implant encases a distal portion of the channel.

[0010] In an application, the implant-gripping element includes a plurality of teeth which increase friction between the implant and the anchor-delivery channel.

[0011] In an application, the plurality of teeth are cut from a distal portion of a cylinder coupled to the distal end portion of the anchor-delivery channel.

[0012] In an application:

each one of the plurality of teeth includes a respective elongate element that is aligned with a longitudinal axis of the distal end portion of the anchor-delivery channel,

a portion of the implant surrounds the plurality of elongate elements, and

the elongate elements are spaced apart from one another such that the plurality of elongate elements are configured to grip the portion of the implant.

[0013] In an application, a respective distal portion of each of the plurality of teeth are configured to grip the implant.

[0014] In an application, the implant includes a braided fabric, and the distal portions of the plurality of teeth are configured to reversibly ensnare the braided fabric.

[0015] In an application, the system/apparatus further includes the tissue anchor, and the tissue anchor includes:

an anchor head; and

a tissue-engaging member, coupled to the anchor head, extending distally away from the anchor head until a distal tip of the tissue-engaging member, and configured to anchor the anchor to the tissue.

[0016] In an application, the tissue-engaging member includes a helical tissue-engaging member, and the implant-gripping element is configured to reversibly grip the implant and prevent twisting of the implant during corkscrewing of the helical tissue-engaging member with respect to the implant.

[0017] In an application, the system/apparatus further includes an anchor driver slidable through the lumen of the anchor-delivery channel, the anchor driver including:

a longitudinal shaft, having a flexible distal portion and a distal end; and

a deployment element coupled to the distal end of the shaft, and reversibly couplable to the anchor head.

[0018] In an application, the implant-gripping element includes at least one deformable element configured to change shape from a resting state to a gripping state in response to passage of the tissue anchor alongside the deformable element.

[0019] In an application, the implant-gripping element includes a plurality of deformable elements disposed circumferentially with respect to the distal end portion of the anchor-delivery channel.

[0020] In an application, the deformable element is shaped so as to define an elongate tine having a straight portion and a curved portion in the resting state of the deformable element, and in the gripping state of the deformable element, the anchor is configured to radially push against the curved portion so as to straighten the curved portion and responsively, longitudinally lengthen the deformable element.

[0021] In an application, in the gripping state, a distal end of the deformable element extends beyond a distal end of the anchor-delivery channel.

[0022] In an application, the at least one deformable element includes a plurality of elongate tines, and the anchor is configured to radially push against the respective curved portions of the plurality of elongate tines.

[0023] In an application, the distal ends of the plurality of elongate tines are configured to increase surface area contact with the inner wall of the implant in the gripping state of the deformable element.

[0024] In an application:

the deformable element is shaped so as to define a laterally-moveable lateral projection, in the resting state of the deformable element, a lateral-most portion of the projection is aligned with a lateral surface of the anchor-delivery channel, and

in the gripping state, the anchor is configured to radially push against the lateral projection so as to extend the lateral-most portion of the projection beyond the lateral surface of the anchor-delivery channel.

[0025] In an application, the at least one deformable element includes a plurality of lateral projections, and the anchor is configured to radially push against the plurality of lateral projections.

[0026] In an application, the plurality of lateral projections are configured to increase surface area contact with the inner wall of the implant in the gripping state of the deformable element.

[0027] There is further provided, in accordance with an application of the present invention, a method including positioning an implant along an annulus of a heart valve of a subject. The implant is optimally dimensioned to be advanced into a body of the subject. The method can further include advancing an anchor-delivery tool with respect to the implant.

[0028] In some applications, the anchor-delivering tool includes an anchor-delivery channel, shaped to define a lumen therethrough, the lumen having a diameter. The channel can be dimensioned to be moveable within a lumen of the implant.

[0029] In some applications, the anchor-delivering tool includes an implant-gripping element disposed at a distal end portion of the anchor-delivery channel, the implant-gripping element being configured to reversibly grip a portion or wall of the implant (e.g., an inner wall of the implant, etc.) during implantation of the tissue anchor via the anchor-delivery channel.

[0030] The method can further include gripping a first portion of the implant using the implant gripping element, and during the gripping of the first portion, anchoring the first portion of the implant to the annulus using a tissue anchor deliverable through the anchor-delivery channel.

[0031] In an application, the method further includes:

decoupling the implant-gripping element from the first portion of the implant subsequently to the anchoring of the first portion of the implant to the annulus;

moving the anchor-delivery channel to a second portion of the implant;

gripping the second portion of the implant using the implant-gripping element; and during the gripping of the second portion, anchoring the second portion of the implant to the annulus using a second tissue anchor deliverable through the anchor-delivery channel.

[0032] In an application, the implant-gripping element includes a radiopaque material.

[0033] In an application, the implant includes a flexible material, and the flexible material of the implant encases a distal portion of the channel.

[0034] In an application, the implant-gripping element includes a plurality of teeth, and gripping the first portion of the implant includes increasing friction between the first portion of the implant and the anchor-delivery channel.

[0035] In an application, the plurality of teeth are cut from a distal portion of a cylinder coupled to the distal end portion of the anchor-delivery channel, and gripping the first portion of the implant includes sandwiching the first portion of the implant between respective distal ends of the plurality of teeth and the annulus.

[0036] In an application:

each one of the plurality of teeth includes a respective elongate element that is aligned with a longitudinal axis of the distal end portion of the anchor-delivery channel,

a lateral portion of the implant surrounds the plurality of elongate elements, the elongate elements are spaced apart from one another, and

gripping the first portion of the implant includes gripping the lateral portion of the implant by the elongate elements.

[0037] In an application, a respective distal portion of each of the plurality of teeth are configured to grip the implant, and gripping the first portion of the implant includes sandwiching the first portion of the implant between respective distal ends of the plurality of teeth and the annulus.

[0038] In an application, the implant includes a braided fabric, and gripping the first portion of the implant includes reversibly ensnaring the braided fabric by the plurality of teeth.

[0039] In an application:

the tissue anchor includes:

an anchor head; and

a tissue-engaging member, coupled to the anchor head, extending distally away from the anchor head until a distal tip of the tissue-engaging member, and configured to anchor the anchor to the tissue, and

anchoring the first portion of the implant to the annulus includes anchoring the first portion using the tissue anchor including the anchor head and the tissue-engaging member.

[0040] In an application:

the tissue-engaging member includes a helical tissue-engaging member, anchoring the first portion of the implant includes corkscrewing the helical tissue- engaging member with respect to the first portion of the implant and into the annulus, and gripping the first portion of the implant includes using the implant-gripping element to reversibly grip the first portion of the implant and prevent twisting of the implant during the corkscrewing of the helical tissue-engaging member with respect to the first portion of the implant.

[0041] In an application, the method further includes sliding through the lumen of the anchor-delivery channel an anchor driver including:

a longitudinal shaft, having a flexible distal portion and a distal end; and

a deployment element coupled to the distal end of the shaft, and reversibly couplable to the anchor head.

[0042] In an application, the implant-gripping element includes at least one deformable element configured to change shape from a resting state to a gripping state in response to passage of the tissue anchor alongside the deformable element, and the method further includes changing the shape of the deformable element by passing the tissue anchor alongside the deformable element.

[0043] In an application, the implant-gripping element includes a plurality of deformable elements disposed circumferentially with respect to the distal end portion of the anchor-delivery channel.

[0044] In an application, the deformable element is shaped so as to define an elongate tine having a straight portion and a curved portion in the resting state of the deformable element, and passing the tissue anchor alongside the deformable element includes radially pushing the anchor against the curved portion, and by the pushing, straightening the curved portion and

responsively, longitudinally lengthening the deformable element such that the deformable element assumes the gripping state.

[0045] In an application, in the gripping state, longitudinally lengthening the deformable element includes extending a distal end of the deformable element beyond a distal end of the anchor-delivery channel.

[0046] In an application, the at least one deformable element includes a plurality of elongate tines, and radially pushing the anchor includes radially pushing the anchor against the respective curved portions of the plurality of elongate tines.

[0047] In an application, gripping the first portion of the implant includes increasing surface area contact with the inner wall of the implant in the gripping state of the deformable element using the distal ends of the plurality of elongate tines.

[0048] In an application:

the deformable element is shaped so as to define a laterally-moveable lateral projection, in the resting state of the deformable element, a lateral-most portion of the projection is aligned with a lateral surface of the anchor-delivery channel,

in the gripping state, the anchor is configured to radially push against the lateral projection so as to extend the lateral-most portion of the projection beyond the lateral surface of the anchor-delivery channel,

passing the tissue anchor alongside the deformable element includes radially pushing the anchor against the lateral projection, and by the pushing, extending the lateral-most portion of the projection beyond the lateral surface of the anchor-delivery channel.

[0049] In an application, the at least one deformable element includes a plurality of lateral projections, and pushing the anchor against the lateral projection includes radially pushing the anchor against the plurality of lateral projections.

[0050] In an application, radially pushing the anchor against the plurality of lateral projections includes increasing surface area contact with the inner wall of the implant in the gripping state of the deformable element.

[0051] The foregoing method(s) and other methods herein can be performed on a living animal or on a simulation, such as on a cadaver, cadaver heart, simulator (e.g. with the body parts, tissue, etc. being simulated), etc.

[0052] The present invention will be more fully understood from the following detailed description of applications thereof, taken together with the drawings, in which:

BRIEF DESCRIPTION OF THE DRAWINGS

[0053] Fig. 1 is a schematic illustration of an example of an implant-gripping element comprising a plurality of teeth;

[0054] Figs. 2A-C are schematic illustrations of an example of an implant-gripping element comprising a deformable element; and

[0055] Figs. 3A-C are schematic illustrations of an example of an implant-gripping element comprising another deformable element.

DETAILED DESCRIPTION OF EMBODIMENTS

[0056] Reference is now made to Fig. 1, which is a schematic illustration of a system 10 providing one or more rotationally-controlled steering catheters configured for delivering an implant to a heart of a subject, in accordance with some applications of the present invention. Fig. 1 shows a distal portion of an implant that comprises an annuloplasty ring structure 222 (i.e., an implant, e.g., an annuloplasty band) comprising a flexible sleeve 26. The implant is dimensioned to be advanced into a body of a subject. System 10 comprises an anchor-delivery tool comprising an implant-decoupling channel 18. As described hereinbelow, channel 18 is used to facilitate delivery of tissue anchors through channel 18 and into a lumen of sleeve 26. Thus, channel 18 functions as an anchor-delivery channel. Channel 18 is shaped so as to define a lumen having a diameter. Sleeve 26 comprises a flexible material which encases a distal portion of channel 18. Channel 18 is dimensioned to be moveable within a lumen of the implant. An implant-gripping element 40 is disposed at a distal end portion of channel 18. Implant-gripping element 40 is configured to reversibly grip an inner wall 50 of the implant during implantation of tissue anchor 32 via channel 18.

[0057] Sleeve 26 typically comprises a braided fabric mesh, e.g., comprising polyethylene terephthalate (such as Dacron (TM)). Sleeve 26 can be configured to be placed only partially around a cardiac valve annulus (i.e., to assume a C-shape), and, once anchored in place, to be contracted so as to circumferentially tighten the valve annulus. Though optionally, the ring structure can also be configured to be placed entirely around the valve annulus.

[0058] Sleeve 26 has a tubular lateral wall 253 that (i) circumscribes a central longitudinal axis of the sleeve, and (ii) defines the lumen of the sleeve.

[0059] In order to tighten the annulus, annuloplasty ring structure 222 comprises a flexible elongated contraction member 226 that extends along sleeve 26. Elongated contraction member 226 comprises a wire, a ribbon, a rope, or a band, which typically comprises a flexible and/or superelastic material, e.g., nitinol, polyester, stainless steel, or cobalt chrome. For some applications, the wire comprises a radiopaque material. For some applications, contraction member 226 comprises a braided polyester suture (e.g., Ticron). For some applications, contraction member 226 is coated with polytetrafluoroethylene (PTFE). For some applications, contraction member 226 comprises a plurality of wires that are intertwined to form a rope structure.

[0060] For some applications, annuloplasty ring structure 222 comprises an adjustment mechanism as described with reference to PCT application PCT/IF2016/050433 to Iflah, et al., which published as WO 16/174669, and which is incorporated herein by reference. The adjustment mechanism facilitates contracting and expanding of annuloplasty ring structure 222 so as to facilitate adjusting of a perimeter of the annulus and leaflets of the cardiac valve. The adjustment mechanism can comprise a rotatable structure (e.g., a spool).

[0061] System 10 can comprise a concentric arrangement of tubes defining an implant-delivery tool. System 10 can comprise a first, outer catheter 12 comprising a sheath configured for transluminal advancement through vasculature of a subject. For some applications of the present invention, outer catheter 12 comprises a sheath configured for advancement through a femoral artery toward an interatrial septum of a heart of a subject. A distal end portion 112 of outer catheter 12 is configured to pass through the transatrial septum of the subject, and to be oriented in a desired spatial orientation within the left atrium. System 10 comprises a second catheter, or guide catheter 14, comprising a distal end portion 114 that is configured to pass through catheter 12 (i.e., a primary lumen thereof), to become disposed outside of a distal end of the outer catheter, and to be oriented in a desired spatial orientation within the left atrium.

[0062] Distal end portion 112 of outer catheter 12 is steerable. That is, distal end portion 112 is deflectable with respect to an immediately more proximal portion of catheter 12 (e.g., by using extracorporeal elements of system 10). Distal end portion 114 of inner catheter 14 is steerable. That is, distal end portion 114 is deflectable with respect to an immediately more proximal portion of catheter 14 (e.g., by using extracorporeal elements of system 10.

[0063] Guide catheter 14 is steerable to a desired spatial orientation in order to facilitate advancing and implantation of an implant in a body cavity of the subject.

[0064] For applications in which system 10 is used to deliver an implant to the mitral valve of the subject, often, outer catheter 12 is configured for initial advancement through vasculature of the subject until a distal end of catheter 12 is positioned in the left atrium. The distal steerable end portion of catheter 12 is then steered such that distal end of catheter 12 is positioned in a desired spatial orientation within the left atrium. The steering procedure can be performed with the aid of imaging, such as fluoroscopy, transesophageal echo, and/or echocardiography. Following the steering of the distal end portion of catheter 12, guide catheter 14 (which houses annuloplasty ring structure 222) is advanced through catheter 12 in order to facilitate delivery and implantation of structure 222 along the annulus of the mitral valve. During the delivery, at least a portion of steerable distal end portion 114 is exposed from the distal end of catheter 12 and is thus free for steering toward the annulus of the mitral valve, as is described hereinbelow.

[0065] During delivery of sleeve 26 to the annulus of the cardiac valve, sleeve 26 is disposed within a lumen of catheter 14 and can be aligned longitudinally with a longitudinal axis of catheter 14.

[0066] In addition, in some applications, system 10 comprises a plurality of anchors 32, typically between about 5 and about 20 anchors, such as about 10 or about 16 anchors. Each anchor 32 comprises a tissue-coupling element 60 (e.g., a helical tissue-coupling element), and a tool-engaging head 62 (e.g., a non-helically-shaped portion), or an anchor head, fixed to one end of the tissue-coupling element. Each tissue-coupling element 60 defines a respective tissue-engaging member. Each anchor 32 is deliverable to the target tissue site by a deployment element of an anchor driver 36 of an anchor deployment manipulator 61. Driver 36 comprises (1) a longitudinal shaft having a flexible distal portion and a distal end, and (2) a deployment element coupled to the distal end of the shaft. The deployment element of driver 36 is reversibly couplable to tool-engaging head 62 of anchor 32. When sleeve 26 is disposed along the annulus of the cardiac valve, deployment manipulator 61 is configured to advance within a lumen of sleeve 26 and deploy each anchor 32 from within sleeve 26 through a wall of sleeve 26 and into cardiac tissue, thereby anchoring sleeve 26 around a portion of the valve annulus.

[0067] Typically, but not necessarily, anchors 32 comprise a biocompatible material such as stainless steel 316 LVM. For some applications, anchors 32 comprise nitinol. For some applications, anchors 32 are coated fully or partially with a non-conductive material.

[0068] Deployment manipulator 61 comprises anchor driver 36 and the deployment element. For some applications, deployment manipulator 61 comprises an implant-decoupling channel

18. As described hereinbelow, channel 18 is used to facilitate delivery of tissue anchors through channel 18 and into a lumen of sleeve 26. Thus, channel 18 functions as an anchor-delivery channel.

[0069] Sleeve 26 is disposed within a lumen of guide catheter 14. Implant-decoupling channel 18 is advanceable within a lumen of sleeve 26. A distal end 17 of implant-decoupling channel 18 is placeable in contact with an inner wall of sleeve 26, e.g., at a distal end thereof.

[0070] For some applications, channel 18 is steerable.

[0071] For some applications, manipulator 61 advances within channel 18. For some applications, system 10 comprises a plurality of anchor drivers of manipulator 61, each driver 36 being coupled to a respective anchor 32. Each driver 36 is advanced within channel 18 in order to advance and implant anchor 32 in tissue. Following implantation of anchor 32, anchor 32 is decoupled from driver 36, as described herein, and driver 36 is removed from within channel 18. A subsequent anchor 32 is then advanced within channel 18 while coupled to a driver 36 (e.g., a new driver).

[0072] As will be described hereinbelow, a first one of anchors 32 is configured to be deployed through an end wall, or an end, of sleeve 26 into cardiac tissue, when sleeve 26 is positioned along the annulus of the valve. Following the deployment of the first tissue anchor, a distal portion of sleeve 26 is slid distally off a portion of implant-decoupling channel 18. In order to decouple sleeve 26 distally from a portion of outer surface of channel 18, (1) a proximal force is applied to channel 18, while (2) a reference-force tube (disposed proximally to sleeve 26) is maintained in place in a manner in which a distal end of the reference-force tube provides a reference force to sleeve 26, thereby facilitating freeing of a successive portion of sleeve 26 from around channel 18. Channel 18 is then positioned at a successive location within the lumen of sleeve 26 while the reference-force tube and/or catheter 14 is steered toward a successive location along the annulus of the valve (as will be described hereinbelow). Consequently, the successive portion of sleeve 26 provides a free lumen for advancement of a successive anchor 32 and deployment of the anchor through the wall of the sleeve at the successive portion thereof. Such freeing of the successive portion of sleeve 26 creates a distance between successive anchors deployed from within the lumen of sleeve 26.

[0073] For some applications, sleeve 26 comprises a plurality of radiopaque markers, which are positioned along the sleeve at respective longitudinal sites. The markers can provide an indication in a radiographic image (such as a fluoroscopy image) of how much of the sleeve has been deployed at any given point during an implantation procedure, in order to enable setting a desired distance between anchors 32 along the sleeve. For some applications, the markers comprise a radiopaque ink, but other configurations are also possible.

[0074] As described hereinabove, implant-gripping element 40 is disposed at a distal end portion of channel 18. For some applications, as shown, element 40 comprises a plurality of teeth 44 which extend beyond the distal end portion of channel 18 and beyond a distal end of the lumen defined by channel 18. The plurality of teeth 44 are circumferentially disposed around a circumference of the distal end portion of channel 18. For some applications of the present invention, each one of teeth 44 is jagged. The plurality of teeth 44 are configured to increase friction between channel 18 and the implant. Collectively, the plurality of teeth 44 form a series of peaks and valleys which increase surface area contact between channel 18 and inner wall 50 of sleeve 26. For some applications of the present invention, teeth 44 are slanted. For some applications of the present invention, teeth 44 are rectangular. In either application, teeth 44 are configured to create increased surface area between the distal end of channel 18 and sleeve 26. Additionally, teeth 44 are configured to reversibly grip sleeve 26 by pressing against sleeve 26.

[0075] As shown, each one of teeth 44 is at a distal end of a respective elongate element 42 that is aligned with a longitudinal axis of the distal end portion of anchor-delivery channel 18. Elongate elements 42 are spaced apart from one another such that the plurality of elongate elements 42 are configured to grip the portion of the implant. Collectively, the plurality of elongate elements 42 form a series of peaks and valleys which increase surface area contact between channel 18 and inner wall 50 of sleeve 26. Elongate elements 42 increase surface area between the lateral surface of channel 18 and inner wall 50 of sleeve 26 while teeth 44 increase surface area between the distal opening of channel 18 and inner wall 50 of sleeve 26. For some applications of the present invention, a respective distal portion of each of the plurality of teeth 44 are configured to grip the implant. That is, the implant comprises a braided fabric, and the distal portions of the plurality of teeth 44 are configured to reversibly ensnare the braided fabric.

[0076] For some applications of the present invention, teeth 44 and/or elongate elements 42 comprise radiopaque material.

[0077] The portion of sleeve 26 reversibly engaged and gripped by teeth 44 is the portion of sleeve 26 that is sandwiched between the distal end channel 18 (i.e., the distal ends of teeth 44) and tissue. For some applications of the present invention, elongate elements 42 reversibly grip and engage lateral portions of sleeve 26 proximal to the portion of sleeve 26 that is sandwiched between the distal end channel 18 (i.e., the distal ends of teeth 44) and tissue. That is, elongate elements 42 are spaced apart from each other creating a series of peaks and valleys which increase surface area so as to increase friction between elongate elements 42 and sleeve 26.

[0078] For some applications of the present invention, the plurality of teeth 44 are cut from a distal portion of a cylinder coupled to the distal end portion of anchor-delivery channel 18. For some applications of the present invention, the plurality of teeth 44 are cut from a distal portion of anchor-delivery channel 18.

[0079] Prior to delivery of tissue anchor 32 into tissue of the subject, a portion of sleeve 26 is sandwiched between the distal end of channel 18 (i.e., the distal ends of teeth 44) and the tissue. This is because a distal end of channel 18 contacts inner wall 50 of sleeve 26. An anchor 32 is passed through a lumen of channel 18 and toward the target tissue site by a deployment element of anchor driver 36 of an anchor deployment manipulator 61. During the driving of the tissue anchor through material of sleeve 26 and subsequently into the target tissue, implant-gripping element 40 grips the material of sleeve 26 to prevent or minimize distortion, movement, deformation, twisting, torsion, bunching, and any other relative movement of sleeve 26 with respect to tissue. For applications in which tissue-coupling element 60 of anchor 32 comprises a helical tissue coupling-element, implant-gripping element 40 prevents or minimizes twisting or torsion of sleeve 26 during the driving of anchor 32 through the material of sleeve 26.

[0080] Once anchor 32 is delivered through sleeve 26, teeth 44 and elongate elements 42 are decoupled from sleeve 26 (and thereby the grip on sleeve 26 by gripping element 40 is removed), by simply applying a pulling force to channel 18. Since sleeve 26 is firmly anchored to tissue of the annulus by anchor 32, a slight upward pulling force to channel 18 overcomes the reversible grip teeth 44 and elongate elements 42 temporarily have on sleeve 26.

[0081] It is to be noted that the gripping and ungripping of gripping element 40 can occur repeatedly throughout the process of anchoring sleeve 26 to tissue of the annulus. For each anchor delivery, gripping element 40 grips sleeve 26 as each anchor 32 is deployed to anchor a given portion of the implant to the annulus, and once anchor 32 has been deployed, gripping element 40 is pulled proximally in order to reverse the gripping of sleeve 26 by gripping element 40. Channel 18 is then moved to a different portion of the implant, and the gripping of sleeve 26 by gripping element 40 occurs once more as another anchor is deployed to anchor the different portion of the implant to the annulus.

[0082] Reference is now made to Figs. 2A-C, which are schematic illustrations of a system 100 comprising one or more rotationally-controlled steering catheters configured for delivering an implant to a heart of a subject, in accordance with some applications of the present invention. System 100 is similar to system 10 described hereinabove with reference to Fig. 1, with the exception that implant-gripping element 40 comprises a deformable element 41 disposed within a housing 120. For some applications of the present invention, housing 120 is tubular and is shaped so as to define a lumen therethrough. Housing 120 is coupled to a distal end portion of a tube of channel 18. For some applications of the present invention, housing 120 defines the distal end portion of channel 18. For some applications of the present invention, a distal end 121 of housing 120 defines the distal end of channel 18. Deformable element 41 comprises a plurality of tines 123 disposed circumferentially with respect to an inner surface of housing 120, i.e., with respect to a distal end portion of channel 18. A proximal end of each tine 123 is coupled to a ring in order to couple together tines 123 and orient tines 123 circumferentially with respect to the distal end portion of channel 18. For some applications of the present invention, tines 123 comprise radiopaque material.

[0083] Deformable element 41 has a resting state (as shown in Fig. 2 A) and a gripping state (as shown in Fig. 2B). Each tine 123 comprises a curved portion 126 and a straight portion 127 and a gripper 128 (e.g., a tooth) at a distal end of the straight portion. In the resting state of deformable element 41, curved portion 126 curves convexly toward and into the lumen of housing 120 such that the overall length of tine 123 is shortened. In the resting state of deformable element 41, gripper 128 is disposed within housing 120 and does not extend beyond a distal end 121 of housing 120 (i.e., gripper 128 does not extend beyond a distal end of channel 18). In the resting state, anchor 32 is disposed proximally to curved portions 126 of deformable element 41.

[0084] Fig. 2B shows deformable element 41 in its gripping state. In the gripping state, anchor 32 is disposed within the lumen of housing 120 and radially, or laterally, pushes against curved portions 126 of tines 123 so as to change a structural configuration of deformable element 41 by straightening curved portions 126 and responsively, longitudinally lengthening the overall length of each tine 123 and thereby longitudinally lengthening deformable element 41. Anchor 32 is disposed within the lumen of housing 120 and radially, or laterally, pushes against curved portions 126 in order to transition deformable element 41 from its resting state to its gripping state. In the gripping state, gripper 128 of each tine 123 is disposed distally to distal end 121 of housing 120, and thereby distally to a distal end of channel 18. In this state, gripper 128 is exposed from within housing 120 so that it is able to grip, press against, ensnare, or otherwise reversibly couple gripping element 40 to sleeve 26. The plurality of elongate tines 123 are configured to increase surface area contact with inner wall 50 of the implant in the gripping state of deformable element 41.

[0085] In the resting state of deformable element 41, as shown in Fig. 2A, grippers are disposed within housing 120 such that they do not ensnare sleeve 26 during advancement of channel 18 with respect to sleeve 26. Only once a tissue anchor 32 is passed through the distal end portion of channel 18, and through housing 120, as shown in Fig. 2B, deformable element 41 is engaged and grippers 128 are exposed.

[0086] Fig. 2C shows the steps involved in implanting two anchors 32 through material of sleeve 26. In the first step, a first anchor 32 is passed through housing 120 in a manner in which anchor 32 pushes radially against curved portions 126 of tines 123 such that portion 126 are straightened and the overall length of tines 123 increases, as shown in Fig, 2B. In this step, the distal grippers 128 engage sleeve 26 by pushing sleeve 26 slightly distally enough to engage sleeve 26 but not penetrate sleeve 26. This distal pushing increases friction between channel 18 and the implant. The portion of sleeve 26 engaged and gripped by grippers 128 is the portion of sleeve 26 that is sandwiched between distal end 121 of housing 120 (i.e., the distal end of channel 18) and tissue. Surface area between grippers 128 and sleeve 26 increases. As shown in the first step, housing 120 defines a plurality of inner grooves 129 which house a respective tine 123. As anchor 32 is being driven through fabric of sleeve 26 from within the lumen of sleeve 26, and into tissue of the subject, grippers 128 of deformable element 41 of anchor-gripping element 40 reversibly grip and hold in place sleeve 26 in order to prevent or minimize distortion, movement, deformation, twisting, torsion, bunching, and any other relative movement of sleeve 26 with respect to tissue. For applications in which tissue-coupling element 60 of anchor 32 comprises a helical tissue coupling-element, implant-gripping element 40 prevents or minimizes twisting or torsion of sleeve 26 during the driving of anchor 32 through the material of sleeve 26.

[0087] In the second step of Fig. 2C, anchor 32 has been driven fully into tissue. Once anchor 32 is driven into tissue, the radial force against curved portions 126 is absent, and curved portions 126 each return to their resting state of a curved shape, as shown in Fig. 2 A, and the overall length of tine 123 decreases. Decreasing the length of tine 123 retracts grippers 128 into housing 120 such that they no longer contact sleeve 26. Since sleeve 26 is firmly anchored to tissue of the annulus, this slight upward movement of tines 123 overcomes the reversible grip grippers 128 temporarily have on sleeve 26.

[0088] It is to be noted that the radial force on curved portions 126 may be provided by tissue coupling element 60 of anchor 32 and/or by tool-engaging head 62 of anchor, and/or by any part of anchor driver 36. For such applications, radial force against curved portions 126 may be

maintained only until anchor driver 36 and/or anchor 32 has been removed from within housing 120 (i.e., in a state in which housing 120 is empty, as shown in the third step of Fig. 2C).

[0089] In the third step of Fig. 2C, deformable element 41 is in its resting state awaiting the advancement through housing 120 of an additional anchor. In the resting state, grippers 128 are disposed within housing 120 and do not extend beyond distal end 121 of housing 120, and thereby of channel 18. Since grippers 128 do not extend beyond distal end 121, deformable element 41 is in its resting state as shown in Fig. 2A, and implant-gripping element 40 does not engage sleeve 26. This stage in which implant-gripping element 40 does not engage sleeve 26 enables channel 18 to move unobstructedly through the lumen of sleeve 26 without ensnaring or inadvertently gripping or engaging sleeve 26 from within the lumen of sleeve 26. Thus, housing 120 and the overall structural configuration of deformable element 41 in its resting state enables such free movement of channel 18 within the lumen of sleeve 26. This is advantageous because channel 18 is able to move freely within a lumen of sleeve 26 and only engage and grip sleeve 26 once the desired location of tissue has been reached and it has been determined that in this location, a tissue anchor 32 be driven into tissue.

[0090] It is to be noted that the gripping and ungripping of gripping element 40 occurs repeatedly throughout the process of anchoring sleeve 26 to tissue of the annulus. For each anchor delivery, gripping element 40 grips sleeve 26 as each anchor 32 is deployed to anchor a given portion of the implant to the annulus, and once anchor 32 has been deployed, gripping element 40 is pulled proximally in order to reverse the gripping of sleeve 26 by gripping element 40. Channel 18 is then moved to a different portion of the implant, and the gripping of sleeve 26 by gripping element 40 occurs once more as another anchor is deployed to anchor the different portion of the implant to the annulus.

[0091] Reference is now made to Figs. 3A-C, which are schematic illustrations of a system 200 comprising one or more rotationally-controlled steering catheters configured for delivering an implant to a heart of a subject, in accordance with some applications of the present invention. System 200 is similar to system 10 described hereinabove with reference to Fig. 1, with the exception that implant-gripping element 40 comprises a deformable element 41 of a housing 220. System 200 is similar to system 100 described hereinabove with reference to Figs. 2A-C, with the exception that implant-gripping element 40 comprises a deformable element 41 comprising laterally-moveable lateral projections 230. For some applications of the present invention, housing 220 is tubular and is shaped so as to define a lumen therethrough. Housing 220 is coupled to a distal end portion of a tube of channel 18. For some applications of the present invention, housing 220 defines the distal end portion of channel 18. For some applications of the present invention, a distal end 221 of housing 220 defines the distal end of channel 18. Deformable element 41 comprises a plurality of laterally-moveable lateral projections 230 disposed circumferentially with respect to housing 220, i.e., slightly proximally with respect to a distal end portion of channel 18. For some applications of the present invention, projections are disposed at a middle section of housing 220, by way of illustration and not limitation. In such a manner, projections 230 grip the lateral portions of sleeve 26 as sleeve 26 hugs channel 18 and/or housing 220. The plurality of projections 230 are configured to increase surface area contact with inner wall 50 of the implant in the gripping state of deformable element 41.

[0092] For some applications of the present invention, projections 230 comprise radiopaque material.

[0093] Deformable element 41 has a resting state (as shown in Fig. 3 A) and a gripping state (as shown in Fig. 3B). Each laterally-moveable lateral projections 230 comprises a lateral-most portion 43. In the resting state of deformable element 41, lateral-most portion 43 is aligned with a lateral surface of housing 220, i.e., with a lateral surface of channel 18. In the resting state of deformable element 41, portion 43 is disposed aligned with housing 220 and does not extend laterally beyond an external surface of housing 220. For some applications of the present invention, an inwardly-facing portion of projection 230 is disposed within the lumen of housing 220. In the resting state, anchor 32 is disposed proximally to projections 230 of deformable element 41.

[0094] Fig. 3B shows deformable element 41 in its gripping state. In the gripping state, anchor 32 is disposed within the lumen of housing 220 and radially, or laterally, pushes against laterally-moveable lateral projections 230 so as to change a structural configuration of deformable element 41 by extending lateral-most portions 43 of projections 230 beyond the lateral surface of anchor-delivery channel 18. As described hereinabove, an inwardly-facing portion of projection 230 is disposed within the lumen of housing 220 in a manner in which anchor 32 pushes against this inwardly-facing portion of projection 230 in order to outwardly push against projection 230 in order to transition deformable element 41 from its resting state to its gripping state. In the gripping state, lateral-most portions 43 of each projection 230 is disposed laterally with respect to housing 220. In this state, projection 230 projects away from housing 220 so that it is able to grip, press against, ensnare, or otherwise reversibly couple gripping element 40 to sleeve 26.

[0095] In the resting state of deformable element 41, as shown in Fig. 3 A, portions 43 are aligned with the surface of housing 220 such that they do not ensnare sleeve 26 during advancement of channel 18 with respect to sleeve 26. Only once a tissue anchor 32 is passed through the distal end portion of channel 18, and through housing 220, as shown in Fig. 3B, deformable element 41 is engaged and projections 230 project beyond a lateral surface of housing 220.

[0096] Fig. 3C shows the steps involved in implanting two anchors 32 through material of sleeve 26. In the first step, a first anchor 32 is passed through housing 220 in a manner in which anchor 32 pushes radially against projections 230 of such that distal-most portions 43 project away from the external surface of housing 220, as shown in Fig, 3B. In this step, the projections 230 engage sleeve 26 by pushing sleeve 26 slightly laterally enough to engage sleeve 26 but not penetrate sleeve 26. This lateral pushing increases friction between channel 18 and the implant. Surface area between projections 230 and sleeve 26 increases. As anchor 32 is being driven through fabric of sleeve 26 from within the lumen of sleeve 26, and into tissue of the subject, projections 230 of deformable element 41 of anchor-gripping element 40 reversibly grip and hold in place sleeve 26 in order to prevent or minimize distortion, movement, deformation, twisting, torsion, bunching, and any other relative movement of sleeve 26 with respect to tissue. For applications in which tissue-coupling element 60 of anchor 32 comprises a helical tissue coupling-element, implant-gripping element 40 prevents or minimizes twisting or torsion of sleeve 26 during the driving of anchor 32 through the material of sleeve 26.

[0097] In the second step of Fig. 3C, anchor 32 has been driven fully into tissue. Once anchor 32 is driven into tissue, the radial force against projections 230 is absent, and projections 230 each return to their resting state by retracting laterally, as shown in Fig. 3A, and proximal-most portions 43 align with the external surface of housing 220. Retracting projections 230 laterally moves lateral-most portions 43 inwardly radially such that they no longer contact sleeve 26. Since sleeve 26 is firmly anchored to tissue of the annulus, this slight inward radial movement of projections 230 overcomes the reversible grip projections 230 temporarily have on sleeve 26.

[0098] It is to be noted that the radial force on projections 230 can be provided by tissue coupling element 60 of anchor 32 and/or by tool-engaging head 62 of anchor, and/or by any part of anchor driver 36. For such applications, radial force against projections 230 may be maintained only until anchor driver 36 and/or anchor 32 has been removed from within housing 220 (i.e., in a state in which housing 220 is empty, as shown in the third step of Fig. 3C). [0099] In the third step of Fig. 3C, deformable element 41 is in its resting state awaiting the advancement through housing 220 of an additional anchor. In the resting state, proximal-most portions 43 of projection 230 align with the external surface of housing 220 and do not extend beyond the lateral surface of housing 220, and thereby of channel 18. Portions 43 of projections 230 do not extend beyond the lateral surface of housing 220, deformable element 41 is in its resting state as shown in Fig. 3A, and implant-gripping element 40 does not engage sleeve 26. This stage in which implant-gripping element 40 does not engage sleeve 26 enables channel 18 to move unobstructedly through the lumen of sleeve 26 without ensnaring or inadvertently gripping or engaging sleeve 26 from within the lumen of sleeve 26. Thus, housing 220 and the overall structural configuration of deformable element 41 in its resting state enables such free movement of channel 18 within the lumen of sleeve 26. This is advantageous because channel 18 is able to move freely within a lumen of sleeve 26 and only engage and grip sleeve 26 once the desired location of tissue has been reached and it has been determined that in this location, a tissue anchor 32 be driven into tissue.

[0100] It is to be noted that the gripping and ungripping of gripping element 40 occurs repeatedly throughout the process of anchoring sleeve 26 to tissue of the annulus. For each anchor delivery, gripping element 40 grips sleeve 26 as each anchor 32 is deployed to anchor a given portion of the implant to the annulus, and once anchor 32 has been deployed, gripping element 40 is pulled proximally in order to reverse the gripping of sleeve 26 by gripping element 40. Channel 18 is then moved to a different portion of the implant, and the gripping of sleeve 26 by gripping element 40 occurs once more as another anchor is deployed to anchor the different portion of the implant to the annulus.

[0101] Reference is now made to Figs. 1-3C. For some applications, systems 10, 100, and 200 are used in combination with one or more techniques and or devices, systems, etc. described in one or more of the following references, which are all incorporated herein by reference:

• US patent application 12/437,103 to Zipory et al., filed May 7, 2009, which published as US 2010/0286767. For example, (1) systems 10, 100, and 200 of the present application may be used to facilitate the techniques described with reference to Figs. 2-3 and/or 6A-12 of US 2010/0286767 to Zipory et al., mutatis mutandis, (2) anchor driver 36 of the present application may comprise or correspond to anchor driver 68 and/or anchor deployment manipulator 24 of US 2010/0286767 to Zipory et al., mutatis mutandis, (3) tissue anchor 32 of the present application may comprise or correspond to anchor 38 of US

2010/0286767 to Zipory et al., mutatis mutandis ; and/or (4) the implant of the present application may comprise or correspond to annuloplasty ring 22 of US 2010/0286767 to Zipory et al., mutatis mutandis.

• US patent application 12/689,635 to Zipory et al., filed January 19, 2010, which published as US 2010/0280604. For example, (1) systems 10, 100, and 200 of the present application may be used to facilitate the techniques described with reference to Figs. 2-3 and/or 11A-17 of US 2010/0280604 to Zipory et al., mutatis mutandis, (2) anchor driver 36 of the present application may comprise or correspond to anchor driver 68 and/or anchor deployment manipulator 24 of US 2010/0280604 to Zipory et al., mutatis mutandis, (3) tissue anchor 32 of the present application may comprise or correspond to anchor 38 of US 2010/0280604 to Zipory et al., mutatis mutandis, and/or (4) the implant of the present application may comprise or correspond to annuloplasty ring 22 of US 2010/0280604 to Zipory et al., mutatis mutandis.

• PCT patent application IL2012/050451 to Sheps et al., filed November 8, 2013, which published as WO 2013/069019. For example, (1) systems 10, 100, and 200 of the present application may be used to facilitate the techniques described with reference to Figs. 14A-I of WO 2013/069019 to Sheps et al., mutatis mutandis, (2) systems 10, 100, and 200 of the present application may comprise or correspond to system 10 of WO 2013/069019 to Sheps et al., mutatis mutandis, (3) anchor driver 36 of the present application may comprise or correspond to anchor deployment manipulator 61 and/or anchor driver 36 of WO 2013/069019 to Sheps et al., mutatis mutandis, and/or (4) the implant of the present application may comprise or correspond to annuloplasty structure 222 and/or sleeve 26 of WO 2013/069019 to Sheps et al., mutatis mutandis.

• PCT patent application IL2013/050860 to Sheps et al., titled "Controlled steering functionality for implant-delivery tool", filed on October 23, 2013, which published as WO 2014/064694. For example, (1) systems 10, 100, and 200 of the present application may be used to facilitate techniques described with reference to Figs. 10A-I, 12A-14B, 18A-C, 21-28, 34, and 36 of this PCT application titled "Controlled steering functionality for implant-delivery tool", mutatis mutandis, (2) systems 10, 100, and 200 of the present application may comprise or correspond to system 10 of this PCT application titled "Controlled steering functionality for implant-delivery tool", mutatis mutandis, anchor driver 36 of the present application may comprise or correspond to anchor deployment manipulator 61, anchor driver 36 and/or deployment element 2338 of this PCT application titled "Controlled steering functionality for implant-delivery tool", mutatis mutandis, and/or (4) the implant of the present application may comprise or correspond to annuloplasty structure 222 and/or sleeve 26 of this PCT application titled "Controlled steering functionality for implant-delivery tool", mutatis mutandis.

• PCT patent application IL2013/050861 to Herman et ah, titled "Percutaneous tissue anchor techniques", filed on October 23, 2013, which published as WO 2014/064695. For example, (1) systems 10, 100, and 200 of the present application may be used to facilitate the techniques described with reference to Figs. 9A-C and/or 13A-D of this PCT application titled "Percutaneous tissue anchor techniques", mutatis mutandis, (2) tissue anchor 32 of the present application may comprise or correspond to tissue anchor 40 of this PCT application titled "Percutaneous tissue anchor techniques", mutatis mutandis, and/or (3) anchor driver 36 of the present application may comprise or correspond to anchor driver 500, anchor driver 236, deployment manipulator 261, or tool 80 of this PCT application titled "Percutaneous tissue anchor techniques", mutatis mutandis.

• PCT patent application IL2019/050777 to Brauon et al., titled " Annuloplasty Systems and Locking Tools Therefor", filed on July 11, 2019, which published as WO 2020/012481.

[0102] It will be appreciated by persons skilled in the art that the present invention is not limited to what has been particularly shown and described hereinabove. Rather, the scope of the present invention includes both combinations and subcombinations of the various features described hereinabove, as well as variations and modifications thereof that are not in the prior art, which would occur to persons skilled in the art upon reading the foregoing description. Further, techniques, methods, operations, steps, etc. described or suggested herein can be performed on a living animal or on a non-living simulation, such as on a cadaver, cadaver heart, simulator (e.g. with the body parts, tissue, etc. being simulated), etc.