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1. (WO2018142275) PERCUTANEOUS VALVE REPAIR AND REPLACEMENT
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CLAIMS

1. Apparatus, comprising:

a plurality of flexible tube guides;

an annular assembly of tubes, each of the tubes being slidably disposed within a respective one of the tube guides;

a plurality of threads, each of which comprising a distal end that is carried by a respective one of the tubes;

an expandable annular structure coupled to the tube guides, configured to expand the assembly of tubes, from a collapsed configuration, over tissue of a subject, by moving the tube guides radially outward; and

a plurality of control wires coupled to the tube guides, configured to position the tubes, subsequently to the expansion of the assembly, for deployment of the threads from the tubes and into the tissue, by flexing the tube guides.

2. The apparatus according to claim 1, wherein the distal end of each one of the threads is disposed over the respective one of the tubes.

3. The apparatus according to claim 1, wherein the distal end of each one of the threads is disposed within the respective one of the tubes.

4. The apparatus according to claim 1 , wherein each one of the tube guides is cylindrical.

5. The apparatus according to claim 1, wherein each one of the tube guides is shaped to define a plurality of circumferential grooves, each of the tube guides being flexible by virtue of the grooves.

6. The apparatus according to claim 1, wherein each one of the tube guides is coupled to at least one of the control wires.

7. The apparatus according to claim 6, wherein each one of the tube guides is coupled to two of the control wires.

8. The apparatus according to claim 6, wherein each one of the control wires comprises a looped distal end, and wherein each one of the tube guides is coupled to the looped distal end of a respective one of the control wires.

9. The apparatus according to claim 8, wherein the looped distal end comprises:

an outer arm, to which the tube guide is coupled, disposed at a first radius; and an inner arm, disposed at a second radius that is smaller than the first radius.

10. The apparatus according to any one of claims 1-9, wherein the tubes comprise respective pointed distal ends configured to pass through the tissue prior to the deployment of the threads.

11. The apparatus according to claim 10, further comprising:

a plurality of expandable anchors disposed, respectively, within the tubes, and coupled to the respective distal ends of the threads; and

a plurality of anchor-pushing elements disposed, respectively, within the tubes proximally to the anchors, the anchor-pushing elements being configured to deploy the threads by pushing the anchors from the tubes, subsequently to the pointed distal ends of the tubes passing through the tissue.

12. The apparatus according to any one of claims 1-11, further comprising a slider,

wherein the control wires pass through the slider, and

wherein the slider is configured to expand the assembly of tubes by sliding proximally along the control wires.

13. The apparatus according to claim 12, wherein each one of the control wires comprises: a looped distal end;

an outer arm, which extends proximally from the looped distal end, and which passes through the slider at a first radius; and

an inner arm, which extends proximally from the looped distal end, and which passes through the slider at a second radius that is smaller than the first radius.

14. The apparatus according to claim 13, wherein the slider comprises:

a first cylinder, through which the respective outer arms of the control wires pass; and a second cylinder, disposed distally from, and being narrower than, the first cylinder, through which the respective inner arms of the control wires pass.

15. The apparatus according to any one of claims 1-14,

wherein the annular structure comprises a triangular-wave-shaped ring having alternating top vertices and bottom vertices, and

wherein each one of the bottom vertices is coupled to a respective one of the tube guides.

16. The apparatus according to claim 15, wherein respective angles of the top vertices and bottom vertices are adjustable.

17. The apparatus according to any one of claims 1-16, further comprising a plurality of longitudinal wires coupled to the annular structure, configured to facilitate crimping the annular structure following the deployment of the threads.

18. The apparatus according to claim 17, wherein the longitudinal wires are further configured to position the tubes prior to the deployment of the threads, by manipulating the annular structure.

19. The apparatus according to claim 18, wherein the longitudinal wires are configured to position the tubes by adjusting respective circumferential positions of the tubes.

20. The apparatus according to any one of claims 18-19, wherein the longitudinal wires are configured to position the tubes by adjusting respective distances between the tubes and the tissue.

21. The apparatus according to any one of claims 1-9 or claims 12-20,

wherein the tubes comprise respective arced distal portions, and

wherein the apparatus further comprises a plurality of arced needles disposed within the arced distal portions and coupled to the threads, the arced needles being configured to deploy the threads by arcedly passing, from the arced distal portions, through the tissue.

22. The apparatus according to claim 21, wherein the arced distal portions comprise pointed distal ends, configured to penetrate the tissue prior to the passing of the arced needles through the tissue.

23. The apparatus according to any one of claims 21-22, wherein the arced needles comprise a plurality of pairs of arced needles, each one of the pairs comprising a first arced needle, coupled to a first one of the threads, and a second arced needle, coupled to a second one of the threads, and being disposed within a different respective one of the arced distal portions,

the first arced needle and the second arced needle being configured to deploy the first one of the threads and the second one of the threads by arcedly passing through the tissue toward one another.

24. The apparatus according to claim 23,

wherein the first arced needle comprises a first pointed distal end, to which the first one of the threads is coupled,

wherein the second arced needle comprises a second pointed distal end, to which the second one of the threads is coupled, and

wherein the first pointed distal end and the second pointed distal end are configured to couple to one another, following the passing of the first arced needle and the second arced needle through the tissue, such that the first one of the threads is coupled to the second one of the threads.

25. The apparatus according to claim 24,

wherein the first arced needle further comprises a first needle body reversibly coupled to the first pointed distal end,

wherein the second arced needle further comprises a second needle body reversibly coupled to the second pointed distal end, and

wherein the first needle body and the second needle body are configured to detach from, respectively, the first pointed distal end and the second pointed distal end, following the coupling of the first pointed distal end to the second pointed distal end.

26. The apparatus according to any one of claims 23-25, further comprising:

a hinge, coupled to respective proximal ends of the first arced needle and the second arced needle; and

a hinge-control rod, configured to cause the first arced needle and the second arced needle to pass through the tissue by controlling the hinge.

27. The apparatus according to claim 26, wherein the hinge-control rod is configured to cause the first arced needle and the second arced needle to pass through the tissue by opening the hinge.

28. The apparatus according to claim 21, wherein each one of the arced needles is disposed within a different respective one of the arced distal portions, and wherein each one of the threads is coupled to a proximal end of a different respective one of the arced needles.

29. The apparatus according to claim 28, further comprising a plurality of shafts coupled to the tubes in contact with the arced needles, the shafts being configured to pass the arced needles through the tissue by rotating.

30. The apparatus according to claim 29, wherein the shafts are distal shafts, and wherein the apparatus further comprises:

a plurality of proximal shafts; and

a plurality of belts, each one of the belts mechanically coupling at least one of the distal shafts to at least one of the proximal shafts, such that the distal shafts are configured to rotate in response to rotation of the proximal shafts.

31. A method, comprising:

expanding an annular assembly of tubes over tissue of a subject, each one of the tubes being slidably disposed within a different respective one of a plurality of flexible tube guides, and carrying a distal end of a different respective one of a plurality of threads;

subsequently to expanding the annular assembly of tubes, positioning the tubes, by flexing the tube guides using a plurality of control wires coupled to the tube guides; and

following the positioning of the tubes, passing the threads from the tubes and through the tissue.

32. The method according to claim 31, wherein expanding the annular assembly of tubes comprises expanding the annular assembly of tubes over an annulus of a valve of a heart of the subject.

33. The method according to any one of claims 31-32,

wherein each one of the control wires includes:

a looped distal end, which is coupled to one of the tube guides,

a first proximal end, and

a second proximal end, and

wherein flexing any one of the tube guides comprises flexing the tube guide by moving the first proximal end of the control wire that is coupled to the tube guide with respect to the second proximal end of the control wire that is coupled to the tube guide.

34. The method according to any one of claims 31-33,

wherein the tubes include respective pointed distal ends, and

wherein passing the threads through the tissue comprises passing the threads through the tissue by passing the pointed distal ends through the tissue.

35. The method according to claim 34,

wherein a plurality of expandable anchors are disposed within the tubes and are coupled to the respective distal ends of the threads, and

wherein the method further comprises, subsequently to passing the pointed distal ends through the tissue, pushing the anchors from the tubes.

36. The method according to any one of claims 31-35, wherein expanding the assembly of tubes comprises expanding the assembly of tubes by sliding a slider proximally along the control wires.

37. The method according to any one of claims 31-36, wherein expanding the assembly of tubes comprises expanding the assembly of tubes by allowing an expandable annular structure, which is coupled to the tube guides, to expand.

38. The method according to claim 37,

wherein the annular structure includes a triangular-wave-shaped ring having alternating top vertices and bottom vertices,

wherein each one of the bottom vertices is coupled to a respective one of the tube guides, and

wherein positioning the tubes comprises positioning the tubes by adjusting respective angles of at least some of the top vertices and bottom vertices.

39. The method according to any one of claims 37-38, wherein positioning the tubes comprises positioning the tubes using a plurality of longitudinal wires coupled to the annular structure.

40. The method according to any one of claims 31-33 or claims 36-39, wherein the tubes include respective arced distal portions, and wherein passing the threads from the tubes comprises passing the threads from the tubes by arcedly passing a plurality of arced needles, which are coupled, respectively, to the threads, from the arced distal portions of the tubes.

41. The method according to claim 40, further comprising penetrating the tissue with the arced distal portions, prior to the passing of the arced needles through the tissue.

42. The method according to any one of claims 40-41,

wherein the arced needles include a plurality of pairs of arced needles, each one of the pairs including a first arced needle, coupled to a first one of the threads, and a second arced needle, coupled to a second one of the threads, and being disposed within a different respective one of the arced distal portions, and

wherein deploying the threads comprises deploying the threads by arcedly passing each one of the pairs of arced needles through the tissue, toward one another.

43. The method according to claim 42,

wherein the first arced needle includes a first pointed distal end, to which the first one of the threads is coupled,

wherein the second arced needle includes a second pointed distal end, to which the second one of the threads is coupled, and

wherein the method further comprises, following the passing of the pair of arced needles through the tissue, coupling the first pointed distal end to the second pointed distal end, such that the first one of the threads is coupled to the second one of the threads.

44. The method according to claim 43,

wherein the first arced needle further includes a first needle body reversibly coupled to the first pointed distal end,

wherein the second arced needle further includes a second needle body reversibly

coupled to the second pointed distal end, and

wherein the method further comprises, following the coupling of the first pointed distal end to the second pointed distal end, detaching the first needle body and the second needle body from, respectively, the first pointed distal end and the second pointed distal end.

45. The method according to any one of claims 42-44, wherein passing the pair of arced needles through the tissue comprises passing the pair of arced needles through the tissue by controlling a hinge that is coupled to respective proximal ends of the first arced needle and the second arced needle.

46. The method according to claim 45, wherein controlling the hinge comprises controlling the hinge by opening the hinge.

47. The method according to claim 40, wherein each one of the arced needles is disposed within a different respective one of the arced distal portions, and wherein each one of the threads is coupled to a proximal end of a different respective one of the arced needles.

48. The method according to claim 47, wherein passing the arced needles through the tissue comprises passing the arced needles through the tissue by rotating one or more shafts that are coupled to the tubes in contact with the arced needles.

49. Apparatus for locking an implant over tissue of a subject, the apparatus comprising: one or more blocks of material, comprising a proximal face and a distal face, and shaped to define a plurality of lumens that run between the proximal face and the distal face;

an inner tube, shaped to define a lateral aperture, and being configured to deliver the blocks to the implant while holding the blocks within the inner tube such that a thread passing through the implant loops through the lumens and exits from the inner tube, proximally to the blocks, through the aperture, and while the implant is in contact with the tissue; and

an outer tube, configured to cut the thread by sliding over the inner tube and over at least part of the aperture, following the delivery of the blocks to the implant.

50. The apparatus according to claim 49, wherein each one of the blocks is disk-shaped.

51. The apparatus according to any one of claims 49-50, further comprising a rod, configured to facilitate releasing the blocks from the inner tube following the delivery of the blocks to the implant, by pushing the blocks against the implant while the inner tube is withdrawn.

52. The apparatus according to any one of claims 49-50,

wherein the blocks comprises a proximal block, which comprises the proximal face, and a distal block, which comprises the distal face, each of the lumens running through both the

proximal block and the distal block,

wherein the inner tube is configured to deliver the blocks to the implant by bringing the distal block into contact with the implant while holding the proximal block at a distance from the distal block, and

wherein the apparatus further comprises a rod, configured to push the proximal block onto the distal block, following the delivery of the blocks to the implant.

53. A method for locking an implant over tissue of a subject, the method comprising:

looping a thread, which passes through the implant, through one or more blocks of material;

subsequently to looping the thread through the blocks, holding the blocks within an inner tube, such that the thread exits from the inner tube, proximally to the blocks, through a lateral aperture of the inner tube;

while holding the blocks within the inner tube, delivering the blocks to the implant, while the implant is in contact with the tissue; and

subsequently to delivering the blocks to the implant, cutting the thread, by sliding an outer tube over the inner tube and over at least part of the aperture.

54. The method according to claim 53, wherein the tissue includes a valve annulus of the subject.

55. The method according to any one of claims 53-54, wherein looping the thread through the blocks comprises looping the thread through the blocks by circling the thread through the blocks between 2 and 10 times.

56. The method according to any one of claims 53-55, further comprising, while pushing the blocks against the implant, releasing the blocks from the inner tube by withdrawing the inner tube, following the delivery of the blocks to the implant.

57. The method according to any one of claims 53-56,

wherein the blocks include a proximal block and a distal block,

wherein the inner tube is configured to deliver the blocks to the implant by bringing the distal block into contact with the implant while holding the proximal block at a distance from the distal block, and

wherein the method further comprises pushing the proximal block onto the distal block, following the delivery of the blocks to the implant.