the following definitions are provided as an aid to understanding the detailed description of the present invention . “ anchors ” for the purposes of this application , is defined to mean any fastener . thus , anchors may comprise c - shaped or semicircular hooks , curved hooks of other shapes , straight hooks , barbed hooks , clips of any kind , t - tags , or any other suitable fastener ( s ). in one embodiment , anchors may comprise two tips that curve in opposite directions upon deployment , forming two intersecting semi - circles , circles , ovals , helices or the like . in some embodiments , anchors are self - deforming . by “ self - deforming ” it is meant that anchors change from a first undeployed shape to a second deployed shape upon release of anchors from restraint in housing . such self - deforming anchors may change shape as they are released from housing and enter papillary or myocardial tissue , to secure themselves to the tissue . thus , a crimping device or other similar mechanism is not required on distal end to apply force to anchors to attach them to tissue . self - deforming anchors may be made of any suitable material , such as a super - elastic or shape - memory material like nitinol or spring stainless steel . in other embodiments , anchors may be made of a non - shape - memory material and made be loaded into housing in such a way that they change shape upon release . alternatively , anchors that are not self - deforming may be used , and such anchors may be secured to tissue via crimping , firing or the like . even self - securing anchors may be crimped in some embodiments , to provide enhanced attachment to tissue . in some embodiments , anchors may comprise one or more bioactive agent . in another embodiment , anchors may comprise electrodes . such electrodes , for example , may sense various parameters , such as but not limited to impedance , temperature and electrical signals . in other embodiments , such electrodes may be used to supply energy to tissue at ablation or sub - ablation amounts . delivery of anchors may be accomplished by any suitable device and technique , such as by simply releasing the anchors . any number , size and shape of anchors may be included in housing . apical or apex refers to a known part of the heart , roughly equivalent to the peak at the bottom of the organ . canula or cannula refers to a well - known tube - like medical instrument . it can be fitted with a trocar , a sharp pointed device for piercing tissue . tether may be one long piece of material or two or more pieces and may comprise any suitable material , such as nitinol , austinetic steel , suture , suture - like material , a dacron strip or the like . hemostasis valve , or valve / sleeve , refers to a device which allows the heart tissue to be pierced at the apex region with little or no blood loss . similar valves / sleeves are well known in the venipuncture field where individual vacutainers can be repeatedly mounted on a single needle , and valves such as the touehy borst valve which allows multiple insertions of catheters while maintaining hemostasis . generally , delivery of the tether device may be advanced by any suitable advancing or device placement method so long as it arrives at the apex of the heart . many catheter - based , minimally invasive devices and methods for performing intravascular procedures , for example , are well known , and any such devices and methods , as well as any other devices or method later developed , may be used to advance or position delivery device into a desired location . for example , in one embodiment a steerable guide catheter is first advanced percutaneously to the apex region . the steerable catheter is inserted into the left ventricle of the heart through the apex of the heart and thus into the space formed by left ventricle . an obturator pushes or holds the tissue in place once it has been pierced . once in this space , the steerable catheter is easily advanced to the papillary muscle or to the ventricular wall , the anchor may then be advanced and inserted into the papillary muscle and / or the lv myocardium . of course , this is but one exemplary method and any other suitable method , combination of devices , etc . may be used . fig1 a is a graphical representation of an apical introduction device used to align papillary muscles . fig1 a shows cannula and the tethering member with four protruding anchors and depth gauge . fig1 b is a graphical representation of an apical introduction device used to align papillary muscles . fig1 b shows cannula and the tethering member with three protruding anchors and depth gauge . fig1 c is a graphical representation of an apical introduction device used to align papillary muscles . fig1 c shows cannula and the tethering member with two protruding anchors . fig2 - 8 show a heart having an enlarged left ventricle 110 , and the instant apical approach 112 to the left ventricle 110 is depicted in fig3 - 8 . in this example embodiment , fig3 shows the left ventricle is accessed by inserting a catheter 114 having a cannula 116 and trocar 118 that is advanced from into the left ventricle 110 . once the catheter 114 reaches the interior of the left ventricle , the trocar 118 is removed in favor of a steerable guide catheter 120 which permits introduction of the instruments which will be used to engage and tether the papillary muscles , as described in more detail below . an advantage of the apical approach is that it eliminates any risks associated with crossing the aortic valve , trans - septal puncture , or arterial damage , and permits the use of larger french catheter , and provides direct access to the papillary muscles , without requiring that the mitral valve be crossed . referring now to fig4 and 4a , the papillary muscles 210 , and 220 need to be address using the proper orientation of the catheters , tools and the like throughout the procedure . such orientation is accomplished using a steerable catheter 120 or equivalent tool . in an example embodiment of the invention , the papillary muscles 210 , 220 are grasped by partial or full penetration or piercing . this may be accomplished with a variety of grasping mechanisms , preferably including one or more piercing prongs extending from an instrument or catheter tool so as to grasp a target structure . referring more specifically to the example embodiment of fig4 , steerable catheter 120 is fed through the guide catheter 114 to secure a first anchor 124 of a tether structure 122 ( see inset fig3 a ) to one of the papillary muscles 210 in the left ventricle . the steerable catheter 120 is advanced from the distal end of the guide catheter 114 and may be observed in real time via any conventional imaging technique . in the illustrated example embodiment , a suture or clip applying instrument ( tethering device ) 122 is passed through the catheter 120 . advantageously , the instrument has a steerable tip so that it may be directed to a position in opposed facing relation to a target portion of a papillary muscle . disposed at or adjacent the distal end of the tethering instrument 122 in this embodiment is a clamp or clip 124 for secure attachment to the respective papillary muscle . the clip or clamp is advanced out of the deployment catheter and into engagement with respective papillary muscle . any suitable mechanism can be sued to close the clip . if deemed necessary or desirable , one or more additional clips with tethers may be applied . referring now to fig5 , once the clip has been secured with respect to a first one of the papillary muscles 210 , the instrument is withdrawn to reveal the flexible strand and the same or another instrument carrying another clip is conducted through the guide catheter adjacent the already placed flexible strand . in the alternative , the instrument carries at least first and second clips and respective flexible strands so that the papillary muscles can be respectively engaged without withdrawing the instrument and reinserting it . whether the clips are attached sequentially by the sequential feed of an instrument or sequentially by manipulating the instrument , after each papillary muscle has been engaged by respective clip ( s ) with respective flexible strand ( s ), the instrument is withdrawn through the guide catheter . according to an alternate embodiment , non - absorbable suture loop ( s ) may be applied directly in the papillary muscles . for example , a variation of the perclose a - t ® vasculature closure device , which is a stitch knot transmitting device with a suture cutter could be used apply a suture loop . there are also known laparoscopic devices , such as the quik - stitch endoscopic suturing system , that may be adapted to transvascularly securing a tether to the papillary muscles . as illustrated in fig5 , the guide catheter 120 remains in place with the flexible tether strand ( s ) 126 extending therethrough from the respective secured clip / anchor 124 on first papillary muscle 210 . then , steerable catheter 120 attaches second anchor 128 to second papillary muscle 220 . referring now to fig6 , the tethered papillary muscles 210 , 220 are tethered by tether strand 126 and 130 . referring now to fig7 , the tether strands 126 and 130 are next drawn together by using a gathering instrument 132 , which is advanced over the flexible tethers and the tethers are pulled through the instrument to draw the clips 124 , 128 toward one another . the tethers are then either tied or fastened together to define the desired spacing of the papillary muscles . for example , two tethers may have a knot transmitted to define the junction , or they are clipped to one another through the existing guiding catheter . the tethering and drawing of the papillary muscles towards one another may be conducted while monitoring the position of the muscles fluoroscopically , and under intra - cardiac ultrasound guidance , so that the papillary muscles can be drawn to a desired transventricular distance . intra cardiac echo doppler can also be used to assess the severity of lv enlargement / cv disease , or regurgitation , to adjust the length of the tethers to an optimum transventricular distance to suppress cardiac deficiency or regurgitation . so bringing the papillary muscles closer together reduces the size of the left ventricular cavity and will limit further distension of the ventricular wall , thereby mimicking the effect of the congenital false tendon to improve ventricular geometry and mitigate the effects of dilated cardiomyopathy . fig8 and 9 show corrected left ventricle 110 having papillary 210 held by anchor 124 , and papillary 220 held by anchor 128 , and joined by connector 134 , which may be adjustable . any suitable instrument may be used to capture and sever the excess tether length such as , for example , a suture trimmer . fig1 is a photo representation of a heart in cross - section being pierced by a device and shows inserting at the apex . fig1 is a photo representation of a heart in cross - section being pierced through the ventricular wall . fig1 is a photo representation of a heart in cross - section being pierced by a device at the apex , and shows interaction with a papillary muscle . fig1 is a photo representation of a heart in cross - section . fig1 is a photo representation of a heart in cross - section showing attachment of tether lines ( in blue ), prior to being cinched , or joined . the references recited herein are incorporated herein in their entirety , particularly as they relate to teaching the level of ordinary skill in this art and for any disclosure necessary for the commoner understanding of the subject matter of the claimed invention . it will be clear to a person of ordinary skill in the art that the above embodiments may be altered or that insubstantial changes may be made without departing from the scope of the invention . accordingly , the scope of the invention is determined by the scope of the following claims and their equitable equivalents .
this invention relates to devices and methods for the therapeutic changing of the geometry of the left ventricle of the human heart . specifically , the invention relates to the apical introduction of an anchoring device to align the papillary muscles .