Abstract:
A collapsible device, such as an annuloplasty ring or prosthetic heart valve, is configured to be collapsed prior to being introduced into a patient via minimally-invasive access points such as port holes or intercostal incisions. A holder is configured to hold the collapsible device, and to selectively collapse the device for introduction into the patient and then re-enlarge the device at the desired deployment site. Collapsible devices include devices that can hingedly fold about hinge lines, and devices that can elongate to form substantially spiral forms with reduced diameters.

Description:
RELATED APPLICATIONS 
     The present application claims priority under 35 USC 119(e) to U.S. Provisional Application Ser. No. 61/844,409, filed Jul. 9, 2013 and entitled “Collapsible Cardiac Implant and Deployment System and Methods,” the entire contents of which are hereby incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates generally to methods and devices for minimally invasive and less invasive surgical access. More particularly, the present invention provides collapsible valve implants, such as rings or prosthetic valves, including systems and methods for collapsing, delivering, and implanting such implants via small incision sites. 
     BACKGROUND OF THE INVENTION 
     Heart valve disease is a widespread condition in which one or more of the valves of the heart fails to function properly. Diseased heart valves may be categorized as either stenotic, wherein the valve does not open sufficiently to allow adequate forward flow of blood through the valve, or incompetent, wherein the valve does not close completely, causing excessive backward flow of blood through the valve when the valve is closed. A heart valve may also be both stenotic and incompetent. Valve disease can be severely debilitating and even fatal if left untreated, particularly if the diseased valve is the mitral valve (between the left atrium and left ventricle) or the aortic valve (between the left ventricle and the aorta). According to recent estimates, more than 80,000 patients are diagnosed with aortic or mitral valve disease in U.S. hospitals each year. Recent statistics show that valvular heart disease is responsible for nearly 20,000 deaths each year in the United States, and is a contributing factor in approximately 42,000 deaths. Currently, the primary treatments of valve disease are valve repair and valve replacement. Worldwide, there are approximately 300,000 heart valve replacement surgeries performed annually. 
     A number of interventional approaches have been developed for treating heart valve disease. For instance, annuloplasty rings have been developed in various shapes and configurations over the years to correct mitral regurgitation and other conditions which reduce the functioning of the valve. Heart valve replacement may be indicated when there is a narrowing of a native heart valve, commonly referred to as stenosis, or when the native valve leaks or regurgitates, such as when the leaflets are calcified. When replacing the valve, the native valve may be excised and replaced with either a biologic or a mechanical valve. 
     Annuloplasty rings are useful in treating some diseased valves where valve function can be restored by reshaping the valve annulus. In an annuloplasty procedure, the effective size of the valve annulus is contracted, and/or the valve annulus is otherwise reshaped, by attaching a prosthetic annuloplasty ring to an interior wall of the heart around the valve annulus. The annuloplasty ring may comprise an inner substrate of a metal such as stainless or titanium, and/or a flexible material such as silicone rubber or Dacron cordage, covered with a biocompatible fabric or cloth to allow the ring to be sutured to the heart tissue. The annuloplasty ring may be stiff or flexible, may be split or continuous, and may have a variety of shapes, including circular, D-shaped, C-shaped, or kidney-shaped. Examples are seen in U.S. Pat. Nos. 4,917,698, 5,061,277, 5,290,300, 5,350,420, 5,104,407, 5,064,431, 5,201,880, and 5,041,130, which are incorporated herein by reference. 
     Using current techniques, most valve repair and replacement procedures require a gross thoracotomy, usually in the form of a median sternotomy, to gain access into the patient&#39;s thoracic cavity. A saw or other cutting instrument is used to cut the sternum longitudinally, allowing two opposing halves of the anterior or ventral portion of the rib cage to be spread apart. A large opening into the thoracic cavity is thus created, through which the surgical team may directly visualize and operate upon the heart and other thoracic contents. Alternatively, a thoracotomy may be performed on a lateral side of the chest, wherein a large incision is made generally parallel to the ribs, and the ribs are spread apart and/or removed in the region of the incision to create a large enough opening to facilitate the surgery. 
     Using such open-chest techniques, the large opening provided by a median sternotomy or thoracotomy can enable the surgeon to see the diseased valve directly, and to position his or her hands within the thoracic cavity in close proximity to the exterior of the heart for cannulation of the aorta and/or coronary arteries to induce cardioplegia, manipulation of surgical instruments, removal of excised tissue, and introduction of an annuloplasty ring or a replacement valve for attachment within the heart. Most interventional techniques are conducted under general anesthesia and require that the patient&#39;s sternum be opened and the chest be spread apart to provide access to the heart. The first 2-3 days following surgery are often spent in an intensive care unit where heart functions can be closely monitored. The average hospital stay is between 1 to 2 weeks, with several more weeks to months required for complete recovery. While often very effective, the use of open-heart surgery to perform cardiac procedures may be highly traumatic to the patient. 
     While heart valve surgery produces beneficial results for many patients, numerous others who might benefit from such surgery are unable or unwilling to undergo the trauma and risks associated with open-chest procedures. Recently, minimally invasive surgical techniques and procedures to perform traditionally open-chest cardiac surgical procedures are gaining acceptance. A wide variety of laparoscopic, arthroscopic, endovascular, and other surgical therapies have been developed. These procedures generally utilize trocars, cannulas, catheters, or other tubular sheaths to provide an artificial lumen through which specialized tools are inserted and manipulated by the surgeon. Such minimally-invasive procedures substitute one or more relatively small port holes or other intercostals incisions through the patient&#39;s chest wall for the larger sternotomy and thoracotomy approach of conventional open-chest surgeries. A major advantage of such minimally-invasive approaches is that the procedure avoids cutting through bones or other hard tissues of the patient, instead cutting incisions only into soft tissue. Such soft tissues typically heal much faster than bones, and with less discomfort to the patient. 
     Annuloplasty rings and even many prosthetic valves are usually relatively small, but even their relatively small sizes can still be a challenge for introduction into and manipulation/positioning within a patient&#39;s chest cavity, particularly where it is desirable to introduce the devices into a patient via intercostal incisions in order to avoid cutting through bone. Typical intercostal incisions have widths of about 20 mm and lengths of about 30 mm. While the large length of many intercostals space may permit the length of an intercostal incision to be extended beyond 30 mm, the width of intercostal spaces prevent the creation of intercostal opening with widths beyond about 20 mm. Greater intercostal opening widths may require cutting into adjacent ribs and/or displacing adjacent ribs to the point where the bones are cracked and/or bruised by the displacement, which can increase the risk of trauma to the patient as well as extend recovery time. Accordingly, devices and handles that can be introduced through an opening of about 20 mm width may be desirable for minimally invasive procedures via intercostals incisions. 
     Annuloplasty ring prostheses are generally mounted on a holder assembly to facilitate their manipulation during the course of a surgical intervention and their implantation. Current holder assemblies are characterized by a number of drawbacks. A great majority of holders are configured with a rigid handle and a fixed orientation of the holder body or prosthesis carrier relative to the handle. Such a mechanical limitation does not allow the surgeon to orient the holder body relative to the handle in order to optimize the delivery of the prosthesis to the implant site. Some holder assemblies have been configured with malleable handles in an attempt to alleviate this drawback. However, such malleable handles are generally difficult to reshape in different bent configurations once they have been initially bent. 
     In view of actual and perceived drawbacks associated with current annuloplasty and prosthetic valve deployment techniques, there is a need for a less invasive approach and improved handle. The current invention satisfies these needs. 
     SUMMARY OF THE INVENTION 
     Preferred embodiments of the present application provide a valve ring or prosthetic valve that can be folded, crimped, or stretched for delivery into and manipulation within a patient&#39;s chest cavity, and then restored to an extended configuration for deployment at the native valve annulus. Such valves and valve rings are particularly useful for delivery via small incisions such as mini thoracotomy, right thoracotomy, or right anterior thoracotomy. Delivery systems and methods of the invention provide handles for introducing, manipulating, and deploying the collapsible valves and valve ring. Such handles may have a series of steering mechanisms that will allow for proper navigation to the deployment site. 
     In one aspect, the present application discloses a holder for delivering an annuloplasty ring or prosthetic valve, comprising holder configured to hold, collapse, and steer the device into the patient. The holder may have a handle with controls to provide for movement of the holder distal portion in any direction and the ability to steer the device into a desired position within the patient. The holder may preferably be configured to be operated with just one hand. The holder may itself actuate the collapse/folding/crimping/elongation of the valve ring or valve, as well as actuating restoration of the valve ring or valve to its deployed configuration. For example, the holder may fold, twist, and otherwise manipulate the device and then re-form the device back to its original shape. 
     A method of implanting devices in a human body, comprises creating an opening in the chest cavity of a patient; grasping a device holder having a collapsible/longitudinally elongatable device on the distal end thereof, wherein the device is a valve ring or prosthetic valve; collapsing the device by operating one or more controls of the device holder to collapse the device; after collapsing the device, advancing the collapsed device through the intercostal opening and into the patient; positioning the device at a desired deployment site in the patient; uncollapsing the device so that the device returns to a deployed configuration; securing the device to the desired deployment site in the patient; releasing the device from the device holder; and removing the device holder from the patient. The method may further include folding the device and/or elongating the device while reducing an outer diameter of the device. The device may be selected from the group comprising annuloplasty rings and prosthetic heart valves, and securing the device to the desired deployment site comprises securing the device within a native valve annulus. Securing the device to the desired deployment site may comprise suturing the device within the native valve annulus. 
     A collapsible intracardiac implant device of an embodiment of the invention has a support ring, the support ring comprising two half segment portions, and hinges securing the two half segment portions to each other to form a completed ring, wherein the hinges permit relative hinging movement between the two half segment portions. The device may be an annuloplasty ring and further have a first central stent structure defining a first of the half portions, a second central stent structure defining a second of the half portions, and a sewing ring extending around the support ring. A cloth cover may surround the sewing ring and first and second stent structures. A suture locking ring may be positioned on top of the support ring on the outer surface of the cloth cover, the suture locking ring having a plurality of suture holes passing from a top surface of the suture locking ring through to a bottom surface thereof, the suture holes configured to receive suture therethrough. A plurality of suture locks may be provided on the suture locking ring, wherein each suture lock is configured to receive a suture therethrough and to lock the suture in place. A suture lock may positioned on the top surface of the suture locking ring at a position immediately radially outward of each of the plurality of suture holes. A hinge lock may be provided to prevent the half segment portions from rotating with respect to each other about the hinges when the device is in an open configuration. The device may be a prosthetic heart valve and have a first central stent structure defining a first of the half portions; a second central stent structure defining a second of the half portions; a first commissural support extending upward from the first of the half portions at a midpoint between opposing ends thereof; second and third commissural supports extending upwardly from the second of the half portions at points spaced away from a midpoint of opposing ends thereof such that when the first and second half portions are rotated toward each other in an upward direction around the hinges, the first commissural support is rotated to a position in between the second and third commissural supports; and a plurality of valve leaflets, wherein each valve leaflet extends between two of the commissural supports, and wherein when the valve leaflets are configured, when the device is in an open/deployed configuration, to coapt to control fluid flow through a central orifice defined within the support ring. A hinge lock may be provided and configured to prevent the half segment portions from rotating with respect to each other about the hinges when the device is in an open configuration. 
     Another embodiment of a collapsible intracardiac implant device has a support ring comprising opposing ends which are positioned adjacent each other when the device is in an open/deployed configuration, wherein the opposing ends can be longitudinally displaced with respect to each other to thereby cause the support ring to transform to an elongated spiral configuration; wherein the support ring comprises a support structure which biases the support ring to the open/deployed configuration. The device may be an annuloplasty ring and have a sewing ring secured around the support structure; and a cover encapsulating the sewing ring. The device may be a prosthetic heart valve having a plurality of commissural supports extending upward from the device, wherein the commissural supports are spaced around the perimeter of the device, where one of the commissural supports comprises a first half positioned adjacent the first opposing end of the support ring and a second half positioned adjacent the second opposing end of the support ring, wherein when the opposing ends are positioned adjacent each other the first half and second half are positioned against each other and function as a single commissural support, and when the opposing ends are longitudinally displaced from each other the first half and second half are longitudinally displaced from each other. A plurality of leaflets may be provide that extends from one commissural support to another commissural support, and wherein when the device is in the open/deployed configuration the leaflets coapt to control fluid flow through a central orifice defined within the support ring, and when the device is in the elongated/spiral configuration the leaflets do not coapt. A sewing ring may be positioned on an outer perimeter of the device outside the central orifice, the sewing ring configured to receive needle and suture therethrough. A suture locking ring may be positioned on top of the sewing ring, and have a plurality of suture holes passing from a top surface of the suture locking ring through to a bottom surface thereof, the suture holes configured to receive suture therethrough; and a plurality of suture locks on the top surface of the suture locking ring, wherein each suture lock is configured to receive a suture therethrough and to lock the suture in place. 
     A system for delivering a device to a position in a patient according to an embodiment of the invention has a collapsible device configured to be collapsed and opened (e.g., via hinging or spiral elongation and to be implanted in a patient, and an elongated delivery holder configured to hold the device and advance the device in into the patient, the holder comprising a proximal portion having a handle with device collapsing and opening controls thereon and a distal portion configured to hold the device and to collapse and open the device responsive to operation of the opening controls of the handle. The collapsible device may be positioned on the distal portion of the holder. 
     Devices of the invention may be configured to collapse to have a minimal profile sufficient to be advanced through an opening of 20 mm in width. 
     The collapsing/tilting/tipping/steering mechanisms of the holder may include a gear train or a pulley system. In a preferred embodiment, the mechanisms may include a push/pull rod linearly movable within the handle. The holder may include a device detachment mechanism that may be configured to release clips and/or sever sutures holding the device to the holder. 
     Methods of implanting devices of the invention include: creating an intercostal access opening in a patient; grasping a device holder having a collapsible/longitudinally elongatable device on the distal end thereof, wherein the device is a valve ring or prosthetic valve; operating the device holder to collapse the device (e.g., in hinge or spiral elongation fashion); advance the collapsed device through the intercostal opening and into the patient; position the device at a desired deployment site in the patient; uncollapsing the device; securing the device to the desired deployment site in the patient; release the device from the device holder; and remove the device holder from the patient. 
     The invention can be used in various procedures. In an example of such a procedure, an intercostal opening of about 20 mm width and 30 mm or more length is created for access using surgical instruments. One or more port hole punctures are provided through which visualization (e.g., cameras) and/or ablation and/or suture catheters may be advanced for use in the procedure. The devices of the invention, as well as other instruments (such as suturing devices) may be advanced through the intercostal opening to perform a desired repair and/or implantation, which may occur on or in the patient&#39;s heart. 
     Further understanding of the nature and advantages of the present invention are set forth in the following description and claims, particularly when considered in conjunction with the accompanying drawings in which like parts bear like reference numerals. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Features and advantages of the present invention will become appreciated as the same become better understood with reference to the specification, claims, and appended drawings wherein: 
         FIGS. 1A and 1B  are perspective and top views, respectively, of a prosthetic heart valve and an intercostal incision opening according to an embodiment of the invention; 
         FIGS. 2A and 2B  are perspective views of a prosthetic heart valve support frame in an open/deployed configuration and a folded/delivery configuration, respectively; 
         FIGS. 3A and 3B  are perspective views of a prosthetic heart valve support ring with sewing ring in an open/deployed configuration and a folded/delivery configuration, respectively; 
         FIGS. 4A-4C  are perspective, side (close-up) and perspective views, respectively, of an annuloplasty ring according to an embodiment of the invention; 
         FIG. 5  is a perspective view of an annuloplasty ring main ring body in an open/deployed configuration according to an embodiment of the invention; 
         FIGS. 6A and 6B  are perspective and close-up views, respectively, of an upper sewing ring for suture retention on an annuloplasty ring or prosthetic valve in an open/deployed configuration according to an embodiment of the invention; 
         FIGS. 7A and 7B  are perspective views of an annuloplasty ring delivery holder with annuloplasty ring in the open/deployed configuration and folded/delivery configuration, respectively, according to an embodiment of the current invention; 
         FIGS. 8A-8C  are top, bottom, and side views, respectively, of a handle portion of an annuloplasty ring delivery holder according to an embodiment of the current invention; 
         FIG. 9  is a schematic depiction of an annuloplasty ring delivery holder according to an embodiment of the invention; 
         FIGS. 10A and 10B  are perspective views of an annuloplasty ring delivery holder with annuloplasty ring in the deployed configuration and stretched/delivery configuration, respectively, according to an embodiment of the current invention; 
         FIG. 11A  is a perspective view of an annuloplasty ring delivery holder with annuloplasty ring in the deployed configuration; 
         FIG. 11B  is a perspective view of the annuloplasty ring delivery holder with annuloplasty ring of  FIG. 11A  in the stretched/delivery configuration; and 
         FIG. 11C  is a perspective view, in close-up, of a portion of the annuloplasty ring delivery holder with annuloplasty ring of  FIG. 11A  in the deployed configuration. 
     
    
    
     DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     An exemplary embodiment of a prosthetic heart valve  10  according to the invention is depicted in  FIGS. 1A and 1B . The prosthetic heart valve  10  comprises a support frame  12 , commissure posts  14 , valve leaflets  16 , and sewing ring  18 . Hinges (not shown) are provided in the support frame  12  that permit the prosthetic heart valve  10  to fold partially along center hinge lines  22 . Valve leaflets  16  extend between commissure posts  14 . Note that, for visibility purposes, in  FIG. 1A  only one of the three valve leaflets is depicted. The valve  10  has an outer diameter  24  and an inner diameter  26 , with the inner diameter  26  defining the flow orifice through which blood flows when the leaflets are in the open position. The valve overall height  28  extends from the valve lower surface to the upper tip of the commissure posts  14 . Note that the dimensions of a particular valve  10  according to the invention depend on the particular embodiment and desired applications. 
     An intercostal incision  30  has a length  32  and width  34 . The length  32  may be  30  mm or more. The width  34  is typically on the order of about 20 mm. As depicted in  FIG. 1B , the heart valve outer diameter  24  of the valve depicted is larger than the intercostal incision width  34 , so that the outer diameter  24  is too large for the heart valve  10  to be advanced directly into the intercostal incision  30  without significant manipulation. By folding the heart valve  10  about the hinge lines  22 , the valve profile can be reduced to permit the valve  10  to be advanced into the intercostal incision  30 . 
       FIGS. 2A and 2B  depict a support frame  12  according to an embodiment of the invention. The support frame  12  has a first half portion  40  and a second half portion  42 , with the half portions  40 ,  42  joined to each other at their respective ends via hinges  44 . The hinges  44  permit the half portions  40 ,  42  to be folded at least partially together, as depicted in  FIG. 2B . 
     In the particular embodiment depicted in  FIGS. 2A-2B , the first half portion  40  has a single commissure post position indicated by a commissure hole  46  through which a commissure support (not shown) can be secured (e.g., via suture) when the valve is assembled. The hole  46  and hence the single commissure position of the first half portion  40  is in the center of the first half portion. The second half portion  42  has two commissure post positions, each indicated by a commissure hole  48  through which a commissure support (not shown) can be secured when the valve is assembled. The commissure holes  48  and hence the commissure positions of the second half portion  42  are positioned well away from the center of the second half portion  42 . This respective positioning of the commissure holes  46 ,  48  permits the prosthetic heart valve, when assembled, to be folded without the opposing commissure posts striking each other. Instead, the single commissure post of the first half portion  40  will be advanced to a position in between the two commissure posts of the second half portion  42 . 
     Note that the support frame  12  and its respective elements may be formed of various materials, including metals (such as stainless steel or nitinol) and polymers. 
       FIGS. 3A and 3B  depict the frame  12  with a first sewing ring portion  18   a  secured to the first half portion  40  and a second sewing rig portion  18   b  secured to the second half portion  42 . The ends  50   a  of the first sewing ring portion  18   a  are angled, as are the ends  50   b  of the second sewing ring portion  18   b . The angled surfaces of the respective ends  50   a ,  50   b  permit the valve frame  12  to be folded inwardly along the hinges  44 , as depicted in  FIG. 3B , without the adjacent ends  50   a ,  50   b  engaging each other and potentially interfering with the valve folding process. 
     Note that the heart valve frame and other designs from  FIGS. 1A-3B  could be applied to an annuloplasty ring according to an embodiment of the invention. Such an annuloplasty ring would have first and second half portions connected via hinges, and could also have angled surface at the adjacent ends of the sewing ring portions for each half portion. 
     A finished valve (or finished annuloplasty ring) according to an embodiment of the invention, such as that depicted in  FIG. 1A , may be biased toward the open configuration (corresponding to the valve configuration depicted in  FIG. 1A  and the frame configurations depicted in  FIGS. 2A and 3A ). Such biasing may be achieved via include spring-loading (e.g., in frame, hinges, other structures of the valve) or elastic elements (e.g., in the sewing ring) to the bias frame toward the open position. Memory metals (such as Nitinol) may be used to bias the frame and/or other valve elements to cause the valve, when unrestrained, to return to its open configuration. The finished valve or annuloplasty ring may include a locking mechanism that will hold the valve/ring in the open position. For example, the locking mechanism may be configured to be activated when the valve/ring is released from a holder used to deploy the device. The locking mechanism may be positioned on the frame or other elements of the valve/ring. 
     An annuloplasty ring  60  according to an embodiment of the invention is depicted in  FIGS. 4A-4C . The ring has a main ring body  62  having a first end  64  and a second end  66 , with the first end  64  and second end  66  overlapping each other to form a lap joint  68 . Secured to the main body  62  is a sewing ring  70 , which in the embodiment depicted is secured to the main body  62  at the top thereof using suture ties  72 . As depicted in  FIG. 4C , the first end  64  can be lifted upward and away (e.g., using mechanical force from some sort of mechanism such as a ring holder portion  74 ) from the second end  66  to cause the ring  60  to assume a stretched, elongated configuration that may be more easily advanced longitudinally into a port hole and/or intercostal opening. Once the ring is at a desired deployment location (e.g., within a heart valve annulus), the mechanism (e.g., ring holder portion  74 ) can reposition the first end  64  in overlapping configuration with the second end  66 , as depicted in  FIGS. 4A and 4B . The annuloplasty ring may include a locking mechanism that can be activated with deployment to prevent the ends  64 ,  66  from separating after the ring is secured within the patient. For example, a suture line could be passed downwardly through the sewing ring  70  and through the main body  62  at a position  76  at the lap joint  68  so that the suture passes through both the first end  64  and the second end  66 , thereby holding the first end  64  against the second end  66  and securing the lap joint  68 . 
       FIG. 5  depicts an embodiment of an annuloplasty ring body  62  having a first end  64  and a second end  66 , with the ends  64 ,  66  overlapping at a lap joint  68 . The ring body  62  has an internal structure, such as an internal spring wire  80 , which provides structural strength and may also bias the ring toward the open configuration where the ends  64 ,  66  overlap at the lap joint  68 . The internal spring wire may be formed of metals (e.g., stainless steel, nitinol) or polymers or other materials. An internal sewing ring  82  surrounds the internal spring wire  80 . The internal sewing ring  82  may be formed from various materials, such as polymers (e.g., thermoplastic), which permit suture to be passed therethrough with relative ease. The internal sewing ring  82  is itself surrounded by a fabric casing  84 . Note that the ring body  62  may itself be used as an annuloplasty ring without further elements, e.g., without the need for an additional sewing ring such as the external sewing ring  70  depicted in  FIG. 4A . 
       FIGS. 6A and 6B  depict the external sewing ring  70  in greater detail. The external sewing locking ring  70  acts as a suture lock ring, and includes a plurality of sewing holes  90  through which needle and suture may be advanced. The sewing holes  90  can thus serve as guides to indicate positions where suture can most easily and/or effectively be passed into the valve body. Small indentations  92  are provided on the outer and inner perimeters of the external sewing ring, with the small indentations provided to assist in securing the locking ring  70  to the main valve ring body at the time of manufacture. Suture locks  94  are provided to assist in locking the sutures in place. In use, a suture is passed through a first suture lock, then passed through a portion of the native valve annulus, and then passed into another suture lock. In such an embodiment, there is no need to tie knots in the suture to hold the ring in place in the annulus. The external suture ring  70  may be formed from a relatively hard (i.e., needle- and suture-resistant material) that prevents the passage of needle and suture therethrough except through the sewing holes  90 . 
     Note that the annuloplasty ring frame and other designs from  FIGS. 4A-6B  could be applied to a prosthetic heart valve according to an embodiment of the invention. Such a prosthetic heart valve could have a frame with adjacent ends which could be longitudinally stretched away from each other to form the frame into a somewhat spiral shape, and then allowed to return to their original position to cause the frame to resume the desired configuration for the deployed valve. Note that the frame adjacent ends (e.g., with lap joint) may have to coincide with a commissural post of the heart valve in order to prevent stretching/tearing of any heart valve leaflets that would otherwise cross over the lap joint form the first end to the second end. 
       FIGS. 7A and 7B  depict an annuloplasty ring  100  secured to device holder  102  according to an embodiment of the invention. The annuloplasty ring  100  is a hinged design similar to the hinged design of the prosthetic heart valve  10  and frame  12  depicted in  FIGS. 1A-3B . The annuloplasty ring  100  has a first half  104  and a second half  106 , with hinges  108  holding the two halves together. In  FIG. 7A , the annuloplasty ring  100  is in its open/deployed configuration, showing the general D-shape of the annuloplasty ring  100 . The device holder  102  has a first arm  110  and a second arm  112  releasably secured to the ring first half  104  and second half  106 , respectively. In  FIG. 7B , the first arm  110  and second arm  112  are drawn together, thereby folding the annuloplasty ring first and second halves  104 ,  106  together about the hinges  108 . The folded annuloplasty ring  100  thus has a lower profile more conducive to advancement into the patient&#39;s chest cavity via minimally-invasive methods. 
     Note that a device holder such as that depicted in  FIGS. 7A-7B  could be used for delivering and deploying various hinged devices, such as a hinged/foldable prosthetic heart valve such as that depicted in  FIGS. 1A-3B . 
       FIGS. 8A-8C  depict the handle portion  120  of the device holder  102 , with multiple controls for manipulating the configuration and position of the annuloplasty ring or other prosthetic device being deployed in the patient. The applications of the various controls are depicted schematically in  FIG. 9 . A device collapse control is provided in the form of an opposing pair of wing levers  122 , where inward movement of the wing levers causes the arms  110 ,  112  to rotate inward against each other and therefore cause a corresponding collapse/hinge-like folding of the device being delivered, and outward movement of the wing levers  122  causes the arms  110 ,  112  to rotate outwardly away from each other and cause a corresponding unfolding/opening of the device being delivered. A device tipping control is provided in the form of a slider  124  which, when slid forward or backward with respect to the handle  120 , causes the device to be tipped in a direction along the z-axis (i.e., out of or into the page) depicted in  FIG. 9 . A device steering control in the form of a rotatable knob  126  causes, when rotated, left or right turning of the device via left or right turning of the distal end  128  of the holder about a hinge-like connection  130 . Note that these controls could be changed in their functions (e.g., the rotatable knob could control the device tipping or device collapse; the slider could control device collapse or device steering; the wing levers could control device tipping or device steering), or entirely different controls or combinations thereof could be used. Other controls are also within the scope of the invention. 
     Note that the device (e.g., annuloplasty ring or valve) could be secured to the holder via various techniques. The device could be secured to the arms of the holder via sutures, with the sutures being severed once the device is secured in place at the desired implantation site (e.g., the valve annulus). The device could be secured to the holder via clips or other mechanisms, which could be activated from the holder handle to release the device from the holder when desired by the surgeon or other user. 
       FIGS. 10A and 10B  depict an annuloplasty ring  140  secured to a device holder  142  according to an embodiment of the invention. (Note that the device holder  142  could also be used for prosthetic heart valves or other devices.) The annuloplasty ring  140  is of the type depicted in  FIGS. 4A-4C , with overlapping first and second ends  144 ,  146  which can be longitudinally displaced to cause the ring  140  to temporarily assume an elongated spiral form (depicted in  FIG. 10B ) for advancement through relatively small openings. The holder  142  has first and second arms  148 ,  150  to which the first and second ends  14   a ,  146  are secured. The first and second arms  148 ,  150  which can be longitudinally displaced with respect to each other, thereby causing corresponding longitudinal displacement of the first and second ends  144 ,  146  with respect to each other to cause the ring to assume an elongated spiral shape. The handle  152  of the holder  142  includes multiple controls, including: a pair of wings  154  to control displacement of the first and second arms  148 ,  150  (and thus control collapse/elongation of the annuloplasty ring  140  or other device); a slider  156  to control tipping of the distal-most portions of the arms (and therefore of the device secured thereto); and a control knob  158  to control side-to-side movement of the annuloplasty ring  140  or other device. 
     Another embodiment of a holder  170  for use in deploying an annuloplasty ring  172  or other device capable of stretching into a spiral shape for reduced profile according to the invention is depicted in  FIGS. 11A-11C . In  FIGS. 11A and 11C , the holder  170  is secured to the ring (e.g., via sutures) with a first overlapping end  174  secured to an upper foot-like element  178  of the holder  170 , and a second overlapping end  176  secured to a lower foot-like element  180  of the holder  170 . The holder  170  has an upper handle portion  182  and a lower handle portion  184 , which can be longitudinally displaced with respect to each other. As depicted in  FIG. 11B , when the upper foot-like element  178  is displaced with respect to the lower foot-like element  180  (via movement of the upper handle portion  182  with respect to the lower handle portion  184 ), the ends  174 ,  176  of the ring  172  are longitudinally displaced, causing the ring  172  to assume an elongate spiral configuration. 
     While the invention has been described in its preferred embodiments, it is to be understood that the words which have been used are words of description and not of limitation. Therefore, changes may be made within the appended claims without departing from the true scope of the invention.