Abstract:
An annuloplasty ring is secured around an annulus of a heart valve of a subject by securing an anterior-configured portion of the annuloplasty ring, a posterior-configured portion of the annuloplasty ring, a first commissural portion of the annuloplasty ring, and a second commissural portion of the annuloplasty ring, to respective portion of the annulus. Subsequently, and while the heart is beating, the first commissural portion of the annuloplasty ring is moved inferiorly downwardly with respect to another portion of the annuloplasty ring by rotating a respective first adjusting mechanism of the annuloplasty ring structure, and the second commissural portion of the annuloplasty ring is moved inferiorly downwardly with respect to the other portion of the annuloplasty by rotating a respective second adjusting mechanism of the annuloplasty ring structure. Other embodiments are also described.

Description:
CROSS-REFERENCES TO RELATED APPLICATIONS 
     The present application is a Continuation of U.S. patent application 13/666,262 to Miller et al, filed Nov. 1, 2012, and entitled “Implant having multiple rotational assemblies”, which published as US 2013/0116780, which issued as U.S. Pat. No. 8,858,623, and which claims priority from U.S. Provisional Application 61/555,570, filed on Nov. 4, 2011, which is incorporated herein by reference. 
    
    
     FIELD OF THE INVENTION 
     The present invention relates in general to valve repair. More specifically, the present invention relates to repair of a mitral valve of a patient. 
     BACKGROUND 
     Mitral regurgitation (MR), mitral insufficiency or mitral incompetence is a disorder of the heart in which the mitral valve does not close properly when the heart pumps out blood. It is the abnormal leaking of blood from the left ventricle, through the mitral valve, and into the left atrium, when the left ventricle contracts, i.e. there is regurgitation of blood back into the left atrium. MR is the most common form of valvular heart disease. 
     In functional mitral valve regurgitation (FMR), otherwise known as Secondary mitral regurgitation is characterized as the abnormal function of anatomically normal valve, i.e., the papillary muscles, chordae, and valve leaflets are otherwise normal. Regurgitation, the result of incomplete closure of normal leaflets occurs in a quarter of patients after myocardial infarction and up to 50% of those with heart failure. 
     FMR can be either due to ischemia and any cause of dilated left ventricle including, annular enlargement secondary to left ventricular dilatation, or papillary muscle displacement due to left ventricular remodeling, which results in tethering and excess tenting of the mitral valve leaflets. 
     Severe FMR is indicative of poor hemodynamics and typically a bad prognosis for the patient. 
     SUMMARY OF THE INVENTION 
     In some applications of the present invention, apparatus is provided comprising an implant structure comprising an adjustable annuloplasty ring structure coupled to at least first and second adjusting mechanisms, each comprising a respective rotatable structure. At least a portion of the annuloplasty ring structure comprises a flexible, longitudinally-compressible segment (e.g., coiled structures, stent-like struts, and/or a braided mesh). The annuloplasty structure is shaped to define a flexible, tubular body portion that is shaped so as to define a lumen thereof that houses at least one flexible longitudinal contracting member. The at least one flexible longitudinal contracting member is coupled to the first adjusting mechanism at a first portion of the flexible longitudinal contracting member. A second portion of the flexible longitudinal contracting member is coupled to a portion of the tubular body portion. The first adjusting mechanism is configured to adjust a perimeter of the annuloplasty ring structure by adjusting a degree of tension of the flexible member housed within the lumen of the annuloplasty structure. For example, the first adjusting mechanism is configured to contract the ring structure in response to rotation in a first rotational direction of the rotational structure of the first adjusting mechanism. The first adjusting mechanism is typically aligned with the tubular body portion. 
     Typically, the annuloplasty structure is configured to be implanted along a native annulus of an atrioventricular valve of a patient. 
     For some applications of the present invention, the second adjusting mechanism is coupled to an outer surface of the tubular body portion. The second adjusting mechanism is coupled to a first portion of a flexible longitudinal tension member. The flexible longitudinal tension member is configured to pass from the annuloplasty ring structure on the annulus of the valve of and into a ventricle. A second portion of the flexible longitudinal tension member is coupled to a tissue-engaging element configured to engage cardiac tissue in a vicinity of the ventricle (e.g., a portion of papillary muscle tissue, a portion of tissue of an inner wall of the ventricle, or a portion of tissue of an outer wall of the ventricle). For some applications, the tissue-engaging element comprises a sharp portion for penetrating the cardiac tissue. For some applications, the tissue-engaging element comprises a planar element abutting against tissue of the patient. Typically, the second portion of the flexible longitudinal tension member is configured to be coupled to a papillary muscle of the patient. The second adjusting mechanism is configured to adjust a degree of tension of the flexible longitudinal tension member in a manner sufficient to (a) adjust a position of the papillary muscle, (b) adjust a degree of distension of the ventricular wall, and/or (c) have the flexible longitudinal tension member function as an artificial chordae tendineae. For applications in which the position of the papillary muscle is adjusted such positioning typically provides therapy to the patient. 
     For some applications of the present invention, an annuloplasty ring structure comprises two or more adjusting mechanisms configured to shape the annuloplasty ring structure into a desired shape. For example, the two or more adjusting mechanisms function, upon actuation thereof, to form the adjustable ring into a saddle shape. Alternatively or additionally, the two or more adjusting mechanisms function, upon actuation thereof, to draw together opposing portions of the ring. 
     Typically, the annuloplasty ring structures described herein, the adjusting mechanisms, and the flexible longitudinal members are advanced and implanted in an open-heart procedure. For some applications, devices described herein may be implanted using a minimally-invasive or percutaneous transcatheter procedure. 
     Methods for delivery and use of the invention are also described. 
     There is therefore provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the apparatus including: 
     an annuloplasty structure, shaped to define a perimeter, and configured to be disposed at the annulus of the native valve of the patient; a first adjusting mechanism, coupled to the annuloplasty structure, and configured to adjust the perimeter of the annuloplasty structure; 
     at least one longitudinal flexible member, having a first end portion, and a second end portion that is configured to be coupled to tissue of the ventricle of the heart of the patient; and 
     at least a second adjusting mechanism:
         coupled to the annuloplasty structure such that the second adjusting mechanism is slidable around at least part of the perimeter of the annuloplasty structure,   coupled to the first end portion of the at least one longitudinal flexible member, and   configured to adjust a distance between the second adjusting mechanism and the second end portion of the at least one longitudinal flexible member.       

     In an application: 
     the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, 
     the at least second adjusting mechanism is configured to be coupled to a location along the annulus, in a vicinity of a fibrous trigone adjacent to the mitral valve. 
     In an application, the apparatus further includes a plurality of sutures, each suture of the plurality of sutures being configured to be fastened to a respective location along a circumference of an annulus of a mitral valve of the patient, the plurality of sutures being configured to facilitate advancement of the annuloplasty structure toward the annulus. 
     In an application, the annuloplasty structure includes a coiled structure having a lumen. 
     In an application, the annuloplasty structure includes a partial annuloplasty ring. 
     In an application, the annuloplasty structure includes a full annuloplasty ring. 
     In an application, the annuloplasty structure is coated with polytetrafluoroethylene. 
     In an application, the annuloplasty structure has a first end and a second end, and a longitudinal axis therebetween, and the second adjusting mechanism is movable along the longitudinal axis of the annuloplasty structure. 
     In an application, the annuloplasty structure includes a body portion that defines a lumen therethrough, and the annuloplasty structure further includes a flexible longitudinal contracting member, having a first end portion, a second end portion, and a middle portion between the first and second end portions, at least one of the end portions being coupled to the first adjusting mechanism, and the middle portion being disposed within the lumen of the body portion. 
     In an application, the first adjusting mechanism is configured to reversibly adjust the perimeter of the annuloplasty structure, and the second adjusting mechanism is configured to reversibly adjust the distance. 
     In an application, the second adjusting mechanism is configured to adjust the distance between the second adjusting mechanism and the second end portion of the at least one longitudinal flexible member, independently of the adjusting of the perimeter of the annuloplasty structure by the first adjusting mechanism. 
     In an application: 
     the at least one longitudinal flexible member includes a first longitudinal flexible member and a second longitudinal flexible member, the first and second longitudinal members each having a first end portion and a second end portion, the second portion of the first longitudinal flexible member being configured to be coupled to a first portion of the tissue, and the second portion of the second longitudinal flexible member being configured to be coupled to a second portion of the tissue, 
     the second adjusting mechanism is coupled to the first end portion of the first longitudinal flexible member, and is configured to adjust a distance between the second adjusting mechanism and the second end portion of the first longitudinal flexible member, 
     the apparatus further includes a third adjusting mechanism, coupled to the annuloplasty structure and to the first end portion of the second longitudinal flexible member, and is configured to adjust a distance between the third adjusting mechanism and the second end portion of the second longitudinal flexible member. 
     In an application: 
     at least one selected from the group consisting of the first portion of the tissue and the second portion of the tissue, includes tissue of a papillary muscle of the patient, and 
     at least one selected from the group consisting of the second adjusting mechanism and the third adjusting mechanism, is configured to adjust a distance between the papillary muscle and the annuloplasty structure. 
     In an application, the third adjusting mechanism is configured to adjust the distance between the third adjusting mechanism and the second end portion of the second longitudinal flexible member, independently of the adjustment, by the second adjusting mechanism, of the distance between the second adjusting mechanism and the second end portion of the first longitudinal flexible member. 
     In an application, the first adjusting mechanism includes a first rotatable adjusting mechanism, and the second adjusting mechanism includes a second rotatable adjusting mechanism. 
     In an application, the first rotatable adjusting mechanism and the second rotatable adjusting mechanism are both rotatable bidirectionally. 
     In an application, the second rotatable adjusting mechanism includes a spool, and the spool is configured to pull the tissue toward the annuloplasty structure, via the longitudinal flexible member, responsively to rotation of the spool. 
     In an application, the apparatus further includes a rotation tool, configured to rotate the first rotatable adjusting mechanism. 
     In an application, the rotation tool includes an elongate rotation tool, configured to extend from outside the patient, to the first rotatable adjusting mechanism. 
     In an application, the rotation tool is configured to facilitate adjustment of the first adjusting mechanism while the heart of the patient is beating. 
     In an application, the rotation tool includes a first rotation tool, and the apparatus further includes a second rotation tool, configured to rotate the second rotatable adjusting mechanism. 
     In an application, at least the first adjusting mechanism includes a locking mechanism: 
     having an unlocked state in which the first adjusting mechanism is adjustable, having 
     having a locked state in which the locking mechanism inhibits adjustment of the first adjusting mechanism, and 
     configured to be intracorporeally moved from the locked state to the unlocked state. 
     In an application, the first rotation tool is configured to intracorporeally move the first rotatable adjusting mechanism into the unlocked configuration thereof. 
     In an application, the tissue includes papillary muscle tissue of the patient, and apparatus is configured to relocate the papillary muscle tissue, by pulling the papillary muscle tissue toward the annuloplasty structure. 
     In an application: 
     the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, and 
     the longitudinal flexible member is configured to relocate the papillary muscle tissue, in response to the pulling by the adjusting mechanism. 
     In an application, the longitudinal flexible member is configured to perform a therapy by relocating the patient&#39;s papillary muscle tissue. 
     In an application, the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, and the apparatus is configured to be transcatheterally advanced toward the annulus. 
     In an application, the apparatus is configured to be transluminally advanced toward the annulus. 
     In an application, the second end portion of the longitudinal flexible member includes a tissue-coupling element. 
     In an application, the tissue-coupling element includes an anchor having at least one sharp portion. 
     There is further provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the apparatus including: 
     an annuloplasty structure, shaped to define a perimeter, and configured to be disposed at the annulus of the native valve of the patient; 
     a first adjusting mechanism, coupled to the annuloplasty structure, and configured to reversibly adjust the perimeter of the annuloplasty structure; 
     at least one longitudinal flexible member, having a first end portion, and a second end portion that is configured to be coupled to tissue of the ventricle of the heart of the patient; and 
     at least a second adjusting mechanism, coupled to the annuloplasty structure and to the first end portion of the at least one longitudinal flexible member, and configured to reversibly adjust a distance between the second adjusting mechanism and the second end portion of the at least one longitudinal flexible member. 
     In an application, the annuloplasty structure has a first end and a second end, and a longitudinal axis therebetween, and the second adjusting mechanism is movable along the longitudinal axis of the annuloplasty structure. 
     In an application, the annuloplasty structure includes a body portion that defines a lumen therethrough, and the annuloplasty structure further includes a flexible longitudinal contracting member, having a first end portion, a second end portion, and a middle portion between the first and second end portions, at least one of the end portions being coupled to the first adjusting mechanism, and the middle portion being disposed within the lumen of the body portion. 
     In an application, the first adjusting mechanism is movably coupled to the annuloplasty structure. 
     In an application, the annuloplasty structure includes a partial annuloplasty ring. 
     In an application, the annuloplasty structure includes a full annuloplasty ring. 
     In an application, the annuloplasty structure is coated with polytetrafluoroethylene. 
     In an application: 
     the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, 
     the at least second adjusting mechanism is configured to be coupled to a location along the annulus, in a vicinity of a fibrous trigone adjacent to the mitral valve. 
     In an application, the apparatus further includes a plurality of sutures, each suture of the plurality of sutures being configured to be fastened to a respective location along a circumference of an annulus of a mitral valve of the patient, the plurality of sutures being configured to facilitate advancement of the annuloplasty structure toward the annulus. 
     In an application, the annuloplasty structure includes a coiled structure having a lumen. 
     In an application, the second adjusting mechanism is configured to reversibly adjust the distance between the second adjusting mechanism and the second end portion of the at least one longitudinal flexible member, independently of the reversible adjusting of the perimeter of the annuloplasty structure by the first adjusting mechanism. 
     In an application: 
     the at least one longitudinal flexible member includes a first longitudinal flexible member and a second longitudinal flexible member, the first and second longitudinal members each having a first end portion and a second end portion, the second portion of the first longitudinal flexible member being configured to be coupled to a first portion of the tissue, and the second portion of the second longitudinal flexible member being configured to be coupled to a second portion of the tissue, 
     the second adjusting mechanism is coupled to the first end portion of the first longitudinal flexible member, and is configured to reversibly adjust a distance between the second adjusting mechanism and the second end portion of the first longitudinal flexible member, 
     the apparatus further includes a third adjusting mechanism, coupled to the annuloplasty structure and to the first end portion of the second longitudinal flexible member, and is configured to reversibly adjust a distance between the third adjusting mechanism and the second end portion of the second longitudinal flexible member. 
     In an application: 
     at least one selected from the group consisting of the first portion of the tissue and the second portion of the tissue, includes tissue of a papillary muscle of the patient, and 
     at least one selected from the group consisting of the second adjusting mechanism and the third adjusting mechanism, is configured to reversibly adjust a distance between the papillary muscle and the annuloplasty structure. 
     In an application, the third adjusting mechanism is configured to reversibly adjust the distance between the third adjusting mechanism and the second end portion of the second longitudinal flexible member, independently of the reversible adjustment, by the second adjusting mechanism, of the distance between the second adjusting mechanism and the second end portion of the first longitudinal flexible member. 
     In an application, the first adjusting mechanism includes a first rotatable adjusting mechanism, and the second adjusting mechanism includes a second rotatable adjusting mechanism. 
     In an application, the first rotatable adjusting mechanism and the second rotatable adjusting mechanism are both rotatable bidirectionally. 
     In an application, the second rotatable adjusting mechanism includes a spool, and the spool is configured to pull the tissue toward the annuloplasty structure, via the longitudinal flexible member, responsively to rotation of the spool. 
     In an application, the apparatus further includes a rotation tool, configured to rotate the first rotatable adjusting mechanism. 
     In an application, the rotation tool includes an elongate rotation tool, configured to extend from outside the patient, to the first rotatable adjusting mechanism. 
     In an application, the rotation tool is configured to facilitate reversible adjustment of the first adjusting mechanism while the heart of the patient is beating. 
     In an application, the rotation tool includes a first rotation tool, and the apparatus further includes a second rotation tool, configured to rotate the second rotatable adjusting mechanism. 
     In an application, at least the first adjusting mechanism includes a locking mechanism: 
     having an unlocked state in which the first adjusting mechanism is adjustable, having 
     having a locked state in which the locking mechanism inhibits adjustment of the first adjusting mechanism, and 
     configured to be intracorporeally moved from the locked state to the unlocked state. 
     In an application, the first rotation tool is configured to intracorporeally move the first rotatable adjusting mechanism into the unlocked configuration thereof. 
     In an application, the tissue includes papillary muscle tissue of the patient, and apparatus is configured to relocate the papillary muscle tissue, by pulling the papillary muscle tissue toward the annuloplasty structure. 
     In an application: 
     the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, and 
     the longitudinal flexible member is configured to relocate the papillary muscle tissue, in response to the pulling by the adjusting mechanism. 
     In an application, the longitudinal flexible member is configured to perform a therapy by relocating the patient&#39;s papillary muscle tissue. 
     In an application, the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, and the apparatus is configured to be transcatheterally advanced toward the annulus. 
     In an application, the apparatus is configured to be transluminally advanced toward the annulus. 
     In an application, the second end portion of the longitudinal flexible member includes a tissue-coupling element. 
     In an application, the tissue-coupling element includes an anchor having at least one sharp portion. 
     There is further provided, in accordance with an application of the present invention, a method for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the method including: 
     adjusting a dimension of the annulus by rotating a first adjusting mechanism of apparatus that has been implanted in the heart of the patient; 
     adjusting a first distance between a first portion of tissue of the ventricle of the patient and the annulus by rotating a second adjusting mechanism of the apparatus; and 
     subsequently to the adjusting of the first distance, adjusting a second distance between a second portion of tissue of the ventricle of the patent and the annulus by rotating a third adjusting mechanism of the apparatus. 
     In an application, the annuloplasty structure has a first end and a second end, and a longitudinal axis therebetween, and sliding the second adjusting mechanism includes sliding the second adjusting mechanism along the longitudinal axis of the annuloplasty structure. 
     In an application: 
     the annuloplasty structure includes a body portion that defines a lumen therethrough, and a flexible longitudinal contracting member, having a first end portion, a second end portion, and a middle portion between the first and second end portions, at least one of the end portions being coupled to the first adjusting mechanism, and the middle portion being disposed within the lumen of the body portion, and 
     adjusting the perimeter of the annuloplasty structure includes adjusting a length of the flexible longitudinal contracting member between the first end portion of the flexible longitudinal contracting member and the second end portion of the flexible longitudinal contracting member. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling the annuloplasty structure to an annulus of a mitral valve of the patient such that the at least second adjusting mechanism is disposed in a vicinity of a fibrous trigone adjacent to the mitral valve. 
     In an application, the method further includes receiving information indicative of blood flow of the patent, subsequently to the adjusting of the first distance, and prior to the adjusting of the second distance. 
     In an application, the method further includes receiving information indicative of blood flow in the heart of the patient, subsequently to the adjusting of the dimension of the annulus, and prior to the adjusting of the first distance. 
     In an application, at least one of: (1) the adjusting of the dimension of the annulus, (2) the adjusting of the first distance, and (3) the adjusting of the second distance, include adjusting while the heart is beating. 
     In an application, adjusting the first adjusting mechanism includes adjusting the first adjusting mechanism while the heart of the patient is beating. 
     In an application, adjusting the at least second adjusting mechanism includes adjusting the at least second adjusting mechanism while the heart of the patient is beating. 
     In an application, coupling the second end portion to the first portion of the tissue of the ventricle includes coupling the second end portion to tissue of a papillary muscle of the patient. 
     In an application, the method further includes adjusting a dimension of the annulus by adjusting the first adjusting mechanism. 
     In an application, the method further includes adjusting a distance between the annulus and the tissue, by adjusting the second adjusting mechanism. 
     In an application, the method further includes adjusting a dimension of the annulus by adjusting the first adjusting mechanism, and adjusting a distance between the annulus and the tissue independently of the adjustment of the dimension of the annulus, by adjusting the second adjusting mechanism independently of the adjustment of the first adjusting mechanism. 
     In an application, coupling the second end portion to the tissue includes rotating an anchor coupled to the second end portion. 
     In an application, at least one selected from the group consisting of adjusting the first adjusting mechanism and adjusting the second adjusting mechanism, includes rotating a rotatable adjusting mechanism. 
     In an application, at least one action selected from the group consisting of adjusting the first adjusting mechanism and adjusting the second adjusting mechanism, includes reversibly adjusting. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling a partial annuloplasty ring to the annulus. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling a full annuloplasty ring to the annulus. 
     In an application, at least one action selected from the group consisting of adjusting the first adjusting mechanism and adjusting the second adjusting mechanism, includes adjusting using a rotation tool. 
     In an application, using the rotation tool includes using an elongate rotation tool that extends from outside the patient, to the apparatus. 
     In an application, the method further includes, prior to adjusting, performing at least one action selected from the group consisting of unlocking the first adjustment mechanism using the rotation tool, and unlocking the second adjustment mechanism using the rotation tool. 
     In an application, the method further includes transcatheterally advancing the annuloplasty structure to the native valve. 
     In an application, transcatheterally advancing the annuloplasty structure to the native valve includes transluminally advancing the annuloplasty structure to the native valve. 
     In an application, the annuloplasty structure is coupled to a third adjusting mechanism that is coupled to a first end portion of a second longitudinal flexible member, and the method further includes coupling a second end portion of the second longitudinal member to a second portion of the tissue of the ventricle. 
     In an application, the method further includes adjusting a distance between the annuloplasty structure and the second portion of the tissue by adjusting the third adjusting mechanism. 
     There is further provided, in accordance with an application of the present invention, a method for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the method including: 
     while the heart is beating, using apparatus that has been implanted in the heart:
         reducing a dimension of the annulus,   reducing a distance between the annulus and at least a first portion of tissue of the ventricle of the patient, and   subsequently, increasing at least one selected from the list consisting of: the dimension, and the distance; and       

     receiving information indicative of blood flow of the patient, the reducing and the increasing of the dimension and the distance being at least in part responsive to the receiving of the information. 
     In an application: 
     reducing the dimension includes rotating a first adjusting mechanism of the apparatus in a first rotational direction, and increasing the dimension includes rotating the first adjusting mechanism in a second, opposing rotational direction, and 
     reducing the distance includes rotating at least a second adjusting mechanism of the apparatus in a first rotational direction, and increasing the distance includes rotating the second adjusting mechanism in a second, opposing rotational direction. 
     There is further provided, in accordance with an application of the present invention, a method for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the method including: 
     coupling, to the annulus, an annuloplasty structure, shaped to define a perimeter, and coupled to:
         a first adjusting mechanism, configured to adjust the perimeter of the annuloplasty structure, and   at least a second adjusting mechanism, configured to be slidable around at least part of the perimeter of the annuloplasty structure, and coupled to a first end portion of at least one longitudinal flexible member;       

     coupling, to at least a first portion of tissue of the ventricle of the heart, a second end portion of the at least one longitudinal flexible member; and 
     sliding the second adjusting mechanism around at least part of the at least part of the perimeter of the annuloplasty structure. 
     In an application, the annuloplasty structure has a first end and a second end, and a longitudinal axis therebetween, and sliding the second adjusting mechanism includes sliding the second adjusting mechanism along the longitudinal axis of the annuloplasty structure. 
     In an application: 
     the annuloplasty structure includes a body portion that defines a lumen therethrough, and a flexible longitudinal contracting member, having a first end portion, a second end portion, and a middle portion between the first and second end portions, at least one of the end portions being coupled to the first adjusting mechanism, and the middle portion being disposed within the lumen of the body portion, and 
     adjusting the perimeter of the annuloplasty structure includes adjusting a length of the flexible longitudinal contracting member between the first end portion of the flexible longitudinal contracting member and the second end portion of the flexible longitudinal contracting member. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling the annuloplasty structure to an annulus of a mitral valve of the patient such that the at least second adjusting mechanism is disposed in a vicinity of a fibrous trigone adjacent to the mitral valve. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling a partial annuloplasty ring to the annulus. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling a full annuloplasty ring to the annulus. 
     In an application, adjusting the first adjusting mechanism includes adjusting the first adjusting mechanism while the heart of the patient is beating. 
     In an application, adjusting the at least second adjusting mechanism includes adjusting the at least second adjusting mechanism while the heart of the patient is beating. 
     In an application, coupling the second end portion to the first portion of the tissue of the ventricle includes coupling the second end portion to tissue of a papillary muscle of the patient. 
     In an application, the method further includes adjusting a dimension of the annulus by adjusting the first adjusting mechanism. 
     In an application, the method further includes adjusting a distance between the annulus and the tissue, by adjusting the second adjusting mechanism. 
     In an application, the method further includes adjusting a dimension of the annulus by adjusting the first adjusting mechanism, and adjusting a distance between the annulus and the tissue independently of the adjustment of the dimension of the annulus, by adjusting the second adjusting mechanism independently of the adjustment of the first adjusting mechanism. 
     In an application, coupling the second end portion to the tissue includes rotating an anchor coupled to the second end portion. 
     In an application, at least one selected from the group consisting of adjusting the first adjusting mechanism and adjusting the second adjusting mechanism, includes rotating a rotatable adjusting mechanism. 
     In an application, at least one action selected from the group consisting of adjusting the first adjusting mechanism and adjusting the second adjusting mechanism, includes reversibly adjusting. 
     In an application, at least one action selected from the group consisting of adjusting the first adjusting mechanism and adjusting the second adjusting mechanism, includes adjusting using a rotation tool. 
     In an application, using the rotation tool includes using an elongate rotation tool that extends from outside the patient, to the apparatus. 
     In an application, the method further includes, prior to adjusting, performing at least one action selected from the group consisting of unlocking the first adjustment mechanism using the rotation tool, and unlocking the second adjustment mechanism using the rotation tool. 
     In an application, the method further includes transcatheterally advancing the annuloplasty structure to the native valve. 
     In an application, transcatheterally advancing the annuloplasty structure to the native valve includes transluminally advancing the annuloplasty structure to the native valve. 
     In an application, the annuloplasty structure is coupled to a third adjusting mechanism that is coupled to a first end portion of a second longitudinal flexible member, and the method further includes coupling a second end portion of the second longitudinal member to a second portion of the tissue of the ventricle. 
     In an application, the method further includes adjusting a distance between the annuloplasty structure and the second portion of the tissue by adjusting the third adjusting mechanism. 
     There is further provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the apparatus including: 
     an annuloplasty structure, shaped to define a perimeter, and configured to be disposed at the annulus of the native valve of the patient; 
     a first adjusting mechanism, coupled to the annuloplasty structure, and configured to adjust the perimeter of the annuloplasty structure; 
     at least one longitudinal flexible member, having a first end portion, and a second end portion that is configured to be coupled to tissue of the ventricle of the heart of the patient; and 
     at least a second adjusting mechanism, coupled to the annuloplasty structure and to the first end portion of the at least one longitudinal flexible member, and configured to adjust a distance between the second adjusting mechanism and the second end portion of the at least one longitudinal flexible member, 
     the first and second adjusting mechanisms each including a respective locking mechanism, each locking mechanism:
         having an unlocked state in which the respective adjusting mechanism is adjustable, having   having a locked state in which the locking mechanism inhibits adjustment of the respective adjusting mechanism, and   configured to be intracorporeally moved from the locked state to the unlocked state.       

     In an application, the annuloplasty structure includes a partial annuloplasty ring. 
     In an application, the annuloplasty structure includes a full annuloplasty ring. 
     In an application, the annuloplasty structure is coated with polytetrafluoroethylene. 
     In an application: 
     the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, 
     the at least second adjusting mechanism is configured to be coupled to a location along the annulus, in a vicinity of a fibrous trigone adjacent to the mitral valve. 
     In an application, the apparatus further includes a plurality of sutures, each suture of the plurality of sutures being configured to be fastened to a respective location along a circumference of an annulus of a mitral valve of the patient, the plurality of sutures being configured to facilitate advancement of the annuloplasty structure toward the annulus. 
     In an application, the annuloplasty structure includes a coiled structure having a lumen. 
     In an application, the annuloplasty structure has a first end and a second end, and a longitudinal axis therebetween, and the second adjusting mechanism is movable along the longitudinal axis of the annuloplasty structure. 
     In an application, the annuloplasty structure includes a body portion that defines a lumen therethrough, and the annuloplasty structure further includes a flexible longitudinal contracting member, having a first end portion, a second end portion, and a middle portion between the first and second end portions, at least one of the end portions being coupled to the first adjusting mechanism, and the middle portion being disposed within the lumen of the body portion. 
     In an application, the first adjusting mechanism is movably coupled to the annuloplasty structure. 
     In an application, the first adjusting mechanism is configured to reversibly adjust the perimeter of the annuloplasty structure, and the second adjusting mechanism is configured to reversibly adjust the distance. 
     In an application, the second adjusting mechanism is configured to adjust the distance between the second adjusting mechanism and the second end portion of the at least one longitudinal flexible member, independently of the adjusting of the perimeter of the annuloplasty structure by the first adjusting mechanism. 
     In an application: 
     the at least one longitudinal flexible member includes a first longitudinal flexible member and a second longitudinal flexible member, the first and second longitudinal members each having a first end portion and a second end portion, the second portion of the first longitudinal flexible member being configured to be coupled to a first portion of the tissue, and the second portion of the second longitudinal flexible member being configured to be coupled to a second portion of the tissue, 
     the second adjusting mechanism is coupled to the first end portion of the first longitudinal flexible member, and is configured to adjust a distance between the second adjusting mechanism and the second end portion of the first longitudinal flexible member, 
     the apparatus further includes a third adjusting mechanism, coupled to the annuloplasty structure and to the first end portion of the second longitudinal flexible member, and is configured to adjust a distance between the third adjusting mechanism and the second end portion of the second longitudinal flexible member. 
     In an application: 
     at least one selected from the group consisting of the first portion of the tissue and the second portion of the tissue, includes tissue of a papillary muscle of the patient, and 
     at least one selected from the group consisting of the second adjusting mechanism and the third adjusting mechanism, is configured to adjust a distance between the papillary muscle and the annuloplasty structure. 
     In an application, the third adjusting mechanism is configured to adjust the distance between the third adjusting mechanism and the second end portion of the second longitudinal flexible member, independently of the adjustment, by the second adjusting mechanism, of the distance between the second adjusting mechanism and the second end portion of the first longitudinal flexible member. 
     In an application, the first adjusting mechanism includes a first rotatable adjusting mechanism, and the second adjusting mechanism includes a second rotatable adjusting mechanism. 
     In an application, the first rotatable adjusting mechanism and the second rotatable adjusting mechanism are both rotatable bidirectionally. 
     In an application, the second rotatable adjusting mechanism includes a spool, and the spool is configured to pull the tissue toward the annuloplasty structure, via the longitudinal flexible member, responsively to rotation of the spool. 
     In an application, the apparatus further includes a rotation tool, configured to rotate the first rotatable adjusting mechanism. 
     In an application, the rotation tool includes an elongate rotation tool, configured to extend from outside the patient, to the first rotatable adjusting mechanism. 
     In an application, the rotation tool is configured to facilitate adjustment of the first adjusting mechanism while the heart of the patient is beating. 
     In an application, the rotation tool includes a first rotation tool, and the apparatus further includes a second rotation tool, configured to rotate the second rotatable adjusting mechanism. 
     In an application, the first rotation tool is configured to intracorporeally move the first rotatable adjusting mechanism into the unlocked configuration thereof, and the second rotation tool is configured to intracorporeally move the second rotatable adjusting mechanism into the unlocked configuration thereof. 
     In an application, the tissue includes papillary muscle tissue of the patient, and apparatus is configured to relocate the papillary muscle tissue, by pulling the papillary muscle tissue toward the annuloplasty structure. 
     In an application: 
     the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, and 
     the longitudinal flexible member is configured to relocate the papillary muscle tissue, in response to the pulling by the adjusting mechanism. 
     In an application, the longitudinal flexible member is configured to perform a therapy by relocating the patient&#39;s papillary muscle tissue. 
     In an application, the annuloplasty structure is configured to be implanted at an annulus of a mitral valve of the patient, and the apparatus is configured to be transcatheterally advanced toward the annulus. 
     In an application, the apparatus is configured to be transluminally advanced toward the annulus. 
     In an application, the second end portion of the longitudinal flexible member includes a tissue-coupling element. 
     In an application, the tissue-coupling element includes an anchor having at least one sharp portion. 
     There is further provided, in accordance with an application of the present invention, apparatus for use with a native valve of a heart of a patient, the native valve having a valve annulus, and the heart having a ventricle, the apparatus including: 
     an annuloplasty structure, configured to be disposed at the annulus of the native valve of the patient, and shaped to define a perimeter; 
     a perimeter-adjusting mechanism, coupled to the annuloplasty structure, and configured to adjust the perimeter of the annuloplasty structure; and 
     at least two longitudinal flexible members, each longitudinal flexible member having a first end portion and a second end portion, the second end portion of each longitudinal flexible member being configured to be coupled to a respective portions of tissue of a ventricle of the heart of the patient; and 
     at least two length-adjusting mechanisms, each being coupled to the annuloplasty structure and to the first end portion of a respective longitudinal flexible member, and configured to adjust a distance between the length-adjusting mechanism and the second end portion of the respective longitudinal flexible member, independently of the adjustment of the perimeter of the annuloplasty structure by the first adjusting mechanism. 
     In an application: 
     the at least two length-adjusting mechanisms include a first length-adjusting mechanism and a second length-adjusting mechanism, 
     the at least two longitudinal flexible members include a first longitudinal flexible member and a second longitudinal flexible member, 
     the first length-adjusting mechanism is coupled to the first end portion of the first longitudinal flexible member, and is configured to adjust the distance between the first length-adjusting mechanism and the second end portion of the first longitudinal flexible member, and 
     the second length-adjusting mechanism is coupled to the first end portion of the second longitudinal flexible member, and is configured to adjust a distance between the second length-adjusting mechanism and the second end portion of the second longitudinal flexible member, independently of the adjustment, by the first length-adjusting member, of a distance between the first length-adjusting mechanism and the second end portion of the first longitudinal flexible member. 
     In an application, at least one of the length-adjusting mechanisms is movable around at least part of the perimeter of the annuloplasty structure. 
     In an application, the annuloplasty structure includes a body portion that defines a lumen therethrough, and the annuloplasty structure further includes a flexible longitudinal contracting member, having a first end portion, a second end portion, and a middle portion between the first and second end portions, at least one of the end portions being coupled to the first adjusting mechanism, and the middle portion being disposed within the lumen of the body portion. 
     There is further provided, in accordance with an application of the present invention, a method, including: 
     providing an annuloplasty structure, the annuloplasty structure including:
         at least one adjusting mechanism couplable to the annuloplasty structure; and   at least one longitudinal flexible member;       

     coupling the annuloplasty structure to an annulus of a mitral valve of a patient; 
     coupling the longitudinal flexible member to a portion of tissue; and 
     relocating the portion of tissue toward the annulus by pulling the tissue with the adjusting mechanism, via the longitudinal flexible member. 
     In an application, coupling the longitudinal flexible member to the portion of tissue includes coupling the longitudinal flexible member to papillary muscle tissue. 
     In an application, the annuloplasty structure includes two adjusting mechanisms, each adjusting mechanism configured to relocate respective portions of tissue, and coupling the annuloplasty structure to the annulus includes: 
     coupling a first one of the adjusting mechanisms to a first location along the annulus in a vicinity of a first fibrous trigone of the mitral valve; and 
     coupling a second one of the adjusting mechanisms to a second location along the annulus in a vicinity of a second fibrous trigone of the mitral valve. 
     In an application, the method further includes transcatheterally advancing the annuloplasty structure to the annulus. 
     In an application, coupling the annuloplasty structure to the annulus includes coupling the annuloplasty structure to the annulus during open heart surgery. 
     In an application, the method further includes: 
     rotating, in a first direction, a rotatable adjusting mechanism that is coupled to the annuloplasty structure, by pulling a contracting member that is coupled to the rotatable structure; and 
     responsively, drawing first and second portions of the annuloplasty structure toward each other. 
     The present invention will be more fully understood from the following detailed description of embodiments thereof, taken together with the drawings, in which: 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS  
         FIG. 1  is a schematic illustration of an annuloplasty structure coupled to at least first and second adjusting mechanisms, in accordance with some applications of the present invention; 
         FIGS. 2A-B  are schematic illustrations of an adjustable annuloplasty structure coupled to adjusting mechanisms that are slidable with respect to the adjustable annuloplasty structure, in accordance with some applications of the present invention; 
         FIG. 3  is a schematic illustration of an adjusting mechanism, in accordance with some applications of the present invention; 
         FIG. 4  is a schematic illustration of another adjusting mechanism, in accordance with some applications of the present invention; 
         FIG. 5  is a schematic illustration of another annuloplasty structure coupled to at least first and second adjusting mechanisms, in accordance with some applications of the present invention; 
         FIGS. 6A-B ,  7 A-B, and  8 A-B are schematic illustrations of placing the implant structure of  FIG. 1  in a heart of a patient, in accordance with some applications of the present invention; 
         FIGS. 9A-B  are schematic illustrations of an implant structure comprising a septo-lateral adjusting mechanism, in accordance with some applications of the present invention; 
         FIGS. 10A-B  are schematic illustrations an implant structure comprising a plurality of adjusting mechanisms which shape the structure into a saddle-shaped ring, in accordance with some applications of the present invention; and 
         FIG. 11  is a schematic illustration of a system for providing information indicative of heart function of the patient, and for facilitating adjusting the adjusting mechanisms of an annuloplasty structure in response to the information, in accordance with some applications of the invention. 
     
    
    
     DETAILED DESCRIPTION OF EMBODIMENTS 
     Reference is now made to  FIG. 1 , which is a schematic illustration of a system  120  comprising an implant structure  122  which comprises an adjustable annuloplasty ring structure that is coupled to two or more flexible-longitudinal-tension-member-adjusting-mechanisms  240  (e.g., flexible-longitudinal-tension-member-adjusting-mechanisms  240   a  and  240   b ), in accordance with some applications of the present invention. For some applications, as shown, the annuloplasty ring structure comprises a full annuloplasty ring. Adjusting mechanisms  240   a  and  240   b  typically comprise rotatable structures (e.g., spools, as described hereinbelow) which are coupled to respective first portions of flexible longitudinal tension members  60   a  and  60   b . When system,  120  is implanted in the heart of the patient, implant structure  122  is configured to be implanted at an annulus of a native valve of a patient (e.g., an atrioventricular valve such as the mitral valve or the tricuspid valve). Tension members  60   a  and  60   b  are configured to extend toward the ventricle of the heart of the patient by passing between the leaflets of the valve or by passing through tissue of the annulus or commissures of the valve. Respective second end portions of tension members  60   a  and  60   b  are configured to be coupled to respective portions of cardiac tissue which are in the vicinity of the ventricle of the heart (e.g., portions of papillary muscle, portions of tissue at the base of the papillary muscle, portions of tissue in a vicinity of the apex, portions of tissue of an inner wall of the ventricle, and/or portions of tissue of an outer wall of the ventricle). Rotation of the rotatable structures of mechanisms  240   a  and  240   b  in a first rotational direction pulls tight the respective tension members  60   a  and  60   b  in order to draw the portions of cardiac tissue toward implant structure  122  (i.e., by reducing a distance between each mechanism  240  and the second end portion of the respective tension member  60 ). Rotation of the rotatable structures in a second, opposing, rotational direction loosens the respective tension members. For some applications of the present invention, system  120  functions to repair and/or effect remodeling of the portions of cardiac tissue, remodeling of the papillary muscles, and/or remodeling of a heart wall of the ventricle to treat distension. For some applications, tension members function as artificial chordae tendineae. 
     Flexible tension members  60   a  and  60   b  comprise a wire, a ribbon, a rope, or a band, comprising a flexible metal. Typically, flexible tension members  60   a  and  60   b  comprise a flexible and/or superelastic material, e.g., nitinol, polyester, stainless steel, or cobalt chrome. In some applications of the present invention, flexible tension members  60   a  and  60   b  each comprise a braided polyester suture (e.g., Ti-Cron™). In some applications of the present invention, flexible contracting members  60   a  and  60   b  are coated with polytetrafluoroethylene (PTFE). In some applications of the present invention, flexible tension member  60   a  and  60   b  each comprise a plurality of wires that are intertwined to form a rope structure. 
     Typically, but not necessarily, each of adjusting mechanisms  240   a  and  240   b  is coupled to a respective longitudinal guide member  86   a  and  86   b . Distal end portions of each guide member  86   a  and  86   b  are coupled to respective portions of mechanisms  240   a  and  240   b  and facilitate guiding along members  86   a  and  86   b  of a rotational tool toward the rotatable structures of mechanisms  240   a  and  240   b.    
     The annuloplasty structure of implant structure  122  is shaped to define a flexible, tubular body portion  24  that is shaped so as to define a lumen along a longitudinal axis of structure  122  that houses at least part of at least one flexible longitudinal contracting member  30  (e.g., a middle portion of member  30 ). At least a portion, e.g., the entirety, of body portion  24  comprises a compressible material (e.g., a coiled element  12 ), as shown by way of illustration and not limitation. For example, body portion  24  may comprise stent-like struts, or a braided mesh (independently of coiled portion  12 ). Typically, coiled element  12  is surrounded by a braided mesh  10 . 
     Typically, body portion  24  comprises a flexible biocompatible material, e.g., nitinol, stainless steel, platinum iridium, titanium, expanded polytetrafluoroethylene (ePTFE), or cobalt chrome. In some applications of the present invention, body portion  24  is coated with PTFE (Polytetrafluoroethylene). In other applications of the present invention, body portion  24  comprises accordion-like compressible structures which facilitate proper cinching of the annulus when structure  122  is contracted. Body portion  24 , when compressed, e.g., typically along a longitudinal axis of structure  122 , enables portions of annuloplasty structure  122  to contract and independently conform to the configuration of the annulus of the mitral valve of a given subject. Thus, the compressible element of body portion  24  facilitates contraction of the annulus in response to contraction of structure  122 . 
     The annuloplasty structure of implant structure  122  comprises a flexible-longitudinal-contracting-member-adjusting-mechanism  40  disposed within a housing  44  and coupled to contracting member  30  (as described hereinbelow with reference to  FIG. 3 ). Adjusting mechanism  40  is configured to adjust a degree of tension of contracting member  30  in order to adjust a perimeter of implant structure  122 . Adjusting mechanism  40  thereby acts as a perimeter-adjusting mechanism. Housing  44  of adjusting mechanism  40  is shaped so as to define first and second coupling members  31  and  35  (shown in  FIG. 3 ). Body portion  24  has first and second ends  21  and  23  which are coupled to first and second coupling members  31  and  35 , and thereby to adjusting mechanism  40 , in order to create a full annuloplasty ring. Thus, adjusting mechanism  40  is aligned with body portion  24  along the longitudinal axis thereof. 
     Adjusting mechanisms  240   a  and  240   b  are coupled to an outer surface of body portion  24 , as shown. Typically, mechanisms  240   a  and  240   b  are coupled via sutures or any other mechanical coupling, as described hereinbelow with reference to  FIGS. 2A-B . Typically, for applications in which structure  122  is implanted on the annulus of a mitral valve, adjusting mechanism  240   a  is coupled to a portion of the annuloplasty structure in a vicinity thereof that is configured to be placed on or near a left fibrous trigone of the annulus of the mitral valve of the patient, and adjusting mechanism  240   b  is coupled to a portion of the annuloplasty structure in a vicinity thereof that is configured to be placed on or near a right fibrous trigone of the annulus of the mitral valve of the patient. 
     Flexible contracting member  30  comprises a wire, a ribbon, a rope, or a band, comprising a flexible metal. Flexible contracting member  30  is coupled at a first end portion thereof to flexible-longitudinal-contracting-member-adjusting-mechanism  40  which is coupled to a first end  21  of body portion  24 . A second end portion of flexible contracting member  30  is coupled to a second end  23  of body portion  24 . Typically, during a resting state of structure  122 , flexible contracting member  30  (e.g., the middle portion thereof) is disposed in parallel with the longitudinal axis of structure  122 . Flexible member  30 , for some applications does not comprise a continuous band that runs through the entire lumen of the annuloplasty devices described herein, and flexible member  30  has at least one free end portion. 
     Typically, flexible contracting member  30  comprises a wire, a cable, or a rope, and taken together with the compressible element of body portion  24  and the braided mesh surrounding body portion  24 , imparts flexibility to the entire annuloplasty structure. 
     Typically, flexible contracting member  30  comprises a flexible and/or superelastic material, e.g., nitinol, polyester, stainless steel, or cobalt chrome, and is configured to reside chronically within structure  122 . In some applications of the present invention, flexible contracting member  30  comprises a braided polyester suture (e.g., Ti-Cron™). In some applications of the present invention, flexible contracting member  30  is coated with polytetrafluoroethylene (PTFE). In some applications of the present invention, flexible contracting member  30  comprises a plurality of wires that are intertwined to form a rope structure. 
     Adjusting mechanism  40  comprises a housing  44  which houses a rotatable structure, or a spool  46 . The rotatable structure is rotatable in first and second opposing rotational directions with respect to housing  44  so as to expand and contract the annuloplasty structure, respectively. Spool  46  has a cylindrical body that is disposed perpendicularly with respect to the longitudinal axis of structure  122 . As shown in  FIG. 3 , spool  46  is shaped to provide at least one hole  42  for coupling of the first end portion of flexible contracting member  30  thereto and, thereby, to adjusting mechanism  40 . For some applications of the present invention, spool  46  is shaped to define one or more holes  42  configured for looping a portion of contracting member  30  therethrough, as described hereinbelow. In such an application: (a) a middle portion, which defines the first end portion, of contracting member  30  is coupled to spool  46  by being looped through one or more holes  42 , (b) first and second portions that extend from the first end portion looped through spool  46  extend toward second end  23  of structure body portion  24 , and (c) first and second free ends of contracting member  30  are coupled to second end  23  of body portion  24  and define a second end portion of contracting member  30 . 
     It is to be noted that for some applications of the present invention, flexible contracting member  30  may be coupled at both its first and second end portions, e.g., first and second ends, to spool  46  of adjusting mechanism  40 . In some applications of the present invention, a first end of flexible contracting member  30  is coupled to spool  46  while a second end of flexible contracting member  30  is coupled to the housing which houses spool  46 . For some applications, contracting member  30  comprises a continuous band that is looped through a portion of spool  46 . 
     As shown, the annuloplasty structure of implant structure  122  defines a substantially ring-shaped configuration, e.g., a “D”-shaped configuration, as shown, which conforms to the shape of the annulus of a mitral valve of the subject. For applications in which structure  122  is implanted at a tricuspid valve of the patient, the annuloplasty structure assumes a shape suitable to fit the tricuspid valve (e.g., a substantially oval shape). 
     Prior to contracting of structure  122 , the compressible element of body portion  24  is relaxed and structure  122  defines a first perimeter thereof. Structure  122  provides portions  49  which are flexible and less longitudinally compressible, e.g., not longitudinally compressible, with respect to the compressible element of body portion  24 . Portions  49  are configured to be disposed along the fibrous portion of the annulus that is between the fibrous trigones of the mitral valve of the heart when structure  122  is anchored, sutured, fastened or otherwise coupled to the annulus of the mitral valve. Portions  49  impart rigidity to structure  122  in the portion thereof that is disposed between the fibrous trigones such that structure  122  better mimics the conformation and functionality of the mitral valve. That is, during rotation of spool  46 , and the concurrent contraction or expansion of structure  122 , energy is not expended on contracting or expanding portions  49 . As shown, coiled portion  12  of body portion  24  has a very small pitch compared to coiled portion  12  in the remaining portions of the annuloplasty structure. For some applications, portions  49  comprise a material that is arranged in a configuration in which portions  49  are more rigid. 
     Typically, both portions  49  have a combined length of 10-50 mm. 
     Thus, the annuloplasty structure of implant structure  122  defines a compressible portion and a non-compressible portion. Typically, a radius of curvature at a center of the compressible portion of body portion  24  is smaller than a radius of curvature at a center of less-compressible portions  49 , when no external force is applied to the annuloplasty structure. 
     It is to be noted that the compressible element of body portion  24  and less-compressible portions  49  comprise flexible coiled elements by way of illustration and not limitation. For example, the compressible element of body portion  24  and less-compressible portions  49  may comprise stent-like struts, or a braided mesh. In either configuration, portions  49  are chronically longitudinally compressed in a resting state of structure  122 . 
     It is to be noted that, structure  122  may be provided independently of less-compressible portions  49 . In such applications of the present invention, the annuloplasty structure comprises a fully compressible ring, e.g., a continuous ring. 
     It is to be noted that housing  44  (and mechanism  40 ) may be disposed at any suitable location along structure  122 , and not only in between portions  49  (e.g., in a portion of the annuloplasty structure designated for implantation at an anterior portion of the mitral valve). For example, housing  44  may be coupled to the section of body portion  24  that is compressible. In some applications of the present invention, housing  44  may be disposed in the middle of the section of body portion  24  that is compressible. In some applications of the present invention, housing  44  may be coupled to structure  122  at an interface between a first end of portion  49  and the section of body portion  24  that is compressible. In such applications of the present invention, portions  49  may be combined to form one substantially less-compressible portion having first and second ends that are in series with the compressible portion of body portion  24 . For some applications, a plurality of housings and adjusting mechanisms  40  described herein may be coupled to the annuloplasty structure. Each adjusting mechanism  40  may be coupled to a respective contracting member  30  which controls a respective portion of the annuloplasty structure. 
     Typically, the annuloplasty structure of implant structure  122  is delivered to the annulus of the valve using an elongate tool  50  that is reversibly coupled to adjusting mechanism  40  of structure  122 . Tool  50  comprises an elongate body portion  52  which houses a flexible rod that is coupled at a distal end thereof to a screwdriver head. The screwdriver head is configured to be disposed within the channel of spool  46 . Typically, the rod functions as a screwdriver which applies force to the screwdriver head in order to rotate spool  46 , and thereby facilitate contraction of structure  122 . 
     For some applications, the screwdriver head comprises force applicator  88 , as described hereinabove with reference to  FIG. 3 . For other applications, force applicator  88  is coupled to an elongate member that is removable from spool  46  by tool  50 . 
     (In this context, in the specification and in the claims, “proximal” means closer to the orifice through which the implant structure is originally placed into the body of the patient, along the path of delivery of the implant structure, and “distal” means further from this orifice along the path of delivery of the implant structure.) 
     In some applications of the present invention, the annuloplasty structure is wrapped around an annuloplasty sizer  121 . Once wrapped around sizer  121 , the flexible member is contracted by tool  50  such that the annuloplasty structure hugs and is stabilized around sizer  121 . Sizer is coupled to a shaft  123 . (It is to be noted that, for clarity of illustration, tool  50 , body portion  52 , and shaft  123  are not shown in the enlarged portion of  FIG. 1 .) Tool  50 , shaft  123 , and sizer  121  help position implant structure  122  along the annulus and stabilize the structure as it is being contracted. Once the structure  122  is positioned at the annulus, structure is sutured, anchored, or otherwise coupled to the annulus. Following the coupling of structure  122  to the annulus, sizer  121  is decoupled from structure  122 . 
     Subsequently, tool  50  facilitates the contraction and/or expansion of the annuloplasty structure of implant structure  122  in order to adjust a dimension of the valve annulus. The distal portion of tool  50  comprises a tool housing which surrounds a portion of housing  44  of mechanism  40 , and stabilizes housing  44  during the advancement and contraction and/or expansion of structure  122 . 
     Reference is now made to  FIGS. 2A-B , which are schematic illustrations of a system  130 , which is similar to system  120 , as described hereinabove with reference to  FIG. 1 , with the exception that adjusting mechanisms  240   a  and  240   b  are coupled to body portion  24  of the annuloplasty structure of implant structure  122  by a slide-facilitating ring  241 , in accordance with some applications of the present invention. Housing  248  of each adjusting mechanism  240  is coupled to ring  241 , as shown in  FIG. 2A . Ring  241  surrounds a portion of the outer surface of body portion  24  and enables mechanism  240  to slide along the outer surface of body portion  24  to any suitable position along the annuloplasty structure of implant structure  122  (as indicated by the arrow and the adjusting mechanism  240  shown in phantom in  FIG. 2B ). 
     It is to be noted that adjusting mechanisms  240  are shown in  FIGS. 2A-B  without guide members  86  (described hereinabove with reference to  FIG. 1 ). 
     Reference is now made to  FIG. 3 , which is a schematic illustration showing a relationship among individual components of flexible-longitudinal-contracting-member-adjusting-mechanism  40 , in accordance with some applications of the present invention. Adjusting mechanism  40  is shown as comprising spool housing  44  which defines an upper surface  45  and a recess  142  at a lower surface thereof. A spool  46  is configured to be disposed within housing  44  and defines an upper surface  150 , a lower surface  180 , and a cylindrical body portion disposed vertically between surfaces  150  and  180 . The cylindrical body portion of spool  46  is shaped so as to define a channel which extends from a first opening at upper surface  150  to a second opening at lower surface  180 . 
     Lower surface  180  of spool  46  is shaped to define one or more (e.g., a plurality, as shown) of recesses  182  which define structural barrier portions  188  of lower surface  180 . It is to be noted that any suitable number of recesses  182  may be provided, e.g., between 1 and 10 recesses. For some applications, recesses  182  are provided circumferentially with respect to lower surface  180  of spool  46 . 
     Typically, spool  46  comprises a locking mechanism  145 . For some applications, locking mechanism  145  is coupled, e.g., welded, at least in part to a lower surface of spool housing  44 . Typically, locking mechanism  145  defines a mechanical element having a planar surface that defines slits  58 . The surface of locking mechanism  145  may also be curved, and not planar. Locking mechanism  145  is shaped to provide a protrusion  156  which projects out of a plane defined by the planar surface of the mechanical element. The slits define a depressible portion  128  of locking mechanism  145  that is disposed in communication with and extends toward protrusion  156 . 
     In a resting state of locking mechanism  145  (i.e., a locked state of spool  46 ), protrusion  156  is disposed within a recess  182  of spool  46 . Additionally, in the locked state of spool  46 , protrusion  156  is disposed within recess  142  of housing  44 . 
     Depressible portion  128  is aligned with the opening at lower surface  180  of spool  46  and is moveable in response to a force applied thereto by a distal force applicator  88 . That is, distal force applicator  88  is configured to be disposed within the channel of spool  46 . A distal end of applicator  88  is configured to push on depressible portion  128  in order to move depressible portion  128  downward so as to disengage protrusion  156  from within a recess  182  of spool and to unlock spool  46  from locking mechanism  145 . 
     It is to be noted that the planar, mechanical element of locking mechanism  145  is shown by way of illustration and not limitation and that any suitable mechanical element having or lacking a planar surface but shaped to define at least one protrusion may be used together with locking mechanism  145 . 
     A cap  1044  is provided that is shaped so as to define a planar surface and an annular wall having an upper surface  244  that is coupled to, e.g., welded to, the lower surface of spool housing  44 . The annular wall of cap  1044  is shaped so as to define a recessed portion  1144  of cap  1044  that is in alignment with recess  142  of spool housing  44 . Locking mechanism  145  is disposed between lower surface  180  of spool  46  and the planar surface of cap  1044 . 
     In an unlocked state of adjusting mechanism  40 , protrusion  156  of locking mechanism  145  is disposed within recessed portion  1144  of cap  1044 . In the unlocked state, force applicator  88  extends through spool  46  and pushes against depressible portion  128  of locking mechanism  145 . The depressible portion is thus pressed downward, freeing protrusion  156  from within a recess  182  defined by structural barrier portions  188  of the lower portion of spool  46 . Additionally, protrusion  156  is freed from within the recessed portion of spool housing  44 . As a result, contracting mechanism  40  is unlocked, and spool  46  may be rotated with respect to spool housing  44 . 
     Cap  1044  functions to restrict distal pushing of depressible portion  128  beyond a desired distance so as to inhibit deformation of locking mechanism  145 . For applications in which adjusting mechanism  40  is implanted in heart tissue, cap  1044  also provides an interface between adjusting mechanism  40  and the heart tissue. This prevents interference of heart tissue on adjusting mechanism  40  during the locking and unlocking thereof. Additionally, cap  1044  prevents damage to heart tissue by depressible portion  128  as it is pushed downward. 
     Spool  46  is shaped so as to define a driving interface  48 . A rotation tool (not shown) is configured to slide engage spool  46  at interface  48 . The rotation tool is configured to rotate spool  46  by applying rotational force to spool  46  at interface  48 . For some applications, a friction-reducing ring (not shown in  FIG. 3 , but shown in  FIG. 4 ) is disposed between upper surface  150  of spool  46  and the inner surface of upper surface  4  of spool housing  44 . 
     For some applications the rotation tool used to rotate spool  46  may be shaped to provide distal force applicator  88  configured to unlock spool  46  from locking mechanism  145 . When unlocked, spool  46  may be bidirectionally rotated. 
     Following rotation of spool  46  such that contraction member  30  is contracted sufficiently to adjust the perimeter of the annuloplasty structure to a desired dimension so as to contract the annulus of the valve, spool  46  is then locked in place so as to restrict rotation of spool  46 . Force applicator  88  is removed from within the channel of spool  46 , and thereby, depressible portion  128  returns to its resting state. As depressible portion  128  returns to its resting state, protrusion  156  is introduced within one of the plurality of recesses  182  of lower surface  180  of spool  46  and within recess  142  of housing  44 , and thereby restricts rotation of spool  46 . 
     Reference is now made to  FIG. 4 , which is a schematic illustration showing a relationship among individual components of flexible-longitudinal-tension-member-adjusting-mechanism  240 , in accordance with some applications of the present invention. Adjusting mechanism  240  is shown as comprising spool housing  248  which defines an upper surface  160  and a lower surface  176  defining a recessed portion (as described with regard to recess  142  with reference to  FIG. 3 ). A spool  246  is configured to be disposed within housing  248  and defines an upper surface  178 , a lower surface  180 , and a cylindrical body portion disposed vertically between surfaces  178  and  180 . The cylindrical body portion of spool  246  is shaped so as to define a channel which extends from a first opening at upper surface  178  to a second opening at lower surface  180 . 
     Lower surface  180  of spool  246  is shaped to define one or more (e.g., a plurality, as shown) of recesses  182  which define structural barrier portions  188  of lower surface  180 . It is to be noted that any suitable number of recesses  182  may be provided, e.g., between 1 and 10 recesses. For some applications, recesses  182  are provided circumferentially with respect to lower surface  180  of spool  246 . 
     Typically, spool  246  comprises a locking mechanism  145 . For some applications, locking mechanism  145  is coupled, e.g., welded, at least in part to a lower surface of spool housing  248 . Typically, locking mechanism  145  defines a mechanical element having a planar surface that defines slits  58 . The surface of locking mechanism  145  may also be curved, and not planar. Locking mechanism  145  is shaped to provide a protrusion  156  which projects out of a plane defined by the planar surface of the mechanical element. The slits define a depressible portion  128  of locking mechanism  145  that is disposed in communication with and extends toward protrusion  156 . 
     In a resting state of locking mechanism  145  (i.e., a locked state of spool  246 ), protrusion  156  is disposed within a recess  182  of spool  246 . Additionally, in the locked state of spool  246 , protrusion  156  is disposed within the recess of housing  248 . 
     Depressible portion  128  is aligned with the opening at lower surface  180  of spool  246  and is moveable in response to a force applied thereto by a distal force applicator  88  that extends in a distal direction from a distal portion of longitudinal guide member  86 . That is, distal force applicator  88  is configured to be disposed within the channel of spool  246 . A distal end of applicator  88  is configured to push on depressible portion  128  in order to move depressible portion  128  downward so as to disengage protrusion  156  from within a recess  182  of spool and to unlock spool  246  from locking mechanism  145 . 
     It is to be noted that the planar, mechanical element of locking mechanism  145  is shown by way of illustration and not limitation and that any suitable mechanical element having or lacking a planar surface but shaped to define at least one protrusion may be used together with locking mechanism  145 . 
     A cap  1044  is provided that is shaped so as to define a planar surface and an annular wall having an upper surface  244  that is coupled to, e.g., welded to, lower surface  176  of spool housing  248 . The annular wall of cap  1044  is shaped so as to define a recessed portion  1144  of cap  1044  that is in alignment with the recessed portion of spool housing  248 . Locking mechanism  145  is disposed between lower surface  180  of spool  246  and the planar surface of cap  1044 . 
     In an unlocked state of adjusting mechanism  240 , protrusion  156  of locking mechanism  145  is disposed within recessed portion  1144  of cap  1044 . In the unlocked state, force applicator  88  extends through spool  246  and pushes against depressible portion  128  of locking mechanism  145 . The depressible portion is thus pressed downward, freeing protrusion  156  from within a recess  182  defined by structural barrier portions  188  of the lower portion of spool  246 . Additionally, protrusion  156  is freed from within the recessed portion of spool housing  248 . As a result, contracting mechanism  240  is unlocked, and spool  246  may be rotated with respect to spool housing  248 . 
     Cap  1044  functions to restrict distal pushing of depressible portion  128  beyond a desired distance so as to inhibit deformation of locking mechanism  145 . For applications in which adjusting mechanism  240  is implanted in heart tissue, cap  1044  also provides an interface between adjusting mechanism  240  and the heart tissue. This prevents interference of heart tissue on adjusting mechanism  240  during the locking and unlocking thereof. Additionally, cap  1044  prevents damage to heart tissue by depressible portion  128  as it is pushed downward. 
     Spool  246  is shaped so as to define a rotation-facilitating head  170 . A rotation tool (not shown) is configured to slide distally along guide member  86  to engage head  170  of spool  246 . The rotation tool is configured to rotate spool  246  by applying rotational force to head  170 . A friction-reducing ring  172  is disposed between upper surface  178  of spool  246  and the inner surface of upper surface  160  of spool housing  248 . 
     For some applications, as described herein, guide member  86  is not coupled to spool  246 . For such applications the rotation tool used to rotate spool  246  may be shaped to provide a distal force applicator (similar to distal force applicator  88 ) configured to unlock spool  246  from locking mechanism  145 . In the unlocked state, spool  246  may be bidirectionally rotated. 
     Following rotation of spool  246  such that tension member  60  is pulled sufficiently to adjust the degree of tension of member  60  so as treat tissue of the ventricle as described herein, spool  246  is then locked in place so as to restrict rotation of spool  246 . Force applicator  88  is removed from within the channel of spool  246 , and thereby, depressible portion  128  returns to its resting state. As depressible portion  128  returns to its resting state, protrusion  156  is introduced within one of the plurality of recesses  182  of lower surface  180  of spool  246  and within the recess of housing  248 , and thereby restricts rotation of spool  246 . 
     Spool  246  is shaped so as to provide a hole  242  or other coupling mechanism for coupling a first portion of flexible longitudinal tension member  60  to spool  246 , and thereby to adjusting mechanism  240 . 
       FIG. 5  is a schematic illustration of a system  220  comprising an implant structure  222  which comprises an adjustable annuloplasty ring structure that is coupled to two or more flexible-longitudinal-tension-member-adjusting-mechanisms  240   a  and  240   b , as described hereinabove with reference to  FIG. 1 , in accordance with some applications of the present invention. For some applications, as shown, the annuloplasty ring structure comprises a partial annuloplasty ring. Adjusting mechanisms  240   a  and  240   b  typically comprise rotatable structures (e.g., spools, as described hereinbelow) which are coupled to respective first portions of flexible longitudinal tension members  60   a  and  60   b . When system,  220  is implanted in the heart of the patient, implant structure  222  is configured to be implanted at an annulus of a native valve of a patient (e.g., an atrioventricular valve such as the mitral valve or the tricuspid valve). Tension members  60   a  and  60   b  are configured to extend toward the ventricle of the heart of the patient by passing between the leaflets of the valve or by passing through tissue of the annulus or commissures of the valve. Respective second end portions of tension members  60   a  and  60   b  are configured to be coupled to respective portions of cardiac tissue which are in the vicinity of the ventricle of the heart (e.g., portions of papillary muscle, portions of tissue at the base of the papillary muscle, portions of tissue in a vicinity of the apex, portions of tissue of an inner wall of the ventricle, and/or portions of tissue of an outer wall of the ventricle). 
     Rotation of the rotatable structures of mechanisms  240   a  and  240   b  in a first rotational direction pulls tight (e.g., shortens) the respective tension members  60   a  and  60   b  in order to draw the portions of cardiac tissue toward implant structure  222  (i.e., to reduce the distance between each mechanism  240  and the second end portion of the respective tension member  60 ). Mechanisms  240   a  and  240   b  thereby act as perimeter-adjusting mechanisms. For some applications of the present invention, system  220  functions to repair and/or effect remodeling of the portions of cardiac tissue, remodeling of the papillary muscles, and/or remodeling of a heart wall of the ventricle to treat distension. For some applications, tension members function as artificial chordae tendineae. 
     Flexible-longitudinal-tension-member-adjusting-mechanisms  240   a  and  240   b , tension members  60   a  and  60   b , contracting member  30 , and flexible-longitudinal-contracting-member-adjusting-mechanism  40  shown in  FIG. 4  are identical to those described hereinabove with reference to  FIG. 1 . For some applications, adjusting mechanisms  240   a  and  240   b  are coupled to the outer surface of body portion  224  of structure  222  by rings  241 , as described hereinabove with reference to  FIGS. 2A-B . The annuloplasty structure of implant structure  221  comprises a body portion  224  which is similar to body portion  24  described hereinabove with reference to  FIG. 1 . It is to be noted that although body portion  224  is shown as comprising only coiled portion  12 , body portion  224  may comprise a braided mesh or may be surrounded by a braided mesh, as described hereinabove with reference to  FIG. 1 . 
     Adjusting mechanism  40  is coupled to a first end  221  of body portion  224 . Flexible contracting member  30  is coupled at a first end portion thereof to adjusting mechanism  40 . A second end portion of flexible contracting member  30  is coupled to a second end  223  of body portion  224 . Typically, during the resting state, flexible contracting member  30  is disposed in parallel with the longitudinal axis of structure  222 . That is, flexible member  30 , for some applications does not comprise a continuous band that runs through the entire lumen of the annuloplasty devices described herein, and flexible member  30  has at least one free end portion. 
     Typically, first end  221  of body portion  224  is welded to coupling member  31  of a housing  344  surrounding spool  46 . Housing  344  is similar to housing  44  described herein, with the exception that coupling member  35  of housing  44  is replaced with a first suture fastener  41 . First suture fastener  41  is shaped to define a hole  43  for passage therethrough of a suture to suture structure  222  to tissue of the patient. Second end  223  of body portion  224  comprises a second suture fastener  37  that is shaped to define a hole  47  for passage therethrough of a suture. 
     Reference is now made to  FIGS. 1-3  and  5 . As shown in  FIG. 3 , spool  46  is shaped so as to provide one or more holes  42   a  and  42   b  or other coupling mechanism for coupling a first portion of flexible longitudinal contracting member  30  to spool  46 , and thereby to adjusting mechanism  40 . In response to a rotational force applied to spool  46  in a first rotational direction, successive portions of flexible contracting member  30  are wrapped around spool  46  in order to tighten contracting member  30 . That is, during rotation of spool  46  in the first direction, successive portions of member  30  contact spool  46 . As flexible contracting member is wrapped around spool  46 , the second end portion of member  30  is pulled toward adjusting mechanism  40 . Pulling the second end of flexible contracting member toward mechanism  40  pulls the respective second ends  23  of structures  122  and  222  toward the respective first ends  21  of structures  122  and  222 . Responsively, the compressible element of body portion  24  is longitudinally compressed, thereby contracting structures  122  and  222 . 
     It is to be noted that the contraction of structures  122  and  222  is reversible. That is, rotating spool  46  in a second rotational direction that opposes the first rotational direction used to contract the annuloplasty structure, unwinds a portion of flexible contracting member  30  from around spool  46 . Unwinding the portion of flexible contracting member  30  from around spool  46  thus feeds the portion of flexible contracting member  30  back into the lumen of body portion  24  of respective structures  122  and  222 , thereby slackening the remaining portion of flexible contracting member  30  that is disposed within the lumen of body portion  24 . Responsively, the annuloplasty structure gradually relaxes and expands (i.e., with respect to its contracted state prior to the unwinding) as the compressible element of body portion  24  gradually expands. 
     Reference is now made to  FIGS. 6A-B , which are schematic illustrations of a system  300  for repairing a mitral valve  14  and papillary muscles  2   a  and  2   b  of a heart  4  of the patient using implant structure  122 , as described hereinabove with reference to  FIG. 1 , in accordance with some applications of the present invention. Implant structure  122  is positioned along the annulus of valve  14  and is coupled thereto using sutures, anchors, and/or any other suitable tissue-coupling element. As shown, implant  122  is positioned along the annulus in a manner in which portions  49  and mechanism  40  are disposed along the annulus at an anterior section  7  of valve  14 , adjusting mechanism  240   a  is implanted in a vicinity of a left fibrous trigone  8  of valve  14 , and adjusting mechanism  240   b  is implanted in a vicinity of a right fibrous trigone  5  of valve  14 . Following the coupling of structure  122  to the annulus of valve  14 , tension members  60   a  and  60   b  are pulled down into a ventricle  6  of heart  4  by the operating physician (e.g., using his/her hands or using a tool). For some applications, members  60   a  and  60   b  pass through an opening created in the annulus of valve  14  (e.g., by puncturing a needle therethrough). Alternatively, members  60   a  and  60   b  pass between the leaflets of valve  14 . Further alternatively, members  60   a  and  60   b  pass through respective commissures of valve  14 . 
     Respective tissue-coupling elements  302   a  and  302   b  are coupled to respective distal portions of members  60   a  and  60   b , respectively. Elements  302   a  and  302   b  comprise helical tissue anchors by way of illustration and not limitation. That is, elements  302   a  and  302   b  may comprise any suitable tissue-engaging structure. As shown, elements  302   a  and  302   b  are configured to be coupled to tissue of respective papillary muscles  2   a  and  2   b.    
     Following the coupling of structure  122  to the annulus of valve  14  and/or the coupling of tissue-engaging elements  302   a  and  302   b , the spool of adjusting mechanism  40  is rotated in order to adjust a dimension of the annuloplasty structure of implant structure  122  and thereby to adjust a dimension of the annulus and relative positioning of the leaflets of valve  14 . For example, in response to rotation of the spool of mechanism  40  in a first rotational direction thereof, the annuloplasty structure is contracted in order to contract the annulus and to draw together the leaflets of valve  14 . 
     Following the coupling of tissue-engaging elements  302   a  and  302   b , the spools of adjusting mechanisms  240   a  and  240   b  are rotated in order to adjust a degree of tension of tension members  60   a  and  60   b . For example, in response to rotation of the spools of mechanisms  240   a  and  240   b  in a first rotational direction thereof, tension members  60   a  and  60   b  are pulled tight in order to pull on papillary muscles  2   a  and  2   b.    
     For such applications, members  60   a  and  60   b  function to relocate and/or alter a geometry and/or spatial configuration of papillary muscles  60   a  and  60   b . For some applications, members  60   a  and  60   b  function as artificial chordae tendineae. 
     For some applications, members  60   a  and  60   b  function to repair a distension of the heart wall surrounding ventricle  6 . 
     It is to be noted that implant structure  122  and tension members  60   a  and  60   b  may be implanted using an open-heart or minimally-invasive procedure. 
     For some applications, whether the implant structure and tension members are implanted using an open-heart or a minimally-invasive procedure, adjustment (e.g., rotation) of mechanisms  40 ,  240   a , and  240   b  is performed off-pump (e.g., while the heart is beating), using a tool to facilitate the rotation of the adjusting mechanisms (e.g., elongate tool  50 , force applicator  88 , or similar). For example, following an open-heart procedure, heart tissue may be closed so as to provide only a small channel through which the tool extends, such that the heart can beat without leaking. Adjustment (e.g., rotation) of the adjusting mechanisms off-pump facilitates adjustment of the valve annulus and ventricle, while monitoring heart function and/or blood flow using imaging techniques, e.g., such that the physician may adjust until optimal heart function and/or blood flow is attained. For example, the physician may advance the tool (e.g., facilitated by imaging, such as fluoroscopy and/or ultrasound), and then sequentially, and/or repeatedly adjust (e.g., rotate) mechanism  40 , mechanism  240   a , and mechanism  240   b  (e.g., facilitated by imaging, such as Doppler ultrasound, in real-time and/or between adjustments). The order in which the adjusting mechanisms are adjusted may be decided by the physician, such as in response to the blood flow monitoring. 
     Reference is now made to  FIGS. 7A-B , which are schematic illustrations of a system  320  for repairing a mitral valve  14  and portions of tissue of ventricle  6  of a heart  4  of the patient, as described hereinabove with reference to  FIGS. 6A-B , with the exception that tissue-engaging elements  302   a  and  302   b  are coupled to respective portions of tissue along an inner wall of ventricle  6 , in accordance with some applications of the present invention. As shown, tissue-engaging element  302   a  is coupled to a portion  16  of tissue in a vicinity of an apex  17  of heart  4 , and tissue-engaging element  302   b  is coupled to a portion  18  of tissue at a base of the papillary muscle. 
     For some applications, members  60   a  and  60   b  function to relocate and/or alter a geometry and/or spatial configuration of papillary muscles  60   a  and  60   b . For other applications, members  60   a  and  60   b  function to repair a distension of the heart wall surrounding ventricle  6 . For yet other applications, members  60   a  and  60   b  function as artificial chordae tendineae. 
     Reference is now made to  FIGS. 8A-B , which are schematic illustrations of a system  340  for repairing a mitral valve  14  and portions of tissue of ventricle  6  of a heart  4  of the patient, as described hereinabove with reference to  FIGS. 6A-B  and  7 A-B, with the exception that respective second portions of tension members  60   a  and  60   b  are configured to extend trans-myocardially to an external surface  19  of heart  4 , in accordance with some applications of the present invention. 
     A respective tissue-engaging element is coupled to the second portion of each tension member  60   a  and  60   b . Each tissue-engaging element comprises a respective tissue-abutting pad  342   a  and  342   b  configured to rest against respective portions of surface  19  of heart  4 . 
     For such applications, members  60   a  and  60   b  function to repair a distension of the heart wall surrounding ventricle  6 . For some applications, members  60   a  and  60   b  function to relocate and/or alter a geometry and/or spatial configuration of papillary muscles  60   a  and  60   b.    
     Reference is now made to  FIGS. 9A-B , which are schematic illustrations of an implant structure  400  comprising an annuloplasty ring structure as described hereinabove with reference to  FIG. 1 , with the exception that structure  400  comprises a proximity-adjusting-mechanism  420 , in accordance with some applications of the present invention. Structure  400  defines an anterior-configured portion  402  configured for placement adjacent the anterior leaflet of the mitral valve. Additionally, structure  400  defines a posterior-configured portion  404  configured for placement adjacent the posterior leaflet of the mitral valve. For some applications, portion  402  is flexible and less longitudinally compressible than portion  404 . For example, portion  402  may comprise portions  49  described hereinabove with reference to  FIG. 1 . 
     As described hereinabove, adjusting mechanism  40  is configured to adjust a dimension of structure  400  by contracting and expanding a contracting member disposed within the lumen of body portion  24 . 
     As shown, flexible-longitudinal-contracting-member-adjusting-mechanism  40  is aligned with body portion  24  along the longitudinal axis thereof, as described hereinabove with reference to  FIG. 1 . Proximity-adjusting-mechanism  420  comprises any rotatable adjusting mechanism described herein (e.g., as described hereinabove with reference to  FIGS. 3 and 4 ). Mechanism  420  comprises a housing  426  configured to surround a portion of the outer surface of body portion  24 , typically surrounding a portion of body portion  24  that opposes adjusting mechanism  40 . The rotatable structure of proximity-adjusting mechanism  420  is coupled to a first portion of a flexible elongate member  422 . A second portion  424  of elongate member  422  is coupled to housing  44  (e.g., typically at an external surface thereof). 
     Typically, the rotatable structure of adjusting mechanism  420  comprises a spool. In response to rotation of the rotatable structure of adjusting mechanism  420  in a first rotational direction, successive portions of elongate member  422  are wound around the spool and pull tight the portion of elongate member  422  disposed between adjusting mechanisms  40  and  420 . In response, a portion of posterior-configured portion  404  is pulled in the direction as indicated by the arrow in  FIG. 9B . Thus, adjusting mechanism  420  is configured to adjust a septo-lateral dimension of structure  400  and of the annulus of the mitral valve when structure  400  is implanted at the annulus of the mitral valve in order to adjust the distance between the leaflets of the valve and to adjust opposing portions of the annulus of the mitral valve. 
     It is to be noted that the rotation of the rotational structure of adjusting mechanism  420  is reversible, and that following rotation of the rotatable structure in order to pull structure  400  into the configuration shown in  FIG. 9B , the rotatable structure may be rotated in a second rotational direction that opposes the first rotational direction in order for structure  400  to assume the configuration shown in  FIG. 9A . 
     It is to be noted that mechanisms  40  and  420  may be positioned at any suitable location along body portion  24  of structure  400 . 
     As shown, the annuloplasty structure of implant structure  400  defines a substantially ring-shaped configuration, e.g., a “D”-shaped configuration, as shown, which conforms to the shape of the annulus of a mitral valve of the subject. For applications in which structure  400  is implanted at a tricuspid valve of the patient, the annuloplasty structure assumes a shape suitable to fit the tricuspid valve (e.g., a substantially oval shape). 
     It is to be noted that structure  400  is shown independently of flexible-longitudinal-tension-member-adjusting-mechanisms  240  and tension members  60  by way of illustration and not limitation. For some applications, structure  400  is coupled to one or more mechanisms  240 . 
     Reference is now made to  FIGS. 10A-B , which are schematic illustrations of an implant structure  500  comprising an annuloplasty ring structure configured to transition between a substantially planar configuration ( FIG. 10A ) and a saddle-shaped configuration ( FIG. 10B ) in response to rotation of two or more (e.g., three, as shown) flexible-longitudinal-contracting-member-adjusting-mechanisms  40 . As shown, structure  500  comprises three adjusting mechanisms  40   a ,  40   b , and  40   c  that are aligned with the body portion of structure  500  along a longitudinal axis thereof, as described hereinabove with reference to  FIG. 1 . Adjusting mechanisms  40   a ,  40   b , and  40   c  are described hereinabove with reference to  FIGS. 1 and 3 . It is to be noted, however, that the adjusting mechanisms may comprise adjusting mechanisms  240 , as described hereinabove with reference to  FIGS. 1 and 4 . 
     Structure  500  defines an anterior-configured portion  502 , a posterior-configured portion  508 , and first and second commissural portions  504  and  506 , respectively. Typically, one or more flexible longitudinal contracting members (e.g., contracting member  30 , as described herein) is disposed within the lumen of the body portion of structure  500 . For some applications the number of contracting members disposed within the lumen of structure  500  corresponds to the number of adjusting mechanisms  40  coupled to structure  500 . 
     In response to rotation of the rotatable structures of adjusting mechanisms  40   a ,  40   b , and  40   c  in first rotational directions, the one or more contracting members are pulled tight (e.g., in response to winding successive portions of the one or more contracting members around the respective rotational structures of adjusting mechanisms  40   a ,  40   b , and  40   c ). Responsively, anterior-configured portion  502  and posterior-configured portion  508  are pulled upward, and first and second commissural portions  504  and  506  are pulled downward, in the direction as indicated by the arrows, such that structure  500  assumes a saddle-shape (as shown in  FIG. 10B ). 
     It is to be noted that the rotation of the rotational structure of adjusting mechanisms  40   a ,  40   b , and  40   c  is reversible, and that following rotation of the rotatable structure in order to pull structure  500  into the configuration shown in  FIG. 10B , the rotatable structure may be rotated in a second rotational direction that opposes the first rotational direction in order for structure  500  to assume the configuration shown in  FIG. 10A . 
     As shown, the annuloplasty structure of implant structure  500  defines a substantially ring-shaped configuration, e.g., a “D”-shaped configuration, as shown, which conforms to the shape of the annulus of a mitral valve of the subject. For applications in which structure  500  is implanted at a tricuspid valve of the patient, the annuloplasty structure assumes a shape suitable to fit the tricuspid valve (e.g., a substantially oval shape). 
     It is to be noted that structure  500  is shown independently of flexible-longitudinal-tension-member-adjusting-mechanisms  240  and tension members  60  by way of illustration and not limitation. For some applications, structure  500  is coupled to one or more mechanisms  240 . 
     It is to be noted that mechanisms  40  may be positioned at any suitable location along body portion  24  of structure  500 . It is to be further noted that any suitable number of mechanisms  40  may be coupled to structure  500 . 
     Reference is made to  FIG. 11 . Following implantation of the implant structures described herein, the implant structures may be adjusted while the patient is not on a cardiopulmonary bypass pump (i.e., “off pump”, e.g., while the heart of the patient is beating) (e.g., as described hereinabove with reference to  FIGS. 6A-B ). Adjustment (e.g., rotation) of the adjusting mechanisms off-pump facilitates adjustment while monitoring heart and/or valve function, and/or blood flow using imaging techniques, such as fluoroscopy and ultrasound (e.g., Doppler ultrasound), such that an operating physician  520  may adjust until optimal heart function and/or blood flow is attained. For example, and as shown in  FIG. 11 , two or more elongate rotation tools  522  (e.g., elongate rotation tools  522   a ,  522   b , and  522   c ), configured to adjust rotate spool  46  and/or spool  246 , may extend from outside of the body of the patient  524 , to respective adjusting mechanisms of the implant structure, such that operating physician  520  can adjust the adjusting mechanisms of the annuloplasty structure while monitoring a display  526  that displays information indicative of the heart and/or valve function and/or the blood flow. 
     The order in which the adjusting mechanisms are adjusted may be decided by the physician, such as in response to the blood flow monitoring. For example, the operating physician may adjust adjusting mechanism  40 , then observe display  526 , then adjust one or more adjusting mechanisms  240 . Alternatively, the physician may adjust one or more adjusting mechanisms  240  first, and subsequently adjust adjusting mechanism  40 . It will be understood by those familiar with the art, that any order of adjustment is possible, and similarly, that display  526  may be monitored simultaneously with the adjustments, and/or between adjustments. It is to be noted that the scope of the invention includes other feedback systems, such as audio and/or tactile feedback, in addition to, or instead of, display  526 . 
     Reference is now made to  FIGS. 1 ,  2 B,  5 ,  6 A-B,  7 A-B,  8 A-B, and  9 A-B. It is to be noted that the annuloplasty structures described herein may be shaped so as to define a saddle-shaped ring. 
     Reference is now made to  FIGS. 1 ,  2 B,  5 ,  6 A-B,  7 A-B,  8 A-B,  9 A-B, and  10 A-B. It is to be noted that for any implant structure described herein, adjusting mechanism  240  may be used in place of adjusting mechanism  40 , and adjusting mechanism  40  may be used in place of adjusting mechanism  240 , mutatis mutandis. As described hereinabove, adjusting mechanisms  40  and  240  are rotatable in first and second opposing rotational directions (i.e., are bidirectionally rotatable), and are thereby configured to reversibly (1) tighten and loosen (e.g., shorten and lengthen) flexible contracting member  30 , and thereby reversibly expand and contract the annuloplasty structure, and (2) tighten and loosen tension member  60 , and thereby reversibly reshape tissue of the ventricle. It is to be further noted that adjusting mechanisms  240  described herein may be provided together with or independently of guide members  86 . 
     Reference is again made to  FIGS. 1 ,  2 B,  5 ,  6 A-B,  7 A-B,  8 A-B,  9 A-B, and  10 A-B. It is to be noted that any suitable number of flexible-longitudinal-tension-member-adjusting-mechanisms  240  may be coupled to the annuloplasty structures of implant structures  122 ,  222 ,  400  and  500 . For some applications, only one flexible-longitudinal-tension-member-adjusting-mechanism  240  is coupled to the annuloplasty structures of implant structures  122 ,  222 ,  400 , and  500 . It is to be further noted that any suitable number of flexible longitudinal tension members  60  may be coupled to each flexible-longitudinal-tension-member-adjusting-mechanism  240 . 
     Reference is now made to  FIGS. 1 ,  2 B,  5 ,  6 A-B,  7 A-B,  8 A-B,  9 A-B, and  10 A-B. It is to be noted that although systems  300 ,  320 , and  340  show implant structure  122 , it is to be noted that the scope of the present invention includes the implantation of implant structure  222 , as described hereinabove with reference to  FIG. 5 , implant structure  400 , as described hereinabove with reference to  FIGS. 9A-B , or implant structure  500 , as described hereinabove with reference to  FIGS. 10A-B . Additionally, it is to be noted that adjusting mechanisms  240   a  and  240   b  are shown as being disposed in the vicinities of respective fibrous trigones  8  and  10  by way of illustration and not limitation, and that mechanisms  240   a  and  240   b  may be positioned at anywhere along the body portion of the annuloplasty structure of implant structure  122 . For example, mechanisms  240   a  and  240   b  may be sutured to the body portion prior to delivery of structure  122 . Alternatively, mechanisms  240   a  and  240   b  are coupled to respective rings  241  (as described hereinabove with reference to  FIGS. 2A-B ), and mechanisms  240   a  and  240   b  are slid to desired locations along the body portion of the annuloplasty structure. It is to be further noted that housing  44  (and mechanism  40 ) may be disposed at any suitable location along structure  122 , and not only in the portion of structure  122  configured to be disposed at the anterior section  7  of valve  14 . 
     It is to be noted that systems  120 ,  220 ,  300 ,  320 ,  340 , and structures  400  and  500  for repairing a dilated annulus of the subject may be used to repair any cardiac valve of the subject, e.g., the mitral valve, the tricuspid valve, the aortic valve, and the pulmonary valve. It is to be still further noted that systems described herein for treatment of valves may be used to treat other annular muscles within the body of the patient. For example, the systems described herein may be used in order to treat a sphincter muscle within a stomach of the subject. 
     Typically, the annuloplasty ring structures described herein, the adjusting mechanisms, and the flexible longitudinal members are advanced and implanted in an open-heart procedure. For some applications, devices described herein may be implanted using a minimally-invasive or percutaneous transcatheter procedure. 
     Additionally, the scope of the present invention includes applications described in one or more of the following:
         U.S. patent application Ser. No. 12/435,291 to Maisano et al., entitled, “Adjustable repair chords and spool mechanism therefor,” filed on May 4, 2009, which published as US Patent Application Publication 2010/0161041 (now US Pat. No. 8,147,542);   U.S. patent application Ser. No. 12/437,103 to Zipory et al., entitled, “Annuloplasty ring with intra-ring anchoring,” filed on May. 7, 2009, which published as US Patent Application Publication 2010/0286767 (now U.S. Pat. No. 8,715,342);   U.S. patent application Ser. No. 12/548,991 to Maisano et al., entitled, “Implantation of repair chords in the heart,” filed on Aug. 27, 2009, which published as US Patent Application Publication 2010/0161042 (now U.S. Pat. No. 8,808,368);   PCT Patent Application PCT/IL2009/001209 to Cabiri et al., entitled, “Adjustable annuloplasty devices and mechanisms therefor,” filed on Dec. 22, 2009, which published as PCT Publication WO 10/073,246;   PCT Patent Application PCT/IL2010/000357 to Maisano et al., entitled, “Implantation of repair chords in the heart,” filed on May 4, 2010, which published as WO 10/128,502; and/or   PCT Patent Application PCT/IL2010/000358 to Zipory et al., entitled, “Deployment techniques for annuloplasty ring and over-wire rotation tool,” filed on May 4, 2010, which published as WO 10/128,503.       

     All of these applications are incorporated herein by reference. Techniques described herein can be practiced in combination with techniques described in one or more of these applications. 
     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.