Abstract:
An implantable device system for controlling the dimensions of internal anatomic passages corrects physiologic dysfunctions resulting from a structural lumen which is either too large or too small. Implantable devices are disclosed which employ various mechanisms for adjusting and maintaining the size of an orifice to which they are attached. Systems permit the implants to be implanted using minimally invasive procedures and permit final adjustments to the dimensions of the implants after the resumption of normal flow of anatomic fluids in situ.

Description:
CROSS REFERENCE TO RELATED APPLICATIONS  
       [0001]     This application is a continuation-in-part of U.S. patent application Ser. No. 10/651,840, filed Aug. 29, 2003, which application claims priority under 35 U.S.C. § 119(e) from U.S. Provisional Patent Application No. 60/406,841 filed Aug. 29, 2002; U.S. Provisional Patent Application No. 60/444,005, filed Jan. 31, 2003; U.S. Provisional Patent Application No. 60/447,383, filed Feb. 14, 2003; and U.S. Provisional Patent Application No. 60/462,435, filed Apr. 12, 2003; all of which are incorporated herein by reference. This application also claims priority under 35 U.S.C. § 119(e) from U.S. Provisional Patent Application No. 60/801,861, filed on May 19, 2006, which is also incorporated herein by reference. 
     
    
     STATEMENT REGARDING SPONSORED RESEARCH OR DEVELOPMENT  
       [0002]     Not Applicable.  
       REFERENCE TO SEQUENCE LISTING  
       [0003]     Not Applicable.  
       BACKGROUND OF THE INVENTION  
       [0004]     1. Field of the Invention  
         [0005]     This invention relates generally to implantable devices for controlling at least one of shape and size of an anatomic structure or lumen.  
         [0006]     2. Description of Related Art  
         [0007]     There is often a need to reduce the internal circumference of an orifice or other open anatomic structure to narrow or increase the size of the orifice or opening to achieve a desired physiologic effect. Often, such surgical procedures require interruption in the normal physiologic flow of blood, other physiologic fluids, or other structural contents through the orifice or structure. The exact amount of the narrowing or widening required for the desired effect often cannot be fully appreciated until physiologic flow through the orifice or structure is resumed. It would be advantageous, therefore, to have an adjustable means of achieving the narrowing or widening effect, such that the degree of narrowing or widening could be changed after its implantation, and after the resumption of normal flow in situ.  
         [0008]     One example of a dysfunction within an anatomic lumen is in the area of cardiac surgery, and specifically valvular repair. Approximately one million open heart surgical procedures are now performed annually in the United States, and twenty percent of these operations are related to cardiac valves.  
         [0009]     The field of cardiac surgery was previously transformed by the introduction of the pump oxygenator, which allowed open heart surgery to be performed. Valvular heart surgery was made possible by the further introduction of the mechanical ball-valve prosthesis, and many modifications and different forms of prosthetic heart valves have since been developed. However, the ideal prosthetic valve has yet to be designed, which attests to the elegant form and function of the native heart valve.  
         [0010]     As a result of the difficulties in engineering a perfect prosthetic heart valve, there has been growing interest in repairing a patient&#39;s native valve. These efforts have documented equal long-term durability to the use of mechanical prostheses, with added benefits of better ventricular performance due to preservation of the subvalvular mechanisms and obviation of the need for chronic anticoagulation. Mitral valve repair has become one of the most rapidly growing areas in adult cardiac surgery today.  
         [0011]     Mitral valve disease can be subdivided into intrinsic valve disturbances and pathology extrinsic to the mitral valve ultimately affecting valvular function. Although these subdivisions exist, many of the repair techniques and overall operative approaches are similar in the various pathologies that exist.  
         [0012]     Historically, most valvular pathology was secondary to rheumatic heart disease, a result of a streptococcal infection, most commonly affecting the mitral valve, followed by the aortic valve, and least often the pulmonic valve. The results of the infectious process are mitral stenosis and aortic stenosis, followed by mitral insufficiency and aortic insufficiency. With the advent of better antibiotic therapies, the incidence of rheumatic heart disease is on the decline, and accounts for a smaller percentage of valvular heart conditions in the developed world of the present day. Commissurotomy of rheumatic mitral stenosis was an early example of commonly practiced mitral valve repair outside of the realm of congenital heart defects. However, the repairs of rheumatic insufficient valves have not met with good results due to the underlying valve pathology and the progression of disease.  
         [0013]     Most mitral valve disease other than rheumatic results in valvular insufficiency that is generally amenable to repair. Chordae rupture is a common cause of mitral insufficiency, resulting in a focal area of regurgitation. Classically, one of the first successful and accepted surgical repairs was for ruptured chordae of the posterior mitral leaflet. The technical feasibility of this repair, its reproducible good results, and its long-term durability led the pioneer surgeons in the field of mitral valve repair to attempt repairs of other valve pathologies.  
         [0014]     Mitral valve prolapse is a fairly common condition that leads over time to valvular insufficiency. In this disease, the plane of coaptation of the anterior and posterior leaflets is “atrialized” relative to a normal valve. This problem may readily be repaired by restoring the plane of coaptation into the ventricle.  
         [0015]     The papillary muscles within the left ventricle support the mitral valve and aid in its function. Papillary muscle dysfunction, whether due to infarction or ischemia from coronary artery disease, often leads to mitral insufficiency (commonly referred to as ischemic mitral insufficiency). Within the scope of mitral valve disease, this is the most rapidly growing area for valve repair. Historically, only patients with severe mitral insufficiency were repaired or replaced, but there is increasing support in the surgical literature to support valve repair in patients with moderate insufficiency that is attributable to ischemic mitral insufficiency. Early aggressive valve repair in this patient population has been shown to increase survival and improve long-term ventricular function.  
         [0016]     In addition, in patients with dilated cardiomyopathy the etiology of mitral insufficiency is the lack of coaptation of the valve leaflets from a dilated ventricle. The resultant regurgitation is due to the lack of coaptation of the leaflets. There is a growing trend to repair these valves, thereby repairing the insufficiency and restoring ventricular geometry, thus improving overall ventricular function.  
         [0017]     Two essential features of mitral valve repair are to fix primary valvular pathology (if present) and to support the annulus or reduce the annular dimension using a prosthesis that is commonly in the form of a ring or band. The problem encountered in mitral valve repair is the surgeon&#39;s inability to fully assess the effectiveness of the repair until the heart has been fully closed, and the patient is weaned off cardiopulmonary bypass. Once this has been achieved, valvular function can be assessed in the operating room using transesophageal echocardiography (TEE). If significant residual valvular insufficiency is then documented, the surgeon must re-arrest the heart, re-open the heart, and then re-repair or replace the valve. This increases overall operative, anesthesia, and bypass times, and therefore increases the overall operative risks.  
         [0018]     If the prosthesis used to reduce the annulus is larger than the ideal size, mitral insufficiency may persist. If the prosthesis is too small, mitral stenosis may result.  
         [0019]     The need exists, therefore, for an adjustable prosthesis that would allow a surgeon to adjust the annular dimension in situ in a beating heart under TEE guidance or other diagnostic modalities to achieve optimal valvular sufficiency and function.  
         [0020]     Cardiac surgery is but one example of a setting in which adjustment of the annular dimension of an anatomic orifice in situ would be desirable. Another example is in the field of gastrointestinal surgery, where the Nissen fundoplication procedure has long been used to narrow the gastro-esophageal junction for relief of gastric reflux into the esophagus. In this setting, a surgeon is conventionally faced with the tension between creating sufficient narrowing to achieve reflux control, but avoiding excessive narrowing that may interfere with the passage of nutrient contents from the esophagus into the stomach. Again, it would be desirable to have a method and apparatus by which the extent to which the gastro-esophageal junction is narrowed could be adjusted in situ to achieve optimal balance between these two competing interests.  
         [0021]     Aside from the problem of adjusting the internal circumference of body passages in situ, there is often a need in medicine and surgery to place a prosthetic implant at a desired recipient anatomic site. For example, existing methods proposed for percutaneous mitral repair include approaches through either the coronary sinus or percutaneous attempts to affix the anterior mitral leaflet to the posterior mitral leaflet. Significant clinical and logistical problems attend both of these existing technologies. In the case of the coronary sinus procedures, percutaneous access to the coronary sinus is technically difficult and time consuming to achieve, with procedures which may require several hours to properly access the coronary sinus. Moreover, these procedures employ incomplete annular rings, which compromise their physiologic effect. Such procedures are typically not effective for improving mitral regurgitation by more than one clinical grade. Finally, coronary sinus procedures carry the potentially disastrous risks of either fatal tears or catastrophic thrombosis of the coronary sinus.  
         [0022]     Similarly, percutaneous procedures which employ sutures, clips, or other devices to affix the anterior mitral leaflets to the posterior mitral leaflets also have limited reparative capabilities. Such procedures are also typically ineffective in providing a complete repair of mitral regurgitation. Furthermore, surgical experience indicates that such methods are not durable, with likely separation of the affixed valve leaflets. These procedures also fail to address the pathophysiololgy of the dilated mitral annulus in ischemic heart disease. As a result of the residual anatomic pathology, no ventricular remodeling or improved ventricular function is likely with these procedures.  
         [0023]     The need exists, therefore, for a delivery system and methods for its use that would avoid the need for open surgery in such exemplary circumstances, and allow delivery, placement, and adjustment of a prosthetic implant to reduce the diameter of such a mitral annulus in a percutaneous or other minimally invasive procedure, while still achieving clinical and physiologic results that are at least the equivalent of the yields of the best open surgical procedures for these same problems.  
         [0024]     The preceding cardiac applications are only examples of some applications according to the present invention. Another exemplary application anticipated by the present invention is in the field of gastrointestinal surgery, where the aforementioned Nissen fundoplication procedure has long been used to narrow the gastro-esophageal junction for relief of gastric reflux into the esophagus. In this setting, a surgeon is conventionally faced with the tension between creating sufficient narrowing to achieve reflux control, but avoiding excessive narrowing that may interfere with the passage of nutrient contents from the esophagus into the stomach. Additionally, “gas bloat” may cause the inability to belch, a common complication of over-narrowing of the GE junction. An adjustable prosthetic implant according to the present invention could allow in situ adjustment in such a setting under physiologic assessment after primary surgical closure.  
         [0025]     Such an adjustable prosthetic implant according to the present invention could be placed endoscopically, percutaneously, or with an endoscope placed within a body cavity or organ, or by trans-abdominal or trans-thoracic approaches. In addition, such an adjustable prosthetic implant according to the present invention could be coupled with an adjustment means capable of being placed in the subcutaneous or other anatomic tissues within the body, such that remote adjustments could be made to the implant during physiologic function of the implant. This adjustment means can also be contained within the implant and adjusted remotely, i.e. remote control adjustment. Such an adjustment means might be capable of removal from the body, or might be retained within the body indefinitely for later adjustment.  
         [0026]     The present invention and the methods for its use anticipate many alternate embodiments in other potential applications in the broad fields of medicine and surgery. Among the other potential applications anticipated according to the present invention are adjustable implants for use in the treatment of morbid obesity, urinary incontinence, anastomotic strictures, arterial stenosis, urinary incontinence, cervical incompetence, ductal strictures, and anal incontinence. The preceding discussions are intended to be exemplary embodiments according to the present invention and should not be construed to limit the present invention and the methods for its use in any way.  
       SUMMARY OF THE INVENTION  
       [0027]     An object of the present invention is to provide an implantable device for controlling at least one of shape and size of an anatomical structure or lumen.  
         [0028]     These and other objects of the present invention are achieved in an implantable device for controlling at least on of shape and size of an anatomical structure or lumen. An implantable device is provided that has an adjustable member configured to adjust the dimensions of the implantable device. In certain embodiments, a torqueable adjustment tool is configured to provide adjustment of the dimensions of the implantable device for a preferred dimension. In other embodiments adjustments for a preferred dimension may be accomplished remotely through activation of internal adjustment mechanisms.  
         [0029]     In another embodiment of the present invention, an implantable device is provided for controlling at least one of shape and size of an anatomical structure or lumen that includes an implantable device has an adjustable member configured to adjust the dimensions of the implantable device, a particularly a preferred dimension. An adjustment tool is configured to provide adjustment of the dimensions of the implantable device, the adjustment tool providing translated motion through rotation.  
         [0030]     In another embodiment of the present invention, an implantable device is provided for controlling at least one of shape and size of an anatomical structure or lumen. An implantable device has an adjustable member configured to adjust the dimensions of the implantable device and includes first and second bands. An adjustment tool is configured to provide adjustment of the dimensions of the implantable device for a preferred dimension.  
         [0031]     In still another embodiment of the present invention, an implantable device is provided for controlling at least one of shape and size of an anatomical structure or lumen. An implantable device has an adjustable member configured to adjust the dimensions of the implantable device. The implantable device has an anterior portion, a posterior portion and dual threads that provide preferential adjustment of one side or the other of the implantable device. An adjustment tool is configured to provide adjustment of the dimensions of the implantable device.  
         [0032]     In yet another embodiment of the present invention, an implantable device controls at least one of shape and size of an anatomical structure or lumen. An implantable device has an adjustable member configured to adjust the dimensions of the implantable device. An adjustment tool is configured to provide adjustment of the dimensions of the implantable device. The adjustment tool provides reciprocating action to provide for the adjustment.  
         [0033]     In another embodiment of the present invention, an implantable device controls at least one of shape and size of an anatomical structure or lumen. An implantable device has an adjustable member configured to adjust the dimensions of the implantable device. An adjustment tool is configured to provide adjustment of the dimensions of the implantable device. The adjustment tool provides both course adjustment and fine adjustment.  
         [0034]     Other features and advantages of the present invention will become apparent upon reading the following specification, when taken in conjunction with the drawings and the appended claims. 
     
    
     BRIEF DESCRIPTION OF FIGURES  
       [0035]      FIG. 1  is a front view of a first embodiment of an implant for reducing the circumference of an anatomic orifice.  
         [0036]      FIG. 2  is a front view of the implant of  FIG. 1  secured to the annulus of a mitral valve, with the implant in an expanded position.  
         [0037]      FIG. 3  is a front view of the implant of  FIG. 1  secured to the annulus of a mitral valve, with the implant in a contracted position to reduced the size of the heart valve opening.  
         [0038]      FIG. 4  is a perspective view of a second embodiment of an implant for reducing the circumference of an anatomic orifice, inserted through an open operative cardiac incision and secured around the mitral valve.  
         [0039]      FIG. 5  is a perspective view of the implant of  FIG. 4 , showing the cardiac incision closed, an adjustment tool extending through the closed incision, and adjustment of the implant possible after the patient has been taken “off pump.” 
         [0040]      FIG. 6  is a perspective view of a first embodiment of an adjustment means for adjusting the circumference of an implant for reducing the circumference of an anatomic orifice.  
         [0041]      FIG. 7  is a right side view of the adjustment means of  FIG. 6 .  
         [0042]      FIG. 8  is a left side view of the adjustment means of  FIG. 6 .  
         [0043]      FIG. 9  is a right side view of a second embodiment of an adjustment means for adjusting the circumference of an implant for reducing the circumference of an anatomic orifice.  
         [0044]      FIG. 10  is a perspective view of a first alternate embodiment of an attachment means for the implant of  FIG. 1 .  
         [0045]      FIG. 11  is a perspective view of a second alternate embodiment of an attachment means for the implant of  FIG. 1 .  
         [0046]      FIG. 12  is a perspective view of a third embodiment of an implant for reducing the circumference of an anatomic orifice.  
         [0047]      FIG. 13  is a perspective view of one end of the implant of  FIG. 12  showing an optional keyed relationship between three coaxial cannulae to prevent relative rotation between the three components.  
         [0048]      FIG. 14  is a perspective view of the implant of  FIG. 12  showing the outer cannula extended to cover the implant.  
         [0049]      FIG. 15  is a perspective view of the implant of  FIG. 12  showing the outer cannula retracted to expose the implant.  
         [0050]      FIG. 16  is a perspective view of the implant of  FIG. 12  showing the middle cannula extended to unfold the implant.  
         [0051]      FIGS. 17 and 18  are schematic views illustrating how extension of the middle cannula causes the implant to unfold, where  FIG. 17  shows the implant in the folded position, and  FIG. 18  shows the implant in the unfolded position.  
         [0052]      FIG. 19  is a perspective view of the lower end of a touchdown sensor of the implant of  FIG. 12 , showing the sensor in an uncompressed condition.  
         [0053]      FIG. 20  is a perspective view of the lower end of the touchdown sensor of  FIG. 19 , showing the sensor in a compressed condition.  
         [0054]      FIG. 21  is a perspective end view of a fourth embodiment of an implant for reducing the circumference of an anatomic orifice.  
         [0055]      FIG. 22  is a side view of the implant of  FIG. 21  with the implant opened up to show its full length.  
         [0056]      FIG. 23  is a side view of the adjustment mechanism of the implant of  FIG. 21 .  
         [0057]      FIG. 24  is a close-up view of two of the retention barbs of the implant of  FIG. 21 .  
         [0058]      FIG. 25  is a front view of a fifth embodiment of an implant for reducing the circumference of an anatomic orifice, with the implant shown in its expanded configuration.  
         [0059]      FIG. 26  is a front view of the implant of  FIG. 25 , with the implant shown in its contracted configuration.  
         [0060]      FIG. 27  is an enlarged view of the area indicated by the circle  27  in  FIG. 25 , with the outer body removed to show interior detail.  
         [0061]      FIG. 28  is a schematic view showing the implant of  FIG. 12  anatomically positioned at the mitral annulus in a heart with the implant in a fully expanded state.  
         [0062]      FIG. 29  is a schematic view showing the implant of  FIG. 12  anatomically positioned at the gastroesophageal opening with the implant in a fully expanded state.  
         [0063]      FIG. 30  is a schematic view showing the implant of  FIG. 29  implanted to reduce the circumference of the gastroesophageal opening.  
         [0064]      FIG. 31  is a schematic view of an embodiment of an implantable device of the present invention.  
         [0065]      FIG. 32A  is a schematic view of another embodiment of an implantable device of the present invention.  
         [0066]      FIG. 32B  is a schematic view of a threaded member in an embodiment of an implantable device of the present invention.  
         [0067]      FIG. 33  is a schematic view of an embodiment of an implantable device of the present invention with an outer tubing and an inner tubing in a relative first position.  
         [0068]      FIG. 34  is a schematic view of an embodiment of an implantable device of the present invention with an outer tubing and an inner tubing in a relative second position.  
         [0069]      FIG. 35  is a schematic view of an embodiment of an implantable device of the present invention with an outer tubing and an inner tubing in a relative third position.  
         [0070]      FIG. 36  is a schematic view of an embodiment of an adjustable member of the present invention, with the distal tip of the adjustment tool coupled to the adjustment member.  
         [0071]      FIG. 37  is a schematic view of an embodiment of an adjustment member of the present invention having an integrated pinion gear.  
         [0072]      FIG. 38  is a schematic view of an embodiment of a flexible tube cover for an implant device.  
         [0073]      FIG. 39  is a cross-section view of an assembled embodiment of an adjustable implant device.  
         [0074]      FIG. 40  is a schematic view of an embodiment of a seal jacket for an adjustable member.  
         [0075]      FIG. 41  is a schematic view of an embodiment of an adjustment band in the implantable member of the present invention.  
         [0076]      FIG. 42  is a disassembled schematic view of part of the adjustment band and adjustment member of  FIG. 41 .  
         [0077]      FIG. 43  is an assembled view of the adjustment band and adjustment member of  FIG. 42 .  
         [0078]      FIG. 44  is a schematic view of an embodiment of the gearbox for the adjustment band of  FIG. 41 .  
         [0079]      FIG. 45  is a schematic view of an embodiment of the implantable device of the present invention with a sliding band that can be opened and closed to effect a preferential shape change.  
         [0080]      FIG. 46  is a schematic view of an embodiment of the implantable device of the present invention with two adjustable screws used to achieve different pulling rates.  
         [0081]      FIG. 47  is a schematic view of an embodiment of the implantable device of the present invention with reciprocating motion and a clover gear.  
         [0082]      FIG. 48  is a schematic view of an embodiment of the implantable device system of the present invention with an adjustment tool having high column strength and stiffness.  
         [0083]      FIG. 49  is a schematic view of an embodiment of the implantable device of the present invention shown in vivo with an adjustment tool having reduced column stiffness.  
         [0084]      FIG. 50  is a cut-away view of an embodiment of the proximal portion of an adjustment tool.  
         [0085]      FIG. 51  is a schematic view of an embodiment of the implantable device of the present invention with an articulated shape. 
     
    
     DETAILED DESCRIPTION OF THE INVENTION  
       [0086]     Referring now to the drawings, in which like numerals indicate like elements throughout the several views, an exemplary implant  10  comprising an implant body  15  is shown in  FIG. 1 . The implant body may be provided in a shape and size determined by the anatomic needs of an intended native recipient anatomic site within a mammalian patient. Such a native recipient anatomic site may be, by way of illustration and not by way of limitation, a heart valve, the esophagus near the gastro-esophageal junction, the anus, or other anatomic sites within a mammalian body that are creating dysfunction that might be relieved by an implant capable of changing the size and shape of that site and maintaining a desired size and shape after surgery.  
         [0087]     The implant  10  of  FIG. 1  comprises a circular implant body  15  which is provided with adjustable corrugated sections  20  alternating with intervening grommet-like attachment means  25  having narrowed intermediate neck portions. As can be seen in  FIGS. 2 and 3 , the implant body  15  may be secured to the annulus of a heart valve  30  by a fixation means such as a suture  35  secured over or through the attachment means  25 . The corrugated sections  20  fold and unfold as the circumference of the implant body  15  shortens or lengthens. Adjustment of the implant  10  in situ may decrease the overall size of the heart valve  30 , increasing the coaptation of the valve leaflets  40 , and changing the configuration from that shown in  FIG. 2  to that shown in  FIG. 3 .  
         [0088]     An additional exemplary embodiment  100  of the present invention is shown in  FIGS. 4 and 5 , with an open operative cardiac incision  105  in a heart  110  shown in  FIG. 4 , and closure of the cardiac incision  105  in  FIG. 5 . As shown in  FIG. 4 , the exemplary adjustable implant  100  according to the present invention comprises an implant body  115  with attachment means  120  that allows fixation to the annulus of a mitral valve  125 . The exemplary adjustable implant  100  is further provided with an adjustment means  130  that is controlled by an attached or coupled adjustment tool  135 . After closure of the myocardial incision  105  in  FIG. 5 , the adjustment tool  135  remains attached or coupled to the adjustment means  130 , so that the size and shape of the implant  100  may further be affected after physiologic flow through the heart  110  is resumed, but with the chest incision still open. Once the desired shape and function are achieved, the adjustment tool  135  may be disengaged from the adjustment means  130  and withdrawn from the myocardial incision  105 . In various embodiments according to the present invention, the adjustment means  130  may be configured and placed to allow retention by or re-introduction of the adjustment tool  135  for adjustment following closure of the chest incision.  
         [0089]     To use the implant  100  of  FIGS. 4 and 5 , the physician makes the open operative incision  105  in the heart  110 , as shown in  FIG. 4 , in the conventional manner. The implant  100 , mounted at the forward end of adjustment tool  135 , is then advanced through the incision  105  and sutured to the annulus of the mitral valve  125 . The adjustment tool  135  is then manipulated, e.g., rotated, depending upon the design of the adjustment means  130 , to cause the adjustment means to reduce the size of the implant body  115 , and hence the underlying mitral valve  125  to which it is sutured, to an approximate size. The myocardial incision  105  can now be closed, as shown in  FIG. 5 , leaving the adjustment tool extending through the incision for post-operative adjustment.  
         [0090]     Once the patient has been taken “off pump” and normal flow of blood through the heart  110  has resumed, but before the chest incision has been closed, further adjustments to the size of the mitral valve  125  can be made by manipulating the adjustment tool  135 .  
         [0091]      FIGS. 6-8  show an exemplary adjustment means  200  for adjusting the circumference of an annular implant such as the implant  100  previously described. The adjustment means  200  comprises a rack and pinion system in which a first cam  205  with geared teeth  210  and an engagement coupler  215  turns on a first axel  220 . In this example, the first cam  205  engages a geared rack  225  on one or more surfaces of a first band  230 . The first band  230  passes between the first cam  205  and a second cam  235  that turns on a second axel  240  that is joined to a second band  245 . As shown in  FIG. 8 , the first and second axels  220 ,  240  are maintained in suitable spaced-apart relation by means of a bracket  250  formed at the end of the second band  245 .  
         [0092]     The adjustment means  200  is preferably set within a hollow annular implant  100  of the type previously described, though it is possible to use the adjustment means in a stand-alone configuration wherein the first and second bands  230 ,  245  are opposing ends of the same continuous annular structure. In either event, to adjust the length of an implant comprising the adjustment means  200 , a tool such as a hex wrench engages the engagement coupler  215  on the first cam  205  and rotates the first cam in a counterclockwise direction as shown in  FIG. 7 , as indicated by the arrow  255 . Rotation of the first cam  205  causes the teeth  210  to drive the rack  225  to move the first band  230  toward the right, as indicated by the arrow  260  in  FIG. 7 . This movement of the first band tightens the circumference of the annular implant. If the physician inadvertently adjusts the implant too tight, reversing direction of the engagement coupler  215  will loosen the implant.  
         [0093]     In various embodiments according to the present invention, the first and second bands  230 ,  245  may be separate structures, or they may be opposing ends of the same continuous structure. In such an embodiment, when motion is imparted to the engagement coupler  215 , the first cam  205  is rotated, causing the geared teeth  210  to engage the geared rack  225 , and causing the first band  230  to move with respect to the second band  245  to adjust the circumference of an implant.  
         [0094]      FIG. 9  shows a somewhat different configuration of an exemplary engagement means  300  according to the present invention, in which there is no engagement coupler, and a bracket  350  is provided on both sides of the cams to maintain the first cam  315  and the second cam  320  in close approximation. In one proposed embodiment, the bracket is designed with close tolerances so as to press the first band  330  closely against the second band  345 , thereby to hold the bands in fixed relative position by friction. In another proposed embodiment, the brackets  350  are fabricated from an elastic material such that the cams  315 ,  320  can be spread apart to insert the first band  330  between the cams, whereupon the cams are pulled back together with sufficient force to hold the bands  330 ,  345  in fixed relative position by friction. In still another proposed embodiment involving an elastic mounting arrangement between the cams  315 ,  320 , the lower edge of the first band  330  and the upper edge of the second band  345  have mating frictional or mechanical surfaces, whereby the cams  315 ,  320  can be spread apart to permit relative movement between the bands or released to clamp the bands together in fixed relation.  
         [0095]      FIG. 10  shows an exemplary attachment means  400  for an implant according to the present invention. The attachment means  400  could be used, for example, in place of the attachment means  25  of the implant  10 . The attachment means  400  takes the form of a grommet  410  comprising a wall  415  defining a lumen  420  and an attachment surface  425 . Such an attachment means would be used with the implant body extending through the lumen  420  and with fixation devices such as sutures or wires either tied over or affixed through the attachment surface  425 .  
         [0096]      FIG. 11  shows another alternate embodiment of an attachment means  500  for an implant according to the present invention. The attachment means  500  could also be used, for example, in place of the attachment means  25  of the implant  10 .  FIG. 11  shows an attachment means  500  in the form of a hollow tube or tube segment  510  comprising a wall  515  defining a lumen  520 , an outer surface  525 , and an attachment tab  530 . Such an attachment means would be used with the implant body extending through the lumen  520  and with fixation devices such as sutures or wires either tied or otherwise affixed over or through the attachment tab  530 . Such fixation devices might be placed through holes  535  provided in the attachment tab  530 . Alternately a solid attachment tab  530  might be provided, and the fixation devices might be passed through the solid tab. Modifications of these attachment means may be used in conjunction with a sutureless attachment system.  
         [0097]      FIGS. 12-18  show another embodiment of a percutaneous annuloplasty device according to the present invention, in which an implant/delivery system array  600  includes a housing sheath  605  (not seen in  FIG. 12 ), an actuating catheter  610  coaxially slidably mounted within the housing sheath  605 , and a core catheter  615  coaxially slidably mounted within the actuating catheter  610 . The core catheter has a central lumen  616  ( FIG. 13 ). The actuating catheter  610  and core catheter  615  may be round tubular structures, or as shown in  FIG. 13 , either or both of the actuating and core catheters may be provided with one or more keyed ridges  618 ,  620  respectively to be received by one or more reciprocal slots  622 ,  624  within the inner lumen of either the housing sheath  605  or the actuating catheter  610 , respectively. Such keyed ridges  618 ,  620  would limit internal rotation of an inner element within an outer element, should such restriction be desirable to maintain control of the inner contents from inadvertent displacement due to undersired rotational motion during use.  
         [0098]     The implant/delivery system array  600  includes a distal tip  625  at the forward end of the core catheter  615 . One or more radial implant support arms  630  have their distal ends  632  pivotably or bendably mounted to the core catheter  615  adjacent its distal tip  625 . The proximal ends  634  of the radial implant support arms  630  normally extend along the core catheter  615  but are capable of being displaced outward away from the core catheter.  
         [0099]     One or more radial support struts  636  have their proximal ends  638  pivotably or bendably mounted to the distal end of the actuating catheter  610 . The distal end  640  of each radial support strut is  636  pivotably or bendably attached to a midpoint of a corresponding radial implant support arm  630 . As the actuating catheter  610  is advanced with respect to the core catheter  615 , the radial support struts  636  force the radial implant support arms  630  upward and outward in the fashion of an umbrella frame. Thus the actuating catheter  610 , core catheter  615 , radial support struts  636 , and radial support arms  630  in combination form a deployment umbrella  642 .  
         [0100]     A prosthetic implant  645  is releasably attached to the proximal ends  634  of the radial implant support arms  630 . Around the periphery of the prosthetic implant  645  and extending proximally therefrom are a plurality of retention barbs  646 . In addition, one or more of the radial implant support arms  630  comprise touchdown sensors  648  whose proximal ends extend proximal to the implant  645 . Extending through the central lumen  616  ( FIG. 13 ) of the core catheter  615  in the exemplary embodiment  600  and out lateral ports  650  ( FIG. 12 ) spaced proximally from the distal tip  625  are one or more release elements  660 , which serve to release the implant  645  from the delivery system, and one or more adjustment elements  665  which serve to adjust the implant&#39;s deployed size and effect. Because the release elements  660  and adjustment elements  665  extend through the proximal end of the core catheter  615 , as seen in  FIGS. 14-16 , these elements can be directly or indirectly instrumented or manipulated by the physician. A delivery interface  670  ( FIGS. 12, 16 ) is defined in this example by the interaction of the deployment umbrella  642 , the release elements  660 , and the implant  645 . In the disclosed embodiment, the release elements  660  may be a suture, fiber, or wire in a continuous loop that passes through laser-drilled bores in the implant  645  and in the radial implant support arms  630 , and then passes through the length of the core catheter  615 . In such an embodiment, the implant  645  may be released from the delivery system at a desired time by severing the release element  660  at its proximal end, outside the patient, and then withdrawing the free end of the release element  660  through the core catheter  610 .  
         [0101]      FIGS. 14-16  show the operation of the implant/delivery system array  600 , in which an umbrella-like expansion of the prosthetic implant  645  is achieved by sliding movement of the housing sheath  605 , the actuating catheter  610 , and the core catheter  615 . Referring first to  FIG. 14 , the housing sheath  605  is extended to cover the forward ends of the actuating catheter  610  and core catheter  615  for intravascular insertion of the implant/delivery system array  600 . From this starting position, the housing sheath  605  is retracted in the direction indicated by the arrows  662 . In  FIG. 15  the housing sheath  605  has been retracted to expose the forward end of the actuating catheter  610  and the collapsed deployment umbrella  642 . From this position the actuating catheter  610  is advanced in the direction indicated by the arrows  664 . This will cause the deployment umbrellas to expand in the directions indicated by the arrows  666 .  FIG. 16  shows the expansion of the deployment umbrella  642  produced by distal motion of the actuating catheter  610  relative to the core catheter  615 . After the implant  645  has been positioned and adjusted to the proper size, the housing sheath  605  is advanced in the direction indicated by the arrows  668  to collapse and to cover the deployment umbrella  642  for withdrawal of the device from the patient.  
         [0102]      FIGS. 17 and 18  are schematic views illustrating the radial implant support arms  630  and the radial support struts  636  of the implant/delivery system array  600 . In  FIG. 17 , a radial support strut  636  is pivotably attached at its proximal end  638  at a first pivotable joint  670  to the actuation catheter  610 . The radial support strut  636  is attached at its distal end  640  to a second pivotable joint  672  at an intermediate point of a corresponding radial implant support arm  630 . The radial implant support arm  630  is attached at its distal end  632  by a third pivotable joint  674  to the core catheter  620 .  FIG. 17  shows the assembly in a closed state. When the actuation catheter  610  is advanced distally over the core catheter  615 , as shown by the arrows  676 , the radial support strut  636  and the radial implant support arm  630  are extended by the motion at the first pivotable joint  670 , the second pivotable joint  672 , and the third pivotable joint  674 , as shown by the arrow  678 . This motion has the effect of expanding the deployment umbrella and folded implant (not shown in  FIGS. 17 and 18 ), allowing it to achieve its greatest radial dimension, prior to engagement and implantation as previously discussed with reference to  FIGS. 12-16 .  
         [0103]      FIGS. 19 and 20  show further details of the touchdown sensors  648  shown previously in  FIG. 12 . The touchdown sensor  648  of  FIGS. 19 and 20  includes a distal segment  680 , an intermediate segment  682 , and a proximal segment  684 . The distal segment  680  is spring-mounted, so that it is capable of slidable, telescoping displacement over the intermediate segment  682  to achieve a seamless junction with the proximal segment  684  upon maximal displacement. When the touchdown sensor  648  is in its normal condition, the spring extends the proximal segment such that the sensor assumes the orientation shown in  FIG. 19 . When the implant  645  ( FIG. 12 ) is seated against the periphery of an anatomical opening, the proximal segment  684  of the sensor  648  is compressed against the distal segment  680 , as shown in  FIG. 20 . The distal segment  680  and the proximal segment  684  are both constructed of, are sheathed by, or otherwise covered with a radio-opaque material. However, the intermediate segment  682  is not constructed or coated with such a radio-opaque material. Therefore, when the distal segment  680  is at rest, it is fully extended from the proximal segment  684 , and the gap represented by the exposed intermediate segment  682  is visible on radiographic examination. However, when the distal segment  680  is brought to maximum closeness with the proximal segment  684 , no such radio-opaque gap is radiographically visible, and the touchdown sensor is said to be “activated”. This embodiment allows radiographic monitoring of the position of the touchdown sensor  648  with respect to the degree of extension of the distal catheter segment  680 . In the embodiment according to the present invention as shown, one or more touchdown detectors  648  are employed to ascertain that the delivery system for the prosthetic device is located in the proper position to deploy the implant into the mitral annulus. As this anatomic structure cannot be directly identified on fluoroscopy or standard radiographic procedures, such precise location could be otherwise difficult. At the same time, precise localization and engagement of the mitral annulus is critical for proper implant function and safety.  
         [0104]     Touchdown detectors within the embodiments according to the present invention can have a multiplicity of forms, including the telescoping, spring-loaded, radio-opaque elements joined by a non-radio-opaque element as in the aforementioned examples. In embodiments employing magnetic resonance imaging, touchdown detectors according to the present invention may utilize metallic segments interposed by nonmetallic segments in a similar telescoping, spring-loaded array. Other embodiments include a visually-evident system with telescoping, spring-loaded elements with color-coded or other visual features for procedures in which direct or endoscopic observation would be possible. Still other embodiments of touchdown detectors according to the present invention include touchdown detectors provided with microswitches at their tips, such that momentary contact of sufficient pressure completes an electrical circuit and signals the activation of the touchdown detector to the operator. Still other touchdown detectors according to the present invention are provided with fiberoptic pathways for Rahmen laser spectroscopy or other spectral analytical techniques which are capable of detecting unique tissue qualities of the tissue at the desired site for implantation. In addition, still other embodiments according to the present invention include touchdown detectors containing electrodes or other electronic sensors capable of detecting and signaling the operator when a desired electrophysiologic, impedance, or other measurable quality of the desired tissue is detected for proper implantation. Such electrophysiologic touchdown detectors may include electrical circuits that produce visual, auditory, or other signals to the operator that the detectors are activated and that the implant is in the proper position for attachment.  
         [0105]     In yet other embodiments according to the present invention, other intracardiac or extracardiac imaging techniques including, but not limited to, intravascular ultrasound, nuclear magnetic resonance, virtual anatomic positioning systems, or other imaging techniques may be employed to confirm proper positioning of the implant, obviating the need for the touchdown sensors as previously described.  
         [0106]      FIGS. 21-24  show an implant  700  according to one embodiment of the present invention. In this embodiment, the implant body  705  is bandlike and flexible. Through much of its length, the implant body  705  is provided with a series of retention barbs  710  which are oriented to facilitate placement, retention, and removal of the device. The implant body  705  is also provided with an adjustable section  715 , which is provided in this example with a series of adjustment stops  720 . The adjustment stops  720  may be slots, holes, detents, dimples, ridges, teeth, raised elements, or other mechanical features to allow measured adjustment of the implant  700  in use. In the embodiment shown in  FIGS. 21-24 , the adjustment stops  720  are engaged by a geared connector  725 .  FIG. 21  is an end view, showing the implant body  705  curved on itself, with the retention barbs  710  to the exterior, and with the adjustable section  715  passing through its engagement with the geared connector  725  and curving internally within the implant body  705  to form a closed, round structure.  FIG. 23  shows details of an exemplary geared connector  725 , in which a housing  730  is connected to the implant body  705 . The housing  730  contains and supports a mechanical worm  740  with an attached first geared head  750  which mates with a second geared head  755 . The second geared head  755  is attached to an adjustment stem  760  which is machined to receive a screwdriver-like adjustment element. The various embodiments according to the present invention may require a number of forms of adjustment elements. In the present example, the adjustment element is provided as a finely coiled wire with a distal tip machined to be received by a receiving slot in the adjustment stem  760  (not shown). The relationship between the distal tip of the adjustment element and the adjustment stem  760  is mechanically similar to a screwdriver bit and screwhead, such that torsion imparted to the adjustment means by the operator will result in the turning of the adjustment stem  760  and second geared head  755  allows motion of the first geared head  750  and worm  740 , which creates motion of the adjustable implant section  715  as the worm engages with the series of adjustment tops  725 . Excess length of the adjustable section  715  passes though a band slot  735  ( FIG. 23 ), thus allowing the band to move concentrically inside the closed implant body  705 . The adjustment element in this embodiment may be designed to remain in place after the deployment umbrella has been retracted and withdrawn. The connection between the adjustment element&#39;s distal tip and the adjustment stem  760  may be a simple friction connection, a mechanical key/slot formation, or may be magnetically or electronically maintained.  
         [0107]     As further shown in  FIG. 21 , the exemplary embodiment employs unidirectional retention barbs  710  which are attached to the outer perimeter of the implant body  705 . The retention barbs  710  are oriented in a consistent, tangential position with respect to the implant body  705  such that rotational motion of the implant body will either engage or release the retention barbs  710  upon contact with the desired tissue at the time of deployment. This positioning of the retention barbs  710  allows the operator to “screw in” the implant  700  by turning the implant  700  upon its axis, thus engaging the retention barbs  710  into the adjacent tissue. As shown in  FIG. 24 , the retention barbs  710  may each be further provided with a terminal hook  775  at the end which would allow for smooth passage through tissue when engaging the retention barbs  710  by rotating the implant  700 , without permitting the implant  700  to rotate in the opposite direction, because of the action of the terminal hooks  775  grasping the surrounding tissue (much like barbed fish hooks). The terminal hooks  775  thus ensure the seating of the implant  700  into the surrounding tissue.  
         [0108]      FIGS. 25-27  illustrate another embodiment of an implant  800  as contemplated according to the present invention. The implant  800  includes a band  805  ( FIG. 27 ), but the retention barbs of the previous example have been eliminated in favor of an outer fabric implant sheath  810 . The fabric sheath  810  can be sutured or otherwise affixed to the anatomic tissue in a desired location. The circumference of the implant body  800  is adjusted through a geared connector  825  similar to the geared connector of the bandlike implant array shown in  FIG. 23 . More specifically, adjustment stops  820  on the band are engaged by a mechanical worm  840  with an attached first geared head  850 . The first geared head  850  mates with a second geared head  855 . The second geared head  855  is attached to an adjustment stem  860  which is machined to receive a screwdriver-like adjustment element.  
         [0109]      FIG. 28  illustrates an example of the method of use of an implant/delivery system array  600  for positioning an implant  645  in a patient with ischemic annular dilatation and mitral regurgitation. Peripheral arterial access is obtained via conventional cutdown, arterial puncture, or other standard access techniques. After access to the arterial system is attained, guidewire placement is performed and intravascular access to the heart  900  is obtained using fluoroscopic, ultrasound, three-dimension ultrasound, magnetic resonance, or other real-time imaging techniques. The guidewire, deployment device, and implant are passed through the aortic valve in a retrograde fashion into the left ventricle  905  and then into the left atrium  910 . At this point, the operator retracts the housing sheath  605 , thus unsheathing the collapsed deployment umbrella  642  and implant  645 . The deployment umbrella  642  is then distended by the distal motion of the actuation catheter, causing the radial support arms and struts to fully distend. At this point, the touchdown detectors  648  are not in contact with any solid structures, and are fully extended with their radiolucent gaps visible on the imaging system. Once the deployment umbrella is distended, the entire assembly is pulled back against the area of the mitral valve  915 . At least two touchdown detectors  648  are employed in a preferred embodiment according to the present invention. When all touchdown detectors show the disappearance of their intermediate, non-opaque, intermediate segments and are thus activated, then the deployment umbrella must be in contact with the solid tissue in the region of the mitral annulus/atrial tissue, and further implant deployment and adjustment may proceed. However, if any one touchdown sensor is not activated, and a radiolucent gap persists, then the device is not properly positioned, and must be repositioned before further deployment. Thus, the touchdown sensor system may assist in the deployment and adjustment of prosthetic devices by the delivery system according to the present invention. Once properly positioned, the operator rotates the actuation catheter in a prescribed clockwise or counterclockwise manner to engage the retention barbs on the implant into the tissue in the region of the mitral annulus/atrial tissue. Should re-positioning be required, a reverse motion would disengage the retention barbs from the annular/atrial tissue, and repositioning may be performed, again using the touchdown detectors for proper placement. Once firmly seated, the adjustment element(s) are operated to achieve the desired degree of annular reduction. Real-time trans esophageal echocardiography, intravascular echocardiography, intracardiac echocardiography, or other modalities for assessing mitral function may then be employed to assess the physiologic effect of the repair on mitral function, and additional adjustments may be performed. Once a desired result has been achieved, the release elements are activated to detach the implant from the deployment umbrella. The operator then retracts the actuation catheter and extends the housing sheath, collapsing the deployment umbrella and covering the components for a smooth and atraumatic withdrawal of the device from the heart and vascular system.  
         [0110]     If desired, the adjustment elements may be left in position after the catheter components are withdrawn for further physiologic adjustment. In yet other embodiments according to the present invention, a catheter-based adjustment elements may subsequently be re-inserted though a percutaneous or other route. Such an adjustment element may be steerably operable by the operator, and may be provided with magnetic, electronic, electromagnetic, or laser-guided systems to allow docking of the adjustment element with the adjustable mechanism contained within the implant. In still other embodiments, the adjustment mechanism may be driven by implanted electromechanical motors or other systems, which may be remotely controlled by electronic flux or other remote transcutaneous or percutaneous methods.  
         [0111]     In the case of pulmonic valve repair, initial catheter access is achieved through a peripheral or central vein. Access to the pulmonary valve is also achieved from below the valve once central venous access is achieved by traversing the right atrium, the tricuspid valve, the right ventricle, and subsequently reaching the pulmonic valve.  
         [0112]     In yet other embodiments according to the present invention, catheter access to the left atrium can be achieved from cannulation of central or peripheral veins, thereby achieving access to the right atrium. Then a standard atrial trans-septal approach may be utilized to access the left atrium by creation of an iatrogenic atrial septal defect (ASD). In such a situation, the mitral valve may be accessed from above the valve, as opposed to the retrograde access described in Example 1. The implant and a reversed deployment umbrella may be utilized with implant placement in the atrial aspect of the mitral annulus, with the same repair technique described previously. The iatrogenic ASD may then be closed using standard device methods. Access to the aortic valve may also be achieved from above the aortic valve via arterial access in a similar retrograde fashion.  
         [0113]     Other embodiments of the adjustable implant and methods according to the present invention include gastrointestinal disorders such as gastro-esophageal reflux disease (GERD), a condition in which the gastro-esophageal (GE) junction lacks adequate sphincter tone to prevent the reflux of stomach contents into the esophagus, causing classic heartburn or acid reflux. This not only results in discomfort, but may cause trauma to the lower esophagus over time that may lead to the development of pre-cancerous lesions (Barrett&#39;s esophagus) or adenocarcinoma of the esophagus at the GE junction. Surgical repair of the GE junction has historically been achieved with the Nissen Fundoplication, an operative procedure with generally good results. However, the Nissen procedure requires general anesthesia and a hospital stay. Utilizing the devices and methods according to the present invention, an adjustable implant would obviate the need for a hospital stay and be performed in a clinic or gastroenterologist&#39;s office. Referring now to  FIGS. 29 and 30 , an umbrella deployment device  600  with implant  645  is passed under guidance of an endoscope  1000 , through the patient&#39;s mouth, esophagus  1005 , and into the stomach  1010 , where the deployment device  600  is opened with expansion of the implant  645  and touchdown detectors  648  with a color-coded or otherwise visible gap. The touchdown detectors are then engaged onto the stomach around the gastroesophageal junction  1015  under direct endoscopic control until all touchdown detectors  648  are visually activated. The implant is then attached to the stomach wall,  1020  the umbrella  642  is released and withdrawn, leaving behind the implant  645  and the adjustment elements. The implant is then adjusted until the desired effect is achieved, i.e., minimal acid reflux either by patient symptoms, pH monitoring of the esophagus, imaging studies, or other diagnostic means. If the patient should suffer from gas bloat, a common complication of gastroesophageal junction repair in which the repair is too tight and the patient is unable to belch, the implant can be loosened until a more desirable effect is achieved.  
         [0114]     In various embodiments anticipated by the present invention, the implant body may be straight, curved, circular, ovoid, polygonal, or some combination thereof. In various embodiments anticipated by the present invention the implant may be capable of providing a uniform or non-uniform adjustment of an orifice or lumen within the body. The implant body may further completely enclose the native recipient anatomic site, or it may be provided in an interrupted form that encloses only a portion of the native recipient anatomic site. In still other embodiments of the present invention, the implant body may be a solid structure, while in yet other embodiments the implant body may form a tubular or otherwise hollow structure. In one embodiment of the present invention, the body may further be a structure with an outer member, an inner member, and optional attachment members. In such an embodiment, the outer member of the implant body may serve as a covering for the implant, and is designed to facilitate and promote tissue ingrowth and biologic integration to the native recipient anatomic site. The outer member in such an embodiment may be fabricated of a biologically compatible material, such as Dacron, PTFE, malleable metals, other biologically compatible materials or a combination of such biologically compatible materials in a molded, woven, or non-woven configuration. The outer member in such an embodiment also serves to house the inner member. In this embodiment, the inner member provides an adjustment means that, when operated by an adjustment mechanism, is capable of altering the shape and/or size of the outer member in a defined manner.  
         [0115]     In alternate embodiments according to the present invention, the adjustment means may be located external to or incorporated within the outer member. In yet additional alternate embodiments contemplated by the present invention, the implant body may consist of an adjustment means without a separate outer member covering said adjustment means.  
         [0116]     In various embodiments according to the present invention, the adjustment means may include a mechanism which may be threaded or non-threaded, and which may be engaged by the action of a screw or worm screw, a friction mechanism, a friction-detent mechanism, a toothed mechanism, a ratchet mechanism, a rack and pinion mechanism, or such other devices to permit discreet adjustment and retention of desired size a desired position, once the proper size is determined.  
         [0117]     In yet other embodiments according to the present invention, the adjustment means may comprise a snare or purse string-like mechanism in which a suture, a band, a wire or other fiber structure, braided or non-braided, monofilament or multifilament, is capable of affecting the anatomic and/or physiologic effects of the implant device on a native anatomic recipient site upon varying tension or motion imparted to said wire or fiber structure by a surgeon or other operator. Such an adjustment means may be provided as a circular or non-circular structure in various embodiments. Changes in tension or motion may change the size and/or shape of the implant.  
         [0118]     In various embodiments according to the present invention, the adjustment means may be a metallic, plastic, synthetic, natural, biologic, or any other biologically-compatible material, or combination thereof. Such adjustment means may further be fabricated by extrusion or other molding techniques, machined, or woven. Furthermore, in various embodiments of the present invention, the adjustment means may be smooth or may include slots, beads, ridges, or any other smooth or textured surface.  
         [0119]     In various embodiments of the present invention, the implant body may be provided with one or more attachment members such as grommets or openings or other attachment members to facilitate attachment of the implant to the native recipient site. In alternate embodiments, the implant body may attach to or incorporate a mechanical tissue interface system that allows a sutureless mechanical means of securing the implant at the native recipient site. In still other alternate embodiments, sutures or other attachment means may be secured around or through the implant body to affix the implant body to the native recipient site. In yet other embodiments of the present invention, mechanical means of securing the implant body to the native recipient site may be augmented or replaced by use of fibrin or other biologically-compatible tissue glues or similar adhesives.  
         [0120]     In additional various embodiments according to the present invention, the adjustable implant may be employed to adjustably enlarge or maintain the circumference or other dimensions of an orifice, ostium, lumen, or anastomosis in which a disease process tends to narrow or constrict such circumference or other dimensions.  
         [0121]     In various embodiments according to the present invention, an adjustment mechanism may be provided to interact with the adjustment means to achieve the desired alteration in the size and/or position of the adjustment means. Such an adjustment mechanism may include one or more screws, worm-screw arrays rollers, gears, frictional stops, a friction-detent system, ratchets, rack and pinion arrays, micro-electromechanical systems, other mechanical or electromechanical devices or some combination thereof.  
         [0122]     In some embodiments as contemplated by the present invention, an adjustment tool may be removably or permanently attached to the adjustment mechanism and disposed to impart motion to the adjustment mechanism and, in turn, to the adjustment means to increase or decrease the anatomic effect of the implant on the native recipient site.  
         [0123]     In alternate embodiments according to the present invention, micromotor arrays with one or more micro-electromechanical motor systems with related electronic control circuitry may be provided as an adjustment means, and may be activated by remote control through signals convey by electromagnetic radiation or by direct circuitry though electronic conduit leads which may be either permanently or removably attached to said micromotor arrays.  
         [0124]     In still other various embodiments according to the present invention, the adjustment mechanism may be provided with a locking mechanism disposed to maintain the position of the adjustment means in a selected position upon achievement of the optimally desired anatomic and/or physiologic effect upon the native recipient site and the bodily organ to which it belongs. In other embodiments, no special locking mechanism may be necessary due to the nature of the adjustment means employed.  
         [0125]     In yet other alternate embodiments according to the present invention, the adjustment means and/or the outer member structure may be a pliable synthetic material capable of rigidification upon exposure to electromagnetic radiation of selected wavelength, such as ultraviolet light. In such embodiments, exposure to the desired electromagnetic radiation may be achieved by external delivery of such radiation to the implant by the surgeon, or by internal delivery of such radiation within an outer implant member using fiberoptic carriers placed within said outer member and connected to an appropriate external radiation source. Such fiberoptic carriers may be disposed for their removal in whole or in part from the outer implant member after suitable radiation exposure and hardening of said adjustment means.  
         [0126]     The present invention also provides methods of using an adjustable implant device to selectively alter the anatomic structure and/or physiologic effects of tissues forming a passageway for blood, other bodily fluids, nutrient fluids, semi-solids, or solids, or wastes within a mammalian body. Various embodiments for such uses of adjustable implants include, but are not limited to, open surgical placement of said adjustable implants at the native recipient site through an open surgical incision, percutaneous or intravascular placement of said implants under visual control employing fluoroscopic, ultrasound, magnetic resonance imaging, or other imaging technologies, placement of said implants through tissue structural walls, such as the coronary sinus or esophageal walls, or methods employing some combination of the above techniques. In various embodiments as contemplated by the present invention, adjustable implants may be placed and affixed in position in a native recipient anatomic site by trans-atrial, trans-ventricular, trans-arterial, trans-venous (i.e., via the pulmonary veins) or other routes during beating or non-beating cardiac surgical procedures or endoscopically or percutaneously in gastrointestinal surgery.  
         [0127]     Furthermore, alternate methods for use of an adjustable implant device may provide for the periodic, post-implantation adjustment of the size of the anatomic structure receiving said implant device as needed to accommodate growth of the native recipient site in a juvenile patient or other changes in the physiologic needs of the recipient patient.  
         [0128]     Adjustment of the adjustable implants and the methods for their use as disclosed herein contemplates the use by the surgeon or operator of diagnostic tools to provide an assessment of the nature of adjustment needed to achieve a desired effect. Such diagnostic tools include, but are not limited to, transesophageal echocardiography, echocardiography, diagnostic ultrasound, intravascular ultrasound, virtual anatomic positioning systems integrated with magnetic resonance, computerized tomographic, or other imaging technologies, endoscopy, mediastinoscopy, laparoscopy, thoracoscopy, radiography, fluoroscopy, magnetic resonance imaging, computerized tomographic imaging, intravascular flow sensors, thermal sensors or imaging, remote chemical or spectral analysis, or other imaging or quantitative or qualitative analytic systems.  
         [0129]     In one aspect, the implant/delivery system of the present invention comprises a collapsible, compressible, or distensible prosthetic implant and a delivery interface for such a prosthetic implant that is capable of delivering the prosthetic implant to a desired anatomic recipient site in a collapsed, compressed, or non-distended state, and then allowing controlled expansion or distension and physical attachment of such a prosthetic implant by a user at the desired anatomic recipient site. Such a system permits the delivery system and prosthetic implant to be introduced percutaneously through a trocar, sheath, via Seldinger technique, needle, or endoscopically through a natural bodily orifice, body cavity, or region and maneuvered by the surgeon or operator to the desired anatomic recipient site, where the delivery system and prosthetic implant may be operably expanded for deployment. When desirable, the implant/delivery system according to the present invention is also capable of allowing the user to further adjust the size or shape of the prosthetic implant once it has been attached to the desired anatomic recipient site. The delivery system according to the present invention is then capable of detaching from its interface with the prosthetic implant and being removed from the anatomic site by the operator. The delivery system and prosthetic implant may be provided in a shape and size determined by the anatomic needs of an intended native recipient anatomic site within a mammalian patient. Such a native recipient anatomic site may be a heart valve, the esophagus near the gastro-esophageal junction, the anus, or other anatomic sites within a mammalian body that are creating dysfunction that might be relieved by an implant capable of changing the size and shape of that site and maintaining a desired size and shape after surgery.  
         [0130]     In various embodiments contemplated by the present invention, the delivery system may be a catheter, wire, filament, rod, tube, endoscope, or other mechanism capable of reaching the desired recipient anatomic site through an incision, puncture, trocar, or through an anatomic passageway such as a vessel, orifice, or organ lumen, or trans-abdominally or trans-thoracically. In various embodiments according to the present invention, the delivery system may be steerable by the operator. The delivery system may further have a delivery interface that would retain and convey a prosthetic implant to the desired recipient anatomic site. Such a delivery interface may be operably capable of distending, reshaping, or allowing the independent distension or expansion of such a prosthetic implant at the desired recipient anatomic site. Furthermore, such a delivery interface may provide an operable means to adjust the distended or expanded size, shape, or physiologic effect of the prosthetic implant once said implant has been attached in situ at the desired recipient anatomic site. In various embodiments according to the present invention, such adjustment may be carried out during the procedure in which the implant is placed, or at a subsequent time. Depending upon the specific anatomic needs of a specific application, the delivery interface and the associated prosthetic implant may be straight, curved, circular, helical, tubular, ovoid, polygonal, or some combination thereof. In still other embodiments of the present invention, the prosthetic implant may be a solid structure, while in yet other embodiments the prosthetic implant may form a tubular, composite, or otherwise hollow structure. In one embodiment of the present invention, the prosthetic implant may further be a structure with an outer member, an inner member, and optional attachment members. In such an embodiment, the outer member of the prosthetic implant may serve as a covering for the implant, and is designed to facilitate and promote tissue ingrowth and biologic integration to the native recipient anatomic site. The outer member in such an embodiment may be fabricated of a biologically compatible material, such as Dacron, PTFE, malleable metals, other biologically compatible materials or a combination of such biologically compatible materials in a molded, woven, or non-woven configuration. The outer member in such an embodiment also serves to house the inner member. In this embodiment, the inner member provides an adjustment means that, when operated by an adjustment mechanism, is capable of altering the shape and/or size of the outer member in a defined manner.  
         [0131]     In some embodiments according to the present invention, at least some portions of the adjustable inner or outer member may be elastic to provide an element of variable, artificial muscle tone to a valve, sphincter, orifice, or lumen in settings where such variability would be functionally valuable, such as in the treatment of rectal incontinence or vaginal prolapse.  
         [0132]     In various embodiments according to the present invention, the delivery interface would have an attachment means to retain and convey the prosthetic implant en route to the native anatomic recipient site and during any in situ adjustment of the prosthetic implant once it has been placed by the operator. Such an attachment means would be operably reversible to allow detachment of the prosthetic implant from the delivery interface once desired placement and adjustment of the prosthetic implant has been accomplished.  
         [0133]     In one embodiment of the present invention, illustrated in  FIG. 31 , an implantable device system  1000  for controlling at least the size or shape of an anatomical structure or lumen includes an implantable device  1002  and an adjustment tool  1006 . The anatomical structure or lumen is an anatomic site with dysfunction that can be relieved by the implantable device  1002  to change a size or shape of the anatomic site.  
         [0134]     The implantable device  1002 , in one exemplary embodiment, has a diameter no larger than 3.5 mm. In another embodiment the implantable device  1002  is configured to have variable size relative to its placement at an annulus of a heart valve. The implantable device  1002  has an adjustable member  1004  configured to adjust the dimensions of the implantable device  1002 . In one embodiment, the torqueable adjustment tool  1006  provides adjustment of the dimensions of the implantable device  1002 . The adjustable member  1004 , in some embodiments, may be oriented to receive the adjustment tool from a direction generally perpendicular to the primary plane defined by the implant device  1002 . Such an orientation is advantageous for intravenous access of the tool and in situ adjustment of the implant device  1002 . The implantable device  1002  can have a configuration where there are different pulling rates at different sections of the implantable device  1002 . The implantable device  1002  may optionally include a flexible tube ( 1032 ,  FIG. 38 ) and an outer fabric sheath ( 810 ,  FIGS. 25 and 26 ), which are not shown in the subsequent figures for clarity. The outer fabric sheath can be sutured, stapled, clipped, coiled, or otherwise affixed to anatomic tissue in a desired location. Generally the desired location is considered to be the internal surface of the area to be controlled, such as (for example) an interior wall of an organ, artery, or other internal anatomic passage. Also, while the implantable device  1002  is generally shown in the subsequent figures to have a “D”-shaped configuration, it should be understood that other shapes can be used in accordance with embodiments of the present invention.  
         [0135]     Still referring to  FIG. 31 , in certain embodiments, the adjustment tool  1006  is at least partially hollow, and in one specific embodiment at least 50% hollow. The adjustment tool  1006  may be an elongated tool, which has a proximal end and a distal end releasably attached to the adjustable member  1004  of implantable device  1002 . The adjustment tool  1006  may extend from its distal end coupled to the adjustable member  1004  to a control interface (e.g., handle) at the proximal end located preferably outside of the patient&#39;s body. The adjustment tool  1006 , when coupled to the adjustable member  1004  of implantable device  1002 , can provide a preferential shape change of the implantable device  1002  in planar and non-planar directions. The adjustment tool  1006  can adjust the implantable device  1002  in terms of narrowing or widening the dimensions of the implantable device  1002 .  
         [0136]      FIG. 32A  is a schematic of the implant device  1002  without showing an optional flexible outer tube and fabric sheath. The implantable device includes an adjustable member  1004  and adjustable tube portions  1013   a  and  1013   b , which slide within hollow tube portions  1014   a  and  1014   b , and retaining tube  1015 .  FIG. 32B  is a schematic of a disassembled portion of implantable device  1002  with retaining tube  1015  removed. As shown in  FIG. 32B , in various embodiments, the implantable device  1002  includes a threaded rod  1008  threaded with right-hand helical grooves  1010  and left-hand helical grooves  1012 . Other embodiments may include a threaded rod  1008  with helical grooves in a single direction (e.g., all right-hand grooves or all left-hand grooves). Threaded rod  1008  may be a rigid material such as titanium, stainless steel, or a polymer. Adjustable tube portions  1013   a  and  1013   b  enclose at least a portion of grooves  1010  and  1012  so that pins  1016   a ,  1016   b  or protuberances on the inside diameter of the adjustable tube portions  1013   a ,  1013   b  are engaged by the grooves  1010  and  1012 , respectively. In other embodiments, pins  1016   a ,  1016   b  may be replaced by threads along the inside diameter of the adjustable tube portions  1013   a ,  1013   b . Helical grooves  1010  and  1012  may be single channels or multiple channels to engage single pins  1016   a ,  1016   b  or multiple pins. Hollow tube portions  1014   a ,  1014   b  are relatively rigid to maintain curvature of the adjustable tube portions  1013   a ,  1013   b  regardless of the adjustment position.  
         [0137]     The implantable device  1002  can have a coating including, but not limited to, heparin, and antibiotic, collagen, and an agent that promotes tissue in growth, PGLA, a de-calcification agent and the like. The implantable device  1002  can be made of a variety of materials including, but not limited to, a shape memory alloy (SMA), a shape memory polymer (SMP), titanium, stainless steel, polymer, a suture-based material, a biological material and the like.  
         [0138]     In another embodiment of the present invention, illustrated in  FIGS. 33 through 37 , the adjustable member  1004  provides translated motion through rotation.  FIGS. 33 through 35  illustrate a theory of operation of an embodiment of the present invention, while  FIGS. 36 and 37  shown details of the adjustment member  1004 .  
         [0139]     Referring to now  FIG. 33 , adjustable member  1004  of implantable device  1102  is shown including a docking port  1021  to receive the distal tip of the adjustment tool  1006  ( FIG. 31 ). In this embodiment, implant device includes a set of inner tubing  1028   a ,  1028   b  and a set of outer tubing  1026   a ,  1026   b  that can move relative to each other. The ends of the inner tubing  1028   a ,  1028   b  that do not engage the outer tubing  1026   a ,  1026   b  are secured to a set of hollow tubing  1014   a ,  1014   b  so that the inner tubing  1028   a ,  1028   b  does not move relative to the hollow tubing  1014   a ,  1014   b . Although hollow tube portions  1014   a ,  1014   b  may be separate pieces that are permanently abutted when assembled, in some embodiments, the hollow tube portions  1014   a ,  1014   b  may be formed from a single tubing piece. An inner cable  1030  passes through the various tubing. Thus, the rigidity of the hollow tubing can be used to maintain the adjustable implant  1102  shape in certain dimensions so that adjustment of the device can be restricted to a preferred dimension, for example, an anterior-posterior dimension.  
         [0140]     As shown in more detail in  FIGS. 36 and 37 , adjustable member  1004  may also include a pinion gear  1022  (which may be integral to a docking port  1021 ) and a crown gear  1024 .  FIG. 36  provides an isometric view of the adjustable member  1004 , and  FIG. 37  provides a cut-away view of the adjustable member  1004 . As can be seen in the figures, the pinion gear  1022  engages the crown gear  1024 . In some embodiments, the pinion gear  1022  may be eliminated from adjustable member  1004 , and the distal tip of the adjustment tool  1006  may serve as the pinion gear when the tool is coupled to the docking port  1021 . When coupled to the docking port  1021 , the adjustment tool  1006  can rotate the pinion gear  1022 .  
         [0141]     Referring back to  FIG. 33 , the implantable device  1102  is shown generally at the middle of its adjustment range. Outer tubing  1026   a ,  1026   b  is affixed to the adjustable member  1004  and extends along a portion of the circumference of implantable device  1102 . Inner tubing  1028   a ,  1028   b  is affixed to hollow tubing  1014   a ,  1014   b , respectively. Similar to the single threaded rod  1008  of  FIG. 32B , threaded rods  1018   a ,  1018   b  sit inside the hollow tubing  1014   a ,  1014   b  and are threadedly engaged therewith. Threaded rods  1018   a ,  1018   b  may be a rigid material such as titanium, stainless steel, or a polymer. Hollow tube portions  1014   a ,  1014   b  enclose the threaded rods  1018   a ,  1018   b  such that rotation of the threaded rods  1018   a ,  1018   b  causes them to move axially within the hollow tube portions  1014   a ,  1014   b . The threaded rod  1018   a  may have right-handed threads, and the threaded rod  1018   b  may have left handed threads. Other embodiments may include threaded rods  1018   a ,  1018   b  with threads in a single direction (e.g., all right-hand grooves or all left-hand threads).  
         [0142]     The crown gear  1024 , and one end of each threaded rod  1018   a ,  1018   b  are all attached to an inner cable  1030 . Inner cable  1030  may be a cable or tube of any material with sufficient flexibility to conform to a shape of the implantable device  1102  while translating torque. For example, suitable material for inner cable  1030  may include titanium or stainless steel. As shown more clearly in  FIGS. 36 and 37 , the rotation of crown gear  1024  imparts rotation to cable  1030  in the same direction.  
         [0143]     Referring to  FIG. 34 , when the handle of adjustment tool  1006  (not shown in this figure) is rotated clockwise in docking port  1021 , it causes clockwise rotation of the pinion gear  1022  (in  FIG. 36 ). Rotation of the pinion gear  1022  in turn rotates crown gear  1024 . The rotation of crown gear  1024  causes rotation of inner cable  1030 , which imparts rotational movement to each threaded rod  1018   a ,  1018   b . The rotation applied to the threaded rods  1018   a ,  1018   b  causes them to advance into their respective hollow tubing  1014   a ,  1014   b  in the directions A 1 , A 2  shown. As shown in  FIG. 34 , when threaded rods  1018   a ,  1018   b  advance toward the middle of the hollow tubing  1014   a ,  1014   b  the overall circumference of the implant device  1002  is reduced. Advancing the threaded rods  1018   a ,  1018   b  drives the inner cable  1030  into the hollow tubing  1014   a ,  1014   b . Translation of inner cable  1030  into the hollow tubing  1014   a ,  1014   b  causes the hollow tubing  1014   a ,  1014   b  to move towards adjustable member  1004  in the direction B 1  shown. Inner tubing  1028   a ,  1028   b  slides into outer tubing  1026   a ,  1026   b  to accommodate movement of the inner cable  1030 .  
         [0144]     Referring to  FIG. 35 , the handle of adjustment tool  1006  (not shown in this figure) is rotated counter-clockwise in docking port  1021  to cause counter-clockwise rotation of the pinion gear  1022  ( FIG. 36 ). Rotation of the pinion gear  1022 , in turn rotates crown gear  1024 . The rotation of crown gear  1024  causes rotation of inner cable  1030 , which imparts rotational movement to each threaded rod  1018   a ,  1018   b . The rotation applied to the threaded rods  1018   a ,  1018   b  causes them to begin to withdraw from their respective hollow tubing  1014   a ,  1014   b  in the directions A 2 , A 1  shown. As shown in  FIG. 35 , as threaded rods  1018   a ,  1018   b  withdraw from the middle of the hollow tubing  1014   a ,  1014   b  the overall circumference of the implant device  1002  is increased. Withdrawal of the threaded rods  1018   a ,  1018   b  pushes the inner cable  1030  out of the hollow tubing  1014   a ,  1014   b . Translation of inner cable  1030  out of the hollow tubing  1014   a ,  1014   b  causes the hollow tubing  1014   a ,  1014   b  to move away from adjustable member  1004  in the direction B 2  shown. Inner tubing  1028   a ,  1028   b  telescopes out of outer tubing  1026   a ,  1026   b  to accommodate movement of the inner cable  1030 .  
         [0145]     The inner tubing  1028   a ,  1028   b , the outer tubing  1026   a ,  1026   b , and the hollow tubing  1014   a ,  1014   b  may be covered by a flexible tube  1032 , such as a silicone tube, shown in  FIG. 38 . In one embodiment, outer flexible tube  1032  is provided with no seam in the axial direction of the tube to allow for better tissue ingrowth after the implant procedure. In other embodiments inner tubing  1028   a ,  1028   b  may be eliminated, as shown in  FIG. 39 .  
         [0146]      FIG. 39  provides an assembled cross-section view of an implantable device  1202  according to an embodiment of the invention. The implant device includes the adjustable member  1004 , the outer tubing  1026   a ,  1026   b , the hollow tubing  1014   a ,  1014   b , the inner cable  1030 , and the threaded rods  1018   a ,  1018   b  as discussed in relation to  FIGS. 33-35 . As shown in  FIG. 39 , hollow tubing  1014   a ,  1014   b  may extend further along the length of inner cable  1030  than shown in other embodiments of  FIGS. 33-35  to better maintain a preferred shape of the implant. Hollow tubing  1014   a ,  1014   b  may be threaded to receive the threaded rods  1018   a ,  1018   b ; or hollow tubing may optionally include a threaded insert (spar  1019   a ,  1019   b ) affixed to the inner diameter of hollow tubing  1014   a ,  1014   b . In operation, as previously described, an adjustment tool may impart motion to the adjustable member  1004 . Gears in the adjustable member translate motion to the inner cable  1030  that, in turn translate motion to the attached threaded rods  1018   a ,  1018   b . Depending on the direction of rotation, rotation of threaded rods  1018   a ,  1018   b  causes the threaded rods  1018   a ,  1018   b  to be drawn toward or away from the middle of the hollow tubing  1014   a ,  1014   b , thus reducing or increasing the overall circumference of the implant device  1002 . The flexible outer tube  1032  and a seal jacket  1100  (also shown in  FIG. 40 ) encapsulate the device so that no moving parts are exposed. The flexible outer tube  1032  provide sufficient rigidity to maintain a generally planar dimension, while allowing the device to adjust shape generally in a preferred dimension, such as the anterior-posterior dimension. As shown in  FIG. 39 , the flexible outer tube  1032  may be further covered by an outer fabric sheath  1110  or thin sewing cuff. Elimination of the inner tubing ( 1028   a ,  1028   b  of  FIG. 35 ) eliminates the need for telescoping parts and prevents the possibility of telescoping tubes being sutured or clipped together during attachment of the implant.  
         [0147]     Referring to  FIG. 40 , the adjustable member  1004  can include a seal jacket  1100 .  FIG. 40  shows an embodiment of the seal jacket  1100 . The seal jacket  1100  may include a cover  1102  for the docking port  1021  ( FIG. 33 ) of the adjustable member  1004 . The cover  1102  may be in the form of a slit septum, flaps, elastic material or the like. The seal jacket cover  1102  may be included as part of a seal jacket  1100  that covers the entire housing of the adjustable member  1004  or a separate piece. In one embodiment, the seal jacket  1100  may be secured to the flexible tube  1032 . The seal jacket  1100  and flexible tube  1032  may be secured by an adhesive bond, a wrap, sutures, or the like. The cover  1102  provides access for an adjustment tool to couple to the docking port, while reducing the possibility of thrombus. In some embodiments, seal jacket cover  1102  and/or the seal jacket  1100  may be made of silicone, and covered by a polyester sewing layer or fabric sheath (e.g.,  1110  of  FIG. 39 ). In various embodiments, the seal jacket fits over the housing of the adjustable member  1004  that includes a crown gear coupled to a cable, can provide pinion access, and the like. In operation, the distal tip of an adjustment tool passes through the cover  1102  to engage the rotatable gear of adjustable member  1004 .  
         [0148]      FIG. 41  shows an embodiment of implantable device  1302  including a first adjustment band  1042   a  and a second adjustment band  1042   b . The first and second adjustment bands  1042   a ,  1042   b  can be overlapped, and the amount of overlap is effected by how the implantable device  1302  is sized. The first and second bands  1042   a ,  1042   b  can be slidable relative to each other. An adjustable member  1304  is coupled to the first band  1042   a  and the second band  1042   b , and pulls or pushes them toward or away from each other. The first band  1042   a  and the second band  1042   b  can have flexible portions  1046   a ,  1046   b  configured to create a flexible zone at the primary bend regions  1047   a ,  1047   b . The flexible portions  1046   a ,  1046   b  can have varying lengths and may also include one or more rigid portions  1044 . These rigid portions  1044  can include welded braids or bands, or have a higher durometer material than the flexible portions  1046   a ,  1046   b . The flexible portions  1046   a ,  1046   b  and rigid portions  1044  may be part of the same material as the first and second bands  1042   a ,  1042   b , or one or more portions may be separate material that is joined to form continuous piece.  
         [0149]     The first and second bands  1042   a ,  1042   b  can have different sizes or the same sizes. In one specific embodiment, the first and second bands  1042   a ,  1042   b  are about 0.5 to 3 mm in thickness and about 5 to 10 mm in width. The first and second bands  1042   a ,  1042   b  can be made of a variety of materials including, but not limited to, an SMA, an SMP, titanium, stainless steel, polymer, a suture-based material, a biological material and the like. In one embodiment, the first and second bands  1042   a ,  1042   b  include a plurality of band layers. At least a portion of the first and second bands  1042   a ,  1042   b  may have superelastic properties. Implant  1302  may include a flexible, extruded outer layer (not shown) or hollow tube, such as flexible tube  1032  of  FIG. 38 , to encase the structure formed by the first and second bands  1042   a ,  1042   b  flexible portions  1046   a ,  1046   b , and rigid portions  1044 . The parts of the first and second bands  1042   a ,  1042   b , that extend past adjustable member  1304  can be contained within the hollow interior of the outer layer.  
         [0150]      FIG. 42  provides a more detailed schematic view of the unassembled adjustment bands and adjustment member of  FIG. 41 . The first and second bands  1042   a ,  1042   b  may include a series of adjustment stops  1048 . Adjustment stops may be in the form of holes, detents, dimples, ridges, teeth, raised elements, other mechanical features or the like. These holes  1048  on each of the bands  1042   a ,  1042   b  are coupled to an adjustable member  1304 . The adjustable member  1304  may be generally cylindrical (such as a spool) with a series of teeth  1050  or protrusions radially positioned to engage the adjustment stops  1048 . Adjustable member  1304  may also include a docking port  1320  to receive an adjustment tool to trigger rotational movement of the adjustable member.  
         [0151]      FIG. 43  provides an assembled view of the adjustment band and adjustment member of  FIG. 42 . When mounted in a housing (not shown in  FIG. 43 ), the adjustable member  1304  may be mounted on an axis to allow for rotational movement. The first and second bands  1042   a ,  1042   b  pass on either side of adjustable member  1304  so that the teeth  1050  engage the adjustment stops  1048  in each of the bands  1042   a ,  1042   b . Rotating the adjustable member in turn tightens or loosens the bands.  
         [0152]      FIG. 44  is a cut-away view of an embodiment of the gearbox for the adjustment band of  FIG. 41 . In this embodiment, the adjustable member  1304  rests on a spring  1052  inside a housing  1040  for the adjustable member. The housing  1040  includes access and guidance for the first and second bands ( 1042   a ,  1042   b  of  FIG. 43 ) to couple with the teeth  1050  of the adjustable member  1304 . The spring  1052  forces the adjustable member  1304  upward so that teeth  1056  on the top of the adjustable member  1304  engage with teeth  1058  on the inside upper surface of the housing  1040 . Engagement of the adjustable member teeth  1056  with the housing teeth  1058  locks the adjustable member  1304  in place to prevent rotational movement. Downward force, applied for example by an adjustment tool, against the spring  1052  disengages the teeth  1056  and  1058  so that the adjustable member  1304  can be rotated to adjust the size or shape of implantable device  1302 .  
         [0153]     In another embodiment,  FIG. 45  provides a schematic view of an implantable device  1402  of the present invention with a plurality of sliding bands that can be opened and closed to effect a shape change. As with the previous embodiments of  FIGS. 41-44 , the first and second bands  1042   a ,  1042   b  pass on either side of adjustable member  1304  so that the teeth  1050  engage the adjustment stops  1048  in each of the bands  1042   a ,  1042   b . Additional bands  1042   c  may be incorporated to increase stiffness at different areas of the implant device  1402  to provide preferential shape change. The additional bands  1042   c  may be secured to the first and second bands  1042   a ,  1042   b  using welds  1043 , adhesive or other mechanical techniques known in the art.  
         [0154]     As illustrated in  FIG. 46 , in one embodiment, an implantable device  1502  has an anterior portion  1060 , a posterior portion  1062  and dual threads that provide preferential adjustment of one side or the other of implantable device  1002 . The implantable device  1502  has two independently adjustable threaded portions  1064   a ,  1064   b  used to achieve different pulling rates and/or lateral dimensions. The adjustable threaded portions  1064   a ,  1064   b  can be connected to one or more adjustable member  1004  of the implantable device  1502  and positioned at either the posterior or anterior portions of the implantable device  1502 . In one embodiment, the posterior portion  1062  may be a rigid member which includes threaded hex screws  1066   a ,  1066   b , internal threads or similar structures. In one embodiment, the hex screws  1066   a ,  1066   b  are attached in a manner that allows rotation of the hex screws so that the threads may engage adjustable threaded portions  1064   a ,  1064   b . Rigid posterior portion  1062  may include one or more of adjustable members  1004  that can receive a tool to impart rotational motion through an inner tube or cable to one or more of hex screws  1066   a ,  1066   b , as described above. Anterior portion  1060  may be a flexible tube to accommodate shape change as the anterior and posterior portions  1060 ,  1062  move relative to each other.  
         [0155]     In another embodiment, differently pitched threads or other mechanisms may be used to provide non-symmetrical shape change of the implant device. For example, referring to  FIG. 46 , wider threads on threaded portion  1064   b , in relation to the threads of threaded portion  1064   a , would allow an adjustable member  1004  to expand or contract the implant  1502  more rapidly on the side of threaded portion  1064   b  to provide preferential shape change for a selected region while using a single adjustable member.  
         [0156]      FIG. 47  is a schematic view of an embodiment of an adjustable member  1604  for an implantable device. An adjustment tool may impart reciprocating motion to the adjustable member  1604  that includes a clover gear  1070  mounted in a housing  1072 . The inner cable  1030  ( FIG. 33 ) of the implantable device, for example, is affixed to the clover gear  1070  such that rotation of the clover gear transmits torque through the inner cable  1030  to a screw or other adjustable portion of the implantable device as previously disclosed. In this embodiment, the adjustment tool can provide reciprocating action to provide for adjustment. The adjustable member takes an axial force applied to the control portion at the proximal end of the adjustment tool and converts it to a rotational force applied to the inner cable  1030  of the implantable device. Reciprocating axial force may be provided from an adjustment tool by using spring-mounted buttons pressed by the user. Pressing a first button may transmit a downward axial motion to a first ribbon  1074  which engages the clover gear  1070  to cause clockwise rotation of the clover gear  1070 . A spring or other return force pushes the first ribbon back to its original position after each click or press of the button. Similarly, pressing a second button may transmit a downward axial motion to a second ribbon  1076  that engages the clover gear  1070  to cause counter-clockwise rotation of the clover gear  1070 .  
         [0157]     In another embodiment, the adjustment tool provides coarse adjustment and fine adjustment. This varied adjustment can be achieved with the adjustment tool having screws with different threads.  
         [0158]      FIG. 48  provides a schematic view of an embodiment of the implantable device system  1000  including an adjustment tool  1706  with high column strength and stiffness. The adjustment tool  1706  has a shaft  1794  and a handle  1096  with sufficient column strength to ensure a downward axial force on the handle  1096  provides proper engagement with the adjustable member  1004  of the implantable device  1002 . The handle  1096  may be a grip-like handle, as shown, or a smaller pen-type handle. The adjustment tool  1706  can include mechanical locking at the distal region  1782  to lock with the adjustable member  1004 . The mechanical locking is configured to provide engagement and disengagement tactile feel to the physician.  
         [0159]      FIG. 49  is a schematic view of another embodiment of the implantable device system  1000  including an adjustment tool  1806  with reduced column stiffness. The adjustment tool  1806  has a handle  1096  a shaft  1080  with reduced column stiffness for greater flexibility and easier articulation of the adjustment tool  1806 . The handle  1096  may be a grip-like handle, as shown, or a smaller pen-type handle. The easier articulation offered by the this embodiment may facilitate user positioning of the device in vivo and clearing adjacent biological structures, particularly when it is docketed to the adjustable member  1004  of the implant  1002 . Flexibility may be varied along the length of the adjustment tool shaft  1080 . Flexibility may be increased at the distal region  1082  of the adjustment tool shaft  1006 , particularly in the region immediately proximal to the gear/fitting at the distal tip of the adjustment tool  1006 . This gear/fitting is constrained orthogonally to the adjustable member  1004 , and it is important that the adjustment tool  1006  be easy to insert/connect and remain clear of biological structures.  
         [0160]      FIG. 50  provides a view of an embodiment of the proximal end of the adjustment tool  1006 . Referring to  FIG. 50 , adjustment tool  1006  includes a flexible cable  1094  or similar structure that is affixed to and rotates with a handle  1996 . In other embodiments, the adjustment tool  1006  can have cables, a band, tubes, rods, and the like to impart rotational and/or axial motion from the proximal end to the distal tip of the tool  1006 . The flexible cable  1094  may be enclosed by a flexible, low-friction cable jacket  1098  that allows the cable  1094  to rotate freely within the jacket  1098 . In some embodiments, adjustment tool  1006  may also include a spring release mechanism to allow disengagement of the distal tip of the tool from the docking port  1021  ( FIG. 33 ) with minimal force being applied to the sutures (or other mechanisms) securing the implant device to the tissue of an anatomic orifice or lumen. As shown in  FIG. 50 , in some embodiments, an e-clip  1099  or similar device may be used near the handle  1996  of the adjustment tool  1006  to secure the release mechanism in the docking station until adjustments are complete.  
         [0161]     In one embodiment illustrated in  FIG. 51 , the adjustment tool  1006  may be inserted inside a rigid sheath  1092  that reaches the implantable device  1002 . Thus,  FIG. 51  is a schematic view of an embodiment of the implantable device system  1000  of the present invention with an articulated shape. The rigidness of the sheath  1092  provides the necessary column strength to support the flexible adjustment tool  1006 . An added benefit to this embodiment is that the sheath may be left in place, docked to the implantable device  1002 . The flexible adjustment tool  1006  may be removed and then reinserted at some future time to engage with the adjustable member  1004  of implantable device  1002 .  
         [0162]     The adjustment tool  1006  can have a handle  1096  that can be adjustable. The handle  1096  can have a length of at least 8 inches, and in one embodiment at least 10 inches. Other embodiments may have a shorter or longer handle length. The handle  1096  may be thick to provide a hand-grip, or, in other embodiments, smaller to provide a pen-like grip. The handle can have a device to quantify a size change of the implantable device  1002 . For example, a half-turn of the adjustment tool handle can be correlated to a distance of travel of the threaded rods  1018   a ,  1018   b  ( FIG. 33 ) of an implant  1002 , thus allowing for measured adjustment of the implant. The handle may include a click-counter or other known device to measure rotational movement. In one embodiment, the adjustment tool  1006  may be included in a percutaneous delivery catheter.  
         [0163]     A sensor, such as the touchdown sensor described in relation to  FIGS. 12-18  above, can be coupled to the implantable device  1002 . A variety of different sensors can be utilized, including but not limited to, sensors that measure pressure, temperature and flow across the implantable device  1002 . Pacing leads are coupled to the sensor and the implantable device  1002 , and in this embodiment, the sensor is responsive to flow through the implantable device  1002 .  
         [0164]     In another embodiment the implantable device system may include a micro-electromechanical motor system in conjunction with or instead of a separate adjustment tool to commence rotational movement in an adjustable member. Power and control of the micro-electromechanical motor system can be provided by electromagnetic radiation or through a direct wire connection and previously described herein.  
         [0165]     Finally, it will be understood that the preferred embodiment has been disclosed by way of example, and that other modifications may occur to those skilled in the art without departing from the scope and spirit of the appended claims.