Patent Publication Number: US-11382749-B2

Title: Systems and methods for delivery of annuloplasty rings

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This application is a Continuation of U.S. patent application Ser. No. 14/775,735 filed Sep. 14, 2015, entitled, “SYSTEMS AND METHODS FOR DELIVERY OF ANNULOPLASTY RINGS,” which is a U.S. national stage filing under 35 U.S.C. § 371 of International Application No. PCT/US2014/030163 filed on Mar. 17, 2014 which claims the priority benefit of U.S. Provisional Patent Application No. 61/791,814, filed on Mar. 15, 2013 and entitled “SYSTEMS AND METHODS FOR DELIVERY OF ANNULOPLASTY RINGS”, the entire contents of each are incorporated herein by reference in [its] their entirety. 
    
    
     BACKGROUND 
     Heart valve defects, such as, for example, regurgitation, may be caused by a relaxation of the tissue surrounding a heart valve (for example, the mitral valve or the tricuspid valve). This causes the valve opening to enlarge, which prevents the valve from sealing properly. Such heart conditions are commonly treated by a procedure during which an annuloplasty ring is fixed or secured to the annulus of the valve. Cinching or securing the tissue of the annulus to the annuloplasty ring can restore the valve opening to approximately its original size and operating efficiency. 
     Typically, annuloplasty rings are implanted during open heart surgery so that the annuloplasty ring can be sewn into the valve annulus. However, open heart surgery is a highly invasive procedure that requires connecting a heart and lung machine (to pump the patient&#39;s blood and breathe for the patient), stopping the patient&#39;s heart, and surgically opening the thoracic cavity and heart organ. Accordingly, the procedure can expose the patient to a high, risk of infection and may result in a long and difficult recovery. The recovery may be particularly difficult for patients in less than optimal health due to the effects of suffering from a heart, valve defect such as regurgitation. 
     SUMMARY 
     In an embodiment, a system for percutaneous, transcatheter heart valve repair may include a catheter configured to provide percutaneous access into a heart of a patient, an adjustable annuloplasty ring, and a stabilizer. The adjustable annuloplasty ring may include a body member that is transitionable from an elongate insertion geometry to an annular operable geometry. The elongate insertion geometry may be configured to allow percutaneous passage of the annuloplasty ring, via the catheter, into the heart of a patient. The annular operable geometry may have an expanded slate to conform to an annulus of a target valve of the heart and a contracted state to reduce a diameter of the annulus of the target valve. The adjustable annuloplasty ring may also include a plurality of anchors deployable in the annular operable geometry to engage the annulus of the target valve. The stabilizer comprising a plurality of prongs configured to engage the annuloplasty ring in the annular operable geometry within the heart to enable percutaneous manipulation of the ring to orient and position the ring in intimate contact with the annulus of the target valve. 
     In an embodiment, a delivery system for percutaneous, transcatheter heart valve repair may include a catheter, a ring shuttle, and a deployment handle. The catheter may be configured to provide percutaneous access into a heart of a patient and configured to receive an adjustable annuloplasty ring in an elongate insertion geometry that is transitionable to an annular operable geometry. The ring shuttle may be configured to releasably couple to the annuloplasty ring and pass the annuloplasty ring through the catheter into the heart of the patient. The deployment handle may be configured to percutaneously manipulate the annuloplasty ring and the ring shuttle to deploy the annuloplasty ring. 
     In an embodiment, a method for percutaneous, transcatheter heart valve repair may include inserting a distal end of a catheter into a target valve, guiding, via a delivery system, an annuloplasty ring in an elongate geometry from a proximal end of the catheter to the distal end such that the annuloplasty ring transitions to an annular operable geometry upon exiling the distal end of the catheter, and deploying a plurality of anchors from the annuloplasty ring to engage an annulus of the target valve. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1A  depicts a perspective view of an illustrative adjustable annuloplasty ring in an annular (D-shaped) operable geometry and a contracted state according to an embodiment. 
         FIG. 1B  depicts a perspective view of an illustrative adjustable annuloplasty ring in an expanded state according to an embodiment. 
         FIG. 1C  depicts a schematic diagram of an illustrative cutting pattern used for laser processing a hypotube of an adjustable annuloplasty ring according to an embodiment. 
         FIG. 2A  depicts a schematic diagram, of a perspective view of a second illustrative adjustable annuloplasty ring in an annular (D-shaped) operable geometry and a contracted state according to an embodiment. 
         FIG. 2B  depicts a schematic diagram of a perspective view of an illustrative adjustable annuloplasty ring in an expanded state according to an embodiment. 
         FIG. 3A  depicts a schematic diagram of a perspective view of a second illustrative adjustable annuloplasty ring in an annular (D-shaped) operable geometry and in an expanded state according to an embodiment. 
         FIG. 3B  depicts a schematic diagram of a perspective view of a second illustrative adjustable annuloplasty ring in a contracted state according to an embodiment. 
         FIG. 4A  depicts a perspective view of an illustrative stepped connector of an adjustable annuloplasty ring according to an embodiment. 
         FIG. 4B  depicts a cross-sectional view of an illustrative stepped connector of an adjustable annuloplasty ring according to an embodiment. 
         FIG. 5A  depicts a schematic diagram illustrating a side view of an internal anchor ribbon including a plurality of curved anchors according to an embodiment. 
         FIG. 5B  depicts a schematic diagram of a top view of illustrative anchors cut into an internal anchor ribbon in an elongate insertion geometry according to an embodiment. 
         FIG. 5C  depicts a schematic diagram of a side view of an illustrative internal anchor ribbon in an elongate insertion geometry and a plurality of anchors in a curled or curved deployed configuration according to an embodiment. 
         FIG. 5D  depicts a schematic diagram of a top view of an illustrative internal glide ribbon in an elongate insertion geometry according to an embodiment. 
         FIG. 5E  depicts a schematic diagram of a side view of an illustrative internal glide ribbon according to an embodiment. 
         FIG. 5F  depicts a front view of a tube-like polymeric element according to an embodiment. 
         FIG. 5G  depicts a side view of a tube-like polymeric element according to an embodiment. 
         FIG. 5H  depicts a top view of a polymeric element according to an embodiment. 
         FIG. 5I  depicts a first side view of a polymeric element according to an embodiment. 
         FIG. 5J  depicts a second side view of a polymeric element according to an embodiment. 
         FIG. 6A  depicts a schematic diagram of a cross-sectional side view of an annuloplasty ring before deployment of a plurality of anchors according to an embodiment. 
         FIG. 6B  depicts a schematic diagram of a cross-sectional side view of the annuloplasty ring of  6 A after deployment of a plurality of anchors. 
         FIG. 6C  depicts a schematic diagram of a side view of various segments of illustrative internal anchors according to an embodiment. 
         FIG. 7  depicts a schematic diagram of a side view of an illustrative internal anchor member including linear anchors according to an embodiment. 
         FIG. 8A  depicts a schematic diagram of an illustrative trans-septal approach for endovascular delivery of an annuloplasty ring to the mitral valve of a heart according to an embodiment. 
         FIG. 8B  depicts a schematic diagram of an illustrative retrograde approach of an annuloplasty ring to the mitral valve of a heart according to an embodiment. 
         FIG. 8C  depicts a schematic diagram of an illustrative trans-apical approach of an annuloplasty ring to the mitral valve of a heart according to an embodiment. 
         FIG. 9A  depicts a flow diagram of a first illustrative method of placing an annuloplasty ring at a target valve according to an embodiment. 
         FIG. 9B  depicts a flow diagram of a second illustrative method of placing an annuloplasty ring at a target valve according to an embodiment. 
         FIG. 9C  depicts a schematic diagram of transcatheter delivery of an annuloplasty ring from a delivery system according to various embodiments. 
         FIG. 9D  depicts a schematic diagram of transcatheter delivery of an annuloplasty ring from a delivery system after  FIG. 9C  according to various embodiments. 
         FIG. 9E  depicts a schematic diagram of transcatheter delivery of an annuloplasty ring from a delivery system after  FIG. 9D  according to various embodiments. 
         FIG. 9F  depicts a schematic diagram of transcatheter delivery of an annuloplasty ring from a delivery system after  FIG. 9E  according to various embodiments. 
         FIG. 10  depicts a schematic diagram of a perspective, partial cross-sectional view of a heart during an expansion of an adjustable annuloplasty ring using a balloon expansion tool preparatory to affixation to the annulus of the mitral valve according to an embodiment. 
         FIG. 11  depicts a schematic diagram of a perspective, partial cross-sectional view of the heart during an expansion of an adjustable annuloplasty ring using a cage or basket expansion tool preparatory to affixation to the annulus of the mitral valve according to an embodiment. 
         FIG. 12A  depicts a perspective view of a stabilizer of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 12B  depicts another perspective view of the stabilizer of the percutaneous annuloplasty system of  FIG. 12A  according to an embodiment. 
         FIG. 12C  depicts a stabilizer including a balloon, according to an embodiment. 
         FIG. 12D  depicts a stabilizer of  FIG. 12C  with the balloon inflated, according to an embodiment. 
         FIG. 12E  depicts a schematic diagram that demonstrates how holes in the arms of a stabilizer may be used to help guide sutures that are exiting the ring according to an embodiment. 
         FIG. 13A  depicts a perspective view of a stabilizer of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 13B  depicts a perspective view of a stabilizer coupled to an annuloplasty ring of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 13C  depicts a perspective view of a stabilizer coupled to an annuloplasty ring of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 13D  depicts a detailed perspective view of a stabilizer coupled to an annuloplasty ring of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 13E  depicts a perspective view of an illustrative annuloplasty ring having strats according to an embodiment. 
         FIG. 13F  depicts a side view of an illustrative annuloplasty ring having strats according to an embodiment. 
         FIG. 13G  depicts a top view of an illustrative annuloplasty ring having strats according to an embodiment. 
         FIG. 13H  depicts a top view of an engagement of annuloplasty ring having strats with a stabilizer according to an embodiment. 
         FIG. 13I  depicts a detailed view of an engagement of annuloplasty ring having strats with a stabilizer according to an embodiment. 
         FIG. 14A  depicts a perspective view of a stabilizer of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 14B  depicts a perspective view of a stabilizer of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 15A  depicts a perspective view of a proximal end of a handle of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 15B  depicts a cross-sectional view of the proximal end of a handle of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 16A  depicts a diagram of a perspective view of an illustrative delivery system of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 16B  depicts a diagram of a perspective view of an illustrative delivery system of a percutaneous annuloplasty system according to an embodiment. 
         FIG. 17A  depicts an illustrative example of a full assembly of the ring, stabilizer and distal end of the catheter as configured in a target site after deployment of the ring from the catheter according to an embodiment. 
         FIG. 17B  depicts an illustrative example of a full assembly of the ring, stabilizer and distal end of the catheter as configured in a target site after deployment of the ring from the catheter according to an embodiment. 
         FIG. 18A  depicts an illustrative longitudinal cross-sectional view of a catheter connecting the distal end of the delivery system of  FIG. 17A  to the proximal end of the delivery system of  FIG. 16A or 16B  according to an embodiment. 
         FIG. 18B  depicts an illustrative longitudinal cross-sectional view of a catheter connecting the distal end of the delivery system of  FIG. 17A  to the proximal end of the delivery system of  FIG. 16A or 16B  according to an embodiment. 
         FIG. 19A  depicts an illustrative example of the proximal side of a delivery system. 
         FIG. 19B  depicts an illustrative example of the proximal side of a delivery system. 
         FIG. 19C  depicts an illustrative example of the proximal side of a delivery system. 
     
    
    
     DETAILED DESCRIPTION 
     This disclosure is not limited to the particular systems, devices and methods described, as these may vary. The terminology used in the description is for the purpose of describing the particular versions or embodiments only, and is not intended to limit the scope. 
     As used in tins document, the singular forms “a,” “an,” and “the” include plural references unless the context clearly dictates otherwise. Unless defined otherwise, all technical and scientific terms used herein have the same meanings as commonly understood by one having ordinary skill in the art. Nothing in this disclosure is to be construed as an admission that the embodiments described in this disclosure are not entitled to antedate such disclosure by virtue of prior invention. As used in this document, the term “comprising” means “including, but not limited to.” 
     The following terms shall have, for the purposes of this application, the respective meanings set forth below. 
     A “heart valve” refers to any valve of a heart. In some embodiments, the heart may be a human heart. In other embodiments, the valve may be a non-human heart. The heart valves include atrioventricular valves (mitral valve and tricuspid valve) and semilunar valves (aortic valve and pulmonary valve). As used herein, the term “valve” is used to denote a heart valve, except where explicitly stated otherwise. Various portions of the heart including the valves, may contain one or more fibrous rings therearound. Such fibrous rings are commonly known (and used herein) as an “annulus.” 
     A “patient” refers to any human or non-human individual. The patient is generally any patient that has been diagnosed or will be diagnosed with a valve-related disorder, such as, for example, a heart valve-related disorder. In some embodiments, the patient may be an individual that would benefit from the apparatuses, systems, and methods described herein. 
     As used herein, “percutaneous” refers to a procedure that uses incisions through the skin of the abdomen for access to a surgical site, such as, for example, a patient&#39;s heart. Thus, as used herein, percutaneous surgery and laparoscopic surgery are mutually exclusive. In the preferred embodiment, the methods described herein are performed percutaneously, although laparoscopic methods are contemplated. As used herein, a percutaneous procedure may be a minimally invasive procedure or a highly invasive procedure. A percutaneous procedure may also include a trans-septal approach and a trans-apical approach. 
     The present disclosure generally relates to tools and assemblies that support treating and repairing heart valves, and specifically to apparatuses, systems, and methods for percutaneous trans-catheter repair of valves, particularly heart valves. Disclosed embodiments include delivery systems and features that are used as a catheter and/or through a catheter, such as, for example, a trans-septal approach, a retrograde approach, or a trans-apical approach. 
     The systems and methods described herein may generally be used to facilitate repair of a heart valve through percutaneous trans-catheter delivery and fixation of an annuloplasty ring to the heart valve. The embodiments of stabilizers and delivery systems can be configured in elongated insertion geometries that can be inserted into a catheter tube and deployed to an operable geometry providing a 3D geometry that corresponds to and attaches to an annuloplasty ring connected to a catheter delivery system. 
       FIG. 1A  depicts a schematic diagram of a perspective view of an illustrative adjustable annuloplasty ring, generally designated  100 , according to an embodiment. As shows in  FIG. 1A , the annuloplasty ring  100  may be in an annular (D-shaped) operable geometry in a contracted state.  FIG. 1B  depicts a schematic diagram of a perspective view of the adjustable annuloplasty ring  100  of  FIG. 1A  when in an expanded state. The annuloplasty ring  100  may be configured to enable percutaneous, transcatheter annuloplasty to repair a heart valve. The annuloplasty ring  100  may be fastened, percutaneously, to the annulus of a target heart valve while in the expanded state and reduced to the contracted state to decrease an A-P distance of the target valve and thereby improve leaflet, coaptation of the target valve and reduce regurgitation through the target valve. 
     Referring collectively to  FIGS. 1A and 1B , the annuloplasty ring  100  may include a body member  101  having a plurality of regions  102   a ,  102   b ,  102   c  (collectively  102 ), biasing elements  103   a ,  103   b  (collectively  103 ), a plurality of anchors  104 , a ring closure lock  106 , and a pivot  108 . In  FIGS. 1A and 1B , as well as in other embodiments disclosed herein, the body member  10 L including the plurality of regions  102 , may be arranged in a “D-shape” in the operable geometry. The D-shaped annuloplasty ring  100  may have a particular geometrical ratio that is in conformance (or approximate conformance) with the anatomical geometry of the human mitral valve annulus. For example, in certain embodiments, the ratio of the A-P distance to the commissure-commissure (C-C) distance of the annuloplasty ring  100  when implanted (for example, in the contracted state) may be about 0.60 to about 0,70, including about 0.60, about 0.61, about 0.62, about 0.63, about 0.64, about 0.65, about 0.66, about 0.67, about 0.68, about 0.69, about 0.70, or any value or range between any two of these values (including endpoints). In a particular embodiment, the implanted ratio of the A-P distance to the C-C distance may be about 0.62. 
     Although the illustrated embodiment of an annuloplasty ring  100  of  FIGS. 1A and 1B  is a D-shaped operable geometry, those having ordinary skill in the art will recognize that other annular-shaped operable geometries may also be used without departing from the present disclosure. For example, circular or oval operable geometries may be used. 
     In some embodiments, the body member  101  may include a hollow hypotube (or outer hollow member). The hypotube may be cut from, for example, a tube to form the plurality of regions  102 . The cute may define a shape and/or characteristics of the body member  101 . For example, laser cuts may define the plurality of regions  102  (and define how the plurality of regions interact), anchor windows  110 , and/or the biasing elements  103 . 
     In various embodiments, the body member  101  may include a shape memory (such as, for example, nitinol) hypotube into which a plurality of cute and/or segments may be laser cut to define a size, a shape, and/or characteristics of the plurality of regions  102 . The shape memory hypotube may be heat set to a “memorized” annular shape (such as, for example, the D-shaped operable geometry). The shape memory hypotube may be superelastic such that applying sufficient stress may place the body member  101 , including the plurality of regions  102 , into an elongate insertion geometry and releasing the stress allows the body member  101 , including the plurality of regions  102 , to resume the D-shaped operable geometry. In some embodiments, laser cuts may define a flexibility of the body member  101 . For example, the laser cuts may allow the body member  101  to be flexible when the annuloplasty ring  100  is in an elongate insertion geometry (as described herein) and/or rigid when the annuloplasty ring is in the operable geometry. 
     In addition to the operable geometry shown in  FIGS. 1A and 1B , the body member  101  may transitionable from an elongate insertion geometry (see, for example,  FIG. 9C ) to the annular operable geometry shown in  FIGS. 1A and 1B . The elongate insertion geometry may allow the annuloplasty ring  100  to be inserted into and passed through a catheter for percutaneous passage into the heart of a patient, as described in greater detail herein. A transition from an elongate insertion geometry to an annular operable geometry is illustrated in  FIGS. 9C-9F , and discussed herein with reference to the same. 
     Once in an annular operable geometry as shown in  FIGS. 1A and 1B , the annuloplasty ring  100  may have a contracted state as shown in  FIG. 1A  and an expanded state as shown in  FIG. 1B . The biasing elements  103  may be configured to expand to increase the A-P distance of the annuloplasty ring  100  to an expanded state. The A-P distance AP 1  of the contracted state of  FIG. 1A  is enlarged by a distance d such that the A-P distance AP 2  of the expanded state  FIG. 1B  is larger (AP 2 =AP 1 +d). Expansion of the biasing elements  103  may allow the body member  101  to be expanded to an expanded state. In situ in the heart, expansion of the body member  101  to the expanded state may enlarge the annuloplasty ring  100  to a size conforming, or approximately conforming, to an annulus of a target heart valve to be repaired. Expansion of the body member  101  may be accomplished by an expansion tool, such as a balloon, a cage, or another tool such as is shown in  FIGS. 10, 11, 12A-12E, 13A-13D, and 14A-14B , and described herein with reference to the same. In the illustrated embodiment of  FIGS. 1A and 1B , a biasing dement  103   a  disposed between a first posterior region  102   a  and an anterior region  102   c  and a biasing element  103   b  disposed between a second posterior region  102   b  and the anterior region  102   c  may enable a desired expansion from the contracted state shown in  FIG. 1A  to the expanded state shown in  FIG. 1B . 
     The expanded state of  FIG. 1B  may be such that the annuloplasty ring  100  is disposed in abutment with, or in intimate contact with, the annulus of the target valve. Disposing the annuloplasty ring  100  in intimate contact with the annulus may enhance an anchoring process in which the plurality of anchors  104  are deployed to fasten the annuloplasty ring  100  to the annulus. Once the annuloplasty ring  100  is fastened to the annulus, it may be contracted from the expanded state of  FIG. 1B  back to the contracted state of  FIG. 1A  to reduce a diameter of the annulus of the target valve. 
     Contraction of the annuloplasty ring  100  from the expanded state to the contracted state may decrease the A-P distance of the annuloplasty ring and, with the plurality of anchors  104  securing the annuloplasty ring to the annulus, may also decrease an A-P distance of the target valve to improve leaflet coaptation and reduce regurgitation through fee target valve. In the illustrated embodiment of  FIGS. 1A and 1B , contraction of the annuloplasty ring  100  from the expanded state to the contracted state may be accomplished by the biasing elements  103 . The biasing elements  103  may bias the annuloplasty ring  100  toward the contracted state such that expansion of the annuloplasty ring to the expanded state stores potential energy in the biasing elements  103 . Releasing the biasing elements  103  (such as, for example, releasing or otherwise removing an expansion tool and/or expansion force) may release the stored potential energy, thereby forcing movement of the first posterior region  102   a  and the second posterior region  102   b  of the body member  101  toward the anterior region  102   c  of the body member to decrease the A-P distance of the annuloplasty ring  100  to the contracted state. In other words, the biasing elements  103 , upon release, may actively transition the annuloplasty ring  100  from the expanded state to the contracted state. 
     A typical range for change of the A-P distance d (between the expanded state and the contracted state) may be about 3 mm to about 8 mm, including about 3 mm, about 3.5 mm, about 4 mm, about 4.5 mm, about 5 mm, about 5.5 mm, about 6 mm, about 6.5 mm, about 7 mm, about 7.5 mm, about 8 mm, or any value or range between any two of these values (including endpoints). In some embodiments, the range of d may depend on the overall size of the annuloplasty ring  100 . For example, for a final geometry of the annuloplasty ring  100  that is 26 mm, a change distance d of about 3 mm may be desired. As another example, for a final geometry of the annuloplasty ring  100  that is 36 mm, a change distance d of about 5 mm may be desired. 
     The biasing elements  103  of the illustrated annuloplasty ring  100  of  FIGS. 1A and 1B  may be a spiral cut or helical portion of the body member  101  that is laser cut into the body member. The spiral cut or helical portion, because it is cut into the body member  101 , is a biasing element  103  that is integral to the body member. The spiral cut portion of the body member  101 , as shown in  FIG. 1B , may form or otherwise define a spiral shape configured to expand to allow the anterior region  102   c  to move away from the first posterior region  102   a  and from the second posterior region  102   b , thereby increasing the A-P distance of the annuloplasty ring  100 . Also, the spiral cut or helical portion of the body member  101  may be biased toward a relaxed position, or the contracted state as shown in  FIG. 1A , such that expansion, of the spiral cut or helical portion, stores potential energy and release of an expansion force results in a release of potential energy and contraction toward the contracted state. 
     In some embodiments, other integral biasing elements  103  may be used. For example, a diamond cut pattern, cut into the body member  101  may allow desired expansion and biasing toward the contracted state. In another embodiment, a corrugated pattern (such as, for example, folds) may be formed in the body member  101 . The corrugated pattern may allow desired expansion to increase the A-P distance of the annuloplasty ring  100  and may be biased toward the contracted state. 
     In addition to integral biasing elements  103  (formed integrally in the body member  101  of the annuloplasty ring  100 ), other biasing elements  103  may be used that are not integral to the body member. For example,  FIGS. 2A and 2B  illustrate an embodiment in which the biasing element  203  is a spring and not integral to the body member  201 , as described herein. In still other embodiments, the biasing element  203  may include a nonintegral biasing component (such as, for example, a spring) to complement or enhance operation of an integrally formed biasing element. 
     Referring back to  FIGS. 1A and 1B , the plurality of anchors  104 , as noted above, may be configured to secure the annuloplasty ring  100  to the annulus of the heart valve. In some embodiments, the anchors  104  may be barbs. As used herein, the terms “anchor” and “barb” may be used interchangeably. In certain embodiments, the anchors  104  are sufficient such that additional suturing of the annuloplasty ring  100  to the valve annulus is not needed. As shown in  FIG. 1A , the anchors  104  may be within the body member  101  in at), insertion geometry. As shown in  FIG. 1B , the anchors  104  may be curved in the illustrated deployed configuration. The anchors  104  in other embodiments may include other shapes, such as linear or helical deployed configurations. In certain embodiments, the anchors  104  may include a shape memory material (such as, for example, nitinol) that is heat set to a deployed configuration (such as, for example, a curved configuration, a linear configuration, or a helical configuration). Those with ordinary skill in the art will recognize that combinations of different deployed anchor configurations may also be used without departing from the scope of the present disclosure. 
     The anchors  104  may be superelastic such that applying sufficient stress places the anchors into an introduction configuration and releasing the stress allows the anchors to resume their respective deployed configurations. In certain embodiments, the anchors  104  may lay flat against the body member  101  in the introduction configuration during insertion of the annuloplasty ring  100  through the catheter. As described in greater detail herein, in other embodiments, the anchors  104  may be retracted inside the hollow body member  101  of the annuloplasty ring  100  in the introduction configuration during insertion of the annuloplasty ring  100  through the catheter. In such embodiments, the anchors  104  may be selectively deployed at a desired time (such as, for example, after the annuloplasty ring  100  is properly positioned against, or in abutment with, the annulus of the heart valve). In certain embodiments, the superelastic property of the anchors  104  may be used to self-propel the anchors into the annulus of the heart valve. The anchors  104  may be configured to be deployed from within the body member  101  through the anchor windows  110 . 
     The ring closure lock  106  may be used to secure two open ends of the annuloplasty ring  100  to form a closed ring of the operable geometry. In certain embodiments, the ring closure lock  106  may include a female snap and a male snap. As discussed in greater detail herein, the annuloplasty ring  100  may be “snap locked” using wires or sutures to pull a male snap into a female snap. The ring closure lock  106  of the illustrated annuloplasty ring  100  of  FIGS. 1A and 1B  may be disposed at a posterior side of the annuloplasty ring. The ring closure lock  106  may allow an angled coupling of the two ends, such as, for example, at an apex of a curved side of a D-shaped annular operable geometry. 
     The pivot  108  may be used to automatically rotate the annuloplasty ring  100  after it exits the catheter within the heart to align the plane of the annuloplasty ring  100  (in the annular operable geometry) with the plane of the heart valve. The annuloplasty ring  100  may be pushed from the catheter in a direction that is substantially perpendicular to the plane of the heart valve (such as, for example, parallel to the general direction of blood flow through the valve). Upon exiting the catheter, the annuloplasty ring  100  may be rotated at or about the pivot  108  to allow proper positioning of the annuloplasty ring  100  against the annulus. With the annuloplasty ring  100  properly oriented in alignment with the plane of the heart valve, the annuloplasty ring  100  may be expanded to the expanded state. For example, an expansion tool may be used to expand the annuloplasty ring  100 , as shown in  FIGS. 10, 11, 12A-12E, 13A-13D, and 14A-14B  and described in greater detail herein. The annuloplasty ring  100  in the expanded state may be pressed against the valve annulus before deploying the anchors  104 , and an act of deploying the anchors may drive the anchors into the adjacent tissue. A positioning tool may facilitate expansion and/or proper positioning/orientation of the annuloplasty ring  100  against the heart valve annulus. A stabilizer, such as a tri-pod tool or a bi-pod tool, shown for example in  FIGS. 12A-12E, 13A-13D , and  14 A- 14 B and described in greater detail herein, may be used to position the annuloplasty ring  100  in abutment against the annulus of the target heart valve, or otherwise in intimate contact with the annulus of the target heart valve. In addition, fluoroscopy, ultrasound, and/or other imaging techniques may be used to assist in proper positioning of the annuloplasty ring  100  against the heart valve annulus. 
     Although not shown in  FIGS. 1A and 1B , certain ring embodiments may include a selectively adjustable member for changing the size and/or shape of the annuloplasty ring  100  postoperatively to compensate for changes in the size of the heart and/or the treated heart valve. An illustrative example of an adjustable member may be a member made of a material that can be adjusted via the application of energy, such as, for example RF energy, light energy, or thermal energy. 
       FIG. 1C  depicts a schematic diagram of an illustrative cutting pattern, generally designated  116 , used for laser processing a hypotube to form a body member  101  of an adjustable annuloplasty ring  100  according to an embodiment. The pattern  116  may enable a hypotube or outer tube (also referred to herein as an “outer hollow member”) to be cut for use as a body member  101  of an annuloplasty ring  100  according to an embodiment. The cutting pattern  116  may correspond to the entire body member  101  as if the body member were cut along a longitudinal axis and unrolled. The cutting pattern  116  may enable cutting the hypotube to form the plurality of regions  102  and the integral biasing  101  elements  103 . The cutting pattern  116  shown in  FIG. 1C  may define the configuration of the plurality of regions  102  and how the regions  102  interact with adjacent regions as the body member  101  transitions from the elongate insertion geometry shown to the annular operable geometry. 
     The cutting pattern  116  may also enable cutting the hypotube to form one or more holes  120 ,  121  at each end to allow one or more pins (not shown) to couple male and/or female components of the ring closure lock  106  to respective ends of the body member  101 . The cutting pattern  116  may also enable cutting the hypotube to form anchor windows  110  through which the plurality of anchors  104  may be deployed. 
       FIG. 2A  depicts a schematic diagram of a perspective view of an illustrative adjustable annuloplasty ring, generally designated  200 , according to an embodiment. The annuloplasty ring  200  may be in an annular (D-shaped) operable geometry and a contracted state.  FIG. 2B  depicts a schematic diagram of a perspective view of an illustrative adjustable annuloplasty ring  200  in an expanded state. The annuloplasty ring  200  may be configured to enable percutaneous, transcatheter annuloplasty to repair a heart valve. 
     Referring collectively to  FIGS. 2A and 2B , the annuloplasty ring  200  may include a body member  201  having a plurality of regions  202   a ,  202   b ,  202   c  (collectively  202 ), biasing elements  203   a ,  203   b  (collectively  203 ), a plurality of anchors  204 , a ring closure lock  206 , and a pivot  208 . The body member  201  may be a “D-shape” in the operable geometry, but those having ordinary skill in the art will recognize that other annular-shaped operable geometries may also be used without departing from the scope of the present disclosure. For example, circular or oval operable geometries may be used. Different from the annuloplasty ring  100  of  FIGS. 1A-1B , the ring closure lock  206  may be disposed on the anterior side of the annuloplasty ring  200  (rather than the posterior side). 
     In addition to the operable geometry shown in  FIGS. 2A and 2B , the body member  201  may be transitionable from an elongate insertion geometry (see, for example,  FIG. 9C ) to the annular operable geometry shown in  FIGS. 2A and 2B . The elongate insertion geometry may allow the annuloplasty ring  200  to be inserted into and passed through a catheter for percutaneous passage of the annuloplasty ring into the heart of a patient. A transition from an elongate insertion geometry to an annular operable geometry is illustrated in  FIGS. 9C-9F , and discussed herein with reference to the same. 
     Once in an annular operable geometry, the annuloplasty ring  200  may have a contracted state as shown in  FIG. 2A  and an expanded state as shown in  FIG. 2B . The biasing elements  203  may be configured to allow expansion of the body member  201  to increase the A-P distance of the annuloplasty ring  200  to an expanded state. In situ within the heart, expansion of the body member  201  to the expanded state may enlarge the annuloplasty ring  200  to a size conforming, or approximately conforming, to an annulus of a target heart valve to be repaired. Expansion of the body member  201  may be accomplished by an expansion tool, such as a balloon, a cage, or another expansion tool, such as is shown in  FIGS. 10, 11, 12A-12E, 13A-13D, and 14A-14B , and described in greater detail herein. In the illustrated embodiment of  FIGS. 2A and 2B , a biasing element  203   a  disposed between a first anterior region  202   a  and a posterior region  202   c  and a biasing element  203   b  disposed between a second anterior region  202   b  and the posterior region  202   c  may enable a desired expansion from the contracted state shown in  FIG. 2A  to the expanded state shown in  FIG. 2B . 
     The expanded state of  FIG. 2B  may be such that the annuloplasty ring  200  is disposed in abutment with, or in intimate contact with, the annulus of the target valve. Disposing the annuloplasty ring  200  in intimate contact with the annulus may enhance an anchoring process in which the plurality of anchors  204  is deployed to fasten the annuloplasty ring  200  to the annulus. 
     Once the annuloplasty ring  200  is fastened to the annulus, it may be contracted from the expanded state of  FIG. 2B  back to the contracted state of  FIG. 2A  to reduce a diameter of the annulus of the target valve. Contraction of the annuloplasty ring  260  may include the first and second anterior regions  202   a ,  202   b  of the body member  201  moving in a telescopic manner into the posterior region  202   c  as the biasing members  203  force movement of the first and second anterior regions of the body member toward the posterior region. Contraction of the annuloplasty ring  200  from the expanded state to the contracted state may decrease the A-P distance of the annuloplasty ring and, with the plurality of anchors  204  securing the annuloplasty ring to the annulus, may also decrease the A-P distance of the target valve to improve leaflet coaptation and reduce regurgitation through the target valve. 
     In the illustrated embodiment of  FIGS. 2A and 2B , contraction of the annuloplasty ring  200  from the expanded state to the contracted state may be accomplished by the biasing elements  203 . The biasing elements  203  may bias the annuloplasty ring  200  toward the contracted state such that expansion of the annuloplasty ring  200  to the expanded state stores potential energy in the biasing elements. Releasing the biasing elements  203  (for example, releasing or otherwise removing an expansion tool and/or expansion force) releases the stored potential energy and thereby forces movement of the first anterior region  202   a  and the second anterior region  202   b  of the body member  201  toward the anterior region  202   c  of the body member to decrease the A-P distance of the annuloplasty ring  200  to the contracted state. In other words, the biasing elements  203 , upon release, may actively transition the annuloplasty ring  200  from an expanded state to the contracted state. 
     The biasing elements  203  of the illustrated annuloplasty ring  200  of  FIGS. 2A and 2B  may include springs or another similar element that is nonintegral to the body member. The springs of the biasing elements  203  may allow the anterior regions  202   a ,  202   b  to move away from the first posterior region  202   c , thereby increasing the A-P distance of the annuloplasty ring  200 . 
     The A-P distance AP 1  of the contracted state of  FIG. 2A  may be enlarged a distance d upon expansion of the annuloplasty ring  200  such that the A-P distance AP 1  of the expanded state  FIG. 2B  is larger (AP 2 =AP 1 +d). The springs of the biasing elements  203  may be biased toward a relaxed position, or the contracted state as shown in  FIG. 2A , such that expansion of the springs stores potential energy and release of the springs results in a release of potential energy and contraction toward the contracted state. 
     In various embodiments, the plurality of anchors  204  may be configured to secure the annuloplasty ring  200  to the annulus of the heart valve. In  FIGS. 2A and 2B , the anchors  204  may be curved in the illustrated deployed configuration. The anchors  204  in other embodiments may include other shapes, such as, for example, linear or helical deployed configurations. In certain embodiments, the anchors  204  may include a shape memory material (such as, for example, nitinol) that is heat set to a deployed configuration (for example, curved configuration, linear configuration, or helical configuration). Those with ordinary skill in the art will recognize that combinations of different deployed anchor configurations may also be used without departing from the scope of the present disclosure. 
     The anchors  204  may be superelastic such that applying sufficient stress places the anchors into an introduction configuration and releasing the stress allows the anchors to resume their respective deployed configurations. In certain embodiments, the anchors  204  may lay flat against the body member  201  in the introduction configuration during insertion of the annuloplasty ring  200  through the catheter. As discussed below, in other embodiments, the anchors  204  may retract inside a hollow body member  201  of the annuloplasty ring  200  in the introduction configuration during insertion of the annuloplasty ring through the catheter. In such embodiments, the anchors  204  may be selectively deployed at a desired time (for example, after the annuloplasty ring  200  is properly positioned against, or in abutment with, the annulus of the heart valve). In certain embodiments, the superelastic property of the anchors  204  may be used to self-propel the anchors into the annulus of the heart valve. 
     The ring closure lock  206  may be used to secure two open ends of the annuloplasty ring  200  to form a closed ring of the operable geometry. Different from the annuloplasty ring  100  of  FIGS. 1A-1B , the ring closure lock  206  may be disposed on the anterior side of the annuloplasty ring  200  (rather than the posterior side). In certain embodiments, the ring closure lock  206  may include a female snap and a male snap. The annuloplasty ring  100  may be “snap locked” using wires or sutures to pull a male snap into a female snap. 
     The pivot  208  may facilitate rotation of the annuloplasty ring  200  after it exits the catheter within the heart to align the plane of the annuloplasty ring (in the annular operable geometry) with the plane of the heart valve, as previously described herein. 
       FIG. 3A  depicts a schematic diagram of a perspective view of an illustrative adjustable annuloplasty ring  300  according to another embodiment. The annuloplasty ring  300  may be in an annular (D-shaped) operable geometry and an expanded state.  FIG. 3B  depicts a schematic diagram of a perspective view of the adjustable annuloplasty ring  300  of  FIG. 3A  in a contracted state. The annuloplasty ring  300  may be configured to enable percutaneous, transcatheter annuloplasty to repair a heart valve. 
     Referring collectively to  FIGS. 3A and 3B , the annuloplasty ring  300  may include a body member  301  having a plurality of regions  302   a ,  302   b ,  302   c  (collectively  302 ), a plurality of anchors  304 , a ring closure lock  306 , and a pivot  308 , similar to previously described embodiments. The annuloplasty ring  300  may be transitionable from an elongate insertion geometry (see, for example,  FIG. 9C ) to the annular operable geometry shown in  FIGS. 3A and 3B . The elongate insertion geometry may allow the annuloplasty ring  300  to be inserted into and passed through a catheter for percutaneous passage of the annuloplasty ring into the heart of a patient as illustrated in  FIGS. 9C-9F  and discussed in greater detail herein. 
     The plurality of regions  302  of the illustrated annuloplasty ring  300  of  FIGS. 3A and 3B  may be separate individual segments. The segments  302  may be coupled together by stepped connectors  330   a ,  330   b  (collectively  330 ) in the annular operable geometry. The stepped connectors  330  may be configured to enable the body member  301  to be adjustable to decrease the A-P distance of the annuloplasty ring  300  from an expanded state as shown in  FIG. 3A  to a contracted state as shown in  FIG. 3B . The stepped connectors  330  may initially couple the posterior segment  302   c  to each of a first anterior segment  302   a  and a second anterior segment  302   b  in the expanded state of  FIG. 3A , conforming, or approximately conforming, to an annulus of a target heart valve to be repaired. The expanded state of  FIG. 3A  may be such that the annuloplasty ring  300  is disposed in abutment with, or in intimate contact with, the annulus of the target valve, thereby enhancing an anchoring process in which the plurality of anchors  304  are deployed to fasten the annuloplasty ring to the annulus. 
     Once the annuloplasty ring  300  is fastened to the annulus, it may be contracted from the expanded state of  FIG. 3A  to the contracted state of  FIG. 3B  to reduce a diameter of the annulus of the target valve. Contraction of the annuloplasty ring  300  may include the stepped connectors  330  moving in a telescopic manner into the posterior region  302   c  as the first and second anterior regions  302   a ,  302   b  of the body member  301  move toward the posterior region. Contraction of the annuloplasty ring  300  from the expanded state to the contracted state may decrease the A-P distance of the annuloplasty ring and, with the plurality of anchors  304  securing the annuloplasty ring  300  to the annulus, may also decrease an A-P distance of the target valve to improve leaflet coaptation and reduce regurgitation through the target valve. The stepped connectors  330  may allow for multiple degrees of adjustment. For example a stepped connector having two engagement steps (see engagement steps  402  in  FIGS. 4A and 4B ) may allow two degrees of adjustment, as discussed in greater detail herein. 
     In the illustrated embodiment of  FIGS. 3A and 3B , contraction of the annuloplasty ring  300  from the expanded state to the contracted state may be accomplished percutaneously through, use of sutures or wires to force the posterior segment  302   c  toward the first and second anterior segments  302   a ,  302   b  and vice versa. 
     In certain embodiments, a biasing element (not shown in  FIGS. 3A and 3B ) may bias the annuloplasty ring  300  toward the contracted state and aid in contraction of the annuloplasty ring  300  from the expanded state to the contracted state, in other embodiments, a biasing element may enable expansion from an initial state to an expanded state, and a stepped connector  330  may operate to ensure expansion from the contracted state is restricted. 
     Different from the embodiments of  FIGS. 1A-1C and 2A-2B , the annuloplasty ring  300  of  FIGS. 3A and 3B  may initially be in an expanded state upon transition to the annular operable geometry. In other words, the initial A-P distance AP 1  of the annuloplasty ring  300  may be sufficient to conform or substantially conform to the A-P distance of a target valve. The A-P distance AP 1  of fee expanded state of  FIG. 3A  may be decreased a distance d upon contraction of the annuloplasty ring  300  such that the A-P distance AP 2  of the contracted state  FIG. 3B  is smaller (AP 2 =AP 1 −d). The decrease of the A-P distance, with the anchors fastening the annuloplasty ring  300  to the annulus of the valve, may decrease the A-P distance of the target valve to improve leaflet coaptation of the target valve and reduce regurgitation through the target valve. 
       FIGS. 4A and 4B  depict a perspective view and a cross-sectional view, respectively, of a male component  400  of a stepped connector  330  of an adjustable annuloplasty ring  300  according to an embodiment. A corresponding female component (not shown) may be configured to receive the male component  400  to form the stepped connector  330 . The stepped connector  330  may include two engagement steps  402   a ,  402   b  (collectively  402 ) to allow two degrees of adjustment and/or gradual adjustment. As shown in  FIG. 4B , a cable  404  or suture may couple to the male component  400  of the stepped connector  330 . The cable  404  or suture may enable a force to move the male component  400  in a telescopic manner into a female component of the stepped connector  330 . Contraction of the annuloplasty ring  300  until engagement of a first engagement step  402   a  within the female component may secure the annuloplasty ring in a partial contracted state. Further contraction of the annuloplasty ring  300  to engagement of a second engagement step  402   b  within the female component may secure the annuloplasty ring in the contracted state. In this manner, the stepped connector  330  may enable two degrees of adjustment (and for gradual adjustment) of the A-P distance of the annuloplasty ring. 
       FIG. 5A  depicts a schematic diagram illustrating a side view of an illustrative internal anchor ribbon  500  including the curved anchors  104  shown in  FIGS. 1A and 1B  according to an embodiment. In certain embodiments, deployment of the anchors  104  may be accomplished using an internal anchor member, such as anchor ribbon  500 , that is selectively movable within a hollow tube of the body member  101  ( FIG. 1A ). The curved anchors  104  may be affixed (for example, laser welded) to the internal anchor ribbon  500  or directly cut into the internal anchor ribbon. Like the anchors  104 , the internal anchor ribbon  500  may include a superelastic shape memory material (such as, for example, nitinol). The shape memory of the anchor ribbon  500  may be heat set to the same memorized annular shape as the plurality of regions  102  of the body member  101  in the contracted state of the annular operable geometry, as shown in  FIG. 1A . 
     The internal anchor ribbon  500  may be slidable (for example, using wires or sutures accessible through the catheter) in the hollow body member  101  of the annuloplasty ring  100 . To reduce friction between the internal anchor ribbon  500  and the body member  101 , certain ring embodiments may include an internal glide ribbon  510 . The internal glide ribbon  510  may include a low-friction material (for example, as a coating or covering) such as polytetrafluoroethylene (PTFE) or other polymer. In addition, or in other embodiments, the internal glide ribbon  510  may include a superelastic shape memory material (such as, for example, nitinol) that is heat set to the same memorized annular shape as the body member  101 . Thus, in particular embodiments, three D-shaped superelastic members (the outer tube of the body member  101 , the internal anchor ribbon  500 , and the internal glide ribbon  510 ) may be included, which may cooperate to increase the rigidity of the annuloplasty ring  100 . 
     In various embodiments, as shown in  FIGS. 5F and 5G , the internal anchor ribbon may be a lube-like polymeric element  502  having a curved wall  503  and an opening  504  therethrough. In some embodiments, the polymeric element  502  may be located inside the ring  101  ( FIGS. 1A and 1B ) such that the anchors  104  ( FIGS. 5A-5C ) slide inside the ring. The general shape and/or pattern of the polymeric element  502  is not limited by this disclosure, and may generally be any pattern that allows for movement of the anchors  104  ( FIGS. 5A-5C ) inside the ring  101  ( FIGS. 1A and 1B ), as described herein. For example,  FIGS. 5H, 5I, and 5J  depict a top view, a first side view, and a second side view, respectively, of an illustrative pattern for a polymeric element  502 . The polymeric material  502  may generally be made of any material now known or later developed to reduce friction and facilitate sliding of the anchors  104  ( FIGS. 5A-5C ) within the ring. Illustrative materials may include, but are not limited to, polytetrafluoroethylene (PTFE), fluorinated ethylene propylene (FEP), polyether block amide (PEBA), and/or the like. In addition, the polymeric element  502  may be constructed by any method now known or later developed, including, but not limited to, an extrusion method, an injection molding method, a machining method, and/or the like. 
       FIG. 5B  depicts a schematic diagram of a top view of the anchors  104  cut into the internal anchor ribbon  500  shown in  FIG. 5A  in the elongate insertion geometry according to an embodiment. In some embodiments, a laser may be used to cut the anchors  104  along a first side  512 , a second side  514  (for example, in a pointed or tip shape), and a third side  516 , while leaving a fourth side  518  of the anchor  104  uncut and attached to the internal anchor ribbon  500 . After cutting, the anchors  104  may be heat set to the desired memorized shape for the deployed configuration. For example,  FIG. 5C  depicts a schematic diagram of a side view of the internal anchor ribbon  500  in the elongate insertion geometry and the anchors  104  in a curled or curved deployed configuration according to an embodiment. The amount of curvature in the deployed configuration of the anchors  104  may depend on the particular application. In the example shown in  FIG. 5C , the anchors  104  may fold back on themselves such that the prong or tip  520  points parallel to or away from the internal anchor ribbon  500 .  FIG. 5D  depicts a schematic diagram of a top view of the internal glide ribbon  510 , and  FIG. 5E  depicts a schematic diagram of a side view of the internal glide ribbon  510 , in the elongate insertion geometry according to an embodiment. 
       FIGS. 6A and 6B  depict schematics of cross-sectional side views of an annuloplasty ring  600  before ( FIG. 6A ) and after ( FIG. 6B ) deployment of the anchors  104  shown in  FIGS. 5A-5C  according to an embodiment. For illustrative purposes, the annuloplasty ring  600  in  FIGS. 6A and 6B  is shown in an elongate insertion geometry. Those having ordinary skill, in the art will recognize, however, that the anchors  104  may generally be deployed when the annuloplasty ring  600  is in the annular operable geometry without departing from the scope of the present disclosure. 
     The illustrated annuloplasty ring  600  may include an outer tube  610  (for example, formed by the body member  101  shown in  FIG. 1 ) including a plurality of anchor deployment windows  612 . During the manufacturing of the annuloplasty ring  600 , and before the annuloplasty ring is loaded into fee catheter, the internal anchor ribbon  500  and the internal glide ribbon  510  may be inserted into the outer tube  610  in a position where the anchors  104  are prevented from exiting through the windows  612 . As shown in  FIG. 6A , inserting the internal anchor ribbon  500  into the outer tube  610  may prevent the anchors from assuming their fully curved deployed configuration. 
     For deploying the anchors  104 , the internal anchor ribbon  500  may include (or may be attached to) a hook or loop  614  for engaging a wire or suture  616  that may be pulled by a user through the catheter (for example, in the direction of arrow  618  in  FIG. 6A ) to move the tip of each anchor  104  to a corresponding window  612 . In particular embodiments, the anchors  104  and windows  612  may be arranged such that the tip of each anchor  104  reaches its respective window  612  at substantially the same time as the other anchor/window pairs. As shown in  FIG. 6B , once the tips of the anchors  104  reach the respective windows  612 , the superelasticity of the anchors may propel the internal anchor ribbon  500  in the opposite direction (as indicated by arrow  620 ) as the anchors spring out the windows (as indicated by arrow  622 ) to resume their curved configurations. As the anchors  104  drive through the windows  612  the anchors may drive into surrounding tissue (for example, the heart valve annulus). The superelasticity of the anchors  104  may allow the anchors to be self-propelled into the tissue adjacent or proximate to the annuloplasty ring  600 . 
     In some embodiments, as shown in  FIG. 60 , the anchors  104  may be divided into a plurality of segments  650   a ,  650   b ,  650   e . While  FIG. 6C  depicts 3 segments, those having ordinary skill in the art will recognize that any number of segments may be used without departing from the scope of the present disclosure. For example, the anchors  104  may be divided into 2 segments, 3 segments, 4 segments, 5 segments, 6 segments, or more. Dividing the anchors  104  into a plurality of segments  650   a ,  650   b ,  650   c  may allow for actuation of one or more of the segments at a time such that the actuated segment deploys its respective anchor(s)  104  while the remaining anchors remain non-deployed. In some embodiments, various segments  650   a ,  650   b ,  650   c  may be actuated sequentially. In other embodiments, various segments  650   a ,  650   b ,  650   c  may be actuated simultaneously. In some embodiments, various segments  650   a ,  650   b ,  650   c  may be actuated based upon which anchors  104  an operator desires to deploy, which may be based upon positioning and location of the annuloplasty ring. In some embodiments, the segments  650   a ,  650   b ,  650   c  may be arranged in a plurality of zones. For example, a posterior side may be a first zone having a first plurality of segments and an anterior side may be a second zone having a second plurality of segments. Thus, the anterior zone may be deployed separately from the posterior zone, or at substantially the same time. 
       FIG. 7  depicts a simplified schematic diagram of a side view of an illustrative internal anchor member (or members)  700  including linear anchors  710  according to an embodiment. The linear anchors  710  may be affixed (for example, laser welded) to the internal anchor member  700 . In the embodiment shown in  FIG. 7 , however, the internal anchor member  700  and linear anchors  710  may be cut from a single superelastic shape memory (such as, for example, nitinol) hypotube.  FIG. 7 , for example, shows remaining tubular portions  712  after the hypotube is cut to form prongs  714  of the linear anchors  710 . The remaining tubular portions  712  may facilitate sliding (for example, using wires or sutures accessible through the catheter) the internal anchor member  700  coaxially within the hollow tube of the annuloplasty ring (for example, within the annuloplasty ring  600  shown in  FIGS. 6A and 6B ). 
     The internal anchor member  700  may be heat set to the same memorized annular shape as the annuloplasty ring  600 . The anchor prongs  714  may be heat set to protrude outward through windows cut in the annuloplasty ring  600 . Barbs  716  may be laser welded to the prongs  714  to form the linear anchors  710 . The linear anchors  710  may be retracted/deployed by sliding the internal anchor member  700  within the annuloplasty ring  600 . 
     As described herein, the annuloplasty ring may be configured for percutaneous transcatheter delivery and fixation to heart valves. The annuloplasty ring may be delivered through a catheter to the mitral valve, for example, using a trans-septal approach, a retrograde approach, or a trans-apical approach. For example,  FIG. 8A  depicts a schematic diagram of an illustrative trans-septal approach for endovascular delivery of an annuloplasty ring (not shown) to the mitral valve  810  of a heart  800  according to an embodiment. For illustrative purposes, a partial cross-section of the heart  800  is illustrated to show the right atrium RA, right ventricle RV, left atrium LA, and left ventricle LV. For clarity, certain features (for example, papillary muscles and chordae tendineae) are not shown. In the trans-septal approach shown in  FIG. 8A , the left atrium LA may be approached by advancement of a catheter  812  through the inferior vena cava  814 , into the right atrium RA, across the interatrial septum  816 , and into the left atrium LA. The annuloplasty ring may be delivered through the catheter  812  into the atrium and anchored to the annulus of the mitral valve  810 . 
     As shown in  FIG. 8A , the catheter  812  may be delivered percutaneously into the heart  800 . A guiding sheath (not shown) may be placed in the vasculature system of the patient and used to guide the catheter  812  and its distal end  818  to a desired deployment site. In some embodiments, a guide wire (not shown) may be used to gain access through the superior or inferior vena cava  814 , for example, through groin access for delivery through the inferior vena cava  814 . The guiding sheath may be advanced over the guide wire and into the inferior vena cava  814  shown in  FIG. 8A . The catheter  812  may be passed through the right atrium RA and toward the interatrial septum  816 . Once the distal end  818  of the catheter  812  is positioned proximate to the interatrial septum  816 , a needle or piercing member (not shown) is advanced through the catheter  812  and used to puncture the fossa ovalis or other portion of the interatrial septum  816 . In some embodiments, the catheter  812  may be dimensioned and sized to pass through the fossa ovalis without requiring a puncturing device. That is, the catheter  812  may pass through the natural anatomical structure of the fossa ovalis into the left atrium LA. 
     Similarly, any chamber (LV, RV, LA, RA) of the heart  800  may be approached through the inferior vena cava  814 . For example, the right ventricle RV may be approached through the inferior vena cava  814 , into the right atrium RA, and through the tricuspid valve  820 . A variety of other endovascular approaches may also be used. 
       FIG. 8B  depicts a schematic diagram of an illustrative retrograde approach of an annuloplasty ring (not shown) to the mitral valve  810  of a heart  800  according to another embodiment. In  FIG. 8B , a femoral approach is shown wherein the delivery catheter  812  may be advanced through the aorta  822  and the aortic valve  824 . Typically, the catheter  812  may be advanced through a sheath positioned within the femoral artery (not shown). Under fluoroscopy or other methods of guidance, the distal end of the catheter  812  may be guided within the left ventricle LV and turned (for example, as shown with a “U-turn”  826 ) within the left ventricle LV so as to pass through the leaflets of the mitral valve  810  and into the left atrium LA. After verification of the appropriate positioning of the catheter  812 , a guide wire (not shown) may be inserted through the catheter  812  into the left atrium LA, which may be used to guide one or more other catheters into the left, atrium LA for delivering and anchoring the annuloplasty ring to the annulus of the mitral valve  810 . 
       FIG. 8C  depicts a schematic diagram of an illustrative trans-apical approach of an annuloplasty ring (not shown) to the mitral valve  810  of a heart  800  according to another embodiment. As shown in  FIG. 8C , the catheter  812  may pass through the apex  830  of the heart  800 , through the left ventricle LV, through the leaflets of the mitral valve  810 , and into the left atrium LA. The annuloplasty ring may be delivered through the catheter  812  into the left atrium LA and anchored to the annulus of the mitral valve  810 , in an embodiment, a needle or trocar may be used to puncture through the apex  830  to create a small opening through which a guide wire (not shown) can be inserted through the left ventricle LV into the left atrium LA. The guide wire may be used to guide successively larger and stiffer catheters so as to gradually increase the size of the opening in the apex  830  of the heart  800 . 
       FIG. 9A  depicts a flow diagram of a first illustrative method of placing an annuloplasty ring at a target valve according to an embodiment. The method may include inserting  960  a distal end of a catheter into a target tissue, such as the heart. The method of insertion  960  is not limited by this disclosure and may be any method, particularly methods described herein with respect to  FIGS. 8A-8C . The annuloplasty ring may be inserted  962  in the proximal end of the catheter and advanced  964  through the catheter and out of the distal end such that it is placed at the location of the target tissue. In some embodiments, advancing  964  may include guiding the annuloplasty via the delivery system described herein. When the annuloplasty ring is inserted  962  and advanced  964 , it may be in an elongate insertion geometry, as described in greater detail herein. As the ring advances  964  out of the catheter, it may be allowed  966  to transition to an annular operable geometry, as described in greater detail herein. In some embodiments, advancing  964  and/or allowing  966  the annuloplasty ring may include manipulating a ring closure knob located on a deployment handle, as described in greater detail herein. 
     The cads of the annuloplasty ring may be drawn  968  together, such as, for example, by pulling a first suture connected to the annuloplasty ring through the catheter. In some embodiments, the ends may be drawn  968  together via manipulating a ring closure knob located on a deployment handle, as described in greater detail herein. In some embodiments, a ring closure lock may lock the two ends of the ring together once they have been sufficiently drawn  968  together. In some embodiments, drawing  968  the ends together may further include manipulating a ring snap knob on a deployment handle to cause the ends to snap together, as described in greater detail herein. 
     In various embodiments, a determination may be made as to whether the ring is sufficiently oriented. In some embodiments, orientation of the ring may be based on the positioning and/or location of the catheter, the location and/or positioning of the target tissue, the shape of the ring, and/or the like. If orientation of the ring is necessary, the ring may be oriented  972 . Orienting  972  may include, for example, rotating the ring, the catheter, and/or various other components described herein. In some embodiments, orienting  972  may include automatically rotating the ring to change a plane of the ring from a first orientation that is parallel to the catheter to a second orientation that is parallel to a plane of the annulus. In some embodiments, orienting  972  the annuloplasty ring may be completed via the stabilizer portion, such as by manipulating a stabilizer knob on a deployment handle, as described in greater detail herein. 
     In various embodiments, a determination  974  may be made as to whether the ring is sufficiently expanded. In some embodiments, expansion of the ring may be based on the construction of the ring, as described in greater detail herein. Thus, in some embodiments, expansion may not occur, particularly in embodiments where the ring is not expandable, as described in greater detail herein. If expansion of the ring is necessary, the ring may be expanded  976 . Expansion of the ring may be completed by manipulating one or more sutures, as described in greater detail herein. In some embodiments, expanding  976  the ring may be completed via an expansion tool, such as, for example, by manipulating an expansion tool knob on a deployment handle, as described in greater detail herein. In some embodiments, a percutaneously, transcatheter-operated expansion tool may be actuated to expand  976  the annuloplasty ring in the annular operable geometry to an expanded state to thereby increase an A-P distance of the annuloplasty ring. Expansion of the annuloplasty ring may include expanding a biasing element of the annuloplasty ring. 
     In various embodiments, a determination  978  may be made as to whether the ring is contacting the annulus. The determination  978  may be necessary, for example, to ensure proper placement of the ring adjacent to the annulus. In some embodiments, the ring may be pressed  980  against the annulus. Pressing  980  may include positioning the annuloplasty ring in abutment or similar relatively intimate contact with an annulus of a target valve to enhance a process of fastening the annuloplasty ring to the annulus. The method may include manipulating a stabilizer, such as via a stabilizer knob, as described in greater detail herein. The method may also include pulling a second suture connected to the annuloplasty ring through the catheter to deploy  982  a plurality of tissue anchors from the annuloplasty ring. Deployment  982  of the anchors may also be completed via manipulation of an anchor deployment knob, as described in greater detail herein. With the anchors deployed  982  and the annuloplasty ring fastened to the tissue of the target valve, the expansion tool may be released  984 . The annuloplasty ring may be contracted  986  to transition the annuloplasty ring in the operable geometry to a contracted state to decrease the A-P distance, thereby decreasing the A-P distance of the target heart valve to improve coaptation and reduce regurgitation through the target heart valve. In some embodiments, contraction  986  of the annuloplasty ring may be completed by biasing elements that have stored potential energy during expansion of the annuloplasty ring. 
     In various embodiments, the annuloplasty ring may be detached  988  from the catheter and the first and second sutures, and the catheter may be removed  990  from the heart. In some embodiments, the ring may be detached  988  via manipulation of a ring release knob on a deployment handle, as described in greater detail herein. 
       FIG. 9B  depicts a flow diagram of a second illustrative method of placing an annuloplasty ring at a target valve according to an embodiment. The method may include inserting  1050  a distal end of a catheter into a target tissue, such as the heart. The method of insertion  1050  is not limited by this disclosure and may be any method, particularly methods described herein with respect to  FIGS. 8A-8C . The annuloplasty ring may be inserted  1052  in the proximal end of the catheter and advanced  1054  through the catheter and out of the distal end such that it is placed at the location of the target tissue. In some embodiments, advancing  1054  may include guiding the annuloplasty via the delivery system described herein. When the annuloplasty ring is inserted  1052  and advanced  1054 , it may be in an elongate insertion geometry, as described in greater detail herein. In some embodiments, the annuloplasty ring may be attached to a catheter. As the ring advances  1054  out of the catheter, it may be allowed  1056  to transition to an annular operable geometry, as described in greater detail herein. In some embodiments, advancing  1054  and/or allowing  1056  the annuloplasty ring may include manipulating a ring closure knob located on a deployment handle, as described in greater detail herein. 
     The ends of the annuloplasty ring may be drawn  1058  together, such as, for example, by pulling a first suture connected to the annuloplasty ring through the catheter. In some embodiments, the ends may be drawn  1058  together via manipulating a ring closure knob located on a deployment handle, as described in greater detail herein, in some embodiments, a ring closure lock may lock the two ends of the ring together once they have been sufficiently drawn  1058  together. In some embodiments, drawing  1058  the ends together may further include manipulating a ring snap knob on a deployment handle to cause the ends to snap together, as described in greater detail herein. 
     The annuloplasty ring may be contacted  1060  with a posterior side of the valve. Such contacting  1060  may generally be completed via the delivery system, as described in greater detail herein. Use of the delivery system may include manipulating at the stabilizer, as described in greater detail herein. A first portion of the anchors may be deployed  1062 , such as, for example, the posterior zone anchors (as described herein). Thus, in some embodiments, anchors located in two posterior zones may be deployed sequentially. Alternatively, anchors located in two posterior zones may be deployed simultaneously. Deployment  1062  may effect engagement of the one or more posterior zones of the annuloplasty ring (or a portion thereof) to the posterior side of the valve. As previously described herein, deployment  1062  may be completed via manipulation of an anchor deployment knob. 
     The valve tissue may be dragged  1064 , via the delivery system, such that the annuloplasty ring may be contacted  1066  to the anterior side of the valve. Use of the delivery system may include manipulating at least the stabilizer, as described in greater detail herein. A second portion of the anchors may be deployed  1068 , such as, for example, the anterior zone anchors (as described herein). Thus, in some embodiments, anchors located in two anterior zones may be deployed sequentially. Alternatively, anchors located in two anterior zones may be deployed simultaneously. Deployment  1068  may effect engagement of the anterior zone of the annuloplasty ring (or a portion thereof) to the anterior side of the valve. 
     With the anchors deployed  1062 ,  1068  and the annuloplasty ring fastened to the tissue of the target valve, the stabilizer may be released  1070 . The annuloplasty ring may be contracted  1072  to transition the annuloplasty ring in the operable geometry to a contracted state to decrease the A-P distance, thereby decreasing the A-P distance of the target heart valve to improve coaptation and reduce regurgitation through, the target, heart valve. In some embodiments, contraction  1072  of the annuloplasty ring may be completed by biasing elements that have stored potential energy during expansion of the annuloplasty ring. 
     In various embodiments, the annuloplasty ring may be detached  1074  from the catheter and the first and second sutures, and the catheter may be removed  1076  from the heart. In some embodiments, the ring may be detached  1074  via manipulation of a ring release knob on a deployment handle, as described in greater detail herein. 
       FIGS. 9C, 9D, 9E, and 9F  depict schematic diagrams illustrating transcatheter delivery of an annuloplasty ring  902  from a delivery system  900  according to various embodiments.  FIG. 9C  depicts a perspective view of a distal end  910  of the delivery system  900 . As shown, in  FIG. 9C , the annuloplasty ring  902  may be in the elongate insertion geometry and partially deployed from the distal end  910  of a delivery catheter  914  in a first deployment stage. In the first stage, the annuloplasty ring  902  may be still substantially in the elongate insertion geometry. As shown in  FIG. 9C , a first suture  919  for snapping together the ends of the annuloplasty ring  902  may pass through a male snap  912  of a ring closure lock  950  (shown in  FIG. 9E ). 
       FIG. 9D  is a perspective view of the annuloplasty ring  902  in a second stage of partial deployment from the delivery catheter  914 . In the second stage, the portion, of the annuloplasty ring  902  that has exited the delivery catheter  914  has begun to transition (due to the shape memory materials used in the annuloplasty ring) from the elongate insertion geometry to the annular operable geometry. 
       FIG. 9E  is a perspective view of the annuloplasty ring  902  in a third stage of deployment in which a ring shuttle  916  of the delivery system  900  has substantially pushed the annuloplasty ring out of the delivery catheter  914 , but the plane of the annuloplasty ring is still aligned with (for example, parallel to) the longitudinal axis of the delivery catheter. In  FIG. 9E , the annuloplasty ting  962  may be in a configuration, for example, immediately before a ring deployment wire  923  cooperates with the pivot  108  to rotate the annuloplasty ring  902  (sec  FIG. 9F ). In the configuration shown in  FIG. 9E , the distal end of the ring deployment wire  923  may include a bend or hook  932  as it passes through a hole in the pivot  108 . The ring deployment wire  923  includes a superelastic shape memory material (such as, for example, nitinol), and bending the distal end of the ring deployment wire  923  into the hook  932  shape may spring load the annuloplasty ring  902  within the outer jacket, delivery catheter  914  such that the annuloplasty ring  902  automatically rotates about the pivot  108  upon exiting the outer jacket delivery catheter  914 . At this third stage of deployment, the hook  932  shape formed in the superelastic ring deployment wire  923  is ready to unload (return to a heat-set memorized straight configuration) as soon as the delivery catheter  914  no longer prevents it from doing so. The suture  919  may be used to draw together the male components  952  and female components  954  of a ring closure lock  950 . 
       FIG. 9F  depicts a perspective view of the annuloplasty ring  902  in a fourth stage of deployment in which the plane of the annuloplasty ring (in its annular operable geometry) has been changed to be perpendicular to the longitudinal axis of the delivery catheter  914 . As shown in  FIG. 9F , the superelastic ring deployment wire  923  has returned to its heat set (memorized) straight configuration. At this fourth stage of deployment, the plane of the annuloplasty ring  902  may be configured to be parallel to the plane of the heart valve annulus. In situ within the heart, a longitudinal axis of the delivery catheter  914  may be oriented parallel to the direction of blood through the valve and approximately perpendicular to the plane of the heart valve. The annuloplasty ring  902 , when oriented such that, the plane of the annuloplasty ring is transverse to (and perpendicular or approximately perpendicular to) the longitudinal axis of the delivery catheter  914 , may be oriented such that the plane of the annuloplasty ring is parallel or approximately parallel to the plane of the heart valve. 
     In further stages of deployment, the annuloplasty ring  902  may be expanded and/or pressed against the heart valve annulus before deploying the anchors (such as the curved anchors  104  shown in  FIGS. 1A and 1B ). As discussed herein, certain anchors may propel themselves into the tissue of the heart valve annulus upon being deployed. In other embodiments, the anchors (such as the linear anchors  710  shown in  FIG. 7 ) may be deployed before pressing the annuloplasty ring  902  against the annulus. After the annuloplasty ring  902  is anchored to the heart valve annulus and transitioned to the contracted state, the ring deployment wire  923  may be pulled from the hole in the pivot  108  to release the annuloplasty ring  902  from the ring shuttle  916 . Any remaining sutures, such as the first suture  919 , may also be cut and/or pulled from the annuloplasty ring  902  before the delivery catheter  914  is removed from the heart. In some embodiments, removal of the ring deployment wire  923  and/or any remaining sutures may be completed via one or more of the knobs, as described in greater detail herein. 
       FIG. 10  depicts a schematic diagram of a perspective, partial cross-sectional view of a heart  1000  during the expansion of an adjustable annuloplasty ring  1002  using an expansion tool  1004 , preparatory to affixation to the annulus of the mitral valve  1006  according to an embodiment. As shown in  FIG. 10 , a delivery catheter  1010  may extend from the left ventricle info the left atrium through the leaflets of the mitral valve  1006 . Thus, this illustrated embodiment may correspond to, for example, a trans-apical approach or a retrograde approach, as discussed herein. Those with ordinary skill in the art will recognize from the present disclosure that similar principles as those illustrated may be used for trans-septal approaches. 
     In  FIG. 10 , an expansion tool  1004  may be used to expand the annuloplasty ring  1002 . The annuloplasty ring  1002  may be positioned on or next to the annulus of the mitral valve  1006 . The expansion tool  1004  may be disposed within the annuloplasty ring  1002  (and within the target valve  1006 ) to expand the annuloplasty ring  1002  to transition it from a contracted state to an expanded state. The expansion tool  1004  of the illustrated embodiment of  FIG. 10  is a balloon expansion tool  1004 . The balloon expansion tool  1004  may be inflated to expand the annuloplasty ring  1002  to an expanded state. In some embodiments, the balloon expansion tool  1004  may include a plurality of sections and may be considered a “multi-chamber” balloon with a plurality of chambers. In particular embodiments, the balloon expansion tool  1004  may have two chambers. In other embodiments, a balloon expansion tool  1004  may have a single chamber. 
     In the embodiment shown in  FIG. 10 , the inflated balloon expansion tool  1004  may reduce or prevent the flow of blood through the mitral valve during at least part of the implantation procedure. In such embodiments, inflation of the balloon expansion tool  1004  may last 20 seconds or less to prevent adverse consequences of occluding the mitral valve  1006 . In other embodiments, such as the embodiment of an expansion tool shown in  FIGS. 11, 12A-12E, 13A-13D, and 14A-14B , blood may be allowed to flow through the target valve  1006  during the entire procedure. 
       FIG. 11  depicts a schematic diagram of a perspective, partial cross-sectional view of a heart  1100  during the expansion of an adjustable annuloplasty ring  1102  using a cage or basket tool  1104  as an expansion tool, preparatory to affixation to the annulus of the mitral valve  1106  according to another embodiment. 
     The basket expansion tool  1104  may include a plurality of flexible members  1108  that lay flat against a central rod  1114  during insertion of the basket expansion tool through the delivery catheter (see  FIG. 10 ) and may be forced into an expanded configuration (shown in  FIG. 11 ) when the central rod is pushed into an end cap  1112 . In another embodiment, each of the plurality of flexible members  1108  may include a superelastic material so as to spring from a delivery catheter into the expanded configuration shown in  FIG. 11 . 
       FIGS. 12A and 12B  depict schematic diagrams of perspective views of an illustrative stabilizer, generally designated  1200 , that may be used in lieu of the expansion tool according to an embodiment,  FIG. 12A  depicts a perspective view of the stabilizer  1200  separated from other components of the percutaneous annuloplasty system.  FIG. 12B  depicts the stabilizer  1200  disposed through a delivery catheter  1204  and engaging an annuloplasty ring  1250 . 
     In order to achieve sufficient intimate contact between an annuloplasty ring  1250  (shown in  FIG. 12B ) and the tissue of the target heart valve (for example, the annulus of the heart valve), the stabilizer  1200  may be used to position, orient, and otherwise manipulate the annuloplasty ring  1250  in the annular operable geometry, prior to affixation to tissue of the valve. The stabilizer  1200  may have a metallic rib structure having a plurality of arms  1202   a ,  1202   b ,  1202   c  (collectively  1202 ) or prongs configured to extend outward at an angle from a central column  1203 . While only three arms  1202  are shown in the present embodiment, those having ordinary skill in the art will recognize any number of arms may be suitable without departing from, the scope of the present disclosure. For example, the stabilizer  1200  may have 2, 3, 4, 5, 6, 7, 8, 9, 10 or more arms  1202 . The rib structure, specifically the arms  1202  and central column  1203 , may be laser cut from a shape memory material, such as nitinol. The stabilizer  1200  may be cut from a hollow tube such that the central column  1203  has a hollow cylindrical shape. The arms  1202  may be heat set to extend at an angle from the central column  1203 . 
     The illustrated stabilizer  1200  of  FIGS. 12A and 12B  may include three arms  1202  arranged, for example, as a tripod. The plurality of arms  1202  of the stabilizer  1200  may be loaded into a delivery catheter  1204  together with the annuloplasty ring  1250  (for example, configured in the elongate insertion geometry). As the arms  1202  emerge from a distal end of the delivery catheter  1204 , they may automatically expand outward. The stabilizer  1200 , and specifically the plurality of arms  1202 , may be configured to align with and engage the annuloplasty ring  1250  as shown in  FIG. 12B . When aligned and engaged with the annuloplasty ring  1250 , the stabilizer  1200  may be used to push/pull the annuloplasty ring  1250  toward the tissue of an annulus of a heart valve. 
     The illustrated stabilizer of  FIGS. 12A and 12B  may be configured to engage a top surface of the annuloplasty ring  1250 , through the annuloplasty ring, to pull the annuloplasty ring downward. For example, the plurality of arms  1202  may include a curved, angled, or hooked portion at a distal end to facilitate engagement with the annuloplasty ring  1250 . The stabilizer  1200  may be used to pull the annuloplasty ring  1250  toward the heart valve to facilitate intimate contact of the annuloplasty ring with the annulus. Intimate contact, or close abutment, of the annuloplasty ring  1250  with the annulus of the valve may enhance an anchor deployment process to fasten the annuloplasty ring  1250  to the annulus. 
     In some embodiments, the stabilizer  1200 , particularly the arms  1202 , may also be configured to function as an expansion tool to engage the annuloplasty ring  1250  and effectuate and/or facilitate transition of the annuloplasty ting from a contracted state to an expanded state. For example, a superelastic property and memorized shape of the plurality of arms  1202  may effectuate expansion of the annuloplasty ring  1250 . The superelastic arms  1202  may engage an inner surface of the annuloplasty ring  1250  and exert outward force to expand the annuloplasty ring. In other embodiments, a suture or other elongate member may enable percutaneous manipulation of one or more of the plurality of arms to effectuate expansion of the annuloplasty ring  1250 . 
       FIGS. 12C and 12D  depict a stabilizer  1200  that includes a balloon  1280 . The balloon  1280  may pass through the central column  1203  of the stabilizer  1200 . When the balloon  1280  is inflated, it may cause the arms  1202  of the stabilizer  1200  to expand. By expanding the stabilizer  1200 , the ring  1250  ( FIG. 12E ) may be expanded to its expanded configuration. In some embodiments, the ring  1250  ( FIG. 12E ) may also be contracted when the balloon  1280  is deflated and the tool  1200  is retracted. 
       FIG. 12E  depicts a schematic diagram that demonstrates how various holes  1270  may be used to guide one or more sutures  1271  that exit the ring  1250 , as described in greater detail herein. The sutures  1271  may be used for deployment or recapturing of the anchors held within the ring  1250 . In some embodiments, the sutures  1271  may extend through the windows in the ring and/or dedicated holes in the laser cut pattern of the ring, as described herein. The holes in the tool  1200  may allow the sutures  1271  to be gathered together and guided through the hollow central column  1203  and the catheter  1204  via the handle at the proximal end of the catheter, as described in greater detail herein. 
     In various embodiments, the expansion tool and/or the stabilizer may be configured to complete one or more additional tasks. Illustrative additional tasks are not limited by this disclosure, and may include, for example, navigating the annuloplasty ring within a chamber of a heart, creating an intimate contact between the annuloplasty ring and the target tissue (such as a valve annulus), expanding the annuloplasty ring, and stabilizing the annuloplasty ring during various deployment and anchoring processes, as described in greater detail herein. 
       FIGS. 13A and 13B  depict schematic diagrams of perspective views of an illustrative stabilizer  1300  to be used as an expansion tool of a percutaneous annuloplasty system according to an embodiment. The illustrated stabilizer  1360  may include one or more arms or prongs  1302 , such as, for example, two arms  1302   a ,  1302   b .  FIG. 13A  depicts a perspective view of the stabilizer  1300  separated from other components of the percutaneous annuloplasty system,  FIG. 13B  depicts the stabilizer  1300  disposed through a delivery catheter  1306  and engaging an annuloplasty ring  1350 . The stabilizer  1300  may be used to position, orient, and otherwise manipulate the annuloplasty ring  1350  to achieve intimate contact in abutment with tissue of the annulus of a target heart valve. 
     Referring generally and collectively to  FIGS. 13A-13D , the arms  1302  of the stabilizer  1300  may be configured to extend outward at an angle from a central column  1304 , thereby forming a rib structure. The rib structure, particularly the arms  1302  and central column  1304 , may be laser cut from a shape memory material, such as, for example, nitinol. The stabilizer  1300  may be cut from a hollow tube such that the central column  1304  has a hollow cylindrical shape. The arras  1302  may be heat set to extend at an angle from the central column  1304 . 
     The illustrated stabilizer  1300  of  FIGS. 13A and 13B  may include two arms  1302   a ,  1302   b  arranged, for example as a bipod. The two arms  1302   a ,  1302   b  in cooperation with a ring shuttle  1361  of a delivery system of the percutaneous annuloplasty system form a tripod structure engaging the annuloplasty ring  1350  at three points. The plurality of arms  1302  may be loaded into a delivery catheter  1306  together with the annuloplasty ring  1350  (for example, configured in the elongate insertion geometry). As the arms  1302  extend from a distal end of the delivery catheter  1306 , they may automatically expand outward and may be configured to align with and engage the annuloplasty ring  1350  as shown in  FIG. 13B . When aligned and engaged with the annuloplasty ring  1350 , the stabilizer  1300  may be used to push/pull the annuloplasty ring toward the tissue of the annulus of a valve. 
     The illustrated stabilizer of  FIGS. 13A and 13B  may be configured to engage a top surface of the annuloplasty ring  1350  to pull the annuloplasty ring. For example, the plurality of arms  1302  may include a curved, angled, or hooked portion at a distal end to facilitate engagement with the annuloplasty ring  1350 . The stabilizer  1300  may be used to pull the annuloplasty ring  1350  toward the heart valve to facilitate intimate contact of the annuloplasty ring with the annulus to enhance an anchor deployment process to fasten the annuloplasty ring to the annulus. 
     The stabilizer  1300 , particularly the arms  1302 , may also be configured to function as an expansion tool to engage the annuloplasty ring  1350  and effectuate and/or facilitate transition of the annuloplasty ring from a contracted state to an expanded state. For example, a superelastic property and memorized shape of the plurality of arms  1302  may enable the arms to engage an inner surface of the annuloplasty ring  1350  and via its inherent material properties, exert outward force to expand the annuloplasty ring. In other embodiments, a suture or other elongate member may enable percutaneous manipulation of one or more of the plurality of arms  1302  to effectuate expansion of the annuloplasty ring  1350 . 
     In some embodiments, the arms  1302  of the stabilizer  1300  may also include a feature feat locks the stabilizer against the annuloplasty ring  1350 , thereby preventing each arm from moving relative to another, such as, for example, after the deployment and during creation of intimate contact between the ring and the tissue. For example, the arms  1302  of the stabilizer  1300  may each have at least one strat  1303   a ,  1303   b  (collectively  1303 ). Each strat  1303  may prevent its respective arm  1302  from sliding on the annuloplasty ring  1350  and may allow and/or facilitate engagement on a particular position of the ring. In some embodiments, a particular position of engagement on the annuloplasty ring  1350  may ensure a proper ring size, shape, and/or orientation. After aligning the stabilizer  1300  relative to the annuloplasty ring  1350 , the stabilizer may be fixed in relation to the ring by the strats  1303 . By manipulating the tool  1300 , the operator may be able to manipulate the position and orientation of the annuloplasty ring  1350 . 
     In various embodiments, as shown in  FIGS. 13E-13I , the annuloplasty ring  1350  may also have at least one strat  1355   a ,  1355   b  (collectively  1355 ). Each strat  1355  may prevent the annuloplasty ring  1350  from sliding when attached to the arms  1302 . In some embodiments, each strat  1355  may allow and/or facilitate engagement of a particular portion of the annuloplasty ring  1350  with a particular arm  1302 . In some embodiments, a particular position of engagement of the strats  1355  on the annuloplasty ring  1350  may ensure a proper ring size, shape, and orientation. After aligning the stabilizer  1300  ( FIG. 13C ) relative to the annuloplasty ring  1350 , the stabilizer may be fixed in relation to the ring by the strats  1355 . In some embodiments, the strats  1355  on the annuloplasty ring  1350  may be used in conjunction with the strats  1303  on the arms  1392  of the stabilizer. In other embodiments, the strats  1355  on the annuloplasty ring  1350  may be used in lieu of the strats  1303  on the arms  1392  of the stabilizer. 
       FIGS. 14A and 14B  depict diagrams illustrating perspective views of a stabilizer  1400  of a percutaneous annuloplasty system according to an embodiment. The stabilizer  1400  may be configured to push and/or press an annuloplasty ring  1450  (from above) into intimate contact with, or abutment against, an annulus of a target heart valve. The illustrated stabilizer  1400  may include a plurality of arms or prongs  1402 , such as, for example two anus  1402   a ,  1402   b .  FIG. 14A  depicts a perspective view of the stabilizer  1400  separated from other components of the percutaneous annuloplasty system.  FIG. 14B  depicts the stabilizer  1400  disposed through a delivery catheter  1406  and engaging an annuloplasty ring  1450  from above. The stabilizer  1400  may be used to position, orient, and/or otherwise manipulate the annuloplasty ring  1450  to achieve intimate contact with or abutment against tissue of the annulus of a target heart valve. 
     The arms  1402  of the stabilizer  1400  may be configured to extend outward at an angle from a central column  1404 , thereby forming a rib structure. The rib structure, particularly the arms  1402  and central column  1404 , may be laser cut from a shape memory material, such as nitinol. The stabilizer  1400  may be cut from a hollow tube such that the central column  1404  has a hollow cylindrical shape. The arms  1402  may be heat set to extend at an angle from the central column  1404 . 
     The illustrated stabilizer  1400  of  FIGS. 14A and 14B  may include two arms  1402   a ,  1402   b  arranged, for example, in the shape of a bipod. The two arms  1402   a ,  1402   b , in cooperation with a ring shuttle  1451  of the percutaneous annuloplasty system, may form a tripod structure engaging the annuloplasty ring  1450  at three points. The plurality of arms  1402  may be loaded into a delivery catheter  1406  together with the annuloplasty ring  1450  (for example, configured in the elongate insertion geometry). As the arms  1402  emerge from a distal end of the delivery catheter  1406 , they may automatically expand outward and may be configured to align with and engage the annuloplasty ring  1450 , as shown in  FIG. 14B . When aligned and engaged with the annuloplasty ring  1450 , the stabilizer  1400  may be used to push/pull the annuloplasty ring toward the tissue of an annulus of a heart valve. 
     The illustrated stabilizer of  FIGS. 14A and 14B  may be configured to engage a top surface of the annuloplasty ring  1450  from above to push the annuloplasty ring. For example, the plurality of arms  1402  may include a curved, angled, and/or hooked portion at a distal end to facilitate engagement with the annuloplasty ring  1450 . The stabilizer  1400  may be used to push the annuloplasty ring  1450  from above in a downward direction toward the heart valve to facilitate intimate contact of the annuloplasty ring with the annulus to enhance an anchor deployment process and/or to aid in the fastening of the annuloplasty ring to the annulus. 
     The stabilizer  1400 , particularly the arms  1402 , may also be configured to function as an expansion tool to engage the annuloplasty ring  1450 , effectuate, and/or facilitate transition of the annuloplasty ring from a contracted state to an expanded state. For example, a superelastic property and shape memory property of the plurality of arms  1402  may enable the arms to engage an inner surface of the annuloplasty ring  1450  and exert an outward force to expand the annuloplasty ring. The stabilizer  1400  may be manipulated to expand the annuloplasty ring  1450  within the annulus of the target valve, or otherwise press the annuloplasty ring against the valve and thereby effectuating expansion of the annuloplasty ring to the expanded state. In other embodiments, a suture or other elongated member may enable percutaneous manipulation of one or more of the plurality of arms  1402  to effectuate expansion of the annuloplasty ring  1450 . 
       FIG. 15A  depicts a diagram of a perspective view of an illustrative proximal end handle, generally designated  1500 , of a percutaneous annuloplasty system according to an embodiment.  FIG. 15B  depicts a diagram of a perspective cross-sectional view of the proximal end handle  1500  of  FIG. 15A . In various embodiments, the proximal end handle  1500  may enable percutaneous transcatheter deployment of an annuloplasty ring. More particularly, the proximal end handle  1500  may enable percutaneous manipulation of an annuloplasty system configured to deliver, configure, and/or orient an annuloplasty ring and to fasten the annuloplasty ring to the annulus of a target valve. 
     In various embodiments, the proximal end handle  1500  may include one or more rotating knobs that are configured to perform or enable one or more functions in some embodiments, one rotatable knob may be used for each function to be performed. In other embodiments, one rotatable knob may be used for a plurality of functions. A ring closure knob  1502  may enable closure of the annuloplasty ring to transition from an elongated insertion geometry to an annular operable geometry, as described in greater detail herein. A ring snap knob  1504  may enable snapping together of first and second ends (for example, distal and proximal ends) of the annuloplasty ring or other manipulation of a ring closure lock, as described herein. An anchor deployment knob  1506  may enable deployment of anchors of an annuloplasty ring to fasten the annuloplasty ring to the annulus of the target heart valve, as described herein. An A-P adjustment knob  1508  may enable contraction of the annuloplasty ring from an expanded state to a contracted state, as described herein. In other embodiments, the A-P adjustment knob  1508  may also enable manipulation of a stabilizer to facilitate expansion of the annuloplasty ring to an expanded stats (for example, prior to deployment of the anchors). A ring release knob  1510  may enable release of the annuloplasty ring from a delivery system and/or delivery shuttle of a percutaneous annuloplasty system. Additional or fewer knobs may be possible, depending on the functions to be performed. Furthermore, the positioning of each knob relative to other knobs as shown in  FIG. 15A  is merely illustrative. Accordingly, those having ordinary skill in the art will recognize other positions of each knob relative to other knobs as being included within the scope of this disclosure. 
     In various embodiments, each of the knobs  1502 ,  1504 ,  1506 ,  1508 ,  1510  may be coupled to an independent system of cables and/or sutures. Manipulation of a respective cable and/or suture may be achieved by rotating the respective knob  1502 ,  1504 ,  1506 ,  1508 ,  1510 . As shown in  FIG. 15B , each of the knobs  1502 ,  1504 ,  1506 ,  1508 ,  1510  may be mechanically coupled to a respective translation gear mechanism. The gear mechanism may be connected to a respective cable or suture that is configured to perform a given function. 
       FIGS. 16A and 16B  depict diagrams of perspective views of an illustrative delivery system, generally designated  1600 , of a percutaneous annuloplasty system, according to an embodiment. In some embodiments, fee delivery system  1600  may include a plurality of sections, such as, for example, a distal end section  1700 , a catheter section  1800 , and/or a proximal handle section  1900 . The delivery system  1600  may be configured to enable percutaneous transcatheter deployment of an annuloplasty ring, as described herein. More particularly, the delivery system  1600  may enable percutaneous manipulation of an annuloplasty system configured to deliver, configure, and/or orient an annuloplasty ring. Further, the delivery system  1600  may be configured to fasten the annuloplasty ring to the annulus of a target, heart valve, as described in greater detail herein. 
       FIGS. 17A and 17B  depict illustrative examples of a full assembly of a ring  1710 , a stabilizer  1730 , and a distal end of the catheter  1740  as configured in a target site alter deployment of the ring from the catheter.  FIGS. 17A and 17B  further depict an illustrative example of an attachment mechanism between the ring  1710  and the stabilizer  1730 . As described in greater detail herein, the connection may be accomplished between a pivot point  1712  on the ring  1710  and the ring shuttle  1722  on the stabilizer  1730  via a wire  1723  that may be configured to pass through the catheter  1740  to the proximal end of the delivery system. 
     Also shown in  FIGS. 17A and 17B  is an illustrative example of a delivery system  1700  showing, at the distal end, a solid piece  1721 . The solid piece  1721  may be manufactured from any material, such as, for example, stainless steel. The solid piece  1721  may be configured for one or more functions. Illustrative functions may include, but are not limited to, holding the ring shuttle  1722  in a particular position, locating the stabilizer  1730  in relation to the ring shuttle and/or the ring  1710  at the target site, and guiding the sutures from the ring through the holes  1724  towards the proximal end of the delivery system  1740 . 
       FIGS. 18A and 18B  depict a longitudinal cross-sectional view of an illustrative catheter, generally designated  1800 , connecting the distal end of the delivery system  1700  ( FIGS. 17A and 17B ) to the proximal end of the delivery system  1900  ( FIGS. 19A and 19B ). The catheter  1800  may include one or more lumens  1810  containing, but not limited to, a hollow outer sleeve  1811  that is attached to the proximal end of the delivery system  1910 . 
     In various embodiments, an inner hollow shaft  1812  may be located within the hollow outer sleeve  1811 . Referring also to  FIG. 19A , the inner hollow shaft  1812  may be connected to a moving member  1931  that is configured to transfer movement of a rotating knob  1932  to the inner hollow shaft  1812  and to the solid piece  1721  ( FIGS. 17A and 17B ) at the distal end of the delivery system  1700  ( FIGS. 17A and 17B ). 
     In some embodiments, a stabilizer shaft  1813  may be located within the inner hollow shaft  1812 . The stabilizer shaft  1813  may connect the stabilizer  1730  to the proximal end of the delivery system  1700  ( FIGS. 16A and 16B ). In some embodiments, the stabilizer shaft  1813  may be configured to allow distal control of the stabilizer  1730  from the proximal end  1950  ( FIG. 19A ). In some embodiments, a guidewire or pig-tail catheter  1814  may be passed through the center of the stabilizer shaft  1813 . The guidewire or pig-tail catheter  1814  may generally be one of a commonly used tool in the cardiovascular field to function as a guide in the heart chambers and/or to function as a conduit for injection of contrast media for fluoroscopy. 
       FIGS. 19A, 19B, and 19C  depict an illustrative embodiment tor the proximal side of the deli very system  1900 , which may function as a handle. The system  1900  may include one or more functional mechanisms. Illustrative functional mechanisms may include, but are not limited to, a ring deployment mechanism  1930 , a ring closure or snapping mechanism  1940 , a barb or anchor deployment mechanism  1920 , and control channel mechanism for the ring release wire  1723  ( FIGS. 17A and 17B ). The ring deployment mechanism  1930  may include a rotating knob  1932  and/or a moving member  1931  that may be attached to the inner hollow shaft  1812 . In some embodiments, the knob  1932  may be configured to be rotated such that the ring  1710  ( FIGS. 17A and 17B ) is pushed distally and away through the outer sleeve  1811 , thereby deploying from the catheter. The end of the suture  1960  from the ring  1710  ( FIGS. 17A and 17B ) may be fixed at the proximal end  1950  such that when the ring deploys, the suture may be placed under a constant tension. 
       FIG. 19B  depicts an illustrative suture  1960  attached to the ring  1710  at the distal end  1951 . The suture may pass through the proximal end of the ring  1715 , the ring shuttle  1722 , the solid piece  1721  and the outer sleeve  1811  to the proximal end of the delivery system  1950  ( FIG. 19A ). The total length of the suture  1960  may be the length of a first portion a plus the length of a second portion b (a+b). 
       FIG. 19C  depicts an illustrative ring  1710  after deployment from the outer sleeve  1811 . As shown in  FIG. 19C , the suture  1960  may remain the same length as it is attached at the same points of the ring  1710  relative to the delivery system. Accordingly, the suture  1960  may be placed under tension. 
     Referring again to  FIG. 19A , a channel  1920  may be provided for one or more barb deployment elongated members (such as, for example, sutures) to be held and pulled once barbs and/or anchors are deployed, as described in greater detail herein. Any number of barb deployment members may be placed via the channel  1920 . In some embodiments, the number of barb deployment members may correspond to a number of windows, as described herein. For example, 1 barb deployment member, 2 barb deployment members, 3 barb deployment members, 4 barb deployment members, 5 barb deployment members, 6 barb deployment members, 7 barb deployment members, 8 barb deployment members, 9 barb deployment members, 10 barb deployment members or more may be placed via the channel  1920 . 
     In the above detailed description, reference is made to the accompanying drawings, which form a part hereof. In the drawings, similar symbols typically identify similar components, unless context dictates otherwise. The illustrative embodiments described in the detailed description, drawings, and claims are not meant to be limiting. Other embodiments may be used, and other changes may be made, without departing from the spirit or scope of the subject matter presented herein. It will be readily understood that the aspects of the present disclosure, as generally described herein, and illustrated in the Figures, can be arranged, substituted, combined, separated, and designed in a wide variety of different configurations, all of which are explicitly contemplated herein. 
     The present disclosure is not to be limited in terms of the particular embodiments described in this application, which are intended as illustrations of various aspects. Many modifications and variations can be made without departing from its spirit and scope, as will be apparent to those skilled in the art. Functionally equivalent methods and apparatuses within the scope of the disclosure, in addition to those enumerated herein, will be apparent to those skilled in the art from the foregoing descriptions. Such modifications and variations are intended to fall within the scope of the appended claims. The present disclosure is to be limited only by the terms of the appended claims, along with the full scope of equivalents to which such claims are entitled. It is to be understood that this disclosure is not limited to particular methods, reagents, compounds, compositions or biological systems, which can, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting. 
     With respect to the use of substantially any plural and/or singular terms herein, those having skill in the art can translate from the plural to the singular and/or from the singular to the plural as is appropriate to the context and/or application. The various singular/plural permutations may be expressly set forth herein for sake of clarity. 
     It will be understood by those within the art that, in general, terms used herein, and especially in the appended claims (for example, bodies of the appended claims) are generally intended as “open” terms (for example, the term “including” should be interpreted as “including but not limited to,” the term “having” should be interpreted as “having at least,” the term “includes” should be interpreted as “includes but is not limited to,” et cetera). While various compositions, methods, and devices are described in terms of “comprising” various components or steps (interpreted as meaning “including, but not limited to”), the compositions, methods, and devices can also “consist essentially of” or “consist of” the various components and steps, and such terminology should be interpreted as defining essentially closed-member groups. It will be further understood by those within the art that if a specific number of an introduced claim recitation is intended, such an intent will be explicitly recited in the claim, and in the absence of such recitation no such intent is present. For example, as an aid to understanding, the following appended claims may contain usage of the introductory phrases “at least one” and “one or more” to introduce claim recitations. However, the use of such phrases should not be construed to imply that the introduction of a claim recitation by the indefinite articles “a” or “an” limits any particular claim containing such introduced claim recitation to embodiments containing only one such recitation, even when the same claim includes the introductory phrases “one or more” or “at least one” and indefinite articles such as “a” or “an” (for example, “a” and/or “an” should be interpreted to mean “at least one” or “one or more”); the same holds true for the use of definite articles used to introduce claim recitations. In addition, even if a specific number of an introduced claim recitation is explicitly recited, those skilled in the art will recognize that such recitation should be interpreted to mean at least the recited number (for example, the bare recitation of “two recitations,” without other modifiers, means at least two recitations, or two or more recitations). Furthermore, in those instances where a convention analogous to “at least one of A, B, and C, et cetera” is used, in general such a construction is intended in the sense one having skill in the art would understand the convention, (for example, “a system having at least one of A, B, and C” would include but not be limited to systems that have A alone, B alone, C alone, A and B together, A and C together, B and C together, and/or A, B, and C together, et cetera). In those instances where a convention, analogous to “at least one of A, B, or C, et cetera” is used, in general such a construction is intended in the sense one having skill in the art would understand the convention (for example, “a system having at least one of A, B, or C” would include but not be limited to systems that have A alone, B alone, C alone, A and B together, A and C together, B and C together, and/or A, B, and C together, et cetera). It will be further understood by those within the art that virtually any disjunctive word and/or phrase presenting two or more alternative terms, whether in the description, claims, or drawings, should be understood to contemplate the possibilities of including one of the terms, either of the terms, or both terms. For example, the phrase “A or B” will be understood to include the possibilities of “A” or “B” or “A and B.” 
     In addition, where features or aspects of the disclosure are described in terms of Markush groups, those skilled in the art will recognize that the disclosure is also thereby described in terms of any individual member or subgroup of members of the Markush group. 
     As will be understood by one skilled in the art, for any and all purposes, such as in terms of providing a written description, all ranges disclosed herein also encompass any and all possible subranges and combinations of subranges thereof. Any listed range can be easily recognized as sufficiently describing and enabling the same range being broken down into at least equal halves, thirds, quarters, fifths, tenths, et cetera. As a non-limiting example, each range discussed herein can be readily broken down into a lower third, middle third and upper third, et cetera. As will also be understood by one skilled in the art all language such as “up to,” “at least,” and the like include the number recited and refer to ranges which can be subsequently broken down into subranges as discussed above. Finally, as will be understood by one skilled in the art, a range includes each individual member. Thus, for example, a group having 1-3 cells refers to groups having 1, 2, or 3 cells. Similarly, a group having 1-5 cells refers to groups having 1, 2, 3, 4, or 5 cells, and so forth. 
     Various of the above-disclosed and other features and functions, or alternatives thereof, may be combined into many other different systems or applications. Various presently unforeseen or unanticipated alternatives, modifications, variations or improvements therein may be subsequently made by those skilled in the art, each of which is also intended to be encompassed by the disclosed embodiments.