Patent Publication Number: US-2011066236-A1

Title: Annuloplasty system and surgical method

Description:
CROSS-REFERENCE TO RELATED APPLICATIONS 
     This patent application is a divisional of U.S. patent application Ser. No. 11/776,915, now allowed, filed on Jul. 12, 2007. 
    
    
     BACKGROUND OF THE INVENTION 
     The described invention relates in general to surgical systems, devices, and methods and more specifically to an annuloplasty system for damaged heart valve repair. This invention is useful for humans and may be used for the surgical correction of a deformed heart valve, and in particular a heart valve that has become dilated. 
     Diseases of the mitral valve affect the annulus, altering annular geometry and function. Dilation and/or deformation of the valve annulus result in the displacement of the cusps away from the center of the valve. This results in an ineffective closure of the valve during ventricular contraction, which results in the regurgitation or leakage of blood during ventricle contraction. 
     Two known surgical methods or techniques, generally referred to as annuloplasty, are typically used to reshape the distended and/or deformed valve annulus. In the technique known as “plication”, the circumference of the valve annulus is reduced by implanting a prosthetic ring of reduced circumference about the base of the annulus while the annulus is pleated to reduce its circumference to that of the ring. In the technique known as “reconstruction”, the circumference of the annulus is not reduced, but the annulus is restructured into an elongate shape. To accomplish this goal, a rigid or semi-rigid ring (e.g., the Carpentier ring) having the same circumference as the annulus but in an elliptical shape is surgically implanted about the base of the valve. Both plication and restructuring are intended to eliminate the gap in the closure of the distended valve by bringing back together the tips of the valve cusps, reinforce suture lines, and prevent further annular dilatation. 
     Interrupted sutures of 2/0 braided synthetic material with double-end needles are typically used for the described surgical methods. The stitches are placed into the fibrous tissue of the annulus. Large bites of the heart annulus are taken, and the needles are passed close together through the ring prosthesis. The annuloplasty ring is slid down over the sutures into position above the mitral valve and the sutures are tied firmly, attaching the device to the annulus. As the sutures are tied down to approximate the prosthetic ring to the mitral valve annulus, the annular diameter is reduced and the contour is improved. 
     A hypothetically “ideal” annuloplasty would correct the dilatation of the posterior annulus in a measured fashion while allowing a full range of motion of the mitral annulus. Initially the prostheses were designed as rigid and flat frame members, to correct the dilation and reshape the valve annulus to the natural state. However, rigidity impedes the beneficial flexing movements and displacements of the native annulus during the cardiac cycle. Another disadvantage with highly rigid ring prosthesis is the tendency of the sutures to tear during the normal movement of the valve annulus. 
     Recognizing that the annulus is a dynamic structure that changes dramatically with the cardiac cycle, thereby facilitating a reduction in mitral orifice size to allow leaflet apposition, flexible annuloplasty rings have been developed. Flexible annuloplasty rings (e.g., the Duran ring) have been shown to minimize risk of dehiscence because there is reduced tension on sutures and reduced negative consequences of inaccurate placement of ring sutures. However, one disadvantage of the completely flexible ring prostheses is that during the implantation process the drawstring effect of the sutures tends to bunch the material covering the flexible ring at localized areas. The rigidity of the Carpentier ring prevents deformity, whereas when the Duran flexible ring is sutured to the annulus by interrupted U-stitches multiple plications of the Dacron polyester fabric occur. This bunching of the prosthesis resulted in the phenomenon known as multiple plications of the ring prosthesis. One result of this phenomenon is variability of the ability of the ring to control the shape of the valve annulus. Each plication of the posterior annulus is dependent on the tension placed on the sutures at the time of tying. Therefore, it is possible to have too small a plication resulting in insufficiency or too large a plication resulting in valve stenosis. Plication of the annuloplasty ring determines a reduction of at least one or two sizes in the selected flexible ring. The residual stenotic effect without early homodynamic repercussion, together with progression of the underlying disease, may be a predisposing factor toward valve stenosis necessitating late reoperation. Some patients in whom the Duran flexible ring had been inserted required valve-related operations as a result of hemolysis with or without prosthetic dehiscence. Patients who underwent reoperation for mitral restenosis showed absence of endothelium in the areas in which the ring was folded. In series of 85 patients reviewed after 10 to 12 years, Duran and coauthors (Duran C G, J L Pomar and J M Revuelta et al., Conservative operation for mitral insufficiency, J Thorac Cardiovasc Surg 79 (1980), pp. 326-337) found a 20.1% incidence of thromboembolic complications. The over narrowing and purse-string effects with irregular contour of the totally flexible ring were the main causes of high rate of thromboembolism. 
     While rigid and semi-rigid annuloplasty rings eliminate the bunching caused by flexible rings, the restrictive nature of such rings is generally detrimental to the valve&#39;s ability to open and close normally. On the other hand, because of their flexibility, flexible rings can be difficult to handle during surgical manipulations and generally must be supported during implantation by a holder, which is subsequently removed before tying off the implanting sutures. The Cosgrove Band is totally flexible; however, bunching of the Cosgrove Band is prevented by the suturing of the device on a rigid template subsequently removed after the implanting sutures are tied off. The approach of tying down over a rigid template eliminates the potential of plication of an inappropriate amount of the posterior annulus of the heart. 
     The rigid template is in turn releasably secured to a bendable handle to facilitate positioning of the template and ring in the heart adjacent to the annulus of the valve to be repaired. Once the template is placed and sutures initiated, the handle is withdrawn to give the surgeon room to work and properly see the annulus. When the procedure is completed, valve closure is tested by injecting saline solution. The sutures attaching the ring to the template are then cut, and the template is removed, leaving the ring in place. Such templates, however, do not prevent the ring from bunching or pleating when the implant sutures are tied off, if the sutures are not precisely placed. The removal of the sutures, which attach the annuloplasty ring to the holder, can be cumbersome and time consuming. Cutting the sutures can also cause damage to the annuloplasty ring. Care must be taken to ensure that pieces of the suture remain attached to the holder and are not left in the patient. The drag from the suture can make it difficult to remove the ring from the holder. Further, the retention sutures can be captured by the sutures used to implant the ring, thereby creating great difficulty in removing the ring from the holder. 
     Using conventional techniques, most valve repair procedures require a gross thoracotomy, usually in the form of a median sternotomy or right thoracotomy, to gain access into the patient&#39;s thoracic cavity. Using such open-chest techniques enables the surgeon to see the affected valve directly, and to position his or her hands within the thoracic cavity in close proximity to the exterior of the heart for manipulation of surgical instruments and introduction of an annuloplasty ring through the atriotomy for attachment within the heart. However, these invasive, open-chest procedures produce a high degree of trauma, a significant risk of complications, an extended hospital stay, and a painful recovery period for the patient. 
     Minimally invasive surgery (MIS) enables valve repair without opening the chest cavity. Such minimally invasive heart valve repair surgeries still require bypass, but the procedures are accomplished by means of elongated tubes or cannulas introduced through one or more small access incisions in the thorax, with the help of endoscopes and other such visualization techniques. Such minimally invasive procedures usually provide speedier recovery for the patient with less pain and bodily trauma, thereby reducing the medical costs and the overall disruption to the life of the patient. The use of a minimally invasive approach, however, introduces new complexities to surgery thus placing a greater burden on the operating surgeon. Most notably, minimally invasive approaches drastically reduce the size of the surgical field available to the surgeon for the manipulation of tissue and for the introduction of necessary surgical instruments. These complexities are especially acute in connection with heart surgery. Unlike common heart surgeries performed using a full medial sternotomy, minimally invasive heart surgery offers a surgical field that may be only as large as a resected intercostal space or a transversely cut and retracted sternum. Consequently, the introduction and proper positioning of tools, such as annuloplasty ring holders, and other such devices, becomes a great deal more complicated. 
     The primary barriers to widespread adoption of minimally invasive, robot assisted (MIRA) cardiac procedures are associated with increased cardiopulmonary bypass (CPB) times and increased surgical skill requirements. Current MIRA technology does not reduce the need for CPB during cardiac procedure. To the contrary bypass times associated with some MIRA cardiac procedures are actually increased. For many MIRA cardiac procedures, the increased time on CPB limits the potential benefits and leads to the exclusion of high-risk patients. 
     Suture management is a primary contributor to increased CPB times in MIRA cardiac procedures. Typical mitral valve repairs involve 15-20 sutures, each requiring 5-6 knots, causing suturing to consume the majority of operating time. Surgeons are typically very experienced and comfortable tying knots with their hands, but robotic technology adds another level of complexity to this task. Knot tying with surgical robots, particularly using the smaller 2-0 sutures required for mitral valve prosthesis fixation, takes considerably longer than with minimally invasive surgical instruments. The large number of required knots in annuloplasty fixation, coupled with the increased difficulty in tying the knots robotically, cause MIRA mitral valve repair to take longer than minimally invasive surgical approaches. Operating within limited space and with limited vision, it is not surprising that surgeons require more time to tie knots in MIRA surgery, despite the assistance of tele-robotic system. Furthermore, current commercial robotic surgery systems provide no force feedback from the instruments and dexterity with current minimally invasive instruments, manual or robotic, is less than optimal. Because there is no tactile sensation, the knot tying depends on visual clues as to appropriate tension and tightness. 
     An improved method of suture-based knotless fixation for MIRA mitral valve repair could allow surgeons all of the flexibility and precision of current techniques, while requiring less time and training to perform. Such an improvement could allow more patients to benefit more fully from the potential of MIRA cardiac surgery through increased access and reduced cost. By reducing CPB time, more patients will be candidates for MIRA cardiac procedures. Reduced CPB time will also help reduce direct surgical cost and indirect cost associated with post-surgical recovery. 
     One final problem associated with the annuloplasty rings of the prior art is that when such annuloplasty rings are implanted into children or adolescents the subsequent growth of the patient may render the annuloplasty ring too small, thus abnormally constricting the annulus. Follow-up surgery would be necessary to replace the originally implanted annuloplasty ring with a larger ring suitable for the current size of the patient. However, the tissue of the heart valve annulus grows into the fabric of the ring making such surgery problematic. Therefore the preservation of growth potential in the native annulus is an important issue in terms of long-term stability of valve repair procedures in children and adolescents. 
     What is needed, therefore, are devices and methods for carrying out heart valve repair that reduce the trauma, risks, recovery time and pain that accompany current techniques. The devices and methods should facilitate surgical intervention without the need for a gross thoracotomy. In particular, the devices and methods should enable the implantation of annuloplasty repair segments without the need for excessive additional implements. 
     SUMMARY OF THE INVENTION 
     The following provides a summary of exemplary embodiments of the annuloplasty system according to the present invention. This summary is not an extensive overview and is not intended to identify key or critical aspects or elements of the present invention or to delineate its scope. 
     In accordance with one aspect of the present invention, and in general terms, an annuloplasty system for repairing incompetent heart valves or other tissues is provided. This system includes a substantially circular valve reinforcing device adapted to be surgically implanted around a heart valve annulus; anchoring means for attaching the substantially circular valve reinforcing device to the heart valve annulus, wherein attaching the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the annulus by plicating annular tissue underneath the valve reinforcing device; and constricting means for reducing the circumference of the substantially circular valve reinforcing device, wherein reducing the circumference of the substantially circular valve reinforcing device further reduces the circumference of the heart valve annulus. The structural (e.g., valve) reinforcing device of this invention is generally flexible in nature; however, the basic component parts thereof (i.e., individual segments), do not typically deform when sutured into the areas of the body that the device is intended to reinforce. 
     In accordance with another aspect of the present invention, and also in general terms, a method for surgically implanting the annuloplasty system described in the previous paragraph is provided. This method includes utilizing the anchoring means to secure the substantially circular valve reinforcing device to the heart valve annulus, wherein securing the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the heart valve annulus by plicating annular tissue underneath the valve reinforcing device; testing the implanted annuloplasty system to verify that appropriate and/or desired constriction has been achieved; and utilizing the constricting means to reduce the circumference of the substantially circular valve reinforcing device if appropriate and/or desired constriction has not been achieved, wherein reducing the circumference of the substantially circular valve reinforcing device further reduces the circumference of the heart valve annulus. 
     Additional features and aspects of the present invention will become apparent to those of ordinary skill in the art upon reading and understanding the following detailed description of the exemplary embodiments. As will be appreciated by the skilled artisan, further embodiments of the invention are possible without departing from the scope and spirit of the invention. Accordingly, the drawings and associated descriptions are to be regarded as illustrative and not restrictive in nature. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The accompanying drawings, which are incorporated into and form a part of the specification, schematically illustrate one or more exemplary embodiments of the invention and, together with the general description given above and detailed description given below, serve to explain the principles of the invention, and wherein: 
         FIG. 1A  is top view of a first exemplary embodiment of the annuloplasty system of the present invention wherein the system includes flexible dual-supportive drawstrings. 
         FIGS. 1B-E  are various views of the suture support segments that are included in the annuloplasty system of  FIG. 1A . 
         FIGS. 1F-R  illustrate an exemplary method for surgically implanting the annuloplasty system of  FIG. 1A  in a dilated heart valve. 
         FIG. 2A  is a top view of a second exemplary embodiment of the annuloplasty system of the present invention wherein the system includes a flexible single supportive drawstring. 
         FIGS. 2B-F  are various views of the suture support segments that are included in the annuloplasty system of  FIG. 2A . 
         FIGS. 2G-O  illustrate an exemplary method for surgically implanting the annuloplasty system of  FIG. 2A  in a dilated heart valve. 
         FIGS. 2P-2Z  illustrate an exemplary method for surgically implanting the annuloplasty systems of  FIGS. 1A and 2A  in a dilated heart valve using robotic assisted surgery. 
       FIGS.  2 AA- 2 AC illustrate a method for surgically implanting the annuloplasty system of  FIG. 2A  in an infant or child. 
         FIGS. 3A-3E  illustrate a third exemplary embodiment of the annuloplasty system and surgical implantation method of the present invention wherein a dual-armed suture that is not attached to a suture support segment and a single supportive drawstring are utilized. 
         FIGS. 4A-4H  illustrate a fourth exemplary embodiment of the annuloplasty system and surgical implantation method of the present invention wherein a dual-armed suture with barbs and an annuloplasty ring or band are utilized. 
         FIGS. 5-7  illustrate an annuloplasty system that utilizes a suture material stored within a suture support segment which is pulled out of the support segment once the suture is needed, as well as single or multiple supportive drawstrings. 
         FIG. 8  illustrates a method of attaching suture support segments using an intracardiac ultra sonic welder. 
         FIGS. 9-11  illustrate a method of attaching suture support segments having an eye-like opening using a one-way suture that includes barbs. 
         FIGS. 12-13  illustrate a method of attaching suture support segments having a one-way suture retaining device embedded therein for attaching the suture without tying. 
         FIGS. 14-15  illustrate a method of attaching suture support segments using a braided suture and a suture support segment with a locking device. 
         FIG. 16  depicts a suture support segment having a locking device that allows for lateral insertion of the suture material into the suture segment body. 
         FIGS. 17-18  illustrate a method of using a suture support segment having a lumen for use in attachment. 
         FIGS. 19-20  illustrate a method of attachment using a self-closing clip assembly. 
         FIGS. 21-23  illustrate various methods of tightening the supportive drawstring. 
         FIG. 24  illustrates a method of implanting suture support segments from opposite ends. 
         FIG. 25-26  show a method of using the supportive drawstrings to achieve a selective reduction of the inferior limb of the posterior annulus. 
     
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
     Exemplary embodiments of the present invention are now described with reference to the Figures. Reference numerals are used throughout the detailed description to refer to the various elements and structures. In other instances, well-known structures and devices are shown in block diagram form for purposes of simplifying the description. Although the following detailed description contains many specifics for the purposes of illustration, a person of ordinary skill in the art will appreciate that many variations and alterations to the following details are within the scope of the invention. Accordingly, the following embodiments of the invention are set forth without any loss of generality to, and without imposing limitations upon, the claimed invention. 
     The present invention relates to an annuloplasty system for repairing incompetent heart valves. A first general embodiment of this invention provides an annuloplasty system that utilizes various suture support segments and two supportive drawstrings; a second general embodiment of this invention provides an annuloplasty system that utilizes various suture support segments and one supportive drawstring; a third general embodiment of this invention provides an annuloplasty system that utilizes segments having a sewing cuff, a plurality of sutures, and a supportive drawstring; a fourth general embodiment of this invention provides an annuloplasty system that utilizes suture apparatus having barbed structures and an annuloplasty band or ring; and a fifth general embodiment of this invention provides an annuloplasty system that utilizes only suture support segments. With reference now to the Figures, various specific embodiments of this invention shall be described in greater detail. 
     A first exemplary embodiment of this invention (shown in  FIGS. 1A-N ) provides an annuloplasty system for repairing incompetent heart valves. This system includes: a substantially circular valve reinforcing device adapted to be surgically implanted around a heart valve annulus; anchoring means for attaching the substantially circular valve reinforcing device to the heart valve annulus, wherein attaching the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the annulus by plicating annular tissue underneath the valve reinforcing device; and constricting means for reducing the circumference of the substantially circular valve reinforcing device, wherein reducing the circumference of the substantially circular valve reinforcing device further reduces the circumference of the annulus. The valve reinforcing device further includes: (i) a plurality of individual suture support segments, wherein the plurality of suture support segments further includes: a) at least one anchor segment, wherein the anchor segment further includes at least two channels passing lengthwise therethrough; and b) a plurality of intermediate segments adapted to be implanted into the heart valve annulus after the anchor segment, wherein each intermediate segment further includes at least two channels passing lengthwise therethrough. The anchoring means further includes: (i) at least two sutures attached to the anchor segment, wherein at least one of the sutures includes a surgical needle attached thereto; and (ii) at least two sutures attached to the intermediate segment wherein at least one of the sutures includes a surgical needle attached thereto. The constricting means further includes: at least two supportive drawstrings, wherein one end of each drawstring is attached to one end of the anchor segment, wherein each of the drawstrings passes through the channels in each intermediate segment, and wherein the ends of the drawstrings are tied together over the last intermediate segment after the heart valve repair is completed. 
     A method for surgically implanting this annuloplasty system includes: (a) utilizing the anchoring means for securing the substantially circular valve reinforcing device to the heart valve annulus, wherein securing the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the heart valve annulus by plicating annular tissue underneath the valve reinforcing device; and (b) utilizing the constricting means to reduce the circumference of the substantially circular valve reinforcing device if appropriate constriction has not been achieved, wherein reducing the circumference of the valve reinforcing device further reduces the circumference of the heart valve annulus by plicating the annular tissue between adjacent segments of the substantially circular valve reinforcing device. Utilizing the anchoring means further includes: (i) affixing the anchor segment to a dilated heart valve annulus by passing one of the surgical needles attached to the sutures on the anchor segment through the heart valve annulus; (ii) pulling the needle and suture which has passed through the heart annulus until the anchor segment aligns with the heart valve annulus; (iii) securing the anchor segment to the heart valve annulus by tying the ends of the sutures on the anchor segment together; (iv) using the supportive drawstrings to guide the intermediate segment through a minimally-invasive tube or small incision to the position above the heart valve annulus adjacent to the anchor segment; (v) affixing the intermediate segment to the heart valve annulus by passing one of the surgical needles attached to the sutures on the intermediate segment through the heart valve annulus; (vii) pulling the surgical needle and suture which has passed through the heart annulus until the intermediate segment aligns with the heart valve annulus; (viii) securing the intermediate segment to the heart valve annulus by tying the ends of the sutures on the intermediate segment together; (ix) repeating steps (iv)-(vii) until the desired circumference around the heart valve annulus is covered by intermediate suture support segments; and (ix) testing the repaired heart valve to verify that appropriate constriction has been achieved. Utilizing the constricting means further includes: (i) pulling both ends of the supportive drawstrings to the desired tension to further decrease the circumference of the heart valve annulus; and (ii) tying the ends of the supportive drawstrings around the last intermediate segment. 
       FIG. 1A  illustrates a dual-supportive drawstring annuloplasty system  100  having an anchor suture support segment  102  with supportive drawstrings  106  attached, and a plurality of intermediate suture support segments  104  threaded through the supportive drawstrings  106 . The supportive drawstrings  106  have a free end  108  wherein approximately 10-14 intermediate suture support segments (not shown)  104  are added after the anchor suture support segment  102  to the supportive drawstring to form a flexible dual-supportive drawstring annuloplasty system  100 . 
       FIGS. 1B-1E  provide various views of the elements that comprise the flexible dual-supportive drawstring annuloplasty system  100 .  FIG. 1B  depicts the detail of an anchor suture support segment  102 . The anchor suture support segment  102  is made up of an anchor suture support segment body  170 , at least one surgical needle  172 , and at least one suture  174 . The anchor suture support segment body  170  may be made from any material that is radio-opaque, preferably inert, non-corrosive, non-thormbogenic and bio-compatible with blood and tissue. By way of example, but not limitation, such material might be a barium sulfate impregnated acetal resin Delrin. The anchor suture support segment body  170  can be cylindrical, tubular, square, round, oval, elongated oval or combinations thereof shaped as necessary to achieve the desired configuration. The anchor suture support segment body  170  may have a textured blood-contacting surface or may be coated, in whole or in part, by a material designed to promote tissue in-growth and reduce thromboemblosim. By way of example, but not limitation, such material might be Dacron, polyester velour or some other suitable material. A preferred size of the anchor suture support segment body  170  is 1 mm to 4 mm in length but more preferably 2 mm to 6 mm in length, with a circumference of 1 mm to 4 mm, although other sizes and dimensions are possible. Attached to the anchor suture support segment body  170  is at least one suture  174 , but more preferably two sutures  174 . The anchor suture support segment body  170  must be rigid or semi-rigid in the longitudinal direction, and must not be deformable, such that when the sutures  174  are tied against the anchor suture support segment body  170 , to secure the anchor suture support segment  102  to the mitral valve annulus  50 , the anchor suture support segment body  170  does not buckle. 
     The material for the suture  174  may be of any conventional type used in surgical procedures such as 2/0 braided suture, mono-filament suture, or polyfilament suture. The length of each of the sutures  174  may range between 1 centimeter to 25 centimeters, and more preferably between 2 centimeters to 10 centimeters. The sutures  174  are attached to the side of the anchor suture support segment body  170  in such a way as to create a dual-armed suture structure  176 . Attached to the free ends of each suture  174  is a surgical needle  172 . The surgical needle  172  is attached to the suture  174  by a conventional swedging process. The surgical needle  172  is a conventional curved surgical needle. Such surgical needles or suture needles are generally known and are normally made from a corrosion-resistant metal, preferably chrome-nickel steel. 
       FIG. 1B  also shows an alternative embodiment where the anchor suture support segment  102 ′ has an anchor suture support segment body  170 ′ with attached suture  174 ′. Only one of the sutures  174 ′ has attached to the free end a surgical needle  172 ′ and the second suture  174 ′ has a free end  178 ′ without a surgical needle  172 ′. 
       FIG. 1C  shows a cross sectional view of an anchor suture support segment body  170  with dual-channels  180 . One end of the supportive drawstring  106  is treaded through one of the dual-channels  180  in the anchor suture support segment body  170  to a desired length and then that same end of the supportive drawstring  106  is looped around the channel opening and treaded back through the other channel  180  of the anchor suture support segment body  170  to create a dual supportive drawstring  106 . The supportive drawstring  106  may be comprised of suture material, Teflon strip, a band, a filament, a wire or a strap. 
       FIG. 1D  depicts the detail of an intermediate suture support segment  104 . The intermediate suture support segment  104  is made up of an intermediate suture support segment body  120 , at least one surgical needle  122 , and at least one suture  124 . The intermediate suture support segment body  120  may be made from any material that is radio-opaque, preferably inert, non-corrosive, non-thormbogenic and bio-compatible with blood and tissue. By way of example, but not limitation, such material might be a barium sulfate impregnated acetal resin Delrin. The intermediate suture support segment body  120  can be a cylindrical, a tubular, a square, a round, an oval, an elongated oval or the like shaped as necessary to achieve the desired configuration. The intermediate suture support segment body  120  may have a textured blood-contacting surface or may be coated, in whole or in part, by a material designed to promote tissue in-growth and reduce thromboemblosim. By way of example, but not limitation, such material might be Dacron, polyester velour or some other suitable material. A preferred size of the intermediate suture support segment body  120  is 1 mm to 4 mm in length but more preferably 2 mm to 6 mm in length, with a circumference of 1 mm to 4 mm, although other sizes and dimensions are possible. Attached to the intermediate suture support segment body  120  is at least one suture  124 , but more preferably two sutures  124 . The intermediate suture support segment body  120  must be rigid or semi-rigid in the longitudinal direction, and must not be deformable, such that when the sutures  124  are tied against the intermediate suture support segment body  120 , to secure the intermediate suture support segment body  120  to the mitral valve annulus  50 , the intermediate suture support segment body  120  does not buckle. 
     The material for the suture  124  may be of any conventional type used in surgical procedures such as 2/0 braided suture, mono-filament suture, or polyfilament suture. The length of the suture  124  may range between 1 centimeter to 25 centimeters, and more preferably between 2 centimeters to 10 centimeters. The sutures  124  are attached to the side of the intermediate suture support segment body  120  in such a way as to create a dual-armed suture structure  126 . Attached to the free ends of each suture  124  is a surgical needle  122 . The surgical needle  122  is attached to the suture  124  by a conventional swedging process. The surgical needle  122  is a conventional curved surgical needle. Such surgical needles or suture needles are generally known and are normally made from a corrosion-resistant metal, preferably chrome-nickel steel. 
       FIG. 1D  also shows an alternative embodiment where the intermediate suture support segment  104 ′ has an intermediate suture support segment body  120 ′ with attached suture  124 ′. Only one of the sutures  124 ′ has attached to the free end a surgical needle  122 ′ and the second suture  124 ′ has a free end  128 ′ without a surgical needle  122 ′. 
       FIG. 1E  shows a cross sectional view of an intermediate suture support segment body  120  with dual-channels  130 . Both free ends  108  of the supportive drawstrings  106  are threaded through the dual-channels  130  in the intermediate suture support segment body  120 . The supportive drawstrings  106  prevent against inadvertently dropping the intermediate support segments into the heart cavity and facilitate the delivery of the intermediate support segments  104  to the remote implantation site during surgery. The intermediate suture support segments can be slid down over the supportive drawstrings into position above the mitral valve from outside of the chest cavity through a small incision or port. 
       FIGS. 1F-1N  depict a method of implantation of the dual-supportive drawstring annuloplasty system  100  described in  FIGS. 1A-1E . The surgical methods used to implant the annuloplasty system  100  may be conventional open heart surgery techniques or minimally invasive heart surgery techniques.  FIGS. 1F-1N  provide an illustration of the superior view of the mitral valve of a human heart. The mitral valve includes a fibrous annulus  50  and anterior and posterior leaflets  42 ,  40 . In a healthy heart the leaflets close tightly during systole and do not allow any of the blood to flow backwards through the mitral valve into the left atrium. However, one consequence of a number of cardiac diseases is that mitral valve annulus  50  becomes dilated so that the anterior and posterior leaflets  42  and  40  cannot close tightly during systole, thereby creating gap  46  between the anterior and posterior leaflets  42  and  40 . As a result, mitral valve regurgitation occurs, resulting in some of the blood flowing backwards through the incompletely closed mitral valve leaflets into the left atrium. 
       FIG. 1F  depicts the first step of the method of implantation which is to guide the surgical needle  172  of the anchor suture support segment  102  into the surgical site  44  on the mitral valve annulus  50 . The surgical needle  172  and suture  174  will be passed through the mitral valve annulus  50  in a conventional surgical technique so as to make a horizontal mattress stitch. As shown in  FIG. 1A  the anchor suture support segment  102  has attached to the distal end supportive drawstrings  106  that have a free end  108 . 
       FIG. 1G  shows the next step in the method of implantation. The surgeon will continue to pull the surgical needle  172  and suture material  174 , which has passed through surgical site  44 , away from the mitral valve annulus  50  which will bring the anchor suture support segment  102  flush with the mitral valve annulus  50 . 
       FIG. 1H  depicts the anchor suture support segment  102  aligned with the mitral valve annulus  50 . To secure the anchor suture support segment  102  the surgeon will first cut off the surgical needles  172  from each of the sutures  174  (not shown). Next, as depicted in  FIG. 1I  the surgeon will tie the two free ends of the sutures  174  together with sufficient tension thereby securing the anchor suture support segment  102  in place on the mitral valve annulus  50 . After five or six knots have been made the free tails of the sutures  174  are cut by any suitable means (not shown). The suture  174  traverses a longer distance along the mitral valve annulus  50  than the distance between two suture attachments in the side of the anchor suture support segment body  170 . Sutures  174 , when tightened and tied, create an imbrication in the mitral valve annulus  50  underneath the segment thereby reducing the circumference of the mitral valve annulus  50  by an amount equal to the difference between the length each suture travels in the tissue of the heart annulus and the distance between the suture attachments in the support segment (not shown). 
       FIG. 1J  depicts the method of implantation of the first intermediate suture support segment  104 . First, the surgeon will guide a surgical needle  122  to the surgical site  48  and then will pass the surgical needle  122  through the surgical site  48  on the mitral valve annulus  50  about 2-4 mm away from the first surgical site  44 . The surgical needle  122  and suture  124  will be passed through the mitral valve annulus  50  in a conventional surgical technique so as to make a horizontal mattress stitch. 
       FIG. 1K  shows how the intermediate suture support segment  104  is guided onto the mitral valve annulus  50 . The surgeon will use the supportive drawstrings  106  which run through the channels  130  in the intermediate support segment  104  to guide the intermediate support segment down toward the mitral valve while pulling on the surgical needle  122  and the suture  124  to shuttle the intermediate suture support segment  104  next to the anchor suture support segment  102 . 
       FIG. 1L  depicts the first intermediate suture support segment  104  aligned with the mitral valve annulus  50  and adjacent to the anchor suture support segment  102 . To secure the intermediate suture support segment  104  the surgeon will first cut off the surgical needles  122  from each of the sutures  124  (not shown). Next, as depicted in  FIG. 1M  the surgeon will tie the two free ends of the sutures  124  together with sufficient tension thereby securing the intermediate suture support segment  104  in place on the mitral valve annulus  50  next to the anchor suture support segment  102 . After five or six knots have been made the free tails of the sutures  124  are cut by any suitable means (not shown). 
     The above described steps shown in  FIGS. 1J-1M  are repeated until the desired circumference around the mitral valve annulus  50  is covered by intermediate suture support segments  104 . The number of support segments placed into the mitral valve annulus  50  determines the overall reduction in the circumference of the annulus.  FIG. 1N  depicts the repaired mitral valve  52  surrounded by an anchor suture support segment  102  and intermediate suture support segments  104  that make up the flexible dual supportive drawstring annuloplasty system  100 . When the desired circumference of the valve annulus has been covered the mitral valve is tested for competence by distending the left ventricle with isotonic solution infused through rubber-bulbed syringe. If needed the annuloplasty system  100  is further adjusted and the suture support segments  102  and  104  are further aligned by pulling the supportive drawstrings  106  that is found at the distal end of the last intermediate suture support segment  104 . Since the support segments  102  and  104  are slidably coupled with the supportive drawstring  106  the annular tissue between adjacent suture support segments will plicate and the circumference of the valve annulus will reduce further. To complete the valve repair the free ends  108  of the supportive drawstring  106  are tied together at the distal end of the last intermediate suture support segment  104 . After seven or eight knots are made the free ends  108  of the supportive drawstring  106  are cut at the point beyond the last intermediate suture support segment  104  by any suitable means. 
       FIG. 1O  depicts an alternate embodiment of the dual-supportive drawstring annuloplasty system  100  which only partially surrounds the mitral valve annulus  50 . The anchor suture support segment  102  is attached to the mitral valve annulus  50  using the process described in  FIGS. 1F-1H . The intermediate suture support segments  104  are attached to the mitral valve annulus using the process described in  FIGS. 1J-1M . The intermediate suture support segments  104  only partially surround the mitral valve annulus  50  and the annuloplasty system  100  is ended by tying the free ends  108  of the supportive drawstrings  106  around the distal end of the last intermediate suture support segment  104 . As an alternate embodiment, this method of implantation can also be done with a single-supportive drawstring annuloplasty system  200 , although it is not depicted. 
       FIG. 1P  depicts a repaired mitral valve annulus  52  and shows how a completed annuloplasty system  100  should look once implanted in the mitral valve annulus  50 . 
       FIG. 1Q  depicts that the anchor suture support segment  102  may be attached to the surgical site  44  using the surgical needle  172  to place the sutures  174  in a counter-clockwise fashion. This also applies to placement of the intermediate suture support segments  104  of the dual-supportive drawstring system  100  and this also applies to all segments ( 202 ,  204 , and  210 ) of the single supportive drawstring system  200 . 
       FIG. 1R  depicts that the anchor suture support segment  102  may be attached to the surgical site  44  using the surgical needle  172  to place the sutures  174  in a clockwise fashion. This method also applies to placement of the intermediate suture support segments  104  of the dual-supportive drawstring system  100  and this also applies to all segments ( 202 ,  204 , and  210 ) of the single supportive drawstring system  200 . 
     A second exemplary embodiment of this invention (shown in  FIGS. 2A-AC ) also provides an annuloplasty system for repairing incompetent heart valves. This system includes: a substantially circular valve reinforcing device adapted to be surgically implanted around a heart valve annulus; anchoring means for attaching the substantially circular valve reinforcing device to the heart valve annulus, wherein attaching the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the annulus by plicating annular tissue underneath the valve reinforcing device; and constricting means for reducing the circumference of the substantially circular valve reinforcing device, wherein reducing the circumference of the substantially circular valve reinforcing device further reduces the circumference of the annulus. The valve reinforcing device further includes: (i) a plurality of individual suture support segments, wherein the plurality of suture support segments further includes: a) at least one anchor segment, wherein the at least one anchor segment further includes a channel passing lengthwise therethrough; b) at least one terminal segment, wherein the at least one terminal segment further includes a channel passing lengthwise therethrough; and c) a plurality of intermediate segments disposed between the at least one anchor segment and the at least one terminal segment, wherein each intermediate segment further includes a channel passing lengthwise therethrough. The anchoring means further includes: (i) at least two sutures attached to the anchor segment, wherein at least one of the sutures includes a surgical needle attached thereto; (ii) at least two sutures attached to the intermediate segment, wherein at least one of the sutures includes a surgical needle attached thereto; and (iii) at least two sutures attached to the body portion of the terminal segment wherein at least one of the sutures includes a surgical needle attached thereto and a third suture attached to the end portion of the terminal segment for tying off the supportive drawstring following implantation. The constricting means for reducing the circumference of the substantially circular valve reinforcing device, wherein reducing the circumference of the valve reinforcing device further reduces the circumference of the heart valve annulus, and wherein the constricting means further includes: (i) a supportive drawstring, wherein one end of the drawstring is attached to one end of the anchor segment, and wherein the supportive drawstring passes through the channel in each intermediate segment and the channel in the terminal segment. 
     A method for surgically implanting this annuloplasty system includes (a) utilizing the anchoring means for securing the substantially circular valve reinforcing device to the heart valve annulus, wherein securing the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the annulus by plicating annular tissue underneath the valve reinforcing device; and (b) utilizing the constricting means to reduce the circumference of the substantially circular valve reinforcing device if appropriate constriction has not been achieved, wherein reducing the circumference of the valve reinforcing device further reduces the circumference of the heart valve annulus by plicating the annular tissue between adjacent segments of the substantially circular valve reinforcing device. Utilizing the anchoring means further includes: (i) affixing the anchor segment to a dilated heart valve annulus by passing one of the surgical needles attached to the sutures through the heart valve annulus; (ii) pulling the suture and surgical needle which has passed through the heart valve annulus until the anchor segment is aligned with the heart valve annulus; (iii) securing the anchor segment to the heart valve annulus by tying the ends of the sutures together; (iv) using the supportive drawstring to guide the intermediate segment through a minimally-invasive tube or small incision to the position above the heart valve annulus adjacent to the anchor segment; (v) affixing the intermediate segment to the heart valve annulus by passing one of the surgical needles attached to the sutures through the heart valve annulus; (vi) pulling the surgical needle and suture which has passed through the heart valve annulus until the intermediate segment aligns with the heart valve annulus; (viii) securing the intermediate segment to the heart valve annulus by tying the ends of the sutures together; (viii) repeating steps (iv)-(vii) until the desired circumference around the heart valve annulus is covered by intermediate suture support segments; (ix) using the supportive drawstring to guide the terminal segment to the position above the heart valve annulus next to the last intermediate segment; (x) affixing the terminal segment to the heart valve annulus by passing one of the surgical needles attached to the sutures through the heart valve annulus; (xi) pulling the surgical needle and suture which has passed through the heart valve annulus until the terminal segment is aligned with the heart valve annulus; (xii) securing the terminal segment to the heart valve annulus by tying the ends of the sutures together; and (xiii) testing the repaired heart valve to verify that appropriate constriction has been achieved. Utilizing the constricting means further includes: (i) pulling the supportive drawstring to the desired tension to further decrease the circumference of the heart valve annulus; and (ii) tying the supportive drawstring that runs through the terminal segment to the third suture attached to the end portion of the terminal segment. 
       FIG. 2A  illustrates a flexible single-supportive drawstring annuloplasty system  200  having an anchor suture support segment  202  with a supportive drawstring  206  attached, a plurality of intermediate suture support segments  204  threaded through the supportive drawstring  206  and a terminal suture support segment  210  threaded through the supportive drawstring  206 . The supportive drawstring  206  has a free end  208  where the intermediate suture support segments  204  and terminal suture support segments  210  are added to the single-supportive drawstring annuloplasty system  200 . The terminal suture support segment  210  has a free suture  260  which is tied with the free end  208  of the supportive drawstring  206  around the terminal segment  210  to complete the flexible single-supportive drawstring annuloplasty system  200 . 
       FIGS. 2B-2F  illustrate various views of the elements that comprise the single-supportive drawstring annuloplasty system  200 .  FIG. 2B  depicts the detail of an anchor suture support segment  202 . The anchor suture support segment  202  is made up of an anchor suture support segment body  270 , at least one surgical needle  272 , and at least one suture  274 . The anchor suture support segment body  270  may be made from any material that is radio-opaque, preferably inert, non-corrosive, non-thormbogenic and bio-compatible with blood and tissue. By way of example, but not limitation, such material might be a barium sulfate impregnated acetal resin Delrin. The anchor suture support segment body  270  can be cylindrical, tubular, square, round, oval, elongated oval or combinations thereof shaped as necessary to achieve the desired configuration. The anchor suture support segment body  270  may have a textured blood-contacting surface or may be coated, in whole or in part, by a material designed to promote tissue in-growth and reduce thromboemblosim. By way of example, but not limitation, such material might be Dacron, polyester velour or some other suitable material. A preferred size of the intermediate suture support segment body  270  is 1 mm to 4 mm in length but more preferably 2 mm to 6 mm in length, with a circumference of 1 mm to 4 mm, although other sizes and dimensions are possible. Attached to the anchor suture support segment body  270  is at least one suture  274 , but more preferably two sutures  274 . The anchor suture support segment body  270  must be rigid or semi-rigid in the longitudinal direction, and must not be deformable, such that when the sutures  274  are tied against the anchor suture support segment body  270 , the anchor suture support segment body does not buckle. The material for the suture  274  may be of any conventional type used in surgical procedures such as 2/0 braided suture, mono-filament suture, or polyfilament suture. The length of the suture  274  may range between 1 centimeter to 25 centimeters, and more preferably between 2 centimeters to 10 centimeters. The sutures  274  are attached to the anchor suture support segment body  270  in such a way as to create a dual-armed suture structure  276 . Attached to the free ends of each suture  274  is a surgical needle  272 . The surgical needle  272  is attached to the suture  274  by a conventional swedging process. The surgical needle  272  is a conventional curved surgical needle. Such surgical needles or suture needles are generally known and are normally made from a corrosion-resistant metal, preferably chrome-nickel steel. 
     As an alternate embodiment (not shown in the Figures) the anchor suture support segment  202 ′ has an anchor suture support segment body  270 ′ with attached suture  274 ′. The sutures  274 ′ are attached to the side of the anchor suture support segment body  270 ′. Only one of the sutures  274 ′ has attached to the free end a surgical needle  272 ′ and the second suture  274 ′ has a free end  278 ′ without a surgical needle  272 ′. 
       FIG. 2F  shows a cross-sectional view of an anchor suture support segment  202  specifically the anchor suture support segment body  270  with a single channel  280  and the cross sectional view of an intermediate suture support segment  204  specifically the intermediate suture support segment body  220 . One end of the supportive drawstring  206  is attached in the channel  280  of the anchor suture support segment body  270 . The supportive drawstring  206  runs through the channel  280  of the anchor suture support segment  202 . The supportive drawstring  206  may be comprised of suture material, Teflon strip, a band, a filament, a wire or a strap. A space  232  will be present between the anchor suture support segment  202  and the intermediate suture support segment  204  when the annuloplasty system  200  is implanted into the heart valve annulus which will allow for flexibility between the individual segments. The supportive drawstring  206  is threaded through the single channel  230  running the length of the intermediate suture support segment  204 . 
       FIG. 2C  depicts the detail of an intermediate suture support segment  204 . The intermediate suture support segment  204  is made up of an intermediate suture support segment body  220 , at least one surgical needle  222 , and at least one suture  224 . The intermediate suture support segment body  220  may be made from any material that is radio-opaque, preferably inert, non-corrosive, non-thormbogenic and bio-compatible with blood and tissue. By way of example, but not limitation, such material might be a barium sulfate impregnated acetal resin Delrin. The intermediate suture support segment body  220  can be cylindrical, tubular, square, round, oval, elongated oval or combinations thereof shaped as necessary to achieve the desired configuration. The intermediate suture support segment body  220  may have a textured blood-contacting surface or may be coated, in whole or in part, by a material designed to promote tissue in-growth and reduce thromboemblosim. By way of example, but not limitation, such material might be Dacron, polyester velour or some other suitable material. A preferred size of the intermediate suture support segment body  220  is 1 mm to 4 mm in length but more preferably 2 mm to 6 mm in length, with a circumference of 1 mm to 4 mm, although other sizes and dimensions are possible. Attached to the intermediate suture support segment body  220  is at least one suture  224 , but more preferably two sutures  224 . The intermediate suture support segment body  220  must be rigid or semi-rigid in the longitudinal direction, and must not be deformable, such that when the sutures  224  are tied against the intermediate suture support segment body  220 , the intermediate suture support segment body does not buckle. The material for the suture  224  may be of any conventional type used in surgical procedures such as 2/0 braided suture, mono-filament suture, or polyfilament suture. The length of the suture  224  may range between 1 centimeter to 25 centimeters, and more preferably between 2 centimeters to 10 centimeters. The sutures  224  are attached to the side of the intermediate suture support segment body  220  in such a way as to create a dual-armed suture structure  226 . Attached to the free ends of each suture  224  is a surgical needle  222 . The surgical needle  222  is attached to the suture  224  by a conventional swedging process. The surgical needle  222  is a conventional curved surgical needle. Such surgical needles or suture needles are generally known and are normally made from a corrosion-resistant metal, preferably chrome-nickel steel. 
     As an alternative embodiment as shown in  FIG. 2C  the intermediate suture support segment  204 ′ has an intermediate suture support segment body  220 ′ with attached suture  224 ′. The sutures  224 ′ are attached to the side of the intermediate suture support segment body  220 ′ Only one of the sutures  224 ′ has attached to the free end a surgical needle  222 ′ and the second suture  224 ′ has a free end  228 ′ without a surgical needle  222 ′. 
       FIG. 2E  is a cross sectional view of an intermediate suture support segment  204 . It shows the single channel  230  that runs the length of the intermediate suture support segment body  220 . 
       FIG. 2D  depicts the detail of a terminal suture support segment  210 . The terminal suture support segment  210  is made up of a terminal suture support segment body  250 , at least one surgical needle  252 , and at least one suture  254 . The terminal suture support segment body  250  may be made from any material that is radio-opaque, preferably inert, non-corrosive, non-thormbogenic and bio-compatible with blood and tissue. By way of example, but not limitation, such material might be a barium sulfate impregnated acetal resin Delrin. The terminal suture support segment body  250  can be a cylindrical, a tubular, a square, a round, an oval, an elongated oval or the like shaped as necessary to achieve the desired configuration. The terminal suture support segment body  250  may have a textured blood-contacting surface or may be coated, in whole or in part, by a material designed to promote tissue in-growth and reduce thromboemblosim. By way of example, but not limitation, such material might be Dacron, polyester velour or some other suitable material. A preferred size of the terminal suture support segment body  250  is 1 mm to 4 mm in length but more preferably 2 mm to 6 mm in length, with a circumference of 1 mm to 4 mm, although other sizes and dimensions are possible. Attached to the terminal suture support segment body  250  is at least one suture  254 , but more preferably two sutures  254 . The terminal suture support segment body  250  must be rigid or semi-rigid in the longitudinal direction, and must not be deformable, such that when the sutures  254  are tied against the terminal suture support segment body  250 , the terminal suture support segment body does not buckle. The material for the suture  254  may be of any conventional type used in surgical procedures such as 2/0 braided suture, mono-filament suture, or polyfilament suture. The length of the suture  254  may range between 1 centimeter to 25 centimeters, and more preferably between 2 centimeters to 10 centimeters. The sutures  254  are attached to the side of the terminal suture support segment body  250  in such a way as to create a dual-armed suture structure  256 . Attached to the free ends of each suture  254  is a surgical needle  252 . The surgical needle  252  is attached to the suture  254  by a conventional swedging process. The surgical needle  252  is a conventional curved surgical needle. Such surgical needles or suture needles are generally known and are normally made from a corrosion-resistant metal, preferably chrome-nickel steel. The terminal suture support segment  210  has a free suture  260  attached to the end portion of the terminal suture segment body  250 . The material for the third suture  260  may be of any conventional type used in surgical procedures such as 2/0 braided suture, mono-filament suture, or polyfilament suture. The length of the third suture  260  may range between 1 centimeter to 25 centimeters, and more preferably between 2 centimeters to 10 centimeters. The third suture  260  on the terminal suture support segment  210  has a free end without a surgical needle  252 . 
       FIG. 2D  also shows an alternative embodiment where the terminal suture support segment  210 ′ has an terminal suture support segment body  250 ′ with attached suture  254 ′. The sutures  254 ′ are attached to the side of the terminal suture support segment body  250 ′. Only one of the sutures  254 ′ has attached to the free end a surgical needle  252 ′ and the second suture  254 ′ has a free end  258 ′ without a surgical needle  252 ′. 
       FIGS. 2G-2O  depict a method of implantation of the single-supportive drawstring annuloplasty system  200  described in  FIGS. 2A-2F . The surgical methods used to implant the annuloplasty system  200  may be conventional open heart surgery techniques or minimally invasive heart surgery techniques.  FIGS. 2G-2O  provide an illustration of the superior view of the dilated mitral valve of a human heart. The mitral valve includes a fibrous annulus  50  and anterior and posterior leaflets  42 ,  40 . In a healthy heart the leaflets close tightly during systole and do not allow any of the blood to flow backwards through the mitral valve into the left atrium. However, one consequence of a number of cardiac diseases is that mitral valve annulus  50  becomes dilated so that the anterior and posterior leaflets  42  and  40  cannot close tightly during systole, thereby creating gap  46  between the anterior and posterior leaflets  42  and  40 . As a result, mitral valve regurgitation occurs, resulting in some of the blood flowing backwards through the incompletely closed mitral valve leaflets into the left atrium.  FIG. 2G  depicts the first step of the method of implantation in which the surgical needle  272  and suture  274  will be passed through the mitral valve annulus  50  in a conventional surgical technique so as to make a horizontal mattress stitch. As shown in  FIG. 2G  the anchor suture support segment  202  has attached to the distal end a supportive drawstring  206  that has a free end  208 . 
       FIG. 2H  shows the next step in the method of implantation. The surgeon will continue to pull the surgical needle  272  and suture material  274 , which has passed through surgical site  44 , away from the mitral valve annulus  50  which will bring the anchor suture support segment  202  flush with the mitral valve annulus  50 . 
       FIG. 21  depicts the anchor suture support segment  202  aligned with the mitral valve annulus  50 . To secure the anchor suture support segment  202  the surgeon will first cut off the surgical needles  272  from each of the sutures  274  (not shown). Next, as depicted in  FIG. 2J  the surgeon will tie the two free ends of the sutures  274  together with sufficient tension thereby securing the anchor suture support segment  202  in place on the mitral valve annulus  50 . After five or six knots have been made the free tails of the sutures  274  are cut by any suitable means (not shown). The suture  274  traverses a longer distance along the mitral valve annulus  50  than the distance between two suture attachments in the side of the anchor suture support segment body  270 . Sutures  274 , when tightened and tied, create an imbrication in the mitral valve annulus  50  underneath the segment thereby reducing the circumference of the annulus by an amount equal to the difference between the length each suture travels in the tissue of the heart annulus and the distance between the suture attachments in the support segment (not shown). 
       FIG. 2K  depicts the implantation of the intermediate suture support segment  204 . The surgeon will guide a surgical needle  222  to the surgical site  48  and then will pass the surgical needle  222  through the surgical site  48  on the mitral valve annulus  50  about 2-4 mm away from the proximal end of the anchor support segment  202 . The surgical needle  222  and suture  224  will be passed through the mitral valve annulus  50  in a conventional surgical technique so as to make a horizontal mattress stitch. 
       FIG. 2L  shows how the intermediate suture support segment  204  is guided onto the mitral valve annulus  50 . The surgeon will use the supportive drawstring  206  which runs through the channel in the intermediate support segment  204  to guide the intermediate support segment down toward the mitral valve while pulling on the surgical needle  222  and the suture  224  to shuttle the intermediate suture support segment  204  next to the anchor suture support segment  202 . 
       FIG. 2M  depicts the intermediate suture support segment  204  aligned with the mitral valve annulus  50  and adjacent to the anchor suture support segment  202 . To secure the intermediate suture support segment  204  the surgeon will first cut off the surgical needles  222  from each of the sutures  224  (not shown). Next, as depicted in  FIG. 2N  the surgeon will tie the two free ends of the sutures  224  together with sufficient tension thereby securing the intermediate suture support segment  204  in place on the mitral valve annulus  50  next to the anchor suture support segment  202 . After five or six knots have been made the free tails of the sutures  224  are cut by any suitable means (not shown). 
     The above described steps shown in  FIGS. 2K-2N  are repeated until the desired circumference around the mitral valve annulus  50  is covered by intermediate suture support segments  204 . To complete the annuloplasty system  200  the terminal suture support segment  210  is added to the supportive drawstring  206  like described in  FIGS. 2K-2N  and is secured into place as shown in  FIG. 2M . The number of support segments placed into annulus determines the overall reduction in the circumference of the annulus.  FIG. 20  depicts a repaired mitral valve  52  surrounded by an anchor suture support segment  202 , intermediate suture support segments  204 , and a terminal suture support segment  210  that make up the flexible single supportive drawstring annuloplasty system  200 . When the entire circumference of the valve annulus has been covered the mitral valve is tested for competence by distending the left ventricle with isotonic solution infused through rubber-bulbed syringe. If needed the annuloplasty system  200  is further adjusted and the suture support segments  202 ,  204 , and  210  are further aligned by pulling the supportive drawstring  206  that is found at the distal end of the terminal suture support segment  210 . Since the support segments  202 ,  204  and  210  are slidably coupled with the supportive drawstring  206  the annular tissue between adjacent suture support segments will plicate and the circumference of the valve annulus will reduce further. To complete the valve repair the free end  208  of the supportive drawstring  206  is tied together with the free suture  260  attached to the end of the terminal suture support segment  210 . After seven or eight knots are made with the free end  208  of the supportive drawstring  206  and the free suture  260  of the terminal suture support segment  210  are cut at the point beyond the terminal suture support segment  210  by any suitable means. 
       FIGS. 2P-2Z  depict an alternate embodiment of using short sutures for robotic mitral valve repair procedures using either the single-supportive drawstring annuloplasty system  200  or double-supportive drawstring annuloplasty system  100 , both systems are described above. The system as depicted in  FIGS. 2P-2Z  uses the single supportive drawstring annuloplasty system  200 , but it may also be used with the double-supportive drawstring annuloplasty system  100 . As shown in  FIG. 2P , the anchor suture support segment body  270 ′ has attached to the side two short sutures  274 ′ and a single or double supportive drawstring  206  with a free end  208 . Attached to one of the sutures  274 ′ is a surgical needle  272 ′, whereas the other suture  274 ′ has a free end  278 ′.  FIG. 2P  shows the implantation procedure of the anchor suture support segment  202 ′. Using robotic surgery instruments (not shown) the surgeon will deliver the anchor suture support segment  202 ′ to the surgical site  44  and will held it approximately 5 cm above the mitral valve annulus  50 . Using robotic surgery instruments (not shown) the surgical needle  272 ′ and suture  274 ′ will be passed through the mitral valve annulus  50  at the surgical site  44  so as to make a horizontal mattress stitch. 
       FIG. 2Q  shows the anchor suture support segment  202 ′ where the anchor suture support segment body  270 ′ is aligned with the mitral valve annulus  50 . The anchor suture support segment  202 ′ is put into place by pulling on the surgical needle  272 ′ and suture  274 ′ using robotic instruments to make the anchor suture support segment body  270 ′ flush with the mitral valve annulus  50 . Once the anchor suture support segment body  270 ′ is in the proper place the surgical needle  272 ′ will be cut off of the suture  274 ′ (not shown). 
       FIG. 2R  shows how the anchor suture support segment is anchored to the mitral valve annulus  50 . The free end  278 ′ of the anchor suture support segment  202 ′ is tied together with the suture  274 ′ that had the surgical needle  272 ′ removed. These two ends are tied together against the rigid or semi-rigid body of the anchor suture support segment  270 ′. Five to seven knots are made with the ends to hold the anchor sutures support segment  202 ′ in place. 
       FIG. 2S  shows how the first intermediate suture support segment  204 ′ is delivered into position above the mitral valve from outside of the chest cavity by sliding the intermediate suture support segment  204 ′ down over the supportive drawstring  206  using surgical knot pusher tool (not shown). There are two sutures  224 ′ attached to the sides of the intermediate sutures support segment body  270 ′. Attached to one end of one sutures  224 ′ is a surgical needle  222 ′ the other suture  224 ′ has a free end  228 ′, without a surgical needle  222 ′. 
       FIG. 2T  shows the implantation of the second intermediate suture support segment  202 ′ into the mitral valve annulus  50 , using robotic assisted surgery. The second support segment is delivered into position over the mitral valve annulus  50  by sliding the intermediate suture support segment  204 ′ down over the supportive drawstring  206 ′ and then the intermediate suture support segment  204 ′ is held above the mitral valve annulus  50 . The surgical needle  222 ′ is passed through the mitral valve annulus  50  at the surgical site  48  using robotic surgical instruments so as to make a horizontal mattress stitch. The intermediate suture support segment  204 ′ will be guided into place by pulling on the surgical needle  222 ′ and suture  224 ′ to make the second intermediate suture support segment body  220 ′ flush with the mitral valve annulus  50  (not shown). Once the intermediate suture support segment body  220 ′ is in the desired location the surgical needle  222 ′ will be cut off of the suture  224 ′ (not shown). 
       FIG. 2U  shows how the second intermediate suture support segment  204 ′ is secured to the mitral valve annulus  50  by robotic-assisted knot tying. The short suture  224 ′ which had the surgical needle  222 ′ removed is tied together with the free end  228 ′ of the short suture  224 ′. The free end  228 ′ and the sutures  224 ′ are knotted together five to seven times against the intermediate suture support segment body  220 ′ to secure the intermediate suture support segment  204 ′ to the mitral valve annulus  50 . 
       FIG. 2V  depicts the addition of another intermediate suture support segment  204 ′ to the mitral valve annulus  50 . The supportive drawstring  206  is used as a guide to deliver the intermediate sutures support segment  204 ′ into position above the mitral valve annulus  50  from outside of the chest cavity through a small incision or port (not shown). These steps are repeated until the desired circumference is covered around the mitral valve annulus  50 . 
       FIG. 2W  depicts the implantation of the terminal suture support segment  210 ′. First, the terminal suture support segment  210 ′ is added by threading the free end  208  of the supportive drawstring  206  through the channel that runs through the body of the terminal suture support segment  250 ′. The terminal suture support segment body  250 ′ has two surgical sutures  254 ′ attached to the terminal suture support segment body  250 ′. One of the surgical sutures  254 ′ has a surgical needle  252 ′ attached to the end and the other surgical suture  254 ′ has a free end  258 ′. Also attached to the terminal suture support segment body  250 ′ is a free terminal suture  260 ′. 
       FIG. 2X  shows how the terminal suture support segment  210 ′ is secured to the mitral valve annulus  50  after the surgical needle  252 ′ and the surgical suture  254 ′ have been passed through the mitral valve annulus  50 . The surgical suture  254 ′ which had the surgical needle  252 ′ removed is tied together with the free end  258 ′ of the second surgical suture to secure the terminal suture support segment  210 ′ to the mitral valve annulus  50 . After five or six knots have been made the free tails of the sutures are cut by any suitable means (not shown). The mitral valve is tested for competence by distending the left ventricle with isotonic solution infused through rubber-bulbed syringe. 
       FIG. 2Y  shows how the repair with the annuloplasty system  200 ′ is completed. The free suture  260 ′ attached to the terminal suture support segment body  250 ′ is tied together with the free end  208  of the single supportive drawstring  206  against the terminal suture support segment body  250 ′. The free end of the suture  260 ′ and the free end  208  of the supportive drawstring  206  are knotted together seven to eight times, and then the excess free tails are cut at a point beyond the terminal suture support segment  210 ′ by any suitable means. 
       FIG. 2Z  shows the suture support segments in place in the mitral valve annulus  50  whose circumference is thereby reduced after the implantation of the annuloplasty system  200 ′ according to the present invention. 
     FIGS.  2 AA- 2 AC depict using the single supportive drawstring annuloplasty system  200  (as shown) or the dual-supportive drawstring annuloplasty system  100  (not shown) in infants and growing children, where the supportive drawstring  206  will either be made from biodegradable material or will be removed after implantation onto the mitral valve annulus  50 . The method of implantation of the annuloplasty system  200  in children and adolescents is similar to that described previously in  FIGS. 2G-2O . As shown in FIG.  2 AB when the entire circumference of the mitral valve annulus  50  has been sutured the mitral valve is tested for competence by distending the left ventricle with isotonic solution infused through rubber-bulbed syringe. The repair is completed by tightening the free ends of the biodegradable supportive drawstrings  206  over the last support segment  204 . After seven or eight knots have been made the free end of the supportive drawstring  206  are cut by any suitable means. After mitral valve repair surgery the absorbable supportive drawstring  206  is eventually resorbed by the patient. The absence of the supportive drawstring  206  allows normal annular growth  292  between the suture support segments,  202  and  204  as the child grows, shown in FIG.  2 AC. The biodegradable supportive drawstrings degrade at a rate that allows substantially complete healing of the patient&#39;s annular structure. The resulting time period to complete resorption may be on the order of 4 to 6 months to the order of 1 to 2 years. 
     In accordance with a further aspect of the present invention, as shown in FIG.  2 AA, the surgeon removes the supportive drawstring  206  once the annuloplasty system  200  has been implanted in children or adolescents. When the entire circumference of the mitral valve annulus  50  has been sutured the mitral valve is tested for competence. The repair is completed by cutting the supportive drawstring  290  between the anchor suture support segment  202  and the first intermediate support segments  204  and then gently pulling on the free ends of the supportive drawstring  206  to withdraw the supportive drawstring  206  from the annuloplasty system  200 , as shown in FIG.  2 AB. The absence of the supportive drawstrings allows normal annular growth  292  between the suture support segments as the child grows, as shown in FIG.  2 AC. 
     Alternatively, the surgeon can implant desirable number of free intermediate support segments (not shown) without supportive drawstrings and the anchor support segment until the entire circumference or at list a portion of the mitral valve annulus has been covered. The absence of the supportive drawstrings allows normal annular growth  292  between the suture support segments as the child grows, as shown in FIG.  2 AC. 
       FIG. 5  depicts another exemplary embodiment of the annuloplasty system for minimally invasive or robotic valve repair procedures. This system is an alternate embodiment of the single-supportive drawstring annuloplasty system  200  or double-supportive drawstring annuloplasty system  100  described previously. As depicted the system has a single supportive drawstring but it can be used with a double supportive drawstring. The annuloplasty system  500  partially shown in  FIG. 5A  uses an anchor suture support segment  502  with an attached single supportive drawstring  506  that has a free end  508 . The anchor suture support segment  502  shown in  FIG. 5A  has an anchor suture support segment body  570  with an attached suture  574  that may or may not have a surgical needle  572  (as shown it does not have an attached surgical needle  572 ) attached. The unique aspect of the embodiment is that the second suture  575  with attached surgical needle  572  is stored inside the anchor suture support segment body  570 . The stored portion of the suture  575  is drawn out of the storage area so that the anchor sutures support segment  502  can be attached. 
       FIG. 5B  shows an intermediate suture support segment  504  of the annuloplasty system  500 . The intermediate suture support segment  504  is made up of an intermediate suture support segment body  520 . Attached to the intermediate suture support segment body  520  is a suture  524  which may or may not have an attached surgical needle  522  (as shown no surgical needle  522  is attached). The second suture  525  has an attached surgical needle  522 . This second suture  525  is stored within the intermediate suture support segment body  570 . The stored portion of the suture  525  is drawn out of the storage area so that the anchor sutures support segment  502  can be attached. 
       FIG. 6  is an illustration of the superior view of the dilated mitral valve of a human heart. The anchor suture support segment  502  is already shown as being attached to the mitral valve annulus  50 . The anchor suture support segment is attached by the same process described in  FIGS. 2G-2J .  FIG. 6  shows how the first intermediate suture support segment  504  is delivered into position above the mitral valve from outside of the chest cavity by sliding the intermediate suture support segment  504  down over the supportive drawstring  506  using surgical knot pusher tool (not shown). Once the desired location is reached the surgeon will pull on the surgical needle  522  attached to the second suture  525 , which will pull the second suture  525  from the intermediate suture support segment body  520  (see also  FIG. 7 ). The intermediate suture support segment  504  is attached in the same manner as described above for the single-supportive drawstring annuloplasty system  200  in  FIGS. 2K-20 . 
     A third embodiment of the present invention (shown in  FIGS. 3A-E ) also provides an annuloplasty system for repairing incompetent heart valves. This system includes: (a) a substantially circular valve reinforcing device adapted to be surgically implanted around a heart valve annulus; (b) anchoring means for attaching the substantially circular valve reinforcing device to the heart valve annulus, wherein attaching the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the heart valve annulus by plicaing annular tissue underneath the valve reinforcing device; and (c) constricting means for reducing the circumference of the substantially circular valve reinforcing device, wherein reducing the circumference of the substantially circular valve reinforcing device further reduces the circumference of the annulus. The valve reinforcing device further includes: (i) a plurality of individual suture support segments, wherein the plurality of suture support segments further includes: a) at least one anchor segment covered with a sewing cuff, wherein the at least one anchor segment further includes a channel passing lengthwise therethrough; b) at least one terminal segment covered with a sewing cuff, wherein the at least one terminal segment further includes a channel passing lengthwise therethrough; and c) a plurality of intermediate segments disposed between the at least one anchor segment and the at least one terminal segment, wherein each intermediate segment is covered with a sewing cuff, and wherein each intermediate segment further includes a channel passing lengthwise therethrough. The anchoring means further includes: (i) a dual-armed suture, wherein at least one end of the suture is attached to surgical needle, and wherein the surgical needle passes through the sewing cuff of the anchor segment; (ii) a dual-armed suture, wherein at least-one end of the suture is attached to a surgical needle, and wherein the surgical needle passes through the sewing cuff of the intermediate segment; and (iii) a dual-armed suture, wherein at least one end of the suture is attached to a surgical needle, and wherein the surgical needle passes through the sewing cuff of the terminal segment. The constricting means further includes: (i) a supportive drawstring, wherein one end of the drawstring is secured to one end of the anchor segment, wherein the supportive drawstring passes through the channel in each intermediate segment and the channel in the terminal segment. 
     A method for surgically implanting this annuloplasty system includes: (a) utilizing the anchoring means for securing the substantially circular valve reinforcing device to the heart valve annulus, wherein securing the substantially circular valve reinforcing device to the heart valve annulus reduces the circumference of the heart valve annulus by plicating annular tissue underneath the valve reinforcing device, and (b) utilizing the constricting means to further reduce the circumference of the substantially circular valve reinforcing device, wherein reducing the circumference of the valve reinforcing device further reduces the circumference of the heart valve annulus by plicating the annular tissue between adjacent segments of the substantially circular valve reinforcing device, if further adjustments are required. Utilizing the anchoring means further includes: (i) affixing the suture to the heart valve annulus by passing one of the surgical needles attached to the sutures through a heart valve annulus; (ii) threading the surgical needles attached to the suture through the sewing cuff of the anchor segment; (iii) pushing the anchor segment down over the strands of the suture until the anchor segment is aligned with the heart valve annulus; (iv) securing the anchor segment to the heart valve annulus by tying the ends of the sutures together; (v) affixing another suture to a heart valve annulus as a horizontal mattress stitch by passing one of the surgical needles attached to the sutures through the heart valve annulus; (vi) threading the surgical needles attached to the suture through the sewing cuff on the first intermediate segment; (vii) using the supportive drawstring and the strands of the suture to guide the intermediate segment to the desired position above the heart valve annulus; (viii) pushing the intermediate segment down over the suture strands until the intermediate segment is aligned with the heart valve annulus; (ix) securing the intermediate segment to the heart valve annulus by tying the ends of the sutures together; (x) repeating steps (v-ix) until the desired circumference around the heart valve annulus is covered by intermediate suture support segments; (xi) threading the supportive drawstring through the channel which passes through the length of the terminal segment; (xii) affixing the suture to a heart valve annulus by passing one of the surgical needles attached to the sutures through the heart valve annulus; (xiii) threading the surgical needles attached to the suture through the sewing cuff on the terminal segment; (xiv) using the supportive drawstring and the strands of the suture to guide the terminal segment to the desired position above the heart valve annulus; (xv) pushing the terminal segment down over the strands of the sutures until the terminal segment is aligned with the heart valve annulus; (xvi) securing the terminal segment to the heart valve annulus by tying the ends of the sutures together; and (xvii) testing the repaired heart valve to verify that appropriate constriction has been achieved. Utilizing the constricting means further includes: (i) pulling the supportive drawstring to the desired tension to further decrease the circumference of the heart valve annulus if further adjustment is needed; and (ii) tying the supportive drawstring that runs through the terminal segment to the third suture attached to the end portion of the terminal segment. 
       FIGS. 3A-3E  illustrate the third exemplary embodiment of this invention. Annuloplasty system  300  includes of an anchor suture support segment  302  with a supportive drawstring  306  attached, a plurality of identical intermediate suture support segments  304 , a terminal suture support segment  310  and a plurality of identical surgical sutures  340  with attached surgical needles  342 . The surgical methods used to implant the annuloplasty system  300  may be conventional open heart surgery techniques or minimally invasive heart surgery techniques. 
     The suture support segments, the anchor sutures support segment  302 , the intermediate suture support segments  304 , and terminal suture support segment  310 , provide sites for suturing of the annuloplasty system  300  about the mitral valve annulus  50 . Each of the suture support segments  302 ,  304 , and  310  accommodate a single horizontal mattress suture incorporating a portion of the circumference of the mitral valve annulus  50  beneath it. The suture traverses a longer distance along the heart annulus than the size of the support segments. Sutures, when tightened and tied, create an imbrication in the valve annulus underneath the segment thereby reducing the circumference of the annulus by an amount equal to the difference between the length each suture travels in the tissue of the heart annulus and the distance between the suture bites in the support segment. 
       FIG. 3A  depicts a cross-sectional view of a suture support segment  301 . The suture support segment  301  could function as an anchor suture support segment  302 , an intermediate suture support segment  304  or a terminal suture support segment  310 . The support segments,  302 ,  304 , and  310 , can be cylindrical, tubular, square, round, oval, elongated oval or combinations thereof shaped as necessary to achieve the desired configuration. The suture support segment  301  has a rigid core  331  which surrounds the channel  330  that will hold the supportive drawstring  306 . As shown it is a single-channel  330  but it could also be a dual channel in the suture support segment  301 . The rigid core  331  is covered with a silicon rubber  313  which is covered by a polyester fabric  312 . The silicon rubber  313  and the polyester fabric  312  together make up the sewing cuff  311 . 
     The suture support segments  302 ,  304 , and  310  have a cylindrical rigid core which includes a channel  330  passing lengthwise therethrough. The rigid core  331  can be made of any suitable material that is preferably inert, non-corrosive, non-thrombogenic and biocompatible with blood and tissue. By way of example, but not limitation, such material might be an acetal resin Delrin. The core  331  is covered with a layer of barium sulfate impregnated silicon rubber  313  and polyester knit fabric  312 . The layer of silicon rubber  313  around the rigid core  331  and the polyester cover  312  provide a sewing cuff  311  for suturing of the support segments  301  about the heart valve annulus. A preferred size of the suture support segment body  320 ,  350 ,  370  is 1 mm to 4 mm in length but more preferably 2 mm to 6 mm in length, with a circumference of 1 mm to 4 mm, although other sizes and dimensions are possible. The suture support segments  302 ,  304 , and  310  must be rigid or semi-rigid in the longitudinal dimension, and must not be deformable, such that when the sutures  340  are tied against the suture support segment body  370 ,  320 ,  350  to secure the suture support segment  302 ,  304 ,  310  to the mitral valve annulus  50 , the suture support segment body  370 ,  320 ,  350  does not buckle. 
       FIG. 3A  is an illustration of the superior view of the dilated mitral valve of a human heart. As depicted the dilated mitral valve has a gap  46  between the anterior and posterior leaflets  42  and  40 .  FIG. 3A  also depicts a side view of a suture support segment  302 ,  304  or  310 . As depicted it is labeled  302 . The suture support segment has channel passing lengthwise therethrough. 
       FIGS. 3A  and B depict the implantation of the anchor suture support segment  302  into the mitral valve annulus  50 . A double-arm suture  340  is placed as a mattress horizontal stitch in the posterior annulus of the mitral valve and then passed through the sewing cuff  311  of the anchor suture support segment  302 . As shown in  FIG. 3B  the surgical needles  342  are used to pierce the sewing cuff  311  of the anchor suture support segment  302 . The sutures  340  that have passed through the surgical cuff  311  of the anchor support segment  302  are then used to slide the anchor suture support segment  302  down onto the desired location of the mitral valve annulus  50 . 
       FIG. 3C  depicts the securing of the anchor suture support segment  302  to the mitral valve annulus  50 . Once the anchor support segment  302  is aligned with the mitral valve annulus  50  the surgical needles  342  are cut off from the sutures  340  and the free ends of the sutures  340  are knotted together, with sufficient tension thereby securing the anchor suture support segment  302  in place on the mitral valve annulus  50 . 
       FIG. 3D  shows the implantation of the first intermediate suture support segment  304  according to the current embodiment of the invention. A new horizontal mattress stitch is placed 2-4 mm from the proximal end of the anchor support segment  302  at the surgical site  48 . The supportive drawstring  306  is used to guide the intermediate suture support segment  304  toward the mitral valve annulus  50 . 
       FIG. 3E  depicts the sliding down of the intermediate suture support segment  304  to the mitral valve annulus  50 . As shown in  FIG. 3D  the supportive drawstring  306  and the sutures  340  that have passed through the sewing cuff  311  of the intermediate suture support segment  304  are used to lower the intermediate suture support segment  304  to the desired location. The surgical needles  342  of the sutures  340  are used to pierce the sewing cuff  311  of the intermediate suture support segment  304 . Once the intermediate support segment  304  is aligned with the mitral valve annulus  50  the surgical needles  342  are cut off from the sutures  340  and the free ends of the sutures  340  are knotted together, with sufficient tension thereby securing the intermediate suture support segment  304  in place on the mitral valve annulus  50 . This process described in  FIGS. 3D-3E  is repeated until the desired circumference around the mitral valve annulus  50  is covered with intermediate suture support segments  304 . 
     After the last intermediate suture support segment  304  is secured on the mitral valve annulus  50 , a terminal suture support segment  310  will be implanted like described in  FIGS. 3E-3E . Next, the mitral valve will be tested for competence by distending the left ventricle with isotonic solution infused through rubber-bulbed syringe. If needed the annuloplasty system will be adjusted by pulling the supportive drawstring  306 . To complete the annuloplasty system  300  the free end  308  of the supportive drawstring  306  then will be tied together with the free suture attached to the end of the terminal suture support segment  310 . After seven or eight knots are made the free tails are cut at the point beyond the terminal suture support segment  310  by any suitable means completing the annuloplasty. 
     A fourth embodiment of this invention (shown in  FIGS. 4A-H ) also provides an annuloplasty system for repairing incompetent heart valves without traditional knotting. This system includes: a substantially circular flexible valve reinforcing device adapted to be surgically implanted into a heart valve; anchoring means for attaching the substantially circular valve reinforcing device to the heart valve annulus and for pleating the annulus to reduce its circumference to substantially that of the valve reinforcing device. The valve reinforcing device further includes: a core formed of a plurality of thin fibers which are held together by a tubular polyester velour cloth. The anchoring means further includes: (i) a suture containing at least one surgical needle at each proximal end of the suture; and (ii) a plurality of barbed structures formed at a medial point on the suture with a first barb structure being placed a distance away from a second barb structure to create a bridge area, wherein the first barbed structure is oriented to permit passage of the suture through the heart valve annulus in a forward direction and prevent movement in a reverse direction, and wherein the second barbed structure is oriented to prevent passage of the suture through the heart valve annulus in a forward direction 
     A method for surgically implanting this annuloplasty system includes: (a) utilizing the anchoring means to secure the substantially circular valve reinforcing device to the heart valve annulus. Utilizing the anchoring means further includes: (i) inserting one of the surgical needles of the suture apparatus into the heart valve annulus and pulling the surgical needle which draws the first portion of the suture through the heart valve annulus until the barbs of the second barbed structure engage the surface of the annulus at the insertion point preventing further advancement of the suture into the heart valve annulus; (ii) inserting another suture apparatus into the heart valve annulus 2-4 mm apart from the previous stitch and pulling the surgical needle which draws the first portion of the suture through the heart valve annulus until the barbs of the second barbed structure engage the surface of the heart valve annulus at the insertion point preventing further advancement of the suture into the heart valve annulus; and (iii) repeating step (ii) until the entire circumference of the posterior annulus of the mitral valve is evenly sutured. (iv) using both surgical needles of each of the suture apparatus to pierce the annuloplasty ring wherein the suture attached to the surgical needles lower the annuloplasty ring over the sutures into position above the heart valve annulus; (v) pushing the annuloplasty ring onto the barbed structures wherein the barbed structures catch the thin fibers in the annuloplasty ring; (vi) using the barbed structures to hold the annuloplasty ring into place; and (vii) cutting off the surgical needles and the remaining suture material. 
       FIGS. 4A-4H  depict the fourth embodiment and method for attaching an annuloplasty system to a damaged mitral valve according the present invention. The annuloplasty system  400  includes a double-armed barbed suture  420  which further includes a plurality of elongated sutures  424  having one or more spaced barbs  426  and  428  projecting from the surface of the suture  424 . Barbs  426  and  428  are configured to allow passage of the suture  424  in one direction through the heart tissue and an annuloplasty ring or band  450  but resist movement of the suture  424  relative to the heart tissue and the annuloplasty ring or band in the opposite direction. The surgical methods used to implant the annuloplasty system  400  may be conventional open heart surgery techniques or minimally invasive heart surgery techniques. 
       FIG. 4A  depicts one of the double-armed barbed sutures  420  of annuloplasty system  400 . The double-armed barbed suture  420  is comprised of a suture  424 , surgical needles  422 , barbs  426 ,  428  and a bridge between the barbs  430 . The suture  424  has attached to each end a surgical needle  422 . The suture  424  also has attached to the surface thereof a set of barbs  426  and  428  facing in opposite directions. The suture  424  includes a set of barbs  426  oriented in one direction on one side of a bridge  430  and another set of barbs  428  oriented in the opposite direction on the other side of the bridge  430 . The barbs  426  and  428  are configured to only allow passage of the suture  424  in one direction through mitral valve annulus  50 . 
       FIG. 4B  is an illustration of the superior view of the dilated mitral valve of a human heart. As depicted the dilated mitral valve has a gap  46  between the anterior and the posterior leaflets  42  and  40 .  FIG. 4B  also depicts the method of implantation of annuloplasty system  400  into heart valve annulus  50 . The surgeon will insert one of the surgical needles  422  into the mitral valve annulus  50  at the surgical site  44  and will advance the surgical needle  422  through the mitral valve annulus  50  until the needle  422  emerges from the mitral valve annulus  50 . 
       FIG. 4C  shows the next step in which the surgeon will grip the surgical needle  422  and pull the surgical needle  422  out of the mitral valve annulus which draws the first portion  424 ′ of the suture body  424  through the mitral valve annulus  50  until the barbs  428  of the second portion of the suture body  424  engage the surface of the mitral valve annulus  50  at the insertion point preventing further advancement of the suture  424  into the mitral valve annulus  50 . 
       FIG. 4D  shows many double-armed barbed sutures  420  attached to the mitral valve annulus  50  by the means described above in  FIGS. 4B-4C . For clarity,  FIG. 4E  shows only one of the double-armed barbed sutures  420  attached to the mitral valve annulus  50  but it also depicts how the annuloplasty band or ring  450  is pierced with the surgical needles  422 . In  FIG. 4E  the annuloplasty band/ring  450  has been penetrated by the surgical needles  422  attached to the sutures  424  which has been passed through the mitral valve annulus  50  by means of the method described above in  FIGS. 4B-4C .  FIG. 4F  is a detailed view of the annuloplasty band/ring  450 . This view shows how the annuloplasty band/ring  450  is comprised. The annuloplasty band/ring  450  has a core  452 . The core  452  of the annuloplasty band is made up of a plurality of distinct thin fibers  454 . The plurality of thin fibers  454  that make up the core  452  of annuloplasty band/ring  450  are covered with a tubular polyester velour cloth  456 . 
       FIG. 4G  shows the full annuloplasty system  400  with all of the double-armed barbed sutures  420  attached to the mitral valve annulus  50  and passed through the annuloplasty ring  450  wherein the annuloplasty ring  450  is lowered in place above the mitral valve annulus  50  over the strands of the double-armed barbed sutures  420 . The next step will be for the surgeon to secure the annuloplasty ring  450  onto the barbed structures  426  and  428  wherein the barbed structures  426  and  428  catch the thin fibers  454  in the annuloplasty ring  450 . The barbs  426  and  428  facing upwards from the mitral valve annulus  50  will catch the annuloplasty ring  450  and will hold the annuloplasty ring  450  onto the mitral valve annulus  50  with out having to tie the sutures. Once the annuloplasty ring  450  is secured into place on the mitral valve annulus  50  the excess suture  424  protruding through the annuloplasty ring  450  is cut at a point against the annuloplasty ring  450 . The barbs  426  and  428  will hold the annuloplasty ring  450  in place on the mitral valve annulus  50  because the barbs  426  and  428  grip the thin fibers  454  and the polyester velour cloth cover of the annuloplasty band/ring  450 .  FIG. 4H  is a superior view of a repaired mitral valve annulus  50  with attached and completed annuloplasty system  400 . 
       FIGS. 8-26  depict various alternate methods used to attach suture support segments quickly in the heart valve annulus without traditional knotting. 
       FIG. 8  provides an illustration of the superior view of the dilated mitral valve of a human heart. As depicted the mitral valve has a gap  46  between the anterior and posterior leaflets  42  and  40 . Any of the above described annuloplasty systems ( 100 ,  200 ,  300 ,  400 ,  500 ) are compatible with this method but the single supportive drawstring annuloplasty system  200  is depicted.  FIG. 8  depicts the use of an intracardiac ultrasonic suture welder  70 , a novel tool that allows one to secure interrupted sutures under tension without tying knots. As pictured the anchor suture support segment  202  has already been implanted in the mitral valve annulus  50 . Instead of knotting the sutures  274  together to secure the anchor suture support segment body  270  to the heart valve annulus  50 , the two ends of each suture  274  (not shown) can be threaded through the end of an intracardiac ultrasonic suture welder  70 . Tension in the sutures  274  is adjusted using downward pressure with the tip of the intracardiac ultrasonic suture welder  70  as well as upward traction on the end of each suture  274  strand. The intracardiac ultrasonic suture welder  70  is then actuated (not shown). Successful welding of each suture  274  is confirmed by visual inspection, and the suture tails are cut 1-2 mm from the weld. This process is repeated for each intermediate suture support segment  204  until the desired circumference around the mitral valve annulus  50  is covered. 
       FIGS. 9-11  depict another alternative embodiment of a suture support segment that does not use traditional knotting to secure the suture support segment body to the mitral valve annulus. The annuloplasty system can be any of the above described having a single supportive drawstring ( 200 ) or a dual-supportive drawstring ( 100 ). 
       FIG. 9  depicts an intermediate suture support segment  604 . The intermediate suture support segment  604  is made up of an intermediate suture support segment body  620 , a suture  624 , a surgical needle  622 , an eye  630 , and barbs  632 . A supportive drawstring  606  (may be a single or dual supportive drawstring, the dual supportive drawstring is not shown) is threaded through the channel(s) in the intermediate suture support segment body  620 . This supportive drawstring  606  is used to guide the intermediate suture support segment  604  to the desired location on the mitral valve annulus. The intermediate suture support segment body  620  has an eye  630  with ratchet means. Attached to the other end of the intermediate suture support segment body  620  is a suture  624  with an attached surgical needle  622 . The suture  624  has attached on the exterior distal surface a set of barbs  632 . The orientation of the barbs  632  make the suture  624  a one-way suture because barbs  632  will only allow passage of the surgical needle  622  and suture  624  in one direction through the heart tissue and the eye  630 , but not in the opposite direction. 
       FIG. 10  shows how the surgical needle  622  is used to thread the suture  624  through the heart tissue and is then passed through the eye  630  to lead the suture  624  there through, whereby the suture  624  is formed into a loop  634 .  FIG. 11  shows how the latching means of the eye  630  and barbs  632  permits forward movement of the suture  624  through the eye  630  but retains the suture  624  securely against reverse movement through the eye  630 . Note that the anchor suture support segment (not shown) used with this embodiment will have the same configuration as the intermediate suture support segment  604 , except that the supportive drawstring  606  is attached to the anchor suture support segment instead of running through a channel(s) of the anchor suture support segment body. 
       FIGS. 12-13  depict another means of attachment without traditional knotting using a suture support segment  704  that has an opening  730  with a one-way suture-retaining device  734  with flexible fingers, barbs or series of sheets  736  that are configured to engage the braided suture  724 . The fingers or barbs  736  preferably have sharp points inclined in a common axial direction for purposes of preventing the braided suture  724  from sliding relative to suture support segment  704  in a direction opposite to the direction of inclination of barbs  736 . The suture-retaining device  734  has a passage of a sufficient diameter to allow a braided suture  724  to easily pass through opening  730  with little resistance, but small enough to allow flexible fingers or barbs  736  to engage the braided suture  724  when the braided suture  724  in the suture-retaining device  734  is moved in a direction opposite to the direction of inclination of barbs or fingers  736 . Thus, the braided suture  724  is locked into position (see  FIG. 13 ). 
       FIGS. 14-15  depict yet another embodiment of the present invention that uses a method to secure the suture support segment in place without traditional knotting and an annuloplasty system using the securing method.  FIG. 14  depicts an intermediate suture support segment  804  which is comprised of an intermediate suture support segment body  820 , a braided suture  824 , a surgical needle  822 , a locking device  830 , and a channel(s) which is not shown. The braided suture  824  has a core  832 , formed of a plurality of fibers which are held together by a tubular braided cover  836 . The fibers are thermally bonded together, to form rigid bridges  834 , at selected short intervals along the longitudinal axis of the braided suture  824 . These rigid bridges  834  are formed from thermally bonded fibers which are configured to allow passage of the braided suture  824  in one direction through locking device  830  but significantly resist movement of the braided suture  824  in the opposite direction and prevent the braided suture  824  from slipping back through the locking device  830 . 
       FIG. 15  provides an illustration of the superior view of the dilated mitral valve of a human heart. As depicted the dilated mitral valve has a gap  46  between the anterior and posterior leaflets  42  and  40 . As shown an anchor suture support segment  802  with an attached supportive drawstring  806  is already secured to the mitral valve annulus  50 . The channel of intermediate suture support segment  804  is threaded through the free end  808  of the supportive drawstring  806 , which is shown as a single supportive drawstring but it could be a dual-supportive drawstring. The supportive drawstring  806  is used to guide each intermediate suture support segment  804  to the desired location on the mitral valve annulus  50 . The surgical needle  822  attached to the intermediate suture support segment  804  is used to make a horizontal mattress stitch in the mitral valve annulus  50 . Once this is completed the surgical needle  822  is passed through the eye of the locking device  830  of the intermediate suture support segment body  820 . The braided suture  824  is pulled through the eye of the locking device  830  while the intermediate suture support segment body  824  is pushed down toward the mitral valve annulus  50  until the required tension is obtained in the loop and thereafter the excess length of the braided suture  824  protruding through the eye of the locking device  830 , is cut away. Such an embodiment allows accurate control over the braided suture  824  tension without having to tie a knot. Alternatively a specially constructed tool (not shown) similar to a cable tie tension and cutter tool can be used. The tool would have a tensioning mechanism for tensioning the suture to a predetermined tension setting and a cutting mechanism for cutting the excess portion of the suture tail after the desired tension is achieved. 
       FIG. 16  depicts still another embodiment of the present invention that uses an opening  930  which provides a slot or passageway  932  for enabling a lateral insertion of suture  924  into opening  930 . As described above in both single and dual supportive drawstring systems the intermediate suture support segments  904  are be slid down over the supportive drawstring  906  into position above the mitral valve (not shown). The surgical needle  922  is passed through the mitral valve annulus, and then the surgical needle  922  would be slipped through slot or passageway  932  into opening  930  of the suture-retaining device. The suture is then pulled through the opening  930  while the intermediate support segment  904  is pushed down toward the heart annulus until the required tension is obtained in the loop and thereafter the excess length of the suture  924  protruding through the opening  930 , is cut away. 
       FIG. 17  illustrates another locking device utilizable with the method discussed above. The suture support segment  1004  has a lumen  1030  formed along the entire axial length of the suture support segment body  1020 . Attached to the outside of the sutures support segment  1004  on the suture support segment body  1020  is a braided suture  1024  with an attached surgical needle  1022 . The interior of the suture support segment body  1020  is made up of a lumen  1030  which is comprised of a plurality of barbs  1036  inclined in a common axial direction for purposes of preventing braided suture  1024  from sliding relative to suture support segment body  1020  in a direction opposite to the direction of inclination of barbs  1036 . As can be seen in  FIG. 18 , the barbs  1036  are constructed such that if braided suture  1024  is pulled in the direction indicated by the arrow, the braided suture  1024  may pass freely with little resistance. However, if braided suture  1024  is pulled in the opposite direction, the barbs  1036  engage the braid of the braided suture  1024 . Thus, braided suture  1024  is locked into position. 
       FIGS. 19-20  show parts of an annuloplasty system  1100  using suture support segments having a self-closing single-arm clip assembly to secure the suture support segment to the mitral valve annulus  50  instead of using traditional knotting.  FIG. 19  is a detailed drawing of an intermediate suture support segment  1104  having an intermediate suture support segment body  1120 , a self-closing single-arm clip assembly  1128 , a suture  1124 , and a surgical needle  1122 . The self-closing single-arm clip assembly  1128  is generally U, C or J-shaped with two end points separated from each other when it is constrained to be in an open configuration, but tends to coil up to assume its naturally closed configuration if the constraint is removed. The self-closing single-arm clip assembly  1128  is attached to the intermediate suture support segment body  1120  by conventional means. Attached to the end of the self-closing single-arm clip assembly  1128  is a suture  1124  which has an attached surgical needle  1122 . 
       FIG. 20  provides an illustration of the superior view of the mitral valve of a human heart. As depicted the mitral valve has a gap  46  between the anterior and posterior leaflets  42  and  40 .  FIG. 20  depicts how an anchor suture support segment  1102  of the current embodiment is attached to the mitral valve annulus  50 . First, the surgeon guides the surgical needle  1172  to the surgical site and passes the surgical needle  1172  through the tissue of the mitral valve annulus  50  similar to interrupted suture placement and then pulls the suture  1174  until the self-closing single-arm clip assembly  1128  passes partially through the mitral valve tissue  50  such that the end point of the self-closing single-arm clip assembly  1128  which is connected to the suture  1174  completely passes through the mitral valve annulus  50 . The other end of the self-closing single-arm clip assembly  1128  does not enter the mitral valve annulus  50  because it is attached to the anchor suture support segment body  1120  which prevents this end of the self-closing single-arm clip assembly  1128  from entering the mitral valve annulus  50 . After the suture  1124  is released from the self-closing single-arm clip assembly  1128  the clip moves to its predetermined closed-loop configuration, reducing the distance between the two end points and securing the anchor suture support segment  1102  to the mitral valve annulus  50 . The internal force of the clip keeps the anchor suture support segment  1102  firmly attached to the mitral valve annulus and reduces the distance separating the two end points thereby reducing the portion of the circumference of the mitral valve annulus  50  between the two end points. After one clip is thus placed in the annulus, the same procedure is repeated with a plurality of other clips. The intermediate suture support segments  1104  are lowered down one-by-one over the supportive drawstring  1106  into position above the mitral valve annulus  50 . Using this method a desired number of suture support segments can be linked together to form a line of linked segments of a desired length, corresponding to the unique size of the heart annulus of the individual patient. 
       FIGS. 21-26  illustrate a superior view of the repaired mitral valve of a human heart with a plurality of support segments in place. As depicted the mitral valve has a residual gap  46  between the anterior and posterior leaflets  42  and  40  as a result of a post-repair residual mitral valve incompetence.  FIGS. 21-26  highlight one of the advantageous features of this annuloplasty system  1100  which is the ability to provide further adjustment or “fine tuning” of the repair once the annuloplasty system  1100  is implanted. In other words, the annuloplasty system  1100  may be adjusted in diameter during or after implantation which will allow the surgeon to correct certain technical errors that might have occurred during implantation and eliminate post-repair residual regurgitation. 
       FIG. 21  depicts how the plurality of suture support segments are slidably coupled with a supportive drawstring(s) and how the tissue between adjacent suture support segments will placate so that the circumference of the valve annulus will be reduced by applying tensile force to the supportive drawstring  1106  in a proximal direction. This will effectuate any residual annulus plication not already effectuated beneath suture support segments  1104 . Tension may be adjusted on the supportive drawstring  1106  under direct visualization or while using ultrasound Doppler echocardiography for precise adjustment of the annular correction. When the entire circumference of the mitral valve annulus  50  has been sutured the mitral valve is tested for competence by distending the left ventricle with isotonic solution infused through a rubber-bulbed syringe. In case of residual regurgitation  46  shown in  FIG. 21  the supportive drawstring(s)  1106  ( FIGS. 20 and 21 ) can be used to further cinch the segments and thereby reduce the annular diameter and correct postrepair residual regurgitation ( FIG. 23 ). Once proper adjustment is achieved, or in the absence of need for any adjustment, the supportive drawstring(s)  1106  are knotted together to maintain the desired degree of annular constriction and prevent further annular dilatation, thereby completing the annuloplasty ( FIG. 22 ). 
       FIG. 24  illustrates a method of implanting suture support segments from opposite ends. In  FIG. 24  two anchor suture support segments would be used and implanted at opposite ends of the mitral valve. The supportive drawstrings attached to the end of the anchor suture support segments would be used to lower the intermediate suture support segments onto the mitral valve. 
       FIG. 25  shows how one of the two partial supportive drawstrings from the annuloplasty systems is used to achieve a selective reduction of the inferior limb of the posterior annulus.  FIG. 25  depicts post-repair residual asymmetric incompetence  49  of the inferior limb of the posterior annulus an dhow a partial supportive drawstring corresponding to the area of asymmetric incompetence is pulled by the left hand of the surgeon to achieve a selective reduction of the inferior limb of the posterior annulus.  FIG. 26  shows a completed system. 
     Another embodiment of this invention provides a suturing method for quickly attaching the suture support segments to the heart tissue without traditional knotting, which is not shown. Suture support segment has an eye sealed with a meltable material (polypropylene) being soft enough to be penetrated by the needle. Alternatively the meltable seal in the eye may have a central passage of a sufficient diameter to allow the needle and the suture to pass through the passage. In the annuloplasty procedure the needle would be passed through the heart annulus, and then the needle would be passed through the eye of the suture support segment. The suture pulled through the eye while the support segment is pushed down toward the heart annulus until the required tension is obtained. A specially constructed tool similar to a cable tie tension and cutter tool then will be used. The tool would have a tensioning mechanism for tensioning the suture to a predetermined tension setting, an ultrasonic welder and a cutting mechanism for cutting the excess portion of the suture tail after the desired tension is achieved and the suture joined to the polypropylene seal in a weld within the eye. 
     The suture is comprised of a melt-resistant braided core or a stainless steel core covered with a meltable sheath made from the same material as the seal in the eye of the support segment. Upon activation of the ultrasonic welder the meltable sheath of the suture and the meltable seal of the eye will melt so that the suture could attach to the support segment in the weld within the eye. The core of the suture will not melt and will remain intact so that the suture will not break upon melting of the meltable sheath of the suture. The tensioning and cutting tool will cut the excess portion of the suture tail after the desired tension is achieved and the suture joined to the polypropylene seal in a weld within the eye. 
     While the present invention has been illustrated by the description of exemplary embodiments thereof, and while the embodiments have been described in certain detail, it is not the intention of the Applicant to restrict or in any way limit the scope of the appended claims to such detail. Additional advantages and modifications will readily appear to those skilled in the art. Therefore, the invention in its broader aspects is not limited to any of the specific details, representative devices and methods, and/or illustrative examples shown and described. Accordingly, departures may be made from such details without departing from the spirit or scope of the applicant&#39;s general inventive concept.