text:
|Publication number
|Publication type
|Application number
|Publication date
|Feb 9, 2010
|Filing date
|Nov 29, 2006
|Priority date
|Jul 27, 2004
|Fee status
|Also published as
|Publication number
|Rose Province, Timothy A. Fayram
|Original Assignee
|Pacesetter, Inc.
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (44), Non-Patent Citations (32), Classifications (8), Legal Events (3)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a continuation of U.S. patent application Ser. No. 10/901,403, filed Jul. 27, 2004, now U.S Pat. No. 7,181,276. This application is related to U.S. patent applications: 1) Ser. No. 10/901,480, filed Jul. 27, 2004, now U.S. Pat. No. 7,308,305, entitled "Optimally Timed Early Shock Defibrillation" to Province and Kroll; 2) Ser. No. 10/901,421, filed Jul. 27, 2004, entitled "Optimized Pathways to Early Shock Defibrillation" to Province and Kroll; and 3) Ser. No. 10/848,853, filed May 18, 2004, now U.S. Pat. No. 7,225,014, entitled "Anti-Arrhythmia Therapy Based on Spatial and/or Temporal Information" to Province. All applications are incorporated herein by reference.
Exemplary methods, devices, systems, etc., presented herein generally relate to cardiac pacing and/or stimulation therapy. Various exemplary methods, devices, systems, etc., aim to deliver anti-arrhythmia stimulation at energies less than those conventionally used for defibrillation.
Ventricular fibrillation is a potentially life-threatening cardiac condition. Most conventional defibrillation devices, whether external or implantable, treat ventricular fibrillation with a cardiac stimulus of quite high energy. For example, external devices typically use an energy level in excess of approximately 200 joules and implantable devices typically use an energy level in excess of 10 joules. Such stimuli can be quite painful when delivered to a conscious patient. For an implantable device, such stimuli can also greatly impact the device's limited power supply. Further, while an implantable device requires lesser energy level stimulus for defibrillation compared to an external device, the consequences on size, weight and/or shape of an implantable device capable of producing a 10 joules stimulus is significant.
Recent studies using mathematical models, non-human animals and/or external devices have shown that at the onset of ventricular fibrillation, the number of reentry wavefronts may be low, for example, on the order of 1 or 2, similar to a monomorphic tachycardia. During subsequent activations, the fast activation rate of reentry wavefronts compared to sinus rhythm wavefronts causes an increase in electrical heterogeneity of the cardiac tissue, which, in turn, can cause an increasing number of wavefronts through wavefront breakup. Indeed, wavefront breakup may play an important role in the acceleration of an arrhythmia into a stable ventricular fibrillation. The time that is takes for such a transition to occur may be expected to vary, for example, from patient to patient, and experimentally from model to model.
As described herein, various exemplary methods, systems and/or devices aim to detect ventricular fibrillation or precursors thereof at an early stage, for example, prior to stabilization. Based on such detection, such exemplary methods, systems and/or devices may deliver one or more stimuli to terminate, disrupt or otherwise convert physiological processes related to wavefront breakup.
An exemplary method includes detecting ventricular fibrillation, delivering a low voltage cardiac stimulus, determining whether the low voltage cardiac stimulus terminated the ventricular fibrillation, and delivering a higher voltage cardiac stimulus if the low voltage cardiac stimulus did not terminate the ventricular fibrillation. In one example, the delivering the low voltage cardiac stimulus occurs within approximately 10 intervals from the detected onset of ventricular fibrillation; otherwise, delivery of an appropriate higher voltage cardiac stimulus occurs. Such a higher voltage stimulus may follow detection and a charging delay (e.g., approximately 7 s to approximately 10 s) when required. Other exemplary methods, devices, systems, etc., are also disclosed.
Features and advantages of the described implementations can be more readily understood by reference to the following description taken in conjunction with the accompanying drawings.
The following description is of the best mode presently contemplated for practicing the described implementations. This description is not to be taken in a limiting sense, but rather is made merely for the purpose of describing the general principles of the implementations. The scope of the described implementations should be ascertained with reference to the issued claims. In the description that follows, like numerals or reference designators will be used to reference like parts or elements throughout.
Exemplary Stimulation Device
The techniques described below are intended to be implemented in connection with any stimulation device that is configured or configurable to stimulate and/or shock a patient's heart.
The right atrial lead 104, as the name implies, is positioned in and/or passes through a patient's right atrium. The right atrial lead 104 optionally senses atrial cardiac signals and/or provides right atrial chamber stimulation therapy. As shown in
To sense atrial cardiac signals, ventricular cardiac signals and/or to provide cardiac therapy, particularly on the left side of a patient's heart, the stimulation device 100 is coupled to a coronary sinus lead 106 designed for placement in the coronary sinus and/or tributary veins of the coronary sinus. Thus, the coronary sinus lead 106 is optionally suitable for positioning at least one distal electrode adjacent to the left ventricle and/or additional electrode(s) adjacent to the left atrium. In a normal heart, tributary veins of the coronary sinus include, but may not be limited to, the great cardiac vein, the left marginal vein, the left posterior ventricular vein, the middle cardiac vein, and the small cardiac vein.
Accordingly, an exemplary coronary sinus lead 106 is optionally designed to receive atrial and ventricular cardiac signals and to deliver left ventricular stimulation therapy using, for example, at least a left ventricular tip electrode 122, left atrial stimulation therapy using at least a left atrial ring electrode 124, and stimulation therapy using at least a left atrial coil electrode 126. Coil electrodes are often used for shock therapy. For a complete description of a coronary sinus lead, the reader is directed to U.S. patent application Ser. No. 09/457,277, filed Dec. 8, 1999, entitled "A Self-Anchoring, Steerable Coronary Sinus Lead" (Pianca et al.); and U.S. Pat. No. 5,466,254, "Coronary Sinus Lead with Atrial Sensing Capability" (Helland), which are incorporated herein by reference. The coronary sinus lead 106 may further include bifurcations or legs. For example, an exemplary coronary sinus lead includes stimulation electrodes capable of delivering pacing pulses to a patient's left ventricle and at least one electrode capable of stimulating an autonomic nerve. An exemplary coronary sinus lead (or left ventricular lead or left atrial lead) may also include at least one electrode capable of stimulating an autonomic nerve, such an electrode may be positioned on the lead or a bifurcation or leg of the lead.
The stimulation device 100 is also shown in electrical communication with the patient's heart 102 by way of an implantable right ventricular lead 108 having, in this exemplary implementation, a right ventricular tip electrode 128, a right ventricular ring electrode 130, a right ventricular (RV) coil electrode 132, and an SVC coil electrode 134. Typically, the right ventricular lead 108 is transvenously inserted into the heart 102 to place the right ventricular tip electrode 128 in the right ventricular apex so that the RV coil electrode 132 will be positioned in the right ventricle and the SVC coil electrode 134 will be positioned in the superior vena cava. Accordingly, the right ventricular lead 108 is capable of sensing or receiving cardiac signals, and delivering stimulation in the form of pacing and shock therapy to the right ventricle. An exemplary right ventricular lead may also include an electrode positioned on a bifurcation or leg of the lead.
Housing 200 for the stimulation device 100 is often referred to as the "can", "case" or "case electrode", and may be programmably selected to act as a return electrode for all "unipolar" modes (e.g., unipolar electrode configurations). Housing 200 may further be used as a return electrode alone or in combination with one or more of the coil electrodes 126, 132 and 134 for shocking purposes. As described herein other electrodes (coil or other) are optionally used to deliver shock therapy. Housing 200 further includes a connector (not shown) having a plurality of terminals 201, 202, 204, 206, 208, 212, 214, 216, 217, 218, 221 (shown schematically and, for convenience, the names of the electrodes to which they are connected are shown next to the terminals).
To achieve right atrial sensing and/or stimulation, the connector includes at least a right atrial tip terminal (AR TIP) 202 adapted for connection to the atrial tip electrode 120. A right atrial ring terminal (AR RING) 201 is also shown, which is adapted for connection to the atrial ring electrode 121. To achieve left chamber sensing and/or stimulation, the connector includes at least a left ventricular tip terminal (VL TIP) 204, a left atrial ring terminal (AL RING) 206, and a left atrial shocking terminal (AL COIL) 208, which are adapted for connection to the left ventricular tip electrode 122, the left atrial ring electrode 124, and the left atrial coil electrode 126, respectively. Connection to suitable autonomic nerve stimulation electrodes is also possible via these and/or other terminals (e.g., via a stimulation terminal S ELEC 221). The stimulation terminal S ELEC 221 may also allow for sensing per appropriate connections or switching.
To support right chamber sensing and/or stimulation, the connector further includes a right ventricular tip terminal (VR TIP) 212, a right ventricular ring terminal (VR RING) 214, a right ventricular shocking terminal (RV COIL) 216, a left ventricle shocking terminal (LV COIL) 217 (e.g., for an optional LV coil or other electrode), and a superior vena cava shocking terminal (SVC COIL) 218, which are adapted for connection to the right ventricular tip electrode 128, right ventricular ring electrode 130, the RV coil electrode 132, an optional LV coil electrode (not shown in
At the core of the stimulation device 100 is a programmable microcontroller 220 that controls the various modes of stimulation therapy. As is well known in the art, microcontroller 220 typically includes a microprocessor, or equivalent control circuitry, designed specifically for controlling the delivery of stimulation therapy, and may further include RAM or ROM memory, logic and timing circuitry, state machine circuitry, and I/O circuitry. Typically, microcontroller 220 includes the ability to process or monitor input signals (data or information) as controlled by a program code stored in a designated block of memory. The type of microcontroller is not critical to the described implementations. Rather, any suitable microcontroller 220 may be used that carries out the functions described herein. The use of microprocessor-based control circuits for performing timing and data analysis functions are well known in the art.
Representative types of control circuitry that may be used in connection with the described embodiments can include the microprocessor-based control system of U.S. Pat. No. 4,940,052 (Mann et al.), the state-machine of U.S. Pat. No. 4,712,555 (Thornander) and U.S. Pat. No. 4,944,298 (Sholder), all of which are incorporated by reference herein. For a more detailed description of the various timing intervals used within the stimulation device and their inter-relationship, see U.S. Pat. No. 4,788,980 (Mann et al.), also incorporated herein by reference.
Microcontroller 220 further includes timing control circuitry 232 to control the timing of the stimulation pulses (e.g., pacing rate, atrio-ventricular (AV) delay, interatrial conduction (AA) delay, or interventricular conduction (VV) delay, etc.) as well as to keep track of the timing of refractory periods, blanking intervals, noise detection windows, evoked response windows, alert intervals, marker channel timing, etc., which is well known in the art.
Microcontroller 220 further includes an arrhythmia detector 234. The detector 234 can be utilized by the stimulation device 100 for determining desirable times to administer various therapies. The arrhythmia detector 234 may be implemented in hardware as part of the microcontroller 220, or as software/firmware instructions programmed into the device and executed on the microcontroller 220 during certain modes of operation.
Microcontroller 220 further includes a morphology discrimination module 236, a capture detection module 237 and an auto sensing module 238. These modules are optionally used to implement various exemplary recognition algorithms and/or methods presented below. The aforementioned components may be implemented in hardware as part of the microcontroller 220, or as software/firmware instructions programmed into the device and executed on the microcontroller 220 during certain modes of operation.
The electronic configuration switch 226 includes a plurality of switches for connecting the desired electrodes to the appropriate I/O circuits, thereby providing complete electrode programmability. Accordingly, switch 226, in response to a control signal 242 from the microcontroller 220, determines the polarity of the stimulation pulses (e.g., unipolar, bipolar, etc.) by selectively closing the appropriate combination of switches (not shown) as is known in the art.
Atrial sensing circuits 244 and ventricular sensing circuits 246 may also be selectively coupled to the right atrial lead 104, coronary sinus lead 106, and the right ventricular lead 108, through the switch 226 for detecting the presence of cardiac activity in each of the four chambers of the heart. Accordingly, the atrial (ATR. SENSE) and ventricular (VTR. SENSE) sensing circuits, 244 and 246, may include dedicated sense amplifiers, multiplexed amplifiers, or shared amplifiers. Switch 226 determines the "sensing polarity" of the cardiac signal by selectively closing the appropriate switches, as is also known in the art. In this way, the clinician may program the sensing polarity independent of the stimulation polarity. The sensing circuits (e.g., 244 and 246) are optionally capable of obtaining information indicative of tissue capture.
Each sensing circuit 244 and 246 preferably employs one or more low power, precision amplifiers with programmable gain and/or automatic gain control, bandpass filtering, and a threshold detection circuit, as known in the art, to selectively sense the cardiac signal of interest. The automatic gain control enables the device 100 to deal effectively with the difficult problem of sensing the low amplitude signal characteristics of atrial or ventricular fibrillation.
The outputs of the atrial and ventricular sensing circuits 244 and 246 are connected to the microcontroller 220, which, in turn, is able to trigger or inhibit the atrial and ventricular pulse generators 222 and 224, respectively, in a demand fashion in response to the absence or presence of cardiac activity in the appropriate chambers of the heart. Furthermore, as described herein, the microcontroller 220 is also capable of analyzing information output from the sensing circuits 244 and 246 and/or the data acquisition system 252 to determine or detect whether and to what degree tissue capture has occurred and to program a pulse, or pulses, in response to such determinations. The sensing circuits 244 and 246, in turn, receive control signals over signal lines 248 and 250 from the microcontroller 220 for purposes of controlling the gain, threshold, polarization charge removal circuitry (not shown), and the timing of any blocking circuitry (not shown) coupled to the inputs of the sensing circuits, 244 and 246, as is known in the art.
For arrhythmia detection, the device 100 may utilize the atrial and ventricular sensing circuits, 244 and 246, to sense cardiac signals to determine whether a rhythm is physiologic or pathologic. The arrhythmia detector 234 may receive such signals or processed signals and determine whether an arrhythmic condition exists, is likely to exist and/or is imminent. Of course, other sensing circuits may be available depending on need and/or desire. In reference to arrhythmias, as used herein, "sensing" is reserved for the noting of an electrical signal or obtaining data (information), and "detection" is the processing (analysis) of these sensed signals and noting the presence of an arrhythmia or of a precursor or other factor that may indicate a risk of or likelihood of an imminent onset of an arrhythmia.
The exemplary arrhythmia detector module 234 optionally uses timing intervals between sensed events (e.g., P-waves, R-waves, and depolarization signals associated with fibrillation which are sometimes referred to as "F-waves" or "Fib-waves") to perform one or more comparisons to a predefined rate zone limit (i.e., bradycardia, normal, low rate VT, high rate VT, and fibrillation rate zones) and/or various other characteristics (e.g., sudden onset, stability, physiologic sensors, and morphology, etc.) to determine a type of remedial therapy (e.g., anti-arrhythmia, etc.) that is desired or needed (e.g., bradycardia pacing, anti-tachycardia pacing, cardioversion shocks or defibrillation shocks, collectively referred to as "tiered therapy"). The exemplary arrhythmia detector 234 may also receive information from a physiologic sensor(s) 270, which may include a hemodynamic sensor, for example, as described below.
Detection techniques for heart condition that may be suitable for use with various exemplary methods, devices, systems, etc., disclosed herein include those of U.S. patent application Ser. No. 10/848,853, entitled "Anti-arrhythmia Therapy Based on Spatial and/or Temporal Information" to Province; and International PCT Application Serial No. PCT/SE03/00338 (WO 03/071945 A1), entitled "Medical Device" to Noren, which is incorporated by reference herein.
Similar rules can be applied to the atrial channel to determine if there is an atrial tachyarrhythmia or atrial fibrillation with appropriate classification and intervention. Such a module is optionally suitable for performing various exemplary methods described herein. For example, such a module optionally allows for analyses related to action potentials (e.g., MAPs, T waves, etc.) and characteristics thereof (e.g., alternans, activation times, repolarization times, derivatives, etc.).
Cardiac signals are also applied to inputs of an analog-to-digital (A/D) data acquisition system 252. The data acquisition system 252 is configured to acquire intracardiac electrogram signals, convert the raw analog data into a digital signal, and store the digital signals for later processing and/or telemetric transmission to an external device 254. The data acquisition system 252 is coupled to the right atrial lead 104, the coronary sinus lead 106, the right ventricular lead 108 and/or the nerve stimulation lead through the switch 226 to sample cardiac signals across any pair of desired electrodes.
The microcontroller 220 is further coupled to a memory 260 by a suitable data/address bus 262, wherein the programmable operating parameters used by the microcontroller 220 are stored and modified, as required, in order to customize the operation of the stimulation device 100 to suit the needs of a particular patient. Such operating parameters define, for example, pacing pulse amplitude, pulse duration, electrode polarity, rate, sensitivity, automatic features, arrhythmia detection criteria, and the amplitude, waveshape, number of pulses, and vector of each shocking pulse to be delivered to the patient's heart 102 within each respective tier of therapy. One feature of the described embodiments is the ability to sense and store a relatively large amount of data (e.g., from the data acquisition system 252), which data may then be used for subsequent analysis to guide the programming of the device.
Advantageously, the operating parameters of the implantable device 100 may be non-invasively programmed into the memory 260 through a telemetry circuit 264 in telemetric communication via communication link 266 with the external device 254, such as a programmer, transtelephonic transceiver, or a diagnostic system analyzer. The microcontroller 220 activates the telemetry circuit 264 with a control signal 268. The telemetry circuit 264 advantageously allows intracardiac electrograms and status information relating to the operation of the device 100 (as contained in the microcontroller 220 or memory 260) to be sent to the external device 254 through an established communication link 266.
As already mentioned, the stimulation device 100 can further include one or more physiologic sensor(s) 270. A commonly used physiologic sensor is a "rate-responsive" sensor that is typically used to adjust pacing stimulation rate according to the exercise state of the patient. However, the physiological sensor(s) 270 may further be used to detect changes in cardiac output (see, e.g., U.S. Pat. No. 6,314,323, entitled "Heart stimulator determining cardiac output, by measuring the systolic pressure, for controlling the stimulation", to Ekwall, issued Nov. 6, 2001, which discusses a pressure sensor adapted to sense pressure in a right ventricle and to generate an electrical pressure signal corresponding to the sensed pressure, an integrator supplied with the pressure signal which integrates the pressure signal between a start time and a stop time to produce an integration result that corresponds to cardiac output), changes in the physiological condition of the heart, or diurnal changes in activity (e.g., detecting sleep and wake states). Accordingly, the microcontroller 220 responds by adjusting the various parameters (such as rate, AV Delay, V-V Delay, etc.) at which the atrial and ventricular pulse generators, 222 and 224, generate stimulation pulses.
While shown as being included within the stimulation device 100, it is to be understood that the physiologic sensor(s) 270 may also be external to the stimulation device 100, yet still be implanted within or carried by the patient. Examples of physiologic sensors that may be implemented in device 100 include known sensors that, for example, sense respiration rate, pH of blood, ventricular gradient, cardiac output, preload, afterload, contractility, and so forth. Another sensor that may be used is one that detects activity variance, wherein an activity sensor is monitored diurnally to detect the low variance in the measurement corresponding to the sleep state. For a complete description of the activity variance sensor, the reader is directed to U.S. Pat. No. 5,476,483 (Bornzin et al.), issued Dec. 19, 1995, which patent is hereby incorporated by reference.
More specifically, the physiological sensor(s) 270 optionally include sensors for detecting movement and minute ventilation in the patient. The physiological sensors 270 may include a position sensor and/or a minute ventilation (MV) sensor to sense minute ventilation, which is defined as the total volume of air that moves in and out of a patient's lungs in a minute. Signals generated by the position sensor and MV sensor are passed to the microcontroller 220 for analysis in determining whether to adjust the pacing rate, etc. The microcontroller 220 monitors the signals for indications of the patient's position and activity status, such as whether the patient is climbing upstairs or descending downstairs or whether the patient is sitting up after lying down.
The stimulation device additionally includes a battery 276 that provides operating power to all of the circuits shown in
The stimulation device 100 can further include magnet detection circuitry (not shown), coupled to the microcontroller 220, to detect when a magnet is placed over the stimulation device 100. A magnet may be used by a clinician to perform various test functions of the stimulation device 100 and/or to signal the microcontroller 220 that the external programmer 254 is in place to receive or transmit data to the microcontroller 220 through the telemetry circuits 264.
The stimulation device 100 further includes an impedance measuring circuit 278 that is enabled by the microcontroller 220 via a control signal 280. The known uses for an impedance measuring circuit 278 include, but are not limited to, lead impedance surveillance during the acute and chronic phases for proper lead positioning or dislodgement; detecting operable electrodes and automatically switching to an operable pair if dislodgement occurs; measuring respiration or minute ventilation; measuring thoracic impedance for determining shock thresholds; detecting when the device has been implanted; measuring stroke volume; and detecting the opening of heart valves, etc. The impedance measuring circuit 278 is advantageously coupled to the switch 226 so that any desired electrode may be used.
In the case where the stimulation device 100 is intended to operate as an implantable cardioverter/defibrillator (ICD) device, it may detect occurrence of an arrhythmia, and automatically apply an appropriate therapy to the heart aimed at terminating the detected arrhythmia and converting the heart back to a normal sinus rhythm. To this end, the microcontroller 220 further controls a shocking circuit 282 by way of a control signal 284. The shocking circuit 282 is presented as an example herein as other exemplary circuits are discussed below for charging and/or discharging stored charge.
In this example, the shocking circuit 282 can generate shocking or stimulation pulses of low (e.g., up to approximately 0.5 J), moderate (e.g., approximately 0.5 J to approximately 10 J), or high energy (e.g., approximately 11 J to approximately 40 J), as controlled by the microcontroller 220. The aforementioned ranges are representative of conventional ranges and various ranges are discussed further below wherein "low voltage" or "low energy" shocks may extend into the lower end of the aforementioned moderate energy range.
Various other mechanisms are described herein whereby an early shock may be delivered in response to an arrhythmic condition or a condition indicative of an arrhythmia. Such early shock mechanisms typically delivery a shock at an energy from approximately 0.1 J to approximately 5.0 J. In some examples, leading edge voltages for such early shocks range from approximately 50 V to approximately 300 V.
In general, shocking pulses are applied to the patient's heart 102 through at least two electrodes, and as shown in this embodiment, selected from the left atrial coil electrode 126, the RV coil electrode 132, and/or the SVC coil electrode 134. As noted above, the housing 200 may act as an active electrode in combination with the RV electrode 132, or as part of a split electrical vector using the SVC coil electrode 134 or the left atrial coil electrode 126 (i.e., using the RV electrode as a common electrode).
Conventional cardioversion level shocks are generally considered to be of low to moderate energy level and synchronized with an R wave and/or pertaining to the treatment of tachycardia. In tiered therapy, a "low energy" or "low level" cardioversion tier is normally considered a first-line treatment for ventricular tachycardia (e.g., rates of over approximately 180 bpm). In conventional cardioversion therapy, synchronous QRS complex or R wave delivery aims to avoid delivery of energy during a vulnerable period of the T wave, which may initiate or accelerate transition to ventricular fibrillation.
Defibrillation shocks are generally of a moderate to a high energy level (e.g., corresponding to thresholds in the range of approximately 5 J to approximately 40 J) and a first-line treatment for ventricular fibrillation. If any recognizable QRS complex or R wave exists, or if atrial pacing is present, a defibrillation shock may be delivered synchronously. Accordingly, the microcontroller 220 is capable of controlling the synchronous or asynchronous delivery of the shocking pulses.
Cardiac Rhythms
An ECG of normal heart activity (e.g., polarization, depolarization, repolarization, etc.) typically shows atrial depolarization as a "P wave", ventricular depolarization as an "R wave", or QRS complex and ventricular repolarization as a T wave. The time span between a P wave and an R wave typically depends on AVN conduction and/or heart rate (e.g., rate of SAN). An ECG may also allow for determination of a QT interval, for example, measured from onset of a QRS complex to the end of ventricular repolarization (e.g., end of T wave). Yet further, an ECG may allow for determination of a ST interval, for example, measured from the end of a QRS complex to the end of a ventricular repolarization.
Ventricular Arrhythmias
Ventricular arrhythmia is a leading cause of sudden cardiac death. Detection of ventricular arrhythmia and/or precursors thereto can help in prevention of such deaths. The aforementioned exemplary implantable cardiac device 100 includes an ability to detect arrhythmia and/or precursors thereto and to respond to such detection. One particular response includes delivery of one or more stimuli to the heart. In general, such stimuli are referred to herein as "low voltage" stimuli or shocks as opposed to high voltage stimuli or shocks commonly associated with defibrillation.
Ventricular arrhythmias often involve reentry wavefronts or circuits that travel around poorly conducting or unresponsive cardiac scar tissue or that travel in a wholly functional myocardial region. Spatial information may help determine locations of such reentry circuits (e.g., their spatio-temporal characteristics). Some studies of pacing to terminate ventricular arrhythmias suggest pacing or delivering stimulation at a site wherein the position of the site is based on location of a reentry circuit. Various studies suggest pacing or delivering at a site proximate to the reentry circuit while others suggest pacing or delivering at a site removed from the reentry circuit. Of course, sometimes pacing or delivering is limited to a single site; consider, for example, an implantable cardiac device having a single lead with a pacing electrode positioned in a patient's right ventricle. In such instances, spatial and/or temporal information pertaining to a reentry circuit may prove beneficial, for example, in determining a pacing time and/or pacing amplitude, frequency, etc. As described herein, such information optionally includes information regarding homogeneity or heterogeneity of a reentry circuit. Further, characteristics of a reentry circuit optionally include information regarding ischemia, conduction velocity, etc.
Various factors may affect successful termination of a ventricular arrhythmia. Such factors include, but are not limited to, arrhythmia rate (e.g., path length and conduction velocity), refractory period at a pacing or stimulation site and/or in a reentry circuit, conduction path from pacing or stimulation site to a reentry circuit (e.g., including conduction velocity, conduction time, etc.), reentry circuit gap characteristics. See, e.g., Sinha, et al., "Critical role of inhomogeneities in pacing termination of cardiac reentry", CHAOS, 12(3): 893-902 (2002).
While the exemplary progression 402 is shown with cardiac waveforms of electrical behavior, a similar progression may be noted using other signals. For example, a hemodynamic sensor may detect hemodynamic behavior that indicates compromised cardiac performance. Thus, a hemodynamic sensor may indicate whether a condition is hemodynamically stable or hemodynamically unstable. Such a sensor may be used in conjunction with intracardiac electrograms. Further, intracardiac electrograms, hemodynamic signals, etc., may be analyzed using morphology or other techniques.
A second progression 442 represents an induced and treated progression wherein induction of arrhythmia occurs via a shock administered during a T wave and treatment occurs via an exemplary low voltage shock administered in an arrhythmic region 452. Waveforms in the progression 442 were acquired in a canine trial wherein sensing occurred using a right ventricular tip electrode (see, e.g., the electrode 128 of
Should irregular beats persist, cardiac condition may be classified as ventricular tachycardia (VT), for example, where three irregular beats of ventricular origin exist with a rate in excess of approximately 100 beats per minute. In general, cardiac waveforms appear abnormal for VT and QRS complexes are often difficult to define. VT waveforms may exhibit "notching" and a broad QRS-like segment (e.g., occurring over approximately 120 ms or more). Further, ST segment and T wave typically exhibit opposite polarity compared to a normal QRS. While the sinus node may be depolarizing normally, there is usually complete AV dissociation and P waves may be observed between the QRS-like segments. Ventricular rhythm during VT is somewhat regular and at a rate greater than approximately 100 bpm and generally less than approximately 220 bpm.
A patient may tolerate some degree of VT; however, VT can be associated with life-threatening hemodynamic malfunction. Sometimes, treatment of VT involves drugs such as lidocaine, procainamide, bretylium tosylate, etc. As mentioned above, an implantable device, upon detection of ventricular tachycardia, may act or respond by delivering a cardioversion stimulus. A cardioversion stimulus of an implantable device typically has an energy level less than approximately 10 joules. For example, a study by Bardy et al., "A prospective randomized repeat-crossover comparison of antitachycardia pacing with low-energy cardioversion", Circulation, 87:1889-1896 (1993), used up to four therapeutic attempts of low-energy cardioversion beginning with a 0.2 J pulse wherein, if ineffective, pulse energy was increased to 0.4, 1.0, and finally 2.0 J. Of course, an alternative therapy or therapy tier may occur prior to delivery of a cardioversion stimulus. Such alternative therapies may include anti-tachycardia pacing, which typically rely on energy levels that approximate those used in pacing. Various exemplary methods, devices, systems, etc., described herein pertain mainly to defibrillation shock therapy and, in particular, to alternative and/or adjunct shock therapies.
As mentioned in the exemplary progressions 400 of
As described herein, various exemplary devices, systems and methods aim to terminate VF at the early, coarse stage. For example, an early, coarse stage of VF may be defined by a number of intervals. Upon detection of an early, coarse stage of VF, an implantable device may act or respond by delivering one or more shocks or stimuli to the myocardium. Such early, coarse VF therapy stimuli may be synchronized and/or unsynchronized and typically delivered at energy levels less than those used for conventional ventricular defibrillation. For example, if an early, coarse stage of VF is defined as less than 10 intervals from detection then such stimuli may be delivered during this stage in an effort to terminate VF and convert back to a normal sinus rhythm or even to a less hazardous VT, which may be treated via other pacing and/or stimulation therapies (e.g., anti-tachycardia pacing, cardioversion, etc.). Such early, coarse VF defibrillation therapy may be a sub-tier of a defibrillation therapy tier.
Moving beyond early, coarse VF, after, for example, a certain set number of intervals, VF may be classified as later, coarse VF. Upon detection of an advanced or later, coarse VF, an exemplary implantable device may act or respond by delivering one or more defibrillation stimuli at appropriate energy levels and appropriate times. Such later, coarse VF defibrillation therapy may be a sub-tier of a defibrillation therapy tier.
Moving beyond later, coarse VF, a coarse VF may transition into fine VF. Fine VF is often indicative of an advanced VF, i.e., a VF somewhat removed from a time of onset. As VF becomes finer, treatment can become more difficult with a lessening probability of success. Upon detection of fine VF, an exemplary implantable device may act or respond by delivering one or more defibrillation stimuli at appropriate energy levels and appropriate times. Such fine VF defibrillation therapy may be a sub-tier of a defibrillation therapy tier.
As already mentioned, fine VF may transition to asystole, which may be characterized as a total absence of ventricular electrical activity. Since depolarization does not occur, there is no ventricular contraction. Asystole may occur as a primary event in cardiac arrest, or it may follow VF or pulseless electrical activity (PEA).
If a lower voltage therapy can successfully treat a cardiac condition normally treated via a higher voltage therapy, several advantages may be realized. For example, a lower voltage therapy may result in less pain, an energy savings, and/or less risk or occurrence of block (e.g., AV block, bundle branch block or other block). Further advantages may be gain by early delivery of such therapy as well.
Ventricular asystole can occur also in patients with complete heart block. Detection of asystole may be confused with VF; therefore, a detection technique may use more than one measure to distinguish VF and asystole. In general, treatment for asystole differs from treatment for VF. Fine VF should be treated with defibrillation whereas defibrillation during asystole is potentially harmful. Upon detection of asystole, an exemplary implantable device may inhibit defibrillation therapy and/or trigger or communicate a need to a device, a patient or a care provider (e.g., for administration of a drug, such as epinephrine and/or atropine).
Another condition 508 may arise from irregular beats or may arise independently of a prior detected condition. The condition 508, characterized by ventricular beats having a rate greater than a limit (e.g., 100 bpm), may indicate presence of a ventricular tachycardia. Such a condition may correspond to the region 408 of early organized activation having at least some characteristics associated with or indicative of ventricular tachycardia.
As an alternative or adjunct, cardiac condition may be classified as ventricular tachycardia (VT), for example, where three irregular beats of ventricular origin exist with a rate in excess of a set number of beats per minute. In general, cardiac waveforms appear abnormal for VT and QRS complexes are often difficult to define. VT waveforms may exhibit "notching" and a broad QRS-like segment (e.g., occurring over approximately 120 ms or more). Further, ST segment and T wave typically exhibit opposite polarity compared to a normal QRS. While the sinus node may be depolarizing normally, there is usually complete AV dissociation and P waves may be observed between the QRS-like segments. In general, ventricular rhythm during VT is somewhat regular and typically at a rate greater than approximately 100 bpm and generally less than approximately 220 bpm.
With respect to actions, decision blocks may direct action to one or more branches, for example, a branch corresponding to slow early intervals and a branch corresponding to fast early intervals (e.g., greater than approximately 240 beats per minute). The "fast" branch may proceed to an action such as a low voltage therapy action 514; whereas, the "slow" branch may continue with normal tiered therapy, which may include anti-tachycardia pacing (e.g., action 510), cardioversion (e.g., action 514), etc.
Yet another condition 512 is characterized as coarse ventricular fibrillation of less than a predetermined number of beat or event intervals (e.g., N), for example, representative of an early stage of ventricular fibrillation (VF). As mentioned in the exemplary progression 402 of
As described herein, various exemplary devices, systems, methods, etc., aim to terminate VF at the early, coarse stage (e.g., condition 512). For example, an early, coarse stage of VF may be defined by a number of intervals. Upon detection of an early, coarse stage of VF, an implantable device may act or respond by delivering one or more cardioversion level shocks to the myocardium (e.g., action 514). Such shocks may be synchronized and/or unsynchronized and typically delivered at energy levels less than those used for defibrillation. For example, if an early, coarse stage of VF is defined as less than 10 intervals from detection of irregular beats or VT, then such a shock may be delivered during this stage in an effort to terminate VF and convert back to a normal sinus rhythm or even to a less hazardous VT, which may be treated via other pacing and/or stimulation therapies. As already mentioned, a decision block may direct action to one or more branches, as appropriate. Thus, a combination of actions may be implemented in a tiered manner wherein actions are selected from ATP (e.g., action 510), cardioversion (e.g., action 514) and low voltage shock (e.g., action 518).
If the ventricular fibrillation persists, with or without treatment, for a set number of intervals, VF may be classified as later, coarse VF (e.g., condition 516). Upon detection of an advanced or later, coarse VF, an implantable device may act or respond by delivering one or more defibrillation shocks 522 (e.g., optionally as part of a tiered therapy). In general, such shocks are delivered in a synchronized manner, though as to the lack of organized R waves that is typical at this stage in a progression, some uncertainty exists as to benefits of synchronized delivery.
As discussed with respect to the progression 402 of
As already mentioned, fine VF may transition to asystole, which may be characterized as a total absence of ventricular electrical activity 524. Since depolarization does not occur, there is no ventricular contraction. Asystole may occur as a primary event in cardiac arrest, or it may follow VF or pulseless electrical activity (PEA).
If a lower voltage therapy can successfully treat a cardiac condition normally treated via a higher voltage therapy, several advantage may be realized. For example, a lower voltage therapy may result in less pain, an energy savings, and/or less risk or occurrence of block (e.g., AV block, bundle branch block or other block).
Ventricular asystole can occur also in patients with complete heart block. Detection of asystole may be confused with VF; therefore, a detection technique may use more than one measure to distinguish VF and asystole. In general, treatment for asystole differs from treatment for VF. Fine VF should be treated with defibrillation whereas defibrillation during asystole is potentially harmful. Upon detection of asystole, an implantable device may trigger or communicate a need for administration of a drug, such as epinephrine and/or atropine 526.
Many commercially available implantable defibrillation devices include two capacitors. In such devices, the two capacitors are typically capable of producing approximately 800V when discharged in series. Capacitors for implantable defibrillation devices are often capable of producing a relatively high voltage, have a relatively high capacitance and of relatively small dimensions and hence volume (e.g., two capacitors may occupy about 8 cubic centimeters). For example, at a volumetric storage capacity of about 4.5 J per cubic centimeter, a total charge of about 30 J would require about 7 cubic centimeters. A commercially available implantable defibrillation device may include two 400 volts direct current (VDC), 188 microfarad (μF) capacitors connected in series to form an equivalent 800 V, 94 μF capacitor. This is capable of producing a short pulse of approximately 30 joules and approximately 10 milliseconds in duration.
A normal load is approximately 50 ohms, with a typical minimum requirement of approximately 20 ohms. Many commercially available implantable defibrillation devices can charge two capacitors in approximately 6 to approximately 15 seconds, depending upon the discharge state of the battery. With respect to capacitance, many commercially available implantable defibrillation devices use anode foil having a stored energy density of approximately 4 joules to approximately 5 joules per cubic centimeter. Where suitable, other types (size, material, number, etc.) of capacitors may be used in various exemplary methods, devices, systems, etc. Other types include, but are not limited to, film dielectric capacitors (e.g., PVDF and polycarbonate), which may include extruded film.
Trials performed using a commercially available capacitor demonstrated that an energy charge capable of delivering a shock with a leading edge voltage of about 350 volts could be achieved in about six intervals of a ventricular fibrillation (e.g., less than about 2 seconds). For low voltage shocks with leading edge voltage of about 200 volts, charge time was less than 1 second and typically less than about 700 ms. In general, a stored charge capable of delivering a shock with a leading edge voltage of about 300 volts to a load of about 50 ohms can be achieved using conventional capacitors and charging circuitry in less than 1 second. Tables 1 and 2, shown further below, indicate that a stored charge of about 4 joules and a 300 volt leading edge can be delivered after a charge time of about 0.72 seconds at the beginning of life of a conventional implanted device.
k=ΔV/V 0=0.5*(1−e −tp/RC) (1)
where tp=0.5/f and ΔV corresponds to a decrease in voltage over the time tp and V0 corresponds to an initial voltage.
Charge Voltage and Charge Time
Potential (V)
Charge Time and Delivered Energy
10 ms/10 ms
65% Tilt
Energy (J)
The plot 800 also includes a voltage divider bracket "RV" which represents use of a voltage divider to allow for delivery of a reduced voltage where the potential exceeds a maximum low voltage value "LVmax". The plot 800 shows a corresponding time "T(D−LVmax)", which may be a maximum time wherein a voltage divider may be applied. In general, such a voltage divider aims to produce a reduced voltage of at least a minimum low voltage "LVmin". During operation, the maximum low voltage LVmax is achieved at a time "T(C−LVmax)" and the minimum low voltage LVmin is achieved at a time "T(C−LVmax)". The plot 800 includes a minimum high voltage "HVmin" and a corresponding time "T(C−HVmin)".
In this example, the H-bridge 910 includes four insulated gate bipolar transistors (IGBTs) labeled SW_1, SW_2, SW_3 and SW_4. Of course, other types of switches may be used in addition to or as alternatives to the IGBT switches and/or other switch configurations may be used. In the switchable H-bridge 910, the switches SW_1, SW_2, SW_3 and SW_4 may be triggered by timing signals received at trigger points labeled T_1, T_2; T_3 and T_4, respectively. The H-bridge includes two electrodes labeled E_1 and E_2, which have a load labeled R, which may represent a patient (e.g., a portion of myocardium, other tissue, etc.). Thus, control of the switches via the trigger points may control discharge of the capacitors labeled C_1 and C_2 across the load R.
Various exemplary circuits allow for simultaneous charge and discharge and/or switching that allows for pseudo-simultaneous charge and discharge (e.g., alternating, etc.). In general, normal charging of the capacitors C_1 and C_2 follows behavior exhibited in the plot 800 of
Biphasic discharge pulses have proven quite effective in various commercially available implantable defibrillation devices. For example, studies conducted on implantable defibrillation devices have shown that biphasic discharge pulses result in a lower defibrillation threshold when compared to monophasic discharge pulses.
Capacitors typically discharge in a manner that can be suitably modeled by an equation including an exponential decay term. For example, the following equation is used commonly to determine charge with respect to time during discharge:
where q(t), represents charge with respect to time, q0, represents charge at an initial time, R is a resistance or load and C is capacitance (e.g., an RC circuit).
While biphasic pulses have proven useful, other phase pulses are possible and may be used where suitable. For example, the exemplary discharge plot 920 shows voltage (or charge) with respect to time for various switch positions. Upon discharge, switches SW_1 and SW_2 are open while SW_3 and SW_4 are closed for a duration Δt (also see, e.g., tp). The duration Δt may be on the order of approximately 2 ms to approximately 4 ms or other suitable time and may be adjustable to suit a particular need. A traditional biphasic pulse may consist of switching switches SW_1 and SW_2 from open to closed while switching switches SW_3 and SW_4 from closed to open (either simultaneously or with a delay). Such a biphasic pulse is often referred to as a truncated biphasic exponential (TBE). Discharge may continue for a time td, which represents the time at which substantially all of the charge of the capacitors C_1 and C_2 has been discharged (e.g., approximately 99% of q0, etc.). In this example, the capacitors C_1 and C_2 discharge in series.
In this example, the H-bridge 1010 includes four insulated gate bipolar transistors (IGBTs) labeled SW_1, SW_2, SW_3 and SW_4 and additional switches labeled SW_5, SW_6 and SW_7, which optionally rely on IGBTs and/or other switching technology. In the switchable H-bridge 1010, the switches SW_1, SW_2, SW_3 and SW_4 may be triggered by timing signals received at trigger points labeled T_1, T_2, T_3 and T_4, respectively, while the switches SW_5, SW_6 and SW_7 may be triggered by timing signals received at corresponding trigger points labeled T_5, T_6 and T_7, respectively. The H-bridge includes two electrodes labeled E_1 and E_2, which have a load labeled R, which may represent a patient (e.g., a portion of myocardium, other tissue, etc.). Thus, control of the switches via the trigger points may control discharge of the capacitors labeled C_1 and/or C_2 across the load R. Further, control of the switches SW_5, SW_6 and SW_7 can allow for selective charging of one capacitor (e.g., C_1) and selective discharging of another capacitor (e.g., C_2).
The switch SW_5 allows for isolating the capacitors C_1 and C_2 and for connecting an electrode of one capacitor with an opposite electrode of the other capacitor, for example, to allow for a connecting the capacitors in series. The switch SW_6 allows for isolating the capacitors C_1 and C_2 and, in combination with switches SW_5 and SW_7, the capacitor C_2 can be isolated from the capacitor C_1 and the charge circuit 1012. As shown, the switch SW_7 allows for isolating the capacitor C_2 and the H-bridge from the charge circuit 1012, for example, by switching to a ground, which may be common with the ground of the battery 1014 and/or which may serve as a ground for the charge circuit 1012.
In the example 1010, the various switches may be implemented without changes to the charge circuit 1012. In an alternative example, a charge circuit may include modifications as appropriate.
The exemplary discharge plot 1020 shows discharge of the capacitor C_2 with respect to time. In this example, the voltage or charge at an initial time is equal to that of the capacitor C_2 alone (e.g., leading edge voltage of approximately X2 VDC). Thus, the capacitor C_2 can discharge while the capacitor C_1 charges. As explained with respect to
The exemplary circuit 1000 also allows for switching between discharge of the capacitor C_2 and discharge of the capacitors C_1 and C_2 in series across the load R. As described herein, such control can allow for delivery of one or more low voltage stimulation pulses that aim to terminate or convert early, coarse ventricular fibrillation. In the instance that such action is unsuccessful, the exemplary circuit 1000 allows for discharge of one or more higher voltage, defibrillation pulses (e.g., TBE, etc.). Time is often of the essence in treatment of ventricular fibrillation and the exemplary circuit 1000 allows for several charge and discharge schemes with different time characteristics, such as, charge time, discharge time, etc. The exemplary circuit 1000 optionally includes a voltage divider, which may be software and/or hardware controlled.
The information in the plots 1200 includes information related to hemodynamic condition indicative of ventricular fibrillation. For example, the information of the plot 1230 is related to blood pressure in the right ventricle wherein a decrease in blood pressure is a hemodynamic condition indicative of ventricular fibrillation. In this specific example, a decrease in blood pressure for a period greater than approximately 0.5 second to approximately 1 second may be indicative of ventricular fibrillation. Information from other parts of the arterial system may also be used as indicators of ventricular fibrillation and may be suitable for fast detection.
Various exemplary methods, devices, systems, etc., described herein optionally allow for charging during discharging. For example an exemplary device optionally operates a charging circuit and an output stage or delivery circuit (H-Bridge) simultaneously. According to such a device, fast detection may occur of a cardiac condition (e.g., ventricular fibrillation and/or a precursor thereto, etc.) which, in turn, causes a charger circuit turns on and remains on while an "early therapy" of one or more low energy stimuli or shocks are delivered. Sensing of cardiac condition may continue wherein the charger circuit is remains on and the device decides whether a conversion to sinus rhythm has occurred. Upon such an occurrence, the exemplary device may turn off the charger circuit. However, if conversion did not occur, the condition did not improve, and/or the condition worsened, then charging continues, as appropriate, to increase stored energy to a level suitable for high voltage therapy. For example, such an exemplary device may discontinue charging upon achieving a desired charge and then command an output stage to deliver conventional high voltage therapy (e.g., delivery of a defibrillation shock of approximately 800 V).
During charging or optionally during a break in charging, a charge level decision block 1316 decides whether the one or more capacitors have a charge level sufficient for purposes of terminating or converting a present arrhythmic condition or precursor thereto. If the decision block 1316 decides or determines that the charge accumulated by the one or more capacitors is insufficient, then the method 1300 continues charging at the charge block 1312; otherwise, the method 1300 continues at a delivery block 1320. If a situation arises where stored charge or stored charge at a delivery time exceeds a desired energy, then a voltage divider or other reduction technique may act to deliver less than all of the stored charge or to deliver charge from less than all capacitors of a charge storage (e.g., for charge storages that include more than one capacitor).
The delivery block 1320 delivers a charge to the myocardium in an effort to terminate or convert an arrhythmic condition or a potentially arrhythmic condition. The delivery block 1320 may delivery the charge via one or more leads and/or via two or more electrodes. Various studies indicate that early stages of ventricular fibrillation may be terminated by one or more stimuli or shocks delivered to or near the septum between the right and left ventricles. A goal of such stimuli or shocks may be to prevent or halt breakup of reentry wavefronts.
As discussed with respect to the exemplary progression 400 of
Other examples include use of conventional defibrillation leads and electrodes. Various electrode arrangements include RV-coil electrode to a can electrode and/or an electrode in the superior vena cava; and an additional left ventricular electrode-bearing lead implanted via the coronary sinus, which may be beneficial if a dominant early wavefront exists in the left ventricle.
After delivery of the one or more stimuli, the method 1300 continues in a sinus rhythm decision block 1324, which decides or determines, for example, after a sufficient delay, whether a normal sinus rhythm exists. If the decision block 1324 decides that a normal sinus rhythm exists, then the delivery was successful at terminating the particular cardiac condition and the method 1300 continues, for example, at the sense block 1304. However, if the decision block 1324 decides that a normal sinus rhythm does not exist, then the method 1300 continues at another decision block 1328.
The decision block 1328 decides or determines on the basis of sensed and/or other information whether a potentially life-threatening cardiac condition exists. If such a condition exists, then the method 1300 continues in an alternative therapy block 1336, which may delivery one or more higher voltage stimuli or shocks or take other action. If the decision block 1328 decides that such a cardiac condition does not exist, then the method 1300 continues at yet another decision block 1332 that decides or determines whether the charge on the one or more capacitors is greater than a maximum value suitable for a low voltage stimulation therapy. If the decision block 1332 decides that the charge exceeds some limit, then the method 1300 continues by progressing to the alternative therapy block 1336, which may simply return to the sense block 1304, etc. However, if the charge is less than some prescribed limit, then the method 1300 may return to the delivery block 1320 and deliver the charge to the myocardium in a prophylactic effort that reduces the chance of reinitiation of the treated cardiac condition.
In instances where low voltage therapy proves successful, an opportunity exists for use of a smaller implantable device.
Although exemplary methods, devices, systems, etc., have been described in language specific to structural features and/or methodological acts, it is to be understood that the subject matter defined in the appended claims is not necessarily limited to the specific features or acts described. Rather, the specific features and acts are disclosed as exemplary forms of implementing the claimed methods, devices, systems, etc.
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|U.S. Classification
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|International Classification
|Cooperative Classification
|European Classification
|Nov 30, 2010
|Certificate of correction
|Mar 14, 2013
|Fee payment
Year of fee payment: 4
|Aug 9, 2017
|Fee payment
Year of fee payment: 8


text:
What do you want to measure?
The IoT system begins with the devices that gather or "sense" information and then, unique to the IoT, periodically and automatically report data over the internet or your cloud without the need for human intervention.
At the IOT Architecture Group, our work takes us across the vast landscape of connected devices: from small, moisture sensors that need to alert owners to a wet floor, to large, inventory tracking devices stored in vending machines and reporting their inventory status.
Sensor endpoints are what enable the IoT to work in objects in industries ranging from healthcare and hospitality, to power utilities and automotive.
A practical IoT scheme needs sensors that operate autonomously, without human intervention. You should not have to supervise the sensors nor write new firmware to change the data output for your devices.
The IOT Architecture Group provides rules engines that automate reporting for the supported sensors. For example, new rules can be downloaded into the sensor over the IoT network by an authorized end-user or systems manager, without needing to go on-site or requiring complex programming tools. Authorized firmware delivered over-the-air (FOTA) maintains the functionality of your sensors by automatically keeping your rules engines up-to-date, preventing disruption of data flow.
The IOT Firmware within a product can be programmed to monitor its sensors and generate:
- Periodic status messages
- Operational test results
- Faults and alarms
Sample sensor rules:
- Report the temperature every 24 hours. Report immediately if the temperature ever goes below 50F or above 90F
- Report immediately, sound alarm and give visual indication of dangerous gas concentration.
- Detect, measure and report water levels every week. Report if level raises above ¼ inch.
- Remotely track usage levels and modify prices in vending machines.
- Locate and remotely service machinery.
The IOT AG has embedded the following sensors in our client's products:
The IOT Architecture Group has developed electronics down to the component level, with appropriate firmware drivers, for all of the following sensor types. We have the engineering depth to develop customized solutions with low production costs.
- Temperature
- Humidity
- Pressure
- Liquid level
- Shock
- Gas sensors (CO2, CO)
- Acceleration, vibration
- Location (GPS)
- Light levels
- Motion detection
- AC power line status
- Battery charge level
- RFID tags; NFC
The IOT Architecture Group will work with you to design and build a sensor network that communicates your data needs. Whether your concern is developing the appropriate sensors for your product sizes, choosing communication options that will adjust to meet your bandwidth, or developing a low-cost innovation to complete your network goals, we have the experience and knowledge to realize each component of your vision. Contact us to get started on developing your custom IoT solution.

subset: commoncrawl


text:
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text:
The Apple Store is located in Conestoga Mall, at 550 King Street North in Waterloo. Travelling on Highway 85, exit for King Street and head north. Conestoga Mall is ahead on the right. The Apple Store is in The Bay wing of Conestoga Mall, across from Ricki's. Closest parking for the Apple Store is near Old Navy in the parking lot close to the main entrance for Conestoga Mall.
Apple Conestoga
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text:
I finally took the plunge. After 4 years of being with a fixed-wireless ISP, I decided to switch to cable. The only reason I had hesitated at all was that I obviously need a static IP address to host my own e-mail, web, and other services.
What I ended up with is Comcast Workplace (business class cable internet). I had been paying $50 per month for the wireless, and this is $74.99 per month, but only $54.99 for the first six months. Now, what about a speed comparison?
This is a speed test before the switch. Note that speed tests of the wireless connection were wildly variable. Sometimes I'd get results like this one, and sometimes it would show a couple megabits. Also, the upload channel was consistently faster than the download.
This is a speed test of the Comcast connection:


text:
Pregnancy, Premature babies and Twins
Patient : If my husband and i were both born prematurely, are we at a higher risk of our baby being born premature? Can having injuries to my hips affect me during labor? If my husband is a twin and my generation is due to have twins, and my husband has twins on his moms side every generation and on his fathers side is every other generation are we going to have twins? What are our odds of having twins?
Doctor : This question is currently in queue and will be answered shortly by one of our doctors. In the meantime you may browse our library of answered questions by clicking here.
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text:
The LIERMANN Family
In 193 1, George 11 and his wife celebrated their 50th Golden Wedding anniversary. They had a family get-together and George gave Title to their farm to his son, George (Bud) III and his wife Bertha. Title to their farm to his daughter Matilda (Tilly) and her husband, Newton Gann. Title to her farm to his daughter Magdalena (Maggie). Title to the Bakery-Buggie building to his son Lawrence and wife, Emily Beatrice, and his daughter Maude May. Title to the Building on 9th Street was retained. George II died 1938, Louisa died 1961 at age 101. They are buried in the Liermann family plot on the very center of the old Civil War Cemetery on North Michigan.
George II & Louisa Liermann
Submitted by L.L. Liermann
Scanned out of the Cowley County Heritage book, pg 226.
Lawrence Leonard Liermann Jr.
Lawrence Leonard Liermann, Jr. of 1516 Millington Street, Winfield, was born June 29, 1925. He married Selma M. Raasch February 17, 1978. 1 grew up in a neighborhood where eventually there would be six or seven families all living in the same house for over fifty years. I attended Lowell Grade School and Winfield High School, graduating class of St. Johns College, Winfield. Repaired shoes for my dad for two years, and in 1950, hired in at Boeing airplane Co. Wichita. I missed four lay-off's by about a week each time. After twenty years Boeing laid off 100,000 employees, Herb Hawk worked in the office, said just the paper work took two years. I was laid off and recalled nine months later but decided not to return (both of my parents had recently died) and I had inherited thefamily home. Cessna built small airplanes at Strother Field. After three years I got on there. On the day they reopened the CEO died and I worked under less than favorable conditions for twelve years. I spent twenty-four years building and modifying airplanes before I received $4.00 an hour. General Dynamics bought Cessna and I wound up as the only employee in bottom pay grade (105,000 employees). I declined to stay and retired before I could collect my pensions. Boeing, twenty years, $2.00 a day, and Cessna, twelve years, $6.00.
In 1978, 1 married Selma M. Raasch. In 1986, she had two strokes and remains partially paralyzed. A week after I retired 1987, I joined a group called Life/Science. We have twenty rules, but the most important is eat nothing cooked. After a three year struggle, I am at about 90% no cooked food. My grandmother lived to 101. I hope to live to be 135. For twenty years I have been teaching myself to write. To be a good writer, you must be a good listener.
Perhaps you would be interested in some of the tales told by the "old timers" in rest homes, hospitals, friendship meals, neighbors, and etc.
Submitted by L.L. Liermann Jr.
Scanned out of the Cowley County Heritage book, pg 226.
Lawrence Leonard Liermann Sr.
Lawrence was the second son of George II and Louisa Liermann. He was born November 20, 1895, died in September 1969. He married Emily Beatrice Fulcher April 15, 1922. For six generations the first son had been named George. Lawrence was the last of six children. Magdalena (1 88 1) (Maggie), Matilda (TiUy), George III (Bud), Maude, Minnie and Lawrence (1895). When Lawrence was born, at home, the doctor told Louisa (age 45) that something had gone wrong. She had six months to live. Minnie, age three, died January 1895 from lack of breath disease. The other five children helped Louisa celebrate her 100th birthday.
Lawrence's Dad, George II married Louisa Cashin 1881, George II's brother Will Lierman married Louisa's sister, Nettie Cash, and both families lived next to each other for sixty years at Elizabeth and John Streets.
Since he was the baby, and the others had already finished grade school at Webster, when Lawrence started first grade (1901), he had to walk the entire one-half mile in the mud and snow alone. Lawrence got himself a cow route. He escorted the milk cows from Main and 12th Street, out to the day pasture east of Black Crook Creek (Charles Cloud on the north side and Gntebury Village south side). In the evening, he would open the gate. The herd had a pecking order with the lead "senior" milk cow leading the way west on 12th Street. Each cow knowing its own barn and would turn in to be milked. Lawrence loved to fish but he was born too late. With the discovery of oil the good fishing was gone. He remembered how it was inthe early days when "old man" Chase ran a thrashing crew. In those days Winfield had no bridge sough on the Walnut River. Broadway was the road into town. Just ford the river and come on to town. When they finally got a bridge, years later, it was built a one-half mile west. When it was too wet to thrash, "old man" Chase would get out his fish seine. It had a six foot fence post on one end. Usually "Oat" Lumbert, local Blacksmith, was chosen to hold anchor while the entire thrashing crew took fifty yards of seine out into the Walnut River and made several sweeps. People came miles with tubs, Lh pans, buckets, etc. to get fish and no one went away without any. At home (Elizabeth and Hackney) the outhouse was at the end of a long grape-vine covered tunnel where Lawrence could take a shower bath when it rained. Early in life, he developed a life-long love of hunting and fishing. Shells cost money so he sold rabbits to Pete Mitchler's Butcher shop. The rabbits too shot up to sell were skinned and left for the chickens. Later the Rabbit bones were run through a corn shelter, or bone grinder. The chickens fought for the bone meal. He grew up on squirrels, chickens, rabbits, ducks, prairie chickens, and Quail. He ate fish every way they could be cooked.
By age thirteen, (1908) he had finished the eighth grade, and his schooling. His dad was "land lord" over a dozen farms in Cowley County. Every two months the buggy was hitched to make rent rounds. The farthest farm was the Kadau farm, eight miles east of Atlanta on Grouse Creek. No stone arch b6dges, yet, north of Cambridge. It was necessary to ford Grouse Creek ten times (five going and five returning) Lawrence went along on many of these all day buggy trips. About 1911, Augustus Kadau decided to move to Winfield. Magdalena (Maggie, Lawrence's sister took over management of the farm). A. Kadau tried his hand at repairing shoes in the buggy building.
George II had his harness factory on 9th Street (now Herlocker, Roberts, and St. Peter Attorneys) but, in back across ie alley was a double building. In the east side Lawrence's sister, Maude, and her husband, Ross May, ran a bakery. The Dodge brothers built buggies until about 1911 when they went into the automobile business. George II used the west side of the building for a display room for twelve different types of buggies. Will Liermann, George II's brother, was to uncrate the buggies, assemble them - twelve different models - and move them in and out. Lawrence and his brother George III (Bud) and three sisters Matilda (Tihy), Maude, and Maggie occasionally took turns acting as sales clerks. If a sale was to be made, a door bell button in the back was pushed and Daddy would come across the alley and conclude the buggy sale. Lawrence worked for A. Kadau in his boot repair business for two years. In 1913 Kadau moved to a nearby farm. Lawrence, then eighteen, decided to go into business for himself. George II decided to retire. Wm. Newton (Hospital) retired and gave his harness business to his two employees. They got involved with a girl and thought it best to leave town, the "Newton" business sold at sheriffs' sale. Lawrence bought it, to the bare walls, and everything wound up in the old "buggy" building. The "old" White Lily cafe was just across the alley west. It had a sign in early days (1900's) beans f ive cents a bowl. It is better to go to bed hungry than to wake up in debt.
1913 was the year Twigg went crazy and shot into the trowd at 9th and Main. Some of the buckshot lodged in the lmnt of the 9th Street building and could be seen until the Law firm put on the modern front.
In 1916, Lawrence got aquainted with Freemont Houston, a third generation mountain man who had lost parts of several fingers to muzzle-loading shot guns. Freemont had made his living by shooting wild game for shipping back east to Chicago fancy restaurants. J. P. Baden shipped it by the barrel from his store at 8th and Main (now 800 Main Place). When J.P. Baden died Pete Mitchier continued buying "target shot" rabbits and squirrels. Lawrence got good money, fifteen cents for a dressed rabbit. Later in the 30's he even sold Red Grantham some crows and Red said they sold just fine.
For several years, Lawrence ran his harness and leather repair shop in the west side while sister, Maude and husband, ran the May Bakery in the east half. In 1918, Lawrence got drafted, so his dad, George II, came out of retirement to run the shop until March 1919 when his son was discharged from the Navy.
Probably the last victim of the "flu" epidemic of 1918 was Maude's husband, Ross May. He died in 1920. The May Bakery was sold to the Dentons, and moved. Frick-Reid oil well supplies moved in until Jones-Laughlin bought them out. Maude and ten year old daughter, Louise (Mrs Beryle Swanholt), moved back home.
Lawrence operated his harness shop until his marriage in 1922. That year Dean Robinson hired in as a shoe repairman. Dean's grandfather had owned the ground on the west side of tunnel mill dam, also the pecan grove south of the fair grounds. Dean Robinson married Vina Bookwalter in 1922. The name was now changed to Liermanns Harness and Shoe Repair on East 10th, Winfield. Dean Robinson's wife, Vina, had been three years old when the Bookwalter family moved to 1405 Manning in 1908. Dean moved in with his wife's folks, then both of her parents died and finally Dean passed away. Vina still lives at the home. Eighty-two years continuously living in the same home, perhaps a record for Winfield. Although Gertrude Hankins lived at 3 1 0 East I I th almost eighty years, and Louisa Liermann lived at Hackney and Elizabeth for eightyone years. Lawrence and Bea built a new home at 1516 Millington Street.
Down at the shop the cash register was built about 1910. There was no phone, not until 1961 when Alex, his son-in-law bought him out and modernized.
Lawrence joined the American Legion, Odd Fellows and Masonic Lodge, fifty year member of each. He worked six days, eight to five, and until eight Saturday night. and went hunting on Sundays. He did not attend church.
Freemont Houston and Lawrence loved to fish, so one year, he and Lawrence went fishing thirteen straight weeks and were rained out twelve of the thirteen times. At that time crows were a nuisance so a bounty was paid, they made enough to buy shells. Lawrence could sew leather using a waxed-end awl and two needles. He learned to use a "sailors Palm" working with canvass at an equipment depot in France in World War I. Lawrence could sew "rounds", no sharp leather edges, on bridles. His f iling system was a hook. One year, during the depression, his profit was the 2% discount for payment within ten days.
Fremont died about 1938, so Lawrence found a new hunting partner, Lou Beltz. Lou put out fifty wheat crops and only lost two. When his fifty-first was lost to flood, near Magnolia Ranch ten miles east of Hackney, he retired.
In the back of Lawrence's shop was a pot bellied stove. Several young high school boys would occasionally eat dinner there. It became a favorite spot for loafers. Occasionally a husband and wife would come to town, both go take care of business and meet at Liermann's stove before going back out to the farm. Lawrence knew most of the farmers within thirty miles and had a hundred offers to come out and hunt and fish. Gradually, the farmers died, the widows moved to town and "No Hunting" signs appeared.
Lou Beltz preferred hunting crows. You could build a blind and set on a shell box. Expenses could be made by collecting the bounty paid for crows. Now crows are an endangered species. Lou's favorite chair by the old pot-bellied stove, was an old wicker rocker. Eventually, his 250 pounds broke it down and the rockers were removed. This made it lower but Lou thought it was still comfortable. Lawrence began sawing off one-fourth inch on each leg and finally Lou was sitting six inches off the floor. He never did catch on.
Times were tough during the depression years. People would leave one shoe to be fixed and either go barefoot or borrow a cast off leather house slipper to wear while it was being fixed.
By 1933, there were four children at home. Nancy, Leonard (Sonny), Harry, and Rosemary. School kids went home at noon for dinner so Lawrence walked home and the whole family had dinner together. Lawrence noticed a tiny hedge tree near the alley between 1 1 th and 12th Street on the east side of Millington Street which was as thick as his wrist, in 1922, when he first started walking home at noon. Hedge trees grow slowly. Sixty-eight years later (1 990) it measures ten and one-half feet around at eye level and may well be the biggest hedge tree in town.
About 1933, the shoe repair shop moved to 1008 Main Street right across the street from the old Zimm Theater where Mr. Layton, next door neighbor, sold popcorn outside. Later this Zimm was replaced by Fox Cinema II.
The McConn sisters ran their bakery in the buggy-bakery building for a number of years. During World War II Ollie McConn was bookkeeper and paid cash, probably she never gave or took a receipt in her life.
George II, Lawrence's Dad, died in 1938, leaving Louisa a widow for twenty-three years. Maggie and Maude took care of their mother who lived her last ten years in a wheel chair. Maude was a widow fifty-one years.
Lawrence repaired miscellaneous items such as combine canvasses, dog muzzles, bee smokers, football uniform pads, while Dean Robinson repaired shoes, Ladies purses, zippers, parasols and you-name-it. Dean's wife , Vina, went to work for Barbour-Collison Abstract Co. Lucien had not yet been born. When she retired after fifty-six years, Lucien Barbour was her boss.
At the start of World War II, Lawrence ordered 150 sets of heavy team harness. He received five at $100.00 each. Harness was rationed. On the day WW II ended he received a shipment of 100 sets (ten thousand dollars). Not one set ever sold. To get rid of them, he made them into trunk handles, dog collars, and reins. His brother, (Bud) George III, left a used set of heavy team harness (used six times) hanging in the shop for six years. No one wanted any of them since they could get tractors.
For several years, truck after truckload of plow horses went by on Main Street towards the packing house at Arkansas City to be made into dog food.
Several people worked for Lawrence following WW II. Charles Chapman, age eighty, repaired shoes, and Floyd Feger, after he sold his shoe repair shop across the street. Leonard (Sonny), two years after college before going to Boeing Airplane Co. Upon the death of his mother, Louisa, in 1961, Lawrence at age sixty-six retired and sold his shop to his son-in-law, Alex Almassy and daughter Rosemary.
Lawrence had a victory garden during WW II and continued it until his death in 1969. His wife, Bea, also passed away in 1969. His son Leonard inherited the family home at 1516 Millington. Leonard married Selma Raasch.
Lawrence and Bea's daughter, Nancy Louise, married Wayne Priest. They have four children: Linda, Terry, Laura, Jeff.
Lawrence and Bea's son, Harry Dean, married Martha Jeanne Brant and they have three children: Craig, Janie, and Chris.
Lawrence and Bea's daughter, Rosemary, married Alex Almassy and they have two children, Maria and Julia.
Submitted by L. L. Liermann Jr.
Scanned out of the Cowley County Heritage book, pg 226 & 227.
|State Coordinators
Tom & Carolyn Ward, Columbus, KS


text:
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An excerpt from www.HouseOfNames.com archives copyright © 2000 - 2017
Bavaria, Germany is the ancestral home of the Wiedman family. The Wiedman surname evolved as a local name. It is a name for a family that lived near a willow tree or near a meadow. The name is composed of the elements Wieden, which derives from the German word weide and can mean either willow or meadow, and mann, which means man.
Wiedman Early Origins
Bavaria, where the name could be considered to have made a major contribution to the feudal society which shaped the course of early European development. The name became prominent in civil affairs and branched into many houses which played important roles in the widespread tribal and national conflicts, as each group sought supremacy in an ever changing territorial profile.
Wiedman Spelling Variations
Wiedman Spelling Variations
In the medieval era, many different cultural groups lived in the German states. There are thus many regional variations of German surnames from that era. Westphalians spoke Low German, which is similar to modern Dutch. Many German names carry suffixes that identify where they came from. Others have phrases attached that identify something about the original bearer. Other variations in German names resulted from the fact that medieval scribes worked without the aid of any spelling rules. The spelling variations of the name Wiedman include Wiedemann, Wiedman, Wiedmann, Wiedeman, Wiemann, Wieman, Wiedemar, Wiedmar, Wiedemer and many more.
Wiedman Early History
Wiedman Early History
This web page shows only a small excerpt of our Wiedman research. Another 207 words (15 lines of text) covering the years 1852, 1870, 1852 and 1841 are included under the topic Early Wiedman History in all our PDF Extended History products and printed products wherever possible.
Wiedman Early Notables (pre 1700)
Wiedman Early Notables (pre 1700)
Prominent among members of the name Wiedman in this period include Carl Wiedemann, who began as a major in the Austrian army, rose to general major and then Commander of the papal Gregor Order of Knights. He was named honored citizen (Ehrenbuerger) of the city Wadowice, married Anna Gussner von Komorna...
Another 51 words (4 lines of text) are included under the topic Early Wiedman Notables in all our PDF Extended History products and printed products wherever possible.
The Great Migration
The Great Migration
Thousands of German settlers came to North America between the mid-17th and mid-20th centuries. The hardships of the long voyage were balanced by the opportunity to escape poverty and religious persecution. The descendents of these settlers still populate the states of Pennsylvania, Texas, New York, Illinois, and California. Many also live in Ontario and the prairie provinces of Canada. An inquiry into the early roots of North American families has revealed a number of immigrants bearing the name Wiedman or a variant listed above:
Wiedman Settlers in United States in the 18th Century
Wiedman Settlers in United States in the 19th Century
Contemporary Notables of the name Wiedman (post 1700)
Contemporary Notables of the name Wiedman (post 1700)
Wiedman Family Crest Products
Wiedman Family Crest Products
See Also
See Also
Other References
The Wiedman Family Crest was acquired from the Houseofnames.com archives. The Wiedman Family Crest was drawn according to heraldic standards based on published blazons. We generally include the oldest published family crest once associated with each surname.
This page was last modified on 18 October 2016 at 15:53.
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