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US 7097611 B2 Abstract A cardiac harness for treating congestive heart failure is disclosed. The harness applies elastic, compressive reinforcement on the left ventricle to reduce deleterious wall tension and to resist shape change of the ventricle during the mechanical cardiac cycle. Rather than imposing a dimension beyond which the heart cannot expand, the harness provides no hard limit over the range of diastolic expansion of the ventricle. Instead, the harness follows the contour of the heart throughout diastole and continuously exerts gentle resistance to stretch. Also disclosed is a method of delivering the cardiac harness to the heart minimally invasively.
Claims(28) 1. A method for providing reverse remodeling of a heart having congestive heart failure, comprising:
providing a cardiac harness that is self-sizing;
providing a delivery device for releasably attaching to the heart;
delivering the cardiac harness to the heart with the delivery device by minimally invasive access;
releasably attaching the delivery device to the heart to provide traction by which the cardiac harness can be pushed onto the heart;
mounting the cardiac harness on the heart so that the self-sizing harness automatically conforms to the size of the heart;
the cardiac harness providing elastic resistance to stretch during diastole and contractile augmentation during systole; and
decreasing elastic resistance of the cardiac harness as reverse remodeling of the heart occurs.
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8. A method for providing reverse remodeling of a heart having congestive heart failure, comprising:
providing a cardiac harness;
providing a delivery device for releasably attaching to the heart;
delivering the cardiac harness to the heart with the delivery device by minimally invasive access;
releasably attaching the delivery device to the heart to provide traction by which the cardiac harness can be pushed onto the heart;
mounting the cardiac harness on the heart so that the harness automatically conforms to the size of the heart; and
the cardiac harness providing elastic resistance to stretch during diastole and contractile augmentation during systole.
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18. A method for treating the heart, comprising:
providing a cardiac harness;
providing a delivery device for releasably attaching to the heart; delivering the cardiac harness to the heart with the delivery device by minimally invasive access;
releasably attaching the delivery device to the heart to provide traction by which the cardiac harness can be pushed onto the heart;
sliding the cardiac harness over at least a portion of the heart so that the harness conforms to the size of the heart; and
the cardiac harness providing elastic resistance to stretch during diastole and contractile augmentation during systole.
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26. The method of clajm 18, wherein the cardiac harness is delivered percutaneously through the skin by a delivery catheter assembly.
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Description This application is a continuation of U.S. application Ser. No. 09/952,116 filed Sep. 10, 2001, now U.S. Pat. No. 6,663,558 which is a continuation of U.S. Ser. No. 09/634,043, filed Aug. 8, 2000, now U.S. Pat. No. 6,702,732 and which claims priority to U.S. application Ser. No. 60/188,282, filed Mar. 10, 2000. 1. Field of the Invention The present invention relates to mechanical systems for treating congestive heart failure. Specifically, the invention relates to devices that interface mechanically with a patient's failing heart in order to improve its pumping function. 2. Description of the Related Art Congestive heart failure (�CHF�) is characterized by the failure of the heart to pump blood at sufficient flow rates to meet the metabolic demand of tissues, especially the demand for oxygen. Historically, congestive heart failure has been managed with a variety of drugs. There is also a considerable history of the use of devices to improve cardiac output. For example, physicians have employed many designs for powered left-ventricular assist pumps. Multi-chamber pacing has been employed to optimally synchronize the beating of the heart chambers to improve cardiac output. Various skeletal muscles have been investigated as potential autologous power sources for ventricular assist. Among these, dynamic cardiomyoplasty using the latissimus dorsi muscle has attracted the most interest. It has been suggested that the beneficial effects of this procedure stem from both an active, dynamic, systolic assistance and a passive, adynamic girdling of the heart that limits diastolic stretch of the ventricle. To exploit these beneficial clinical features, researchers and cardiac surgeons have experimented with prosthetic �girdles� around the heart. One such design reported in the literature is a prosthetic �sock� that is wrapped around the heart. Others have proposed the application of an intraventricular splint to reduce the volume of the left ventricle. Several design shortcomings are apparent with each. The intraventricular splint, for example, extends through the left ventricular wall. Consequently, some components of the splint contact the patient's blood. This creates the potential for thrombogenesis, or the generation of blood clots. In addition, splint placement requires perforation of the ventricular wall, which may lead to leakage problems such as hemorrhage or hematoma formation. Furthermore, because one end of the splint extends to the epicardial surface of the left ventricle, options for the orientation of the splint are limited. Pulling opposite walls of the ventricle closer together may reduce average wall stress via LaPlace's law, by reduction in ventricular diameter. However, this may create an irregular ventricular wall contour. This creates stress concentrations in the regions of the ventricle that are between the localized compression points. Consequently, this may lead to aneurysm formation, fibrosis, and impairment of the contractility and compliance of the ventricle. Also, the resulting irregular contour of the endocardial surface of the left ventricle may lead to localized hemostasis or turbulence, which may in turn lead to thrombus formation and possible thromboembolism. Coronary artery disease causes approximately 70% of congestive heart failure. Acute myocardial infarction (�AMI�) due to obstruction of a coronary artery is a common initiating event that can lead ultimately to heart failure. This process by which this occurs is referred to as remodeling and is described in the text Heart Disease, 5th ed., E. Braunwald, Ch. 37 (1997). Remodeling after a myocardial infarction involves two distinct types of physical changes to the size, shape and thickness of the left ventricle. The first, known as infarct expansion, involves a localized thinning and stretching of the myocardium in the infarct zone. This myocardium can go through progressive phases of functional impairment, depending on the severity of the infarction. These phases reflect the underlying myocardial wall motion abnormality and include an initial dyssynchrony, followed by hypokinesis, akinesis, and finally, in cases that result in left ventricular aneurysm, dyskinesis. This dyskinesis has been described as �paradoxical� motion because the infarct zone bulges outward during systole while the rest of the left ventricle contracts inward. Consequently, end-systolic volume in dyskinetic hearts increases relative to nondyskinetic hearts. The second physical characteristic of a remodeling left ventricle is the attempted compensation of noninfarcted region of myocardium for the infarcted region by becoming hyperkinetic and expanding acutely, causing the left ventricle to assume a more spherical shape. This helps to preserve stroke volume after an infarction. These changes increase wall stress in the myocardium of the left ventricle. It is thought that wall tension is one of the most important parameters that stimulate left ventricular remodeling (Pfeffer et al. 1990). In response to increased wall tension or stress, further ventricular dilatation ensues. Thus, a vicious cycle can result, in which dilatation leads to further dilatation and greater functional impairment. On a cellular level, unfavorable adaptations occur as well. This further compounds the functional deterioration. Some have proposed that an elastic wrap around the heart might attenuate the remodeling process that is actively underway in failing hearts, prompting treatment with latissimus dorsi cardiomyoplasty. Based on experimental work to date, passive latissimus dorsi muscles appear to be best suited for this application. Oh et al. (1997) published experimental work in which they found a relatively inelastic prosthetic fabric wrap to be inferior to adynamic latissimus dorsi in bringing about reverse remodeling in an experimental model of heart failure. This was attributed to the greater elasticity of the muscle wrap. It is thought that application of a device to provide compressive reinforcement similar to that of adynamic cardiomyoplasty might be therapeutic in treating dilated, failing hearts. Because heart failure is only the clinical end-stage of a continuous remodeling process, such a device might be able to attenuate or stop remodeling after a myocardial infarction far before the onset of heart failure. Such a device would have different functional requirements from a device that is used solely to treat established heart failure. One requirement is to provide a slight elastic compression to the epicardial surface of the left ventricular wall. The device should allow expansion and contraction of the heart, but continue to apply gentle elastic compression to the left ventricle. This would reduce circumferential and longitudinal wall tension, thereby improving efficiency, lowering energy expenditure, reducing neurohormonal activation, encouraging favorable cellular changes, and stabilizing the dimensions of the heart. This mechanical action is often referred to as �myocardial sparing.� The device should effect myocardial sparing without limiting the motion or the dimensions of the heart. Nor should it actively change the shape of the heart by pulling it or squeezing it. In fact, imposing a rigid barrier to limit distension or to squeeze the heart can be potentially dangerous. Shabetai in The Role of the Pericardium in the Pathophysiology of Heart Failure notes that the pericardium exerts 3�4 mm Hg of pressure against the heart. Cardiac function can be adversely affected with just a slight increase in pericardial constraint. For example, cardiac tamponade begins to be seen with-pericardial pressures as low as 5�10 mm Hg. A second requirement of such a device is to provide reinforcement that prevents the further shape change of the left ventricle without acutely changing the shape by its application. The device would act to prevent both global dilatation toward a more spherical shape and local infarct expansion after a myocardial infarction. In fact, if the local infarct expansion can be minimized with such a device, the compensatory global dilatation and increase in sphericity may be prevented. What is needed is a mild compressive support that conforms to the epicardial contour. As the left ventricle or portions of the left ventricle distend outward, they would be met with greater pressure from the device. The presence of the device would likely cause the left ventricle to reverse-remodel and its dimensions to stabilize and even shrink. As this occurs, the device would be able to shrink with the left ventricle like a latissimus dorsi muscle. The device would supply less pressure as the diameter decreases. Conversely, the device would supply gradually increasing pressure as the diameter or local distention increases. This ideal was expressed by Oh et al. in their description of the benefits of a passive latissimus dorsi muscle wrap. The ability of the device to conform to the heart as it shrinks or expands is of great importance. A device would need to possess considerable elasticity in order to do so. The left ventricle in a dilated, failing heart does not distend significantly because small diameter changes are sufficient to achieve the necessary stroke volume. In contrast, a normal heart has a much smaller left ventricular diameter. For example, Li (1997) noted that to achieve a 70-cc stroke volume, a normal left ventricle of 2.8 cm radius contracts down to 1.7 cm, a 40% decrease. However, a dilated ventricle of 4.5-cm radius achieves the same stroke volume by contracting to 4.2 cm, only a 7% decrease. Thus, in order to achieve the same stroke volume as a dilated heart, the normal heart's ventricular diameter must change by a greater amount. Consequently, a device with sufficient elasticity for treating dilated hearts in established heart failure may not be able to treat a heart of normal dimensions that has suffered a myocardial infarction. The ability of a harness to conform to the heart is also theoretically important in preventing dilated heart failure after acute myocardial infarctions because it may be important to provide reinforcement during systole, especially early systole. Prosthetic fabrics impose a relatively inelastic barrier that acts only at the end-limits of diastole. In addition to providing more myocardial sparing over a greater portion of the cardiac cycle, a device that remains in compressive contact with the heart into systole would counteract the �paradoxical bulging� of the infarct region that occurs in dyskinetic, aneurysmal hearts during systole. This may attenuate infarct expansion and therefore limit the extent of remodeling that further ensues. Another problem with the inelastic nature of fabric wraps, or knits, is that normal, healthy changes in the dimensions of the heart are not accommodated. In addition to chronic pathologic changes in ventricular diameter that can occur, such as those that accompany remodeling, normal physiological changes also occur. For example, in order to keep up with increased metabolic demands from physical exertion or exercise, the heart may dilate acutely. A wrap must be able to accommodate these increases without imposing excessive pressures. An important problem with the use of fabrics, such as knits and weaves, as well as with other materials previously used for this application, is their dimensional coupling between orthogonal directions. When stretched in one direction, there is considerable foreshortening in the perpendicular direction. Typically, the greater the elasticity present, the greater the foreshortening that is seen in the perpendicular direction. When used in a wrap around the heart, such a material can lead to serious problems. The greatest distension and wall stress is oriented in the circumferential direction around the left ventricle. Therefore it is logical to align the more compliant direction of the fabric to be parallel to it. As the left ventricle fills and the diameter increases, the fabric stretches in the circumferential direction. This causes shortening in the longitudinal direction, which is perpendicular to the direction of stretch. When used in a cardiac wrap, this results in increased sphericity of the ventricle during diastole, relative to the unwrapped heart. Sphericity is defined as the ratio of the diameter to the length of the heart or ventricle. Increased sphericity of the left ventricle is associated with decreased survival and an increased incidence of mitral regurgitation. Kono (1992) and Douglas (1989) documented this in published studies. There is a need for a structure that does not foreshorten and increase sphericity as it provides elastic, compressive reinforcement to the heart, especially the left ventricle. Since the mid 1980's a promising procedure has been evaluated clinically. The procedure, dynamic cardiomyoplasty, involves surgically dissecting the patient's latissimus dorsi muscle, introducing it into the thoracic cavity, and then wrapping and attaching the muscle to the heart. An implantable electrical stimulator is connected to the muscle in order to stimulate and pace it in synchrony with the heart. This causes the muscle to contract and also transforms the muscle, making it more fatigue-resistant. The original premise behind dynamic cardiomyoplasty was that these muscle contractions, by virtue of the geometry of the wrap, would squeeze the heart, and thus provide systolic assistance. If successful, an essentially patient-powered, relatively inexpensive, non-blood-contacting, easily placed ventricular-assist device could be employed. The first reported clinical case of dynamic cardiomyoplasty using a latissimus dorsi wrap was published in 1985. Since then, over 1,000 patients have been treated with this experimental procedure. Numerous published studies have shown that the, procedure produces significant improvement in clinical status, as graded by the New York Heart Association (�NYHA�) classification scale, a slight but significant hemodynamic or systolic function improvement, and a reduction in the number of patient hospital visits after the procedure. However, an improvement in survival has yet to be consistently demonstrated. Furthermore, perhaps due to their frail condition, NYHA class IV patients have not fared well with the procedure. This has limited its use to NYHA class III patients. It appears that the skeletal muscle wrap, probably because of its deterioration over time, does not provide sustained squeezing of the heart over time. Yet, the clinical benefits of the procedure appear to persist. This paradox has led to considerable research into the underlying mechanisms of dynamic latissimus dorsi cardiomyoplasty. This research has resulted in several independently additive hypothetical mechanisms to explain the benefits of dynamic cardiomyoplasty. The original concept of systolic squeezing of the heart, in particular the left ventricle, was shown in experimental work to provide hemodynamic benefit. But there additionally appears to be a considerable benefit derived from the presence of the passive, unstimulated latissimus dorsi wrap alone. Drs. Chiu (1992), Carpentier (1993), and others hypothesized that the presence of the latissimus dorsi wrap provides a beneficial passive function beyond the benefits of systolic-squeezing augmentation. It was speculated that the muscle wrap acts as a girdle around the heart. The girdle is thought to impose a physical limit on the heart to prevent it from dilating beyond its boundaries. This is commonly referred to as the �girdling� effect. A separate and equally powerful hypothesis was that the muscle wrap helps the native myocardium bear some of the load, in essence reducing myocardial tension or wall stress, via Laplace's law, by creating a thicker wall. This has been referred to as the �myocardial sparing� effect by virtue of the reduction in wall stress and concomitant reduction in oxygen consumption. The benefits of these two passive mechanisms are thought to be additive with the systolic squeezing benefits of cardiomyoplasty. Published experimental work by Nakajima et al. (1994), Chen et al. (1995), Kawaguchi et al. (1992 & 1994), Kass et al. (1995), Capouya et al. (1993), Chekanov (1994) and others provide support to the validity of the hypothetical mechanisms. The concept of using a permanently implantable passive, non-contracting wrap around the heart to prevent its further deterioration is not new. Suggestions have been published in the literature. Kass et al. (1995) questioned whether an �artificial elastic sock� could be used in lieu of skeletal muscle. They speculated that in dynamic cardiomyoplasty, the latissimus dorsi wrap provides some of its benefit by acting as an elastic constraint around the epicardial surface. They further suggest that the passive skeletal muscle wrap stiffens gradually with stretch, unlike pericardium, which is highly compliant at low levels of stretch but becomes very stiff when expanded beyond resting dimensions. Throughout the article, the importance of gradually increasing stiffness over the entire range of cardiac operating dimensions is emphasized. Despite the conceptual discussion, however, there is no mention of how a cardiac wrap that is both elastic over the entire range of cardiac dimensions and gradually stiffens with stretch can be designed or built. Vaynblat et al. (1997) report on the experimental use of an expanded polytetrafluoroethylene (�ePTFE�) prosthetic wrap in animals. They constructed the wrap from sheets of ePTFE material that were sized to the heart and sutured to finish the wrap. ePTFE has very limited elasticity and stretch. The ePTFE sheet wraps were shown to reduce ventricular dilatation in a failing-heart model, but they did not improve cardiac function. Oh et al. (1998) report on a similar study using a Marlex polypropylene mesh sheet material. In this study they compared the benefits of unpaced, adynamic latissimus dorsi muscle wraps with those constructed of Marlex sheet material. It was found that the latissimus dorsi wrap attenuated dilatation of left ventricle in a failing heart model to a greater extent than the Marlex wrap. The superiority of the latissimus dorsi wrap was attributed largely to its �elastic stretchability� and the resulting dynamic constraint that it provided. This �yield-and-support� characteristic could not be attained using prosthetic membranes, such as Marlex and ePTFE. In addition, the fibrotic reactions that are likely to be induced by the prosthetic membranes have a further adverse effect on compliance. In further support of the contention made by Kass, Oh et al. state that pericardium �shows virtually no restraining effect on chronic cardiac dilatation.� Despite this, the authors mention that latissimus dorsi cardiomyoplasty, whether dynamic or adynamic, is a very invasive and complex surgical procedure. The exclusion of NYHA Class IV patients from the dynamic cardiomyoplasty clinical trials was partially attributed to this. Oh et al. suggest that cardiac binding with a prosthetic membrane may still be of value, even with shortcomings, because it lends itself to minimally invasive surgical techniques. None of these prosthetic cardiac wraps operates elastically in this manner over the entire range of cardiac dimensions. Thus, only an �end-girdling� effect is provided. The myocardial sparing effect is only present for a brief moment at the end of diastole. In addition, because these inelastic wraps counteract dilatation at the limits of diastole, they prevent the heart from expanding beyond that dimensional limit to accommodate increased physiological demand, such as during exercise. In addition, even if the wraps could bring about desirable reverse-remodeling and shrinkage of the heart, a wrap, due to its fixed circumference, may not be able to shrink evenly with a heart whose circumference is decreasing. In fact, the prosthetic wraps may interact with the heart like a fiber-reinforced composite material and even fix or �cement� the circumference and diameter of the heart, such that it is unable to shrink. Because the three underlying mechanical mechanisms of dynamic cardiomyoplasty discussed above are considered to be independently additive, it is thought that the addition of active systolic assistance to the heart would be more beneficial than a passive wrap alone. In a published experiment by Mott et al. (1998), dynamically paced latissimus dorsi was compared with unpaced, adynamic latissimus dorsi in an experimental heart failure model. It was found that the dynamic, paced wrap was capable of reversing remodeling to a much greater extent than an unpaced latissimus dorsi wrap. Mott et al. also speculate that perhaps the dynamic and adynamic functions of latissimus dorsi wraps provide complimentary benefit to failing hearts. The adynamic wrap provides reinforcement only during diastole, while the dynamic wrap provides reinforcement during systole. Additional support for this idea can be found in published anecdotal reports of documented hemodynamic deterioration in patients in whom cardiomyostimulators malfunctioned and ceased to provide stimulation to the latissimus dorsi wrap. This further suggests that the systolic assistance mechanism may provide increased benefit compared to a passive girdle alone. Despite the prevailing sentiment that stimulated latissimus dorsi wraps should be more beneficial than non-stimulated wraps, the manner in which dynamic cardiomyoplasty has been executed clinically has limited its clinical success and therefore its acceptance. The underlying mechanisms of dynamic cardiomyoplasty have been the focus of substantial investigation. Preservation of the latissimus dorsi as a power source has also been an issue. Because of muscle atrophy and fibrosis, the amount of squeezing power that is available has not been sustainable. Ischemia, especially to the distal portion of the muscle whose blood supply was interrupted by surgical dissection, has been considered to be a major cause. In addition, some have speculated that damage to the thoracodorsal nerve during the procedure and as a result of the relocation of the muscle is a cause of loss of contractility of the muscle. Another possible problem is the unnatural configuration in which the muscle is forced to operate. The preloads and afterloads against which the muscle works are clearly altered from those of in situ latissimus dorsi. The complexity and invasiveness of the dynamic cardiomyoplasty surgical procedure has been implicated as well. Even if the muscle were to remain viable in the long term, there are some physical limitations to its ability to provide the systolic assistance that was once the hope of dynamic cardiomyoplasty. Cho et al. (1994) published a study in which three-dimensional magnetic resonance imaging (3-D MRI) reconstruction was used to analyze experimental dynamic cardiomyoplasty. The authors found that muscle wrap stimulation brought about considerable translation of the heart in the plane of the short axis of the left ventricle and rotation about the long axis. Little short-axis or radial squeeze was seen. However, long-axis compression was observed. This long-axis compression was confirmed in a similar study published by Pusca et al. (1998). This suggests that the muscle power provided by the latissimus dorsi is not channeled very efficiently into systolic assistance. One observation by Hayward is especially noteworthy. The author suggested that the contractile properties of the distal portion of the latissimus dorsi muscle in dynamic cardiomyoplasty degenerates the most. This is attributed to ischemia and the use of the muscle in an inefficient configuration. Yet, this is the portion of the muscle that is in contact with and expected to squeeze the heart. The proximal portion of the muscle, which is better perfused and oriented in a more linear, efficient, and natural configuration, does not contact with the heart. As such, stimulation of the muscle is likely to result in more contraction of the proximal portion of the muscle, the portion that does not squeeze the heart. Contraction of this portion of the muscle causes the heart to translate and rotate as observed experimentally by Cho. Because the heart is attached to the great vessels at its superior end, it would be expected to behave as if it were-attached to a pivot at this point. Thus, any lateral force or moment applied to the heart should result in lateral translation and rotation. However, in this superior-pivot hypothesis, there should be less freedom to translate vertically. Therefore, any vertical force applied to the heart would likely cause longitudinal compression rather than translation. Thus, it is not surprising that stimulation of the muscle results in more translation, rotation, and lifting of the entire heart. Even if the distal portion of the latissimus dorsi muscle remains viable, there may be a physical limit to how much systolic hemodynamic benefit it can provide. The overall volume of the left ventricle is more sensitive to changes in its short-axis dimension, i.e., its diameter, than its long-axis dimension, i.e., its length. For example, the volume of a cylinder is proportional to its length and to the square of its diameter. It would thus be expected that the greatest change in volume could be brought about by a change in the diameter of the ventricle. Skeletal muscle such as the latissimus dorsi is capable of shortening less than 15% over its length. Assuming that the muscle is adhered to the epicardium, the circumference of the heart would only be capable of shortening 15%. For approximation purposes, the left ventricle can be treated as a cylinder. If the circumference of a cylinder of 5-cm diameter shortens by 15%, then the volume of the cylinder changes by approximately 28%. It is interesting to note that this number is consistent with the maximum ejection fractions that have been achieved clinically and experimentally. A device that does not have the limitation of 15% stretch or shortening might be able to overcome this ejection-fraction limitation and provide more hemodynamic improvement, particularly in cardiac output. Poor increases in ejection fraction and cardiac output have been cited as a shortcoming of the dynamic cardiomyoplasty procedure. Another limitation of dynamic cardiomyoplasty is the potential mismatch between the orientation of the direction of shortening of the latissimus dorsi muscle fibers and that of the epicardium. The principal direction of shortening corresponds to the direction of muscle fiber orientation of each. Although the myocardial muscle fiber orientation varies in the left ventricle, the principal direction of shortening has been reported to follow the epicardial muscle fiber orientation, which follows a left-handed helical orientation from the apex to the base of the chamber. If it is assumed that the latissimus dorsi becomes adhered to the epicardial surface of the heart, then any misalignment between the muscle fibers would result in inefficiency of energy transfer. Each muscle shortens and stretches somewhat across the �grain� or fiber direction of the other. To compound matters, Strumpf et al. (1993) report a significant increase in the stiffness of passive skeletal muscle in the cross-fiber direction. As a result, the muscle wrap may limit the extent of myocardial lengthening and shortening, and thus limit cardiac function. An additional source of drag may stem from the inertia added by the muscle itself. It is estimated that an adult latissimus dorsi muscle weighs roughly 600 grams. This additional weight adds considerable inertia to the heart. This may be responsible for the reported impairment of cardiac function immediately following the application of the muscle by Corin et al. (1992), Cheng et al. (1992), and as suggested by Vaynblat et al. (1997). Experimentally, passive, unstimulated latissimus dorsi cardiomyoplasty wraps appeared to be the best at attenuating remodeling and heart failure. However, in a clinical setting, the surgery required to dissect and attach the muscle around the heart is very extensive and traumatic. Even if such a therapy were proven clinically efficacious, this factor limits its potential acceptance. Accordingly, there is still a need in the art for a prosthetic elastic wrap that does not foreshorten in the direction perpendicular to the primary direction of ventricular expansion, and that reduces wall stress by maintaining compressive contact over a significant portion of the cardiac cycle. Additionally, there is a need for a device that aids in preventing, in addition to treating, heart failure after acute myocardial infarction through attenuation of the remodeling process. Accordingly, it is a principal object and advantage of the present invention to overcome some or all of the aforementioned disadvantages. One aspect of the present invention comprises a cardiac harness for treating or preventing congestive heart failure. The harness comprises a plurality of interconnected elastic bending hinges, each of which has a central portion connected on opposite sides to respective arm portions. The arm portions interact with the central portion in response to deflection of the arm portions to create a bending moment in the hinge to store potential energy. In certain embodiments, the cardiac harness comprises bending hinges that are substantially U-shaped, V-shaped, square-wave-shaped, teardrop-shaped, or keyhole-shaped. Advantageously, at least one of the bending hinges from a first row is connected to another of the bending hinges from a second row. In some preferred embodiments, the bending hinges comprise at least one strand of Nitinol. The strand(s) can comprise a wire or a ribbon. In some embodiments, the cardiac harness further comprises a power source that supplies energy to the harness, causing the harness to contract. That power source may deliver electrical energy to at least one of the bending hinges, causing at least one of the bending hinges to produce a bending moment. Alternatively, the power source may deliver mechanical energy to the cardiac harness, such as through a cable. Advantageously, the power source is programmable via transcutaneous radiofrequency signals, and can be rechargeable via transcutaneous electromagnetic coupling, and/or transcutaneous inductive field coupling. In another aspect of the invention, the cardiac harness has a plurality of spring elements, and the harness is adapted to be placed around at least a cardiac base. The spring elements interact such that the harness expands and contracts in a substantially transverse dimension of the harness in the region of the cardiac base in response to the mechanical cardiac cycle, without substantial expansion or contraction in the longitudinal dimension of the harness in the region of the cardiac base. In another aspect of the invention, the cardiac harness is adapted to be placed around at least a cardiac apex. The spring elements interact such that the harness expands and contracts in a substantially longitudinal dimension of the harness in the region of the cardiac apex in response to the mechanical cardiac cycle, without substantial expansion or contraction in the transverse dimension of the harness in the region of the cardiac apex. Another aspect of the invention includes at least one elongate strip sized to fit around a base of a ventricle, such that the strip extends substantially transverse to the longitudinal axis of the heart. The strip comprises at least one spring element configured to cause the strip to provide force against the base of the ventricle in a substantially transverse direction without substantial force in a longitudinal direction. The strip can comprise at least one undulating strand. In some embodiments, the spring element comprises a central portion and two arm portions. In another aspect, the harness of the disclosed embodiments can treat or prevent congestive heart failure in a heart having a ventricle that changes sphericity in response to diastolic filling. The harness comprises a plurality of interconnected spring elements, limiting diastolic distention of the ventricle to a degree of expansion without substantially altering naturally occurring changes in the sphericity of the ventricle through the same degree of expansion caused by diastolic filling of the heart. Alternatively, the harness can limit diastolic distention of the ventricle to a degree of expansion while substantially decreasing the magnitude of a naturally occurring increase in the sphericity of the ventricle through the same degree of expansion caused by diastolic filling. In another aspect of the invention, the harness comprises a series of interconnected spring elements, each spring element comprising a central portion and a pair of arm portions extending along respective paths that originate at respective sides of the central portion and converge toward each other along at least a portion of the paths as the paths extend away from the central portion. In a further aspect, the harness comprises first and second strands of material, each strand having a plurality of hinges. Each of the hinges is formed by a pair of arm portions extending from a central portion, and each hinge within the plurality of hinges of the first strand has both arm portions disposed within a hinge of the second strand, between the arm portions of the hinge of the second strand. In some embodiments, at least one of the strands comprises a band. Also disclosed is a method of assembling a cardiac harness, comprising providing a plurality of rings, each of the rings having a series of periodic undulations, each of the rings being unattached to other of the rings, and interconnecting the rings by interleaving the undulations without interrupting continuity of the rings. In certain embodiments, the cardiac harness comprises interconnected strands of material. The harness also has at least one pad having a marginal edge which is oriented for placement in proximity to at least one coronary artery, so as to reduce compression of the artery by the harness. In further embodiments, the harness comprises interconnected strands of material which traverse an exterior surface of a ventricle of the heart, without traversing a substantial portion of the length of at least one of the following coronary arteries: the left anterior descending artery, the right coronary artery, the left circumflex artery, the posterior descending artery, and the obtuse marginal artery. And in some embodiments, the harness comprises a support member which supports a portion of the strands, the member having side portions disposed on opposite sides of the at least one coronary artery. Also disclosed is an apparatus for delivering a cardiac harness having side portions and an apex portion. The apparatus comprises a catheter body having a distal end portion, configured to retain the harness in a substantially inverted condition with an interior side of the harness facing outward away from a ventricle and an exterior side facing inward toward the ventricle. The apparatus further comprises an activation member which is movable distally relative to the catheter body. The apex portion of the harness is releasably connected to the catheter body. The activation member drives the side portions of the harness distally and outwardly relative to the apex portion such that the harness expands circumferentially. The harness thereby everts to at least partially surround the ventricle, with the interior side of the harness facing inward toward the ventricle and the exterior side facing away from the ventricle. In some embodiments, the distal end portion comprises a suction cup. Another aspect of the invention includes a method of delivering a cardiac harness onto a heart. The method comprises providing a catheter having an inverted harness mounted on a distal end portion of the catheter, inserting the catheter into a thorax such that an apex portion of the inverted harness is proximate to the apex of a ventricle, and everting side portions of the harness while the apex portion of the harness remains positioned proximate to an apex of the ventricle. Also disclosed is a method of manufacturing a cardiac harness. The method comprises forming an elongate member having undulations from a sheet of material. In a preferred arrangement, forming the elongate member comprises forming the undulations in a plane substantially parallel to the sheet of material. In some embodiments, forming the elongate member comprises cutting the elongate member on a flat surface, and in certain arrangements, the method further comprises annealing the material with the undulations oriented at a substantial angle relative to the plane. Further features and advantages of the present invention will become apparent to one of skill in the art in view of the Detailed Description of the Preferred Embodiments which follows, when considered together with the attached drawings and claims. The preferred embodiment comprises an apparatus and method for treating established congestive heart failure (�CHF�), as well as for preventing its onset after acute myocardial infarction. Although reference is frequently made throughout this discussion to CBF caused by acute myocardial infarction, the cardiac harness of the disclosed embodiments can be used to treat CHF caused by forward-pump failure from any disease, such as idiopathic dilated cardiomyopathy, hypertrophic cardiomyopathy, and viral cardiomyopathy. The harness acts by the application of a elastic compressive reinforcement on the left ventricle to reduce deleterious and excessive wall tension and to resist shape change of the left ventricle during diastole. Use of this harness can attenuate and potentially reverse the remodeling process that occurs in the left and/or right ventricle following myocardial infarction. The harness applies compressive reinforcement around the left ventricle over a significant portion of the cardiac cycle while minimizing change to the shape of a ventricle and heart. Rather than imposing a dimension beyond which the heart cannot expand, the preferred embodiment attempts to set no distinct limit to end-diastolic volume. Instead, the apparatus of the preferred embodiment follows the contour of the epicardium and continuously applies a gentle resistance to wall stretch. This avoids the potential to create dangerous restrictive and constrictive conditions, similar to those seen in restrictive cardiomyopathy, constrictive pericarditis, and cardiac tamponade. A great advantage of the harness of the disclosed embodiments is its elasticity. Elasticity refers to the ability of a material or object to deform and recover its shape when a load is first applied and then removed from it. The greater the deformation from which it can recover, the greater is the elasticity of the material or object. Elasticity allows the cardiac harness to conform and apply pressure to the heart as it fills and empties. Elasticity of the harness is achieved by the use of hinges, which can be U-shaped, that bend elastically under load. These hinges can be arrayed or networked in various ways to impart a desired amount of support in a desired orientation, at a desired location. Another advantageous aspect of the cardiac harness is that the hinges are arranged so as to minimize or avoid foreshortening, especially in the longitudinal direction during circumferential expansion. This allows the device to reinforce the heart without necessarily altering the heart's sphericity to a great degree. In addition to providing passive elastic support of the heart, the device can also provide an interface to the heart that allows the application of noncardiac power to assist systolic ventricular function. A preferred embodiment comprises an array of connected hinge elements that are configured to be in compressive contact with the left ventricle. In another preferred arrangement, the connected hinge elements are in contact with the right ventricle or with both ventricles. The array of hinge elements provide selective elastic resistance to stretch during diastole and contractile augmentation during systole. Typically, elastic materials resist deformation with a force that increases with increasing deformation. This force is stored in the material and is released during the unloading of the material. Because wall stress in the left ventricle is thought to be greatest in the circumferential direction, the hinges are predominantly aligned to act in this direction, although it may be desirable to have some elastic support in the longitudinal direction, or some other direction, as well. Each hinge 6 provides unidirectional elasticity, in that it acts in one direction and does not provide much elasticity in the direction perpendicular to that direction. An advantageous feature is that the hinges 6 are designed such that the elastic limit or yield point of their material is not exceeded during use. In other words, the hinges 6 operate in their elastic range so that they can recover to their original, stress-free configuration when they are unloaded. In addition, an important aspect to the use of a harness 4 comprised of elastic hinges 6 is that the harness 4 is sized such that it remains in elastic, compressive contact with the heart 2. Another advantageous characteristic of the elastic bending hinges 6 is that they apply increasing resistive force with increasing bending. The more they are stretched, the greater force with which they resist. Overall, a harness 4 constructed of these hinges 6 will behave in a similar fashion. A goal of cardiac or left-ventricular harnessing according to the preferred embodiment is to apply a gentle compressive pressure against the surface of the epicardium of the heart 2. As the left ventricular wall distends locally or globally, it will be met with increasing pressure by the hinges 6, locally or globally. Increased pressure exerted by the harness 4 lowers wall stress within the left ventricle and thus may prevent further infarct expansion, global dilatation, and remodeling. The cardiac harness 4 according to the preferred embodiment mechanically resists size and shape changes that take place in the heart 2 after an acute myocardial infarction. In addition, the harness 4 may be capable of reversing the remodeling process that occurs post-infarction. If reverse remodeling occurs, and the left ventricular shape and size consequently decrease back toward normal, then resistive pressure from the harness 4 will commensurately decrease, as well. One of the most-effective means of limiting infarct expansion and preventing the onset of the remodeling process after an acute myocardial infarction is revascularization of infarcted and jeopardized myocardium. Most often this is achieved by coronary artery bypass grafting. The application of a cardiac harness according to the preferred embodiment during bypass grafting can provide further benefit. The myocardial sparing effect of the harness, by decreasing wall tension, has been shown experimentally to reduce myocardial energy consumption and therefore reduce myocardial oxygen demand. If a bypass graft should become stenosed over time and cause the myocardium to become ischemic, the harness may attenuate any remodeling that might result. In addition to being an accompaniment to coronary artery bypass grafting, application of the cardiac harness might occur at the time of aortic or mitral valve repair or replacement surgeries. Hinges 6 can be disposed in helical elements, also referred to in this discussion as rings 80, rows, or strips 20, around the circumference of the left ventricle or the heart. Strips 20 can contain one or more connected hinges 6. Hinges 6 in a strip 20 are oriented to have the same axis of elasticity as other hinges 6 in a strip 20. Strips 20 can be joined or they can be independent of one another. As shown in In Joined strips 20 can be linked by longitudinally oriented hinges 18 which act as interconnections between strips 20. These longitudinally oriented hinges 18 provide elastic recoil in the longitudinal direction, while the strips 20 of hinges 6 provide the usual elasticity in the transverse direction. This arrangement imparts a more isotropic elastic structure than the previously described embodiments. An advantageous feature of the preferred embodiment is the decoupling of the action of the harness in the circumferential or transverse dimension from the longitudinal direction. This decoupling is accomplished by allowing a hinge 6 to stretch or bend circumferentially, or transversely, without pulling much longitudinally on the adjacent hinges. This principal is illustrated in An additional way that the longitudinal expansion of the harness can be decoupled from the transverse expansion of the harness is through the use of elastically recoiling interconnecting elements 16, as illustrated in Alternatively, as illustrated in Another embodiment comprises a variable hinge network (not illustrated). In this network, hinges within a strip vary in height. Thus, a short hinge may be followed by a tall hinge, followed by a short hinge, and so on within a strip. This variable hinge network provides the capability to tailor the stiffness of the harness such that the stiffness varies with the degree of stretch. For example, at some first threshold of distension, the tall hinges deform, and at some higher threshold of distension, the shorter hinges, which are stiffer, begin to deform. This arrangement can advantageously provide a pressure-versus-diameter curve for the harness that exhibits two distinct stiffness peaks at different diameters�with diameter corresponding to ventricular wall stretch or degree of distension. An important difference between the decoupled hinge harness construction of the preferred embodiment and a knitted fabric harness, or cardiac �sock,� is the hinge harness's ability to closely track changes in sphericity of the underlying heart, whether the heart is healthy or diseased. This has been demonstrated experimentally by using an inflated latex bladder, which simulates a heart in its expansion and contraction. First, relative changes in sphericity of the bladder were measured. Note that sphericity is defined as diameter (D) divided by length (L):
This relationship is illustrated in The hinges 6 can be made of a variety of materials, including metals, polymers, composites, ceramics, and biologic tissue. Specific materials include stainless steel, Elgiloy, titanium, tantalum, Nitinol, ePTFE, collagen, nylon, polyester, and urethane. Advantageously, the hinges are made from a metal, particularly Nitinol, because metals have a higher Young's modulus or stiffness, than polymers or tissue. This allows less mass and volume of material to be used to achieve the same mechanical reinforcing strength. Prosthetic materials that are directly applied to the epicardium, especially if there is some relative movement between the epicardium and the material, can induce fibrosis, which is marked by collagen deposition leading to scarring. Consequently, an implant with less surface area in contact with the epicardium tends to generate less fibrosis on the surface of the heart. Excessive fibrosis can lead to a constrictive pericarditis and, ultimately, to elevated venous pressures with disastrous consequences. Nitinol is especially suitable for the construction of the harness 4. It has the advantageous capability of being able to remain elastic over a great range of strain, up to 4%, which is greater than other metals. It generates a relatively benign foreign body response from tissue, and it is relatively magnetic-resonance-imaging-compatible, as it is not highly ferromagnetic. Nitinol is also corrosion- and fatigue-resistant. In addition, metal such as Nitinol are more creep-resistant than polymeric or tissue based materials. In a passive elastic harness application, hinge 6 would be formed in an austenitic state at body temperature when no load is applied and the material is in a stress-free state. When the harness is placed on the heart, the contact pressure between the harness and the heart may stress-induce martensite within the otherwise austenitic structure. The hinge elements can be made from wire, or they may be machined from sheet or tubing material, or a combination of these. In order to make such a structure out of Nitinol wire, the wire is wound and constrained in the desired configuration. It is then annealed at approximately 470� C. for approximately 20 minutes to set the shape. Alternatively, Nitinol tubing can be machined with a laser to create the desired structure. Another alternative is the photochemical etching of sheets of Nitinol. In both of these latter methods, a subsequent annealing can be performed. In addition to varying the direction of elastic support, the extent of support or stiffness can be varied as well. Hinges of different shape or of different material dimensions can accomplish this. Because of the difference in compliance between the left and right ventricles, it can be desirable to have the left side of the harness stiffer than the right side. This can be achieved in several ways. A harness structure can be constructed with stiffer hinges against the surface of the left ventricle than the right, as illustrated in In a preferred arrangement, a wire or plastic frame comprising two struts (not illustrated) can be integrated with the harness 4. The frame acts similarly to a clothespin, in that it exerts a clamping pressure along vectors 180 degrees apart, limiting the amount the ventricle(s) are allowed to distend. The amount of pressure exerted by the frame can be adjusted by making the frame larger or smaller, or thicker or thinner. The harness can also feature more than one frame. The harness's hinges 6 positioned between the wire frames, or between struts of frames, can be of varying thickness or size to apply varying stiffness and to allow for more or less ventricular distension. In another embodiment, illustrated in Advantageously, most or all of the surface of the left ventricle is covered by the harness 4. This ensures maximum reinforcement both globally, to attenuate global shape change and dilatation, and locally, to prevent ventricular wall thinning and stretch in an infarcted area. Note that this not to say that the actual surface area of the harness in contact with the epicardium needs to be large. Another approach to minimizing compression of the coronary artery 26 is illustrated in Advantageously, the compliance of the elastic harness 4 is in the range of compliance of native pericardium or latissimus dorsi muscle wraps. Preferably, the compliance of the harness 4 increases gradually as a function of stretch. Over the operational range of the harness, compliance should not fall so low that the harness 4 becomes constrictive. Therefore, the pressure exerted on the heart 2 by the harness 4 preferably does not exceed 10 mm Hg. However, if only the left ventricle is reinforced by the harness 4, then greater pressures are possible without causing constrictive conditions. Various designs incorporating decoupled hinges 6 are possible. The hinges 6 can wrap continuously around both ventricles or just around the left ventricle or right ventricle. The harness 4 can have a seam for size adjustment, or it can be of a one-size-fits-all design. A Nitinol harness can be provided presized to fit the dimensions of a patient's heart. Alternatively, the harness components can be provided in a kit that a surgeon can custom-assemble in the operating room, based on sizing information gained before or at the time of surgery. A kit can consist of modular components that can be assembled quickly. The use of hinge strips 20 that are ring-shaped and of varying diameters and stiffness is one possibility. The surgeon can interlock hinges 6 between adjacent hinge strips 20 in order to couple the strips 20, as illustrated in Delivery of the harness 4 can be accomplished through conventional cardiothoracic surgical techniques through a median sternotomy. Alternatively, the harness 4 may be delivered through minimally invasive surgical access to the thoracic cavity, as illustrated in The harness 4 can be secured in place on the heart 2, using sutures or staples to prevent it from migrating. Alternatively, the harness 4 can self-anchor to the epicardium to prevent it from migrating. This self-anchoring can be accomplished by incorporating inward-facing barbs or anchors 50 in the harness structure 4, as illustrated in The harness 4 not only has the capability of acting as a passive restraint around the heart, but may also be actively powered to provide contractile assistance during systole. This may be done by the application of electrical or mechanical power to the harness 4. If electrical current or heat is applied to the harness 4 in the stressed state, the resistive force generated by the bending deformation increases. In essence, the harness 4 generates a contractile force when current is applied to the harness 4. Hence, it is possible to actively power an otherwise passive elastic harness 4 in order to achieve systolic pumping assistance. This effect is additive in the myocardial sparing benefit that the harness 4 provides. During systole and perhaps at end-diastole, current can be applied to the harness 4 to make it contract and thus assist in left ventricular contraction. Such a mechanism is illustrated in In this context, the internal power supply 54 is a device that supplies electrical energy to the harness 4. It may also comprise a battery and, in some embodiments, a radiofrequency transducer for receiving and/or transmitting radiofrequency signals to and from an external radiofrequency (�RF�) transducer 56 which may send and/or receive RF signals from the internal power supply 54. Thus, the external RF transducer 56 may recharge a battery within the internal power supply 54. Also, the external RF transducer 56 may be used to send program information from the external RF transducer 56 to the internal power supply 54, or vice versa, regarding electromechanical sensing and/or pacing information, cardiac rhythm, degree of ventricular or harness contractility, heart-rate information, or the like. Alternatively, the external RF transducer 56 may supply electrical power through inductive field coupling between the external RF transducer 56 and the internal power supply 54. In some embodiments, an external power supply 58 can be used, which may be a 5 battery pack in various preferred arrangements. The external power supply 58 may supply current to the external RF transducer 56, which may in turn supply electrical energy to the internal power supply 54 through inductive field coupling. The technology for this inductive field coupling, including electronic programming and power transmission through RF inductive coupling, has been developed and is employed in, for example, cardiac pacemakers, automatic internal cardiac defibrillators, deep brain stimulators, and left ventricular assist devices. The power requirement of the device of the disclosed embodiments is significantly lower than that of conventional left ventricular assist device because the native heart in the present application continues to do some work. The powered harness 4 merely augments native cardiac contractions. Rather than a Nitinol harness 4 providing active systolic assistance, variable current can be applied to the Nitinol to simply vary the harness's 4 passive stiffness. As such, power is not used to actively �squeeze� the heart 2 during systole. The harness 4 is instead a passive elastic harness with adjustable compliance. A physician can adjust the power to a harness 4 to vary the amount of resistive pressure it exerts on the left ventricle during both systole and diastole. The passive stiffness of the harness 4 can be set to change throughout the cardiac cycle, or it can be adjusted to maintain constant levels. For example, when the cardiac harness 4 is placed on the heart 2, the physician can set the harness 4 to a certain degree of stiffness. Depending on how the patient responds, the physician can then increase or decrease stiffness by varying the electrical stimulating parameters to the harness 4. Adjustment and stimulation of the harness 4 can be accomplished through an implantable pacemaker-like box, the internal power supply 54, that is electrically connected to the harness 4 through at least one wire 60. This is one embodiment of the configuration illustrated in The harness 4 may be integrated with an implantable pacemaker or a internal cardiac defibrillator, according to the needs of the patient. Mechanical power can be applied to the harness 4 through sliding cables 70 as illustrated in Also illustrated in Compared to conventional left ventricular assist devices, the harness 4 of the disclosed embodiments has many advantages. It can be minimally invasively delivered, and it can be permanently implanted without need for subsequent removal. This allows it to provide incremental therapy as needed. If necessary, it can be powered to provide contractile assistance. If this is not necessary, the power can be shut off to allow it to act as a passive elastic reinforcement for the failing heart. In addition, such a system can provide circulatory assistance with a fraction of the power demands of a left ventricular assist device. Left ventricular assist devices are estimated to require nearly ten watts of power. The heart itself operates at only approximately one watt of power. Because a powered harness works with the existing heart, it should not need nearly the amount of power of a left ventricular assist device. In addition, because the harness 4 does not come in direct contact with blood, there is no need to anticoagulate the patient with, for example, warfarin (Coumadin) or heparin. There is also no independent reason to treat the patient with antiplatelet drugs. A harness system involves less machinery than a left ventricular assist device. This and other attributes impose less detriment to a patient's quality of life. Last, such a system is relatively simple and therefore less costly than a left ventricular assist device. Power to actuate the cable 70 can come from an internal or external source. An internal source can alternatively be skeletal muscle, such as in situ latissimus dorsi muscle or a mechanical motor. If power is needed, it can be delivered transcutaneously as described above, using existing technology developed by, for example, left-ventricular-assist device companies. Although the present invention has been described in terms of certain preferred embodiments, other embodiments that are apparent to those of ordinary skill in the art are also within the scope of the invention. Accordingly, the scope of the invention is intended to be defined only by reference to the appended claims. Patent Citations
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MRC Add-on Calcium Reactor Chamber When your reef is ready, a second chamber can make a significant difference in your calcium reactor's ability to take on more advanced systems. For example, a larger system will need more room to mix replenishing minerals and keep alkalinity and CO2 at their optimal levels for your marine friends. It also buffers the pH in the out-going water, which helps to maintain a pH level of 8.0-8.4. An added chamber is a great way to keep the chemical balance stable as your system grows.
MRC Add-on Calcium Reactor Chamber

subset: commoncrawl


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Rentals Available: 151
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© 2015 RentPath, Inc. All rights reserved. All photos, videos, text and other content are the property of RentPath, Inc. RENTALS and the RENTALS Trade Dress are registered trademarks of RentPath, Inc. or its affiliates.
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Ted Opderbeck
I am a high school photography club advisor. The only thing I enjoy more than the excitement of creating a photo, is watching the joy on the faces of my students as they do the same while developing artistic passion and vision. I am constantly blown away by the talent on this site and consistently learning from all of you.
"The real voyage of discovery consists not in seeking new landscapes but in having new eyes" - Marcel Proust
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We the south end of WB yesterday, super fun waves. About 30 min later someone turned the wave machine switch and it went flat.
So I left and of course my buddy who stayed behind said as soon as I left it got better.
Jellies were out in droves too - pieces were all over the beach.


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Front View larger RetroSound Ford Antenna Chrome-plated collapsible mast antenna for 1948-56 Ford F1-F8 trucks (Model A4856FPUFC) Item #: 068A4856FP In Stock Be the first to write a review Your price: $84.99 Earn up to 85 Rewards points Add to Cart Free Shipping Lifetime Tech Support + Add to wishlist + Email me alerts for this product Ships Free From Manufacturer View all associated offers Need help? 1.888.955.6000 Email Chat Does it fit my car? Select your car Find what fits your car ----- Please select a year ----- ----- Please select a make ----- ----- Please select a model ----- ----- Please select a body ----- ----- Please select an option ----- Loading... Will that piece of gear fit your car? We've climbed into thousands of vehicles to find out. x By buying this product you'll earn up to 85 Rewards points. When you sign up for a Crutchfield account, you'll be enrolled in Crutchfield Rewards. You'll earn one point for every dollar you spend on gear from us. You can turn your points into Rewards Cards that you can use toward future purchases. You can sign up for an account now, or after you complete your purchase (you'll get credit for the points either way). Sign up for a Crutchfield account
by John Pollard RetroSound's classic car antennas aren't your typical replacement. RetroSound built this chrome-plated antenna with a brass mast and 100% metal mounting parts — it's made to last and it'll look right at home on your classic car or truck. The antenna features a factory-correct bright chrome finish and a collapsible mast, and comes equipped with a 10-foot antenna cable and bezel, along with all the gaskets and antenna nuts needed for installation. Warranty: 1 year.


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Warning!!! Do NOT purchase a FORD FUSION!! This car has been nothing but a problem!! The A/C has stopped working, replaced the sensor at the dealership. 6 months later same thing. The door handle on the inside broke thanks to it being made of PLASTIC. I have had it at the dealership due to the trunk slamming on my head numerous times.. And now this piece of crap sounds like a wagon when I am doing anything under 20 mph. The grinding noise when...
Ford Fusion Problem Reports
Newest Ford Fusion Problem Reports
Noticing for a couple of months a burning smell coming into the car, at random times. Sometimes very strong, enough to have to drive with the windows down. Took into dealer and discovered the PTU (the thing off the transmission that powers the AWD) was leaking fluid, possibly dripping on exhaust causing the burning smell. Shop said parts inside were possibly worn or broken and the fluid was very burned. Covered under drive train warranty thank...
The transmission needs to be replaced on a 2010 Ford Fusion after 60,000 miles. The transmission struggles to upshift until third gear and then kicks in. The transmission slips randomly while shifting during drive. The transmission slips occasionally when downshifting to a complete stop.
The Check Engine Light may come on due to failure of the Variable Camshaft Timing (VCT) solenoid. The VCT solenoid will need to be replaced to correct this concern.
Squeaks and creaks heard while driving over bumps and turning can be caused be a couple common sources and should be carefully diagnosed. Possible weld issues on the lower control arms can cause the noise concerns and require repair kits for the lower control arms from Ford. A jounce bumper (bump stop) rubbing against dry strut plate can cause an abrasion noise from the strut area. In this case the strut assembly should be disassembled to lubricate the jounce bumper and then reinstalled.
Power steering fluid may leak at the power steering pump, line, and / or steering rack. The lines may not be clamped tightly enough, causing a leak. Add new clamps and seals to the power steering line to the pump and to the steering rack.
If the transmission oil leaks out of left side half shaft area, it may be from a worn axle shaft seal. The seal can be damaged by a poor surface finish on the axle shaft. The axle shaft and seal should be replaced to correct the problem.
The automatic transmission may develop shifting concerns. On lower mileage vehicles, upgrading the software in the powertrain control module (PCM) and the transmission control module (TCM) may correct the problem. As the mileage increases, internal transmission damage can occur. Repairs could involve replacement of the valve body or a complete transmission rebuild. Whenever major transmission repairs are made, it is important to be sure the PCM and the TCM have the latest software updates to help prevent these issues from reoccurring.
My sun roof doesnt close properly, has any one else experienced this problem
I had to replace my battery and ever since, my CD player is not working .. any suggestions
Electrolysis can cause repeated failures of the heater core and radiator. The diagnosing technician should check for voltage present in the coolant, with the battery disconnected, because electrical current in the coolant causes electrolysis. Corroded or deteriorated parts should be replaced, and the coolant should be flushed. Ground straps can be added to help prevent future corrosion of components.
If the key will not come out of ignition, this may be related to problems with the shifter knob sticking and / or binding of the shifter bezel. Replace the shifter knob and / or shifter bezel as needed.
The electric trunk latch solenoid can get stuck in the open position making it so the trunk will not latch closed. The diagnosing technician should verify correct electrical connection at the solenoid and check for correct cable routing. The trunk latch most commonly will need to be replaced.
Once temps dip below 30F I experience crank and no start symptoms, if you let the car set for about a .5 hour then go and start again, it starts up. Anybody else see this with their 2006 3.0L Fusion?
Let's see, had to replace rear brakes and rotors at 27000 miles, have had to replace all 4 tires, 11000 miles after brakes and rotors were replaced I hear a grinding noise so I take the car back in-have to replace both yet again (which they were still under warranty where I had had them replaced, so it was free thank god), but then they tell me that the rear driver's side calipers had seized up-so goodbye to 400.00. Plus calipers would have be...


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Minor, Nicasio get the call for Braves, Rockies
Braves left-hander Mike Minor will make his third career start at Coors Field on Tuesday against the Rockies.
In his first two outings in the hitter-friendly ballpark, Minor -- who will oppose Colorado right-hander Juan Nicasio -- was split in his performances.
In May 2012, his debut at Coors, Minor was lit up for eight earned runs on 10 hits, including two home runs, over five innings, though the Braves went on to win. He fared better in his most recent start, in April 2013, when he held the Rockies to three earned runs on five hits over six innings and didn't surrender a home run. The Braves won that one as well.
"I don't think it lives up to all of the hype of breaking balls not breaking, and every ball they hit in the air [going] over the fence," Minor said of Coors Field. "You hear all of those stories, and it's a little bit different. But it's not as much as you think. The ball travels farther, but I haven't seen where the ball doesn't break as much. I think everything plays pretty much the same."
Minor missed the first month of the season because of soreness in his shoulder, not making his first start until May 2. He allowed six home runs over his first five outings but none in his past two, during which he surrendered just one earned run over seven innings.
Meanwhile, Nicasio has struggled mightily in his past two starts. On May 30, at Cleveland, he gave up five earned runs on nine hits over 4 2/3 innings in a 5-2 loss. And in his most recent start, on Thursday, he surrendered seven earned runs on 11 hits, including two home runs, over 5 1/3 innings in a 12-7 loss to the D-backs.
He is 1-2 with a 6.75 ERA in his past three outings.
Rockies: Outfield beset by injuries
The Rockies, already without the services of Carlos Gonzalez -- who will undergo exploratory surgery on his injured left index finger on Tuesday -- placed Michael Cuddyer on the disabled list prior to Monday's game, and afterward announced that the 2013 National League batting champion will miss six to eight weeks with a non-displaced fracture in his shoulder socket.
"It's something that as a professional team we have to push through," said Cuddyer. "Nobody in the league is going to feel sorry for us."
Braves: Walden's return to provide relief for bullpen
Right-handed setup man Jordan Walden will return for Tuesday's game against the Rockies after missing five weeks with a strained left hamstring.
Before sustaining the injury on May 4, Walden compiled a 1.59 ERA and .171 opponents' batting average while striking out 39 percent of the batters he faced in 13 appearances. But with reliever Jonny Venters still sidelined because of an elbow injury, the Braves struggled to find a quality replacement for Walden during the past month.
"It's always nice to have a guy like Walden come back, especially with the ability that he brings and what he brings to the table," said right-handed reliever David Carpenter, who posted a 5.68 ERA during Walden's absence. "We were just trying to piece things together after he went down. To get a guy like that back is definitely a good feeling."
Worth noting
• Entering the series opener against the Rockies, Braves first baseman Freddie Freeman had a .349 batting average, a 1.163 OPS with four home runs in 10 games at Coors Field. He went 0-for-4 with a run scored in Monday's 3-1 victory.
• The Rockies promoted right-hander Chad Bettis from Triple-A Colorado Springs on Monday. Bettis was available from the bullpen for the series opener, but he didn't see any action.
Daniel Popper is an associate reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


text: I'm thinking about it, esp. since it uses the Mali T604 GPU, which hopefully the Lima driver will support someday. Could end up being a great, fully-open platform. Does anyone know how the T604 would compare to a desktop graphics card? Would it be comparable to something like an ATI 4650 or closer to something like an NVidia 9400M?


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FACT: The years since the 9/11 terrorist attacks have been a boon to defense contractors. Back in 2001, Defense Department contracts totaled $147.9 billion. After that, contract spending went up every year to a high of $402 billion in 2008. Add up the full decade of post-9/11 spending on defense contractors and it comes to $3.3 trillion – nearly as much as the entire federal government spent in 2012. These contractors do everything from build ships and warplanes to serve meals to troops abroad. There are already plans in place to cut back contractor spending, and sequestration could force even deeper cuts if Congress fails to agree on a spending plan by the end of the year.
Defense contractors have seen a boom since 9/11 (Infographic)
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Good to see someone doing reviews on these processors on gnu/linux.
Personally I'm a little confused by the i7/i5 series on our platform. Are these cpu's optimised for the kernel? Why si that major distros force people on AMD64 opcodes when both AMD and Intel have unique abilities that surely can make a difference in cpu operations.
Maybe someday I'll have to learn how to build my own kernel, like I did in early days when I tried linux.


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CHARACTER Emmet | |
Appearance(s): | Grand Theft Auto: San Andreas |
Full name: | Emmet |
Status: | Alive |
Gender: | Male |
Home: | Willowfield, Los Santos |
Nationality: | American |
Main affiliation: | Seville Boulevard Families Grove Street Families |
Vehicle(s): | Tampa (destroyed) |
Businesses: | Emmet's |
Voiced by: | Eugene Jeter Jr. |
Emmet is a character in the Grand Theft Auto series who appears as a minor character in Grand Theft Auto: San Andreas.
Emmet is associated with the Seville Boulevard Families, and to a certain degree, the Grove Street Families. Emmet runs a small-time gun dealership in Willowfield, Los Santos although he is unable to compete with Ammu-Nation, who owns a store opposite. Emmet, who has been providing guns for over thirty years which would mean he's been selling weapons since 1962, supplies not only the Seville Boulevard Families but the Temple Drive Families and Grove Street Families as well.
Emmet is known to the Johnson Family (in particular Carl and Sweet) along with Big Smoke and Ryder. However, they stopped buying guns from Emmet as his stock was out of date. Emmet, during the mission Nines and AKs, mistakes Carl for his deceased younger brother Brian, which could possibly mean Brian and Carl looked alike. Emmet also appears to have known Carl's mother Beverly Johnson and says that he is sorry about her death and that he knows that she would be proud of Carl.
Emmet provides basic target practice for Carl and Big Smoke with old pistols he had in storage; the targets being glass beer bottles and an old car. However, Emmet reminds them to not say where they got the guns from, suggesting he does not have a license to sell guns: "But remember this, you didn't get 'em from me." Emmet leaves a Pistol in the yard he runs his business from for Carl to pick up, which is free for Carl to use.
[show]Mission AppearancesEdit
- GTA San Andreas
- Emmet has a different cutscene model (csemmet.txd) from the actual appearance (emmet.txd). In the cutscne, he has a red shirt but when he is out of a cutscene, he has a white shirt similar to the Combat Jacket from Binco.


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Sale Items
(13321 items)
Product ID: 1305566
Main Content
Wow everyone with your killer look in the Brights full zip hoodie from Hurley! It has a soft fleece lining and embroidered Hurley lettering.
- 60% Cotton/40% Polyester
- Full zip front
- Hood with drawstring
- Imported
- Quality embroidery
- Soft fleece lining
- Two front pockets
- Woven Hurley clip tag
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Customized items can be personalized with options such as your name, your favorite
number, and/or designs. Some options may be limited by league rules.


text:
248-360-7355 7196 Cooley Lake Road Waterford, MI 48327
PWB Marketing Communications is a full-service integrated marketing communications firm located in Ann Arbor, Michigan. Founded in 1973, PWB has a long history of helping clients solve marketing challenges by building brands and generating customer demand. PWB provides everything from strategy development through execution for business-to-business and targeted consumer marketers. The agency works with businesses in a number of industries including Manufacturing Technology, Insurance and Banking, Healthcare and Life Sciences, Professional Services, Outdoor and Enthusiast, and other categories. Clients include Ann Arbor Area Convention and Visitors Bureau, Center for Plastic and Reconstructive Surgery, Lake Trust Credit Union, and Siemens PLM Software. PWB Marketing Communications employs seven people with expertise across the entire range of marketing services including strategy development, graphic design and copywriting, web design and development, social media and Internet marketing, event marketing, and other services. Learn more about PWB by reading their blog, finding them on Facebook, or following them on Twitter.
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248-626-0006 32255 Northwestern Highway Suite 298 Farmington Hills, MI 48334
"Connecting Clients With Customers." That's our mission at PCGCampbell.
313-336-9000 3200 Greenfield, Suite 280 Dearborn, MI 48120
BBDO is a worldwide advertising agency founded in 1928. Their world headquarters is in New York, with offices across the globe. One happens to be in Troy.
248-293-4000 880 W Long Lake Rd Troy, MI 48098


text:
Please Note: By clicking a link to any resource listed on this page, you will be leaving this site.
Stalking the Mysterious Microbehttp://www.microbe.org/On this American Society for Microbiology site, kids can learn more about bacteria, viruses, and other microbes.
BAM! Body and Mindhttp://www.cdc.gov/bam/This CDC website is designed for 9- to 13-year-olds and addresses health, nutrition, fitness, and stress. It also offers games for kids.


text:
Duke assistant Chris Collins, left, gestures in a Jan. 30 game this season with Duke coach Mike Krzyzewski, right. / Chuck Burton, AP
Northwestern hired longtime Duke assistant Chris Collins as its basketball coach Wednesday night.
His task is to get Northwestern to the NCAA tournament. That's something the Wildcats have never done, although they came close in recent years under Bill Carmody. He was let go after 13 seasons.
Collins, who has never been a head coach, interviewed last year for the job at Illinois State - his father's alma mater - before withdrawing.
"I'm so grateful ... for the opportunity to lead the men's basketball program at one of the premier universities in the world, to compete in the Big Ten Conference, and to do so in my hometown," Collins said in a statement released by the school. "Northwestern University is a special place that strives for excellence in every regard, and our program will be no different. I can't possibly thank Coach Krzyzewski and Duke University enough for preparing me for this day."
Collins, whose father is Philadelphia 76ers coach Doug Collins, is a native of the Chicago suburb of Northbrook, Ill. - roughly 15 miles from the Northwestern campus in Evanston. The former Mr. Basketball in Illinois was a star guard for Duke from 1993 to 1996 and played overseas before starting a coaching career that included stints with the WNBA's Detroit Shock and with Tommy Amaker's staff at Seton Hall.
Collins joined coach Mike Krzyzewski's staff in 2000 and was promoted to associate head coach in 2008. Even though the Blue Devils are still playing in the NCAA tournament, the program was far from blindsided.
"I could lose any of my guys at any time," Krzyzewski said in Philadelphia during the NCAA tournament's second and third rounds. "I feel I have the best staff in America, pro or college."
Information from the Associated Press was used in the report.
Copyright 2015
Read the original story: Northwestern to hire Duke assistant coach Chris Collins


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The Poet
A young German officer and the daughter of a Rabbi find their blooming relationship threatened by the onset of World War II in director Damian Lee's emotional war romance. The setting is German occupied Poland, and Europe is finally feeling the full devastation of Hitler's might. German Officer Oskar and his Jewish girlfriend Rachel are deeply in love, but tragically torn apart by the violent village massacres that spread like a plague across the land. Convinced that she will never be reunited with her true love, expectant mother Rachel reluctantly marries respectable Jewish man Bernard, who longs to earn her love by raising her child as his own. Later, when Rachel and Oskar unexpectedly cross paths amidst the violence of the Russian front line, a sudden tragedy prompts one man to make the ultimate sacrifice.~ Jason Buchanan, All Movie Guide
Cast: Jonathan Scarfe, Kim Coates, Colm Feore, Nina Dobrev, Zachary Bennett
Produced by: Lowell Conn
Directed by: Damian Lee
Written by: Jack Crystal
Running time:
1hr 36min
Theaters for Today |
Pick a day
on this day. |


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Streaking Brewers take on visiting Cardinals in opener
Milwaukee's Garza set to take on St. Louis' Lynn at Miller Park
The Brewers, winners of nine straight, have a chance to prove their hot start signifies they are a legitimate threat in the National League Central when they host the defending NL champion Cardinals on Monday at Miller Park.
Brewers manager Ron Roenicke said over the weekend that his Monday starter, Matt Garza, has rejuvenated the rotation since joining the club as a free agent in January.
"There have been some guys we added here that are bringing not just a better quality on the field, but off the field," Roenicke said. "Some guys are vocal -- Garza is very vocal -- and we need some guys like that. These guys have a chance to win here, and that gives you extra energy, and it does for me and the coaches, also."
Despite being the only Milwaukee starter without a win, Garza has been one of the many bright spots on a loaded pitching staff. His 2.57 ERA is astonishingly higher than the team ERA, which was a MLB-leading 1.80 after Sunday's win against the Pirates.
Brewers starters have allowed three runs or fewer in a club-record 26 consecutive games. Since 1990, only three teams (Braves, Dodgers, Cubs) have had longer streaks of that nature.
Garza will have his hands full against the two St. Louis batters who have seen him the most -- shortstop Jhonny Peralta and left fielder Matt Holliday. The pair has combined to hit .395 against the righty.
Meanwhile, Cardinals starter Lance Lynn (2-0, 6.55) will need to avoid running into trouble in the first inning, as he has in his first two starts.
In both outings, against Cincinnati, he allowed three runs in the opening frame. And both times, the St. Louis offense managed to bail him out, coming back to win the game after Lynn settled in and pitched into the sixth inning.
In each of Lynn's two full seasons, he began the year at least 5-0.
Cardinals: Significance of Jackie Robinson Day not lost
Tuesday, Major League Baseball will continue to honor the legacy of Jackie Robinson across its parks with Jackie Robinson Day.
"I think Jackie Robinson Day is a real special day for all of baseball," center fielder Jon Jay said. "He broke the color barrier for Latin players, for all sorts of different players. As a Latin player, I think it's something that's big where he really paved the way for us and we owe a lot to him. If it wasn't for him, a lot of us wouldn't be playing in the Major Leagues right now."
Brewers: K-Rod boosting bullpen
One reason behind the Brewers' stellar team ERA is Francisco Rodriguez's dominant start.
Rodriguez has four saves and has allowed only one hit over six innings of work.
"I've seen him when he gets on a roll, and this is what he does," Roenicke said. "He's got all these pitches he can throw, so whatever's working that night, whatever he wants to do with a particular hitter, he's got the opportunity to do it."
Worth noting
• With a 10th straight win Monday, Milwaukee would surpass the longest winning streak from last season. The franchise record is 13 in a row, set in 1987.
• At 308 saves, Rodriguez is two shy of matching Hall of Famer Goose Gossage for 20th place on the all-time list.
• Garza is 3-1 with a 3.96 ERA in seven career starts against the Cardinals.
Matt Slovin is an associate reporter for MLB.com. This story was not subject to the approval of Major League Baseball or its clubs.


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8th November 2010 11:14 PM | |
RobW | I have the 13 cm front fins. It works fine with 4.7 sail and smaller. With larger sail a prefer the 16 cm to get that extra drive and grip on the wave... |
2nd November 2010 01:59 PM | |
Ola_H | I think the 13 cm front fins are still available to order from STarboard so if you really want them it should be possible to get ahold of a pair. Otherwise you can contact Tarifa fin company (if you're in Europe) and let them make you a fin. They make both symmetric and asymmetric fins, but for this board I think symmetric is better, so be sure to specify that. I think something in the 13cm range would be a good high wind fin. |
2nd November 2010 01:31 AM | |
Huberch | I wanted to try 15cm front fin's_ instead 16cm_to allow strong wind ability of my Q81 , it seem's shy regards your's 13cm front fin's ! Any opinion ? |
24th October 2010 03:11 PM | |
Ola_H |
Hey Rob, if you read this contact me about the EVO IQ 71. firstname.lastname@example.com |
9th October 2010 10:20 PM | |
RobW |
OlaH: that would be really nice, thanks! I was yestarday ordered by the doctor to rest min 2 weeks and get some physio therapy because of overburdened muscles in the shoulder and arm :-( We had really good E-SE wave/freestyle weather for nearly 2 weeks in a row so I managed to awake an old injury... I will drop you a line later this autumn.... |
9th October 2010 03:51 PM | |
Ola_H |
RobW: I have the EVO 71 IQ. If you can come to the Swedish west coast some windy day.... Drop me a line on firstname.lastname@example.com and we'll set something up. |
9th October 2010 02:09 PM | |
RobW |
That really good to hear, because a was very worried also about the width of the 2011 boards. My biggest problem was picking a board for 3.7-4.2 weather, so I hope the EvoIQ71 is good when it gets a bit windy... For 4.7-5.7 again there is a lot of boards to choose from and Im really looking forward to try the new Quad. Do you know if anybody has the EvoIQ71 in DK or SWE on stock? They have the Quad in DK so I will have a look at that, but not the EvoIQ. It would really help to see the shape, as now I have only seen the pics on SB home page... |
9th October 2010 05:22 AM | |
Unregistered |
I was thrilled when I read that Evo is back. But when I saw those tail dimensions I was little skeptic. I thought that tail is too much for me. I'm 173cm and 70kg. But I just got opportunity to test EvoIQ71 and tail feels much narrower than it is. Overall nice board for Scandinavian conditions. Maybe I have to update my gear. |
9th October 2010 01:14 AM | |
RobW |
I have now read every thread I have found about the Evo IQ and the Quads for 2011 :-) And I must say Ola, you really have produced a lot of quality text about the boards. Big thanks for that! I think I will change my 2010 Quad 81 for the new QIQ82, which I understood should feel a bit looser and able to make tighter turns. The fin setup is atractive also as you also can sail with the big finns in front and get that massive drive on the wave what is the thing I have liked very much about the 2010 Q81 i lighter wind conditions. And for the windy stuff I will get the EvoIQ71. I understood its based on the Evo70 shape which was a good board. Cheers! |
6th October 2010 04:07 AM | |
Ola_H | Checked my data on the 69 and it has a 33.6cm tail. |
This thread has more than 10 replies. Click here to review the whole thread. |


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"The highest and chief abomination of the pope."The phrase, describing infant baptism, is from the Schleitheim Articles, the first official...
Fr. Dwight Longenecker
Some Christians claim that Baptism is not necessary for salvation, that it is an empty ritual symbolizing the inner conversion that has already...


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Fail Software Compilation.
This software is unusable on most of the machines do to the unoptimized, slow, memory hungry code. It was such a pain on my laptop for the last few months, there's no word to describe it. Still has a stupid long logout and startup, plus disk grindage everywhere. Simple thing like launching kwrite requires serious disk grindage.
I should be quiet now I guess, back to BFS scheduler, fluxbox, and my 5400RPM laptop disk but yet 80MB/s read rate, sorry for the rage .


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Main Content
Take your car and NASCAR fandom to the next level with the Brite Lite Logos Backlit LED Motion Sensing Automotive decal. It attaches to your window with the included adhesive strips and lights up the night, glowing with team pride (and LEDs). Motion and light sensors trigger an automatic on/off feature for long-lasting battery power.
- AAA batteries included
- Adhesive strips included
- Automatic on/off
- LED lights
- Light-up decal
- Made in China
- Motion and light sensors
- Officially licensed
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Men's Sale Hats
Budget-minded men wear many hats, which is why we've stocked our men's hat sale with a broad variety of dapper and distinguished hats for sale. At a fraction of the cost of other retailers, Hats in the Belfry's affordable men's hats don't compromise on style or quality. We even offer reduced prices on luxurious and designer men's hats, including high-style fedora hats constructed with the best-of-the-best materials, like authentic fur felt and cashmere.All of our men's sale hats are made by popular hat makers such as Belfry, Bailey, Kangol, Christys' Crown, Stetson and Wigens. Because we know that our customers love all kinds of hats and caps, we've got discounted ivy caps, newsboy caps, derby/bowler hats, knit caps, pub caps, duckbill caps and safari hats in this huge assortment. From casual, down-to-earth men's sun hats to wool top hats that would complement any three-piece suit, these men's hats for sale cover a broad spectrum of styles.
Biltmore Handmade Hoyt
color:Classic Shantung Pork Pie
Regular Price: $199.00
Special Price: $148.00
Biltmore Handmade Hugh
color:Water Resistant Shantung Fedora
Regular Price: $129.00
Special Price: $98.00
Biltmore Handmade Howe
color:Water Resistant Shangtung Fedora
Regular Price: $199.00
Special Price: $148.00


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Barnard College Greek Games, 1965
The Barnard Archives and Special Collections acts as the final repository for the historical records of Barnard College, from its founding in 1889 to the present day. We collect materials that reflect campus and academic life at Barnard.
Our primary purpose is to document the history of the College and to provide source material to administrators, alumnae, students, faculty, and other members of the Barnard College and Columbia University communities, as well as to outside researchers. We also seek to acquire Special Collections materials that relate to broader issues of Feminism; Women's, Sexuality, and Gender Studies; Dance; and the history of the education of women and female-identified individuals in the United States.
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Please visit our new Digital Collections site to view digitized materials from the archives, including the Mortarboard, the Barnard Bulletin, and historical photographs. For further information, please visit our contact page or email us at firstname.lastname@example.com.
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