text:
Article ID: 979295 - View products that this article applies to.
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Consider the following scenario:
Note Error code "-1605" is the "JET_errKeyDuplicate" Jet error.
Log Name: DFS Replication
Source: DFSR
Event ID: 2104
Task Category: None
Level: Error
Keywords: Classic
User: N/A
Computer: <computer name>
The DFS Replication service failed to recover from an internal database error on volume <drive letter>:. Replication has been stopped for all replicated folders on this volume.
Additional Information:
Error: 9214 (Internal database error (-1605))
Volume: <GUID>
Database: <drive letter>:\System Volume Information\DFSR
At the same time, the event 2212 is logged in the DFS Replication log on an upstream server:
After a while, the DFS Replication service restarts automatically. However, the same problem may occur again.
Log Name: DFS Replication
Source: DFSR
Event ID: 2212
Task Category: None
Level: Warning
Keywords: Classic
User: N/A
Computer: <computer name>
The DFS Replication service has detected an unexpected shutdown on volume <drive letter>:. This can occur if the service terminated abnormally (due to a power loss, for example) or an error occurred on the volume. The service has automatically initiated a recovery process. The service will rebuild the database if it determines it cannot reliably recover. No user action is required.
Additional Information:
Volume: <drive letter>
The DFS Replication service error occurs because the DFS Replication database recovers from a dirty shutdown state on the upstream server that logged an instance of the event ID 2122. However, a database inconsistency on the downstream server is introduced.
The upstream server populates a global version sequence number for an update to its downstream server before the upstream server commits the global version sequence number to its database. Then, the upstream server crashes or it encounters a power loss or a hard disk failure before it commits the latest global version sequence number to its database.
After the upstream server resumes, it reuses the global version sequence number that is already published for another update. The downstream server detects an inconsistency because there are various updates that have the same global version sequence number.
However, the downstream server cannot resolve the inconsistency because two ID_RECORDs in the same content set cannot have the same global version sequence number. The attempt to resolve the issue fails and generates a "-1605" error code that represents the "JET_errKeyDuplicate" error.
After the hotfix is installed, DFS Replication calls another Jet database function. This function makes sure that the database transaction is committed to the disk of the upstream server before the upstream server populates a global version sequence number for an update to the downstream server.
To resolve this issue, follow these steps:
Hotfix informationA supported hotfix is available from Microsoft. However, this hotfix is intended to correct only the problem that is described in this article. Apply this hotfix only to systems that are experiencing the problem described in this article. This hotfix might receive additional testing. Therefore, if you are not severely affected by this problem, we recommend that you wait for the next software update that contains this hotfix.
If the hotfix is available for download, there is a "Hotfix download available" section at the top of this Knowledge Base article. If this section does not appear, contact Microsoft Customer Service and Support to obtain the hotfix.
Note If additional issues occur or if any troubleshooting is required, you might have to create a separate service request. The usual support costs will apply to additional support questions and issues that do not qualify for this specific hotfix. For a complete list of Microsoft Customer Service and Support telephone numbers or to create a separate service request, visit the following Microsoft Web site:
http://support.microsoft.com/contactus/?ws=supportNote The "Hotfix download available" form displays the languages for which the hotfix is available. If you do not see your language, it is because a hotfix is not available for that language.
PrerequisitesApply this hotfix on the upstream server that is running Windows Server 2003 R2 Service Pack 2 (SP2).
For more information about how to obtain a Windows Server 2003 service pack, click the following article number to view the article in the Microsoft Knowledge Base:
(https://support.microsoft.com/kb/889100/ )How to obtain the latest service pack for Windows Server 2003
Registry informationTo use the hotfix in this package, you do not have to make any changes to the registry.
Restart requirementYou must restart the computer after you install this hotfix.
Hotfix replacement informationThis hotfix does not replace a previously released hotfix.
File informationThe English (United States) version of this hotfix installs files that have the attributes that are listed in the following tables. The dates and the times for these files are listed in Coordinated Universal Time (UTC). The dates and the times for these files on your local computer are displayed in your local time together with your current daylight saving time (DST) bias. Additionally, the dates and the times may change when you perform certain operations on the files.
Windows Server 2003 R2 file information note
For all supported x86-based versions of Windows Server 2003 R2 SP2
Collapse this tableExpand this table
For all supported x64-based versions of Windows Server 2003 R2 SP2
Collapse this tableExpand this table
For all supported IA-64-based versions of Windows Server 2003 R2 SP2
Collapse this tableExpand this table
Workaround for the DFS Replication errorTo work around this issue, manually perform a tombstone operation on the old ID_RECORD record and creates a new global version sequence number. To do this, follow these steps:
Workaround exampleFor example, assume that you receive the following debug log on the affected downstream server:
In this scenario, the "{58A90409-3866-4DC1-B474-BE1C8DE41B84}-v22461" GUID and the "SOME_RG" RgName have the same "{B890770A-6043-4004-A149-41E3A1935AC1}" CSID. Therefore, follow these steps to work around the delay issue in this scenario:
20091213 01:55:56.862 8820 RDCX 808 Rdc::SeedFile::Initialize The hashes coincide. The download is redundant, uid:{8BB53DB2-9446-47D0-94E0-F93A56589D18}-v2357 gvsn:{58A90409-3866-4DC1-B474-BE1C8DE41B84}-v22461 fileName:4-5269.dot csId:{B890770A-6043-4004-A149-41E3A1935AC120091213 01:55:57.705 8820 DOWN 5186 [ERROR] DownstreamTransport::RdcGet Failed on connId:{7D927665-24BF-4F16-B503-708AABDBC9AE} csId:{B890770A-6043-4004-A149-41E3A1935AC1} rgName:SOME_RG update:
Microsoft has confirmed that this is a problem in the Microsoft products that are listed in the "Applies to" section.
For more information about software update terminology, click the following article number to view the article in the Microsoft Knowledge Base:
(https://support.microsoft.com/kb/824684/ )Description of the standard terminology that is used to describe Microsoft software updates
Article ID: 979295 - Last Review: March 24, 2010 - Revision: 3.1
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YIELD: Serves 2
In a small saucepan combine 3/4 cup water, the oil, the cuminseed, and the salt and bring the mixture to a boil. Stir in the couscous and let the mixture stand, covered, off the heat for 5 minutes. Fluff the mixture with a fork and stir in the scallion, the parsley, and salt and pepper to taste.

subset: commoncrawl


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Raja Bahadur Mill Road • Pune, Maharashtra 411001 • India • Map
Book online at lemeridien.com and you will find the lowest rate - guaranteed! If you do find a lower published rate prior to, or within 24 hours of booking your room, simply submit a Best Rate Guarantee Claim and the lower rate will be will honored. It's now easier than ever with our online claim form. We'll also give you an additional 20% discount or 2,000 Starpoints®*. Guaranteed.
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Since I hardly ever agree with President Obama on anything, I thought that I would take this opportunity to say that it appears to me that his response to this situation seems reasonable (IMHO):
Copied from the Washington Post article tinyurl.com :
President Obama said Tuesday that the abduction of nearly 300 girls from a school in Nigeria is "heartbreaking," and he believes the incident may mobilize the world to act against the Islamic militant group that has taken credit for the mass kidnapping.
Speaking with ABC News, Obama said the organization, Boko Haram, has been "killing people ruthlessly for years" and is among the world's worst local terrorist organizations.
Obama said the U.S. has sent a team of military, law enforcement and other agencies' personnel to help the Nigerian government identify where the girls may be. Nigerian President Goodluck Jonathan spoke with Secretary of State John Kerry Tuesday morning, the White House said, underscoring that the offer of aid does not include troops. Obama said that the United States has long wanted to work with Nigeria on eradicating Boko Haram.
"Weve long sought to work with Nigeria in dealing with them and were going to do everything we can to assist them in recovering these young women," Obama told CBS News.
Nearly 300 girls were abducted from a rural school in the country's northeast by Boko Haram, an Islamic militant group that does not believe girls should be sent to school. Its name means "Western Education is Sinful." The group admitted responsibility this week and has threatened to sell the girls. According to reports, eight more girls between the ages of 12 and 15 were abducted this week.
I hope the efforts pay off. These radical Islamic militants really exhibit extreme sub-human behavior.


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News Archive
June 26, 2015
At congressional hearing, officials at American institutions operating in China say that academic freedom is preserved.
June 26, 2015
In Germany, university students who delay their work are more likely than others to lie about it and to engage in other forms of academic misconduct, study finds.
June 25, 2015
Federal accountability system won't compare colleges or assign scores, as Obama sought, but will instead be a data-rich, consumer-facing tool on access, affordability and performance.
June 25, 2015
More students at Florida's two-year colleges are failing college-level courses in the aftermath of a new state law that allows them to skip remediation.
June 25, 2015
TIAA-CREF survey reveals adjunct faculty members' concerns about having enough savings to retire. Experts say the situation for most adjuncts is even more dire.
June 25, 2015
Saudi Arabian students are snared in a grade-change scandal at Montana Tech that became a diplomatic incident.
June 25, 2015
Columbia's core literature course, long criticized for its lack of diversity, adds to the list a novel by Toni Morrison -- the first living author and the first nonwhite author.
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Connecting Positive People
The purpose is for members to "share a smile" with at least one person on a daily basis. It's that simple. Or, you can go even larger than that and do one kind gesture for someone - something as simple as opening a door for a stranger. Whatever it is, share your experience with the group. My hope is that those you "share a smile" with will share one with someone else. You never know if just a simple smile can change someone's mood, thereby changing their day. Also, those in the group may be given motivation to do the same by seeing your comment. Share a smile and SPREAD LOVE AND POSITIVITY!
Members: 112
Latest Activity: Sep 14, 2014
Started by abubaker aldubai Jun 28, 2013. 0 Replies 0 Likes
Your smile in the face of your brother's charityContinue
Started by Gandalf O'Daugherty May 15, 2013. 0 Replies 1 Like
I AM GANDALF O'DAUGHERTY....ON FB I AM KNOWN AS JOY PANDEMIC AND I WOULD LIKE TO INVITE EVERYONE WHO READS THIS TO JOIN OUR MOVEMENTS FIRST EVENT....I WOULD ALSO LIKE TO ENCOURAGE YOU TO INVITE…Continue
Started by Lata Asha. Last reply by Elvina Damastuti May 7, 2013. 11 Replies 9 Likes
Everyone smiles in the same language,if you smile at someone, they might smile back, the shortest distance between two people is a smile,you are not fully dressed until you wear a smile.a smile is a…Continue
Today is the first day of 28 DAYS OF KINDNESS. CLICK HERE to find out how to participate.
Had smiles spread all around today when two males kept a door open for me. Every body saw this and asked me how I make it happen? Well, I answered: "The look on your face tells a happy story or a miserable one. The latter one you leave at home. The happy face tells people volumns!!." You become approachable; easy to talk to and that you listen. Like "Body Language" your face is readable to; It tells a story. Always saying Thank You is very important because it brightens someones day. It is respect; and a little respect goes a long way. Try practising with a mirror. For me it comes natural. I was brought up as a child to always be respectfull to my elders. Well, why not people my own age? And it is working, apparently, to my advantage.
Smiles, everyone!!!!
Little Tony was staying with his Grabdmother for a few days.
He'd being playing out side with the other kids for a while when he came into the house and asked her "What is that called when 2 people are sleeping in the same room and one is onto of the other?"
She was a little taken aback, but decided to tell him the truth.
"It's called sexual intercourse, darling"
Little Tony just said "Oh, O.K." and went back outside to talk and play with the other kids.
A few minutes later he came back in and said angrily,
"Grandma, it is not called sexual intercourse! It's called Bunk Beds and Jimmy's Mom wants to talk to you!"


text:
5 (0) 4 (2) 3 (0) 2 (0) 1 (0)
4 stars 4/5 Stars Average score of 2 user reviews spread across 3 releases and 0 DLC
Welcome To Cosmic Smash 0
(This is a review I wrote in 2002, it's been unedited or updated.).Welcome to Cosmic Smash. Do you ever sit there and wonder what designers are thinking when they make a game? Do they know they're making a bad game? Does the game just become bad at the last minute and then they can see what bunk they made? Or do you think they just never know until people point out how bad it sucks. I know I have, but until I played Cosmic Smash...I never thought the reverse. Did Sega Rosso know they were makin...1 out of 1 found this review helpful.
An Addicting, Albiet Shallow, Entry into the Dreamcast Library. 0
[POSITIVES]: (Fun, simple, and addicting gameplay with hidden depth. Unique, efficient visuals. No load times. You can choose which levels to complete. Easy to pick up, difficult to master.)[NEGATIVES]: (Completing every level in a single run is not even an option. Glowing orb makes percieving depth difficult sometimes. Bare in terms of gameplay modes and extras. No multiplayer.)Sega has proved its mastery of the arcade gaming genre time and time again, both in its actual arcade and console re...0 out of 0 found this review helpful.
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Methods for treating anatomic tissue defects such as patent foramen ovale (PFO) generally involve positioning a distal end of an elongate catheter device at the site of the anatomic defect, exposing an expandable housing and energy transmission member out of the distal end of the catheter device, engaging the housing with tissues at the site of the anatomic defect, applying suction to the tissues via the housing to bring the tissues together; and applying energy to the tissues with the energy transmission member to substantially close the anatomic defect acutely. Apparatus generally include an elongate catheter body, a housing extending from a distal end of the catheter body for engaging tissues at the site of the anatomic defect, and an energy transmission member adjacent a distal end of the housing, the energy transmission member having at least one substantially planar surface.
1. An apparatus for treating an anatomic defect in a heart, the apparatus comprising:
an elongate catheter body having a proximal end and a distal end;
a housing extending from the distal end of the catheter body for engaging tissues at the site of the anatomic defect;
an energy transmission member adjacent to a distal end of the housing, the energy transmission member having at least one substantially planar surface,
wherein the housing is adapted to apply vacuum to the tissues to bring them together and position them against the energy transmission member; and
a plurality of struts formed in a pattern, the struts coupled to the housing.
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an inferior attachment member for attaching proximally to an inferior portion of the housing; and
multiple superior attachment members for attaching proximally to a superior portion of the housing.
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This application is a divisional of U.S. patent application Ser. No. 10/952,492 (Attorney Docket No.: 022128-000220US), filed Sep. 27, 2004, which is related to U.S. patent application Ser. No. 10/873,348 (Attorney Docket No. 022128-000210US), filed Jun. 21, 2004, which is a continuation-in-part of U.S. patent application Ser. No. 10/679,245 (Attorney Docket No. 022128-000200US), filed Oct. 2, 2003, which claims priority to U.S. Provisional Patent Application Nos. 60/458,854 (Attorney Docket No. 022128-000100US), filed on Mar. 27, 2003; 60/478,035 (Attorney Docket No. 022128-00011US), filed on Jun. 11, 2003, and 60/490,082 (Attorney Docket No. 022128-000120US), filed on Jul. 24, 2003. The full disclosures of all of the above-listed patent applications are hereby incorporated by reference.
The invention generally relates to medical devices and methods. More specifically, the invention relates to energy based devices and methods for treatment of anatomic defects in human tissue, such as patent foramen ovale (PFO), atrial septal defect (ASD), ventricular septal defect (VSD), patent ductus arteriosis (PDA), left atrial appendages (LAA), blood vessel wall defects and certain electrophysiological defects.
The following is an example of how one particular type of anatomical defect—a PFO—is formed. Fetal blood circulation is very different from adult circulation. Because fetal blood is oxygenated by the placenta, rather than the fetal lungs, blood is generally shunted past the lungs to the peripheral tissues through a number of vessels and foramens that remain patent (i.e., open) during fetal life and typically close shortly after birth. For example, fetal blood passes directly from the right atrium through the foramen ovale into the left atrium, and a portion of blood circulating through the pulmonary artery trunk passes through the ductus arteriosus to the aorta. This fetal circulation is shown in attached
At birth, as a newborn begins breathing, blood pressure in the left atrium rises above the pressure in the right atrium. In most newborns, a flap of tissue closes the foramen ovale and heals together. In approximately 20,000 babies born each year in the US, the flap of tissue is missing, and the hole remains open as an atrial septal defect (ASD). In a much more significant percentage of the population (estimates range from 5% to 20% of the entire population), the flap is present but does not heal together. This condition is known as a patent foramen ovale (PFO). Whenever the pressure in the right atrium rises above that in the left atrium, blood pressure can push this patent channel open, allowing blood to flow from the right atrium to the left atrium. A patent ductus arteriosis (PDA) is a tubular communication between the pulmonary artery and the aorta, which typically closes shortly after birth. Patent foramen ovale has long been considered a relatively benign condition, since it typically has little effect on the body's circulation. More recently, however, it has been found that a significant number of strokes may be caused at least in part by PFOs. In some cases, a stroke may occur because a PFO allows blood containing small thrombi to flow directly from the venous circulation to the arterial circulation and into the brain, rather than flowing to the lungs where the thrombi can become trapped and gradually dissolved. In other cases, a thrombus might form in the patent channel of the PFO itself and become dislodged when the pressures cause blood to flow from the right atrium to the left atrium. It has been estimated that patients with PFOs who have already had cryptogenic strokes may have a risk of having another stroke.
Further research is currently being conducted into the link between PFO and stroke. At the present time, if someone with a PFO has two or more strokes, the healthcare system in the U.S. may reimburse a surgical or other interventional procedure to definitively close the PFO. It is likely, however, that a more prophylactic approach would be warranted to close PFOs to prevent the prospective occurrence of a stroke. The cost and potential side-effects and complications of such a procedure must be low, however, since the event rate due to PFOs is relatively low. In younger patients, for example, PFOs sometimes close by themselves over time without any adverse health effects.
Another highly prevalent and debilitating condition—chronic migraine headache—has also been linked with PFO. Although the exact link has not yet been explained, PFO closure has been shown to eliminate or significantly reduce migraine headaches in many patients. Again, prophylactic PFO closure to treat chronic migraine headaches might be warranted if a relatively non-invasive procedure were available.
Currently available interventional therapies for defect closure are generally fairly invasive and/or have potential drawbacks. One strategy is simply to close a defect during open heart surgery for another purpose, such as heart valve surgery. This can typically be achieved via a simple procedure such as placing a stitch or two across the defect with vascular suture. Performing open heart surgery purely to close an asymptomatic PFO or even a very small ASD, however, would be very hard to justify.
A number of interventional devices for closing defects percutaneously have also been proposed and developed. Most of these devices are the same as or similar to ASD closure devices. They are typically "clamshell" or "double umbrella" shaped devices which deploy an area of biocompatible metal mesh or fabric (ePTFE or Dacron, for example) on each side of the atrial septum, held together with a central axial element, to cover the defect. This umbrella then heals into the atrial septum, with the healing response forming a uniform layer of tissue or "pannus" over the device. Such devices have been developed, for example, by companies such as Nitinol Medical Technologies, Inc. (Boston, Mass.) and AGA Medical, Inc. (White Bear Lake, Minn.). U.S. Pat. No. 6,401,720 describes a method and apparatus for thoracoscopic intracardiac procedures which may be used for treatment of PFO.
Although available devices may work well in some cases, they also face a number of challenges. Relatively frequent causes of complications include, for example, improper deployment, device embolization into the circulation and device breakage. In some instances, a deployed device does not heal into the septal wall completely, leaving an exposed tissue which may itself be a nidus for thrombus formation. Furthermore, currently available devices are generally complex and expensive to manufacture, making their use for prophylactic treatment of PFO and other defects impractical. Additionally, currently available devices typically close a PFO by placing material on either side of the tunnel of the PFO, compressing and opening the tunnel acutely, until blood clots on the devices and causes flow to stop.
Research into methods and compositions for tissue welding has been underway for many years. Of particular interest are technologies developed by McNally et.al., (as shown in U.S. Pat. No. 6,391,049) and Fusion Medical (as shown in U.S. Pat. Nos. 5,156,613, 5,669,934, 5,824,015 and 5,931,165). These technologies all disclose energy delivery to tissue solders and patches to join tissue and form anastamoses between arteries, bowel, nerves, etc. Also of interest are a number of patents by inventor Sinofsky, relating to laser suturing of biological materials (e.g., U.S. Pat. Nos. 5,725,522, 5,569,239, 5,540,677 and 5,071,417). None of these disclosures, however, show methods or apparatus suitable for positioning the tissues of an anatomic defect for welding or for delivering the energy to an anatomic defect to be welded.
Causing thermal trauma to a patent ovale has been described in two patent applications by Stambaugh et al. (PCT Publication Nos. WO 99/18870 and WO 99/18871). The devices and methods described, however, cause trauma to PFO tissues to hopefully eventually cause scar tissue formation which will close the PFO. In addition, Blaeser et al. (US Patent Publication US2003/0208232), further describes causing trauma, or abrading, and holding the abraded tissue in apposition to allow the tissue to heal together. Using such devices and methods, the PFO typically remains patent immediately after the procedure, or abrasion, and only closes sometime later, or is treated and then held together to heal over time. Frequently, scar tissue may fail to form or may form incompletely, resulting in a still patent PFO.
In addition to PFO, a number of other anatomic tissue defects, such as other ASDs, ventricular septal defects (VSDs), patent ductus arteriosis (PDA), aneurysms and other blood vessel wall defects, atrial appendages and other naturally occurring cavities within which clot can form, and the like cause a number of different health problems (note that the term "defect" may include a naturally occurring structure that results a potential health risk such as the clot forming in the atrial appendage). U.S. Patent Application No. 2004/0098031 (Van der Burg), and U.S. Pat. Nos. 6,375,668 (Gifford) and 6,730,108 (Van Tassel et al.), the full disclosures of which are incorporated herein by reference, disclose a variety of techniques and devices for treating anatomic defects. In addition, the inventors of the present invention have described a number of improved devices, methods and systems for treating PFO, many of which may be adapted for treating other anatomic tissue defects as well. For example, related patent applications assigned to the assignee of the present invention include U.S. patent application Ser. Nos. 10/665,974 (Attorney Docket No. 022128-000300US), filed on Sep. 16, 2003; 10/679,245 (Attorney Docket No. 022128-000200US), filed Oct. 2, 2003; 10/787,532 (Attorney Docket No. 022128-000130US), filed Feb. 25, 2004; and 10/811,228 (Attorney Docket No. 022128-000400US), filed Mar. 26, 2004, the full disclosures of which are incorporated herein by reference.
Despite improvements made thus far, it would be advantageous to have even further improved methods and apparatus for treating anatomic tissue defects such as PFOs and the other anatomic structures mentioned above. Ideally, such methods and apparatus would help seal an anatomic tissue defect during, immediately after or soon after performing a treatment procedure. Also, such devices and methods would leave no foreign material (or very little material) in a patient's heart. Furthermore, such methods and apparatus would preferably be relatively simple to manufacture and use, thus rendering prophylactic treatment of PFO and other tissue defects a viable option. In addition, based upon the unique characteristics of the devices of the present invention, such devices may also be employed for treating certain electrophysiological defects, such as atrial fibrillation, supraventricular tachacardia (SVT), atrial flutter, A-V node re-entry, and Wolf Parkinson White syndrome. At least some of these objectives will be met by the present invention.
The present invention generally provides devices and methods for treating anatomic defects in human tissues, such as patent foramen ovale (PFO), atrial septal defect, ventricular septal defect, patent ductus arteriosis, left atrial appendages, and blood vessel wall defects. In one aspect of the present invention, apparatus for treating an anatomic defect in a heart includes an elongate catheter body having a proximal end and a distal end, a housing extending from the distal end of the catheter body for engaging tissues at the site of the anatomic defect, and an energy transmission member adjacent a distal end of the housing. The energy transmission member has at least one substantially planar surface, and the housing is adapted to apply vacuum to the tissues to bring them together and position them against the energy transmission member. In various embodiments, the anatomic defect may be any suitable tissue defect, such as but not limited to those listed above. The following description will often focus on PFO treatment, but various embodiments may be employed for treating any other suitable tissue defect.
In some embodiments, the apparatus also includes a sheath disposed over at least part of the catheter body and having a proximal end and a distal end. In such embodiments, the energy transmission member and the housing are collapsible and axially movable relative to the sheath, from a collapsed position within the sheath to an expanded position beyond the distal end of the sheath. Optionally, the sheath may include a bend, closer to its distal end than its proximal end. In some embodiments, the catheter body also includes a bend, closer to its distal end than a proximal end of the sheath. In such embodiments, the catheter body bend and the sheath bend allow a user to change an angle of orientation of the energy transmission member and the housing by moving the catheter body relative to the sheath. Optionally, the sheath may also include a stretchable distal end for facilitating movement of the housing and the energy transmission member from the expanded configuration to the collapsed configuration within the sheath.
The phrase "tissues adjacent an anatomic defect," for the purposes of this application, means any tissues in, around or in the vicinity of an anatomic defect which may be used or manipulated to help close the anatomic defect, or decrease viability of tissue conduction, such as in ablation for electrophysiological defects. For example, tissues adjacent a PFO include septum primum tissue, septum secundum tissue, atrial septal tissue lateral to the septum primum or septum secundum, tissue within the tunnel of the PFO, tissue on the right atrial surface or the left atrial surface of the atrial septum and the like.
In various embodiments, any of a number of energy transfer devices and forms of energy may be used to provide energy transfer. Types of energy used may include, for example, radiofrequency energy, cryogenic energy, laser energy, ultrasound energy, resistive heat energy, microwave energy and the like. Application of energy to tissues to substantially close the anatomic defect acutely may sometimes be referred to as "tissue welding." Preferably, tissue welding methods of the present invention will be performed without using tissue soldering material or other foreign material. In some embodiments, however, it may be advantageous to use one or more solder materials. Various solders and other tissue soldering matrices are described more fully in U.S. patent application Ser. No. 10/665,974, which was previously incorporated by reference. Examples of tissue solders or adhesives which may be used include, but are not limited to, autologous blood, albumin, collagen, fibrin, cyanoacrylates, mussel byssus adhesives, polymer hot melt adhesives and the like.
In various embodiments, tissues may be brought together (or "apposed") before, during and/or after application or removal of energy to the tissues. Generally, energy application or removal will act to denature collagen in the anatomic defect tissues. If the tissues are apposed before and/or during denaturation and/or after denaturation, the collagen in once-separated tissues binds together to bring the tissues together. Therefore, various embodiments of the invention include one or more devices for bringing (and possibly holding) tissues together before, during and/or after energy application or removal. Such devices include, for example, tissue covering members, which may also be suction or vacuum application members, expandable members for insertion and expansion within an anatomic defect, distal tip members for contacting a left atrial surface of PFO tissue and the like.
In some embodiments, the housing includes a narrow proximal end coupled with the distal end of the catheter body and a flared distal end. Optionally, the housing may also include a flexible, cylindrical foot extending from the flared distal end for contacting the tissues. In some embodiments, the housing and the flexible foot comprise different materials, while in others they are made of the same material. In one embodiment, the flexible foot extends laterally from the flared distal end to have a larger diameter than a diameter of the flared distal end. In some embodiments, the electrode is movable relative to the housing to allow for a lower profile device, and alternatively to apply energy to the tissues at multiple locations within the larger diameter of the flexible foot without re-acquiring the targeted region. The flared distal end of the housing may have any suitable shape, such as but not limited to circular, ovoid, elliptical, rectangular, triangular, pentagonal, hexagonal, octagonal, crescent-shaped or fan-shaped.
In various embodiments, the housing may comprise any suitable material or combination of materials, typically selected to give the housing a degree of resiliency, to allow it to collapse for housing within a catheter sheath and to expand when exposed out of the distal end of the sheath. For example, materials used to manufacture the housing may include but are not limited to PET, DACRON�, other polyesters, polypropylene, PTFE, ePTFE, PEEK, nylon, polyurethane, polyethylene, silicone, urethane or metal. In some embodiments, the housing further comprises a lubricious coating over at least part of its outer surface. Optionally, the housing may further include at least one supportive strut for preventing complete collapse of the housing when vacuum is applied to the tissues. In some embodiments, the housing and the strut(s) comprise the same material, while in others they are made of different materials. The housing may also optionally include at least one radiopaque marker or radiopaque material.
In some embodiments, the catheter device further includes an irrigation tube extending through the catheter body and having a distal aperture disposed within the housing and a vacuum tube extending through the catheter body and having a distal aperture disposed within the housing. In one embodiment, an inner surface of the housing includes a plurality of ridges and valleys forming channels to direct irrigation fluid from the irrigation tube distal aperture toward the tissues and subsequently toward the vacuum tube distal aperture. The inner surface may optionally further include an irrigation fluid blocking surface feature to help direct fluid forward and away from the irrigation tube distal aperture. In some embodiments, the irrigation tube is adapted to allow passage of a guidewire therethrough.
In some embodiments, the at least one energy transmission member comprises a planar radiofrequency energy electrode disposed adjacent the distal end of the housing. In one embodiment, the electrode is axially movable in and out of the distal end of the housing. Alternatively, the electrode may be directly attached to the housing. In various embodiments, the planar surface electrode may have any suitable shape, such as but not limited to circular, ovoid, elliptical, rectangular, triangular, pentagonal, hexagonal, octagonal, crescent-shaped or fan-shaped.
In some embodiments, the planar surface electrode includes an outer rim extending at least partially around an outer circumference of the electrode and a plurality of metallic struts formed in a pattern within the outer rim. In one embodiment, the rim is discontinuous, thus enhancing collapsibility of the electrode. In other embodiments, the rim includes one or more inward bends directed toward the struts, the inward bends adapted to promote collapsibility of the electrode. In some embodiments, some of the struts are attached to other struts as well as to the outer rim. In other embodiments, the struts are attached only to the outer rim and not to one another. In other embodiments, the struts are not attached at all to the outer rim, and may be attached to the housing through the material of the housing or other structure. The pattern of struts may include at least one area of more closely positioned struts relative to another area of less closely positioned struts, such that different areas of the electrode provide different amounts of energy transmission to the tissues. Alternatively or additionally, the pattern of struts may include at least one area of thicker struts relative to another area of thinner struts, such that different areas of the electrode provide different amounts of energy transmission to the tissues.
In some embodiments, the pattern of struts includes at least one fold line along which the electrode folds to allow the electrode to collapse. In some embodiments, the struts are attached asymmetrically to the outer rim such that a first half of the housing and electrode folds into a second half of the housing and electrode when the housing and electrode assume their collapsed configurations. For example, in some embodiments, the struts are attached to the outer rim at between 8 and 16 attachment points to enhance collapsibility of the electrode.
In some embodiments, the device further includes a plurality of metallic attachment members extending from the outer rim for attaching the electrode to the housing. For example, the plurality of attachment members may include an inferior attachment member for attaching proximally to an inferior portion of the housing and multiple superior attachment members for attaching proximally to a superior portion of the housing. In one embodiment, the inferior attachment member extends onto an inferior portion of the catheter body, and the superior attachment members extend onto a superior portion of the catheter body. In one embodiment, the inferior attachment member divides before attaching to the outer rim at two attachment points. In an alternative embodiment, the inferior attachment member curves asymmetrically before attaching to the outer rim. In some embodiments, the struts are attached to the outer rim at locations apart from attachment points of the attachment members to the outer rim. Alternatively, the struts may be attached to the outer rim at attachment points of the attachment members to the outer rim.
In various embodiments, an electrode may include any of a number of additional features. For example, in some embodiments, the electrode further comprises at least one guidewire aperture to allow passage of a guidewire through the electrode. The guidewire aperture may be disposed along the electrode in an offset position to facilitate positioning of the electrode over the anatomic defect. Some embodiments include two offset guidewire apertures for facilitating positioning of the electrode over the anatomic defect. Some embodiments further include a thermocouple attached to the electrode.
In some embodiments, the energy transmission member comprises a radiofrequency electrode having multiple planar surfaces connected by one or more bends, such as a "stepped" electrode. For example, such an electrode may have a first planar surface, a bend, and a second planar surface. Such configuration may help promote contact of the electrode with asymmetrical anatomic tissues and tissue defects. Optionally, the housing may also have such a stepped, or "multiplanar," configuration that matches that of the electrode. In yet another embodiment, the energy transmission member may comprise a planar, expandable, braided wire electrode.
In another aspect of the present invention, a method of treating an anatomic defect in human tissue involves: positioning a distal end of an elongate catheter device at the site of the anatomic defect; exposing an expandable housing and energy transmission member out of the distal end of the catheter device; engaging the housing with tissues at the site of the anatomic defect; applying suction to the tissues via the housing to bring the tissues together; and applying energy to the tissues with the energy transmission member to substantially close the anatomic defect acutely. In one embodiment, the method further involves repositioning the housing and the energy transmission member within the catheter device and removing the catheter device from the site of the anatomic defect.
By "substantially," it is meant that a stable tissue bridge will be formed across the anatomic defect, which will withstand physiologic pressures. A substantially closed anatomic defect, however, may still have one or more small gaps or openings, which will in at least some cases close over time via the healing process. By "acutely," it is meant that the anatomic defect is substantially closed when the closure procedure is completed. Thus, acute closure distinguishes devices and methods of the present invention from prior protocols, which rely on delayed anatomic defect closure via tissue healing and scarring. "Acutely," for purposes of this application, does not mean temporarily, since devices and methods of the present invention will typically provide for permanent (or at least long-term) anatomic defect closure.
In some embodiments, exposing and repositioning the housing and the energy transmission member involve moving a sheath of the catheter device relative to a catheter body of the catheter device. For example, repositioning the housing and the energy transmission member may involve advancing the sheath and/or retracting the catheter body to cause the housing and the energy transmission member to collapse as they enter the sheath. In some embodiments, the housing and energy transmission member collapse along one or more lines of structural weakness adapted to promote collapsibility. In some embodiments, collapsing of the housing and energy transmission member comprises one lateral side of the housing and energy transmission member folding over an opposite lateral side.
Optionally, the method may further involve passing fluid out of an irrigation fluid aperture in the housing and suctioning the fluid back into a suction aperture in the housing. In some embodiments, the method may further comprise directing the fluid, via multiple channels on an inner surface of the housing, away from the irrigation fluid aperture and toward the suction aperture. Alternatively, the multiple channels could be used to direct the irrigation fluid away from the fluid aperture and over targeted areas of the electrode to cool the electrode, wholly or in selected regions, to prevent the electrode from adhering to the tissue. Some embodiments also include monitoring the suctioned fluid to determine the blood content of the fluid. Alternatively or additionally, a flow rate of fluid from a fluid supply reservoir into the catheter may be monitored to determine whether a seal has been formed.
In some embodiments, engaging the housing with the tissues automatically engages the energy transmission member with the tissues. In other embodiments, applying suction to the tissues automatically engages the energy transmission member with the tissues. Still other embodiments further involve moving the energy transmission member relative to the housing to engage the energy transmission member with the tissues. These latter embodiments may optionally also involve repositioning the energy transmission member relative to the housing to engage the tissues at a different location.
The energy applied to the tissues may include, but is not limited to, radiofrequency, microwave, ultrasound, laser, heat and/or cryogenic energy. In some embodiments, the energy is applied at different levels to different areas of tissue via the energy transmission member. For example, the different levels of energy may be applied via different densities of material comprising the energy transmission member. In other embodiments, the different levels of energy are applied via multiple energy delivery devices coupled with the energy transmission member at different regions of the ETM. In addition, in some embodiments it may be advantageous to heat the electrode prior to applying it to tissue, to facilitate the application of higher temperatures to the surface of the defect to be treated, as in direct heating versus use of RF, which relies on conductive or inductive heating of tissue at some depth below the surface.
These and other embodiments are described in further detail in the following description related to the appended drawing figures.
Devices and methods of the present invention generally provide for treatment of anatomic defects in human tissue, such as patent foramen ovale (PFO), atrial septal defect, ventricular septal defect, left atrial appendage (LAA), patent ductus arteriosis, vessel wall defects and/or the like through application of energy. In addition, electrophysiological defects, such as atrial fibrillation, supraventricular tachacardia (SVT), atrial flutter, A-V node re-entry, and Wolf Parkinson White syndrome, may be treated using various embodiments of the present invention. Therefore, although the following descriptions and the referenced drawing figures focus primarily on treatment of PFO, any other suitable tissue defects, such as but not limited to those just listed, may be treated in various embodiments.
As mentioned in the background section above,
1. Catheter Device
Referring now to
Many of the above-mentioned features are described in further detail below. In alternative embodiments, additional features or fewer features may be included on catheter device 10. For example, a number of modifications may be made to catheter body proximal end 12 b without departing from the scope of the invention. Therefore, the following description of embodiments is intended to be primarily exemplary in nature and should not be interpreted to limit the scope of the invention as it is described in the claims.
That being said, and with reference now to
Referring now to
Referring to
One or more structural elements, such as a struts 1317, a resilient mesh embedded in the housing and/or a torque cable or rod attached to the electrode may be incorporated to allow the electrode and housing 1312 to be torqued and maneuvered. One such housing 1312 is further detailed in FIGS. 2F-2G″, showing struts 1317 optionally embedded into housing material to provide control and rigidity to housing 1312 when shaft 1310 is torqued. Struts may extend the length of the catheter, or be terminated at the point of the radiopaque marker (RO) on the catheter shaft. In addition, struts may be truncated to only run a partial length of the housing as shown in
Referring now to
In general, catheter device 210 comprises an elongate, flexible catheter which may be advanced through the vasculature of a patient to a position in the heart for treating a defect. Thus, catheter device 210 may have any suitable length, diameter, cross-sectional profile and the like, and may be constructed of any suitable material. Tissue apposition member 212 (or multiple tissue apposition members in some embodiments) is disposed at or near the distal end of catheter device 210. Although many different types of devices may be used to bring tissues of the defect together, in one embodiment (shown in
To optimize use, the device of the present invention is typically positioned so as to best treat the defect tissue. In addition, the device typically apposes or approximates the tissue to be treated to allow a "weld" or fusion to occur. Such positioning and tissue apposition may be achieved in a variety of ways, including those described herein. In the embodiment shown in
In this and other embodiments, tissue apposition member 212 may also include one or more vacuum members for applying vacuum to the defect tissues or those surrounding the defect. In one embodiment, for example, suction lumen 236 (
To further facilitate use and positioning of apparatus 200, catheter device 210 may include one or more radiopaque markers 226 for facilitating visualization of the device 210. Catheter device 210 may also include a "flexible isolation portion" 228, which in some embodiments comprises a rigid but shapeable portion disposed toward the distal end of catheter device 210, between tissue apposition member 212 and the generally flexible proximal portion of catheter device 210. Flexible isolation portion 228 may help to isolate tissue apposition member 212 from some or all movement experienced by the more flexible, proximal portion of catheter device 210, thus allowing a PFO treatment procedure to be performed without significant movement of tissue apposition member 212. In other embodiments, flexible isolation portion 228 may be more flexible than the more proximal portion of catheter device 210, thus enhancing maneuverability, shapability or the like of the position of tissue apposition member 212 relative to the more proximal portion.
Guide catheter 220 is generally a flexible catheter along which catheter device 210 may be slidably advanced to a position for defect treatment. Guide catheter 210 is configured to fit at least partially within or against the defect, and optionally through the defect such as into the left atrium of the heart when treating a PFO. Optionally, one or more radiopaque markers 224 may be included on guide catheter. Guide catheter 220 may contain one or more expandable members 222 or other similar devices for expanding within the defect to help bring the defect tissues together, anchor catheter device to the defect tissues, or both. As shown in
Expandable member 222 may have any suitable configuration and may be constructed from any suitable materials. For example, expandable member 222 may be spring loaded, made of shape memory material, such as nitinol or spring stainless steel or the like. Alternatively, expandable member 222 may be expanded mechanically by one or more expansion members coupled with expandable member 222 and controlled via an actuator at the proximal end of guide catheter 220. During delivery of guide catheter 220, expandable member 222 reside within guide catheter 220. Guide catheter 220 may then be withdrawn to deploy expandable member 222 either within the defect or in the case of a PFO treatment, within the left atrium to be drawn back into the PFO. In some embodiments, expandable member 222 has one or more pre-shaped or shapeable distal tips 223. Tips 223 may be used, for example, to help locate and cross the defect. In the case of treating a PFO for example, tips 223 may also be used to contact a left atrial surface of the septum primum or other PFO tissue, so that when the expandable member 222 is pulled proximally tips 223 help bring the PFO tissues together and/or anchor apparatus 200.
In some embodiments, one or more expandable members 222 may include or be coupled with one or more energy transmission members. For example, expandable member 222 may include one or more radiofrequency transmission members for monopolar or bipolar RF transmission. A fish mouth expandable member 222, for example, may include a bipolar RF transmission member on each prong of the fish mouth. In some embodiments, energy transmission members may be included in or coupled with both expandable member 222 and tissue apposition member 212. In any such embodiments, some portions of the energy transmission member(s) may be insulated, to prevent unwanted energy transmission to tissues. For example, in some embodiments a distal tip extending to contact a left atrial surface of PFO tissues may be insulated to prevent energy transmission from the tip.
Referring now to
Apparatus 300 may include any of the features described above in relation to
Referring now to
In use, catheter device 410 is typically advanced over guidewire 420 to a treatment location. Split portion 422 and optionally distal tip 423 are then used to help appose the tissues adjacent the defect. Before, during or after retraction of guidewire 420, energy transmission portion 432 is retracted into tissue apposition member 412. Defect tissue is then brought together using tissue apposition member 412, and energy is transmitted to the tissues using energy transmission portion 432. In some embodiments, tissue apposition member 412 provides for application of vacuum energy to the tissues to suction the tissues at least partially into tissue apposition member 412, thus enhancing contact of the tissues with energy transmission portion 432. Energy transmission portion 432 may comprise, for example an electrode mesh material, while tissue apposition member 412 may comprise an elastic coated mesh or other material. Again, any features described above in reference to other embodiments may be applied to the embodiment shown in
With reference now to
Referring now to
II. Application of Energy
Generally, devices of the invention apply energy tissues using one or more energy transmission members (ETM). Such ETMs are typically described as electrodes, such as RF electrodes, for example as electrodes 214, 313, 314, 1213, 1313. In various embodiments, however, an ETM may comprise any of a number of devices and may transmit any suitable type of energy for closing a n anatomic defect. Some types of energy which may be used, for example, include radiofrequency, cryogenic, resistive heat, ultrasound, microwave and laser energy. Radiofrequency ETMs may be either monopolar or bipolar, with monopolar catheter devices also including a grounding member. Energy transmission members may have any suitable configuration. For example, they may have a curved shape to approximate a radius of curvature of the defect, as shown in
Referring again to
Electrode 1213 also includes a guidewire port or ports 1214 for passage of a guidewire 1211. Guidewire port 1214 may be centrally located on the electrode face, or offset depending on the desired approach to the defect. The outlet of guidewire port 1214 may have a counter-bored, chamfered or rounded leading edge to provide for smooth guidewire passage. In various embodiments, electrode 1313 may have one or more than one guidewire port 1314. Is some cases, guidewire port 1314 is centered on electrode 1313, while in other embodiments, one or more guidewire ports 1314 may be located off-center on electrode 1313 as in
As mentioned earlier, the phrase "tissue welding" herein is used to mean application of energy to (or removal of energy from) defect tissues to substantially and acutely close the defect. Energy transmission members generally provide for transfer of energy to or from PFO tissues to denature collagen in the tissues, and when the collagen is allowed to renature, with the tissues apposed, the once separated tissues bind together to form a stable tissue bridge. This stable tissue bridge substantially and acutely closes the PFO, preferably permanently. PFO tissues may, in some embodiments, be brought and held together by one or more tissue apposition members 212. Energy transmission members provide sufficient energy transfer, for a sufficient time, to weld the tissues. The time span of energy transmission may be, for example, from about 0.5 seconds to about 15 minutes, and more preferably from about 30 seconds to about 5 minutes. Energy transmission, in some embodiments, may be from about 0.5 Watts to about 100 Watts, and more preferably from about 2 Watts to about 40 Watts. Any other suitable energy and timing combination may also be used. In one experimental example, a PFO in a section of pig heart tissue used ex-vivo in a flowing saline test fixture was closed by applying suction to appose the PFO tissues and applying RF energy at approximately 25 watts for 7 minutes. RF energy application was then discontinued, but suction was continued for an additional 1 minute to keep tissues in apposition while the tissue cooled, to allow collagen in the tissues to reorganize and bind together to form a stable tissue bridge. Many other energy amounts, energy application times, tissue apposition times and the like are contemplated, however. Similarly, in the event that devices of the present invention are employed for ablation of EP defects, a variety of temperature, power and time combinations may be used.
Although any type of energy may be transmitted by ETMs, some embodiments will make use of monopolar or bipolar RF energy. Devices may use monopolar radiofrequency energy, for example, wherein energy is applied simultaneously to all conductive elements, completing the circuit through an external ground pad affixed to the skin of the patient. Alternatively, bipolar energy may be applied to all conductive elements simultaneously, and the circuit completed through a ground element incorporated elsewhere on apparatus 200. Further embodiments may include applying bipolar energy between two or more ETMs, which are electrically isolated from one another within catheter device 210.
Control systems coupled with ETM or tissue apposition member 212, or otherwise disposed within apparatus 200, may sense an amount of energy delivered to PFO tissues and, optionally, may automatically stop energy delivery upon detecting a change in condition of energy delivery, for instance an increase in electrical resistance or impedance or rate of change in impedence, in PFO tissues or in apparatus 200, an increased energy draw from the treatment apparatus, and/or the like. In some embodiments, energy delivery may be automatically stopped when an amount of delivered energy reaches a desired level, such as an amount of energy sufficient to substantially close the PFO. The amount of delivered energy may be monitored by any suitable method, such as monitoring temperature or impedance in PFO tissues or the like. In some embodiments, one or more sensors coupled with tissue apposition member 212, ETMs, or any other part of apparatus 200 may be used for monitoring such indicia. Examples of sensor devices include but are not limited to infrared sensing devices, thermistors and thermocouples. A control system may also include a microprocessor coupled with the sensors to determine when a desired amount of energy has been delivered and/or to automatically stop energy transmission. In alternative embodiments, a microprocessor may be included in apparatus 200 which can sense, monitor and control energy delivery, thus not requiring separate sensors.
III. Method of Treatment
That being said, in one embodiment, a PFO treatment method includes advancing a guide catheter 720 through the PFO, between tissues T adjacent the PFO, the guide catheter 720 containing an expandable member (
Once guide catheter 720 is in place and expandable member 722 is deployed, catheter device 710 may be advanced over guide catheter 720 to a position for treatment of the PFO (
Next, as shown in
Once the tissues T are contacted with the electrode, energy may be applied to the tissues T via electrode 802. In some embodiments, vacuum force may first be stored in a reservoir and may then be applied to the tissues T as an impulse of vacuum to quickly form a seal and thereby minimize loss of blood from the patient. The vacuum force applied ensures that the flap of the defect furthest from the vacuum application member is snugly apposed with the flap nearest thereto. In addition, in cases where the defect is an opening and not a flap, applied vacuum force is typically sufficient to bring the tissues to be sealed in contact with each other. A number of PFO defects are accompanied by aneursysmal disease. In some embodiments, in addition to treating a PFO a method may also tighten or reinforce the septum of the heart, thus also treating the aneurysmal disease.
In some embodiments, irrigation fluid may be circulated through device 800 to irrigate the area of energy application to the tissues T. Such irrigation fluid may be circulated within vacuum housing 804, for example, by introducing fluid through a lumen of device 800 and then using the vacuum force to bring the fluid back into the lumen. In some instances, fluid flushing is used to prevent clotting and/or blood accumulation in housing 804. For this purpose a nonconductive fluid such as heparinized D5W may be used. In addition or alternatively, saline may be used to prevent clotting within the patient and/or device 800 (e.g., electrode housing, catheter lumen(s), or the like). Saline may also be employed to affect the heating characteristics of the desired treatment. Infusion may also act to cool the tissue interface, thereby preventing rapid tissue necrosis.
The procedure may be monitored in several ways. In some embodiments, the fluid brought back through device is monitored for color, to determine when there is little or no blood in the fluid, thus helping to determine when a seal has been acquired and/or the PFO is closed. It may also be desirable to measure the impedance of the treatment region to determine if a seal is being maintained (impedance of blood is lower than tissue, so a change may indicate the presence of blood (leak) or lack of seal). Alternatively, an optical detector may be employed to control vacuum and shut off the force if blood is detected in the evacuated fluid. Similarly, the rate of extraction of fluid may be monitored and calculated to ensure that the rate of extraction equals that of infusion. In many cases, it may be sufficient to infuse fluid "passively" (from an IV fluid bag), e.g. gated by the rate of vacuum, to form a "closed loop" system where the rate of suction and aspiration maintain a seal on the defect site to allow the thermal energy treatment of the site. For safety purposes, a suction lock apparatus as is known in the art, may be employed on the proximal end of the catheter to ensure that fluid is not inadvertently extracted from the patient. Alternatively, the rate of extraction of the fluid from the supply reservoir (e.g. an IV bag) may be monitored to detect whether or not a seal against the tissue has been achieved. If a seal is achieved, the flow rate from the reservoir will increase. If a seal has not been achieved, or has been lost, passage of blood into the housing will predominate, slowing the flow rate from the reservoir.
The foregoing devices are particularly appropriate for welding of tissues where a device can be applied against two layers of tissue with or without suction as described above. However, some tissue defects, such as ASDs, VSDs, and similar defects, have a hole which must be closed. This means that the tissue must first be drawn into apposition either by vacuum or mechanical approximation before applying energy to weld those tissues together. One device which would be effective in drawing the tissues surrounding such an opening together was described in U.S. patent application Ser. No. 10/811,228 (Attorney Docket No. 022128-000400US) filed Mar. 26, 2004, which was previously incorporated by reference. This device described a tubular expandable clip with multiple distal-facing tines, mounted around an expandable tubular balloon. The balloon could be positioned in the defect and inflated until the balloon diameter is as large as the defect, while the clip and tines are proximal to the defect. The balloon and clip could then be advanced through the defect until the tines of the clip pierce the tissue surrounding the defect. The balloon could then be deflated, causing the clip to also contract radially, gathering the tissues together. Energy would then be applied to the tissue, either using the clip itself as the electrode, or an electrode on the surface of the balloon, or an entirely separate electrode. This energy would serve to weld the tissues in their gathered state. After welding, the balloon and clip could be withdrawn from the tissue, leaving the welded defect with little or no residual opening. This is only one exemplary device which could be used to draw the tissue surrounding an opening in a tissue structure together in order for the purpose of welding the tissue together. A PDA might also be closed using the balloon device described in the material incorporated immediately above, which would gather the tissue of the walls of the PDA together before applying energy.
As mentioned above, the foregoing method may be altered in any number of ways without departing from the scope of the invention. In some embodiments, for example, tissues adjacent the defect are brought at least partially together and energy is applied to the tissues to acutely close the defect with fewer steps and/or fewer device components than just described. For example, application of suction to appose tissues is not required in all embodiments. Furthermore, a variety of different types of energy may be applied to the tissues from a variety of differently configured energy transmission devices. In some embodiments, one or more of the steps described above may be repeated one or more times, such as by repeating a tissue welding step. The above description, therefore, is provided for exemplary purposes only.
IV. Catheter Device Additional Features
As is described above, and with reference now to
Referring to
With reference now to
Referring to
In other embodiments, and with reference to
Referring to
In an alternative embodiment, with reference to
In yet another embodiment, shown in
In one embodiment, and with reference now to
Referring now to
As shown in
Referring to
In some embodiments, and with reference now to
As already mentioned,
Referring to
In another embodiment, and with reference now to
Surfaces 1934, 1936, 1938 of electrode 1930 may have any suitable shape or configuration. In the embodiment shown, surfaces 1934, 1936, 1938 have a pattern generally radiating out from the center of electrode 1930, which may be advantageous due to the behavior of the current, which generates in a radial pattern. Additionally, the electrodes struts used to form surfaces 1934, 1936, 1938 may have any suitable thickness (short, solid-tipped arrows), and in some embodiments may have variable thicknesses. Any suitable combination of features for providing variable energy delivery is contemplated within the scope of the invention.
Referring now to
Although the foregoing description is complete and accurate, it has described only exemplary embodiments of the invention. Various changes, additions, deletions and the like may be made to one or more embodiments of the invention without departing from the scope of the invention. Additionally, different elements of the invention could be combined to achieve any of the effects described above. Thus, the description above is provided for exemplary purposes only and should not be interpreted to limit the scope of the invention as set forth in the following claims.
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(+632) 8450268(+63917) 8135637info [at] tosolve [dot] com [dot] ph
Welcome to the Official ToSolve Website
Thank you for your interest in our company.
As the Philippine sole distributor of ZW3D, we are dedicated to promote affordable CAD/CAM solution without compromising quality and support.
Our roster of hardworking and success-driven team will ensure that pre and post sales are done with utmost customer satisfaction.
Through this site, we aim to provide you with up-to-date news about our products, services, on-going promos, activities and more!
ZW3D Hybrid Modeling
Unique Solid-Surface Hybrid Modeling technology can unleash your 3D design ideas by breaking down the boundaries between solid and surface features. It provides designers with more creativeness and opportunities.
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Pricing Strategy – Did You get it Right?
Pricing your product is one of the most critical steps in getting your business right in the market. Figuring out how much a product is worth and what might be a fair pricing in the market can be quite a tough task for any business. Pricing, unlike what it seems, is a very complex area. Get it right- the profits will just flow in. Get it wrong - your business is going to shut down even before you know it.
Pricing - Basics and More
So what does it take to get your pricing right and increase your likelihood of success? When it comes to pricing, the saying stands true - poor planning leads to poor performance. Pricing of a product sends a lot of messages to your consumers and helps your brand to position itself in the market as well as people's mind.
For instance, you are at a perfume counter and want to buy a gift for your friend. If you are a person who are not very up-to-date with perfume brands, pricing is the only way that you can consider the quality of a brand or whether it's a cheap imitation of a big brand.
Of course, merchandising and packaging helps, but pricing is very important. So here are key questions that you need to ask yourself before setting a price for your product.
- Is your product new in the industry?
- Who is your target audience
- What does your consumers currently use or might compare your product with when they are shopping?
- What are the benefits that you offer with your product?
- Will these benefits make a difference to your consumers and are they willing to change and try your product for these benefits?
- How affordable is your product?
- Who is your competition?
- What price does your competition charge for a product similar to yours?
- How is your product different from your competition's product?
- Do you see a repeat purchase of your product or is it just a one-time purchase?
- Is there anything consumable attached with your product?
- What kind of risk a consumer might be taking by choosing your product over their usual product?
- Are you offering any guarantee or reassurance?
Answering these above questions will surely help you to understand better where your product stands in the market and how willing your customers might be in trying your product. Pricing also depends upon your targeted audience's standard of living and their affordability.
Our tool will help you figure out your pricing strategy against other products in the market. Since pricing is a very important factor in the success of your business, it's important that you consider this decision crucial and take your time in making the right choice. Since it's always not possible for you to hire an expert who may or may not be able to give you the right advice, using this tool is the most accurate way to find out an effective pricing strategy.


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- 800.878.7323
More copies of this ISBN
Other titles in the Ultimate Kauai Guidebook: Kauai Revealed series:
Ultimate Kauai Guidebook 5TH Editionby Andrew Doughty
Synopses & Reviews
Publisher Comments:
The finest guidebook ever written for Kauai. This brand new fifth edition has more useful information, the most up to date maps and scores of hidden gems listed nowhere else. This book and a rental car are all you need to discover what makes the Garden Island so special. Maps include beach access to even the most remote beaches, mile markers so you always know where you are, hiking trails and numerous details in an easy to follow format. Symbols quickly identify recommended sights and companies. We identify which companies really are the bestand which to avoid. Special expanded sections on Hiking and Adventures. Clear, concise directions to get to those hard to find places. Web site with links to every business, last minute updates and more. Plus Web pages available exclusively to our readers that expand on all accommodation reviews with aerial photos of all the resorts (so you'll know if oceanfront really means oceanfront). Written by Kauai residents who know the island. Frank, honest opinions from anonymous reviewsNo advertisements. We've covered it allfrom the top of Wai[ale[ale to the sparkling underwater reefs. This is the best investment you can make for your trip to Kauai. Whether you are a first time visitor, or a long time Kama[aina, you will find out more about the Garden Island from this book than from any other source.
Hailed by "Islands Magazine" and "Conde Nast Traveler" as "the best Kaua'i guidebook." This new editions reveals even more hidden gems, a 64-page "Activities" chapter, and a unique "Adventures" section. A comprehensive, humorous and easy-to-use guide.
Most travel titles are put together in a few weeks by visiting travel writers. Wizard guidebooks take over a year to compile and the writers are residents who personally and anonymously review every facet of the island. Their maps are the best you'll find. From restaurants to helicopter companies to scuba to beaches to trails. They see it all and show you the best the island has to offer. They also reveal who's the worst and who to stay away from. All told in a frank, humorous way that keeps the reading fun.
The finest guidebook ever written for Kauai and the only one written by writers who anonymously review the island. They visit every beach, restaurant, activity and trail on the island. The result is this comprehensive, humorous and easy-to-read full color guide that will lead you to more adventures than any other book. A must for travelers.
Table of Contents
ABOUT THIS BOOK INTRODUCTION How It Began The First Settlers Ni[ihau THE BASICS Getting Here What to Bring Getting Around Getting Married on Kaua[i Weather Geography Hazards Traveling with Children The People The Hawaiian Language Music The Hula Books A Note on Personal Responsibility Miscellaneous Information The Internet NORTH SHORE SIGHTS Anahola Kilauea Kalihiwai Princeville Hanalei Ha[ena North Shore Shopping North Shore Best Bets EAST SHORE SIGHTS Wailua/Kapa[a Lihu[e East Shore Shopping East Shore Best Bets SOUTH SHORE SIGHTS Koloa Po[ipu Kalaheo South Shore Shopping South Shore Best Bets WEST SHORE SIGHTS Hanapepe Waimea Kekaha Polihale Waimea Canyon West Shore Shopping West Shore Best Bets BEACHES Beach Safety A Word About Shells North Shore Beaches East Shore Beaches South Shore Beaches West Shore Beaches 1 ACTIVITIES ATV Biking Boogie Boarding Camping Fishing Golf (Powered) Hang Glider Helicopters / Air Tours Hiking Horseback Riding Jet Skiing Kayak Land Tours Ocean Tours Parasailing River Trips SCUBA Diving Snorkel SNUBA Spas 173 Surfing Tennis Tubing Waterskiing Whale Watching Windsurfing / Kiteboarding ADVENTURES Na Pali Kayak Trip The Kalalau Trail Ni[ihau Scuba Dive [Opaeka[a Falls Hike Makaleha Hike Blue Room Honopu Ridge Hike Mountain Bike/Hike Secret Tunnel Hike DINING Restaurant Index Island Fish / Seafood Lu[au Foods Other Island Foods North Shore Restaurants East Shore Restaurants South Shore Restaurants West Shore Restaurants Island Lu[aus Dinner on a Beach Island Nightlife Dining Best Bets WHERE TO STAY Where to Stay Index North Shore Accommodations East Shore Accommodations South Shore Accommodations West Shore Accommodations INDEX
What Our Readers Are Saying
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Product Details
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Related Subjects
Travel » North America » United States » Hawaii


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Volleyball Camp at Brown University
Athletic Camps on the Brown Bears Campus
Each camper must be registered separately.
Online registration for this camp closes on July 27, 2015 at 11:59 pm provided the camp has not sold out prior to this date. Registration may be available onsite during the camp check in on a first come first serve basis.
Ideal camp for those players who want to strengthen their individual and team skills and prepare for try-outs and future competition.
Brown University Sports Camps are open to any and all entrants that meet the listed age requirements for each camp.


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Please send me a message if you have a Toy Story Buzz Lightyear vinylmation you would like to trade or sell.
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Celebrate Thanksgiving Kentucky-style with this festive cocktail, a tasty blend of cardamom-infused Wild Turkey bourbon, lemon juice, Campari and demerara syrup. One sip of this delicious cocktail and you'll be talking with a smooth Southern drawl.
Kentucky Thanksgiving
Courtesy of Wild Turkey Bourbon
1.5 oz. Wild Turkey Thanksgiving Infusion (see instructions below)
1 oz. lemon juice
.25 oz. Maraschino Liqueur
.25 oz. Campari
.5 oz. Demerara syrup
Shake ingredients and strain into a coup or martini glass. Stir and garnish with a wide lemon disc twist.
In a wide-mouthed glass infusion jar place 1 liter of Wild Turkey 101 and 2 barspoons of cardamom seeds. Close and leave in a dark cool place for 1 day. Strain out cardamom and add 1.5 cups dried unsweetened cranberries and 3 sticks of cinnamon. Close and leave for another two days, agitating once per day. Strain solids and store in the original Wild Turkey bottle with proper labeling.
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This 1954 Kaiser Special is a nice example of this very rare car. Priced to sell - call for details!... More
If you are ready to build a car, then we have the perfect car for you to start with in this 1952 Kaiser Henry... More
~CALL US FOR A DETAILED DESCRIPTION OF THE CAR! WE DO A 150+ POINT CHECK ON EACH VEHICLE AND ARE HAPPY TO SHARE... More


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Here's a great example of a company with an effective concept and website to go along with it. A great company and a great business concept. Apartment Science in Houston, Texas is a service that uses an entertaining approach to finding your next rental. Search the website to find properties you have chemistry with and fill in your information by placing the Lab numbers that you are interested in. They will send you a detailed listing of all of your choices. Well.....yes. You use this site to find an apartment, but what makes it different from the others? There are several reasons.
• This company is run by licensed Real Estate agents.
• They claim to have more data than any other service of its kind.
• They do all of the legwork for you.
• The listings are comprehensive and doesn't skip any information.
• Their website is fun and engaging.
• They offer a $200 rebate upon verification of a signed lease, when you say that they referred you.
That last part? Yes you get a $200 refund. When visiting the apartments, list Apartment Science as your referral source on the guest card and/or rental application. Once you signed a lease agreement and have your move in date, they begin processing your refund. Now that is something worth noting!
There's a fun infomercial on the homepage that explains the entire scientific but simple process. What makes it so simple is that the company does everything for you. Their listings include Houston apartments, town homes, lofts, condos, and more. They have connections with property managers throughout the Greater Houston area which allow them premium access to current specials and availability. You don't have to do a lot of driving and searching. You can search through some of the site's listings but Apartment Science will offer more suggestions based on your search criteria or 'Lab Report'. If you are searching in the Houston Area, check out the site. You'll be glad you did.
Go to www.apartmentscience.com or call 832-409-4059 for more information.
They have Got Your Apartment Search Down To A Science!


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I am 17wks as of yesterday and still haven't really felt any kicks. This is my 3rd pregnancy and I'm pretty sure that by now I was already feeling my son's kicks and positive I was feeling my daughter's kicks by now. I'm just worried something is not right with the baby. I'm also already experiencing BH contractions, which isn't really unusual for me. I felt them at 13wks with my son and these began about 2wks ago. Has anyone else not felt kicks? And is anyone else experiencing BH contractions?Ā
No kicks at 17wks? BH contractions anyone?
Proud mommy of Ashleigh (9/28/06), Mason (10/25/10), and Eli (10/3/11).
Comments (9)
Yes, to both questions....this one has been kicking me since 16 weeks..I couldn't believe it because I didn't feel my son kick me until at least 22 - 23 weeks along. I do experience BH after a work out or after having sex.
Mom to a one-year old and expecting #2 on October 16th!
I felt my daughters' kicks really early in my last pregnany.┬Ā I'm am now 18w4d and just started feeling him yesterday.┬Ā I never experienced BH with my daughter and have not yet felt them with this one.┬Ā
Wife to Jim June 9th 2007
Mommy to Brenna (6/20/10) and Collin (10/18/11)
i feel the kicks i actualy can see them and i get BH every once in a while not that much i had them a lot with my son
Expecting Boy #2 :)
Fall 2011 babies/No negativity Group
This is my second time around, and I'm 17 weeks and 2 days. ┬ĀI haven't felt a thing! ┬ĀIt's making me so paranoid. ┬ĀI never had BH with my son, and I haven't had any yet with this one either. ┬ĀMy next appointment isn't for another 2 weeks, so hopefully I'll feel something by then or I'll just be a neurotic mess while waiting.
I'm 20 weeks and only felt my baby move MAYBE 3 days. I haven't felt her move at all today. I just think she's lazy
No BH here but I never had┬Āa single one (that I noticed) with my 1st. And, it took a lot longer to feel movement this time around.┬Ā Nothing really consistent until a little over 19 weeks.┬Ā I felt my daughter consistently at 17 weeks.┬Ā I do know from my last appointment that I have an anterior placenta b/c the dr. had a hard time hearing the heartbeat and said my placenta was anterior.┬Ā I'm wondering of that's why he or she is harder to feel...
Mom to Maryn Kathleen 3/17/2010 and Brynlee Sue 10/1/11
I'm 16w5days and 2 days ago i had a good rumble, but after that its faint... I think i occasionally get little flutters, but they are so faint i'm still wondering if that's what really going on. As long as i can feel him/her move (lump wise) in my stomach for now i'm good. But i'm desperately awaiting more and more movements
Ugh! Can't wait to smell her :-)
Im 18 weeks and not feeling anything. I had some flutters weeks ago then it just stopped out of no where. I asked the Dr and they moved up my sono appt. The baby has a normal heartbeat which is the only thing thats keeping me from not freaking out.
I'm in the same boat!┬Ā I'm hitting 19 weeks today and not feeling anything much.┬Ā Levi was much more of a kicker.┬Ā I'm wondering if this baby is just more calm ;)┬Ā I've also had some BH which I didn't have with Levi until the end of the pregnancy.
Married to Tell 06/07/08
LeviĀ10/19/09 Next LO due 10/16/11


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Why use Tart Cherry Ultra?
Tart Cherry Ultra contains beneficial flavonoid compounds called anthocyanins, which give tart cherries their bright red color. Anthocyanins are potent antioxidants that help to prevent oxidative damage.*
Three capsules daily. If pregnant, nursing, or taking any medications, consult a healthcare professional before use.
† Based on 2000 calorie diet.
plant-derived capsule (modified cellulose), cellulose, magnesium stearate, silicon dioxide
While it's difficult to compare to Tart Cherry concentrates, we can make an equivalent comparison to cherries. Our tart cherry supplier uses 95 pounds of tart cherries to make one pound of the concentrate used in Tart Cherry Ultra. That translates into each bottle of Tart Cherry Ultra being equivalent to 7.5398lbs of tart cherries—or approximately ¼ lb. of tart cherries per serving (7.5398 divided by 30 servings per bottle).
†† For homeopathic products: these indications are based solely on traditional homeopathic use. They have not been evaluated by the Food & Drug Administration.
* For dietary supplements: this statement has not been evaluated by the Food & Drug Administration. This product is not intended to diagnose, treat, cure or prevent any disease.


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You can now invite anyone to meet at your favorite Starbucks.
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31 year old man | Washington, DC, USA | Seeking women 21-31 in District of Columbia, United States
Active within 3 days
Grad student/ College Swimmer
I am a retired competitive swimmer. Going to grad school, currently applying for federal jobs as a cop. I love sports and to travel, and being tan naturally. Been to a lot of states, and to very limited amount of foreign countries. I speak a very limited amount of Quebecois French, and love accents haha. I love all sports, especially collegiate and Detroit sports teams. I love to explore...anything. I read alot, and love to visit historical places and sights. Love going to movies and just hanging out low key-ish. I love to joke around, and find comedy a great trait. Just ask for more.
Alumni connections , Coffee and conversation , Cooking , Dining out , Hobbies and crafts , Movies/Videos , Museums and art , Music and concerts , Exploring new areas , Nightclubs/Dancing , Performing arts , Playing sports , Political interests , Travel/Sightseeing , Video games , Watching sports
Baseball, Basketball, Billiards / Pool, Bowling, Football, Hockey, Inline skating, Other types of exercise, Swimming, Weights / Machines
I exercise 3-4 times per week.
I have Cats
I like Birds, Dogs, Exotic Pets, Fish, Horses, Other
2 kitties. 1 is very smart, the other: dumb as a rock.
Great Lakes, open road, the basement, anywhere exotic.
Michigan State University, East Lansing, MI
All kinds, except twangy country. Not a big fan of depressing music either.
Movies, Museum, Sport Events, TV, Books
Consent to Kill by Vince Flynn, The Terrorist Watch, but I read constantly.
Z{{Cta}} {{#if HasMoreInfo}} ?{{CtaSecondary}} {{/if}}
|What he is looking for
|6'3" (190cms)
|5'0" (152cms) to 6'6" (198cms)
|Body type:
|A few extra pounds
|Slender, Athletic and toned
|Black, Blue, Brown, Grey, Green, Hazel
|Light brown
|Auburn / Red, Black, Light brown, Dark brown, Blonde, Salt and pepper, Dark blonde, Platinum
|No Way
|No Way, Occasionally, Yes, but trying to quit
|Social Drinker
|No preference
|No preference
Work in a Law firm, going to graduate school for Law Enforcement. Smoke cigars occasionally, never touche cigarettes.
|$35,001 to $50,000
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French-Candian, German, Irish, Sardinian, Polish.
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|English, French
|Graduate degree
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