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|24 posts found
Novice Member
Joined: 1/07/04
In this Wednesday's column, Jess Lebow presents "Design By Bug," an insider's look at how most MMOs are really assembled. Lebow has worked on Pirates of the Burning Sea and Guild Wars, as well as a being a novelist and writer for Wizards of the Coast and Magic the Gathering.
Each Wednesday, his column appears exclusively on this site.
Check out Design By Bug.
Dana Massey
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Novice Member
Joined: 3/04/04
That is just my opion and we all know what THAT is good for!
Now THAT was freakin hillarious! Good story.
Say hello, To the things you've left behind. They are more a part of your life now that you can't touch them.
Advanced Member
Joined: 6/22/04
Good wrte-up. I'd really love to see this expanded upon in future articles.
An aside to mmorpg.com, I like the new columnists you've been adding recently. Sanya and Jess are nice additions. I'm going to have to look at some of the other writers now to see if anyone else is new. Keep it up!
Novice Member
Joined: 6/18/03
Great anecdote! It exposes a rarely talked about but oft experienced side of the creative process.
Elite Member
Joined: 1/06/05
I'm assuming that that "window" thing was in Guild Wars as I've witnessed that exact stame story telling mechanic in that game.
Thanks for the article. - S
Elite Member
Joined: 8/27/04
Perhaps tomorrow will be better.
I wish i could remember the game but i cannot.Just in the last week there was one developer on this site that stated they actually had no vision,they created the game as it went along,and it was a big name title so ,not every game is well thought out before hand.
I tend to feel from my long experience around gaming that MANY developers grasp onto one or two niche ideas and go from there.When i see the mobs out in the world i also get the feel the world was just automated and the mobs scattered around with no planning.
Quests...i see oh so many quests that are just fetch me quests and the side show ones just make you wander as far as they can to make you waste time.Planning?i don't buy it,most games are just money making ventures,we need true gamers to make games and not these old fashioned MUD geeks or some coder that spends 12 hours a day reading all the different languages.
How many games hire the main manager ,AFTER the game has already been implemented or in progress?I know WOW was looking for a lead direction manager on their secret MMO.So how can they already have a secret MMO thought out before they even have a lead manager?This is probably the BIGGEST reason we see so many poorly constructed games,they are not well thought out by true gamers,but more so started by a lead CEO who is thinking money and marketing.
Time frame? how can a developer put a time frame on developing a game ,if they have a vision?they have no idea how long it can take,they can guesstimate within a year i would say but nothing more.This is again why we see so many incomplete games,because the CEO has put a time limit on development and anything over that costs the developer money.So he has to save face by mis quoting cost of production by forcing early release.
You have some good points. And we could argue about hiring strategies for all eternity. I could even give you a bunch of really good reasons for why you might hire a lead designer/creative/manager after you've already established funding. But none of those reasons is ideal, and as you say, the person or persons driving the vision of the game should be in place long before you get into real production.
I can't speak for other companies, but when I was working on this particular game (which was correctly guessed as Guild wars), the key visionaries were hired before production ever began. I am a firm believer that this is why the game hangs together so well and does not, as you point out, make players do a lot of unnecessary or mindless questing. Could some of the design or story have been better or tighter? Sure, but my point is the more planning you can do up front the better your game will be. We did a lot, and the game was well-received because of it.
As far as timeframe, well, as an industry we've made a lot of games. We have a pretty good idea how long it should take at this point. But again, I would acquiesce and say that you are essentially right. There is probably a variation from project to project of about one year. I've never worked on a game that didn't slip at least a year. Again, that was my point. That MMOs just take a long time to make. Usually longer than you expect.
Novice Member
Joined: 1/07/04
Originally posted by JDexter
Right now we're running with four columnists, but the more you guys read/react the more I will try and bring in. =) All four are listed on the main page just under the square ad.
Dana Massey
Novice Member
Joined: 4/16/06
Well then, I will add a vote to bring in more columnists. I find it very interesting to get a glimpse behind the curtain of game development. And these articles have the added bonus of being intelligently written. I'm enjoying them all.
Novice Member
Joined: 9/17/04
Good article. It's nice to see more news items like this related to MMO's as a whole starting to pop up.
Advanced Member
Joined: 1/19/06
I like to hear about the insights of how games are made. Stuff like this, I didn't even think that developers even did, running an escort quest. I just assumed this stuff worked as the code was written haha.
It's funny to see a dev get confused about stuff like this, good read....Also, I too also like this new columns into the insights of MMOs. There is so much stuff people like me take advantage of and have no real clue of the behind the scene's stuff. Like, the "Server Stability Blues" article, I just assumed when a server died, it was because the hamster had a heart attack or something!
Novice Member
Joined: 8/08/04
Good article. Now I know more of the story of Prince Rurik's rescue mission.
Advanced Member
Joined: 1/09/08
my thoughts exactly
Hard Core Member
Joined: 2/27/07
Well Jess, the big problem with game design today is that the developers use existing MMO's as a boilerplate for their ideas. Hardly original and the reason the industry has not had much glowing success lately with new MMO's.
You can lay the blame for this directly at the feet of Smedley and McQuaid for their design of EQ. They were the ones who instigated rigid class lines and levels in MMO's. Probably the D&D people are equally to blame as they probably influenced the development of EQ. Now most developers out there are afraid to break the mold.
So a design meeting today starts out with what is good that we should copy from other MMO's and is there something we should change in the way it works. That is the problem, there is no originality of thinking any more. All I see any more is a dumbing down of the genre. Developers seem to avoid having players work for anything.
So discussing how a game gets designed today is more like how can we copy so and so and avoid making anything challenging.
Apprentice Member
Joined: 5/13/06
There are only 10 kinds of people in the world. Those that understand Binary and those that do not.
LOLOL, This article is great and I can defintely attest to some of the same issues while developing Force of Arms. I was working on one quest in which I had to go fetch something from an NPC. Everything spawned just fine the whole quest was working except for the several iterations of re-writing the quest text because it was too long. I got to the part where I had to talk to the NPC and forgot code had called for a Patrol for the npc so that he would continue randomly running along a path. Well as I click on the NPC and go to move the quest to the next stage the NPC runs off and closes my window. So i run after him and try again. He repeats and I try again....5 times just to try to get the quest finished because of one line of code that sends the NPC carreening off at warp speed in a random direction for so many seconds...lolol
Great read...feel your pain brother...oh and I have since fixed that darn quest so he's more stationary ...:D Now npc's are put in first as static and then later given attributes like patrols...
While I can't entirely disagree with you, I do believe there is value in knowing the marketplace. There are some mechanics that are taken for granted by the industry, and, well, they should be.
Everybody has gone through a change of operating systems, right? Maybe it was from Windows XP to Vista, or maybe it was Apple OS 9 to OS 10, or whatever. But do you remember how difficult it was to reorganize the way you thought about interacting with your computer? Nevermind if you liked the change or not, there was a period of exploration that was required by you, the user, in order for you to change your habits and learn a new system.
Sometimes that's necessary and good. But if it's done too often or without reason then you should really take a look at why you feel the need to reinvent the system. A good example of this in MMOs is the quest bang. People get it. You click on the guy with the shiny over his head, and he tells you something important. I, personally, have tried to find a system that would take the quest bang out of the equation. My goal was to more fully immerse players in the world, and not break the fourth wall by adding a piece of art that clearly doesn't belong. But do you know what I found? People understand what it means to click on an NPC with a bang. They know if they do they'll be given a mission. I don't have to teach them anything new. I don't have to worry about them getting lost. They don't have to be frustrated by a new, potentially complex set of rules, but can instead focus on the fun parts of game play. If your underlying system is quest based, then why change a delivery device that players all already get?
So there are things, a lot of things, that make sense to copy from previous games. But at the end of the day you are right in that the industry will never grow and we will never get the next generation of games if EVERYTHING is simply copied from the last game. (If the serial numbers are just covered up by a new art style.) I think you are right in that there needs to be more innovation, and that MMOs need to push the genre. Stories need to be better, game mechanics need to be mixed up and improved, and the overall box we are in needs to grow.
However, as far as laying the blame at someone's feet goes, I think you're being unfair. If you don't like a particular game, blame the lead designer or the founders of the company. But those guys aren't responsible for the game the next studio over is making. Saying that one or two high-profile figures are to blame for the lack of creativity in the industry is just wrong. If you don't like EQ or D&D, fine. But if the next game to come out is unimaginative, that's only the fault of the guys who made it.
Haha! I've had that problem too. NPC patrol routes are another one of those things, like escorts, that make sense but need some extra TLC to really work.
Advanced Member
Joined: 4/03/04
Assholes and Elbows! Stay frosty people...
Originally posted by Dana
I have to agree with the others, these new columns are a really interesting insight to the inner workings of the games we all love to play, most of which normally remains a mystery until we get to try them out ourselves.
Great Stuff!
Nice to meet you Jess!
Novice Member
Joined: 11/22/06
Good read as always!
I think the reasuring Daniel Jackson face is a cheat tho ;)
Maybe if you had a columist that looked like Jack Oneil or some other favored Character like Jean Luc Picard then I think people would read them no matter what was said xD
Anyway back to the article...
I think the last paragraph was most interesting, because as a developer you clearly stumble upon things which turn out to be great ideas, but this is also fun for players... MMO's are by now, known to most people and everyone comes to expect the usual, even in a different guise, but its those unexpected / random things which developers put in games which, for a lack of a better expression 'tickles the excitment'
If a developer could somehow add more of those random, un-expected things then maybe the mmo genré can be given a fresh breath of life.
At the moment, before an MMO is released we have loads of articles about how AMAZING and PERFECT the game is, everyones excitment reaches untold levels of anticipation, only to be completly let down by the usual grind fest. and cut'n'paste quests.
I read so much about AoC before it was released, I was so excited, but what a complete let down.
My only question would be, why dont dev's write more about the way they are developing thier game? not specifics of course but this idea of everyone getting together and brainstorming, instead of this cone of silence and the usual "this game is going to be awesome because x" attitude.
Novice Member
Joined: 12/30/07
Originally posted by Pemberton
I really liked this article. It reminded me of my very first escort quest, in EQ, CT, following the Gnome, killing spawned raptors. It was difficult and rewarding different and--most importantly--fun. Thanks for that. :)
Certainly knowing the market is good; reinventing the wheel is silly and evolving it or learning from it is not. Starting from scratch just for the sake of it would be hard on resources and probably manifest little gain--though, I don't work in the industry so I'm just making an educated guess. I do program, and Don't Repeat Yourself is a good principle.
I would absolutely love for the quest bang to disappear. I'm a big immersion player though; casual, but I don't want the game to be played for me (I'm looking at you, WoW). I loved "talking" to NPCs in EQ, and I'm really sad that isn't done anywhere else. Combine that with EQ2's voice-overs and it would be a great system--for me--and there's the problem. Every (good?) MMOG is a niche MMOG. I guess there isn't one for me yet. You can't please everyone, certainly not at this scale. I would love it if, instead of a "!" over their head, they said "Hey, come over here!" in their language when I came in proximity. If I hail them, they say something like "I could use some [help]". I get that introducing a new mechanic, like removing bangs for this, is different and scary, but as you said, when you go from PC to Mac you have to learn some new things. The problem I guess is two fold:
1. One needs to define who they're targetting. For me, it would be an RPer I suppose. Someone that enjoys pretending they're in another place, not so much getting to the highest level as fast as possible.
2. Are the changes an improvement? Are you pushing the genre? Innovating? Is it a good innovation? I suppose there could be bad innovations (like, IMHO, instancing).
I don't know of any MMOGs that do this currently, really. Nobody wants to make a difficult game, I guess because nobody thinks a sustainable amount of players want to play a difficult game. I don't count EQ anymore; that's a sad, abandoned, much too large a place nowadays. I'm glad some people are finally experimenting with skill-based games (I loved Shadowbane for this) and even no levels. The levels and classes always seemed (to me) to be a disconnected system that shouldn't be used, but served a purpose for players. I can't help but think that there's a more fitting way to do that, though.
I agree that there needs to be more innovation and experimentation. Maybe with cookie-cutter engines available, we'll see more of this. Unfortunately, we may also see a huge increase in the number of games (we are already), which may just fragment the population and make the games less MM, making experimentation more risky. I'm eagerly awaiting the Trion game, which sounds on paper like it will be more dynamic. Currently, games aren't much more dynamic than EQ was: simple scripts. The NPCs don't interact or react, really, there's very little AI. I think this is an area that could really use some attention. I read that Darkfall has better than usual NPC AI. Lore is sorely lacking also. Not the availability of it, certainly not, but the integration of it. I remember in EQ figuring out the lore as I was playing. Later on I read about some of it. In newer games, it's such a non-important part that it's almost irrelevant. I know almost nothing about WoW's lore, even though I played for years. I know the names of factions, but not their history. In EQ I learned that through reading NPC text (because you had to pay more attention), being KoS, watching NPCs fight each other, rather than clicking Accept and just checking how many Boars to slay.
Maybe it's just me, but I think the changes in questing have gone backwards in overall gameplay. They undermine some aspects of the game, but do make it easier to fly through to the higher levels, and probably ultimately raise subscriptions. I played EQ for over four years, and had fun for all four years. I played WoW since closed beta, but got bored after six months of release. WoW had a much longer tail in terms of my gameplay; it became a glorified chat server much sooner. If I had other things to do, I would've dropped it after those six months. Fortunately (if you're a Blizzard employee) I'm an anti-social nerd.
I do wonder, though, about "living" games. Writing above about EQ being too big and abandoned made me think about something I've thought would be good for the game, though risky, as all changes are. What if the game actually evolved instead of just getting fatter? Why do companies come up with a defined set of mechanics, and not change them later or implement new ideas? As far as I know, people don't patent things like public quests (yet). EQ's world is huge, and mostly empty. Everything post-Velious could be removed, nobody goes to old zones any more. These zones are wasted space and time, yet they keep adding new places. Why not change Blackburrow to a higher-level dungeon (perhaps gradually, perhaps affected by player action)? Put new quests in old cities, make the world more dynamic, integrated, dependent on itself. Sort of designers versus players. Maybe make magic items more rare, introduce damage to help money drain in the economy...there are a lot of things they could do to bring the game up to current gameplay standards and fix some problems, but they don't. The main idea is to make the world and it's mechanics evolutionary. I suppose they are worried about alienating their current players, but really I think EQ could last another 10 years if they did things like this.
Anyway this is probably a good time to stop. :P Thanks again!


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Originally written on Fox Sports | Last updated 11/12/12
Golden Tate opened the scoring by leaping over a cornerback to pull in a perfectly placed touchdown pass, then capped the day for Seattle with a TD toss of his own. In between those bookend moments, the Seahawks did their part in adding another chapter to the tough season of the New York Jets. ''My mindset is any time a get the ball I can make something special happen, a touchdown, a big first down in a crucial moment, a big gain, that's just how I am,'' Tate said. ''That's how I approach every single ball that comes my way because I don't know how many I'm going to get so I want to make the most out of every single ball that comes my way.'' Russell Wilson had two TD passes, before Tate's shot put TD pass to Sidney Rice late in the fourth quarter completed the Seahawks' 28-7 rout of the New York Jets on Sunday. Tate's 23-yard TD toss to Rice was punctuated by the receiver taking a bow to three sides of CenturyLink Field. It might as well have been a collective bow by the entire...
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subset: commoncrawl


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Kevin Remde's IT Pro Weblog
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When you're doing a Live Migration** of a virtual machine between hyper-v hosts, you want it to go quickly. You may be doing the migration of one or several or dozens of virtual machines all at once, and the performance of the network and the network paths you choose are going to determine how quickly you can get the job done. Yes, sure, in one sense it doesn't matter how long it takes if the VMs will continue to run and provide service during the migration. But if I'm doing, say, an automated update of all of the hosts in my cluster, and allowing it to drive the live migrations of machines among hosts, the speed with which those migrations complete will ultimately determine how long it takes to complete the updates of all of those hosts. If I'm really maxing out the capabilities of Hyper-V in Server 2012 R2 or Hyper-V Server 2012 R2, that could mean as many as 8,000 virtual machines moving around and among 64 clustered hypervisor nodes. So, speed is still important.
In the past, memory of a running virtual machine was just sent over the wire (TCP/IP) as it was. Nothing special was done to it. But as hardware costs have improved to support larger and larger scale, and as we're afforded the ability to run more virtual machines with more and more memory, we certainly want to do everything we can to make that transfer of memory and configuration data go as quickly as possible. So to address this and improve things, we've added two new technologies to hyper-v in Windows Server 2012 R2 and Hyper-V Server 2012 R2:
Let's talk about those, shall we?
Live Migration With Compression
Did you know that your hypervisor host isn't typically suffering much when it comes to processor capacity?
"I didn't know that."
It's true. So, what we're going to is borrow some extra CPU cycles while we're doing a live migration, and actually compress the migration data before it goes over the wire, and decompress at the destination.
If it sounds just that simple, well, it is. And it's just a simple choice in the Live Migrations –> Advanced Features settings on your Hyper-V hosts:
And as if that wasn't good enough…
Live Migration via SMB Direct (RDMA)
In Windows Server 2012 we introduced a new version of SMB – SMB 3. Among other things, this version of the protocol greatly improves performance; even to the extent that we can trust a basic file share to be the location for live data such as a virtual machine's hard disks and data disks, or a SQL Server database. (Click here for a good summary of what SMB 3 provides.)
SMB Direct (SMB over Remote Direct Memory Access, or RDMA) is technology that, given hardware (the NICs) supporting it, can establish an efficient memory-to-memory transfer of data. In Server 2012 the main beneficiary of this was faster file services. But in R2 we're using this to send live migration data between the Hyper-V hosts.
So now instead of just sending the memory and configuration of a VM over the wire using TCP/IP, or compressing it first, we'll use a direct memory-to-memory channel.
Can you say "FAST"?
I knew you could.
"But, can you give me an example? Can you show me how they compare?"
The best example I can give you is Jeff Woolsey's demonstration he did for the TechEd 2013 North America keynote this past June.
Click this link to watch his demo (at 1:56:15) : TechEd 2013 North America Keynote Video – Jeff Woolsey's Live Migration Demo
And for a more detailed description of Live Migration and the improvements made, check out this page: Virtual Machine Live Migration Overview
Questions? Comments? Make sure you add them to the comments at the bottom of this post! And try it out yourself by downloading the evaluations of either Windows Server 2012 R2 or Hyper-V Server 2012 R2.
**That's a 'vMotion' for those of you who are more familiar with the VMware terminology.
Two days of in depth talks on Hyper-V in San Francisco November 14-15 by the IT Pro community. More info at www.techdays.org
Thanks, Doug. Is Jennelle involved in this? I should hope so. :)
Yes she is. Hyper-V is a very hot topic for IT Pros right now and we are seeing lots of jobs for folks who know Hyper-V. These two days are meant to give IT Pros the latest in depth info on Hyper-V, VMware, High Availability and all the new storage options.
Fantastic! I wish I could join you guys there again. Say 'hi' for me. :)


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Chicory Belgian Endive with Cheese and Ham
|Chicory heads
|1⁄2 , juiced
|1 1⁄2 Ounce
|1 1⁄2 Ounce
|1⁄2 Pint
|Cheddar cheese
|2 Ounce, grated
|To Taste
|Ground black pepper
|To Taste
|Grated nutmeg
|1 Pinch
|Cooked ham slices
|For finishing
|Fresh white breadcrumbs
|1 Ounce
|1 Ounce
1) Preheat the oven to 400°F.
2) In a pan, bring salted water to a boil, with lemon juice.
3) Place the chicory in the boiling water and simmer for 25 minutes.
4) Pour of the liquid, reserving 1 1/4 cups .
5) In a saucepan, melt the butter and blend in the flour, cook for 2 minutes, stirring constantly.
6) Take the pan away from heat and gently stream in the milk and the reserved cooking liquid.
7) Return to the heat, allow the flour mixture to boil and reduce the heat and cook until thick, stirring constantly.
8) Stir in cheese, seasoning and the nutmeg.
9) Place each chicory wrapped in a slice of ham, in an individual heatproof serving dish and cover with sauce.
10) Dredge with cheese and breadcrumbs, dot with bitter and bake for 15 minutes or until light browned and heated through.
11) If you wish to freeze the dish, then do so at this stage. Wrap the each head of chicory in a ham slice and place in plastic container.
12) Stream over the sauce.
13) Allow to cool, seal, label and freeze the container.
14) Serve hot sprinkled with chopped parsley if desired.
15) If using frozen chicory, reheat from frozen, uncovered, in a preheated moderately hot oven for 30 minutes.
16) For finishing follow step 9.
17) Serve as mentioned in step 13.


text:
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Heard of the AMD VISION Engine?
Subject: Graphics Cards, Processors | November 15, 2011 - 05:22 PM | Jeremy Hellstrom
Tagged: AMD VISION Engine, amd, fusion, APU, steady video
The AMD VISION Engine is the name that AMD is using to describe the new features they are offering for users of their GPUs, APUs and those with both. One example is the AMD Steady Video feature that Ryan and Ken showed off in July. That is not all, this encompasses the hybrid Crossfire that exists in Llano laptops with discrete GPUs straight through to support for 30bit colour depth (aka 10bit per channel, 10 bit per pixel) and the GPU accelerated Flash.
If you are interested in getting more from your APU then head to the AMD VISION site to download their driver package, think of it as a Catalyst with benefits.
This one goes all the way to 11! The November Catalyst update is here.
Subject: Graphics Cards | November 15, 2011 - 05:06 PM | Jeremy Hellstrom
Tagged: catalyst, catalyst 11.11, amd
Head to AMD for your newest version of Catalyst as the November update arrives for download.
Highlights this month include:
- Adobe Flash Player 11 support
- Enables full support of the GPU accelerated Stage 3D API and Stage 3D applications
- Supported on the AMD Radeon HD Series of GPUs, A-Series APU and E-Series APU
Resolved Issues for the Windows 7 Operating System:
- Images and textures are no longer corrupted (Blue) in Rage.
- Bezel compensation now works correctly with Far Cry 2.
- Screen tearing is no longer randomly observed while moving a window on the desktop while in Clone mode or Eyefinity mode.
- A black screen is no longer observed when extending displays.
- Homefront no longer crashes randomly when Crossfire is enabled.
- DC – Universe Online no longer hangs soon after selecting a character and entering the game.
AMD Catalyst Linux introduces:
- OpenSUSE 12.1 early look support
- Seamless GPU Compute support
- The AMD Accelerated Parallel Processing (APP) OpenCL runtime is now enabled by default within the AMD Catalyst driver for Linux. Applications that leverage OpenCL for GPU based compute tasks will automatically benefit from the significant performance boost that this provides
The rest of the release notes can be found here.
Podcast #178 - EVGA GTX 560 Ti 2Win, a Puget Systems silent HTPC, Tegra 3 and more!
Subject: Editorial | November 10, 2011 - 04:39 PM | Ken Addison
Tagged: tegra 3, tegra, ram, Puget, podcast, nvidia, maingear, Intel, gtx560 ti, evga, corsair, amd
PC Perspective Podcast #178 - 11/10/2011
Join us this week as we talk about the EVGA GTX 560 Ti 2Win, a Puget Systems silent HTPC, Tegra 3 and more!
You can subscribe to us through iTunes and you can still
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- 1-888-38-PCPER or email@example.com
- http://pcper.com/podcast
- http://twitter.com/ryanshrout and http://twitter.com/pcper
- 0:02:55 EVGA GeForce GTX 560 Ti 2Win
- 0:13:25 SilverStone Strider Gold
- 0:17:00 This Podcast is brought to you by
MSI Computer, and their all new Sandy Bridge Motherboards!
- 0:18:00 Puget System Serenity Core i5 HTPC Review
- 0:28:05 Samsung Infuse 4G Delivery
- 0:31:20 Tegra 3 and Asus Transformer Prime
- 0:42:30 Maingear Epic 180 Cooler
- 0:49:20 64 GB Corsair DDR3
- 0:51:30 Asus 3 Board 900 Series Review
- 1:00:00 Ryan pretends to make a difference.
- 1:02:40 Hardware / Software Pick of the Week
- Jeremy: Quick defroster
- Josh: Nice musics! http://www.amazon.com/Greatest-Video-Music-Amazon-Bonus/dp/B005WV6ZI8/ref=sr_1_1?ie=UTF8&qid=1320891616&sr=8-1
- Allyn: mp3tag
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- http://pcper.com/podcast
- http://twitter.com/ryanshrout and http://twitter.com/pcper
- Closing
See what happens when you harness three GPUs to a Bulldozer and try to get them to pull it along
Subject: Processors | November 9, 2011 - 04:05 PM | Jeremy Hellstrom
Tagged: amd, bulldozer, sli, FX 8150, GTX580
In a good mood? If so, do not read this [H]ard|OCP article on Bulldozer's gaming performance when coupled with two and three GTX580s. By using an SLI setup you can see just how powerful a CPU is as it tries to keep up with the GPUs and as you might expect the Bulldozer is not up to the task. In most tests [H] saw a 70% performance difference between the FX 8150 and the Core-i5 2500K, with both processors clocked at 4.8GHz. In a very few tests the results were a little closer but this is bad news for AMD, especially when you consider it is the more expensive of the two chips.
"We are taking the new AMD FX-8150 and giving it the power of Dual and Triple-SLI GeForce GTX 580 video cards. We are going to take the new CPU up to large NV Surround resolutions and see how performance stacks up when it comes to high-end gaming scenarios."
Here are some more Processor articles from around the web:
- NVIDIA's Tegra 3 Launched: Architecture Revealed @ AnandTech
- HTC adopts Nvidia Tegra 3 processors @ DigiTimes
- NVIDIA's Tegra 3 (Kal-El) Quad-Core Mobile Superchip Detailed @ Tweaktown
- AMD FX-4100 Quad Core 3.6GHz Bulldozer Processor Review @ Legit Reviews
- AMD vs Intel: Bulldozer vs Sandy Bridge @ HCW
- AMD Bulldozer Cache Aliasing Issue Fix @ Phoronix
- Open64 Compiler Tuning On AMD Bulldozer FX-8150 @ Phoronix
- AMD FX 8150 Revisited @ Madshrimps
AMD's retail Bulldozer watercooler
Subject: Cases and Cooling | November 7, 2011 - 12:17 PM | Jeremy Hellstrom
Tagged: amd, bulldozer, water cooler
When the Bulldozer process first started to hit the review bench one of the most commented on facts was that AMD had plans to release a watercooler with some models of the FX-8150. The basic design will be familiar to anyone who has seen a self contained watercooler, with a waterblock directly attached to a radiator. In this case you can use two 120mm fans to move air over the radiator, which might be a good thing considering the small diameter tubing and questionable finish on the waterblock. Neoseeker shows of the monitoring software and the cooling prowess of this bundled watercooler in their latest review.
"In our review of the AMD FX-8150 last month, we noted that AMD would at some point begin bundling the new Bulldozer CPU with a stock water cooler with the promise of opening the doors to even better overclocking performance for enthusiasts. We've at last got our hands on the model which will come included with the FX-8150 in the near future, and we put it to the test in our updated coverage for the FX-8150 CPU. Find out just how large the additional overclocking headroom becomes with the upcoming stock water cooler."
Here are some more Cases & Cooling reviews from around the web:
- Corsair Hydro Series: H60, H80 and H100 @ AnandTech
- Evercool Transformer 3 CPU Cooler @ Tweaktown
- SilenX EFZ-92HA3 CPU Cooler @ Bjorn3D
- Thermalright True Spirit 120 CPU Cooler Review @ Hardware Secrets
- NZXT HAVIK 140 CPU Cooler @ Real World Labs
- Gelid GX-7 CPU cooler @ Guru of 3D
- Antec SOLO II Chassis Review @ Kitguru
- Antec SOLO II Mid Tower Case Review @ Hi Tech Legion
- Lian Li PC-6 @ Computing on Demand
- Fractal Design Core 3000 Case Review @ Hardware Secrets
- CM Storm Trooper @ techPowerUp
- Lian Li PC6 Case Review @ Ninjalane
- BitFenix Outlaw Mid Tower @ Tweaktown
- LEPA LPC302 Series Case Review @ HardwareHeaven
- Corsair 500R @ OC3D
- Thermaltake Overseer RX-I Review @ HardwareLOOK
- Silverstone RV03 Raven 3 Case Review @ Ninjalane
- NZXT Tempest 410 Elite Mid Tower Case Review @ ThinkComputers
If you fire your whole PR Team, how will you tell the industry that you did?
Subject: General Tech | November 7, 2011 - 11:59 AM | Jeremy Hellstrom
Tagged: amd
Last week AMD took a scythe to their staff, not so much a separation of the chaff from the wheat and more of a slash and burn approach. As one press report put it "AMD has announced a restructuring plan and implementation of operational efficiency initiatives designed to strengthen the company's competitive positioning." As you can tell, the PR team is already suffering from regressive corporate double speak. Some names which have represented the face of AMD to hardware sites, such as Patrick Moorhead and Carrell Killebrew are gone from AMD, though not from social media nor the industry. The Tech Report looks at just how AMD handled this announcement to the industry and reveiw sites and details on what exactly happened.
"Following up on AMD's mass layoff announcement, TR's Scott Wasson reveals that the chipmaker has laid off virtually its entire public relations team, and he speculates about where the company is now heading."
Here is some more Tech News from around the web:
- Lion on a Hackintosh @ The Tech Report
- DIY spot welder can join anything together, even copper @ Hack a Day
- Weekend Project: Ensure a Hassle-Free Linux Upgrade @ Linux
- Mainstream desktop CPUs future evolution [Haswell, New Sockets, Enhancements...] @ VR-Zone
- Ubuntu 12.04 Developer Summit Summary @ Phoronix
- The 48GB DDR3 Weekend! @ ThinkComputers
- SiSoftware Sandra Lite 2012 Now Available on NGOHQ
- Weekly Giveaway #15: G.Skill 4GB DDR3 2133MHz Memory Kit @ eTeknix
- Real World Labs And Patriot Memory Joint Contest
AMD lays off 10-12% of workforce, new CEO cleans house
Subject: General Tech, Processors | November 3, 2011 - 08:22 PM | Scott Michaud
Tagged: layoffs, amd
We have been discussing AMD's condition and future outlook over most of recent memory. Since the lawsuit versus Intel and the subsequent trying by the Big Blue Giant: AMD's apparent jab-haymaker combo of lawsuit-Sempron to push heavily in the consumer market seems to have been mostly dodged and countered by Intel. While this last quarter has been positive there is little time for positive press; AMD has, today, removed 1400 employees from their company.
There was a time that AMD said they could beat anything Intel could throw at them.
That means that what AMD is releasing now is as-good or better than where they thought CPUs would be.
Food for thought.
It is not very uncommon to see layoffs during restructuring in the 10% range when a new CEO enters a company. The sad part of restructuring is that there is often little consideration about which employees comprise that 10%; rather, their job descriptions. These layoffs in isolation do not say much about AMD's health in the upcoming time but should tint in one way or another how to perceive their upcoming actions. Where the future is positive or negative depends on how this ties into that.
Podcast #177 - Lenovo Portable Monitor, GTX580M vs HD6990M, Hard Drive prices spiking and more!
Subject: Editorial | November 3, 2011 - 05:44 PM | Ken Addison
Tagged: x79, podcast, nvidia, Intel, hd6990m, gtx580m, earnings, amd, 6990m, 580m
PC Perspective Podcast #177 - 11/03/2011
Join us this week as we talk about a Lenovo Portable Monitor, GTX580M vs HD6990M, Hard Drive prices spiking and more!
You can subscribe to us through iTunes and you can still
The URL for the podcast is: http://pcper.com/podcast - Share with your friends!
- iTunes - Subscribe to the podcast directly through the iTunes Store
- RSS - Subscribe through your regular
- MP3 - Direct download link to the MP3 file
Hosts: Ryan Shrout, Josh Walrath, Jeremy Hellstrom, and Allyn Malvantano
This Podcast is brought to you by
Program Schedule:
- 0:00:28 Introduction
- 1-888-38-PCPER or email@example.com
- http://pcper.com/podcast
- http://twitter.com/ryanshrout and http://twitter.com/pcper
- 0:01:17 Lenovo ThinkVision LT1421 Portable Monitor Review: A Second Display for Road Warriors
- 0:03:42 Mobile GPU Comparison: GeForce GTX 580M and Radeon HD 6990M
- 0:16:50 iPhone 3GS / 4 / 4S Battery Life Testing - Putting the Conjecture to Rest
- 0:23:40 This Podcast is brought to you by
MSI Computer, and their all new Sandy Bridge Motherboards!
- 0:24:30 AMD Reports Q3 2011 Results
- 0:31:35 Hard Drive Prices Spike on Thailand Flooding
- 0:39:40 Gigabyte brings Bluetooth 4.0 and WiFi to their X79 boards
- 0:44:04 Video Perspective: AMD A8-3850 vs Core i3-2105 on Battlefield 3
- 0:47:10 Intel Releases Updated SSD Toolbox
- 0:51:15 NVIDIA Upgrading GTX 560 to 448 CUDA Cores?
- 0:55:15 Hardware / Software Pick of the Week
- Ryan: Not Steam Uninstaller
- Jeremy: Maxwell Technologies HSN-1000 Nuclear Event Detector < wait what?!?! :) or http://ca.movember.com/mospace/1422966/ Movember
- Josh: Gettin cheeeap: http://www.newegg.com/Product/Product.aspx?Item=N82E16820227706
- Allyn: Electricsheep pre-rendered screen saver
- 1-888-38-PCPER or email@example.com
- http://pcper.com/podcast
- http://twitter.com/ryanshrout and http://twitter.com/pcper
- Closing
A sub $200 AMD FirePro benchmarked on Linux
Subject: Graphics Cards | November 3, 2011 - 01:17 PM | Jeremy Hellstrom
Tagged: amd, firepro, V4900, linux, turks
Workstation graphics cards tend to be significantly more expensive than their desktop counterparts, something the new AMD FirePro V4900 seeks to overcome. The card is available for less than $200 but still comes with the advantages of the FirePro series, workstation application certification, a three-year hardware warranty and greater technical support than with a desktop GPU. Performance wise, the benchmarks that Phoronix ran showed the card to be nicely between the V4800 and V5800 so perhaps not worth immediately running out and upgrading from the previous low end model but definitely worth considering for new machines.
"AMD is announcing today a new FirePro workstation graphics card. What is being announced is not a new ultra high-end creation, but instead it's a new entry-level graphics card to fit in between the FirePro V4800 and FirePro V5800 / V5900: it's the AMD FirePro V4900. The FirePro V4900 will retail for less than $200 USD while offering up some nice capabilities for the price. Here is a launch-day look at the FirePro V4900 along with the first Linux benchmarks of this latest AMD workstation graphics creation."
Here are some more Graphics Card articles from around the web:
- HIS Radeon HD 6870 IceQ 1GB @ Legion Hardware
- VTX3D Radeon HD6770 & HD6670 Streamer Edition @ Kitguru
- Catalyst 11.10 Windows 7 Driver Analysis @ Tweaktown
- Sapphire HD6970 Battlefield 3 Flex Edition @ Guru3D
- i3DSpeed, October 2011 @ iXBT Labs
- The Effect of GPU Memory on Surround & Stereo 3D Performance @ Hardware Canucks
- KFA2 GeForce GTX 580 Anarchy Edition SLI @ kitguru
A look into AMD's future
Subject: General Tech | November 3, 2011 - 12:38 PM | Jeremy Hellstrom
Tagged: amd, vector computing, exascale, APU
Chuck Moore, CTO of AMD's Technology Group, gave a talk this week about AMD's plans for the future of their architecture. As you might conjecture the focus was on the further integration of the CPU and GPU, with an eye on power consumption. The hurdle he feels will be the tallest is the bandwidth for passing data back and forth between the two processors and he sees 3D stacks of memory sitting between the main system memory, the GPU and the CPU. Once developed he feels that the stacks of memory should be able to increase the amount of available communication bandwidth to the point where tasks can be handed smoothly back and forth between the two processors depending on which is more effective at certain tasks. Performance is not everything however, when The Register quotes Moore when he discusses the power requirements of a mid-range exascale class machine costing $200 million just to power and cool over a year, you begin to see the importance of bringing down power consumption and heat production.
"Because Advanced Micro Devices has not yet announced its 16-core "Interlagos" Opteron 6200 processors, it has to talk about something, and in situations like that, it is best to talk about the far-off future. And so AMD rounded up a bunch of its partners on Wednesday in San Francisco for a shindig to talk about the challenges of exascale computing."
Here is some more Tech News from around the web:
- JPR Reports Q3 Graphics Numbers @ SemiAccurate
- Western Digital and Samsung will not supply hard drives to Taiwan channels in November @ DigiTimes
- Facebook's "Open Compute" Server tested @ AnandTech
- HIS Desperate Upgrade GPU Competition @ XSReviews
- HiTechLegion Founder's Birthday Contest
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Results 1 to 5 of 5
Thread: Anyone Published A Book?
July 19th, 2005 #1
Anyone Published A Book?
I'm wondering what the process is like (getting it copyrighted, getting it published, etc.) Anything like a novel? I'm going to try to get something I'm writing now published, but I'm not sure where to get it published, what I should do to copyright it and protect it from getting stolen. Any first-had advice would be greatly appreciated.-Brad Cossey
The secret to creativity is knowing how to hide your sources.
Hide this ad by registering as a memberJuly 20th, 2005 #2
I might be able to help with info/guidance. Can you post a couple of more details without giving anything away?
How big? What genre? What do you see as your potential market? (Who's gonna read it?) Is this a one shot deal or are you planning more? Is subject matter mainstream or narrow field? (Like, are you talkin' about sex, or describing how to build a 16th-century hope chest...)
July 20th, 2005 #3
I am in the process and have found some very useful, and yet sometimes quite contradictory, information at:
Most of the controversy seems to stem around POD publishing and vanity publishing; how they are similar and how they are different.
Sans la colère. Sans la haine. Et sans la pitié.
I always find myself instinctively arrayed on the side of the barbarian, against the powers of organized civilization. -- Robert E. Howard
Writer, illustrator and artist.
July 20th, 2005 #4Originally Posted by Ilaekae
-Brad Cossey
The secret to creativity is knowing how to hide your sources.
July 20th, 2005 #5
Hate to say this, but your best bet is probably to submit to the range of publishers who specialize in Science Fiction. You could possibly build up some interest first by attempting to serialize or adapt part of one of the stories to the requirements of the SciFi magazine market.
If you were going to do a specialized sort of thing with limited appeal, I would have suggested self-publishing, which isn't as complicated as most people make out. It's just a bitch when it comes to publicity and distribution.
Your books sound like they have a possible appeal to a wide audience, so trying to compete with the established publishers would be almost futile. Use what's there and works. As for copyrights, they belong to you. Automatically. Make sure you retain your notes and an original printout, as well as a doc on CD or some such if possible. Most of the publishers are pretty on the up and up, but there's always a prick somewhere that surpises you. If you can't find out anything specific about where you're sending you material (track record, history, list of their authors, minimal info on payment arrangements and legal requirements, etc.), don't send it.
Before you submit, I'd suggest getting a copy of "The Writer's Market" (I think that's what it's called...) and doing a fast scan on it. It comes out once a year and has tips and updated lists of all the ultimate publisher and Mag markets with contact info. It also has a lot of shit like advice that can be useful from people who have "been there, done that..."


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Home » Sauce » Fruit Sauce » Orange Sauce » Simple Orange Sauce » Honey Spiced Chicken With Orange Sauce
Honey Spiced Chicken With Orange Sauce
23 Sep 2010
|Vegetable oil/Chicken fat
|2 Tablespoon
|Broiler fryer chicken
|3 Pound, cut up
|2 Medium, sliced
|1 Teaspoon
|1 Teaspoon
|1⁄8 Teaspoon
|Orange juice
|1 Cup (16 tbs)
|1⁄4 Cup (4 tbs)
|Lemon juice
|2 Tablespoon
|Ground ginger
|1⁄2 Teaspoon
|Ground nutmeg
|1⁄4 Teaspoon
|Pitted ripe olives
|1⁄2 Cup (8 tbs)
|Cold water
|1 Tablespoon
|2 Teaspoon
|Orange slice
Heat oil in skillet until hot.
Cook chicken over medium heat until brown on all sides, about 15 minutes.
Place chicken in ungreased oblong baking dish, 11 x 7 x 1 1/2 inches; top with onions.
Sprinkle with salt, paprika and pepper.
Mix orange juice, honey, lemon juice, ginger and nutmeg; pour over chicken.
Add olives.
Cover and cook in 350° oven until thickest pieces of chicken are done, 45 to 60 minutes.
Arrange chicken, onions, and olives on platter.
Pour pan juices into saucepan; heat to boiling.
Mix water and cornstarch; stir into juices.
Cook and stir until slightly thickened, 1 to 2 minutes.
Garnish chicken with orange slices; serve with orange sauce.
Rate It
0 Comments
Honey Spiced Chicken With Orange Sauce Recipe


text:
Favorite Characters
A list of my favorite characters over the years.
A list of my favorite characters over the years.
My all time favorite. Hands down. Introduced to me as a child in 1989 watching Keaton in theaters I haven't stopped being a fan, ever.
The Great One, The Brahma Bull, The People's Champion, The Chosen One, The Incorporable, The Most Electrifying Man in All Entertainment! The Rock was my favorite character from 90's TV and wrestling.
Snake the legendary soldier himself. Metal Gear Solid completely changed my video game life and Solid Snake was such a cool, calm, and compelling character.
Dr Thomas "Tommy" Oliver is by far the greatest Ranger of all time and bonified fan favorite.
The greatest Autobot that ever lived (and died). The bot once known as Orion Pax was always one of my favorites. Up there with Batman in my book.
My 90's favorite. Growing up I loved the original Superboy that emerged from that Cadamus facility and told the world "Don't you ever call me Superboy!" His dialogue and antics in Hawaii spoke to a 90's, MTV, Generation X world. I miss that version.
Greatest incarnation of the Justice League. Greatest League stories ever told. Period.
Favorite X-Team ever! 90's X-Men was everything!
Awesome character! He's the perfect blend of bad@$$, everyman, cowboy, monster killing, bounty killer mayhem.
Beautiful, warrior, princess... so many things describe what makes this woman one of the all time greats.
Favorite Batman related team, idea, eventuality, inevitability, and evolution (of Batman).
Favorite bounty hunter. Love Cowboy Bebop!
One of the sexiest and most versatile female characters EVER. Love this woman.
It's Goku. Any DBZ fan can tell you why this guy is amazing.
One of the greatest non-white DC characters ever created. Hopefully he won't end up being a missed opportunity. Set the internet a blaze when the Green Lantern film cast a white lead... hint hint WB/DC. Lots of people watched "Justice League".
I mean it's Superman... Nuff said.
Has SO much potential... I'd LOVE to write him.
Wally West my favorite Flash, the best Flash, and best version of the character Wally West
Such an interesting brotha. This character has uber potential being wasted away by lame writers.
Best GL there ever was imo. He repped hard for the 90's and was apart of the greatest Justice League there ever was in the JLA.
Another character I appreciate from the 90's. Brilliant scientist and a great representation of Black characters.
The first Batman character in years to truly challenge the martial arts prowess of Bruce Wayne, that alone lands her on this list.
Gen. 13. Nuff said!
Justice League Unlimited version is a favorite of mine.
Young Justice version specifically.
90's version is my favorite of him
One of my favorite Morrison characters. Created because Hawkman's convoluted origin halted any involvement from the character, so Morrison created the angel from Heaven to defend the Earth.
Use your keyboard!
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text:
A cardiac rhythm management device is configured to detect oscillations in cardiac rhythm by measuring the amplitudes of heart sounds during successive heart beats. Upon detection of acoustic alternans, the device may adjust its operating behavior to compensate for the deleterious effects of the condition.
1. An implantable cardiac rhythm management device, comprising:
an accelerometer for generating a phonocardiogram signal;
a controller for processing the phonocardiogram signal to detect heart sounds within the phonocardiogram signal and to measure oscillations in the amplitudes of the heart sounds during successive heart beats; and,
wherein the controller is programmed to detect acoustic alternans when the measured oscillations exceed a specified magnitude and to adjust the operating behavior of the device when acoustic alternans is detected.
2. The device of
3. The device of
4. The device of
a sensing/pacing channel; and,
wherein the controller is programmed to deliver pacing therapy in accordance with a bradycardia mode, and further wherein the controller is programmed to decrease a programmed pacing rate when acoustic alternans is detected.
5. The device of
a sensing/pacing channel; and,
wherein the controller is programmed to deliver anti-tachycardia pacing therapy when a measured heart rate exceeds a specified tachycardia threshold rate, and further wherein the controller is programmed to decrease the tachycardia threshold rate when acoustic alternans is detected.
6. The device of
a first ventricular pacing channel;
a second ventricular pacing channel; and,
wherein the controller is programmed to deliver pacing therapy in accordance with a bradycardia mode, and further wherein the controller is programmed to initiate ventricular resynchronization pacing by delivering paces through both ventricular pacing channels when acoustic alternans is detected.
7. The device of
a first ventricular pacing channel;
a second ventricular pacing channel; and,
wherein the controller is programmed to deliver ventricular resynchronization pacing by delivering paces through both ventricular channels, and further programmed to adjust a resynchronization operating parameter when acoustic alternans is detected.
8. The device of
9. The device of
10. The device of
a first atrial pacing channel;
a second atrial pacing channel; and,
wherein the controller is programmed to deliver pacing therapy in accordance with a bradycardia mode, and further wherein the controller is programmed to initiate atrial resynchronization pacing by delivering paces through both atrial channels when acoustic alternans is detected.
11. A method for operating an implantable cardiac rhythm management device, comprising:
generating a phonocardiogram with an accelerometer;
processing the phonocardiogram signal to detect heart sounds within the phonocardiogram signal and to measure oscillations in the amplitudes of the heart sounds during successive heart beats; and,
detecting acoustic alternans when the measured oscillations exceed a specified magnitude and adjusting the operating behavior of the device when acoustic alternans is detected.
12. The method of
13. The method of
14. The method of
15. The method of
16. The method of
17. The method of
18. The method of
19. The method of
20. The method of
21. The method of
22. The method of
[0001] This patent application pertains to methods and apparatus for cardiac rhythm management. In particular, it relates to the detections of oscillations in heart rhythm and its use by a cardiac rhythm management device.
[0002] Cardiac rhythm refers to the temporal pattern of electrical or mechanical activity in the heart. Cardiac rhythm management devices are implantable devices that provide electrical stimulation to selected chambers of the heart in order to treat disorders of cardiac rhythm. An implantable pacemaker, for example, is a cardiac rhythm management device that paces the heart with timed pacing pulses. The most common condition for which pacemakers are used is in the treatment of bradycardia, where the ventricular rate is too slow. Atrio-ventricular conduction defects (i.e., AV block) that are permanent or intermittent and sick sinus syndrome represent the most common causes of bradycardia for which permanent pacing may be indicated. If functioning properly, the pacemaker makes up for the heart's inability to pace itself at an appropriate rhythm in order to meet metabolic demand by enforcing a minimum heart rate. Cardiac rhythm management devices may also be used to treat tachyarrhythmias where the heart rhythm is too fast. In a type of pacing therapy called anti-tachycardia pacing, one or more pacing pulses are output during a cardiac cycle in an effort to interrupt the reentrant circuit causing a tachycardia. Other tachyarrhythmias, such as fibrillation, can be treated by devices that deliver a cardioversion/defibrillation shock when the tachyarrhythmia is detected.
[0003] Also included within the concept of cardiac rhythm is the manner and degree to which the heart chambers contract during a cardiac cycle to result in the efficient pumping of blood. For example, the heart pumps more effectively when the chambers contract in a coordinated manner. The heart has specialized conduction pathways in both the atria and the ventricles that enable the rapid conduction of excitation (i.e., depolarization) throughout the myocardium. These pathways conduct excitatory impulses from the sino-atrial node to the atrial myocardium, to the atrio-ventricular node, and thence to the ventricular myocardium to result in a coordinated contraction of both atria and both ventricles. This both synchronizes the contractions of the muscle fibers of each chamber and synchronizes the contraction of each atrium or ventricle with the contralateral atrium or ventricle. Without the synchronization afforded by the normally functioning specialized conduction pathways, the heart's pumping efficiency is greatly diminished. Patients who exhibit pathology of these conduction pathways, such as bundle branch blocks, can thus suffer compromised cardiac output.
[0004] Heart failure refers to a clinical syndrome in which an abnormality of cardiac function causes a below normal cardiac output that can fall below a level adequate to meet the metabolic demand of peripheral tissues. It usually presents as congestive heart failure (CHF) due to the accompanying venous and pulmonary congestion. Heart failure can be due to a variety of etiologies with ischemic heart disease being the most common. Some heart failure patients suffer from some degree of AV block or are chronotropically deficient such that their cardiac output can be improved with conventional bradycardia pacing. Such pacing, however, may result in some degree of discoordination in atrial and/or ventricular contractions because pacing excitation from a single pacing site spreads throughout the myocardium via the conducting muscle fibers of either the atria or the ventricles, and not the faster specialized conduction pathways as in a physiological heart beat. Most pacemaker patients can still maintain more than adequate cardiac output with artificial pacing, but the diminishment in cardiac output may be significant in a heart failure patient whose cardiac output is already compromised. Intraventricular and/or interventricular conduction defects are also commonly found in heart failure patients and can contribute to cardiac dysfunction by causing unsynchronized contractions during intrinsic beats. In order to treat these problems, cardiac rhythm management devices have been developed that provide electrical pacing stimulation to one or more heart chambers in an attempt to improve the coordination of atrial and/or ventricular contractions, termed cardiac resynchronization therapy.
[0005] The present invention relates to an implantable cardiac rhythm management device that is configured to detect oscillatory behavior in the rhythm of the heart as reflected by alternations in the measured amplitudes of heart sounds, referred to herein as acoustic alternans. Acoustic alternans is indicative of alternations in the strength of systolic contractions and pulse pressure, a condition known as pulsus alternans. Pulsus altenans is generally taken by clinicians to indicate systolic dysfunction and possible heart failure. A cardiac rhythm management device may therefore also be configured to compensate for the decrease in cardiac output when acoustic altemans is detected by initiating or modifying the delivery of cardiac resychronization therapy. Pulsus alternans is also highly correlated with oscillations in the electrical activity of the heart, called electrical alternans. Since electrical alternans is known to be potentially arrhythmogenic, the device may be further configured to adjust its operation when the condition is detected to deal with this situation. Such operational adjustments may relate to the manner in which either bradycardia pacing or anti-tachycardia pacing is delivered.
[0006]FIG. 1 is a system diagram of an exemplary cardiac rhythm management device.
[0007]FIG. 2 illustrates pulsus alternans with accompanying acoustic alternans.
[0008]FIG. 3 illustrates an exemplary implementation of an algorithm for detecting acoustic alternans.
[0009] Under certain conditions, some individuals exhibit oscillations in the mechanical function of the heart that result in alternations in pulse pressure, referred to as pulsus alternans. Pulsus alternans is generally taken by clinicians to indicate systolic dysfunction, particularly in the left ventricle. It would be useful for an implanted cardiac rhythm management device to be able to detect this condition when it arises so that the presence of the condition can be communicated to a clinician and, as explained below, so that the operating behavior of the device can be adjusted appropriately. Direct detection of blood pressure by an implantable device, however, is problematic. The present invention provides a method for detecting pulsus alternans by using alternations in the amplitudes of measured heart sounds, referred to herein as acoustic alternans, as a surrogate.
[0010] Pulsus alternans occurs due to a difference in the strength of systolic contractions during successive heart beats so that a strong beats alternate with weak beats. As explained below, the strength of a systolic contraction affects the velocity at which the AV and semilunar valves close, which closures are responsible for producing the first and second heart sounds, S1 and S2, heard during cardiac auscultation. Thus, alternating loud and soft heart sounds, or acoustic alternans, is directly reflective of pulsus alternans. Heart sounds may be detected and measured by an implantable device equipped with an accelerometer that responds to the acoustic vibrations transmitted through body fluids. Accelerometers are commonly used in pacemakers to measure the physical activity of the patient so that the pacing rate can be adjusted accordingly. By detecting and measuring the amplitudes of heart sounds during successive heart beats, acoustic alternans can be detected.
[0011] As noted above, certain cardiac rhythm management devices are designed to deliver pacing therapy in a manner that improves the coordination of both ventricles (or both atria) during systolic contractions, termed cardiac resynchronization therapy. The presence of pulsus alternans in such patients indicates that systolic function has been further impaired, and it may be beneficial for a device configurable for delivering resynchronization pacing to adjust its operating parameters to compensate for this when acoustic alternans, serving as a surrogate for pulsus alternans, is detected. For example, a device may be configured to deliver bradycardia pacing to one ventricle in a conventional manner or even no pacing under normal conditions. If acoustic alternans is detected, however, the device may be programmed to initiate resynchronization therapy by, for example, pacing both ventricles or one ventricle at multiple sites. In another embodiment, a device configured to deliver resynchronization pacing during normal conditions may adjust one or more operating parameters when acoustic alternans is detected so that the resynchronization pacing is modified. Examples of operating parameters that may be so adjusted are the biventricular delay interval between paces delivered to the right and left ventricles and the atrio-ventricular delay interval between an atrial pace or intrinsic sense and a subsequent ventricular pace.
[0012] The pattern of electrical excitation of the human heart may also exhibit oscillations during successive heart beats. This phenomena is referred to as electrical alternans and is usually indicative of a pathological state in which potentially dangerous cardiac arrhythmias are more likely to occur. Since the pumping action of the heart is due to the electromechanical coupling between electrical depolarization of myocardial cells and their mechanical contraction, electrical alternans and pulsus alternans may be different manifestations of the same underlying phenomena in certain cases. In any event, detection of acoustic alternans means that it is highly probable that electrical alternans is also present. Since the presence of electrical alternans in an individual may indicate that an arrhythmogenic condition exists, it may be deleterious for an implantable cardiac rhythm management device to deliver its therapy to the patient in a normal manner under such circumstances. In accordance with the invention, an implantable cardiac rhythm management device that detects acoustic alternans in the manner described above is also configured to adjust its operating behavior when alternans is detected. Such a device may deliver any kind of cardiac rhythm management therapy to the patient during normal conditions including bradycardia pacing, anti-tachycardia pacing, and/or cardioversion/defibrillation. Since it is known that electrical alternans occurs above a critical threshold heart rate, for example, bradycardia pacing at a rate above that critical threshold when electrical alternans is present may aggravate the situation. In one embodiment, a device configured to deliver bradycardia pacing adjusts its pacing rate to a lower value when acoustic alternans is detected. Rapid heart rates may also more readily trigger arrhythmias when an arrhythmogenic condition is present. In another embodiment, a device configured to deliver anti-tachycardia pacing lowers the threshold heart rate at which such therapy is initiated when acoustic alternans is detected in order to reduce the probability of an arrhythmia occurring.
[0013] 1. Exemplary Hardware Platform
[0014] Cardiac rhythm management devices are usually implanted subcutaneously or submuscularly on a patient's chest and have leads threaded intravenously into the heart to connect the device to electrodes used for sensing and pacing. Leads may also be positioned on the epicardium by various means. A block diagram of a multi-site pacemaker having three sensing/pacing channels is shown in FIG. 1. (As the term is used herein, a "pacemaker" should be taken to mean any cardiac rhythm management device, such as an implantable cardioverter/defibrillator, with a pacing functionality.) Pacemakers sense intrinsic cardiac electrical activity by means of internal electrodes disposed near the chamber to be sensed. A depolarization wave associated with an intrinsic contraction of the atria or ventricles that is detected by the pacemaker is referred to as an atrial sense or ventricular sense, respectively. In order to cause such a contraction in the absence of an intrinsic beat, a pacing pulse (either an atrial pace or a ventricular pace) with energy above a certain pacing threshold is delivered to the chamber. The controller of the pacemaker is made up of a microprocessor 10 communicating with a memory 12 via a bidirectional data bus, where the memory 12 comprises a ROM (read-only memory) for program storage and a RAM (random-access memory) for data storage. The controller can be implemented by other types of logic circuitry (e.g., discrete components or programmable logic arrays) using a state machine type of design, but a microprocessor-based system is preferable. The controller is capable of operating the pacemaker in a number of programmed modes where a programmed mode defines how pacing pulses are output in response to sensed events and expiration of time intervals. An accelerometer 330 enables the controller to adapt the pacing rate in accordance with detected changes in the patient's physical activity that indicate changes in exertion level and metabolic demand. A telemetry interface 80 is also provided for communicating with an external programmer.
[0015] The multiple sensing/pacing channels may be configured to deliver bradycardia pacing, cardiac resynchronization therapy, or anti-tachycardia pacing. Illustrated in FIG. 1 is a configuration with one atrial and two ventricular sensing/pacing channels for delivering biventricular pacing. Other embodiments may include additional sensing/pacing channels for multi-site pacing of an atrium and/or ventricle. The atrial sensing/pacing channel in FIG. 1 comprises ring electrode 43 a, tip electrode 43 b, sense amplifier 41, pulse generator 42, and an atrial channel interface 40 which communicates bidirectionally with the controller 10. The device also has two ventricular sensing/pacing channels that similarly include ring electrodes 23 a and 33 b, tip electrodes 23 b and 33 b, sense amplifiers 21 and 31, pulse generators 22 and 32, and ventricular channel interfaces 20 and 30. Each channel thus includes a pacing channel made up of the pulse generator connected to the electrode and a sensing channel made up of the sense amplifier connected to the electrode. The channel interfaces may include analog-to-digital converters for digitizing sensing signal inputs from the sensing amplifiers, registers that can be written to for adjusting the gain and threshold values of the sensing amplifiers, and, in the case of the ventricular and atrial channel interfaces, registers for controlling the output of pacing pulses and/or changing the pacing pulse amplitude. For each channel, the same electrode pair is used for both sensing and pacing. In this embodiment, bipolar leads that include two electrodes are used for outputting a pacing pulse and/or sensing intrinsic activity. Other embodiments may employ a single electrode for sensing and pacing in each channel, known as a unipolar lead. A MOS switching network 70 controlled by the microprocessor is used to switch the electrodes from the input of a sense amplifier to the output of a pulse generator.
[0016] The controller 10 controls the overall operation of the device in accordance with programmed instructions stored in memory, including controlling the delivery of paces via the pacing channels, interpreting sense signals received from the sensing channels, and implementing timers for defining escape intervals and sensory refractory periods. The sensing circuitry of the pacemaker detects a chamber sense, either an atrial sense or ventricular sense, when an electrogram signal (i.e., a voltage sensed by an electrode representing cardiac electrical activity) generated by a particular channel exceeds a specified detection threshold. Pacing algorithms used in particular pacing modes employ such senses to trigger or inhibit pacing. The time intervals between such senses can also be measured in order to detect tachyarrhythmias so that appropriate therapy can be delivered by the device. As described below, the controller may also be programmed to detect acoustic alternans and to adjust the manner in which pacing therapy is delivered by the device upon such detection.
[0017] 2. Detection of Acoustic Alternans
[0018] When the heart beats, closure of valves brought about by pressure differentials in the heart are associated with audible heart sounds that can be heard by auscultation with a stethoscope. The first heart sound, designated SI, results when the AV valves (the mitral and tricuspid valves) close at the beginning of systole as the ventricular contraction causes a sudden backflow of blood toward the atria and against the valves. Due to the elastic nature of the valves, the movement of blood toward the atria causes the valves to bulge toward the atria and then recoil blood back toward the ventricle. This causes a period of reverberation that results in vibrations being transmitted through the blood and body tissues. The second heart sound, designated S2, similarly results when the semilunar valves (the aortic and pulmonary valves) close at the end of systole as the ventricular pressure drops. Because right-sided pressures are significantly lower than left-sided pressures, the amplitude of the heart sounds are primarily due to the closure of the mitral and aortic valves. During pulsus alternans, the strength of systolic contractions is alternately strong and weak. During a strong contraction, the mitral valve is stretched farther into the atria which then sets up a larger amplitude period of vibration. A stronger systolic contraction also causes an increased rate of pressure increase in the ventricle or dp/dt which may increase blood flow velocity. Thus the measured amplitude of both S1 and S2 would be expected to exhibit oscillatory behavior during pulsus alternans.
[0019]FIG. 2 shows an example of how pulsus alternans is reflected by acoustic alternans based upon data published in the literature (See Smith D., Craige E. Am J Cardiol 1985; 55:205). In the figure, five waveforms are shown with respect to a common time axis: a dp/dt waveform which is the time derivative of the left ventricular pressure and reflects the systolic force of contraction, a phonocardiogram which is the acceleration signal measured at the apex, the aortic pressure, the left ventricular pressure, and an electrocardiogram. Six cardiac cycles are shown, numbered CC1 through CC6. In each cardiac cycle, the beginning of ventricular systole is indicated by an R wave in the EKG. At about the same time as the R wave, there is a spike in the dp/dt waveform indicating ventricular contraction, and the left ventricular pressure begins to rise. When the left ventricular pressure exceeds the pressure in the left atrium, the mitral valve closes as indicated by the occurrence of an S1 heart sound in the phonocardiogram. Blood is ejected from the left ventricle into the aorta upon opening of the aortic valve as indicated by the simultaneous rise of both aortic and left ventricular pressure. As the ventricle relaxes, as marked by the T wave in the EKG indicating ventricular repolarization, the left ventricular pressure falls. When the left ventricular pressure falls below the aortic pressure, the aortic valve closes as indicated by the occurrence of an S2 heart sound in the phonocardiogram. Inspection of the left ventricular and aortic pressure waveforms reveals that the patient from whom this data was taken is exhibiting pulsus alternans, with cycles CC2, CC4, and CC6 being strong beats and cycles CC1, CC3, and CC5 being weak beats. It can also be seen that both S1 and S2 are of greater amplitude during the strong beats than during the weak beats. Although this amplitude difference could not be discerned by a clinician performing auscultation, an implantable device can measure the amplitudes with enough precision to allow the condition of acoustic alternans to be detected.
[0020] In order to detect acoustic alternans with specificity, specified threshold values may be employed so that the magnitude of the beat-to-beat oscillation must be above a certain value and must persist for a certain number of heart beats or period of time before acoustic alternans is detected. FIG. 3 shows an exemplary algorithm for detecting acoustic alternans based upon measurement of the amplitudes of the first and/or second heart sounds that can be implemented by the controller in conjunction with the phonocardiogram signal produced by an accelerometer or other microphonic device. In one embodiment of the invention, heart sounds may be detected without reference to any concomitant electrical activity in the heart, with the heart sounds themselves used to define cardiac cycles. In order to more reliably detect such heart sounds within each cardiac cycle, however, it may be advantageous to only look for them in a time window defined in relation to detected electrical cardiac activity. Accordingly, at step A1, the device waits for a ventricular sense (i.e., an R wave) indicating that a systolic contraction is beginning. After a ventricular sense and during a defined time window, the S1 sound is detected and its amplitude measured at step A2. During another subsequent defined time window, the S2 sound is detected and its amplitude measured at step A3. The time window defined for detection of S2 may optionally be defined with respect to the detection of ventricular repolarization (i.e., a T wave) indicating mechanical relaxation of the ventricles. A heart sound amplitude measurement is thus produced that can be compared with a heart sound amplitude measurement from the immediately preceding cardiac cycle. In various embodiments, the heart sound amplitude measurement may consist of the amplitude of S1, the amplitude of S2, or a value that is a function of the amplitudes of both S1 and S2. The difference between the heart sound amplitude of the present cardiac cycle and the heart sound amplitude of the previous cardiac cycle is then computed at step A4. If the heart sound amplitude difference exceeds a specified threshold, as determined at step A5, a counter that keeps track of the number of consecutive heart sound amplitude differences that exceed the threshold is incremented at step A8. Otherwise, a condition of no acoustic alternans is detected at step S6, the counter is reset at step A7, and the device waits for the next R wave at step A1. If the heart sound amplitude difference does exceed the threshold, after incrementing the counter at step A8, the counter's value is compared to a threshold count value at step A9. The threshold count value specifies the number of consecutive heart beats that the heart sound amplitude difference must be above threshold before acoustic alternans is detected. If the count exceeds the count threshold value, acoustic alternans is detected at step A10. The device then returns to step A1 and measures the heart sound amplitudes of the next heart beat.
[0021] 3. Adjustment of Bradycardia Pacing Rate
[0022] Bradycardia pacing modes refer to pacing algorithms used to pace the atria and/or ventricles when the intrinsic atrial and/or ventricular rate is inadequate due to, for example, AV conduction blocks or sinus node dysfunction. Such modes may either be single-chamber pacing, where either an atrium or a ventricle is paced, or dual-chamber pacing in which both an atrium and a ventricle are paced. Modern pacemakers are typically programmable so that they can operate in any mode which the physical configuration of the device will allow. Additional sensing of physiological data allows some pacemakers to change the rate at which they pace the heart in accordance with some parameter correlated to metabolic demand, called rate-adaptive pacing. Measurement of minute ventilation or body activity can be used to estimate metabolic demand for this purpose.
[0023] Pacemakers can enforce a minimum heart rate either asynchronously or synchronously. In asynchronous pacing, the heart is paced at a fixed rate irrespective of intrinsic cardiac activity. There is thus a risk with asynchronous pacing that a pacing pulse will be delivered coincident with an intrinsic beat and during the heart's vulnerable period which may cause fibrillation. Most pacemakers for treating bradycardia today are therefore programmed to operate synchronously in a so-called demand mode where sensed cardiac events occurring within a defined interval either trigger or inhibit a pacing pulse. Inhibited demand pacing modes utilize escape intervals to control pacing in accordance with sensed intrinsic activity. In an inhibited demand mode, a pacing pulse is delivered to a heart chamber during a cardiac cycle only after expiration of a defined escape interval during which no intrinsic beat by the chamber is detected. If an intrinsic beat occurs during this interval, the heart is thus allowed to "escape" from pacing by the pacemaker. Such an escape interval can be defined for each paced chamber. For example, a ventricular escape interval can be defined between ventricular events so as to be restarted with each ventricular sense or pace. The inverse of this escape interval is the minimum rate at which the pacemaker will allow the ventricles to beat, sometimes referred to as the lower rate limit (LRL).
[0024] In atrial tracking and/or atrio-ventricular sequential pacing, another ventricular escape interval is defined between atrial and ventricular events, referred to as the atrio-ventricular interval (AVI). The atrio-ventricular interval is triggered by an atrial sense or pace and stopped by a ventricular sense or pace. A ventricular pace is delivered upon expiration of the atrio-ventricular interval if no ventricular sense occurs before. Atrialtracking ventricular pacing and atrio-ventricular sequential pacing attempt to maintain the atrio-ventricular synchrony occurring with physiological beats whereby atrial contractions augment diastolic filling of the ventricles. If a patient has a physiologically normal atrial rhythm, atrial-tracking pacing also allows the ventricular pacing rate to be responsive to the metabolic needs of the body. A pacemaker can also be configured to pace the atria on an inhibited demand basis, where an atrial escape interval is then defined as the maximum time interval in which an atrial sense must be detected after a ventricular sense or pace before an atrial pace will be delivered. The LRL in that case is the sum of the atrial escape interval and the AVI.
[0025] Rate-adaptive algorithms may be used in conjunction with bradycardia pacing modes. Rate-adaptive pacemakers modulate the ventricular and/or atrial escape intervals based upon measurements corresponding to physical activity. Such pacemakers are applicable to situations in which intrinsic atrial rates are unreliable or pathological. In a rate-adaptive pacemaker, for example, the LRL is adjusted in accordance with exertion level measurements such as from an accelerometer or minute ventilation sensor in order for the heart rate to more nearly match metabolic demand.
[0026] The adjusted LRL is then termed the sensor-indicated rate.
[0027] Mechcanical alternans is indicative of electrical alternans which is known to occur only above a certain critical threshold heart rate that varies with the individual patient. A pacemaker operating in an inhibited demand mode, by enforcing a specified minimum heart rate, can be responsible in some cases for maintaining a heart rate that allows electrical alternans to occur. The controller may therefore be programmed to decrease the LRL by a specified amount upon detection of acoustic alternans. In the case of rate-adaptive pacing, the maximum sensor-indicated rate and/or the rateresponse curve used to map an exertion level to a sensor-indicated rate may be adjusted to also result in a decreased LRL. Such a decrease in the LRL may be beneficial even if the alternans persists by making the triggering of an arrhythmia less likely.
[0028] 4. Adjustment of Anti-Tachycardia Pacing
[0029] The cardiac rhythm management device of FIG. 1 may be programmed with a plurality of selectable ATP pacing protocols that define the manner in which antitachycardia pacing is delivered. In a microprocessor-based device, the output of pacing pulses is controlled by a pacing routine that implements the selected pacing protocol as defined by various parameters. A data structure stored in memory contains the parameter sets that define each of the available pacing protocols. Pacing protocols for ATP therapy can generally be divided into two classes: those that deliver one or more pulses in timed relation to detected depolarizations and those that deliver a continuous pulse train for a specified time beginning after a detected depolarization. Both types of ATP protocols attempt to block the reentrant depolarization wavefront causing the tachycardia with a second depolarizing wavefront produced by a pacing pulse. Protocols of the first group may vary according to parameters that define the number of pulses delivered and the particular timing employed. Protocols of the second group include so-called burst pacing in which a short train of pulses is delivered for a specified time and may vary according to parameters that define the duration, frequency, and timing of the pulses.
[0030] The device delivers ATP therapy or a defibrillation shock under programmed control of the microprocessor in response to sensed activity from the sensing channels. A sensing routine analyzes the electrical activity received from the sensing channels in order to detect a tachyarrhythmia, and the tachyarrhythmia is then classified as a tachycardia (i.e., a terminable tachyarrhythmia) or fibrillation based upon rate and/or other criteria. The device detects a ventricular tachyarrhythmia, for example, by counting ventricular senses received via the ventricular sensing channel in order to measure the heart rate and determine whether the rate exceeds a selected threshold value. Once a tachyarrhythmia is detected, the rhythm is classified into either a tachycardia or a fibrillation zone by comparing the heart rate to a fibrillation rate boundary or by other means such as assessing the stability of the rhythm. If the tachyarrhythmia is classified as terminable, a pacing routine executed by the microprocessor delivers ATP pulses in accordance with the parameters of a selected protocol.
[0031] As noted above, the object of anti-tachycardia pacing is to create a pace-induced wavefront that propagates into the re-entrant circuit of the tachycardia and extinguishes it. Different protocols are apt to be more successful than others in terminating particular tachyarrhythmias that may differ as to rate and/or depolarization pattern. For this reason, modern cardiac rhythm management devices are capable of employing a number of different ATP protocols to deliver therapy where pacing parameters affecting the magnitude and timing of the pulses can also be adjusted for each protocol. Ideally, a clinician would program the device to deliver pacing therapy using a protocol and parameters that will perform best for a particular patient's tachyarrhythmia.
[0032] Upon detection of acoustic alternans, the controller may be programmed to adjust the manner in which anti-tachycardia pacing is delivered that takes account of the greater potential for onset of an arrhythmic episode. In one example, the tachyarrhythmia rate threshold at which anti-tachycardia pacing is initiated is decreased so that the anti-tachycardia therapy is delivered sooner than in a normal mode of operation. Clinical testing of an individual patient may also reveal that certain antiDocket tachycardia pacing protocols are more successful than others in terminating a tachycardia preceded by acoustic alternans but less successful in terminating a tachyeardia not preceded by acoustic alternans. In those cases, the controller can be programmed to adjust the particular anti-tachycardia pacing protocol to be used for terminating a tachycardia and/or particular parameters defining that protocol when acoustic alternans is detected.
[0033] 5. Adjustment of Cardiac Resynchronization Therapy
[0034] Cardiac resynchronization therapy is pacing stimulation applied to one or more heart chambers in a manner that restores or maintains synchronized contractions of the atria and/or ventricles and thereby improves pumping efficiency. Certain patients with conduction abnormalities may experience improved cardiac synchronization with conventional single-chamber or dual-chamber pacing as described above. For example, a patient with left bundle branch block may have a more coordinated contraction of the ventricles with a pace than as a result of an intrinsic contraction. Resynchronization pacing, however, may also involve delivering paces to multiple sites of a heart chamber or pacing both ventricles and/or both atria in accordance with a resynchronization pacing mode as described below. Ventricular resynchronization pacing is useful in treating heart failure because, although not directly inotropic, resynchronization results in a more coordinated contraction of the ventricles with improved pumping efficiency and increased cardiac output. Resynchronization pacing of the atria may also be beneficial in certain heart failure patients, particularly for preventing the onset of atrial arrhythmias.
[0035] One way to deliver resynchronization therapy is to pace a site with a synchronous bradycardia pacing mode and then deliver one or more resynchronization paces to one or more additional pacing sites in a defined time relation to one or more selected sensing and pacing events that either reset escape intervals or trigger paces in the bradycardia pacing mode. One such resynchronization pacing mode may be termed offset resynchronization pacing. In this mode, a first site is paced with a bradycardia mode, and a second site receives a resynchronization pace at an offset interval with respect to the pace delivered to the first site. The offset interval may be zero in order to pace both sites simultaneously, positive in order to pace the first site after the second, or negative to pace the first site before the second. For example, in biventricular resynchronization pacing, one ventricle is paced with a bradycardia mode while the contralateral ventricle receives resynchronization paces at the specified biventricular offset interval. The offset interval would normally be individually specified to optimize cardiac output in a particular patient. Ventricular resynchronization can also be achieved in certain patients by pacing at a single unconventional site, such as the left ventricle instead of the right ventricle. In such a mode, right ventricular senses may be used to trigger left ventricular paces or used to define an escape interval that upon expiration causes delivery of a left ventricular pace.
[0036] Cardiac rhythm management devices for delivering resynchronization therapy may be configured in a number of different ways and with a number of different parameter settings. These parameters can be initially programmed after implantation while a physician is monitoring the patient so that the resynchronization therapy is delivered optimally. When the pumping efficiency of the patient's heart deteriorates as may be indicated by detection of an oscillatory rhythm, however, modification of those parameters may be necessary for continued optimal treatment. Accordingly, the controller may be programmed to modify its resynchronization pacing parameters upon detection of acoustic alternans, with the exact manner in which such parameters are modified depending upon the individual patient's condition. Such parameter modifications may result in, for example, initiation of resynchronization pacing when such pacing is not normally delivered by the device, reconfiguration of pacing sites so that different cardiac sites are paced, adjustment of a biventricular offset interval for biventricular pacing modes, and adjustment of the atrio-ventricular interval for resynchronization pacing modes that employ atrial tracking or atrio-ventricular sequential pacing.
[0037] Although the invention has been described in conjunction with the foregoing specific embodiments, many alternatives, variations, and modifications will be apparent to those of ordinary skill in the art. Such alternatives, variations, and modifications are intended to fall within the scope of the following appended claims.
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