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Quick Links
Shop All Jewelry
ERZ10302 In Stock
Look hot wearing these channel set 1.25 inch inside out sterling silver cz hoops. These shimmering sterling silver hoop earrings glimmer with intrigue with their rhodium finish and incandescent cubic zirconia. Their round design complements the face pleasantly to enhance the deeper beauty of a face. The channel set CZs line the front and back of the earring equaling a total carat weight of 1.2 carats to give the earrings a sparkle of light. These channel set 1.25 inch inside out sterling silver cz hoop earrings will make a fabulous addition to your jewelry collection.
Eve's Addiction.com wants you to be a happy customer. We want you to be completely satisfied with the sterling silver jewelry that you receive from us, as we only sell high quality silver and cubic zirconia cz jewelry. We do understand that you may not like your purchase for some reason.
You may return or exchange your jewelry within 60 days of purchase if you are not satisfied with it. The jewelry must be returned in its original condition for a refund or exchange. Engraved, personalized, photo, monogram, name and initial, chocolate and clearance items are not returnable or exchangeable.


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4375 Lincoln Avenue
Lisle, IL 60532
Welcome to
Volvo of Lisle,
proud member of the Lisle Auto
Plaza, servicing and selling cars in the Chicago area since 1962
as one of the Largest Chicago
Volvo dealers in the Midwest. Visit our
Volvo dealership from Chicago, Oak Park or
Naperville. We are happy to assist you with the
financing and leasing of
a new 2012 -
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Sedan, used S80 sedan, used V70 wagon, used XC70 Cross over, used XC90
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subset: commoncrawl


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Narrow your search
A couple of weeks after Microsoft's $900 million Surface RT write-down, Surface RTs seem to be selling -- at least at Walmart.
The Nvidia Tegra processors will still be available in some versions, according to Bloomberg.
The patent may hold up the launch until December, when it expires, according to Swiss broadcaster RTS.
Google might still be testing its driverless car, but the mining industry is already operating with vehicles that don't require humans.
Looking for a new game to play on your mobile device? Here's our pick of the best released in March 2014.
EA's remake of the Peter Molyneux classic for mobile represents some of the more unscrupulous tactics mobile gaming has to offer.
Not only did Apple ship its latest update to OS X this year, it also gave away iWork for free.
Company temporarily pulls its recently released Windows RT 8.1 update for ARM-based devices owing to an unexplained issue.
Microsoft's Windows 8.1 will be commercially available starting this week. What will Microsoft do for an encore on the Windows front?
Will the next major version of the Windows Phone OS work on 7- to 10-inch devices? The latest Windows Phone rumors indicate it might be possible.


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The SwimWays® Sea Squirts™ Life Jacket is a U.S. Coast Guard certified Type III PFD (Personal Flotation Device).
Features include:
- Buoyancy Technology helps kids achieve greater control and stability in the water.
- Quality neoprene cover and fabric liner for extreme comfort.
- Fins are water-tight, and fold flat so a child can sit comfortably when not in the water.
- Heavy duty zipper, straps and clips.
- Fun Orca Whale, Blue Dolphin, Pink Dolphin, or Clown Fish designs kids will love to wear.
- Medium size fits children with a chest measurement of 23-25 inches & weighing 30-50 pounds. (Also available in Small or Large.)
Wearing a life jacket has never been more fun!


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You are here
At a glance: Political Science
Did you know? All members of the Political Science faculty hold PhDs.
Political Science Features:
Capitol Opportunity
Ohio Northern University's political science students develop the skills and knowledge needed to succeed in a wide variety of careers, graduate school and law school. Comprehensive curricula emphasize strong research and writing skills, the ability to effectively analyze and synthesize data and communicate findings to others. Additional majors, minors, study-abroad experiences, internships, Mock Trial or Model United Nations programs are encouraged. Advisors assist in tailoring the student's major and strengthen the student's preparation for the chosen career objectives.
Distinctive features
- Faculty research and teaching interests include American Government, State and Local Politics, and International Relations, Comparative Politics, as well as courses on Interest Groups, the Electoral College, and Conflict Resolution.
- The HPJ Department emphasizes writing and encourages students to present their research at professional meetings.
- Recent graduates have gone to graduate school in Political Science and law school. Others have begun careers in government, public policy, and electoral politics.
The department is located in the most historic building on Ohio Northern's campus, Hill Memorial Building. Hill is the oldest building on campus, but it houses the latest in instructional technology, a computer laboratory and a welcoming environment for students and faculty alike. Hill is in the process of a multi-year renovation.
Student organizations
Phi Alpha Delta – pre-law honorary; Phi Alpha Theta – history honorary; Pi Sigma Alpha – political science honorary; Phi Beta Delta – international honorary; Studia Socialia Americae – national social studies honorary
Professional Placement and internships
Students are introduced to ONU's Career Services Center during their first quarter on campus and are encouraged to work closely with the Center throughout their college career to develop career strategies, résumés and summer employment. Employers value the strong research and communication skills that students who major in history, political science, international studies and social studies develop.
Graduates have gone on to graduate studies in history or museum studies, journalism, political science, law and public administration at institutions such as:
- Case Western Reserve University
- Duke University
- Georgetown University
- University of Michigan
- William and Mary
- Boston College
- The Ohio State University
Career opportunities
Many ONU graduates with these majors have embarked on successful careers in government, business or secondary education.
In the spotlight
Nationally competitive internships with the Justice Department, State Department, Department of Commerce, U.S. Marshals and others
Participation in undergraduate research conferences at the national and regional levels
Record of participation in high-profile programs, including Washington Center convention programs and inauguration programs
Publication in national peer-reviewed journals, including the most widely read journal in political science
Three majors served as program assistants in the Japanese-U.S. Camp
Faculty Achievements
Proven record of research through conference participation and publication (peer-reviewed publications, books, opinion-editorials)
Frequently called upon for media analysis at the local, regional, national and international levels (e.g., MSNBC, NPR, The Toledo Blade, etc.)
Service on National Boards (Mock Trial, National Liaison Advisory Board for the Washington Center, Editorial Boards)
Procuring external grant money (Over $10,000 in last five years to support student-faculty projects; grant proposals done in tandem with students)
Politics from the Hill (Publication of ONU student political science manuscripts distributed to prospective students and alumni)
Multiple professors selected as teachers of the year


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While many may use Pinterest to build an imaginary, magical wardrobe, or a full list of do-it-yourself activities, others are beginning to plan their entire wedding off of the simple app that is filled with hundreds upon thousands of photos, submitted by users. However, as an avid "pinner," many will find themselves looking into their future wedding plans.
Growing up, many girls do not think about planning their wedding. However, those same girls who opened up an account on Pinterest, will find themselves looking through hours of wedding videos and photos. Some of the photos are simply beautiful and inspire dress designs, while others are quirky and absolutely adorable idea for photo ops between the bridal parties. Some of the best bridesmaids dresses, wedding gowns, tuxedos, and photo ops come out of these ideas people have made public.
Pinterest's wedding boards also feature wedding videos that have gone viral and inspired many to follow in their footsteps. These trailers make every wedding seem like a movie, and the posts even recommend the videographers to get the job done.
The idea is that regardless of the stress that a wedding will cause those who have to plan it, these photos can help with a little bit of the inspiration. Over the past year, many have even seen some Pineterest inspired wedding photos that generate quite a bit of attention. There is something about wedding photos, maybe it is that they capture pure and real emotion, but they really can get you excited about planning your wedding, even if you're like those old tomboy girls and don't plan on getting married for the next four or five years.


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Behrend Drops Hawks
- Release Date:
- October 19, 2011
- Contact:
- The Office of Sports Information
- (716) 649-7900 ext. 333
ERIE, PA - The Hilbert College men's soccer team lost an AMCC match-up to Penn State Behrend (3-0) October 19. Three different Lions players scored for Behrend improving their conference record to 6-1 and solidifying their second place ranking in the AMCC.
Hilbert (1-14-1) played close the first half heading into intermission down 1-0. The hosts scored off a header from a corner kick at 26:56. Behrend riffled off 17 shots in the first 45 minutes while Hilbert's defense took angles away from the net. Kamil Cislak was credited with 5 saves before intermission.
The second half saw Behrend's Aaron Meehl and Jake Gamble each put one past Cislak to secure the victory.
Hilbert's Tyler Coniglio and Ed Minkel worked for one shot each against Jarrod Wassell who protected the goal for the Lions.
Up next for Hilbert is Penn State Altoona October 22. The men's soccer team will honor their four seniors - Ed Heffron, Eric Russell, Scott Walker and David Walkow before the first kick at 1pm.
Hilbert College, located in suburban Hamburg, N.Y., south of Buffalo, is a private four-year college founded in 1957 in the Catholic Franciscan tradition. With nearly 1,100 students, Hilbert is a dynamic Western New York college that offers career-focused majors, including one of the top criminal justice programs in the region, and more than 50 minors and concentrations. The college's engaging, student-centered campus community offers numerous leadership, internship, and service learning opportunities from which students launch successful careers while making positive changes in their communities. The Hilbert Blueprint promotes a well-rounded student experience over four years – starting with the Foundations Seminar in the freshman year, followed by Sophomore Service, Junior Symposium, and culminating with the Senior Capstone. Hilbert has expanded its academic offerings with the college's first graduate programs and new Accelerated Degree Programs geared to adult learners.
Upcoming Events
- First Year Student Orientation
- Aug 14, 2015
- Summer Session A2 Ends
- Aug 21, 2015
- First Year Student Orientation
- Aug 28, 2015


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Allgemeine und Vergleichende Literaturwissenschaft
Document Type
- Working Paper (7)
- Article (4)
- Other (1)
- Literaturwissenschaft (3)
- Luther (3)
- Johann Wolfgang von Goethe (2)
- Martin (2)
- 1926> (1)
- Beethoven (1)
- Bertolt / Die Dreigroschenoper (1)
- Brecht (1)
- Christopher (1)
- Deutschland / Vereinigung (1)
- Ludwig Tieck : Eckbert the fair (2010)
- Eckbert the Fair. From Six German Romantic Tales, trans. Ronald Taylor. Dufour Editions. Here is my own more literal translation of the poems as they appear on pp. 21, 27 and 32.
- An ode to joy : a season of grief (2007)
- Beethoven's Ninth in Bailey Hall the other evening, April 20, ending in an instant standing ovation by a clearly enchanted audience, was an unforgettable experience. And, like all such truly extraordinary events that are marked not only by artistic merit, but draw their power from the circumstances surrounding their creation or performance, it recalled others and enhanced their significance. I was reminded of a stellar performance on Christmas Day of 1989, only weeks after the unexpected fall of the Berlin Wall on November 9, that haunting date in German history. Few people believed it would ever happen. But now, suddenly, reunification in justice and freedom, as the truncated old national anthem phrases it, was within reach.
- Germans against Hitler (2010)
- "The sun shines, and Hitler is master of this city. The sun shines, and dozens of my friends are in prison, possibly dead. Thousands of people like Frl. Schroeder are acclimatizing themselves, like an animal which changes its coat for the winter. After all, whatever government is in power, they are doomed to live in this town." These are among the final entries in Christopher Isherwood's Berlin Diaries. Hitler has legally assumed power and Isherwood, who "can't altogether believe that any of this has really happened," will leave the city he has come to love and return to England. The Nazi Movement that began a decade ago in seedy Bavarian beer halls has now conquered its very antithesis, Prussia. It seems unstoppable. The people, as always, will adapt or perish.
- Martin Luther : 1483-1546 (1996)
- 450 years ago, in the early hours of February 18, the charismatic reformer and fearless combatant who had changed the face of Europe and of Christianity died in his home town of Eisleben while on a peace mission. The feuding Counts of Mansfeldt had asked him to mediate. Accompanied by his three sons, Luther, old at 62 and ailing, made the trip in mid-winter against the advice of friends and family. His body was returned to Wittenberg and buried there on February 22. It is impossible to overestimate his impact. The common priesthood of man, "everybody his own priest", this truly revolutionary notion at the core of his teaching, was immediately recognized for its (unintended) political, democratic implications. To him, all the faithful were one community, there was no room for separate casts. His zeal as a preacher of the "true faith", and his denunciation of those who would not accept it, earned him the reputation of intolerance, even anti-Semitism. The latter would surprise him, for he considered himself a prophet, though anointed against his will, like those of the Old Testament who also admonished, cajoled and condemned the "wayward children of Israel"'
- Murnau's Faust : eine deutsche Volkssage (2010)
- The 1926 silent classic was directed by FW Murnau and stars Emil Jannings (Prof. Unrat in "The Blue Angel") as Mephisto. Goesta Ekman is Faust, the incomparable Camilla Horn an unforgettable Gretchen.
- Inta Ezergailis : 9/11/1932 - 1/1/2005 (2005)
- Words spoken at the Memorial Service on March 13, 2005, Sage Chapel, Cornell University
- Luther on authority : law and order (2010)
- This is a version of an often revised lecture first given at Cornell University in 1983 during a symposium commemorating Luther's birth five hundred years earlier and is based on six major writings dating from 1522 to 1531.


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We watch for new behaviours and share what we learn
The world spends too much time thinking and talking about new technology. We focus on people. Digital tools are changing the way we think and make choices. Understanding this change is the key to making better business and design decisions. We write and share something pretty much every day.
Find it here, or on Twitter.


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The Museum Day Live! ticket provides free admission for two people. Tickets will be avaliable for download on August 1, 2015
In the spirit of the Smithsonian Museums, which offer free admission every day, Museum Day Live! is an annual event hosted by Smithsonian magazine in which participating museums across the country open their doors to anyone presenting a Museum Day Live! ticket… for free.
Click here to view the list of 2015 participating museums.
Read about some of the participating museums here.


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|After the Bell
Event Type: Children's Program
Date: 10/24/2012
Start Time: 2:30 PM
End Time: 4:00 PM
It's our weekly after-school program for kids in 1st through 5th grades! Activities include crafts, movies, plays, and contests. All are welcome, no registration required.Library: Oak Park Public Library Dole Branch
Location: Meeting Room - Dole Branch
Contact: Dole Branch Library
Contact Number: 708-386-9032


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Ryan Scott recently returned to hometown Louisville and set up his custom guitar shop at Mellwood Art Center. He repairs and custom crafts acoustic and electric guitars.
Upcoming Events
Event Finder
Restaurant Finder
The Weekender
Subscribe to The Weekender, Louisville's weekly guide for where to go and what to do!
Most Read Stories
- Where to Go and What to Do in Louisville This Weekend (July 23 - 26)
- Southside Quarry: the Best Place to Spend Your Louisville Summer
- Best of Louisville 2015 Winners Announced
- Ariana Grande Honeymoons in Louisville
- (Sweaty) Humans of Forecastle Photo Gallery
- 2013 Louisville Area Child Support Arrears List (Deadbeat Parents)
- Epic Sammich Co. Is Open - Here's the Menu
- Best of Forecastle 2015
- Louis-Villainz Market for Mischief Is for Night Owls
- Leading Ladies of Louisville: Susan Barry


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17 May, 2013 | (01 hr)
Sign In to access this Webcast
As the accepted practice of setting executive compensation by peer groups is challenged, this webcast will explore alternative models for setting executive compensation and attempt to outline an alternative paradigm to the current peer group-driven process for setting executive compensation.
In viewing, participants will:
- Understand the argument against the use of peer groups
- Hear proposed alternative methods for setting executive compensation
Audience: Compensation committee members, board members, CEOs, general counsel, chief legal officers, corporate secretary, directors of corporate governance, chief human resources officers, heads of total rewards, compensation and benefits executives
James D. C. Barrall
James D. C. Barrall is a partner in the Los Angeles office of Latham & Watkins LLP and is the Global Co-Chair of the firm's Benefits and Compensation Practice. Mr. Barrall specializes in executive compensation, corporate governance, empl... Full Bio
Charles M. Elson
Charles M. Elson is the Edgar S. Woolard, Jr., Chair in Corporate Governance and the Director of the John L. Weinberg Center for Corporate Governance at the University of Delaware. He is also "Of Counsel" to the law firm of Holland & Kni... Full Bio
Craig K. Ferrere
Craig K. Ferrere is the Edgar S. Woolard, Jr., Fellow in Corporate Governance at the Weinberg Center for Corporate Governance at the University of Delaware. He is a graduate of the University of Delaware. He has conducted research in t... Full Bio
Marcel Bucsescu
Marcel Bucsescu serves as co-program director of The Conference Board Council of Chief Legal Officers. Bucsescu is also executive director of the Ira M. Millstein Center for Global Markets and Corporate Ownership at Columbia Law School, where he l... Full Bio


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How You Can Find Out If You Gamble Poker Online Skillfully
When you need to take part in poker on line it becomes very useful if you find time to analyze about it initially. When selecting a certain poker site it is vital that you understand the essential requirements from a great one.
To make the right decision may just be sometimes challenging though with the right understanding you would not get it wrong.
Security and also safety during the poker gameplay is required to prevent yourself from annoying occurrences when you're on the net. Take a look at first the poker site's competition policies which were being implemented for reasonable contests. It's also beneficial to see if primary deposits and most importantly your own private matters are taken care of properly.
If you love taking part in poker on-line, then make certain that the room you would want delivers wide range of game selection. There also need to be numerous buy-in levels being offered and even poker alternatives so that you can acquire more game options. And ultimately the best poker room ought to have a differing level of real cash games as well as tournament events.
Bonuses as well as promotions can also be important to examine in a poker room apart from the other variables explained before. Deals make any sort of poker gaming far more fun and exciting and so check that out in any poker site you could opt for. All these facts may be able to
aid in choosing a poker room that won't simply present big poker bonuses but fantastic game also.


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Merchant's Brass Scale Cane
- Item No.
Key Features
Click to See Complete Item Details »
Item Details
- Height:
36 3/4 Inches
This rare walking stick with a ram's horn handle has a scale integrated into the shaft for weighing dry goods. The cane unscrews to reveal the hook while a bar on the shaft slides to indicate the weight.


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An apparatus for forming a lesion in cardiac tissue includes an optical fiber for guiding a coherent waveform of a selected wavelength to a fiber tip. The wavelength is selected to have a low absorption in water. The fiber tip is contained within a guide member having a discharge bore for a direction of energy discharge to define an unobstructed light pathway from the fiber tip through a discharge end of the discharge bore. A fluid pathway is in fluid flow communication with the guide member to admit a bio-compatible flushing fluid to the discharge bore.
1. An apparatus for treating a biological tissue of a patient in situ, comprising:
a. an optical fiber for guiding a coherent waveform of a selected wavelength to a fiber tip for discharge of light energy from said fiber tip in a direction of energy discharge, said wavelength selected to have a low absorption in water;
b. said fiber tip contained within a guide member having a discharge bore for said direction of energy discharge to define an unobstructed light pathway from the fiber tip through a discharge end of said discharge bore;
c. said guide member further having a smooth, curved surface to be placed against a surface of said tissue for said guide member to be slidable along said surface in atraumatic sliding engagement and with said end of said discharge bore opposing said surface and with said fiber tip spaced from said tissue in a substantially fixed spacing;
d. a fluid pathway in fluid flow communication with said guide member to admit a bio-compatible flushing fluid to said discharge bore;
e. said fiber adapted to be connected to a source of energy for energizing said source during said movement with an application of energy selccted to form a lesion in an atrial tissue without perforation of said atrial tissue through a thickness of said atrial tissue.
2. An apparatus according to
3. An apparatus according to
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This patent application is a continuation application of commonly assigned and copending U.S. patent application Ser. No. 10/975,674 filed Oct. 28, 2004 and which claims priority to U.S. Provisional Patent Application Ser. No. 60/516,242 with an assigned filing date of Oct. 31, 2003 and filed in the names of Gregory G. Brucker and Robert H. Svenson.
1. Field of the Invention
The present invention relates to surgical instruments for laser cardiac ablation procedures. More particularly, the invention relates to a wand including a fiber optic transmission channel for atrial cardiac ablation.
2. Description of the Prior Art
A. Atrial Fibrillation
It is known that at least some forms of cardiac arrhythmia are caused by electrical impulses traveling through the cardiac muscle tissue by abnormal routes. In a normal, non-arrhythmic heart, electrical nerve impulses travel in an orderly and well-defined fashion through the sinoatrial node and then through the atrioventricular node in order to create an orderly flow of nerve impulses that lead to contraction in the heart.
In cardiac arrhythmia, cardiac impulses travel disorderly and undesirable paths through the cardiac tissue leading to disorderly and inefficient contraction of heart muscle. These fibrillations prevent the heart from pumping blood efficiently and can lead to death.
B. Maze Procedure—Generally
One technique for treating atrial fibrillation is to surgically create lines in the heart muscle tissue (myocardium) whereby electrical conduction of nerve impulses is blocked or rerouted. This technique for creating lines of electrical blockage is referred to as the Maze procedure.
Initial approaches to performing the Maze procedure involved invasive surgery in which a series of linear incisions are made in the cardiac tissue and then sutured together. The lines of scar tissue that form in the incisions do not conduct nerve impulses and are intended to prevent disorderly contraction of the atrial tissue.
In a typical Maze procedure, up to six non-conductive lines are required. Each of the non-conductive lines is typically several centimeters in length. Once these lines scar and heal, they disrupt electrical pathways that may support atrial fibrillation. Examples of the Maze procedure and other surgical techniques for treating atrial fibrillation are described in Chiappini, et al., "Cox/Maze III Operation Versus Radiofrequency Ablation for the Surgical Treatment of Atrial Fibrillation: A Comparison Study", Ann. Thorac. Surg., No. 77, pp. 87–92 (2004) and Cox, "Atrial fibrillation II: Rationale for surgical treatment", J. Thoracic and Cardiovascular Surg., Vol. 126, No. 6, pp. 1693–1699 (2003).
C. Less Invasive Maze Procedure Technologies
Less invasive ablation techniques have also been utilized to perform the Maze procedure. In such techniques, the surgeon typically drags an electrode in a linear fashion along the endocardial (internal) or epicardial (external) surface to produce a series of focal lesions. The scaring created by the focal lesions is hopefully contiguous and non-conductive of electrical impulses. For endocardial use, standard ablation catheters or catheters with extended distal electrodes are employed. Epicardially, specially designed handheld probes with a distal electrode for the application of ablating energy are often used.
For the greatest likelihood of success in a Maze procedure, it is particularly important that the lesions created be transmural. A transmural lesion extends through the full wall thickness of the cardiac muscle at the location of the lesion. One factor that obstructs obtaining transmural lesions from an epicardial approach of the heart is the cooling effect of blood in and around the heart. This is a particular difficulty when radio frequency (RF) energy is employed. The application of RF energy relies exclusively on thermal diffusion to create transmural lesions. The cooling effect of blood within the atrium tends to limit the depth to which thermal lesions can be formed.
It is desirable to create a full thickness transmural lesion but undesirable to perforate the atrial wall. Perforation of the atrial wall leads to a weakening of the heart structure as well as significant bleeding during surgery that must be controlled.
Additionally, producing transmural lesions with RF energy tends to heat the surface tissue at the point of probe contact this. This tends to create burns and adhesion between the probe and the heart tissue. Such adhesions can insulate the probe from the heart tissue blocking the efficient application of energy. These procedures are also a problem for the surgeon and staff who often must stop to clean the tip of the probe.
A discussion of techniques and technologies for treating atrial fibrillation is set forth in Viola, et al., "The Technology in Use for the Surgical Ablation of Atrial Fibrillation", Seminars in Thoracic and Cardiovascular Surgery, Vol. 14, No. 3, pp. 198–205 (2002). Viola et al. describe numerous ablation technologies for treating atrial fibrillation with the Maze procedure. These include cryosurgery, microwave energy, radiofrequency energy, and laser ablation.
D. Laser Ablation and the Maze Procedure
The use of lasers in treating atrial fibrillation is desirable. Laser ablation is fast and the resulting lesion is narrow. Viola, et al., "The Technology in Use for the Surgical Ablation of Atrial Fibrillation", Seminars in Thoracic and Cardiovascular Surgery, Vol. 14, No. 3, pp. 201, 204 (2002). However, in the prior art, laser ablation for treating atrial fibrillation has been troublesome.
Viola et al. discuss problems associated with the use of laser energy to treat atrial fibrillation. These concerns are directed to safety and reliability and note that lasers are prone to overheating because of the absence of a self-limiting mechanism. The authors note that over-heating with lasers can lead to crater formation and eventually to perforation, especially when using pin-tip devices. Viola, et al., supra, at p. 203. The authors note that the high power of laser ablation (described as 30 to 80 Watts) results in the laser technique not being widely clinically applied. Id., at p. 201. The mechanical effects resulting from direct heating of the myocardial tissue with laser energy results in cellular explosions caused by shock waves. Viola, et al., supra, at p. 201.
The possibility for perforation of the myocardium with laser energy raises a particular concern for treating atrial fibrillation. The myocardial wall of the atria is quite thin (e.g., about 2 mm in thickness in some locations). A coring of the myocardium by a laser could result in a full wall thickness perforation and resulting leakage of blood.
Viola et al. note the development of a long probe laser that allows diffusion of the laser thermal energy over the long probe tip in a unidirectional fashion. Id., at p. 201. While not mentioning the source of this long probe tip, it is believed by the present inventors to be referring to the atrial fibrillation laser of CardioFocus, Inc., Norton, Mass. (USA) as described in U.S. Patent Application Publication No. 2004/6333A1 in the name of Arnold, et al. (published Jan. 8, 2004) and U.S. Pat. No. 6,579,285 issued to Sinosky. Unfortunately, this technology defocuses energy and increases the risk (particularly on a beating heart) of creating a lesion that is less than transmural.
Lasers have been effectively used for treating ventricular tachycardia. An example of such is described in U.S. Pat. No. 5,104,393 to Isner et al. dated Apr. 14, 1992.
Unfortunately, while such laser treatments are appropriate for treating the left ventricle. They are not applicable to treating the atria.
The myocardial wall of the left ventricle is substantially thicker than the atria. Therefore, perforation risks are less. Also, in a ventricular treatment, the laser is targeted against a tissue area for substantial periods of time (e.g., about two minutes). To accomplish this, the lasers have a fixation member at the laser tip. (see, e.g., element 42 in the '393 patent). The lasers may also be provided with a temperature sensing tip as described in U.S. Pat. No. 5,830,209 to Savage et al. dated Nov. 3, 1998. Temperature probes provide a temperature profile at the tissue treatment site. U.S. Pat. No. 5,827,267 to Savage et al. dated Oct. 27, 1998 teaches a multi-fiber laser with recirculating coolant contained by a quartz lens and a 50 to 100 watt power source with irradiation up to ten minutes.
The aforementioned lasers are catheter delivered to project laser energy to the interior (endocardial) surface of the heart in the ventricle. In treating tachycardia as described, the laser is intended to create a lesion of necrosed tissue at a discrete target site. To accomplish this, a high power laser is provided with an anchor or fixation device to hold the laser tip at the target site for a prolonged period of laser irradiation.
Ventricular treatment lasers are not applicable to treating atrial fibrillation. In treating atrial fibrillation, a long, narrow, transmural lesion is desired to be formed in a pathway consistent with the Maze procedure. The high power laser of the ventricular treatment lasers presents risk of damage and perforation of the thin-walled atrium as noted by Viola, et al. Further, the single-point treatment of ventricular lasers (created with the assistance of myocardial fixation) is inappropriate to the objectives of the Maze procedure and the tips of such lasers are not optimized for atraumatic movement over the epicardial surface of the atria.
In the foregoing, applicants have referred to the use of lasers in atrial fibrillation as "ablation" techniques. While the use of the term "ablation" is a common usage when describing atrial fibrillation treatments, such usage is an unfortunate misnomer. In treating atrial fibrillation, there is no intent or desire to ablate tissue to the extent that term implies removal of tissue. In fact, in a strict sense, ablation is to be avoided. As noted in Viola et al, it is undesirable to create perforations through laser ablation. Instead, the desire is to create a full myocardial wall thickness (i.e., "transmural") lesion of scar tissue or necrosed myocardial tissue which is narrow and remains in situ in the surrounding myocardium to act as a barrier to undesirable transmission of electrical or neural impulses through the myocardium.
In the strict sense of tissue removal, ablation lasers have been used in the ventricle in transmyocardial revascularization ("TMR") procedures. In TMR procedures, the object is to form a bore from the left ventricle partially through the myocardium with the hope the bore will facilitate the flow of oxygenated blood into ischemic myocardial tissue. Of course, such technology is not applicable to atrial fibrillation treatments were bore formation (or perforations) are to be avoided.
In all types of laser treatments or RF electrode treatments, it is important that the apparatus not damage the tissue through mechanical damage. In ventricular lasers, the traumatic tip does not risk damage to the endocardial tissue since it is immobilized in place with an anchor or fixation as described in the aforementioned U.S. Pat. No. 5,104,393. In the afore-mentioned U.S. Patent Application Publication No. 2004/6333A1, such risks are minimized by laying the diffusing probe over the tissue area.
In the present invention, it is contemplated to draw the tip of a laser wand over the surface of the heart in the region of the atria. In doing so, care must be taken to minimize risk of injury to the atria. For example, the atria are very thin walled. Also, while not as abundant in the atria as in the ventricle region, superficial blood vessels reside on the epicardial surface. A moving object should minimize snags or tears.
From the above, while laser treatment of atrial fibrillation is desirable, existing technology has been inadequate. It is an object of the present invention to provide an apparatus and method formatting atrial fibrillation with the benefits of a laser treatment. The surgical art would benefit from a laser probe for creating transmural non-perforating lesions without the problems of sticking or snagging on the atrial wall tissue. Further, it is desirable that the probe itself not heat up and that energy be efficiently applied to the heart tissue.
E. Conductivity Verification
A further difficulty with creating linear nonconductive lesions is the inability to verify that a truly nonconductive lesion has been produced. If a transmural lesion is not properly formed in accordance with the Maze procedure, the treatment for atrial fibrillation may not be successful. This could require a second surgical procedure. It would be helpful if the surgeon could promptly discern whether a particular linear lesion is truly non-conducting at the time of the original procedure to permit correction at that time. This would enable prompt re-treatment if necessary.
F. Additional Cardiac Ablation Technology
A large variety of devices for cardiac ablation exist in the art. Devices for cardiac ablation combining electrodes and laser include: U.S. Pat. No. 4,785,815 issued to Donald Cohen, U.S. Pat. No. 5,172,699 issued to Robert Svenson et al, U.S. Pat. No. 5,306,274 issued to Gary Long. U.S. Pat. No. 5,769,843 issued to George Abela et al, U.S. Pat. No. 5,824,005 issued to Massoud Motamedi et al, U.S. Pat. No. 6,024,739 issued to Dean Ponzi et al and U.S. Pat. No. 6,200,310 B1 issued to Shlomo Ben-Haim et al.
Devices for cardiac ablation including electrodes but no laser include: U.S. Pat. No. 5,354,296 issued to David Turkel, U.S. Pat. No. 6,063,081 issued to Peter Mulier et al., U.S. Pat. No. 6,161,543 issued to James Cox et al., and U.S. Pat. No. 6,231,518 B1 issued to James Grabek et al.
Device employing laser for cardiac ablation include: U.S. Pat. No. 4,693,244 to Daikuzono, U.S. Pat. Nos. 4,985,028 and 5,104,393 to Jeffrey Isner et al., U.S. Pat. No. 5,282,798 issued to Bruse et al., U.S. Pat. No. 4,955,267 issued to Jacobs, et al., U.S. Pat. No. 5,389,096 issued to Michael Aita et al., U.S. Pat. No. 5,897,551 issued to Everett, et al., U.S. Pat. No. 5,951,541 issued to Simpson, et al., U.S. Pat. No. 6,066,131 issued to Richard Mueller et al., U.S. Pat. No. 6,110,167 issued to Cozean, et al., U.S. Pat. No. 6,135,996 issued to Kolesa et al., U.S. Pat. No. 4,693,244 issued to Daikuzuno, U.S. Pat. No. 5,046,810 issued to Steiner et al and U.S. Pat. No. 5,534,000 issued to Bruce.
Devices for intracardiac use as catheters include: U.S. Pat. No. 5,782,828 issued to Peter Chen, U.S. Pat. No. 5,800,428 issued to Dale Nelson et al and U.S. Pat. No. 6,063,080 issued to Dale Nelson et al.
Devices for epicardial procedures include: U.S. Pat. Nos. 5,380,316 and 5,925,033 issued to Michael Aita et al., U.S. Pat. No. 5,728,091 also issued to Sam Payne et al, U.S. Pat. No. 6,231,568 B1 issued to Marvin P. Loeb et al, U.S. Pat. No. 6,237,605 B1 issued to Matthias Vaska et al.
According to a preferred embodiment of the present invention, a method and apparatus are disclosed for treating a body tissue in situ (e.g., an atrial tissue of a heart to treat) atrial fibrillation. The method and apparatus include identifying a patient with atrial fibrillation and accessing a surface of the tissue. A lesion formation tool is positioned against the accessed surface. The tool includes an optical fiber for guiding a coherent waveform of a selected wavelength to a fiber tip for discharge of light energy from the fiber tip. The wavelength is selected for the light energy to penetrate a full thickness of the tissue to form a volume of necrosed tissue through the thickness of the tissue. The tool further includes a guide tip coupled to the fiber tip. The guide tip is adapted to have a discharge bore aligned with the fiber tip to define an unobstructed light pathway from the fiber tip to the tissue surface. The guide tip is further adapted to be placed against the tissue surface with the guide tip slidable along the tissue surface in atraumatic sliding engagement. The lesion formation tool is manipulated to draw the guide tip over the tissue surface in a pathway while maintaining the discharge bore opposing the tissue surface to form a transmural lesion in the tissue extending a length of the pathway.
In an alternate embodiment, an operator can manipulate an angle of the tool tip relative to a handle. In a still further embodiment, the tool has sensing electrodes to allow for immediate verification of the nonconductive nature of a lesion produced.
In a detailed preferred embodiment, the tool includes a fluid pathway for perfusing a liquid around the location where the lesion is created. The tool includes an optical fiber, a support assembly including a tubular shaft and handle, an internal lumen for a flushing fluid and an optical connector for interfacing to a laser. The tip assembly includes an optical fiber that couples the probe to a laser and transmits laser energy to the tip. Preferably the tip of the probe is shaped to allow for easy movement across the surface of the heart. In addition, the tip also spaces the fiber at a fixed position relative to the tissue surface to optimize achievement of transmural lesions without perforation of the tissue.
Referring now to the drawing figures in which identical elements are numbered identically throughout, a description of a preferred embodiment of the present invention will now be provided. In the preferred embodiment, the invention is described as a lesion formation tool in the form of a surgical wand for applying laser energy to the epicardial surface of the heart to create a transmural ablation line along the heart. It will be appreciated that the atraumatic nature of the distal tip of the invention, as will be described, could also be used in a tool for creating such a line by applying the energy against the endocardial surface of the heart. As used in this application, the term "ablation" is used in the context of creating necrosed tissue in the myocardium while avoiding tissue perforation or removal.
Atraumatic Atrial Laser
Referring first to
A waveguide in the form of an optical fiber 20 passes axially through the entire length of the shaft 12 and substantially though the entire length of the guide tip 24. The fiber 20 resides within aligned bores 26, 27 (
The fiber 20 is retained in the bores 26, 27 by a fixation collar 21 shown in cross-section in
The fiber 20 (
A coupling member 28 is connected to the proximal end 16 of the shaft 12 by a flexible connecting tubing 30. In
A power source 32 (
Any wavelength suitable to create necrosed tissue in the myocardium without tissue removal could be used. In a preferred embodiment, the wavelength is a near-infrared wavelength selected to have a very low absorption and very high scatter in myocardial tissue. Biological tissue (such as the myocardium) is largely water. Wavelengths in the ranges of between about 470 to about 900 nanometers and between about 1050 to about 1150 nanometers are known to penetrate water with low absorption (e.g., less than about 30% absorption). Lasers in Cardiovascular Medicine and Surgery Fundamentals and Techniques, George S. Abela, M.D., Editor, Kluwer Academic Publishers, 101 Philip Drive, Assinippi Park, Norwell, Mass. 02061 USA, p. 28 (1990). More preferably, the wavelength is selected from the ranges of 790 to 850 nanometers (which range corresponds to commercially available medical diode lasers) and 1050 to 1090 nanometers (which range corresponds to Nd:YAG lasers commonly used in other medical procedures). A laser energy source with a wavelength selected from these ranges will penetrate the full thickness of the myocardium and result in a transmural lesion (i.e., a full-thickness necrosis of myocardial tissue in the atrium). Further such a wavelength minimizes carbonization of the tissue and perforation of the myocardial tissue. Such laser emissions are substantially coherent.
Only one wavelength need be passed through the fiber 20 to treat the tissue as described. Conveniently, this may be referred to as the therapeutic wavelength. The therapeutic wavelengths described are invisible to the human eye. It may also be desirable to concurrently pass a visible wavelength (the "targeting" wavelength) through the fiber 20 to permit an operator to visualize the precise location on the heart tissue being targeted by the therapeutic wavelength. With a targeting wavelength, if an operator holds the guide tip 24 at too great an angle to the heart surface, the visible light can escape the tip 24 giving the operator a visual signal that the tip 24 is at too great an angle.
The laser surgical wand 10 is also connected to a fluid source 40 which is a reservoir of a cooling fluid as will be described. An infusion fluid pump 42 urges fluid from the source 40 through a tubing 44 to a fluid inlet 28 c of the coupling member 28. Therefore, the fluid is admitted to flow through the annular passages 26, 27 and discharge through the guide tip 24.
As will be more fully described, the fluid flow cools the material of the guide tip 24, washes biological material (e.g., blood, tissue debris or the like) from the light path between optical fiber 20 and the heart surface, and acts as a lubricant to further facilitate atraumatic gliding movement of the guide tip 24 over the surface of the heart.
The washing action of the fluid maximizes the laser energy impinging on the surface of the heart. Additionally, this fluid provides a means to cool the tissue in the region of the guide tip 24 to help ensure that tissue carbonization and subsequent vaporization of cardiac tissue do not occur. This substantially reduces the likelihood of perforation of the heart wall. Also, the fluid forms a protective layer at the discharge end 22 of optical fiber 20 which reduces the likelihood biological residue will impinge on and/or adhere to the discharge end 22 which can otherwise cause spalling of the fiber face 22 and reduce optical transmission of laser energy.
Since the fluid flows into the body of the patient, the fluid should be medical grade and biocompatible. Also, the fluid should have a low absorption of the laser energy. A preferred fluid is a physiological saline solution which may be supplied at ambient temperature.
The pump 42 includes control knobs and the like to permit an operator to set or modify a flow rate of the fluid. For example, an operator can set fluid flow as low as 0.2 milliliters per minute or as high as 20 milliliters per minute or any other desired setting. As will be described, some flow is preferred to cool the tip and wash the end of the fiber. For treating thin atrial tissue, the flow rate is preferably about 10 milliliters per minute which provides the aforementioned benefits but minimizes excessive fluid infusion into the patient.
In the description of
In the embodiment of
As shown in
The curvature of the shaft 12 at the distal end 24 of the laser surgical wand 10 is beneficial for assisting the physician in aligning the guide tip 24 in a perpendicular orientation to the myocardial tissue while maintaining a comfortable grip for the physician at the handle 18. A perpendicular alignment provides optimal coupling efficacy between the laser energy exiting the laser surgical wand 10 and the targeted cardiac tissue. The angle A can range from 0 to 135 degrees but is preferably between 20 and 90 degrees.
Referring to
The optical fiber 20 extends through the lumen 27 with the discharge end 22 slightly spaced from a distal edge 50 of the guide tip 24. While the discharge end 22 could terminate at the distal edge 50, it is preferably spaced receded into the guide tip 24 by a spacing S of about 0.5 mm (and most preferably about 0.25 mm) from the distal edge 50.
It is desirable to have as close a spacing S of the discharge tip 22 to the distal edge 50 as possible to maximize laser energy penetration of myocardial tissue. The power density impinging on cardiac tissue decreases rapidly with increasing spacing S. However, a small spacing S (about 0.25 mm preferred) from the surface of the heart is desirable to prevent coagulation of biological products onto the face of the optical fiber. Build-up of tissue is undesirable because it can cause carbonization and spalling of the optical fiber face which reduces laser energy output from the optical fiber. If sufficient biological material is present in the vicinity of the optical fiber face, overheating and subsequent melting of the tip 24 can occur.
As shown in
The widening of the lumen 27 serves several purposes. Preferably, the laser energy source is a commercially available diode laser. Such laser energy sources have a high divergence angle for laser energy exiting the discharge tip 22 of the fiber 20. The widening of the distal end of the lumen 27 accommodates the discharge divergence of the laser energy. Further, the widening increases the surface area of the lumen 27 at the distal edge 50. This increases the area of the heart surface being washed by the fluid passing through the lumen 27.
At the distal edge 50 of the guide tip 24, the guide tip 24 does not present a flat surface opposing the heart tissue. Instead, the distal edge 50 is a radiused edge which presents a rounded ring opposing the heart surface. The edge 50 is radius at a radius of 0.75 mm over an arc of 90 degrees with an internal edge 50 a beginning at the maximum diameter 27 b of the lumen 27. The radiused or rounded edge 50 presents an atraumatic surface abutting the heart throughout the operating angle of the guide tip 24. The operating angle is the preferred angle of the axis A—A of the fiber 20 in the guide tip 24 to the surface of the heart. Preferably, this is within 45 degrees off perpendicular and, more preferably, within 30 degrees of perpendicular to ensure adequate coupling of the optics with the heart tissue. The outer surface 31 of the guide tip 24 is cylindrical and parallel to the fiber axis A—A. The rounded edge 50 blends into the cylindrical surface at 33 with a tangent of the edge 50 co-linear (in the same plane as axis A—A) with the cylindrical surface 31 so that no sharp edge is presented.
The guide tip 24 is circular in cross-section (taken perpendicular to the fiber axis A—A). The tip 24 has an outer cylindrical diameter of 5 mm and a cylindrical height of 6 mm. The discharge lumen 29 has a conical axis co-linear with the fiber axis A—A (which is collinear with the axis of light discharged from the fiber tip 22). The fluid flows from the guide tip in a direction parallel with axis A—A and flows radially outwardly in response to impinging upon the heart surface.
To further enhance the atraumatic nature of the guide tip 24, the tip 24 is formed of a soft material having a low coefficient of friction or lubricious-like nature against the heart tissue. Also, it is desirable that the material of the tip 24 be as transparent as possible to the therapeutic wavelength. For the preferred wavelengths described above, a preferred material is Delrin� acetal of DuPont Co., New Jersey (USA). While such material is generally transparent to the preferred laser energy wavelengths, the material may absorb some of the energy. Therefore, the fluid flowing through lumen 27 acts to cool the guide tip 24 as it flows though and around the tip 24.
In operation, the laser source 32 is adjusted to an appropriate power level, for example, from five to fifty watts. In addition, an appropriate flow rate for liquid cooling and flushing is set on infusion pump 42. An appropriate flow rate, for example, preferably is in the range of one to thirty milliliters per minute. The laser surgical wand 100 is then purged of air.
With the laser power source 32 and pump 42 activated, the surgeon applies the laser surgical wand 100 to epicardial tissue of the left or right atrium 102, 104 while tip 24 is in contact with the exterior surface of the heart 100 and held within the desired angle (preferably perpendicular or with 30 degrees of perpendicular) to the heart surface. The laser tip 22 is spaced from tissue by an unobstructed light pathway which is cleansed by the fluid from reservoir 40 (such fluid being non-absorbing or only minimally absorbing to the selected wavelength). With the present invention, the light impinging on the heart surface is a point which is then moved over the surface in a linear or curved path. Due to the unobstructed path, the light is a non-diffused or unmodified beam directed at the heart surface either perpendicularly of at an angle as described above.
The physician moves the probe 10 along the exterior surface of the heart in order to create lines of ablated (i.e., non-conducting) tissue by raising the temperature of the cardiac tissue to that required to achieve cellular death (typically 55� C.). For effective treatment of atrial fibrillation, the lines of ablated tissue must be transmural (i.e., cellular death extends the full thickness of the atrial tissue) and contiguous (no gaps of surviving tissue along the lines of cardiac ablation). The physician creates a pattern of lines which effectively divides the atria into electrical compartments. Commonly used patterns are called the MAZE pattern with its derivative patterns. If desired, the physician can easily re-trace the created pattern with additional application of energy. With the current invention, the physician can easier create complex, non-linear curved patterns or pathways around anatomical features (such as pulmonary veins).
Advantageously, the laser surgical wand 10 of the present invention utilizes laser energy that penetrates more deeply and is more highly focused than radio frequency energy. Laser energy is light that is converted into heat when absorbed by cardiac tissue. This allows the applied laser energy to first be scattered through the full thickness of the myocardium as light because of the optical properties of cardiac tissue and, secondarily, to be diffused as heat, because of the thermal properties of cardiac tissue. This allows for formation of lesions which have a smaller width than those created with more traditional radio frequency energy. Additionally, use of laser energy allows the creation of transmural lesions while there is full cardiac flow in the heart.
Radio frequency energy, on the other hand, relies on thermal diffusion to transmit energy from the epicardium to the endocardium. Because heat diffuses equally in all directions, radio frequency lesions are wider and its energy less focused than laser energy, especially in a unipolar mode. As a result, the cooling effect of the blood flow within the atria prevents subendocardial tissue from achieving the requisite temperature for cellar death. Therefore, to produce transmural lesions with radio frequency energy requires that cardiac flow be stopped by placing the patient on cardiac bypass. Otherwise, the surface of the heart must be heated to above a maximum (e.g., 75 degrees C.) to provide an adequate temperature gradient across the myocardium. However, at such temperatures, steam is created resulting in undesirable tissue damage and possible perforation. Any tissue removal in the thinned-walled atrium (about 2 mm thick in places) is undesirable.
The guide tip 24 permits the physician to slide the guide tip 24 over the heart surface in an atraumatic manner as the surgeon creates the ablation lines.
Fluid flow through the lumen 27 cools the heart surface (to prevent carbonization) and cools the guide tip 24 while washing debris from a wide area around and below the fiber discharge end 22. Further, as the fluid flows between the guide tip 24 and the heart, the fluid acts as a lubricant further facilitating atraumatic gliding motion of the guide tip 24 over the heart surface.
Unlike laser treatment for ventricular ablation, the laser of the present invention is in continuous liner motion along the surface of the heart. The novel guide tip 24 permits atraumatic linear sliding motion not safely possible with prior art ventricular lasers which are adapted for anchoring in place at a specific location on the ventricular wall.
Optional Adjustable Tip
Referring to
In the embodiments of
Imaging Capabilities
In addition to manipulating the angle of the guide tip 24, it may be desirable to clearly visualize the target area of tissue being ablated by the present invention. It has previously been described that a visually perceptible wavelength can be passed through the fiber 20 simultaneous with a therapeutic wavelength. However, the operator may not have adequate positioning relative to the guide tip 24 to fully view and inspect the ablation procedure. In such cases, it is desirable to add a second optical fiber to the laser wand to permit light to be passed back to the fiber to a camera or the like for permitting remote visualization.
Optional Conductivity Testing
As previously mentioned it would be helpful if the surgeon could promptly discern whether a particular linear lesion is truly non-conducting at the time of the original procedure to permit correction at that time. This would enable prompt re-treatment if necessary.
Unlike the previously described embodiments, a first electrode 50 a′ and a second electrode 50 b′ are preferably located on diametrically opposite sides of lumen 29′ at the distal edge 50′ to contact the heart surface for purposes that will be described. First electrode 50 a′ and second electrode 50 b′ are preferably separated by a distance on the order of several millimeters, preferably 3 to 6 mm. The distance selected is appropriate to ascertain that first electrode 50 a′ and second electrode 50 b′ can be readily applied to opposite sides of a linear lesion produced by the laser surgical wand. First electrode 50 a′ and second electrode 50 b′ are selected and adapted to sense an electrical potential in the local area of each.
Referring to
With the embodiment of
Upon completion of the procedure, the surgeon retraces the created lines with laser surgical wand 10 so that first electrode 50 a′ or 50 a″ is on one side of the line and second electrode 50 b′ or 50 b″ is on the opposite side of the line. Electrical stimuli are then transmitted to the electrodes 50 a′, 50 b′ or 50 a″, 50 b″ from electrophysiology monitoring equipment 36 (
The response of the cardiac tissue is observed. Tracing the created lines in this manner allows the surgeon to test to insure that two different electrical potentials exist on either side of the line. Differing electrical potentials indicate that a complete blockage of electrical energy transmission has been obtained. In the event different potentials are not indicated, the procedure of applying laser energy to the surface of the heart may be repeated as necessary until the desired effect of different potentials are obtained.
A major advantage of the current invention is the ability to create transmural lesions with full cardiac flow present, i.e. on a beating heart in an atraumatic manner without risk of perforation. With a beating heart, electrical isolation testing can optionally be done and, if gaps are found as evidence by lack of electrical isolation, these gaps can be repaired with additional application of laser energy. With radio frequency energy, the heart must be stopped which terminates all electrical activity. Thus, it is not possible to perform electrical isolation testing at the time of lesion creation. This essentially precludes repairing a failed line to obtain complete isolation unless the patient is placed on bypass a second time which is highly undesirable and unlikely. As a result, these patients remain in some degree of atrial fibrillation after surgery.
Another advantage of laser energy system and technique of the present invention is that it can be done concurrently with other beating heart procedures.
The present invention in other specific forms without departing from the spirit of any of the essential attributes thereof. Therefore, the illustrated embodiments should be considered, in all respects, as illustrative and not restrictive, reference being made to the appended claims rather than to the forgoing description to indicate the scope of the invention.
Optional Multiple Fibers
Referring to
With any of the foregoing embodiments, access to the surface of the heart could be to either the endocardial or epicardial surface. Access could be either through a sternotomy or less invasive port access or other surgical access (e.g., open heart to access endocardial tissue) or could be catheter delivered. The procedure can be on a beating heart or on a heart with a patient supported on a by-pass machine.
It has been shown how the objects of the invention have been achieved in a preferred embodiment. It is intended that such modifications and equivalents which will appear to one of ordinary skill in the art with the benefit of the teachings of the present invention shall be included within the scope of the claims.
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|170 posts found
Highlighted Blogger
Joined: 6/29/06
Co-Leader of Inquisition
I respectfully disagree. The fact that the biggest budget MMO ever made is going free to play in only 7 months after release can't not be interpretted as anything short of a massive failure.
Consider this blog post my counter-point.
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Originally posted by Mors-Subita
Fact: Just because they are subs doesn't mean people are playing. Maybe they only play on weekends, or after 10:00 when the kids (or wife) is asleep. Maybe they are early risers. You have to know that even if there is an average of 30,000 players per server, there would likely never be more than 5000 on per server at peak times. And they still have queues if things get too crazy, but it's not likely. This is a standard server model for MMO's. You need X amount of servers based on the average at peak times, not based on subscriptions.
Novice Member
Joined: 8/06/04
"So, Lone Star, now you see that evil will always triumph, because good is dumb." Dark Helmet
Originally posted by Paragus1
Yes. But the massive failure isn't that it is going Freemium too early, it's that it didn't do so from day one. It's the most appropriate fit for the way the game is designed.
Peace is a lie, there is only passion.
Originally posted by Paragus1
Hard Core Member
Joined: 7/18/10
Veni, Vidi, Converti
I don't know anything about SWTOR. I always thought that a space & guns mmo would need more FPS-design to it and not tab-target fantasy? Anyway that's besides the point, here's a graph from MMO Data:
So the general pattern for these (with WoW being a raging exception):
So the KEY PATTERNS:
The TREND might be observed to be that sub mmorpgs are peaking lower, total size of mountain is smaller and speed of peak and crash (mmorpg in it's prime) are all becoming MUCH MUCH shorter. This is statement and question.
So it seems to make these sub mmorpgs something is changing FAST!
Apprentice Member
Joined: 11/02/08
If I ever kill you, you'll be awake, you'll be facing me, and you'll be armed.
Originally posted by Tayah
I whole heartedly agree with both of these comments. Subs don't make games fail Bad games make games fail. Subs dont succeed in bad games. the majority of the MMO market is willing to pay subs for a GOOD SOLID game, But none have come out as of late.
Spotlight Poster
Joined: 1/15/04
Duh, all newly released subscription games are planned to go F2P sooner or later. That way you just get the best money/effort value.
Build a mediocre game, hype it up like crazy, sell it for a high initial cost to the people, including, of course, lots of special and limited and deluxe editions. But sell all that before the game is released, as preorder, so that the people don't really know what they're buying.
Then you already made a large chunk of money, and for a while, the subscription model will give you a lot of money too. Then people realize that it's just a mediocre game like 99% of the others, and start dropping. Once enough dropped, open the game up as free to play, and people will come back. And those with rich parents or who just have enough money, will then play pvp with the equipment they bought in the shop.
Apprentice Member
Joined: 9/13/09
"A strange game. The only winning move is not to post."
STO, DCUO, and now SWTOR. All three championed and defended heavily by members of the staff here in the face of massive criticism, and yet all three games have gone over like a lead balloon. Maybe, just maybe, it isn't the so called "Schadenfreudes" who are having an issue of clarity.
I'm sorry but three strikes and you're out. Might I suggest you turn that angry finger of insight on yourself for a bit. Because personally I don't feel the hysterical blindness about this game has been completely one sided.
"Gypsies, tramps, and thieves, we were called by the Admin of the site . . . "
Advanced Member
Joined: 3/24/09
Actualy I think the real title of this piece should be "Lowered Expectations - and how to pretend it's something else."
Here's a dumb thought....
Maybe the REAL problem is that they designed a game that most people didn't feel was WORTH $15 per month to play....
but instead of admiting that the quality was TOO LOW...they spin it as "the price being too High"..... cute but functionaly equivalent.
$15 per month is DIRT CHEAP as far as entertainment dollars go. I probably loose more then that to pocket change falling into the couch each month. I'd gladly pay 3 to 4 times that for a decent MMO....unfortunately they simply aren't building any these days. It's sad when the closest thing availble to a quality MMO experience is a 1980's text based MUD (and I can't quite bring myself to go back to that).
No Mike....the problem isn't the pricing model....the problem is that Dev's these days seem to have failed to get the barest grasp on how to build a half-way decent game actualy WORTH playing.....and TOR is just another sad example of that.
The real news flash here.... F2P is neither the Solution, NOR the problem.... it's the SYMPTOM.
Symptom of industry who's products for the most part aren't really WORTH BUYING..... and when no one thinks your products are worth buying....the only choice you have is to give them away for FREE.
I've been sitting here for years now with money buring a hole in my pocket....just waiting for a half-way decent, half-way fun MMO to spend it on.... and it's still just sitting there....because all I keep seeing is one piece of badly over-hyped dreck after the next.... TOR being the latest iteration.
THAT's your problem, right there.
Elite Member
Joined: 6/10/09
Originally posted by CazNeerg
That is it exactly. The same can be said for most P2P games at this point. What I'll be watching is how many more shift to F2P and how many stick to remaining P2P. I can see TSW moving this way and RIFT too. I just don't see people sticking with the sub model anymore with so many game options available now that don't require a sub and more are on the way.
Originally posted by Saryhl
So...How long did you play? Did you resub? if so why? All the people saying how bad it was, did you think so for the first 20 hours you played? how about the second 20 hours? If you only played an hour, good. You made a wise choise if you didn't like the game. When are people going to realize that the obsessive "I have to play this game at least 4 hours a day and love it more than pizza!" attitude about MMO's was based on people never having played anything like it before. After the party ends, well people just treat them like any other game, which get's old an boring if you play too much. If this game had been released as a single player game I think there would have been a lot less complaining. Games are just not meant to be played as obsessively as some people think they should to be successful. It ruins the game and you end up with a bad taste in your mouth when you finally quit.
Novice Member
Joined: 6/13/06
"Star Wars: The Old Republic hasn't necessarily experienced a decline in subscribers as sharp as we've seen solely due to any particular failure on BioWare's designers to create a solid MMO..."
"Huh? Seriously???...Have you played the Game? This is absolutely a ridiculous statement...It's also incorrect and ill-informed...And lastly, it's surely not going to help the Devs realize what they need to do to fix this complete mess...
Come on now...
Novice Member
Joined: 8/06/04
"So, Lone Star, now you see that evil will always triumph, because good is dumb." Dark Helmet
Originally posted by KyngBills
It's not at all a ridiculous statement. In many ways, TOR is better than the average themepark MMO, and in no way is it *substantially* worse than any of them. The problem is too many gamers coming to the decision, for a wide variety of reasons, that *no* game is worth $15/month for any substantial length of time. If you ignore the example of WoW, as you should since it's pretty clear at this point that it is a total fluke, the subscription only model just doesn't bring in large numbers. It actually never has, outside of WoW, but it's even less now than it used to be.
Peace is a lie, there is only passion.
Advanced Member
Joined: 9/21/10
Ok, you lost me at "It isn't Bioware's fault for creating a bug riddent craptastic WoW clone with Star Wars skins slapped on, it's EA's fault for choosing to make it a subscription based game instead of F2P right out of the gate."
Honestly, I don't know what it is with you Mike B but you seem to have a veil over your eyes when it comes to this game.
The game failed because of what it is, not how you pay for it. If the game had launched TODAY with every single feature it has right now intact and working the game would explode and be the most successful thing in recent years!!!! People would gladly pay their monthly subs and BW would have their full staff and everything would be candy and rainbows.
But they didn't, they launched a year to early and it showed. I played every single class on each faction to experience the stories since I was a KOTOR fanatic. And the stories were alright, some better then others. But the game itself was a dull and pointless mess.
This game is going f2p in less then a year because of that. People have left because the game was a pos, not because they didn't want to pay a monthly sub. Well hand in hand I guess lmao nobody wants to pay a sub for a pos. So they make it f2p and people can play a pos for free!!!
124 US servers reduced to about 8, yeah... free to play in less then a year, ok... Have fun with your Cartel Coins, buying content for more then a monthly sub. Mike B, take off the veil and see your disfigured god for what it really is.
Playing: Smite, Marvel Heroes
Novice Member
Joined: 6/13/06
Originally posted by CazNeerg
It's a ridiculous statement...The Game does not stand up as is...And it won't either...The vote in my Guild was 15 against, and 2 for, and there is not a single person who had a problem paying $15 a month...The Game is lacking severely in many areas...And it's not like I wanted that...I was looking forward to this Game and talking about it since before the actual announcement on the old BioWare Forums...So...Sorry...Disagree...
Novice Member
Joined: 8/06/04
"So, Lone Star, now you see that evil will always triumph, because good is dumb." Dark Helmet
Originally posted by KyngBills
Different games are designed to serve different niches. TOR was clearly, and this was obvious from before it launched, designed for people who wanted more RPG in their MMO. And judged as an RPG, it is at *least* as good a game as most of BioWare's other offerings, and BioWare is one of the best RPG creators in the business (even if the ending of ME3 does suck.) The areas in which the game could be perceived as "lacking" are exactly the areas which a game needs to focus on in order to justify a subscription, which is why the game never should have launched without a free option.
The core of the game is an excellent single-player experience, eight of them in fact, but charging a subscription for single player content is just bad business, and most of the type of people who want to spend the majority of their time in a MMORPG doing single player content aren't going to get enough value out of the multiplayer portion of the game to justify 15/month, even if that content was up to the same quality standard as the single player story content.
Peace is a lie, there is only passion.
Novice Member
Joined: 11/09/04
This whole article just feels like one huge rationalization. SwToR failed...face it.
And I really dislike the tendency on this website to push for the F2P model in MMO's. I prefer subscriptions, always will, and generally avoid MMO's that have gone F2P. When an MMO that was designed to be a sub and it goes free, it's a failure. End of story.
Games fail because they are BORING, not because you pay $15 a month. I can't remember ever quitting an MMO because of the subscription amount. Every single time it was because I wasn't being entertained, or disliked certain game mechanics.
Novice Member
Joined: 7/17/12
I popped too many blood vessels to give a damn anymore.
It has nothing to do with trend or sub choice or whatever. Going from a sub based game to F2P is not because of any of those, it's because the game is hurting.
Going from sub to F2P is life-support.
They spent a fortune to create a mediocre, co-op multiplayer, believing that because it has "Star Wars" on it that it would sell. Now, while at first it did sell good, it started to drop in a hurry because gamers wanted, stay with me here, a good game.
Had it have been a worthwhile game, people would gladly pay a sub, as it has already been mentioned here. But developers, or more importantly, publishers don't bloody care.
They want money, that's all it comes down to now. And with what's happening with SWTOR, this could very well be a wake-up call that a good well-made game brings in more money than a piece of shit product.
If it was really about the "trend", then WoW would've gone that route long ago. But it' hasn't, because it's not a damn trend, it's a result. A result of pathetic, blind money grab attempts.
I thought the same way about those who hammered the game at the beginning. Brushed them off as trolls, I bought into the hype. Last mistake I make. I knew what they were going on about now after hearing about how beta went and the PTRs after the first 4 months.
There was a point in Skyrim with a quote that best describes this, "Don't give me goat piss and call it mead!"
You know what's fun about chaos? I do, but I won't tell.
I guess I see this announcement as a way that I can experience the storylines I started in the beta weekends :)
Novice Member
Joined: 8/06/04
"So, Lone Star, now you see that evil will always triumph, because good is dumb." Dark Helmet
Originally posted by TheBigDRC
Ok. So explain why converting to Freemium always results in increased revenue, often to the point where previously stagnating games are able to release frequent updates, and on occasion even well received expansions. Why do so many subscription worshippers insist on ignoring the reality that Freemium has been a more effective business model for every game that has tried it?
Peace is a lie, there is only passion.


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About the Collection
Make your skin glow with Pür Minerals, a results-based line of color cosmetics that gives you a clean, flawless finish every time. Pür Minerals's secret lies in their perfect fusion of nature's finest ingredients and the latest skincare technology.
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Step 1: What You'll Need
1 x Reflector Mount (a friendly bike shop will give these away for free)
1 x Shim for reflector mount (also probably free at your LBS)
1 x 2 inch 1/4" x 20 thread count screw of your choice (pretty standard for most cameras)
2 x 1/4" wing nuts
2 x 1/4" washers
2 x 1/4" rubber washers
You might also need a drill with a 1/4" drill bit
Step 2: Drill Out Hole
You can use a mount that has only one hole, you'll just have the mounting screw double as the screw for the camera. Make sure you take into account that you'll need a 1/4" diameter hole through there when rummaging through their reflector bin.
Step 3: Assembly
metal washer
rubber washer
wing nut (could also use a regular nut)
wing nut (upside down! this one is more helpful if it's a wing nut)
metal washer
rubber washer
the rubber washers were to help absorb shock. it's not perfect, but it does a better job than nothing. still looking for an improvement on that though.
Step 4: Put it on your bike!
Excellent tutorial, thanks.
I was going to buy a mount but then thought I'd do a quick search on here, I'm now happy that I did the search.
The video is somewhat acceptable on smooth roads, but I wouldn't want to go anywhere near a trial. It's not the fault of the mount so much as the weight of the camera. The L20 is a pretty compact model, but it still weighs too much to hold steady, and I bet other similarly sized cameras will have the same issue.


text:
|The most helpful favorable review
|The most helpful critical review
4 of 4 people found the following review helpful:
By Damian from USA on 2012-05-21 18:19:17Things I liked:For starters, this gun is a legend! My friend has had his for 20 years and I watched him put a nice sized "dimple" on a solid brass padlock! I was sold. The T-06 was a very nice surprise! I couldnt believe how the trigger played a key role in achieving nice groupings. I like the stock, as I like wood. The remainder of the gun seems really nice. Comes equipped with a nice scope rail. The order processing and shipping was fast. I would highly reccomend this rifle for anyone who, like the legendary Ruger 10/22; wants to own a true classic that lasts.
Things I would have changed:Plastic components!
What others should know:I have the .22 and Crossman Premier pellets work great. The staff at Pyramyd are really great, and Rick Eutsler was very informative and prompt when answering questions. Thanks Pyramyd, you'll always be at the top of my list!
5 of 6 people found the following review helpful:
By Joe from USA on 2009-07-28 19:02:31Things I liked:I found the wood stock and stainless steel bore appealing. It is a good thing that the trigger is adjustable, the second stage vanishes regularly.
Things I would have changed:I cannot fit three screwdrivers into my rifle bag. See below.
What others should know:I purchased this gun from Pyramydair.com less than a month ago, and have had nothing but problems with it. Every five shots or so, the rear sight shakes loose, regardless of the mounting screws positioning. In other words, I am quite literally always sighting the gun in. Also, the stock simply does not fit the gun --- It actually looks dangerous, as though a pin could fly out. (these pins are above the trigger, and are not visible on any photographs I have seen of 34s.) It appears the stock is supposed to hold these pins in place, but the stock apparently does not fit, nor does it perform this function. Finally, the large, plastic safety housing is very loose. It is impossible to set the safety on or off without grinding its housing against the metal. I've put about 400 pellets through mine, and now have a nice 1-2 inch silver ring where the finish has been ground off the gun. Umarexusa has not returned my calls. This gun is garbage.
|By Kenneth from USA on 2014-07-14
CheckoutSubtotal (USD):
does not include shipping and tax


text:
Rotator Cuff Injury
- Home
- Health Info
- Rotator Cuff Injury
(Rotator Cuff Tear; Impingement Syndrome)
|Rotator Cuff Injury
|Copyright © Nucleus Medical Media, Inc.
- Direct blow to the shoulder area
- Falling on an outstretched arm
Chronic degenerative wear and tear on the tendons:
- Arthritis may decrease the space for the tendons
- Chronic instability of the humerus may traumatize the tendons
Repetitive overhead motion of the arm such as in:
- Swimming
- Baseball (mainly pitching)
- Tennis
Risk Factors
- Heavy lifting
- Abnormalities of the shoulder, or in rotator cuff anatomy or function
- Activities that involve repetitive overhead arm motion such as throwing or work related
- Weakened shoulder muscles from inactivity or previous injury
- Recurrent, constant pain, particularly when reaching overhead
- Pain at night that prevents you from sleeping
- Shoulder muscle weakness, especially when lifting the arm
- Popping or clicking sounds when the shoulder is moved
- Limited range of motion in the shoulder joint
- Ultrasound
- Arthrogram
- MRI scan
- Arthroscopy
- Rest helps the shoulder to heal. The doctor may recommend that you wear an arm sling to help rest the shoulder area.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) to help control the pain and/or inflammation.
- Topical pain relievers, such as creams or patches, that are applied to the skin.
- Corticosteroid injections to help reduce pain and inflammation.
- Injection of platelet rich plasma (PRP) to reduce bleeding.
- Ice to help relieve pain and inflammation. Apply ice to shoulder area for 15 minutes, 3-4 times a day.
- Physical therapy to help strengthen and increase motion in the shoulder area.
- Avoid overhead repetitive motion
- Limit duration of work that involves
- Moving hands above shoulders
- Using shoulder in extreme outward rotation
- Vibrating tools
- Avoid heavy lifting
- Exercise regularly to strengthen the muscles around the shoulder joint
The American Orthopaedic Society for Sports Medicine http://www.sportsmed.org
Ortho Info—American Academy of Orthopaedic Surgeons http://www.orthoinfo.org
Canadian Orthopaedic Association http://www.coa-aco.org
The University of British Columbia Department of Orthopaedics http://orthopaedics.med.ubc.ca
Castricini R, et al. Platelet-rich plasma augmentation for arthroscopic rotator cuff repair: a randomized controlled trial. Am J Sports Med. 2011 Feb;39(2):258-65.
Deu RS. Common Sports Injuries: Upper Extremity Injuries. Clin Fam Pract. 2005 Jun; 7(2); 249-265.
Rotator cuff tear. EBSCO DynaMed website. Available at: http://www.ebscohost.com/dynamed. Updated July 13, 2014. Accessed September 28, 2014.
Smith MA, Smith WT. Rotator cuff tears: an overview. Orthop Nurs. 2010;29(5):319-322
10/26/2010 DynaMed's Systematic Literature Surveillance http://www.ebscohost.com/dynamed: Massey T, Derry S, Moore R, McQuay H. Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev. 2010;(6):CD007402.
Revision Information
- Reviewer: John C. Keel, MD
- Review Date: 08/2014 -
- Update Date: 10/31/2012 -


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How to turn off iOS 7 frequent location tracking and increase your privacy
By default, iOS 7 will track and record places that you visit most often to provide better location-based data such as in the Today summary of Notification Center. If you value your privacy more than you do location-based data, you can turn the feature off. Turning off features like these can also help save a bit of battery life too.
Here's how:
- Launch the Settings app from the Home screen of your iPhone or iPad.
- Tap on Privacy.
- Now tap on Location Services at the top.
- Towards the bottom of the next screen, tap on System Services.
- Again, towards the bottom of the next page, tap on Frequent Locations.
- At the top of the next screen, turn the Frequent Locations option to the Off position.
That's all there is to it. Locations you travel to most will no longer be tracked. While this comes at the expense of not having as accurate location data in places like the Today Summary screen, it also preserves your privacy better and to a lot of us, that's more important.
Have something to say about this story? Leave a comment! Need help with something else? Ask in our forums!
Reader comments
How to turn off iOS 7 frequent location tracking and increase your privacy
Thanks! I honestly have no idea. It's not even in my camera roll anymore either. Random google search for fall iphone 5 wallpaper would be my guess :)
You (and everyone else on the team) have been doing a great job on these posts today. This kind of fundamental stuff is invaluable, even to someone like me having read every article about the changes in iOS 7 since it was first announced. :-) Kudos.
I am having the same issue...worked in the beta, now on my iPhone 5s it's a no go...
Does the iPad have Frequent Locations on/off? I don't see it on my iPad 4.


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One of my favorite changes in Capybara 2.1 is ignoring all hidden elements by default. This could be viewed as a limiting of Capybara's feature set, since you can no longer (easily) test certain elements on a page. I will argue that it steers you into writing tests that are more realistic, causing this limitation to actually enhance the quality of your acceptance tests.
Less is more in Capybara 2.1
Sunday, April 28, 2013