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Aeto Bamboo & Wild Mango Fortifying Mask
We know you want the goods as soon as possible, which is why orders received by 3pm ET leave our warehouse the very same day. We'll send you an email that day to confirm shipment and the email will include your tracking information.
Our warehouse is closed Saturday & Sunday, so orders received after 3pm ET on Fridays will not ship out until Monday.
Based on 4 Reviews
Sunny K.HairDark BrownNormal HairThis Product Really Works!After just one use, my hair looked healthier and stronger! I got lots of compliments about my hair after use this product.
I like to use deep clean shampoo before the mask so the hair can get maximum benefit from the mask.posted Nov 26, 2011Link to this post
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Sophie F.HairDark BrownNormal HairOily HairCurly HairThick or Coarse HairSuper Soft Hair!I hate products with parabens in them, so when i saw this product had no parabens in it, i immediately liked it! Many products without parabens in them do not seem to work as well as others though! This one does! I feel as if it really penetrates the strands of hair and moisturizes them from root to tip! My hair feels lighter(in a good way, still full of volume) and best of all healthy! It is a lot easier to manage my hair after using this product! I absolutely love it! It is amazing and works miracles! It works on all types of hair! Mine is curly, kind of coarse, and can be very frizzy! I used it and it made my hair much smoother, and eliminated frizz! It's amazing! I recommend it for all hair types! You will not be disappointed!
Funtabulousbeauty.blogspot.composted Jul 6, 2011Link to this post
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DawnSCHairMedium BrownColor Treated HairThick or Coarse HairWorth The MoneyThis line of hair care (shampoo, conditioner, mask and occasionally contouring serum) is by far the best I've ever used. What I like most about it is that it does not leave a build up after a number of consecutive uses, and this mask makes my long, highlighted hair (brunette, slightly coarse and somewhat overprocessed) very soft but shiny and silky. This is whether I wear it wavy w/ some help from the curling iron or straightened with a flatiron. I've used higher end ($60+) masks as well as organic masks from the health food store, and while they work well, I still get a build up after several uses, though I only use them once a week with several shampoos in between. This even occurs while using clarifying shampoos. I've used this mask three times in a row with no dulling residue. It probably could be a fine daily conditioner- just use a little less. I seriously like the fragrance as it is really clean and fresh, with maybe a very light cedar undertone. It doesn't interfere with perfume, though this is so good I don't usually wear additional fragrance. I've been using this line for about six months, through the winter, and it has been great. It is starting to get a bit humid now, and so far, so good.posted Apr 21, 2011Link to this post
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NellNJHairFine or Thin HairExcellent Treatment, Even For Fine Hair!Typically I shy away from hair treatments fearing they will make my fine hair weighed down and greasy. But this treatment is perfect! I use it once a week and its helping keep my strands smooth, long and strong.1 out of 1 shoppers thought this review was helpful.
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In spite of all the problems and the controversy associated with it, the Unlocked iPhone 4 has managed to sell as much as 3 million units already just about under a month from its release. Selling at around one million units per week, this handset is sold out in almost all places. However the problems have been plaguing the company pretty badly. CEO Steve Jobs decided to directly address this issue in a press event where he acknowledged the issue but at the same time doled out certain figures which were aimed at proving that the iPhone 4 was selling marvelously irrespective of the problems that they were facing.
Apple has said that the iPhone has hit the level of three million customers and they have also gone to the extent of saying that this is the foremost gadget they have ever made. If that was not enough, they have also said that this is the top ranked smartphone in the market. Well, from the reports that we have got, this is pretty different as consumer reports have slowly been pulling their recommendations off and the reports are not very encouraging. Apple had come up with a slew of software upgrades for the iPhone 4 unlocked handset which they said would help the phones which would lose its reception when one would hold the phone in a certain way. There has also been some research done on the part of some private agencies and what they found was pretty bad for the iPhone. It has been found that one would need to either place tape on their palms or at least get bumper cases for their phones to be able to operate it.
Judging by the amount of money that one pays for this phone, it is expected that they will get the best performance. For its defense, the phone is pretty well loaded with features and we hope they can turn it around.

subset: commoncrawl


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Beefeater 24 Lemon Gin Cocktail Recipe
Happy Hour: Desmond's Pleasure
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I recently enjoyed Beefeater 24 in a cocktail named for its creator, master distiller Desmond Payne, at Clock Bar in San Francisco. Crafted by one of my favorite bartenders, Steven Liles, this drink is full of tart citrus flavor. The combination of elderflower liqueur, lemon juice, bitter lemon soda, and Pimm's does not overshadow the Beefeater 24. Instead, it enhances and balances out the gin, resulting in a drink that is intricate and refreshing.
To look at Steven's recipe,
From Steven Liles of Clock Bar
Desmond's Pleasure
1 1/2 oz. Beefeater 24
1/2 oz. St. Germain elderflower liqueur
1/2 oz. Lemon juice
3 dashes Fees Bros. Grapefruit Bitters
Fever Tree bitter lemon soda
1/2 oz. Pimm's No.1
- Shake first 4 ingredients and strain into ice filled Collins glass.
- Add bitter lemon soda and float pimm's over the top. Garnish with a long slice of lemon peel.
Makes 1 drink.
- Category
- Drinks, Cocktails


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Mikasa Volleyball Carts & Hammocks
Mikasa Volleyball Carts & HammocksMikasa Volleyball Carts and Hammocks are just what the volleyball coach needs. Two styles, multiple color options and all for a great price! Order now and enjoy easier volleyball practices and warm ups when you use your new cart or hammock.
$122.40As Low As: $117.15Compare
$122.40As Low As: $117.15Compare


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The Felician College New Student S.O.A.R. program is an interactive session that provides essential information sessions, introduces concepts of college culture and assists students in navigating buses, buildings, services and resources available on the two campuses in Rutherford and Lodi. it is designed to ease the transition of new undergraduate students into the academic, social and extracurricular communities of Felician College. Beginning with the New Student Orientation program and welcome Week, we aim to help students acclimate to the Felician campus and to develop the tools needed to succeed in their first year. All sessions are held on the Rutherford Campus.
Student Orientation Leaders will serve as hosts and share their experiences with new students. Administrators and faculty will also be present throughout the sessions to answer questions and give advice about your educational future. There are two sessions scheduled for Monday, June 16: 8 a.m. to 1 p.m. and 12 p.m. to 5 p.m.
RSVP: http://www.felician.edu/form/new-student-summer-orientation-soar-rsvp
Email: email@example.com
Phone: (201) 355-1457


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Dr. Steven Zeitels is a preeminent Laryngeal Surgeon & has pioneered many of the state-of-the-art operative techniques to restore human voice for benign and malignant lesions and diseases. He has published & lectured extensively on this subject.
BiographySteven M. Zeitels is the Eugene B. Casey Profesor of Laryngeal Surgery at Harvard&Director of the MGH Center for Laryngeal Surgery and Voice Rehabilitation. He has contributed >200 publications & videos, >300 papers & lectures & has been a visiting professor at >30 institutions including Memorial Sloan Kettering, Columbia Univ. Medical School, & Univ. of Pittsburgh. He has served on the editorial board of 5 journals, has designed >20 new laryngeal & pharyngeal procedures & holds 3 laryngoscope patents. Dr. Zeitels has received >50 awards & honored lectureships including the Casselberry Award of the American Laryngological Association, which was only awarded 24 times in the 20th century. His work has been featured in the Harvard Medical Alumni Journal, Harvard Magazine, & the BU Alumni Journal. It has also been discussed extensively in the other print, radio and televsion media: [e.g. Good Morning America, Today SHow, ABC World News, Wall Street Journal, NY & London Times, NPR, BBC, National Geographic, Boston Globe, Boston Magazine]. Dr. Zeitels conceived and directs the Voice Restoration Research Program, which is a collaborative effort of investigators at HMS, MGH, MIT and Julie Andrews. He has served as President of the American Broncho-Esophagological Association. In 2004, the first endowed Chair in Laryngeal Surgery at Harvard Medical was created for him whil he re-established a Laryngeal Surgery service at the MGH, which had not been present since the 1920's. Dr. Zeitels was a member of the 1st class of BU Trustee Scholars, attended the BU 6-year medical program and graduated the BU Medical School in 1982. He completed the BU-Tufts Otolaryngology - Head & Neck Surgery Residency in 1987 and a Head & Neck Cancer Fellowship at BU & VAMC in 1988. He received the Distinguished Alumnus Award from the BU School of Medicine in 2007.
View my most recent publications at PubMedSee Pubmed.gov: "Zeitels SM"[Author]
The first long-term study of a pioneering endoscopic laser treatment for early vocal-cord cancer, developed at the MGH and previously shown to provide optimal voice outcomes, finds that it is as successful as traditional approaches in curing patients' tumors while avoiding the damage to vocal quality caused by radiotherapy or by conventional laser or cold-instrument surgery.
MGH surgeons have developed a new technique for reconstructing the larynx after surgery for advanced cancer. The approach uses cryopreserved aortas from deceased donors to replace removed larynx tissue and allows some patients to avoid a permanent tracheotomy and maintain voice and swallowing function.
The first long-term study of a pioneering endoscopic laser treatment for early vocal-cord cancer, developed at MGH and previously shown to provide optimal voice outcomes, finds that it is as successful as traditional approaches in curing patients' tumors while avoiding the damage to vocal quality caused by conventional treatments.
Statement regarding treatment of Sam Smith by Steven Zeitels, MD.
Phone: 617-726-1444
Phone 2: 617-726-0218
Fax: 617-726-0222
Phone: 617-726-1444
Phone 2: 617-726-0218
Fax: 617-726-0222
Call the Massachusetts General Hospital physician referral service at 800-711-4644.
Mass General accepts most health insurance plans. Find out what you need to know before coming to Mass General.
Driving to Mass General? Get driving directions or locate a parking lot on the hospital's main campus.


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- Northern New York Newspapers
- Watertown
- Ogdensburg
- Massena-Potsdam
- Lowville
- Carthage
- Malone
- NNY Business
- NNY Living
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MASSENA Village officials plan to borrow money to finance the lease of a new firetruck to replace an aging pumper.
The village Board of Trustees will vote March 19 on a resolution to take out $475,000 in bonds for the new fire engine, according to village officials. If approved, the bonds would be subject to a permissive referendum, which mandates that any action on the bonds be delayed for a 30-day waiting period to allow concerned members of the public to petition against the bonding.
Massena Fire Department Chief Thomas C. Miller said the new engine would replace either a 1987 truck or a smaller 1989 truck. Both have cost us large amounts of money repairing them over the years, Mr. Miller said.
He described the pumper the department is seeking to lease as an initial-attack, front-line truck. The pumper is equipped with a water tank, hoses, ladders, ventilation equipment, air packs and other equipment that is critical to extinguishing a blaze. It is the first vehicle to respond to the scene of a fire, Mr. Miller said.
The Fire Department has six vehicles: a tanker truck, a tower ladder, an equipment truck, two full-size pumpers and the smaller 1989 pumper, which is specially designed to extinguish grass fires. Replacing the 1989 pumper could provide another resource for responding to fires and would save on the costs of repairing the trucks.
Trustee Patricia K. Wilson said the villages Fire Committee has considered using $50,000 from the fire equipment capital fund to make a down payment on the truck to reduce interest costs on the financing. However, interest rates are so low that village officials may find it preferable to finance the purchase without using reserve funds.
In other news from the fire station, Massena Fire Department foreman and career firefighter Kenneth J. McGowan said fellow career firefighter Walter J. Bean had completed his code compliance training, bringing to six the number of Massena career firefighters trained in code enforcement.
Following the retirement of code enforcement officer Gregory C. Fregoe on Jan. 22, the Fire Department has been responsible for code enforcement in the village.
Three career firefighters, Mr. McGowan, Aaron T. Hardy and Bill OBrien, are fully trained code enforcement officers. Three others, Mr. Bean, Jeremy Lefeve and Matthew R. Tuper, are trained as code compliance technicians.
A code compliance technician is trained in enforcing the fire and property maintenance codes, but is not certified in other code enforcement officer duties, such as issuing building permits or inspecting new construction projects.
Mr. Tuper recently began his code enforcement training, Mr. McGowan told the village board. Once Mr. Tupers training is complete, the Massena Fire Department will be able to keep one official fully trained in code enforcement on staff at all times of the week, Mr. McGowan said.
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The season's first extended period of temperatures in the 90s means some seasonal businesses and services are bustling.
Other area employees and at-risk groups have to take special care not to be harmed by sweltering conditions.
The pool at Radcliff's Colvin Community Center on Freedom Way has maintained steady attendance.
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Video: Milk: Morning Run
Video: Speedstick: Laundry
Video: Skechers: Untitled
Video: KIA: Hotbots
Video: Volkswagen: Get Happy
Video: SodaStream: Effect
Video: Anheuser Beck's: Sapphire
Video: Go Daddy: Perfect Match
Video: Anheuser Budweiser: Brotherhood
Video: AXE: Lifeguard
Video: Century: Wedding
Video: Taco Bell: VIVA Young
Video: Hyundai: Stuck
Video: Hyundai: Epic Playdate
Video: Audi: Prom Heartbeat
Video: Toyota: RAV4 Wish Granted
Video: Hyundai: Team Hit
Video: E Trade: Untitled
There are those who watch the Super Bowl to soak in every second, dissecting each play throughout the always-epic pigskin battle.
Then there are those who watch just for the commercial breaks.
Photos: Super Bowl 2013 commercials
The multi-million dollar television ads are always among the moments that churn up watercooler chat after the big game.
Some spur controversy like the Snickers man-kissing spot from 2009, while others ignite a moment for the memories like the now-famous Coca-Cola commercial with Mean Joe Greene or the 1984 Apple ad for the first Macintosh computer.
Most, like Doritos ads, are aimed at hitting your funny bone with silly concepts to make their spot memorable.
The ads have even flared fame for folks like the Old Spice man and long-time TV star Betty White, who found herself skyrocketing back into the spotlight for her performance on the gridiron in this Snickers commercial back in 2010. Remember how it sparked a campaign to get her a hosting gig with "Saturday Night Live"?
Plus, who can forget the Budweiser bullfrogs and Clydesdales, Coke's polar bears or even the E*Trade baby? They are Super Bowl commercial stars.
Super Bowl facts you may not know
It's also the time in which major movie studios unleash extended trailers or first teases for some of summer's biggest upcoming releases, just like they did last year with the partially Cleveland-lensed "Avengers" flick.
Looking back: Photos of 2012's Super Bowl commercials
What will the commercials during Super Bowl XLVII deliver? Which ones will stand out and be remembered years to come?
Instead of waiting to feast your starving eyes on the slew of Super Bowl spots set to air in Sunday's big game, we've assembled a barrage of some of the spots to keep your eye out for.
Scroll down this page to watch some of the spots before they air during Super Bowl Sunday.
One of them, titled "VIVA Young" by Taco Bell, features an elderly batch of pals partying the night away to the tune of fun.'s "We are Young" as it's sung in Spanish. After an obvious crazy night out, they chow down at Taco Bell.
Among the other ads, car commercials are also heavy hitters during the Super Bowl. You can watch some of those in this story, too, including the one at the top of this page titled "Space Babies" by Kia.
After you take an advanced glance at some of the spots Super Bowl XLVII has to offer, leave your thoughts about your favorite one in our comments section below.
Is there one Super Bowl commercial from recent years that sticks in your mind as a favorite?


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Metro Super Adjustable Metroseal 3 Wire ShelvingMetro Super Adjustable wire shelves boast a unique corner release system which allows them to be adjusted quickly and easily without the use of tools! Super Adjustable stainless steel shelving has a unique Metroseal 3 finish with antimicrobial protection that makes it perfect for damp environments such as walk in freezers and coolers, dishwashing stations, and laundry rooms.
With shelves and posts designed to meet the diverse needs of today's always-changing storage challenges, webstaurantstore.com has all of the parts you need to build your own fully-customized unit! Also make sure to check out other great items from Metro.


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Posted on May 31, 2013
Suffolk's most cherished Cradle Of Filth formed back in 1991. The line-up originally comprised of Dani Filth, Paul & Benjamin Ryan, Jonathan Pritchard & Darren White. Over the years Cradle Of Filth would become known for their revolving line-up with other 20 musicians. Cradle Of Filth's extreme gothic metal has made them an enigma to categorise, neither falling fully within black metal & offering a sound far more extreme than traditional heavy metal. It is safe to say that they have created their own sombre, horrific & grandiose niche of extreme metal. After 3 demos, 5 full studio albums & a t-shirt which would be banned in certain countries, Cradle Of Filth signed to Roadrunner Records for their 6th studio album 'Nymphetamine.'
The album was produced by ex-Anthrax guitarist Rob Caggiano & released on September 28th 2004. The 14 track album included the singles 'Devil Woman' & 'Nymphetamine Fix' which featured Liv Kristine from Theatre Of Tragedy. The album also included narration by Doug Bradley AKA Pinhead from the Hellraiser movies & King Diamond backing vocals on 'Devil Woman.'
2006 saw the release of their 2nd Roadrunner album 'Thornography'. According to frontman Dani Filth the title is meant to represent man's obsession with sin & self. The album featured the bands controversial cover of Heaven 17's hit 'Temptation'. The deluxe edition of the record was released in 2008 & featured more covers in the form of 'Halloween II' originally by Glenn Danzig's Samhain & 'Stay' by 'Shakespears Sister'.
The concept album 'Godspeed On The Devil's Thunder' was the bands final Roadrunner release & came out in 2007. The album which saw Cradle Of Filth as a four piece for the first time was a concept album based upon the life of Gilles de Rais. Cradle Of Filth's lyrical content has always gravitated towards horror, mythology & gothic literature. In this instance the character of Gilles de Rais became the focal point. He had fought side by side with Joan Of Arc before becoming a murderer, sexual deviant & Satanist.
Click here to listen to these vicious slabs of extreme metal on Spotify now!


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About accessing files on your computer from your device
Imagine arriving at a meeting, only to discover that a document you need is on your computer. With remote file access, you can use the File Manager app on your BlackBerry device to view, download, and delete music, pictures, videos, and documents that are on the computer that BlackBerry Link is installed on. For information about how to use the File Manager, tap the Help app on the home screen of your device.
By default, devices running BlackBerry 10 OS version 10.1 or later that you set up with BlackBerry Link can access the files in your music, pictures, videos, and documents libraries on your computer if they are associated with the same BlackBerry ID that you are signed in to BlackBerry Link with. You can grant remote file access to specific folders on your computer and you can turn off remote access for specific devices.
Was this information helpful? Send us your comments.


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greeting cards, abstracts greeting cards, rust greeting cards, holes greeting cards, circles greeting cards, shadows greeting cards, round greeting cards, shapes greeting cards, forms greeting cards, textures greeting cards, color greeting cards, color photography greeting cards
"Mind - Contemplation" greeting card by Steven Milner. Ships within 2 - 3 business days and includes a plain white envelop for mailing and/or gift giving. Available in vertical and horizontal orientations.
A note to my Customers: The Fine Art America water mark WILL NOT Appear on your purchased prints. As of October 2012, I have started signing all of my work. It is done in a subtle way and gives my work a more personal touch. This electronic signature will remain a part of your final purchase. If you desire work not signed, please contact me by email, I will be happy to arrange for unsigned work to reach your walls, rooms, homes and offices.
Our return policy is very simple:
If you're not happy with a purchase that you made on FineArtAmerica.com, for any reason, you can return it to us within 30 days of the order date. As soon as it arrives, we'll issue a full refund for the entire purchase price. Please note - Fine Art America does not reimburse the outgoing or return shipping charges unless the return is due to a defect in quality.
Fine Art America sells thousands of pieces of artwork each month - all with a 100% money-back guarantee.
If you've hesitated to purchase artwork online in the past, why not give us a try? You have nothing to lose!
We take great pride in the fact that hundreds of thousands of artists have chosen Fine Art America to fulfill their orders, and we look forward to helping you select your next piece!
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BC-Lodges.com is not affiliated with, endorsed by, associated with, or sponsored by Talking Rock Resort and Quaaout Lodge. To make a reservation at Talking Rock Resort and Quaaout Lodge (Chase) please submit a booking request directly to this lodge using the following contact information
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When it comes to smartphone protection, no brand compares to OtterBox. For years they have been the industry leader in manufacturing cases that offer full body protection against the elements, and they have products for all the top smartphone models. A high quality polycarbonate shell with a separate durable silicone skin with port covers can only be found on these amazing OtterBox cases from PureMobile.com.
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Weekend Review (MLB): Hairston, Upton, Jays C & free-agent OF
Here are some other noteworthy Hot Stove rumors and news from this past weekend…
The Yankees have been negotiating with free-agent OF Scott Hairston. (New York Post)
The is just a 10% chance that Justin Upton is traded this winter, a D-Backs source said. (Jon Heyman)
The Blue Jays are shopping catchers J.P. Arencibia and prospect Travis D'Arnoud, but more likely to deal CJohn Buck. (Boston Herald)
The Royals are listening to offers for Eric Hosmer, Mike Moustakas, Alex Gordon, Billy Butler, and even Wil Myers. (Boston Herald)
The Red Sox are more likely to deal C Jarrod Saltalamacchia than C prospect Ryan Lavarnway. (Boston Herald)
The Marlins signed free-agent OF Juan Pierre to a one-year, $1.6 million deal.
The Blue Jays signed free-agent OF Melky Cabrera to a two-year, $16 million deal.
The Braves signed free-agent C Gerald Laird to a two-year deal worth around $3 million.


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Can I restore MS-SQL DB from difffull backup?
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|Burglary Suspect Caught, Another Sought
|Written by Steve Frank
|Tuesday, 12 March 2013 07:17
Caldwell County Sheriff's Office received a call late Sunday night reporting a Burglary that had just occurred on Smokey Creek Road in Lenoir. Deputies responded to the incident location and learned that Marcus Lee Smith had kicked in the back door of the residence and robbed the two
persons inside. No weapons were displayed but intimidation was used. Marcus Lee Smith was assisted in commission of the crime by Dalton Nicholas Hendrix. The suspects fled the incident location in a red Honda Civic which was located in the area a short time later by deputies. Smith was arrested for first degree burglary, common law robbery, and injury to real property. He is currently being held in the Caldwell County Detention Center under a $100,000 secured bond. Hendrix is still at large and warrants have been issued for his arrest by Sheriff's Office Detectives. Anyone with information on Hendrix is urged to contact the Caldwell County Sheriff's Office or Caldwell/Lenoir Crime Stoppers at (828)758-8300. All information will remain confidential.
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|Publication number
|Publication type
|Application number
|Publication date
|29 May 2008
|Filing date
|5 Feb 2008
|Priority date
|15 Nov 2002
|Also published as
|Publication number
|William E. Webler, James D. Breeding, Brad D. Bisson, Firas Mourtada, Gregory M. Hyde, Stephanie A. Szobota, Gabriel Asongwe, Jeffrey T. Ellis
|Original Assignee
|Webler William E, Breeding James D, Bisson Brad D, Firas Mourtada, Hyde Gregory M, Szobota Stephanie A, Gabriel Asongwe, Ellis Jeffrey T
|Export Citation
|BiBTeX, EndNote, RefMan
|Referenced by (40), Classifications (20), Legal Events (1)
|External Links: USPTO, USPTO Assignment, Espacenet
This application is a divisional of co-pending U.S. patent application Ser. No. 10/712,553, filed Nov. 12, 2003 which claims the benefit of U.S. Provisional Patent Application No. 60/426,663, filed Nov. 15, 2002.
1. Field
Atrioventricular valve repair, including percutaneous atrioventricular valve repair.
2. Background
Generally speaking, oxygenated blood travels from the lungs to the left atrium by way of the pulmonary veins. The veins from the systemic circuit, the venae cavae and coronary sinus carry blood deficient in oxygen into the right atrium. The right ventricle takes blood received from the right atrium and sends it to the lungs, while the left ventricle takes blood received from the left atrium and sends it to the aorta.
The atrioventricular valves between respective ones of the atria and ventricles play important roles in the transport of blood through the body. The atrioventricular valves open during diastole, when the heart muscle relaxes, to allow blood to flow from the atria into the ventricles. The atrioventricular valves close during systole, when the heart muscle contracts, preventing the backflow of blood into the atria and allowing blood from the ventricles to be efficiently pumped into the lungs via the pulmonary artery and to the rest of the body via the aorta.
The mitral valve is the atrioventricular valve that controls blood flow from the left atrium into the left ventricle. The mitral valve is a bicuspid valve, describing the two cusps or leaflets that open and close the valve. The cusps or leaflets are attached to a muscular and fibrous ring around the orifice (mitral valve annulus) and their apices hang down into the left ventricle. When the ventricle fills with blood and begins to contract, the valve cusps or leaflets flow into position in the atrioventricular opening and are forced shut (coaptate) by the increasing pressure. To prevent the valve cusps or leaflets from turning into the left atrium and regurgitating blood, tendinous cords, the chordae tendineae, are attached to the free margins and ventricular surfaces of the cusps or leaflets. At the other ends, these cords are attached to one of a respective pair of papillary muscles projecting from the ventricular wall. By contracting, these muscles maintain the integrity of the valve during ventricular contraction or systole.
When the two cusps or leaflets of the mitral valve do not completely close, there is backflow, or regurgitation of blood. The backflow increases the pressure in the left atrium which leads to pulmonary hypertension and dilation of the heart which are the most common symptoms to congestive heart failure. A heart then has to work harder pumping blood for the body which can lead to heart damage. Incomplete closing of the mitral valve cusps or leaflets is common, occurring generally in about seven percent of the population. Conditions contributing to incomplete closure of the mitral valve cusps or leaflets include genetic defects, infections, coronary artery disease, myocardial infarction, or congestive heart failure. These conditions contribute to mitral valve regurgitation resulting from enlargement of the mitral valve annulus and/or movement of the papillary muscles away from the valve as a result of ventricular enlargement. When the annulus enlarges, the cusps or leaflets of the valve are no longer able to close (coaptate), because the distance between the two cusps or leaflets has increased too much for the cusps or leaflets to touch each other and thus close off blood flow to the left atrium during, for example, systole. Mitral valve regurgitation can also result as a secondary etiology due to the remodeling of a distorted left ventricle in ischemic heart disease. It is known that as the ventricle is remodeled, the papillary muscles can be displaced away from their natural position. This displacement alters the natural tethering of the cusps or leaflets and restricts the ability of the cusps or leaflets to close properly at the level of the annulus.
In general, most cases of mitral valve regurgitation are mild and the symptoms may be controlled with drugs. In more serious cases, the mitral valve can be repaired through a procedure known as annuloplasty, a surgical procedure in which a synthetic ring is placed around the valve annulus. Annuloplasty encourages aptation of the mitral valve cusps or leaflets by shrinking the size of the valve opening. In other instances, a faulty mitral valve must be surgically replaced with a new valve. These surgical repairs require the opening of the chest by sternotomy or at best through small incisions in the chest wall, heart lung bypass and stopping the heart beat. Further techniques under investigation include remodeling the adjacent coronary sinus and joining two middle edges of the cusps or leaflets where they should coaptate.
A second type of regurgitation occurs not necessarily by the enlargement of the mitral valve annulus but by the extending of a cusp or leaflet into the atrium during systole. A condition known as billowing occurs when the mitral valve cusps or leaflets do not meet well but instead get pushed up into the atrium. A condition known as prolapse occurs generally when a single cusp or leaflet extends into the atrium causing incomplete closure of the valve. A condition known as flail typically occurs when a tendon is ruptured and the corresponding cusp or leaflet extends into the atrium during systole.
Current mitral valve regurgitation may be diagnosed by Trans-Thoracic Echo (TTE) in many patients or Trans-Esophagael Echo (TEE). TEE tends to provide the most reliable and definitive structural and functional mitral valve information. Both TTE and TEE imaging devices are reusable.
TTE images the heart with a hand-held transducer from under the rib cage and between the ribs and thus has limited views of the mitral valve. TTE becomes less reliable in large or obese patients as the increased distance from the probe to the valve reduces image echo strength and resolution. Also, the imaging windows between the ribs become narrower as the probe is further away from the ribs in obese patients.
TEE images the heart from inside the esophagus (canal from the throat to the stomach) using an articulating probe and is relatively unaffected by patient size. However, it is very uncomfortable for a conscious patient and some patients cannot tolerate it while conscious. TEE is commonly used to check a surgical repair prior to closing the chest.
Another diagnostic technique is Intra-Cardiac Echo (ICE). One ICE is the ACUSON ACU-NAV™ System (10F) manufactured by Siemens Corporation. ICE is a one time use, array type articulating probe, placed in the right heart and, consequently, is relatively expensive and thus is not widely used at this time. It provides good views of the mitral valve, but may not have as good Doppler views as TTE or TEE.
The historical standard for diagnosing mitral valve regurgitation is angiographically observing the regurgitation of contrast injected into the left ventricle and is the basis of the common grading system for regurgitation (1+, 2+, etc.). It is widely recognized that the angiographic technique is not as reliable or as good an outcome predictor as the measurements of regurgitant volume and flow cross-section that can be made with the Doppler enhancements of modern echo systems.
In one embodiment, an apparatus is disclosed. The apparatus includes a tether having a length suitable for extending through a ventricle of a heart from, at a proximal end, an atrioventricular valve annulus to, at a distal end, a wall of a ventricle or one or more papillary muscles. Representatively, at a distal end, the apparatus may include a hook, or hooks and/or a barb or barbs connected to the tether. The apparatus also includes an aptation device connected to the tether at a position corresponding to a location to contact one or more cusps or leaflets of an atrioventricular valve during systole. The apparatus disclosed is suitable for percutaneous delivery to a patient.
In another embodiment, a method is described. The method includes percutaneously advancing an aptation device to a location to contact one or more cusps or leaflets of an atrioventricular valve and tethering the aptation device to a wall of a ventricle. In this manner, the apparatus and/or method may be used to modify (e.g., improve) the atrioventricular valve function, including the aptation of valve cusps or leaflets during contraction (e.g., systole). The capability to insert an atrioventricular valve modifying apparatus percutaneously provides an approach that can reduce patient discomfort and improve recovery and hospitalization time over current techniques such as annuloplasty. In one embodiment, the aptation device is connected to the tether at a position corresponding to a position between cusps of an atrioventricular valve when the tether is positioned through an atrioventricular valve. The aptation device may have a size suitable, when placed between the cusps of an atrioventricular valve, that the cusps aptate against the aptation device. In this manner, atrioventricular valve regurgitation conditions resulting from, among other things, a disconnect between cusps at systole, may be corrected with the aptation device. In another embodiment, the aptation device resides substantially above the cusps or leaflets, near the level of the valve annulus, or completely within an atrium during systole when the tether is positioned through an atrioventricular valve. In this manner, one or both cusps or leaflets particularly cusps or leaflets that would otherwise extend improperly into the atrium, can contact a surface of the aptation device during systole. An apparatus such as described is suitable for correcting problems such as prolapse, billowing and flail.
In another embodiment, an apparatus is described. The apparatus includes a support annulus including a length corresponding to a circumference of one of an interior portion of an atrium and an atrioventricular valve annulus. The apparatus also includes an aptation device connected to the support annulus at a location corresponding to a location to contact cusps of an atrioventricular valve during at least one of systole and diastole when the support annulus is seated in either the atrium or the atrioventricular valve annulus. The support annulus and aptation device are suitable for percutaneous delivery to a patient offering an improvement in atrioventricular valve modification without more invasive surgical procedures.
An apparatus including a support annulus may or may not have a tether that may support the apparatus at a location where the apparatus may modify an atrioventricular valve. The support annulus is of a size and shape corresponding to an interior diameter of an atrium or an atrioventricular valve annulus. The aptation device, in one embodiment, is connected at a first point and a second point on the support annulus where the first point and second point are selected such that when the support annulus adopts a shape corresponding to the shape of an atrium or an atrioventricular valve annulus, the adaptation device forms a bridge across the support annulus. Representative aptation devices include, but are not limited to, a bladder having a length dimension, when the support annulus is positioned in an atrium or an atrioventricular valve annulus, suitable to extend between cusps or leaflets of an atrioventricular valve. The volume of the bladder may be modified to conform the aptation device to a necessary size to modify (e.g., improve) the aptation of the atrioventricular valve. Alternatively, the aptation device may include a portion suitable, when the support annulus is positioned in an atrium or atrioventricular valve annulus, to contact cusps or leaflets of an atrioventricular valve to address problems of prolapse, billowing, or flail.
In a further embodiment, a method is described. The method includes percutaneously advancing an aptation device to an atrioventricular valve location and deploying the aptation device to contact cusps of the atrioventricular valve. Suitable aptation devices include, but are not limited to, aptation devices that modify the aptation of the atrioventricular valve either by being positioned in the valve or above the valve during systole.
The features, aspects, and advantages of the invention will become more thoroughly apparent from the following detailed description, appended claims, and accompanying drawings in which:
In the following description, various embodiments of an apparatus suitable, in one aspect, for use in modifying an atrioventricular valve (such as by improving the aptation or closing of the valve) are described. Methods of locating apparatuses and improving atrioventricular valve aptation are also described. Various properties, dimensions, functionalities, and techniques (collectively "attributes") are described with regard to the embodiments. It is appreciated that many if not all the attributes, may be applied to all of the embodiments. Thus, the following description should be read broadly in the sense of incorporating various attributes (where not specifically mentioned) to each embodiment.
In one embodiment, tether 110 is adapted to be fixed (anchored) to a wall of a ventricle, such as the left ventricle, or papillary muscles by twisting (screwing) an anchoring device at a distal end of tether 110 into the wall of the ventricle. When delivered percutaneously, tether 110 is provided with sufficient torsional stiffness to allow it to respond in kind at a distal end to a torque applied at a proximal end of the tether. In one embodiment, tether 110 includes duplex spring 115 to provide the torsional stiffness. A duplex spring is a spring within a spring, each spring wound in a different direction. The springs are usually multi-filar (contain more than one wire). When torqued/twisted in the proper direction, the diameter of the outer coil tends to decrease and the diameter of the inner coil tends to increase, locking the inner coil and the outer coil together and providing an increased torsional modulus. Duplex springs are often made of various 18-8 type stainless steel (SST) wires like 302 and 304. For duplex springs that are used as a part of pacing leads (IDF3538), it is common to include an inner core of a better conductor than SST, like silver, within the SST wire of the duplex spring. If apparatus 100 were to be placed in a patient that could benefit from bi-ventricular pacing, then the duplex spring could be made from pacing lead-like materials, the tether lengthened and it could function, for example, as the left heart pacing lead, avoiding the coronary sinus pacing lead placement procedure. The outside diameter (OD) of a representative duplex spring (duplex spring 115) will be on the order of 0.030 inches to 0.125 inches. Although a duplex spring is described with reference to
Duplex (and three or more layers) springs can be made to resist compression, usually by winding the inner spring closed (little or no gap between adjacent windings), but are generally poor in tensile characteristics. Coating of tether 110 may not provide an adequate increase in the tensile characteristics of the tether. Increased tensile characteristics (higher tensile modulus) may be required for the delivery of certain designs (e.g., pressure on aptation device 120 during systole and setting of attachment hooks). A higher tensile modulus can be attained by attaching (e.g., by an adhesive) a fiber(s) (e.g., Kevlar, nylon, etc.) or a wire(s) to the inner diameter (ID) or outside diameter (OD) of the spring at two or more places.
Duplex springs are also very flexible (low flexural modulus) which is beneficial in many portions of apparatus 100 and this can be preserved by using a flexible fibers(s) or wire(s) to provide desired tensile properties. However, in the portion of the tether between helical anchor 130 and connection 125 of aptation device 120 to tether 110 both a higher tensile modulus and a higher flexural modulus may be required to keep aptation device 120 in position during diastole and systole. During systole, for example, aptation device 120 is subjected to the pressure differential between a ventricle and an atrium and thus tether 110 is placed in tension in this portion. A high tensile modulus keeps aptation device 120 from changing its position due to tether 110 extension as ventricular pressure rises and falls (reduces requirements for aptation device placement accuracy and reduces possible leaflet abrasion). During diastole, when the blood in the atrium rushes into the ventricle, aptation device 120 and thus, tether 110 are under pressure and subjected to viscous forces that tend to wash the aptation device 120 into the ventricle. A higher flexural modulus will prevent tether 110 from buckling (bending too much) and allowing aptation device 120 to wash into the ventricle. If aptation device 120 washed into the ventricle, then it could be forced into the closed valve cusps or leaflets during systole and damage the cusps or leaflets. If aptation device 120 got between the cusps or leaflets before they closed fully, there could still be some abrasion and the inertia of a blood filled aptation device 120 could place undesirably high forces on a distal anchor for tether 110 when tether 110 straightened. The higher flexural modulus can be accomplished by the choice of material for sheath 117 and/or by choosing a larger outside diameter (OD) wire to provide an increased tensile modulus. The enlarged distal view of
In one embodiment, an anchoring device at the distal end of tether 110 of apparatus 100 is adapted to be twisted (screwed) into a wall of a ventricle.
A patch may be placed between tether 110 and helical anchor 130. Patch 140, in one embodiment, has a diameter greater than a width (diameter) of helical anchor 130. Patch 140 may be used as a twist or screw stop to indicate to a physician or other operator inserting tether 110 into a wall of ventricle, a stopping point for insertion. Alternatively, a torquing device (e.g., torque wrench) may be connected by an operator at a proximal end of a catheter and connected to tether 110. The torquing device may be set to indicate a stopping point for insertion of helical anchor 130 into a wall of a ventricle. Patch 140, when positioned, is, in one embodiment, designed to be within a ventricle (e.g., left ventricle). Patch 140 may also be configured to promote healing, through tissue incorporation into a porous body of patch 140 or a bioactive coating on patch 140.
In another embodiment, apparatus 100 may be secured to a tissue, for example, a wall of a ventricle or a papillary muscle(s) by hooks. The hooks may be connected to or a portion of a distal segment of tether 110. Tether 110, in one embodiment, may not need to be designed to resist torsion.
To deploy hook portion 136 in tissue 190, hooks 138 may be pressed against tissue 190 and set with a proximal pulling (tension) on tether 110.
In one embodiment, apparatus 100 is suitable for residence in the left atrium and ventricle of a heart. It is generally recognized that thrombosis or clotting caused by foreign materials is particularly significant on the left side of the heart. Although clots from foreign articles may form on either side of the heart, clots on the left side tend to be problematic in their ultimate effect. In some situations, of course, articles must be placed on the left side of the heart that have a potential to induce thrombosis. To reduce the risk of problems, patients with such articles often are required to take an anti-thrombotic medication, potentially for the rest of their lives. Therefore, articles placed on the left side of the heart generally seek to reduce the potential for thrombosis or clot formation. In one embodiment, therefore, it is preferred that blood contact surfaces of apparatus 100 be made of non-thrombogenic or less thrombogenic materials. One material that is suitable as tending to inhibit thrombosis is a treated tissue such as porcine tissue. A treated tissue is generally a tissue including the connective tissue matrix with the cells of the tissue removed. Thus, the connective tissue web when placed within, for example, the left side of the heart provides an area for cell growth within the matrix or web. The tissue can undergo endothelialization which inhibits thrombosis.
In addition to modified tissue, certain artificial materials are similarly suitable as materials that inhibit or reduce the tendency for thrombosis. Suitable materials include, but are not limited to, woven polymers, including but not limited to, expanded polytetrafluoroethylene (ePTFE) or GORTEX™ (a registered trademark of W.L. Gore & Associates, Inc. of Wilmington, Del.), woven DACRON™ (polyethylene terephthalate) (DACRON™ is a registered trademark of E.I. duPont de Nemours and Company of Wilmington, Del.), and certain high density polyethylenes (HDPE). One type of expanded high density polyethylenes (eHDPEs) suitable as a material that inhibits thrombosis is described in commonly-assigned U.S. patent application Ser. No. 10/174,073, titled "Porous Polymer Articles and Methods of Making the Same," filed Jun. 17, 2002. Expanded HDPEs have a node and fibril microstructure allowing cells to take up residence within the node and fibril microstructure to encourage or promote endothelialization.
In one embodiment, it is desired that materials for apparatus 100 that are exposed to blood, particularly on the left side of a heart, such as a material for sheath 117 of tether 110, patch 140, aptation device 120, and any distal anchor portion exposed in the ventricle are a material that does not promote or inhibits thrombosis (e.g., non-thrombogenic or less thrombogenic). Alternatively or additionally, the surface of one or more materials for apparatus 100 may be modified (e.g., treated to reduce its/their thombogenicity). Other materials such as silicone (e.g., poly(dimethyl siloxane))) may be used for the exposed materials. However, it is appreciated that the use of such material may also require a regimen of anticoagulation drugs for a patient having apparatus 100 placed in the left side of his or her heart. Another alternative embodiment is to coat blood contact surfaces of apparatus 100 with a material that reduces its thrombogenicity or incorporate bioactive drugs/materials into the material to encourage endothelialization and/or to reduce thrombogenicity.
As noted above, in one embodiment, tether 110 shown in
Connected to tether 110 in the embodiment shown in
As noted above, one purpose of aptation device is to provide surface area at the closure point of the atrioventricular valve. Aptation device 120 is, in one embodiment, a hollow cylindrical material that is suitable for residence on the left side of the heart. Preferably, aptation device 120 is a material that resists or inhibits thrombosis, such as porcine tissue or artificial material such as ePTFE or eHDPE. Aptation device 120 is deformable in the sense that its hollow cross-section may deform in response to forces applied to it by the atrioventricular valve cusps or leaflets contacting aptation device 120 and thus may cushion the compact/impact forces of the cusps or leaflets. In one embodiment, aptation device 120 is connected to tether 110 (at connection 125) only at a proximal end of aptation device 120.
In one embodiment, aptation device 120 has sufficient structural integrity to be folded within a catheter sheath suitable for percutaneous delivery and to adopt a desired shape when deployed. Aptation device 120 may therefore include, necessary or desired, structural support.
As noted above, in one embodiment, the apparatus suitable for modifying the cusps or leaflets of an atrioventricular valve is also suitable to be inserted percutaneously.
In the embodiment, shown in
To deliver catheter 200 and apparatus 100 into the left ventricle of left atrium of a heart, standard catheter procedures may be followed. For instance, a guidewire may first be inserted via the femoral or jugular artery. The guidewire (and possibly a guide catheter) may be advanced through the aortic arch and into the left ventricle and across the mitral valve. In another embodiment, the catheter may be delivered via a vein into the right atrium and cross to the left atrium, by a transeptal approach. One way this may be accomplished is by puncturing the fossa ovalis, a thin-walled structure between the right and left atriums (in adults). The fossil ovalis may be punctured and the left atrium accessed using the methods and tools currently used for this purpose, e.g., for percutaneous atrial ablation to prevent or reverse atrial fibrillation. Such a puncture may be performed or followed by a guidewire or guidewire-like device that may then provide a path for a guiding catheter, a deflecting guide, a device delivery catheter, and the like, as in other percutaneous procedures.
To maintain proximal portion 410 of tether 110 in right atrium 310 and medial portion 420 in left atrium 330, tether 110 is connected about interatrial septum 380. One way this is accomplished is shown in
Connected to proximal portion 410 of tether 110 is patch 460. Patch 460 is positioned on tether 110 to abut a proximal side (right atrium side) of interatrial septum 380. Proximal to patch 460 is raised bump 470 to hold patch 460 in position against a proximal side (right atrium side) of interatrial septum 380. Patch 460 inhibits the movement of tether 110, once positioned, into left atrium 330. In one embodiment, patch 460 is a material selected to be collapsed or folded onto tether 110 when apparatus 100 is disposed within a catheter sheath and percutaneously positioned within the heart. Patch 460 is also selected, in one embodiment, to have sufficient structural strength to hold tether 110 in position against a proximal side (right atrium side) of interatrial septum 380. A suitable material is, for example, ePTFE, eHDPE, or a DACRON™ material possibly with support structures similar to support structures in aptation device 120. Patch 460 may also be configured to promote healing, through tissue incorporation into a porous body of patch 460 or a bioactive coating on patch 460. In one embodiment, patch 460 has a diameter larger than an outside diameter of tether 110 and sufficient to cover any opening around tether 110 through interatrial septum 380.
Raised bump 470 is connected to a proximal side of patch 460. In one embodiment, raised bump 470 surrounds a portion, including the entire portion, of tether 110. Raised bump 470 is of a size suitable to maintain patch 460 in position (e.g., greater than a cross-sectional opening of patch 460 around tether 110). Raised bump 470 may be selected from various materials suitable to be placed on a right side of the heart and bond, possibly through an adhesive, to a material selected for tether sheath 117. Suitable materials include, but are not limited to, polymers and metals (e.g., a stainless steel band).
In one embodiment, tether 110, in addition to being fixed on a proximal side of interatrial septum 380, is also fixed to interatrial septum 380 to prevent movement of tether 110, once fixed, into right atrium 310. Referring to
Spring screws 510 are configured, in one embodiment, to be set in interatrial septum 380 by a twist action. Representatively, spring screws 510 are configured to have a wind angle, θ, representatively on the order of 30� and higher, for example on the order of 60� to 70�. In general, the higher the wind angle, θ, the less rotation occurs and the more push force in a distal direction is translated into a twisting force. To locate spring screw 510 in interatrial septum 380, patch 460 and/or bump 470 is pushed in a direction toward left atrium 330 (e.g., a distal direction) by the sheath or a guide to locate spring screws 510 on a proximal side of interatrial septum 380. The pushing of spring screws 510 causes it to twist into the septum tissue in a cork screw fashion. With equally spaced spring screws 510 (e.g., three or more), prior to and during pushing of/on patch 460 and/or bump 470, the points of multiple spring screws 510 will contact interatrial septum 380 at multiple points (e.g., three or more points) and be supported at the proper angle relative to the septum (e.g., will not bend/tip tether 110 during pushing) and the force applied to each of them will be relatively similar. One or more spring screws 510 may include one or more protruding barbs 515. Patch 460 may be free to rotate relative to tether 110 with its position confined by bump 470 and/or raised bump 530 (described below).
In addition to or as an alternative to spring screws 510, tether 110 may be fixed at interatrial septum 380 by raised bump 530 (shown in
As an alternative to one or more spring screws 510 and/or raised bump 530, a distal side of patch 460 may include a number of protruding barbs 540 (shown in ghost lines). Barbs 540 are of a dimension (e.g., length) suitable for embedding in interatrial septum 380. Barbs 540 serve in one aspect to connect patch 460 to interatrial septum 380. In one embodiment, patch 460 need not be rotationally free of tether 110 when one or more barbs 540 is/are employed.
Disposed between cusp or leaflet 510 and cusp or leaflet 520 in
As can be seen in
One way to selectively place aptation device of apparatus 100 at a point or region of the closure or aptation line of cusp or leaflet 510 and cusp or leaflet 520 is by adjusting tether 110 to position aptation device 120 toward or away from interatrial septum 380.
For a pulling force on tether 110, a sheath used to percutaneously deliver the apparatus (e.g., sheath 210 in
Bumps may pass in either direction through diaphragm 560 with the application of a small force. This allows the operator to locate the device to achieve the best result (e.g., minimize regurgitation). The required force to effect movement can be modified by the design/materials used. Tissue ingrowth should seal any small gaps after deployment.
Using the embodiment illustrated in
In certain of the above paragraphs, attention has focused on connecting apparatus 100, including tether 110 and aptation device 120, principally within left atrium 330 and left ventricle 340. One consideration in connection with an apparatus such as apparatus 100 within the left side of a heart, is the amount of pressure or force that the apparatus will see in the operation (e.g., contracting) of the heart. Referring to tether 110 of apparatus 100, in general, distal portion 430 sees a significantly greater force during the operation of a heart than medial portion 420 (see
In the above description (e.g.,
The body of aptation device 1120 may include support or reinforcement material such as a shape memory material that maintains an open inner diameter (ID) of aptation device 1120 at, in one example, a point below region 1150 identified by line A-A′.
In another embodiment, aptation device 1120 includes a reinforcement structure (skeleton) that extends through the device including below line A-A′. Accordingly, under pressure by the reinforcement structure, the ID of aptation device 1120 below line A-A′ is slightly open in a rest state. The pressure is sufficient to avoid an endothelial closure. During an event such as systole, however, the pressure applied to aptation device 1120 by cusps or leaflets of an atrioventricular valve is transmitted distally by the reinforcement structure (skeleton) to force the distal end of aptation device 1120 (the ID at the distal end) closed. It is appreciated that aptation device 1120 may close by other mechanisms besides the pressure from cusps/leaflets contacting it. For example, the rapid flow of blood up the ID of aptation device 1120 causes its ID to be at a lower pressure than its OD and, therefore, a closure force is generated (venturi effect). When the cusps/leaflets close around aptation device 1120 and the left ventricle muscle contracts at systole, the pressure in the left ventricle exceeds that of the left atrium. As a result, the ID of aptation device 1120 which communicates with the left atrium is at a lower pressure than the OD of aptation device 1120 which communicates with the left ventricle. As before, this pressure differential between the ID and the OD creates a force that tends to close aptation device 1120.
In the embodiment shown in
In the embodiment shown in
The embodiments shown above in
The material of support annulus 1310 and body 1320 is also suitable for being reduced in diameter (e.g., folded or collapsed) to a diameter suitable to be placed within a catheter sheath. Thus, in one embodiment, apparatus 1300 is suitable for percutaneous delivery. One percutaneous delivery approach is the transeptal approach described above with reference to apparatus 100 (e.g.,
In one embodiment, where apparatus 1300 is selected to modify the aptation of a mitral valve, support annulus 1310 is selected to have a shape corresponding to the shape of the inner surface of the left atrium, particularly, the base of the left atrium. Representatively, the shape is circular. It is appreciated that with the contracting of a heart, the shape of the left atrium is not completely static. Accordingly, support annulus 1310 may be selected of a diameter, D1, suitable to maintain its shape with contraction of a left atrium in which it is placed. A representative diameter, D1, is on the order of 19 to 31 centimeters. In another embodiment, the diameter, D1, and shape of support annulus 1310 is selected to conform to the shape of an atrioventricular valve annulus (e.g., a mitral valve annulus). To maintain support annulus 1310 at a location either in the atrium or an atrioventricular valve annulus, barbs 1330 extending from the exterior diameter of support annulus may be included to anchor support annulus to the tissue that makes up the atrium or atrioventricular valve annulus inner circumference.
To properly position apparatus within an atrium or atrioventricular valve annulus, support annulus 1310 (possibly body 1320) may include visualization markers included therewith (e.g., embedded therein). Suitable markers include, but are not limited to, radiopaque markers.
Apparatus 1300 also includes body 1320, in this embodiment, shown as having a funnel or a conical shape from a first diameter, approximately D1, to a smaller second diameter, D2. Body 1320, in one embodiment, is selected to have a length, L, suitable for being deployed either in an atrium or an atrioventricular valve annulus and to extend beyond an atrioventricular valve so that the cusps or leaflets of the atrioventricular valve can contact body 1320 and collapse body 1320 onto itself upon closing. For an apparatus, such as apparatus 1300, intended to modify a mitral valve, where support annulus 1310 is intended to be anchored into the wall of an atrium, a suitable length, L, for body 1320 is on the order of 20 to 30 millimeters. Body 1320 may also include visualization markers (e.g., embedded therein).
In operation in an atrioventricular valve, it is desirable that an apparatus such as apparatus 1300 minimize the inhibition of blood flow from an atrium to a ventricle during, for example, diastole. Accordingly, a suitable diameter, D2, for a base of a body 1320 is on the order of three to four centimeters. In addition, to further improve blood flow from an atrium to a ventricle during, for example, diastole, body 1320 may include a number of orifices preferably located, when apparatus 1300 is positioned in an atrioventricular valve location superior to the portion of body 1320 that will be collapsed by atrioventricular valve cusps or leaflets. One representative location of orifices 1350 is that position of the body that will reside within an atrium when an atrioventricular valve is closed. Body 1320 may also have reinforcement structures disposed therein or thereon.
Disposed within lumen 1420 of catheter sheath 1410 is apparatus 1300. As illustrated in
When deployed, support annulus 1310 and body 1320 of apparatus 1300 may need assistance in adopting a desired shape, such as the shape illustrated in
Support annulus 1910 has a diameter, D1, suitable to be anchored against the wall of an atrium (e.g., left atrium) or atrioventricular valve annulus (e.g., mitral valve annulus). A representative diameter is on the order of 19 to 31 centimeters. Body 1920 has a length, L, selected to be long enough to extend between cusps or leaflets of an atrioventricular valve and provide surface area for the cusps or leaflets to aptate against when the atrioventricular valve is closed. Body 1920 is shown with a proximal diameter, D1, of support annulus 1910. At a distal end, the diameter, D2, of body 1920 tapers (or is reduced).
Support annulus 1910 may be a material that is flexible to maintain its position with the contraction of a heart. Support annulus 1910 may also be a material that is selected to be suitable to stabilize the size and geometry of the atrioventricular valve annulus to inhibit progressive valvular degradation and to provide a stable platform for body 1920. The material of support annulus 1910 and body 1920 is also suitable for being reduced in diameter (e.g., folded) to a diameter suitable to be placed within a catheter sheath. Thus, in one embodiment, apparatus 1900 is suitable for percutaneous delivery.
Apparatus 1900 shown in
In one embodiment, body 1920 of apparatus 1900 in
Apparatus 1900 also includes flexible cords or tethers 1950 extending beyond the base of body 1920 and, optionally, connected at a proximal end to struts 1940. Cords or tethers 1950 have a length suitable to anchor apparatus 1900 to the papillary muscles associated with an atrioventricular valve. Cords or tethers 1950 may terminate in distal clips 1960 to anchor apparatus 1900 to papillary muscle.
Disposed within lumen 2020 of catheter sheath 2010 is apparatus 1900 disposed over optional guide support 2040 (e.g., guide wire). As illustrated in
One percutaneous delivery approach is the transeptal approach described above with respect to apparatus 100 (e.g.,
In one embodiment, support annulus 2310 includes "C"-shaped or "U"-shaped rings 2315 connected to the exterior perimeter of support annulus 2310 as mechanical features to anchor support annulus 2310 to an atrioventricular valve annulus.
Apparatus 2300 shown in
In one embodiment, body 2320 is designed to be laterally immobile. According to this embodiment, a width, W, of body 2320 is slightly wider (e.g., 105 to 115 percent) than a nominal width of a native atrioventricular valve (e.g., mitral valve). In another embodiment, body 2320 is designed to be laterally mobile. In this embodiment, a width, W, of body 2320 is the majority of the width of a native atrioventricular valve (e.g., mitral valve). A representative majority is greater than 50 percent, and, in another embodiment, 70 percent to 80 percent of the native valve. Representatively, an operator (e.g., physician) can move body 2320 laterally to a desired location within the valve. In one embodiment, apparatus may include a rod across support annulus 2310 to which body 2320 is connected and can be displaced laterally (e.g., a proximal end of body 2320 may wrap around the rod). For example, after deployment of support annulus 2310, an operator can verify proper placement/orientation of body 2320 within an atrioventricular valve using various visualization techniques. Once positioned, body 2320 can be locked in place such as by clamping a proximal end of body 2320 to a rod or to support annulus 2310. In another embodiment, possibly including a rod bridging support annulus 2310, body 2320 may have a lateral dimension less than an inner diameter of support annulus 2310. In this embodiment, body 2320 is fixed in place (e.g., fixed to a rod) in an offset position. The off-center embodiment may be desired, for example, in situations where regurgitation results from chordae rupture on one end of a mitral valve.
As noted above, in one embodiment, body 2320 is formed of a tear-drop-like shape.
As illustrated in
In another embodiment, body 2320 of apparatus 2300 includes chamber or cavity volume 2330 inside, as illustrated, the thickest part of the body. Chamber or cavity volume 2330 provides a volume for injecting material to enlarge (uniformly or non-uniformly, as needed) the thickness of body 2320 to match the contour of a patient's valve requirement for a given patient. Alternatively, chamber or cavity volume 2330 provides a volume for contrast material to be included in body 2320 to act, in one sense, as a visualization aid.
In one embodiment, the apparatuses described with reference to
In an embodiment where the apparatus is shown in
A representative diameter for lumen 3020 to contain apparatus 2800 is on the order of 16-24 Fr. Disposed within lumen 3020 of catheter sheath 3010 is apparatus 2800. As illustrated in
Wires or cords 3040 extend through primary lumen 3005 to a proximal end of the catheter. On a distal end, wire or cords 3040 are connected to apparatus 2800 to provide a capability to position apparatus 2800 within an atrioventricular valve (e.g., to support annulus 2810 or body 2820 (e.g., wires or cords 2842 and 2844). As noted above, cords 3065, connected at a distal end to protective sheath 3012, extend, in one embodiment, through primary lumen 3005. Wire or cords 3040 may also be connected in one embodiment to mandrel 3050 to maneuver mandrel 3050 and orient support annulus 2810. Alternatively, separate wire or cord 3075 may be connected to mandrel 3050.
Using real-time imaging modality such as two-dimensional or three-dimensional color doppler, the placement of body 2820 may be optimized by manipulating its location relative to mitral valve annulus 3320 and support annulus 2810. For example, the optimization may be based on providing spatial and temporal information about the actual extension, direction, origin, and size of intracardiac flows. Representatively, the procedure for the segmentation of turbulent and laminar flows using three-dimensional color doppler allows for the measurement of mitral regurgitant jet volumes that may be used to optimize location of body 2820.
In one embodiment, support annulus 3410 is a tubular structure having first end 3430 and second end 3435. First end 3430 and second end 3435 are connected to define the annular shape. A number of hooks or barbs, possibly similar to ENDO-HOOKS™ are shown on an exterior of support annulus 3410 to assist in anchoring support annulus to an atrium wall or an atrioventricular valve annulus.
Aptation device or body 3420 has a length, L, selected in one embodiment to extend from support annulus 3410 (a superior portion of body 3420 viewed) through an atrioventricular valve (e.g., mitral valve). In this manner, when apparatus is deployed, for example, with support annulus 3410 in a mitral valve annulus, cusps or leaflets of the mitral valve will contact body 3420 during, for example, systole. A representative length, L, is such that body 3420 is on the order of zero to five millimeters above and one to 30 millimeters below support annulus 3410.
Aptation device or body 3420 may be formed of an elastic material suitable for being folded into a catheter sheath and possibly stretched with the placement of support annulus 3410 in a catheter sheath. An exposed portion of body 3420 and support annulus 3410 may include or be coated with a material that resists or inhibits thrombosis.
Housing 3520 also includes opening 3560 therethrough for the placement of transport tube 3540 therethrough. Transport tube 3540 extends between ends 3530 to 3435 and connects to bladder 3562 in body 3420.
In one embodiment, apparatus 3400 may be introduced percutaneously. To introduce apparatus 3400 to modify a mitral valve, apparatus 3400 may be introduced transeptally or through the aortic arch into the left ventricle and across the mitral valve. One advantage to the embodiment shown is that apparatus 3400 may be conformed to a desired shape and geometry of an atrioventricular valve annulus (or atrium) in situ. Representatively, apparatus 3400 may be introduced through a catheter as a linear structure (e.g., support annulus 3410) and modified to an annular shape about an atrioventricular valve.
Once all hooks 3415 are in place and support annulus 3410 encircles mitral valve annulus 3770, the diameter of support annulus 3410 is modified or optimized. Referring to
As illustrated in
Once support annulus 3410 is in place and inner body 3510 is adjusted or modified, body 3420 extends between cusps or leaflets of a mitral valve. At this point, a liquid or other material may be introduced into bladder 3562 to modify the volume (thickness) of body 3420.
Apparatus 4000 includes body 4020 extending as a bridge across the inner diameter of support annulus 4010. Body 4020 is connected to support annulus 4010 at points 4060 and 4070 and is made of material that is flexible enough to expand to allow support annulus 4010 to be configured linearly in a catheter body.
In one embodiment, body 4020 is intended to modify the aptation of an atrioventricular valve, specifically addressing problems of prolapse, billowing, and flail. Specifically, body 4020 has a dimension, width, W, that, when apparatus 4000 is seated in an atrioventricular valve annulus, is suitable to inhibit cusps or leaflets of an atrioventricular valve from extending above the valve annulus. In this manner, the cusps or leaflets are maintained together when the cusps or leaflets are under pressure.
It is appreciated that width, W, of body 4020 may be minimized to minimize the obstruction of blood flow through an atrioventricular valve. It is appreciated that by orienting body 4020 properly across cusps or leaflets 4150 and 4160, a width, W, may be minimized. It is appreciated that, when positioning apparatus 4000 within mitral valve annulus 4170, visualization markers may be utilized to assist in establishing a desired orientation for apparatus 4000.
Connected to tether 4310 in the embodiment shown in
In one embodiment, aptation device 4320 is a circular disk having a thickness sufficient to inhibit cusps or leaflets of an atrioventricular valve from prolapse, billowing, or flail when suited in an atrioventricular valve annulus. Representatively, aptation device 4320 is a polymer material having a thickness on the order of 0.001 to 4 millimeters. Aptation device 4320 also has a diameter selected to be of a size sufficient to inhibit cusps or leaflets of a mitral valve from extending to an atrium as part of prolapse, billowing, or flail. A representative diameter is on the order of 5 to 25 millimeters. Openings 4540 may facilitate diastole flow into the ventricle and/or a holding force on the leaflets during systole (due, representatively, to the pressure difference between the ventricle and the atrium).
Aptation device 4320 has proximal side 4510 and distal side 4520. Referring to distal side 4520 of aptation device 4320, aptation device 4320 may include a plurality of cylindrical ridges 4530 and may include a plurality of openings 4540 through aptation device 4320. Ridges 4530 may facilitate a holding force on the leaflets during systole. Ridges 4530 are shown with end portions angled toward tether 4310 at, for example, angle, α, of 45-90�. The ridges may get deeper (deeper into aptation device 4320) toward the outer edge of aptation device 4320.
In one embodiment, it is contemplated that aptation device 4320 will be seated approximately in an atrioventricular valve annulus and the cusps or leaflets of an atrioventricular valve may contact aptation device 4320 when a pressure builds in a ventricle and causes the cusps or leaflets to aptate. Thus, the cusps or leaflets will be raised to contact aptation device 4320. When the cusps or leaflets contact aptation device 4320, openings 4540 through aptation device 4320 create a pressure difference during systole. Cusps or leaflet material will tend to be forced into openings 4540 providing friction to aptation device to inhibit a cusp or leaflet from moving from distal side 4520 and pushing around aptation device 4320 and escaping, resulting in prolapse, billowing, or flail. Ridges 4530 may serve similarly to inhibit cusps or leaflets from moving or sliding off distal side 4520.
In one embodiment, apparatus 4300 is suitable for percutaneous delivery. Thus, aptation device 4320 may be made of a material that can be reduced to the diameter of a delivery catheter lumen. Representatively, aptation device 4320 may include a shape memory material (e.g., NiTi alloy) or superelastic metal and/or elastic metal and/or polymer reinforcement material to define or support a desired implanted shape, possibly coated or embedded in a material that inhibits thrombosis.
To deliver apparatus 4300 to modify a mitral valve, the apparatus may be delivered transeptally or through the aortic arch into the left ventricle and across the mitral valve. For a transeptal approach including coupling of tether 4310 to a left ventricle and interatrial septum, reference is made to
Aptation device 4320 of apparatus 4300 is connected to tether 4310 and, in this embodiment, disposed in mitral valve annulus 4670. As viewed, aptation device 4320 is above or superior to mitral valve cusps or leaflets 4680 and 4690. The mitral valve is shown in
Aptation device 4820 is connected to tether 4810, in one embodiment, at a position coinciding with an atrioventricular valve annulus or atrium such that, aptation device 4820 contacts cusps or leaflets of an atrioventricular valve upon closure of the valve, such as during systole. Aptation device 4820 includes plication portion 4825 including, in one embodiment, a groove (e.g., a "V" shaped groove) on a distal side. Plication portion 4825 allows aptation device 4820 to fold distally toward tether 4810 in response, for example, to blood flow from the atrium to the ventricle.
Apparatus 4800, in this embodiment, also includes support stop 4850 disposed on a proximal side of aptation device 4820. Support stop 4850 is connected to tether 4810 by, for example, an adhesive 4855. In one embodiment, support stop 4850 has a butterfly-like shape of a wire construction that is collapsible for delivery and minimizes obstruction to diastolic flow.
Referring to
In the embodiment shown in
Support annulus 5205 has an exterior diameter, in one embodiment, suitable for location in an atrioventricular valve annulus (or atrium). The exterior surface of support annulus 5205 may include crenulations or barbs 5208 that extend from support annulus 5205 to anchor support annulus 5205 to, for example, an atrioventricular valve annulus. Tether 5210 may be similar to the tether described above in reference to
Support annulus 5405 has an exterior diameter, in one embodiment, suitable for location in an atrioventricular valve annulus (or atrium). An exterior surface of support annulus 5405 may include barbs or crenulations (shown as crenulations) to anchor support annulus 5405 to, for example, an atrioventricular valve annulus. Tether 5410 may be similar to the tether described above in referenced to
In one embodiment, aptation device 5420 is a circular disk shaped device positioned on tether 5410 to contact cusps or leaflets of an atrioventricular valve (e.g., mitral valve) when the cusps or leaflets are desired to be in a closed (aptated) position, such as during systole. Thus, when an atrioventricular valve is closed, aptation device 5420 resides completely in an atrium (e.g., the left atrium). For a further discussion on the function of aptation device 5420, reference is made to
In the above embodiments, apparatuses suitable to contact cusps or leaflets of an atrioventricular valve (e.g., mitral valve) are anchored in place in an atrium or atrioventricular valve annulus, or ventricle or one or more combinations. In some cases, aptation device is anchored to an interatrial septum and a ventricle.
In the preceding detailed description, the invention is described with reference to specific embodiments thereof. It will, however, be evident that various modifications and changes may be made thereto without departing from the broader spirit and scope of the invention as set forth in the claims. The specification and drawings are, accordingly, to be regarded in an illustrative rather than a restrictive sense.
|Citing Patent
|Filing date
|Publication date
|15 Nov 2007
|31 Aug 2010
|Maurer Christopher W
|Mitral spacer
|8 Mar 2010
|25 Oct 2011
|Dc Devices, Inc.
|Devices, systems and methods to treat heart failure
|23 Feb 2009
|6 Dec 2011
|Medtronic, Inc.
|Method and apparatus for resecting and replacing an aortic valve
|26 Oct 2005
|10 Jan 2012
|Cardiosolutions, Inc.
|Heart valve implant
|8 Mar 2010
|17 Apr 2012
|Dc Devices, Inc.
|Devices, systems and methods to treat heart failure
|8 Mar 2010
|8 May 2012
|Dc Devices, Inc.
|Devices, systems and methods to treat heart failure
|28 Apr 2009
|10 Jul 2012
|Cardiosolutions, Inc.
|Implant delivery and deployment system and method
|8 Mar 2010
|28 Aug 2012
|Dc Devices, Inc.
|Devices, systems and methods to treat heart failure
|14 May 2007
|28 May 2013
|Cardiosolutions, Inc.
|Balloon mitral spacer
|7 Nov 2011
|11 Jun 2013
|Dc Devices, Inc.
|Prosthesis for reducing intra-cardiac pressure having an embolic filter
|19 Jan 2010
|25 Jun 2013
|Evalve, Inc.
|Methods, systems and devices for cardiac valve repair
|14 May 2007
|9 Jul 2013
|Cardiosolutions, Inc.
|Solid construct mitral spacer
|31 Aug 2010
|16 Jul 2013
|Cardiosolutions, Inc.
|Mitral spacer
|10 Jul 2012
|13 Aug 2013
|Cardiosolutions, Inc.
|Implant delivery and deployment system and method
|10 Sep 2007
|29 Oct 2013
|Edwards Lifesciences Corporation
|Integrated heart valve delivery system
|28 Jul 2009
|26 Nov 2013
|Cardiosolutions, Inc.
|Steerable catheter and dilator and system and method for implanting a heart implant
|15 Nov 2007
|3 Dec 2013
|Cardiosolutions, Inc.
|Heart regurgitation method and apparatus
|5 Dec 2011
|7 Jan 2014
|Medtronic, Inc.
|Apparatus for replacing a cardiac valve
|24 Nov 2010
|3 Jun 2014
|Dc Devices, Inc.
|Prosthesis for retrieval and deployment
|24 Nov 2010
|10 Jun 2014
|Dc Devices, Inc.
|Methods for mounting a prosthesis onto a delivery device
|24 Nov 2010
|17 Jun 2014
|Dc Devices, Inc.
|Mounting tool for loading a prosthesis
|6 Apr 2007
|8 Jul 2014
|Medtronic, Inc.
|Method and apparatus for resecting and replacing an aortic valve
|14 May 2007
|15 Jul 2014
|Cardiosolutions, Inc.
|Safety for mitral valve implant
|15 Nov 2007
|7 Oct 2014
|Cardiosolutions, Inc.
|Implant delivery system and method
|10 Feb 2012
|11 Nov 2014
|Dc Devices, Inc.
|Apparatus and methods to create and maintain an intra-atrial pressure relief opening
|10 Jan 2012
|18 Nov 2014
|Cardiosolutions, Inc.
|Heart valve implant
|23 Apr 2013
|25 Nov 2014
|Cardiosolutions, Inc.
|Balloon mitral spacer
|24 Dec 2012
|10 Feb 2015
|Dc Devices, Inc.
|Methods and devices for intra-atrial shunts having adjustable sizes
|14 Sep 2012
|17 Feb 2015
|Medtronic, Inc.
|Apparatus for replacing a cardiac valve
|4 Apr 2012
|3 Mar 2015
|Edwards Lifesciences Corporation
|Prosthetic insert for treating a mitral valve
|3 Feb 2013
|14 Apr 2015
|Dc Devices, Inc.
|Devices and methods for treating heart failure
|28 May 2013
|23 Jun 2015
|Evalve, Inc.
|Methods, systems and devices for cardiac valve repair
|21 Aug 2014
|14 Jul 2015
|Georg Lutter
|Truncated cone heart valve stent
|17 Mar 2011
|Thornton Troy L
|Methods, systems and devices for cardiac valve repair
|4 Apr 2012
|26 Jul 2012
|Edwards Lifesciences Corporation
|Prosthetic insert for treating a mitral valve
|27 Jul 2012
|25 Jul 2013
|Samir Kapadia
|Apparatus, system, and method for treating a regurgitant heart valve
|28 May 2013
|19 Dec 2013
|Evalve, Inc.
|Methods, systems and devices for cardiac valve repair
|2 Mar 2015
|25 Jun 2015
|Edwards Lifesciences Corporation
|Prosthetic insert for treating a mitral valve
|8 Mar 2010
|13 Jan 2011
|Dc Devices, Inc.
|Devices, systems and methods to treat heart failure
|1 Jun 2012
|6 Dec 2012
|Neochord, Inc.
|Minimally invasive repair of heart valve leaflets
|U.S. Classification
|International Classification
|Cooperative Classification
|European Classification


text:
Jewelry Roundup
- 1 of 17Yesterday we showed you some of the most memorable looks from the annual Costume Institute Gala at the Metropolitan Museum of Art, but today, we'd like you to feast your eyes on the stunning baubles your favorite tastemakers sported with their ensembles! From January Jones' intricate Cartier collar necklace to Solange Knowles' geometric cuff bracelet, these style savants were dripping in jewelry. Click through our slideshow for some of the most chic and covetable pieces we spotted on the red carpet last night!
- 2 of 17Dramatic Clip-Ons
Repossi Diamond Neree Earrings ($32,500)
- 3 of 17Stud Factor
Pomellato Sabbia Collection 18k rose gold earrings
- 4 of 17Stone-Gold Genius
Jean Schlumberger for Tiffany & Co. Diamond Flame ear clips
- 5 of 17Extreme Earrings
Eddie Borgo Custom Edie earrings
- 6 of 17Timeless Ticker
Van Cleef & Arpels Charms Pave Diamond watch
- 7 of 17Diamonds In The Rough
Repossi rings
- 8 of 17Wrist Candy
Lorraine Schwartz bracelets
- 9 of 17Exotic Touches
Fred Leighton earrings
- 10 of 17Sapphire Sparkle
Bulgari High Jewelry Collection platinum earrings
- 11 of 17Chicest Snake
Bulgari Serpenti necklace
- 12 of 17Knockout Hoops
Anna Hu Haute Joaillerie Summer Bamboo earrings
- 13 of 17The Bling Ring
Fred Leighton jewelry
- 14 of 17Geometric Glamour
Lady Grey Symtra Bangle ($239), Spike Channel Cuff ($300), and Reflected Triangle Cuff ($254); Jennifer Fisher Twisted Cone Ring ($250)
- 15 of 17Bohemian Brilliance
Fred Leighton necklace
Jaeger-LeCoultre vintage watch circa 1900
- 16 of 17Marvelous Match
Tiffany & Co. Oval Unenhanced Pink Sapphire and Diamond ring
- 17 of 17Perfect Pair
Fred Leighton Victorian Cuff Bangles


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Crawdaddy on Sun site posted this...Aaron Fitt put out the first word
Pretty good if they get it done. Jason Coats, along with Jason Esposito (getting closer too?)and of course Dylan Bundy who I have no doubt will sign would make this a very nice draft.
Delmonico I'm guess goes to RF?


text:
SIGCSE 2011: Reaching Out
The 42nd ACM Technical Symposium on
Computer Science Education
March 9-12, 2011, Dallas, Texas, USA
All submssions to SIGCSE 2011 are available only to authorized viewers, normally through a session's number and password. However, the on-line program may contain links to materials from accepted sessions -- once those materials have been revised for publication.
Unfortunately, such links to accepted materials are not yet available. Please try this link again later, after program links have been enabled.


text:
Is there a tendency to sing flat when singing out of tune?
I would not be surprised to hear that singers are more commonly corrected in that direction, but it's certainly not impossible to be "a little sharp." A few reasons this might be perceived:
So, what everyone has said about tendencies of singers to go flat still applies, but keep in mind that a lot of this behavior you notice has to do with the fact that sharp pitches usually sound like a change in tone, making them harder to identify than notes that are flat.
In contrast with many here, I do think that an untrained singer will tend to go flat more often than sharp. This is usually a technique thing; a collapsed soft palate and improper posture will decrease breath support and drop the pitch of the note. It also closes off the airways which will reduce the natural overtones of the human voice, which makes the note sound duller and lower. Lastly, a lot of difficulties are in high-note singing; if a note is at the extreme high end of your range, it requires even more attention to technique to get there and stay there, and if you don't keep the support, the note will trend flat.
However, improper technique can also cause notes to go sharp. A tight throat and "pushing" will generally tighten the vocal chords and force or pinch a note sharp. These are just as common in novice singers, and in combination with the previous you can get a shotgun effect of roughly equal sharp/flat, But, back to my original point, I think that in most group singing, you'll get more notes trending flat than sharp, unless the piece is fast and/or difficult, in which case your singers will tense up and pinch sharp.
I don't believe that people are inherently more likely to be a little flat than a little sharp. There are various situations in which untrained singers may be more likely to go flat or sharp, however, and I've put a few possibilities below as a taster. If you are consistently being told that you are little flat, you may want to examine in particular whether you are keeping your soft palette up (to allow for a more resonant, less dulled sound).
And I am sure there are lots more...
I've heard singers (especially choirs) go flat more than I've heard them go sharp.
There's a standard piece of advice that a lot of choir directors give: "Make your ascending intervals big and your descending intervals small." Obviously, this isn't meant to be taken literally (or else everyone would go sharp all the time); it's meant to compensate for a tendency to go flat.
I know more karaoke singers go slightly sharp than slightly flat, whereas the opposite seems to be true for choirs.
I always let them know if they are too sharp (well, if they're friends, and not someone who might flatten* me in a fit of rage)
My theory would be that if you can't master the song your vochal chords and all that won't achieve the desired note and be a little down, most likely you wont overshoot the note because 1: Your body will try to hit the note on the spot; 2: Your body may not handle the strain very well of a higher note.
So if you aren't in tone, you'll probably be on the one that pushes your body the less...


text:
- Northern New York Newspapers
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CANTON A Waddington man accused of attempting to sexually assault three women on separate occasions in 2010 took the stand in his own defense Monday afternoon in St. Lawrence County Court.
James Sabre Jr., 44, of 56 Oak St., was called to the witness box at 4:10 p.m., and was questioned by defense attorney Peter A. Dumas for about 20 minutes before court was adjourned for the day.
According to prosecutors, Sabre knew all three women and tried to force himself on each of them: at the youngest womans home when he knew she was there alone; another time at the entrance to a bar when he took a woman there late one summer night to retrieve a lost phone; and the third time at his own residence, where he had driven a woman after a night of drinking.
The first woman, 25, testified Friday. The other two women testified Monday, but Sabre was only questioned about the mobile-phone case before days end.
Sabre described a night of dancing, drinking and hanging out and drug use at a Waddington bar the evening of Sept. 17, 2010, the night before prosecutors say he entered the first womans nearby mobile home at 6 a.m. and tried to force her to have sex with him.
We were doing pills and smoking pot, the four of us in the bars kitchen, Sabre said.
That quartet included himself, the woman whose home he allegedly entered the next morning, her boyfriend and another woman he allegedly tried to assault during the summer of 2010.
The 25-year-old woman testified Friday that she couldnt remember whether she had smoked marijuana that night, but insisted she had never taken pills. That alleged victim also testified that she had never had sexual relations with Sabre, a friend of her boyfriend, but may have engaged in flirty behavior with him in the past.
Mr. Dumas on Monday called to the stand Amy L. Miller, a Waddington resident who referred to herself as bar friends with the alleged victim and said she saw the woman performing oral sex on Sabre in the bars kitchen one night in late 2009 or early 2010.
Assistant District Attorney Amanda N. Nissen asked Ms. Miller if she was headed into the bars back room in search of drugs.
Yes, maam, Ms. Miller replied.
Ms. Nissen asked Ms. Miller if she had been arrested before, asking case-by-case about petit larceny, criminal personation and DWI charges dating back to 1997.
That has nothing to do with how well I can see, Ms. Miller said.
Sabre denied he ever entered the womans mobile home that Saturday, but knocked on her door to ask about a ride to a pig roast later that day in South Colton. He said she became agitated, started looking for her mobile phone, ran out and drove away.
The woman had testified that she woke up to the sound of Sabre in her bedroom, where he tried to assault her.
I never left the doorway, said Sabre.
Testimony is set to resume this morning with Sabre on the stand. Judge Jerome J. Richards told jurors the case could be in their hands by days end.
Thousands of readers like you have made Northern New York Newspapers the number one ranked website* for local news and sports coverage in the north country.
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Video: Time Warner to Bring 152 New Jobs to Buffalo
BUFFALO, N.Y. -- Time Warner Cable has chosen the Queen City as the location for its new call center on the East Coast.
The location chosen by Time Warner is the old Sheehan Hospital, which has been vacant since the facility went bankrupt last year. Time Warner will become the main tenant in the building, now known as Compass East, when it moves its East Coast hub for its Business Class call center to Buffalo's East Side.
The move creates 152 new jobs, and more than 150 current Time Warner employees will also work out of the old hospital.
Time Warner has signed a ten year lease and will take up more than half of the building.
Monday, the Lieutenant Governor announced Time Warner is getting $3.1 million in tax credits for job creation.
State Assemblywoman Crystal Peoples-Stokes is hopeful the jobs will pay about $15 an hour, what she calls a living wage, and will offer employment to people who live on the East Side.
"A lot of people I represent are looking for work and are unemployed and are under-employed working two parttime jobs just to make up to a full time job, so they will be opportunities for people to make lateral moves as well," she says.
"We could've put it anywhere. We chose Buffalo because we've had such wonderful experiences in this wonderful city. What we'll wind up doing is adding to that one-thousand. Over the next five years, we'll be adding 152, hopefully more than that, jobs as Business Class flourishes," says Time Warner's Regional VP Terence Rafferty.
Time Warner says it expects a quick build-out and thinks the grand re-opening of the call center could happen within the next few months. Time Warner has also recently extended its lease for five years on the building it currently operates out of in Buffalo.
McGuire Development Company, which is in charge of the Compass East project, is moving some of its staff and departments to the building.


text:
Product Description
Lace is SO in! Keep up with the latest fashion trend with Tres Chic Lacelets! Fun, brightly colored bracelets match any outfit and are ready to tie and wear! Lace up your wrists with soft, lovely bracelets in 5 colors and styles! A tres chic look, straight from the runways.


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roma sandals
by A.P.C.
Women's Size Chart
Product Details
Easy, two strap sandal in smooth metallic leather with a low wedge heel. Adjustable ankle strap with antiqued brass closure and round open toe. Smooth leather insole with reinforced heel and rubber outsole.
• 1" heel
• 100% calfskin
• imported