text:
|Publication number
|Publication type
|Application number
|Publication date
|Sep 14, 1999
|Filing date
|Jun 30, 1997
|Priority date
|Jun 30, 1997
|Fee status
|Also published as
|Publication number
|Fritz Brauer
|Original Assignee
|Clinicon Corporation
|Export Citation
|BiBTeX, EndNote, RefMan
|Patent Citations (50), Non-Patent Citations (32), Referenced by (88), Classifications (16), Legal Events (7)
|External Links: USPTO, USPTO Assignment, Espacenet
1. Field of the Invention
The present invention relates to an instrument for transmitting laser radiation for application to biological tissue for removal, penetration or treatment of the tissue and more particularly to an instrument for efficiently and accurately delivering laser radiation to a predetermined location on the biological tissue.
2. Description of Related Art
Surgical applications of lasers are well established in opthalmology, otolaryngology, gynecology, dermatology and plastic surgery, having been in use, in some cases, for over two decades. Lasers have also become well accepted in the treatment of cardiovascular diseases. The types of lasers are nearly as numerous as the procedures that use them, and selection of a laser for any given procedure depends upon the laser-tissue interaction, which phenomena have been widely reported, and the desired outcome of that interaction. See, e.g., M. J. C. van Gemert and A. J. Welch, "Time Constants in Thermal Laser Medicine", Lasers in Surgery and Medicine 9:405-421 (1989); and J. L. Ratz, "Laser Physics", Clinics in Dermatology 13:11-20 (1995), which are incorporated herein by reference. The types of lasers may be grouped into ultraviolet (193-351 nm), visible wavelength (400-700 nm), and infrared (700-100,000 nm). The visible light lasers, such as argon (488-514 nm), flashlamp-pumped dye (510 nm), copper vapor (578 nm) and ruby (694 nm), are commonly used for selective photothermalysis, e.g., photocoagulation of vascular and pigmented lesions. Laser light within the visible range can be delivered using a number of conventional optical techniques including refractive lenses and quartz fiber optics. Examples of visible light delivery systems are provided in U.S. Pat. No. 5,207,673 of Ebling, et al., "Fiber Optic Apparatus for Use with Medical Lasers", No. 5,495,541 of Murray, et al., "Optical Delivery Device with High Numerical Aperture Curved Waveguide", and No. 5,530,780 of Ohsawa, "Fiber Optic Laser Conducting and Diffusion Device", the disclosures of which are incorporated herein by reference. Ultraviolet (UV) lasers, or excimer lasers, which include argon-fluoride (193 nm) and krypton-fluoride (248 nm), have been used predominantly in photorefractive keratectomy to ablate corneal tissue. Excimer lasers have also been reported for ablation of skin. (See, e.g., R. J. Lane, et al., "Ultraviolet-Laser Ablation of Skin", Arch. Dermatol.--121: 609-617 (May 1985).)
Visible, UV and near IR laser light have been combined with surgical tips to provide precise control of application of laser radiation and/or to provide means for coagulating blood adjacent an incision. U.S. Pat. No. 4,126,136 of Auth, et al., describes a transparent scalpel blade connected to a fiber optic waveguide which transports laser radiation to the blade. The blade, which is preferably synthetic sapphire (Al2 O3), emits laser radiation through the tapered cutting edge to photocoagulate the blood. U.S. Pat. No. 4,627,435 of Hoskin discloses a surgical knife formed from a diamond blade optically coupled to a Nd:YAG laser by a fiber optic bundle. The diamond blade is heated by the laser radiation to provide a cauterizing action while making the incision. The diamond blade may also be coupled to a visible laser to provide illumination for enhanced visibility of the incision site. U.S. Pat. No. 4,693,244 of Daikuzono describes an artificial sapphire tip coupled to a quartz optical fiber to transmit radiation from a Nd:YAG laser. The sapphire tip is heated by the radiation to coagulate the blood at an incision made with a separate surgical blade. U.S. Pat. No. 5,320,620 of Long, et al., describes a laser surgical device with a blunt light emitting element for coagulation. The tip, which may be sapphire, silica or YAG, is coupled to an optical fiber for receiving laser energy. The tip may be coated with a high melting point material to absorb the radiation and heat the tip. The disclosures of each of the above patents, and all other patents cited in this specification, are incorporated herein by reference. U.S. Pat. No. 5,194,712 of Jones describes a single crystal diamond cutting tool with an anti-reflection coating bonded to the entry and exit faces of the cutting tool to provide efficient transfer of laser light, or to concentrate laser light at the desired incision.
Of the infrared lasers, which include CO2 (10.6 micron) and Nd:YAG (neodymium:yttrium-aluminum-garnet) (1.06 micron), the CO2 laser is most widely used for surgical applications of ablation and cutting of tissue. It is also more readily available and more economical, costing much less than other types of surgical lasers. While Ho:YAG and Nd:YAG lasers still emit light at a short enough wavelength that conventional optical delivery techniques can be used, because of its position in the far-infrared region of the electromagnetic spectrum, the CO2 laser cannot be delivered through quartz fiber optics, or silica or sapphire lenses, since these materials are opaque to the 10 micron wavelength and absorb the infrared laser radiation. (Materials that are commonly used with CO2 laser light, both as lenses and as mirrors, include sodium chloride, potassium chloride, zinc selenide, and germanium.) The CO2 laser light is typically directed through a series of mirrors in a complex articulating system through which the light is delivered to a handpiece containing a lens which will allow the beam to be focussed in a non-contact manner onto the target location. Examples of delivery optics for CO2 laser radiation are disclosed in U.S. Pat. No. 5,497,441 of Croitoru, et al., "Hollow Waveguide Tips for Controlling Beam divergence and Method of Making Such Tips"; No. 5,005,944 of Laakmann, et al., "Hollow Lightpipe and Lightpipe Tip Using a Low Refractive Index Inner Layer"; and No. 4,917,083 of Harrington, et al., "Delivery System for a Laser Medical System." Relatively recent developments in waveguide technology include a flexible hollow waveguide which is suitable for use with CO2 lasers having powers over 80 W. Such waveguides are disclosed in U.S. Pat. Nos. 5,440,664 and 5,567,471 of Harrington, et al.
It is known that single crystal type II diamond (pure carbon, effectively free of nitrogen impurity) has very low absorption at 10.6 microns, on the order of 0.03 cm-1, and also has high thermal conductivity, on the order of 2,000 W/m/K in comparison with other far-IR transmitting materials. High quality synthetic diamonds, including diamond films formed using chemical vapor deposition (CVD) have been made possessing similar mechanical, optical and thermal characteristics. For this reason laser cavity windows formed from diamond have been described for use in high power lasers, particularly CO2 lasers. See, e.g., U.S. Pat. No. 5,335,245 of Marie, et al.; and U.S. Pat. No. 5,245,189 of Satoh, et al. See, also, U.S. Pat. No. 5,194,712 of Jones, supra with regard to use of diamond for transmission of laser radiation, including that from a CO2 laser.
In recent years significant attention has been focused on the application of lasers to treating cardiovascular diseases, in particular, techniques for revascularization of ischemic myocardium. The procedure, laser transmyocardial revascularization (TMR), was first reported in the early 1980's following procedures which used a CO2 laser to form channels in damaged heart tissue to increase myocardial perfusion via the transport of oxygenated blood through the channels. (See, e.g., M. Mirhoseini, et al., "Myocardial Revascularization by Laser: A Clinical Report", Lasers in Surgery and Medicine 3:241-245 (1983).) This initial work was performed on an arrested heart using a low power (80 W) CO2 laser. Subsequent work in TMR led to the numerous laser systems which could be used on a beating heart, such as the one disclosed in U.S. Pat. No. 4,658,817 of Hardy ("Method and Apparatus for Transmyocardial Revascularization Using a Laser"), in which a CO2 laser was used. U.S. Pat. Nos. 5,380,316, and 5,554,152, of Aita, et al., assigned to CardioGenesys Corporation of Santa Clara, Calif., disclose the use of a CO2 laser or a Holmium:YAG laser for TMR procedures, however, the commercial system actually marketed by CardioGenesys is based upon a Ho:YAG laser with a fiber optic/lens contact-type delivery system. The wavelength emitted by the Ho:YAG laser, 2.1 microns, like the Nd:YAG, is sufficiently short to permit use of conventional optical delivery techniques, eliminating the delivery limitations experienced with CO2 lasers. U.S. Pat. No. 5,607,421 of Jeevanandam, et al., describes a laser TMR system which uses a thulium-holmium-chromium:YAG laser (THC:YAG) laser with conventional optical fiber delivery via a catheter passed through the left atrium.
Development of other laser TMR systems for investigational use has been reported by PLC Systems, Inc., of Franklin, Mass., Eclipse Surgical Technologies, Inc., of Sunnyvale, Calif., and Helionetics, Inc., of Van Nuys, Calif., all for use on a beating heart. The Eclipse TMR system uses a Ho:YAG laser with a fiber optic handpiece for contact delivery to the myocardium. The Helionetics system is based an excimer laser and uses conventional fiber optic delivery techniques. PLC Systems uses a high power (1000 Watt) CO2 laser in its Heart Laser™ with an articulated arm delivery system, such as that described in U.S. Pat. No. 5,558,668 of Lankford, et al., assigned to PLC Medical Systems, Inc.
Primary distinctions between the use of Ho:YAG or excimer lasers and CO2 lasers include that the CO2 lasers can create a transmural channel with a single pulse synchronized with the R wave (beginning of contraction) of a beating heart. (An exemplary synchronization system is disclosed in U.S. Pat. No. 5,125,926 of Rudko, et al.) The Ho:YAG and excimer lasers utilize low pulse energy and must fire multiple pulses over multiple cardiac cycles, typically without synchronization, in order to form a single channel. Another important distinction is in the delivery systems, with CO2 based systems using articulated arms, supplying the laser energy in a non-contact manner, thus requiring higher power laser sources and more invasive access methods, e.g., open chest surgery. Distinctions also lie in the relative costs and reliability of CO2 and excimer laser-based systems: CO2 lasers are relatively readily available, inexpensive and easily maintained, and many hospitals already possess or have access to such lasers. Excimer lasers are large, expensive, and difficult to maintain, requiring frequent service, and use highly toxic gas as the lasing medium.
The precision required for safe and controllable formation of multiple small diameter channels in the myocardium suggests that a contact or near-contact methods for application of laser energy would be preferred. Further, the ability to utilize contact delivery methods enables the use of less invasive procedures for obtaining access to the heart, e.g., small incisions between the ribs (thoracotomy) as opposed to open chest surgery. However, according to TMR techniques currently in use, the advantages of contact delivery must be offset by the lower ablative energy provided by shorter wavelength (mid- or near-IR) light.
In view of the above-identified deficiencies in the TMR prior art, there remains a need for a system and method for delivering laser radiation, especially radiation from a CO2 laser, in a precisely controlled manner as required for delicate surgical procedures. The delivery system and method disclosed in the following written description and drawings addresses and overcomes each of these deficiencies as well as providing other effective laser surgery techniques.
It is an advantage of the present invention to provide a laser delivery system and method which permits precise control of the location of impingement of laser radiation on biological tissue in both contact and non-contact applications.
It is another advantage of the present invention to provide means for combining optical and mechanical means for ablation/incision of biological tissue.
Still another advantage of the present invention is to provide a system and method for performing transmyocardial revascularization using a low power CO2 laser.
Yet another advantage of the present invention is to provide a delivery system for inexpensively retrofitting an existing CO2 laser system for performing CO2 laser surgery at low power levels.
Another advantage of the present invention is to provide a system and method for performing left ventricular remodeling procedures using a combination of laser and mechanical surgical devices.
Still another advantage of the present invention is to provide a system and method for performing laser myringotomy with improved patency.
In an exemplary embodiment, the system and method of delivery of laser radiation comprises a flexible hollow waveguide connectable at a first end to a low power CO2 laser source, a rigid hollow waveguide having a proximal end and a distal end, a coupler for coupling the second end of the flexible hollow waveguide to the proximal end of the rigid hollow waveguide and a diamond tip partially disposed within and extending from the distal end of the rigid waveguide. The diamond tip has an entrance face for receiving laser radiation and at least one exit face for transmitting laser radiation toward a target area of biological tissue. Means are provided for controlling the rigid hollow waveguide to direct movement of the diamond tip and the laser light emitted therefrom.
The rigid hollow waveguide is a stainless steel tube with an inner diameter and a smooth, polished internal surface for reflection of the laser radiation. Other materials which meet the reflective and heat absorptive requirements for transmitting the laser radiation may be substituted for the stainless steel. The entrance end of the diamond tip has an outer diameter to closely fit within the inner diameter of the rigid waveguide, where it is brazed, glued or otherwise firmly affixed. The exit end of the diamond tip may be flat, parallel to the entrance face, curved, to act as a lens providing a focusing function, or beveled, to create one or more blade edges to limit the point(s) of exit of the laser radiation and to provide a cutting edge which may be used in combination with the radiation to simultaneously create and cauterize an incision. The diameter and emission location of the radiation leaving the diamond tip are controlled by polishing only the desired exit area of the exit face, leaving the remainder of the diamond with a roughened or "frosted" surface which will reflect the majority of laser radiation back into the body of the diamond so that it can be re-directed out of the exit face. Alternatively, for more efficient internal reflection, the areas of the diamond tip through which no radiation should escape may be bonded with a metal or ceramic coating which reflects the laser light.
The combination of the flexible waveguide, coupler, rigid hollow waveguide and diamond tip may be used for formation of channels in a transmyocardial revascularization (TMR) procedure. Using a low power CO2 laser (under 1000 Watts, preferably less than 100 W) emitting at 10.6 microns coupled via a flexible waveguide to a rigid waveguide/diamond tip assembly, the distal end of the assembly is guided to an area of the heart to be revascularized. The diamond tip is preferably configured as a flat window or a slightly curved lens, i.e., a lens having a relatively long focal point which will not significantly modify the beam diameter or power density at close range. Placement of the diamond tip at the desired location may be by catheter through one of the patient's major vessels, so that the ablation begins on the interior of the beating heart, or through a small incision in the chest wall, with the laser radiation being introduced outside-in, through the exterior (epicardial) portion. The diamond tip is placed in direct contact with the tissue of the beating heart for delivery of ablative laser radiation for formation of a channel. The tip is advanced as the ablation proceeds to control the depth of the channel. In order to avoid arrhythmogenesis, it is preferred that the laser pulses be synchronized to the peak of the R-wave of the patient's ECG.
Monitoring of the TMR procedure is achieved using a three-dimensional image acquisition endoscope with a head-mounted display. This may be supplemented using an ultrasonic imaging endoscope inserted into the patient's esophagus, as is known in the art. Conventional heart rate monitoring techniques may be used to generate a trigger signal to synchronize delivery of the laser radiation with the heart beat.
A similar delivery system in combination with a low power CO2 laser may be used for performing left ventricular remodeling, a surgical procedure for severe dilated cardiomyopathy in which a section of the enlarged left ventricle is surgically removed to reduce the size of the heart and to increase pumping function. A variation from the TMR embodiment, the diamond tip is formed as a blade which is frosted or otherwise treated to minimize escape of laser radiation everywhere except at the cutting edge. The cutting edge in combination with the laser radiation allows the simultaneous cutting of the heart tissue and photocoagulation of blood along the incision.
Treatment of otitis media by perforation of the eardrum (myringotomy) can be achieved by combining the delivery system as described for TMR with an otoscope to permit viewing of the tympanic membrane to properly position the perforation. Using a low power laser with the diamond tip held a short distance from, but not in contact with the membrane, an area of the tissue is denatured. Using a diamond tip shaped as a lance, or a diamond lens for focusing the laser to a small point, a small area of the denatured tissue is then punctured to provide a vent for pressure behind the eardrum. The puncturing is achieved by ablation, cutting, or a combination of both. After the pressure has been reduced, a larger perforation is made through the denatured tissue, leaving a rim of necrosis to delay healing of the perforation to provide improved patency, thus permitting the draining of fluids from the middle ear without requiring placement of a drainage tube.
Understanding the present invention will be facilitated by consideration of the following detailed description of preferred embodiments of the present invention taken in conjunction with the accompanying drawings, in which like numerals refer to like parts and in which:
FIG. 1 is a diagrammatic view of the laser delivery system of the present invention;
FIG. 2 is a side elevation, partially cut away, showing the rigid waveguide and diamond tip of a first embodiment of the delivery system;
FIGS. 3a-3d are diagrammatic views of alternative embodiments of diamond tips for use in the delivery system of the present invention, where FIG. 3a shows a blade having one beveled edge, FIGS. 3b and 3c show alternate configurations of blades having two beveled edges, and FIG. 3d shows a blade having four beveled edges;
FIGS. 4a and 4b are diagrammatic views of an alternative embodiment of the rigid waveguide, with FIG. 4a being a side elevational view and FIG. 4b being a top view;
FIG. 5 is a diagrammatic view of the system for performing a TMR procedure;
FIGS. 6a-6d are diagrammatic views of a human heart, partially cut away at the left ventricle, showing the steps of a TMR procedure, where FIG. 6a shows initial placement of the diamond tip, FIG. 6b shows a channel partially formed in the myocardium, FIG. 6c shows a completed channel and FIG. 6d shows a plurality of completed channels and a partially completed channel;
FIGS. 7a and 7b are diagrammatic views of a human heart showing the steps of a PLV procedure, where FIG. 7a shows formation of the incision around the wedge of tissue to be excised, and FIG. 7b shows the heart after completion of the procedure;
FIGS. 8a and 8b are diagrammatic views of a tympanic membrane, where FIG. 8a shows the first step of denaturing the tissue and FIG. 8b shows the second step of perforating the tympanic membrane within the denatured area; and
FIG. 9 is a diagrammatic view of a partial cross-section of a human ear and an otoscope adapted for performing a myringotomy according to the present invention.
As illustrated in FIG. 1, a surgical laser radiation delivery system for use with a low power laser source 102 comprises a flexible hollow waveguide 104 connectable at a first end 106 to laser source 102, a rigid hollow waveguide 112 having a proximal end 114 and a distal end 116, a coupler 110 for coupling the second end 108 of flexible hollow waveguide 104 to the proximal end 114 of rigid hollow waveguide 112 and a diamond tip 120 partially disposed within and extending from distal end 116 of rigid waveguide 112. As can be seen in more detail in FIG. 2, diamond tip 120 has an entrance face 202 for receiving laser radiation and at least one exit 204 face for transmitting laser radiation toward an area of biological tissue 100. The rigid hollow waveguide 112 may include means for gripping in the user's hand to support and direct movement of the diamond tip 120 and the laser light emitted therefrom, or may be combined with a steerable endoscope to enable guidance.
Flexible waveguide 104 is preferably be constructed according to the disclosure of Harrington, et al. in U.S. Pat. No. 5,567,471, which is incorporated herein by reference. The waveguide of Harrington, et al. comprises a hollow tube of flexible, thin-wall silica-glass tube with a protective sheath on its outer surface. The inner surface of the tube is coated with a material that is optically reflective at mid-infrared wavelengths, such as silver, so that the coating is optically smooth. A dielectric film, such as silver iodide, is deposited on the reflective layer.
The rigid hollow waveguide 112 is a stainless steel tube with an inner diameter and a smooth, polished internal surface for reflection of the laser radiation. The inner diameter of waveguide 112 is preferably on the order of 1.0 to 1.5 mm or less to provide greater control over the spatial profile of the output laser beam. The outer diameter is determined primarily by the materials used, to assure that the tube can be formed with a smooth internal surface without irregularities form creases or wrinkles which might disrupt the efficient transfer of laser energy. The outer diameter may also depend on any requirements for housing waveguide 112 within some other structure, such as a catheter. Other materials which meet the reflective and heat absorptive requirements for transmitting the laser radiation may be substituted for the stainless steel. Such materials include invar, nickel, platinum, and other high specific heat metals or alloys.
The entrance face 202 of the diamond tip 120 has an outer diameter to closely fit within the inner diameter of the rigid waveguide, i.e., on the order of 1.0 to 1.5 mm or less, where it is brazed, glued or otherwise firmly affixed, for example, by crimping the end of waveguide 112 around the tip 120. The surface of entrance face 202 is preferably flat, perpendicular to the axis of waveguide 112, and may be coated or bonded with an anti-reflective coating 210 such as silicon nitride or silicon carbide, as disclosed in U.S. Pat. No. 5,194,712 of Jones. The exit face 204 of the diamond tip 120 may be flat, parallel to entrance face 202, as shown in FIG. 2, curved, to act as a lens providing a focusing or beam expanding function, or beveled, as shown in FIGS. 3a-3d, to create one or more blade edges to limit the point(s) of exit of the laser radiation and to provide a cutting edge which may be used in combination with the radiation to simultaneously optically and mechanically cut and induce photocoagulation as the incision is made. (Note that, for purposes of this description, the phrase "mechanically cut" means the cutting performed using a sharp blade pressed against the tissue, while "optically cut" means removal or separation of tissue by laser ablation, regardless of whether the laser radiation is applied in a contact or non-contact manner.)
As in conventional diamond surgical blades for mechanical cutting, multiple facets may be created to form, for example, a spear tip (using two facets), a triple edge (using three facets), or a curved tip (with four or more facets to approximate a rounded blade). FIG. 3a shows a blade 300 with a single beveled edge 302. In this configuration, laser radiation would be emitted only through beveled edge 302, which is also the only cutting edge. FIG. 3b illustrates a blade 304 with two beveled edges 306,308 to form a lance or spear. Both edges 306,308 can be used to cut, and apex 310 can be used to pierce. Laser radiation will be emitted through both beveled edges 306,308. FIG. 3c shows an alternate two-edge blade 312 with beveled edges 314,316. Edge 314 is long and may be used for larger-area slicing, with apex 318 for piercing. FIG. 3d illustrates a curved blade 320 with four beveled edges 324,326,328,330 formed at the distal end of the blade.
The diameter and emission location of the radiation leaving the diamond tip may be further controlled by polishing only the desired area of the exit face, leaving the remainder of the diamond with a roughened or "frosted" surface which will reflect the majority of laser radiation back into the diamond so that it can be re-directed out of the exit face. Alternatively, for more efficient internal reflection, the areas of the diamond tip through which no radiation should escape may be bonded or coated with a metal or ceramic film. In the embodiment of FIG. 2, the sidewalls 206 of diamond tip 120 are treated with internally reflective coating 208 to minimize escape of laser radiation. In FIGS. 3a-d, all areas but the beveled edges may be treated to enhance internal reflection and guide the laser radiation toward edge. The beveled edges are formed in accordance with conventional techniques for forming surgical diamond cutting blades, in which a facet is formed at the cutting edge. The dimensions of such surgical blades are generally appropriate for use in combination with the inventive laser system. For example, the base end of a commercially-available surgical blade manufactured by the Drukker Group (D. Drukker & Zn, N.V., Amsterdam, The Netherlands) may have a width in the range of 0.7 to 1.4 mm and a thickness of 0.17 mm, such that it would easily fit within the interior of the hollow waveguide 112. It may be preferable to form the base end of the blade to have an entrance face with a shape and an area the just fits within the cross-sectional shape and area of the hollow waveguide to enhance efficiency in capture of the laser radiation incident upon the entrance face and to minimize diffraction losses where the laser radiation impinges upon a corner or edge of the entrance face. Thus, if the hollow waveguide is rounded, the entrance face is preferably rounded. Since it may be easier to form the base of a diamond blade with a rectangular or square cross-section, the hollow waveguide may be crimped or otherwise modified to create a corresponding rectangular or square cross-section at its interior with approximately the same cross-sectional area as the base of the blade. Commercial diamond blades can range from 0.25 mm down to less than 35 microns in thickness with widths on the order of 1 mm or less. A modification for accommodating an exemplary commercial diamond blade is illustrated in FIGS. 4a and 4b, showing a hollow waveguide 400 with a circular cross-section at proximal end 402 and a rectangular cross-section at distal end 404 to match the rectangular shape of the base 406 of diamond blade 408. The transition 410 from circular to rectangular cross-section is made as gradual as possible to retain the smooth internal surface to minimize scattering loss and mode conversion. With the laser radiation being emitted only from beveled edge(s) 412, the edge can simultaneously cut the tissue and coagulate the blood at the incision.
The diamond tip is preferably formed using a single crystal natural diamond, which, ideally, is a type IIa diamond. Type IIa diamonds are effectively free from nitrogen impurities and have enhanced optical and thermal properties. Other types of diamonds may be used as long as they possess the thermal and optical characteristics required to efficiently transmit infrared laser radiation while tolerating thermally-induced stresses and strains.
Type Ib diamonds (most synthetics) and polycrystalline diamond films manufactured by chemical vapor deposition (CVD), e.g., DIAFILM™ available from De Beers Industrial Diamond Division, Berkshire, England, may also be used.
The delivery system of the present invention be used in a TMR procedure for formation of channels in the myocardium. Such a system is illustrated in FIG. 5. The distal end 516 of hollow waveguide 512 is fitted with diamond tip 520 configured as a flattened or slightly curved lens at exit face 524. Hollow waveguide 512 is axially slidably retained within channel 502 of an endoscope 500 so that it may be extended from at least partially retracted into the housing 530. Housing 530 may also contain means for preforming one or more other functions in addition to retaining the waveguide 512 and diamond tip 520. At least a portion of flexible waveguide 510 is also retained within endoscope 500. The proximal end 536 of waveguide 510 is attached via connector 538 to laser 526.
In the preferred embodiment, housing 530 also retains within sheath 534 a plurality of axially-running control lines 532 which are attached at the distal end 502 for guiding the endoscope 500, as is known in the art, and a plurality of optical fibers 504, a first portion of which provide a source of visible illumination and a second portion of which provide visual feedback to the surgeon in the form of a three dimensional image. The three dimensional image, which is computer-enhanced using the images obtained via the optical fibers 504, is viewed using a binocular head mounted display 506 which is worn by the surgeon to provide real-time visual feedback in a minimally invasive surgical procedure. A three dimensional endoscope system is disclosed and described in International Patent Application Publication Number WO 94/28783 of American Surgical Technologies Corporation, the disclosure of which is incorporated herein by reference. One such commercial three-dimensional viewing system is available as the Vista Series 8000 Visualization and Information System, which incorporates the CardioScope™, for image acquisition, and CardioView™, for the head-mounted display, manufactured by Vista Medical Technologies, Vista Cardiothoracic Surgery Division, of Westborough, Mass.
Briefly, the three-dimensional image is produced by a conventional stereoscopic endoscope 500 which converts optical images of an object, in this case, the patient's heart, to left and right video image signals. Conversion of the two-dimensional optical images into left and right signals is achieved using a camera head 514 connected to a video processing module 516. After processing, the images are displayed on the left and right lenses 518,520 of the head mounted display 506. The lenses 518,520 may be liquid crystal displays (LCDs), such as described in U.S. Pat. No. 5,532,852 of Kalmanish, or may be passive displays as described in above-referenced International Publication No. WO 94/28783.
Visual monitoring of the procedure may be supplemented using known techniques of ultrasonic imaging by placing a ultrasonic probe within the patients esophogus. (See, e.g., I. Kupferwasser, et al., "Quantification of mitral valve stenosis by three-dimensional transesophageal echocardiography", Int'l J. Cardiac Imag., 12:241-247, 1996.)
Synchronization of the laser activation with the R waves of the electrocardiogram (ECG) signal utilizes a conventional ECG device 522 which is connected to a trigger pulse generating device 524. The trigger pulse is passed to a laser firing circuit which activates the laser 526 on the R wave of the electrocardiographic cycle, when the ventricle is maximally distended. An exemplary synchronization system is disclosed in U.S. Pat. No. 5,125,926 of Rudko, et al.
Referring to FIGS. 6a-6d, the method for performing a TMR procedure comprises making one or more small left anterior incisions (thoracotomies) through the fourth, fifth or sixth intercostal space to provide access to the left ventricle area of the heart 602. The distal end 604 of an endoscope 606 retaining flexible waveguide 607, hollow waveguide 608 and diamond tip 610 is inserted through and fed into incision 612 (indicated by dashed lines) until the tip 610 comes in contact with the pericardium 614. Endoscope 606 is configured such that it also retains the viewing optics, including illumination means, for providing a three-dimensional image for viewing using head-mounted display 616, which is described above with regard to FIG. 5. It also may include guidance means, such as control lines running axially along the length of the endoscope for manipulating the distal end 609 of the endoscope. Such guidance means are known in the art. Alternatively, the viewing optics may be housing within a separate endoscope which is inserted through a separate incision near incision 612.
As illustrated in FIG. 6a, which shows the system set-up, the patient's ECG is monitored using an ECG device 618 which provides a trigger signal for activating CO2 laser 620 in synchrony with the R wave 619, as indicated on ECG output display 621. Upon triggering, laser 620 emits a pulse of low power 10.6 micron laser light, i.e., less that 1000 W and preferably having a power within the range of 25-50 W, with a beam diameter of approximately 1 mm. (Generally, the laser should have a power density of greater than 5000 W/cm2.)
In FIG. 6b, which illustrates portions of both the heart 602 and overall system components, the distal end 607 of endoscope 606 is indicated by dashed lines to show the relative movement of the diamond tip 610 for advancing the tip into the heart tissue. It should be noted that, where the viewing and lasing components are housed in a common endoscope, distal end 607 is positioned to achieve the desired depth of view based upon the viewing optical components, since tip 610 can be advanced as needed relative to the distal end 607. The laser light emitted through diamond tip 610 in contact with the pericardium 614 ablates the tissue, providing a point of entry without tearing the pericardial tissue, and allows the tip 610 to be advanced into the myocardium 622. Triggered by detection of another R wave, the laser radiation ablates the myocardial tissue with which the tip 610 is in contact. As the myocardial channel 624 is formed, the tip 610 is advanced until the channel extends through the myocardium 622 and the endocardium 626 and, finally, the tip 610 extends into the left ventricle 628, as shown in FIG. 6c. In prior art TMR systems based on high power CO2 lasers, "overshoot" after the channel is fully punched through the heart wall is controlled by blood contained within the left ventricle, since the water in the blood will absorb the radiation. However, such reliance may be risky and could result in damage to the opposite inner wall of the left ventricle. In the present method, since the ablation is advanced gradually, there is no "overshoot" with an uncontained high power laser beam. Stop 632, shown only in FIG. 6c, may be disposed within endoscope 606 to limit the travel of tip 610 by preventing flange 634 from advancing further, thus providing even greater control and accuracy in the application of the laser radiation. If such a stop is utilized, the length of hollow waveguide 608 should be sufficient to allow tip 610 to pass completely through the myocardium 622 and enter the left ventricle 628.
The tip 610 is then backed out through the channel 624 and another channel is begun at a different point on the outer wall of the left ventricle. FIG. 6d shows three completed channels 624 with another one in the process of being formed. As is known in the TMR art, a number of channels are formed, typically on the order of 15 to 40 channels, with diameters of about 1 mm, to provide the desired improvement in myocardial perfusion.
Since multiple applications of the laser radiation are required to create each channel, activation of the laser may be triggered by the R wave for every n beats, depending on the patient's heart rate. For example, for a rate of 60 beats/minute, n might be selected to be 5, 10, or some other integer value. Consideration may also need to be given to how long the laser requires between pulses, with the triggering rate being set to a value corresponding to a period equaling an integer times the heart rate which is greater than the laser recharge cycle.
The pericardium 614 may provide a relatively high amount of initial resistance due to its density. Therefore, as an alternative to the flat or slightly rounded tip, it may be desirable to utilize a lance or spear-type diamond tip, such as that illustrated in FIG. 3b, to facilitate perforation of the pericardial tissue. The pericardium 614 heals almost immediately, as indicated in FIG. 6d, while the channels in the myocardium remain patent.
Variations in the TMR procedure with the inventive system can occur based upon the method of obtaining access to the myocardium. In one alternative method, the heart is accessed through catheters placed in the patient's femoral artery and passed through the aorta 630, which can be seen in FIG. 6a, across the aortic valve and into the left ventricle 628. Using this method, perforation of the pericardium 614 is not required, and the channels are created in the myocardium 622 to a pre-determined depth. In another alternative method, access is gained in an open chest procedure via a sternotomy or thoracotomy. As in the first method, the diamond tip is initially placed in contact with the pericardium 614, and the channels are formed completely through the myocardium 622.
Because the CO2 laser radiation is delivered by contacting the tissue, the optical components of the system can be simplified as compared to conventional CO2 laser-based TMR systems, which require an additional laser, typically helium-neon (He-Ne), which emits a visible red light (632.8 nm), with corresponding optics, for aiming purposes. In the present invention, contact, and thus, aiming, is readily monitored using the images generated by the 3-D endoscope 606 and viewer 616. As previously mentioned, esophageal ultrasonic imaging may also be used to monitor the positioning of the device and the progress of the procedure.
An important advantage of the present invention is that, because of its low power requirements, it may be used with virtually any CO2 laser head, including retrofitting of a CO2 laser which may already be available within the hospital. This provides greater access to TMR capability for hospitals which may not have the budget for purchasing dedicated TMR systems, which systems cost well over $100,000, and makes it possible to perform the procedures more cost effectively. The contact procedure allows the power level to be significantly lower than that required for non-contact CO2 laser-based systems, which require power levels of 800 W and up in order to supply sufficient energy to create a complete channel in a single pulse. (A non-contact TMR system must create the channel in a single pulse since exact positioning of a subsequent pulse at the same point may be difficult on the beating heart.) The contact delivery system of the present invention allows for greater precision and improved safety, while providing a more economical means for performing TMR procedures.
In an alternate embodiment, the laser delivery system of the present invention may be used to perform a partial left ventriculectomy (PLV), also known as the Batista procedure, for treatment of severe dilated cardiomyopathy. The same low power CO2 laser may be used as that used for the TMR procedures. Other types of lasers, such as Ho:YAG or Nd:YAG may be used, however, the advantages of cost savings with the low power CO2 laser may not be available. The diamond tip used for the delivery system will have at least one cutting edge, and may be any of the configurations shown in FIGS. 3a-3d, or variations thereupon.
The method of performing a PLV using the inventive system comprises providing access to the heart by way of a sternotomy or thoracotomy. It may be preferred to utilize recently reported systems and procedures for minimally invasive surgery, such as the system developed by Cardio Thoracic Systems, Inc. of Cupertino, Calif. under the trademark MIDCAB™. Such systems permit access to the heart through an incision through one of the left intercostal spaces. Spreaders are used to increase the spacing between a pair of ribs to provide a window to the heart.
The patient is placed on a heart-lung bypass machine. The heart continues beating in order to permit identification of the area to be removed. As illustrated in FIG. 7a, using the inventive laser delivery system with a low power CO2 laser 700, typically on the order of 25-50 W, the diamond tip 702, shown here with two beveled edges 704,706, is retained within hollow waveguide 730 and is used to simultaneously cut and irradiate tissue in the wall of the left ventricle 708 between the papillary muscles (not shown) to remove a wedge of tissue 710. The laser radiation is emitted through edges 704,706 to facilitate cutting, particularly through the pericardium 712, and to induce photocoagulation of the tissue as the incision is made through the myocardium 714 and endocardium 716 thus reducing bleeding. The stippling at the incision through the myocardium 714 is provided to indicate photocoagulated tissue. The dotted line indicates the intended line of incision 720. After the wedge of tissue 710 is removed, the edges 718, 720 of the incision are pulled together and sutured to form a smaller left ventricle, as shown in FIG. 7b, with thicker walls. The stippling at the joined incision again indicates photocoagulated tissue of the pericardium 712. The patient's heart is restarted, the heart-lung machine is removed, and the thoracic incision is closed.
Other types of lasers may be substituted for the low power CO2 laser in this procedure in order to provide photocoagulation of the tissue as the incision is made mechanically with the diamond blade. Alternative lasers include Ho:YAG, Nd:YAG, and solid state, all emitting within the IR range. Other lasers are known for their photocoagulation capabilities including argon and excimer.
The laser delivery system of the present invention provides several advantages over current PLV techniques. These advantages includes reduced tearing of the heart tissue resulting from conventional steel blade knives or surgical scissors, since the diamond blade has a much cleaner, sharper edge, which produces less cell damage, and the laser radiation augments the mechanical cutting with ablation, at least with the CO2 laser, and induces photocoagulation to reduce bleeding as the cut is made with the CO2 laser as well as many other types of laser. These advantages, in turn, reduce the time in surgery and the risk of post-operative bleeding, and contribute to faster healing.
A third embodiment of the inventive laser delivery system may be used for performing a myringotomy for treatment of otitis media. In this case, two different diamond tips may be used. The first diamond tip 802 mounted within hollow waveguide 804, shown in FIG. 8a, is configured as an expanding lens which slightly enlarges the diameter of beam 816 from a low power CO2 laser 814, e.g., 25-50 W, to irradiate an area 806 on the tympanic membrane 808, preferably, but non-necessarily non-contact (for the patient's comfort), resulting in the denaturing of the tissue in the area 806. The denaturing is indicated by stippling. A hollow waveguide with a second diamond tip 810, shown in FIG. 8b, is then attached at the distal end of the waveguide 812 connected to the CO2 laser 814 to complete the procedure. Second diamond tip 810 may be configured as a focusing lens, a flat window, or a lance-type blade as shown. The key to second diamond tip 810 is that it generates a narrower, more focused beam than that delivered by first diamond tip 802 so that a smaller area of impact is defined on the tympanic membrane 808 with a higher power density. The smaller, diameter, higher power density beam is then used to ablate a small perforation 818 generally at the center of the area of the denatured tissue 806 so that a rim 820 of denatured tissue remains around the perforation. This latter aspect of the procedure is preferably performed in two steps. The first step is that a small "vent" hole is formed to release any pressure that has built up behind the tympanic membrane which could otherwise lead to bursting of the membrane if it were suddenly perforated. After the pressure has been equalized, a larger perforation is formed to provide the desired drainage. The small vent hole may be created by gently pushing the tip 822 of the lance blade 810 against the membrane, then backing the blade away from the tissue to allow the pressure release. The desired, larger perforation 816 can then be created by a combination of mechanical pressure from the blade 810 and the laser ablation, or by either alone.
The rim of denatured tissue 820 retards the healing of the perforation, giving it extended patency. This eliminates the need for placement of a shunt for drainage such as is required in most current myringotomy procedures.
Observation and control of the myringotomy procedure using the inventive system may be achieved using conventional viewing optics including an otoscope 830 with an illumination source 832, illustrated in FIG. 9 along with a section of an ear 840. Illumination source 832 may double as the targeting means, and, in this case, is shown as a He-Ne laser along with the appropriate optics for directing the beam 834 from the He-Ne laser 832 along substantially the same optical path as, or to convergence with, the ablation laser 814.
The myringotomy procedure is not limited to the wavelength emitted by a CO2 laser, and a wide range of laser wavelengths may be used, including lasers emitting in the near- and mid-IR, including Ho:YAG, and near-UV ranges, such as excimer. The only requirement is that the laser radiation must be sufficient for achieve adequate denaturing of the tissue as required for extended patency of the perforation.
The described myringotomy procedure takes advantage of the benefits of laser ablation and other laser/tissue interactions without requiring the complex optical systems taught by others in the art. For example, U.S. Pat. No. 5,280,378 of Lombardo describes a cyclically scanned laser for use in myringotomy procedures. The scanned beam forms many tiny holes in the tympanic membrane to outline an area which can then be punched through at the perforations. In that procedure, the laser is used only for cutting/piercing, and no intentional denaturing occurs. Thus, the patency of the perforation is not improved significantly relative to mechanical lancing procedures and a shunt will still be required.
The laser delivery system of the present invention provides means for precise control of surgical lasers, especially CO2 lasers, allowing the safe usage of inexpensive conventional lasers for advanced laser surgical techniques. The delivery system allows hospitals and physicians to avoid the significant expense involved in purchasing new, dedicated laser surgical systems when they already have access to CO2 lasers which were part of an older and possibly out-of-date surgical system. The combined laser and mechanical surgical techniques which are enabled by the low power levels allow surgeons to exploit the benefits of each technique without compromise, providing significant advantages over prior art laser systems, particularly for transmyocardial revascularization and myringotomy procedures. Further, the disclosed invention introduces the use of laser techniques for use in partial left ventriculectomy procedures and similar cardiac surgeries. Other surgical procedures not specifically mentioned will similarly benefit from the improvements disclosed herein relating to laser delivery.
It will be apparent to those skilled in the art that various modifications and variations can be made in the system and method of the present invention without departing from the spirit or scope of the invention. Thus, it is intended that the present invention cover the modification and variations of this invention provided they come within the scope of the appended claims and their equivalents.
|Cited Patent
|Filing date
|Publication date
|Feb 9, 1976
|Nov 21, 1978
|Research Corporation
|Photocoagulating scalpel system
|May 5, 1981
|Sep 4, 1984
|Davi Samantha K
|Apparatus for and method of utilizing energy to excise pathological tissue
|May 14, 1984
|Dec 9, 1986
|Micra Limited
|Surgical knives
|Apr 1, 1985
|Apr 21, 1987
|Children's Hospital Medical Center
|Method and apparatus for transmyocardial revascularization using a laser
|Feb 19, 1985
|Aug 18, 1987
|The United States Of America As Represented By The United States Department Of Energy
|Excimer laser phototherapy for the dissolution of abnormal growth
|Nov 17, 1986
|Sep 15, 1987
|Surgical Laser Technologies, Inc.
|Medical and surgical laser probe I
|Mar 27, 1987
|Aug 2, 1988
|Kaiser Aerospace And Electronics Corporation
|Compact helmet mounted display
|Jul 5, 1988
|Oct 31, 1989
|Kaiser Aerospace & Electronics Corporation
|Stereoscopic display
|Mar 4, 1988
|Apr 17, 1990
|Heraeus Lasersonics, Inc.
|Delivery arrangement for a laser medical system
|Feb 27, 1989
|May 22, 1990
|Acculase Inc.
|Liquid filled flexible distal tip light guide
|Aug 2, 1989
|Feb 19, 1991
|Eclipse Surgical Technologies, Inc.
|Method and apparatus for removal of obstructive substance from body channels
|Feb 17, 1989
|Apr 9, 1991
|Luxar Corporation
|Hollow lightpipe and lightpipe tip using a low refractive index inner layer
|Mar 13, 1990
|Jun 4, 1991
|United Technologies Corporation
|Low distortion window for use with high energy lasers
|Jan 18, 1990
|Sep 3, 1991
|Acculase, Inc.
|Method and apparatus for coupling high energy laser to fiberoptic waveguide
|Apr 24, 1990
|Dec 10, 1991
|Luxar Corporation
|Lightpipe tip for contact laser surgery
|Mar 29, 1990
|Mar 17, 1992
|Heraeus Lasersonics, Inc.
|Optical transmission device
|Sep 15, 1989
|May 19, 1992
|Eclipse Surgical Technologies, Inc.
|Catheter torque mechanism
|Sep 24, 1990
|Jun 30, 1992
|Laser Engineering, Inc.
|Heart-synchronized pulsed laser system
|Dec 7, 1990
|Jan 5, 1993
|The General Hospital Corporation
|Use of lasers to break down objects for removal from within the body
|Apr 22, 1991
|Mar 16, 1993
|Jones Barbara L
|Cutting tool using a diamond window
|Dec 6, 1991
|May 4, 1993
|Premier Laser Systems, Inc.
|Fiber optic apparatus for use with medical lasers
|Feb 25, 1991
|Jun 22, 1993
|Miles Gregory M
|Fiber diverter
|Mar 13, 1992
|Sep 14, 1993
|Sumitomo Electric Industries, Ltd.
|Infrared optical element and method of making the same
|Jul 20, 1992
|Dec 28, 1993
|The University Of Utah
|Preparation of diamond and diamond-like thin films
|Oct 19, 1990
|Jan 18, 1994
|I.L. Med, Inc.
|Cyclically scanned medical laser
|Jul 17, 1992
|Apr 19, 1994
|Premier Laser Systems, Inc.
|Multiwavelength medical laser method
|Jul 1, 1991
|Jun 14, 1994
|Laser Centers Of America
|Laser surgical device with blunt flat-sided energy-delivery element
|Feb 17, 1993
|Aug 2, 1994
|L'air Liquide, Societe Anonyme Pour L'etude Et L'exploitation Des Procedes Georges Claude
|Power laser with uncoated diamond window
|Oct 20, 1993
|Dec 27, 1994
|Kmi, Inc.
|Undercut diamond surgical blade and method of using the same
|Jun 16, 1993
|Jan 10, 1995
|Advanced Cardiovascular Systems, Inc.
|Method for intra-operative myocardial device revascularization
|Feb 25, 1993
|Feb 14, 1995
|Advanced Cardiovascular Systems
|System and method for percutaneous myocardial revascularization
|Jun 28, 1993
|Jun 13, 1995
|Chiron Vision Corporation
|Keratorefractive diamond blade and surgical method
|Jan 13, 1994
|Aug 8, 1995
|Rutgers, The State University Of New Jersey
|Coherent, flexible, coated-bore hollow-fiber waveguide
|Dec 14, 1994
|Jan 2, 1996
|Surgilase, Inc.
|Monolithic hollow waveguide method
|Apr 19, 1994
|Feb 27, 1996
|Murray; Steven C.
|Optical delivery device with high numerical aperture curved waveguide
|Jul 6, 1994
|Mar 5, 1996
|Ramot University Authority For Applied Research & Industrial Development Ltd.
|Hollow waveguide tips for controlling beam divergence and method of making such tips
|Jan 27, 1995
|Apr 9, 1996
|Cardiogenesis Corporation
|Shapeable optical fiber apparatus
|Jun 7, 1995
|Jun 25, 1996
|Lederle (Japan), Ltd.
|Fiber optic laser conducting and diffusion device
|Feb 23, 1994
|Jul 2, 1996
|Kaiser Aerospace And Electronics Corporation
|High speed, high ambient viewability liquid crystal display assembly
|Mar 8, 1995
|Jul 16, 1996
|Vista Medical Technologies, Inc.
|Optical surgical device with scraping tool
|Dec 20, 1994
|Sep 10, 1996
|Cardiogenesis Corporation
|Method for intra-operative myocardial revascularization
|Oct 11, 1994
|Sep 24, 1996
|Plc Medical Systems, Inc.
|Medical laser treatment system and method
|Aug 8, 1995
|Oct 22, 1996
|Rutgers, The State University Of New Jersey
|Coherent, flexible, coated-bore hollow-fiber waveguide, and method of making same
|Sep 7, 1994
|Jan 7, 1997
|Hennings; David R.
|Method and apparatus for tympanic membrane shrinkage
|Nov 9, 1994
|Jan 7, 1997
|Taheri; Syde A.
|Transcavitary myocardial perfusion apparatus
|May 25, 1994
|Mar 4, 1997
|The Trustees Of Columbia University In The City Of New York
|Myocardial revascularization through the endocardial surface using a laser
|Jun 7, 1995
|Aug 19, 1997
|Trimedyne, Inc.
|Surgical laser instrument
|Oct 26, 1989
|May 16, 1990
|Premier Laser Systems, Inc.
|Multiwavelength medical laser system
|Title not available
|Jun 14, 1994
|Dec 22, 1994
|American Surgical Tech
|Medical video endoscope system
|"A Diamond in Miniature", D. Drukker & SN, N.V.
|"Advanced Diamond Products", Drukker International BV.
|"Cardio Genesis Corporation--Prospectus", Bear, Stearns & Co. Inc., Montgomery Securities, Piper Jaffray Inc., May 21, 1996.
|"Clinical Report: Laser Myocardial Revascularization", Mahmood Mirhoseini, M.D., et al., Lasers in Surgery and Medicine, 6:459-461 (1986).
|"Diafilm", De Beers Industrial Diamond Division.
|"Drukker Diamond Blades", Dubbeldee Harris Diamond Corp., May 1, 1991.
|"Jungle 2 City: A Slice of Life", Rex Dalton, The San Diego Union-Tribune, Apr. 16, 1997.
|"Long- and Short-Term Effects of Transmyocardial Laser Revascularization in Acute Myocardial Ischemia", K.A. Kadipasaoglu, Ph.D. et al., Lasers in Surgery and Medicine 20:6-14 (1997).
|"Myocardial Revascularization by Laser: A Clinical Report", M. Mirhoseini, M.D., et al., Lasers in Surgery and Medicine, 3:241-245 (1983).
|"Myocardial Revascularization With Laser, Preliminary Findings", O.H. Frazier, MD et al., Circulation, 1995; 92 suppl II!:II-58-II-65.
|"One Hundred Consecutive Patients Undergoing Video-Assisted Thoracic Operations", Ralph J. Lewis, M.D. et al., Annual Meeting of The Society of Thoracic Surgeons, Feb. 3-5, 1992, 54:421-6.
|"Present Role of Thoracoscopy in the Diagnosis and Treatment of Diseases of the Chest", Michael J. Mack, M.D. et al., Annual Meeting of The Society of Thoracic Surgeons, Feb. 3-5, 1992, 54:403-9.
|"Properties of Diamond", De Beers Industrial Diamond Division, 199.
|"Quantification of Mitral Valve Stenosis by Three-Dimensional Transesophageal Echocardiagraphy", Iri Kupferwasser et al., International Journal of Cardiac Imaging 12:241-0247, 1996, Kluwer Academic Publishers.
|"Saving the Whole with a Smaller Hole", Rex Dalton, The San Diego Union-Tribune, Apr. 16, 1997.
|"TMR Becomes an Option for Heart Patients", Individual Inc., 1997.
|A Diamond in Miniature , D. Drukker & SN, N.V.
|Advanced Diamond Products , Drukker International BV.
|Cardio Genesis Corporation Prospectus , Bear, Stearns & Co. Inc., Montgomery Securities, Piper Jaffray Inc., May 21, 1996.
|Clinical Report: Laser Myocardial Revascularization , Mahmood Mirhoseini, M.D., et al., Lasers in Surgery and Medicine, 6:459 461 (1986).
|Diafilm , De Beers Industrial Diamond Division.
|Drukker Diamond Blades , Dubbeldee Harris Diamond Corp., May 1, 1991.
|Jungle 2 City: A Slice of Life , Rex Dalton, The San Diego Union Tribune, Apr. 16, 1997.
|Long and Short Term Effects of Transmyocardial Laser Revascularization in Acute Myocardial Ischemia , K.A. Kadipasaoglu, Ph.D. et al., Lasers in Surgery and Medicine 20:6 14 (1997).
|Myocardial Revascularization by Laser: A Clinical Report , M. Mirhoseini, M.D., et al., Lasers in Surgery and Medicine, 3:241 245 (1983).
|Myocardial Revascularization With Laser, Preliminary Findings , O.H. Frazier, MD et al., Circulation, 1995; 92 suppl II :II 58 II 65.
|One Hundred Consecutive Patients Undergoing Video Assisted Thoracic Operations , Ralph J. Lewis, M.D. et al., Annual Meeting of The Society of Thoracic Surgeons, Feb. 3 5, 1992, 54:421 6.
|Present Role of Thoracoscopy in the Diagnosis and Treatment of Diseases of the Chest , Michael J. Mack, M.D. et al., Annual Meeting of The Society of Thoracic Surgeons, Feb. 3 5, 1992, 54:403 9.
|Properties of Diamond , De Beers Industrial Diamond Division, 199.
|Quantification of Mitral Valve Stenosis by Three Dimensional Transesophageal Echocardiagraphy , Iri Kupferwasser et al., International Journal of Cardiac Imaging 12:241 0247, 1996, Kluwer Academic Publishers.
|Saving the Whole with a Smaller Hole , Rex Dalton, The San Diego Union Tribune, Apr. 16, 1997.
|TMR Becomes an Option for Heart Patients , Individual Inc., 1997.
|Citing Patent
|Filing date
|Publication date
|Mar 6, 2000
|Oct 15, 2002
|Plc Medical Systems, Inc.
|Myocardial revascularization
|Feb 24, 1999
|Oct 22, 2002
|Scimed Life Systems, Inc.
|Device and method for percutaneous myocardial revascularization
|Oct 11, 2000
|Feb 18, 2003
|Trimedyne, Inc.
|Laser devices for performing a myringotomy
|May 29, 2001
|Jul 15, 2003
|Plc Medical Systems, Inc.
|Myocardial revascularization
|Jul 31, 2000
|Jan 6, 2004
|Brookhaven Science Associates
|Slender tip laser scalpel
|May 24, 2001
|Jan 27, 2004
|Chase Medical, Inc.
|Kit and method for use during ventricular restoration
|Jun 29, 2000
|Mar 2, 2004
|Herman Philip Godfried
|Cutting blade for surgical instrument
|May 24, 2001
|Mar 9, 2004
|Chase Medical, L.P.
|Sizing apparatus and method for use during ventricular restoration
|May 26, 2000
|Sep 6, 2005
|Boston Scientific Scimed, Inc.
|Bone anchors for bone anchor implantation device
|Jun 5, 2003
|Nov 1, 2005
|Chase Medical, L.P.
|Kit and method for use during ventricular restoration
|Apr 10, 2000
|Dec 13, 2005
|Clinicon Corporation
|Cutting and cauterizing surgical tools
|May 24, 2001
|Feb 7, 2006
|Chase Medical, L.P.
|Ventricular restoration shaping apparatus and method of use
|Apr 8, 2005
|Jan 23, 2007
|Omniguide, Inc.
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Apr 8, 2005
|Feb 19, 2008
|Omniguide, Inc.
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Apr 8, 2005
|Mar 25, 2008
|Omniguide, Inc.
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Sep 5, 2002
|Feb 3, 2009
|Chase Medical L.P.
|Method and device for percutaneous surgical ventricular repair
|Apr 18, 2006
|Mar 17, 2009
|Dornier Medtech Laser Gmbh
|Systems and methods for cleaning an optical fibre
|Dec 4, 2006
|Jul 28, 2009
|Implicitcare, Llc
|Surgical threading device and method for using same
|May 9, 2007
|Sep 1, 2009
|Schott Corporation
|Illuminable image-conducting optical assembly including light-conductive optics housing for creating an illuminating halo
|Jul 14, 2005
|Apr 6, 2010
|Sialo-Lite, Ltd.
|System and method for salivary stones removal and joint arthroscopy
|May 15, 2008
|Jun 8, 2010
|Lockheed Martin Corporation
|Hollow core waveguide for laser generation of ultrasonic waves
|Dec 4, 2006
|Jun 22, 2010
|Implicitcare, Llc
|Necklift procedure and instruments for performing same
|Dec 4, 2007
|Nov 16, 2010
|Implicitcare, Llc
|Surgical threading device and method for using same
|Dec 4, 2007
|Nov 30, 2010
|Implicitcare, Llc
|Necklift procedure and instruments for performing same
|Dec 4, 2007
|Mar 29, 2011
|Implicitcare, Llc
|Surgical instrument docking device
|Oct 2, 2008
|Aug 2, 2011
|Omniguide, Inc.
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Sep 18, 2008
|Sep 27, 2011
|Implicitcare, Llc
|Surgical threading device and method for using same
|Oct 24, 2007
|Jan 31, 2012
|Tarek Ahmed Nabil Abou El Kheir
|Endoscopic system and method for therapeutic applications and obtaining 3-dimensional human vision simulated imaging with real dynamic convergence
|Oct 17, 2007
|Feb 14, 2012
|Dornier Medtech Laser Gmbh
|Light guide
|Jun 18, 2007
|Apr 17, 2012
|Ethicon Endo-Surgery, Inc.
|Methods and devices for repairing damaged or diseased tissue using a scanning beam assembly
|Jun 9, 2008
|May 29, 2012
|Cynosure, Inc.
|Thermal surgical monitoring
|Mar 2, 2006
|Oct 2, 2012
|Omniguide, Inc.
|Photonic crystal fibers having a preferred bending plane and systems that use such fibers
|Aug 18, 2008
|Oct 23, 2012
|Reliant Technologies, Inc.
|Adaptive control of optical pulses for laser medicine
|Jun 21, 2011
|Nov 27, 2012
|Omniguide, Inc.
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Apr 28, 2004
|Mar 12, 2013
|Medtronic, Inc.
|Papillary muscle stimulation
|Jan 12, 2012
|Jun 25, 2013
|Cheetah Omni, Llc
|System and method for voice control of medical devices
|May 31, 2011
|Feb 18, 2014
|Vanderbilt University
|Apparatus and method for real-time imaging and monitoring of an electrosurgical procedure
|Jan 25, 2013
|Mar 11, 2014
|Omni Medsci, Inc.
|Broadband or mid-infrared fiber light sources
|Jan 31, 2013
|Jun 24, 2014
|Omniguide, Inc.
|Medical system including a flexible waveguide mechanically coupled to an actuator
|Dec 4, 2006
|Sep 9, 2014
|Implicitcare, Llc
|Surgical tape and method for using same
|Feb 15, 2008
|Dec 23, 2014
|Palomar Medical Technologies, Llc
|Method and apparatus for photothermal treatment of tissue at depth
|Sep 23, 2011
|Feb 10, 2015
|Implicitcare, Llc
|Surgical threading device and method for using same
|Nov 5, 2013
|Mar 3, 2015
|Omni Medsci, Inc.
|Broadband or mid-infrared fiber light sources
|Feb 18, 2014
|Apr 21, 2015
|Vanderbilt University
|Apparatus and method for real-time imaging and monitoring of an electrosurgical procedure
|Aug 3, 2009
|May 12, 2015
|Cynosure, Inc.
|Picosecond laser apparatus and methods for its operation and use
|Dec 7, 2012
|May 19, 2015
|Implicitcare, Llc
|Surgical threading device with removable suture
|Dec 13, 2010
|Jun 23, 2015
|Omni Guide, Inc.
|Two-part surgical waveguide
|Feb 21, 2014
|Jul 7, 2015
|Omni Medsci, Inc.
|Broadband or mid-infrared fiber light sources
|Sep 22, 2006
|Aug 18, 2015
|The Invention Science Fund I, Llc
|Switchable sterilizing cutting system
|May 24, 2001
|Sep 19, 2002
|Gregory Murphy
|Sizing apparatus and method for use during ventricular restoration
|May 24, 2001
|Sep 19, 2002
|Gregory Murphy
|Ventricular restoration shaping apparatus and method of use
|May 24, 2001
|Sep 19, 2002
|Gregory Murphy
|Ventricular restoration patch apparatus and method of use
|Jan 10, 2002
|Oct 3, 2002
|Osaka University
|Method for processing cells
|Sep 29, 2003
|Jun 17, 2004
|Dornier Medtech Laser Gmbh
|Laser with intelligent therapeutic fiber
|Apr 22, 2004
|Oct 7, 2004
|Haan David Jon
|Method of ablating biological material with electromagnetic radiation delivered by an optical fiber
|Jan 23, 2004
|Nov 11, 2004
|Oded Nahleili
|System and method for pulverizing stones and scar removal in soft tissues
|Apr 28, 2004
|Nov 18, 2004
|Medtronic, Inc.
|Papillary muscle stimulation
|Mar 1, 2004
|Dec 2, 2004
|Mitta Suresh
|Method and device for percutaneous surgical ventricular repair
|Sep 5, 2002
|Dec 9, 2004
|Chase Medical, Lp
|Method and device for endoscopic surgical ventricular repair
|Jun 30, 2004
|Jan 20, 2005
|Paithankar Dilip Y.
|Endovascular treatment of a blood vessel using a light source
|Dec 8, 2004
|May 12, 2005
|Cali Douglas S.
|Method of cutting material for use in implantable medical device
|Apr 8, 2005
|Nov 24, 2005
|Burak Temelkuran
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Apr 8, 2005
|Nov 24, 2005
|Burak Temelkuran
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Apr 8, 2005
|Nov 24, 2005
|Burak Temelkuran
|Photonic crystal fibers and medical systems including photonic crystal fibers
|Apr 25, 2005
|Dec 15, 2005
|Gregory Murphy
|Kit and method for use during ventricular restoration
|Jun 29, 2004
|Dec 29, 2005
|Howard Root
|Laser fiber for endovenous therapy having a shielded distal tip
|Jan 22, 2004
|Mar 9, 2006
|Ramot At Tel Aviv University Ltd.
|Minimally invasive control surgical system with feedback
|Jul 14, 2005
|Apr 20, 2006
|Sialo-Lite Ltd.
|System and method for salivary stones removal and joint arthroscopy
|Nov 22, 2004
|May 25, 2006
|Kihong Kwon
|Apparatus and method for performing laser-assisted vascular anastomoses
|Oct 24, 2005
|Jun 8, 2006
|Bommannan D B
|Apparatus and method to treat heart disease using lasers to form microchannels
|Oct 6, 2005
|Jun 29, 2006
|Chase Medical, L.P.
|Ventricular restoration shaping apparatus and method of use
|Dec 29, 2003
|Aug 17, 2006
|Omid Kermani
|Mar 29, 2006
|Oct 26, 2006
|Hanzhang Zhu
|Series of closed operation accupotome
|Apr 18, 2006
|Jan 18, 2007
|Dornier Medtech Laser Gmbh
|Optical fibre
|Sep 13, 2006
|Mar 1, 2007
|Branson Ultrasonics Corporation
|Waveguide for plastics welding using an incoherent infrared light source
|Mar 2, 2006
|Mar 8, 2007
|James Goell
|Photonic crystal fibers having a preferred bending plane and systems that use such fibers
|May 10, 2012
|Cheetah Omni, Llc
|System and method for voice control of medical devices
|Nov 15, 2012
|J. Morita Manufacturing Corporation
|External tube, laser transmission path, and laser treatment tool
|May 31, 2011
|Dec 6, 2012
|Karen Joos
|Apparatus and method for real-time imaging and monitoring of an electrosurgical procedure
|Dec 13, 2010
|Mar 14, 2013
|Omniguide, Inc.
|Two-part surgical waveguide
|Mar 14, 2013
|Mar 20, 2014
|The Spectranetics Corporation
|Tissue slitting methods and systems
|Nov 11, 2013
|May 14, 2015
|General Electric Company
|Optical gas sensor
|Oct 6, 2000
|Apr 19, 2001
|Advanced Res & Tech Inst
|Apparatus and method for non-invasive myocardial revascularization
|Oct 18, 2000
|May 3, 2001
|Scimed Life Systems Inc
|Guided injection device
|Jan 18, 2007
|Jul 26, 2007
|James C Chen
|Method and apparatus for light-activated drug therapy
|Jan 18, 2007
|Jan 31, 2008
|James C Chen
|Method and apparatus for light-activated drug therapy
|Sep 20, 2007
|Apr 3, 2008
|Edward S Boyden
|Sterilizing cutting system
|Jun 9, 2008
|Dec 18, 2008
|Cynosure Inc
|Surgical waveguide
|U.S. Classification
|606/10, 606/13, 606/17
|International Classification
|Cooperative Classification
|European Classification
|Feb 8, 1999
Owner name: CLINICON CORPORATION, CALIFORNIA
Free format text: ASSIGNMENT OF ASSIGNORS INTEREST;ASSIGNOR:BRAUER, FRITZ;REEL/FRAME:009761/0322
Effective date: 19990203
|Mar 13, 2003
|Fee payment
Year of fee payment: 4
|Apr 2, 2003
|Maintenance fee reminder mailed
|Apr 4, 2007
|Maintenance fee reminder mailed
|Sep 10, 2007
|Surcharge for late payment
Year of fee payment: 7
|Sep 10, 2007
|Fee payment
Year of fee payment: 8
|Mar 3, 2011
|Fee payment
Year of fee payment: 12


text:
The Human Aura
Astral Colors and Thought Forms
The dictionaries define the word aura as: "Any subtle, invisible emanation or exhalation." The English authorities, as a rule, attribute the origin of the word to a Latin term meaning "air," but the Hindu authorities insist that it had its origin in the Sanscrit root Ar, meaning the spoke of a wheel, the significance being perceived when we remember the fact that the human aura radiates from the body of the individual in a manner similar to the radiation of the spokes of a wheel from the hub thereof. The Sanscrit origin of the term is the one preferred by occultists, although it will be seen that the idea of an aerial emanation, indicated by the Latin root, is not foreign to the real significance of the term.
Be the real origin of the term what it may, the idea of the human aura is one upon which all occultists are in full agreement and harmony, and the mention of which is found in all works upon the general subject of occultism. So we shall begin by a consideration of the main conception thereof, as held by all advanced occultists, ancient and modern, omitting little points of theoretical variance between the different schools.
Briefly, then, the human aura may be described as a fine, ethereal radiation or emanation surrounding each and every living human being. It extends from two to three feet, in all directions, from the body. It assumes an oval shape - a great egg-shaped nebula surrounding the body on all sides for a distance of two or three feet. This aura is sometimes referred to, in ordinary terms, as the "psychic atmosphere" of a person, or as his "magnetic atmosphere."
This atmosphere or aura is apparent to a large percentage of persons in the sense of the psychic awareness generally called "feeling," though the term is not a clear one. The majority of persons are more or less aware of that subtle something about the personality of others, which can be sensed or felt in a clear though unusual way when the other persons are near by, even though they may be out of the range of the vision. Being outside of the ordinary range of the five senses, we are apt to feel that there is something queer or uncanny about these feelings of projected personality. But every person, deep in his heart, knows them to be realities and admits their effect upon his impressions regarding the persons from whom they emanate. Even small children, infants even, perceive this influence, and respond to it in the matter of likes and dislikes.less
Read online, or download in secure EPUB or secure PDF format
Title: The Human Aura
Author: Swami Panchadasi
More Body Mind
The Alchemist 2015 US$ 9.99 208 pages
E-Squared 2013 US$ 6.99 194 pages
Man's Search For Meaning 2015 US$ 14.00
The Untethered Soul 2007 US$ 16.95 200 pages

subset: commoncrawl


text:
50-Unit Monday Night Side/Total ParlayI have worked overtime on this one and concluded it is the perfect spot for a knockout 50-unit side/total parlay - 20 units on the winner, 20 units on the total and 10-units on the parlay.
15-Unit Best Bets Club College Football PlayI closed out last week with a winning 50-unit side/total parlay on the Pittsburgh Steelers and the Under Monday night and am opening this week with a 15-unit Best Bets Football Investment Club play on the nationally-televised (ESPN2) Arkansas State (2-3) at South Alabama (3-2) game.
Kelso Octoberfest FootballKelso Sturgeon is THE man when it comes to finding the games most worth betting on: games with the biggest hidden edges...games where the team that is dead certain to win has been underrated by at least two touchdowns! Such games DO exist.
Major League Baseball PlayoffsI continued my winning run in the Major League Baseball Playoffs yesterday, winning a 10-unit play on the underdog Kansas City Royals (+115) with their 9-6 come-from-behind victory over the Houston Astros while losing a totals bet (under 7.5) on the Chicago Cubs-St. Louis Cardinals game.
The Pros vs. Joes Debate
Kelso's Advanced Sports Betting: The Pros vs. Joe's DebateIt's becoming more common in the national media and on social media for people in the sports betting industry to talk about the Pros vs. Joe's divide, or sharps vs. squares. Same thing. What are the professional wagerers betting? When are they opposite what the general public is betting?Today I want to make that a point of focus for you regulars here in my College of Advanced Sports Betting and Handicapping. You're surely coming across these discussions yourself. If that hasn't happened to you yet...it will soon. The media is still getting its feet wet in terms of knowing how to present relevant sports gambling information. This is a simple way for them to create the illusion of "insider" access without getting too hardcore.
Handicapping MLB Divisional Rounds
Kelso's Advanced Sports Betting: Handicapping MLB's Divisional RoundsOnce the Wildcard play-in games are taken care of, baseball handicappers will be trying to pick winners in the best-3-of-5 divisional rounds that begin Thursday. It's going to be a busy week as things get rolling. So, be sure you regular students here in my College of Advanced Sports Betting and Handicapping have your attack planned in advance.STARTING PITCHERS
You only want to invest in pitchers who have proven they can control their own destiny when on the mound. That usually means high strikeout guys. But, there may some situations that pop up where fly ball pitchers make sense in a spacious park or in cool conditions...or a decent lefty is on the mound against an offense that doesn't hit lefties well.
Exclusive Coverage of all NFL 10/13/2015
Cardinals sign Dwight Freeney, place LB Kenny Demens on IR
TEMPE, Ariz. (AP) The Arizona Cardinals confirmed the signing of veteran defensive end/outside linebacker Dwight Freeney and placed linebacker Kenny Demens on injured reserve Tuesday.
Exclusive Coverage of all College Football 10/13/2015
West Virginia-Baylor Preview
A loss to West Virginia last year cost Baylor a chance at a national title, and coach Art Briles insists the No. 2 Bears aren't looking for revenge.


text:
difference between '12 vs '13 Rome Mod Rocker
Did they make any improvements on the board. I was looking at getting a mod rocker and found last years for about $200 cheaper but was wondering if the board improved at all from last years.
|All times are GMT -5. The time now is 11:34 AM.
Powered by vBulletin® Version 3.8.7
Copyright ©2000 - 2015, vBulletin Solutions, Inc.
Content Relevant URLs by vBSEO 3.6.0 PL2


text:
genesis energy l.p.
(GEL:New York Consolidated)
Last $43.66 USD
Change Today +0.62 / 1.44%
Volume 391.9K
GEL On Other Exchanges
As of 4:15 PM 10/7/15 All times are local (Market data is delayed by at least 15 minutes).
BOARD MEMBERS AFFILIATED WITH James Ellis Davison Jr.*
Director of Genesis Energy,LLC and Member of Governance, Compensation & Business Development Committee
*Data is at least as current as the most recent Definitive Proxy.
|Recently Viewed
MOST CONNECTED PEOPLE TO James Ellis Davison Jr.
|Kenneth M. Jastrow
|156 Relationships
|S. James Nelson
|34 Relationships
|Corbin J. Robertson
|33 Relationships
|Jack T. Taylor
|32 Relationships
|Sharilyn S. Gasaway
|30 Relationships
Sponsored Financial Commentaries
Sponsored Links
Report Data Issue
To contact GENESIS ENERGY L.P., please visit . Company data is provided by Capital IQ. Please use this form to report any data issues.
Please enter your information in the following field(s):
Your requested update has been submitted
Our data partners will research the update request and update the information on this page if necessary. Research and follow-up could take several weeks. If you have questions, you can contact them at email@example.com.


text:
UStec Granted Wireless Wallport Patent
With wireless taking over the world it is only a matter of time before houses and buildings have wireless relays integrated into rooms. This is where UStec comes in. They were granted a patent on their Wallport technology, which is essentially that. Integrated wireless relays in every room for better signals and no… »


text:
Before playing, musician Raven Wolf transformed KDHX's small recording studio into sacred space. Raven only performs surrounded by instruments and special objects: saxophones, drums, a teapot, flowers from his grandmother's gravesite and a flute made of carved wood, with a raven on one end and a wolf on the other.
Raven plays from the heart, not improvising, but instead letting the sound come from a mysterious place within him. As he plays, Dwight Bitikofer recites or chants poetry that is full of straightforward images and little stories: a Halloween drive around St. Louis, an animal by the side of the road, a train.
Dwight's earnest poetry gives roots to Raven's otherworldly sound; they perform in a place where dreams meet the earth. Together, they call their collaboration "Spiritual Jazz Meets PoJazz."
The two are well-known figures in St. Louis. Wolf performs in front of Vintage Vinyl or at Soulard Market often, along with other stints in Missouri, including Columbia and Kansas City's Farmers Market. Dwight is an active reader and organizer in the St. Louis lit community and established the First Friday Notes reading at the Whole Foods in Town and Country.
All photos by Virginia Harold


text:
Uptown 3 Theatre Movie Showtimes
4341 South Highway 92
Sierra Vista AZ 85650 map
Accessible to Disabled Audiences
Prices:adult: 7.25, senior: 5.00, child: 5.00
12:45pm, 3:45pm, 6:45pm
1:00pm, 4:00pm, 7:00pm
1:00pm, 7:00pm
User reviews on Uptown 3 Theatre
I do wish this website would remove the old, outdated reviews of this theatre that are so negative. They have been on this website for way too long. Everything has changed for the better at the Uptown 3 Theatre in the past couple of years. The theater has new seats and things are clean and comfortable. The staff are always friendly and helpful. The sound and picture quality are both very good. And they definitely play some of the better movies that come to Sierra Vista. We are lucky to have this small, independent theatre in our community.
Whoah. I went to Uptown 3 Theatre, and that's the last time I spend money at that dump. It smells like piss. It's old and run down. How that place gets first-run movies is beyond me. Also, the clientele were ghetto as ghetto can be. Kids running around. People loud and obnoxious. Nope. Never again.
Oh, and the fact that I'd take the time to create an account just to complain about this place will tell you... It's horrible!
They sold us tickets to "The Master" without having the courtesy to tell us their copy was not the right one for their projector. The tops and sides of the film were truncated. Their "solution" was to say we could come back and see another film for free. Funny thing, though, at first we thought the scenes with the character's heads cut off were an intentional part of this "artsy" film.
Just saw "The Artist." FINALLY Sierra Vista is getting some culture and foreign films. I am tired of the never ending super natural, monster, violence, war games and cartoon flicks. Not everyone around here is of the "under the age of 12" mind frame category. Keep up the good work Uptown, and you will be assured more patronage.
Uptown has started to bring in a "classier" set of movies.......Hugo........The Artist....
If this continues it will provide a good compliment to the more general fare at The Mall....
Good Job !!
I took my granddaughter to see "Cars 2" and was bitterly disappointed. The quality of the video was abysmal! It was blurry, the contrast was poor, there was no sharpness, nothing jumped off the screen, and at times it did not appear to be in 3D at all! It is obvious this theater does not have the correct equipment to show a 3D movie. Why in the world would the distributors allow this filthy theater to have a first run movie? It would be well worth the trip to Tucson to see this movie as the Imagineers at Disney intended it to be seen! I might just as well have waited to see this on DVD.
Stinks, stinks, stinks....that says it all. I hate going there and spending ANY money, I'd almost rather drive to Tucson to see a movie I can't see anywhere else or wait for it on video.
The Uptown 3 smells like urine to me. Whatever the smell actually is, you have to have a strong stomach to stay and get used to it. The theater is dirty and the health department really should take a look at the filth in and around the concession stand and in the rest rooms. We went once and would never go again even if it was the only theater in town. I was afraid I'd walk away with a disease from just going in and sitting down. YUCK doesn't even begin to describe the theater
It's always very upsetting when the A-list movie me and my family want to see is playing at the Uptown 3 Theatre. Going to that place is like walking into the ghetto. The theatre always smells, the floors and chairs are always sticky and the consession stand is a JOKE!!
Any type of profit that theatre makes is pocketed other then putting money towards any type of cleaning or god forbid any updated changes.
I have lived in Sierra Vista for over 20years and that place has not changed one bit.
Going to the movies and spending your money to see a movie on the big screen should be enjoyable and fun. Uptown 3 theatre makes u leaving the place feeling dirty.
I advise waiting for the movie to come out on DVD then wasting your money going there!!
Alright so I find the reviews in general so far to be hit and miss. Overall the Uptown 3 theater is just a place to go and watch a movie. They match their prices in just about every way to Cinemark without giving half the experience. They pop the popcorn early in the day and keep it covered with a trash bag. The "game room" is outdated and usually busted. The bathrooms usually have something out of order and the people there almost never smile. Cinemark isn't that great either, they don't bring in enough movies, they constantly have trouble with the equipment and almost never do they use all of their speakers except for big releases. Their is however a deal between the two that lets Uptown get some of the higher projected movie releases. Not sure who the deal was made through but having worked at Cinemark I do know it exists.


text:
Statistics: prosecution for domestic violence cases 06.02.08
Successful prosecutions for domestic violence cases rose from 46% (of all cases brought before the courts) in a December 2003 'snapshot' to 65% during the whole of 2006-07. By September 2007, successful prosecutions had reached 68%. Vernon Coaker MP (in response to PQ from Jim Cunningham MP) attributed this rise to a number of government initiatives including:
- The National Delivery Plan for Domestic Violence which has an objective to improve the criminal justice response to domestic violence, including actions to increase reporting, arrests and conviction rates for domestic violence.
- The continued expansion of the Specialist Domestic Violence Court (SDVC) Programme. From April 2007, 64 SDVCs were operational, with more planned which will bring the total to over 100.
- Guidance and training is being rolled out to all police officers and Crown prosecutors to improve investigations and increase successful prosecutions for domestic violence.
- Domestic Violence Co-ordinators have been identified in all police force and Crown Prosecution Service areas to co-ordinate individual agencies' responses to domestic violence.
- Funding has been made available for Independent Domestic Violence Advisers, whose involvement with victims of domestic violence has been shown to reduce the number of victims unwilling to support a prosecution.


text:
Exploring the Futurist Manifesto
Claudia Calirman
Wednesday, August 21, 2013, 1:30 p.m.
The John Hay and Betsey Whitney Painting and Sculpture Gallery, Gallery 3, fifth floor
Explore Italian Futurism by taking a closer look at Umberto Boccioni's Dynamism of a Soccer Player (1913), and its elements of speed, danger, energy, racing, and war. Examine other Futurist works by reading excerpts from the first Futurist Manifesto of 1909.
Gallery Sessions, impromptu interactions facilitated by Museum educators that explore the creative process, art history, and the experience of art, take place daily in select galleries. Groups meet in the galleries noted on the schedule. Gallery Sessions are free with Museum admission. No registration is required.
FM headsets for sound amplification are available for all talks.


text:
Timberwolves rookie forward Shabazz Muhammad has been sent home from the NBA's Rookie Transition Program. "USA Today" reports Muhammad violated a rule by bringing a female guest to his hotel room on Tuesday night. He will be fined for the incident. The T'wolves selected Muhammad 14th overall in the draft out of UCLA.
T-Wolves Rookie Disciplined


text:
Becky has spent her entire career cooking and baking, which are also her favorite hobbies outside of work. For her, time spent in the kitchen not only relieves stress, but is lots of fun as well. Becky's love for baking began as a child, standing on a chair next her mom, adding ingredients and mixing up dough.
Get to know the members of the Land O'Lakes Co-op with a seasonal look at family life on the dairy farm.
View our story
Chicken fajitas made with Cajun seasonings give fajitas a new flavor.
Combine Italian seasoning, garlic powder, ground red pepper and pepper in small bowl. Rub onto chicken strips; let stand 15 minutes at room temperature.
Melt butter in 10-inch skillet until sizzling; add chicken. Cook over medium heat, stirring occasionally, 3-5 minutes or until chicken is no longer pink. Add green pepper and onion; continue cooking 4-6 minutes or until vegetables are crisply tender. Add tomatoes; continue cooking 1 minute.
To serve, spoon chicken mixture into warmed tortillas; serve with desired toppings.
*Substitute 1/4 teaspoon each oregano leaves, dried marjoram leaves and dried basil leaves and 1/8 teaspoon rubbed sage.
Calories: 380
Fat: 10g
Cholesterol: 60mg
Sodium: 410mg
Carbohydrates: 45g
Dietary Fiber: 4g
Protein: 26g
When I first found this recipe years ago, it called for mozzarella cheese instead of American cheese for a topping. Made that way, it gets 5 stars. Also, I never used the cilantro; the flavor is just fine without it.
I think it is great with grilled chicken breast.
Email address will not be published
How Did This Recipe Work Out for You?
Please return to landolakes.com to rate and review this recipe.
Your comments and suggestions are appreciated by others.
This recipe was reprinted from landolakes.com. http://www.landolakes.com/recipe/2699
© 2015 Land O'Lakes, Inc.
Once the temperature drops a few degrees, I'm in full-on fall foods mode. Pumpkin bars, apple crisp, cranberry bread…you name it, I'm making it. However, most of it revolves around sweets. Why doesn't dinner get a fair chance?
More ...
The Simple Rewards® Club is your personal online resource for exclusive offers and information. It's also our way of saying "thank you" for trusting Land O'Lakes and inviting us into your home. Membership is free, so sign up today.
We'll email instructions to the address you used to register.
We've sent a confirmation email to the address associated with your account. Check your email and follow the link within 3 hours in order to complete the password reset process.
If you are already a member, please sign in.
Look for an email soon with instructions to reset your password.
If you did not receive the email, please check your email junk folder (just in case) or contact us.
Hi, I'm Becky. I'm eager to share my best ideas and favorite recipes from my 20+ years in the Land O'Lakes Test Kitchen. I'm also excited to help with any questions you have about cooking and baking with Land O Lakes® products. Some of the questions and answers will be published in our newsletter, The Measuring Cup®. Please use the short form below to ask your questions, or share your tip or memory.
Your question has been submitted.
Your email has been sent. Thanks for sharing this Land O Lakes recipe!


text:
Worship and Prayer
Welcome to the worship and prayer section of our website. Worship is a meeting between God and his people. It is at the heart of our faith. Perhaps you are a visitor or a new member and want to know a little more about worship in the Church of England. Or, perhaps you have been an Anglican for a long time, but want to know more about our customs and traditions in the Diocese of Ely.
Here are a few links to help you find out more about taking part in public worship, the biblical basis for our services, understanding the sacraments and the use of music in worship.
Here are a few links to help you find out more about the biblical basis for Christian prayer, suggest a few useful prayers and introduce you to our daily prayer calendar.
Here you will find useful resources for spirituality Quiet Days and Retreats and also Spiritual Accompaniment, having someone alongside you as you explore your relationship with God.
It also includes information on the Simieon Centre for Prayers based in Ridley Hall, Cambridge.
This section of the website is concerned with the ministry of healing and wholeness.
Music education and training in the diocese is overseen by the Ely RSCM Committee (Royal School of Church Music).
Baptisms, Weddings and Funerals
The Church of England helps to celebrate and commemorate many of the milestones on the journey through life; these include weddings, funerals, and also baptism and confirmation services. If you wish to find out more about these, the first step is to contact either your local parish priest, or a Church of England chaplain. They will be able to tell you more and arrange for a meeting if you then wish to take things further.
Ely Diocesan Association of Church Bell Ringers
© 2015 Diocese of Ely, a Fairtrade Diocese


text:
Freddy's Nightmares
From Wikiquote
Freddy's Nightmares Is a T.V. series staring Robert Englund as Freddy Krueger, the main character From the A Nightmare on Elm Street films.
Season 1[edit]
No More Mr. Nice Guy [1.1][edit]
- Lt. Blocker: You're dead!
- Freddy Krueger: Big deal!
- Freddy Krueger: (to Blocker, restrained in the dentist's chair) Oh, those teeth! Tsk, tsk, tsk! I'm afraid they'll ALL have to go! You tell Freddy when it doesn't hurt!
- Freddy Krueger: (voiceover for postcard) I'm burning in Hell. Wish you were here.
It's a Miserable Life [1.2][edit]
Killer Instinct [1.3][edit]
- Freddy: Game ain't over 'til the fat lady... dies.
Freddy's Tricks and Treats [1.4][edit]
- Freddy: Two for one day! [Freddy kills Zack and moves toward Marsha]
Judy Miller, Come on Down [1.5][edit]
Saturday Night Special [1.6][edit]
See also[edit]
External links[edit]
- Freddy's Nightmares quotes at the Internet Movie Database


text:
Local Sports Briefs: Sept. 3
Hernandez delivers walk-off hit
Rookie Bryant Hernandez notched his first walk-off hit as a professional on Tuesday night to lead the Ogden Raptors to a 6-5 victory over Idaho Falls in extra innings.
Hernandez, a St. Bonaventure High graduate, cracked a two-out line drive down the right-field line in the bottom of the 12th inning to score Thousand Oaks High graduate David Iden with the tying run and Nick Akins with the winning run.
The game lasted exactly four hours.
Fall ball tryouts: The Valley Titans club team will hold tryouts today from 6:45 to 8:30 p.m. on the Somis Pony field. The coaches are Sean Collins (Kansas City Royals organization) and Derron Spiller (St. Louis Cardinals organization). Al Medina is the general manager.
Information: Medina at 701-9855 or e-mail email@example.com.
Ventura prevails over Citrus
The Pirates defeated visiting Citrus in the season opener winning in five games. The final scores were 25-19, 14-25, 17-25, 25-18, 15-10. The Pirates host Long Beach on Friday at 6 p.m.
Bengals start registration at PAL
The Bengals will start registration today at 6:30 p.m. at the Oxnard PAL classroom building across from Fire Station No. 1 at the corner of Fifth and K streets in Oxnard. Registration will be taken every Tuesday and Thursday during September.
Boys and girls ages 5-14 are welcome and trial programs are available. The club is looking for additional coaches this season.
Information: Jim Stych at 320-1904 or Eric Bautista at 824-4805.
Cougar Classic helps basketball teams
The seventh annual Cougar Golf Classic Oct. 3 will benefit the Ventura High boys' and girls' basketball programs. The tournament will be played Oct. 3 at Elkins Ranch in Fillmore,
Entry deadline is Sept. 21. Proceeds will fund new uniforms, training equipment, tournament and summer travel expenses.
There will be a silent auction, raffle and dinner. Sponsorships are available at all levels of participation.
Information: http://www.cougarclassic.net or call Ann or Dan Larson at 643-7669.
Subscribe to the Ventura County Star
Need Help? Call us at 1-877-710-6182.
Monday-Friday: 6am-3pm / Saturday: 6:30am-10:30am / Sunday: 7am-11am


text:
GRAND RAPIDS, Mich. (WZZM) - If you're expecting a child in the next several months, here's something you'll want to know - several Grand Rapids hospitals are joining a movement to ban formula samples from their birthing units in an effort to promote breast feeding.
It's part of a world-wide effort to help promote breast feeding.
By 2020 the World Health Organization (WHO)wants 81% of new moms' breast feeding as part of their Healthy People Initiative.
What new moms will notice is that the decision to formula feed will be met with a stronger encouragement towards breast feeding. "What they will hear from us is, 'well these are the reasons.' Again it's about education and they are making an informed choice."
Mary Schubert is the director of Saint Mary's Birthing Center. She is helping the hospital move towards a certification as Baby Friendly.
One of the requirements is a nearly 100% rate of breast feeding. "We want to get them out of the hospital still breast feeding."
And that's not the only change
"Now the babies stay with mom and dad. There's no separation between baby and parents, so they are learning the babies cues at an earlier point."
Schubert says in April, Saint Mary's began something called Skin to Skin to help promote not only bonding, but better breast feeding success.
"Now we put the baby right on mom's chest. So for the first hour mom and baby are right tight together skin to skin and the baby nurses within the first hour."
And that's exactly what happened for Janine Brookhouse and her daughter Molly. "She came out and she was already sucking her thumb and ready to eat. She was eating within the first 15 minutes."
New moms will still be allowed to formula feed, Schubert adds. Moms will still make the ultimate decision. "As far as when a mom says this is my choice, that is her choice to make."
Spectrum Health is also on track to stop the use of formula samples. They plan to end that tradition by this time next year.
Metro Health says that they will continue to encourage breast feeding but have no plans at this time to stop formula samples.
The states of Oklahoma, Massachusettes and Rhode Island have already banned free formula sample from all their hospitals.