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Four-chamber pacing system for optimizing cardiac output and determining heart condition
A pacing system and method for providing multiple chamber pacing of a patient's heart, and in particular, pacing programmed for treatment of various forms of heart failure. The system utilizes impedance sensing for determining optimum pacing parameters, e.g., for pacing the left ventricle so that left heart output is maximized. The impedance sensing also is used for determination of arrhythmias or progression of heart failure. Impedance sensing is provided for between selected pairs of the four chambers, to enable optimizing of information for control and diagnosis. In a preferred embodiment of the invention, impedance measurements are obtained for determining the timing of right heart valve closure or right ventricular contractions, and the timing of delivery of left ventricular pace pulses is adjusted so as to optimally synchronize left ventricular pacing with the right ventricular contractions. Impedance sensing in the left heart also provides timing of mechanical contraction, and the pacemaker controls pacing to maintain bi-ventricular mechanical synchronization adjusted for maximum cardiac output.
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This application is a divisional of and claims the benefit of U.S. application Ser. No. 09/799,710, filed Mar 7, 2001, entitled "FOUR-CHAMBER PACING SYSTEM FOR OPTIMIZING CARDIAC OUTPUT AND DETERMINING HEART CONDITION" to Leinders et al., now abandoned, which is a divisional of and claims, the benefit of U.S. Ser. No. 08/890,427 commonly assigned U.S. Pat. No. 6,070,100, filed Dec. 15, 1997, entitled "PACING SYSTEM FOR OPTIMIZING CARDIAC OUTPUT AND DETERMINING HEART CONDITION" to Bakels et al.FIELD OF THE INVENTION
This invention relates to cardiac pacing systems and, more particularly, to four-chamber pacing systems with sensors for measuring cardiac mechanical characteristics so as to improve cardiac output for congestive heart failure and other patients.BACKGROUND OF THE INVENTION
Congestive heart failure (CHF) is defined generally as the inability of the heart to deliver enough blood to the peripheral tissues to meet metabolic demands. Frequently CHF is manifested by left heart dysfunction, but it can have a variety of sources. For example, CHF patients may have any one of several different conduction defects. The natural electrical activation system through the heart involves sequential events starting with the sino-atrial (SA) node, and continuing through the atrial conduction pathways of Bachmann's bundle and internodal tracts at the atrial level, followed by the atrio-ventricular (AV) node, Common Bundle of His, right and left bundle branches, and final distribution to the distal myocardial terminals via the Purkinje fiber network. A common type of intra-atrial conduction defect is known as intra-atrial block (IAB), a condition where the atrial activation is delayed in getting from the right atrium to the left atrium. In left bundle branch block (LBBB) and right bundle branch block (RBBB), the activation signals are not conducted in a normal fashion along the right or left bundle branches respectively. Thus, in a patient with bundle branch block, the activation of the ventricle is slowed, and the QRS is seen to widen due to the increased time for the activation to traverse the conduction path.
CHF manifested by such conduction defects and/or other cardiomyopathies are the object of considerable research into treatments for improving cardiac output. For example, drug companies have recognized CHF as a market opportunity, and are conducting extensive clinical studies organized to test the outcome of newly developed drugs in terms of improving cardiac performance in these patients. Likewise, it is known generally that four-chamber cardiac pacing is feasible, and can provide significant improvement for patients having left atrial-ventricular dysfunction, or other forms of cardiac heart failure. While there has been relatively little commercialization of four-chamber pacing, the hypothesis remains that cardiac pump function can clearly be improved by such pacing.
The benefits of four-chamber pacing generally have been disclosed and published in the literature. Cazeau et al., PACE, Vol. 17, November 1994, Part II, pp. 1974-1979, disclose investigations leading to the conclusion that four-chamber pacing is feasible, and that in patients with evidence of interventricular dyssynchrony, a better mechanical activation process can be obtained by resynchronizing depolarization of the right and left ventricles, and optimizing the AV sequence on both sides of the heart. In the patent literature, U.S. Pat. No. 4,928,688 is representative of a system for simultaneous left ventricular (LV) and right ventricular (RV) pacing; natural ventricular depolarizations are sensed in both chambers, if one chamber contracts but the other one does not within a window of up to 5-10 ms, then the non-contracting ventricular chamber is paced.
In addition to the above-mentioned disclosures concerning the advantages of substantially simultaneous or synchronous pacing of the two ventricles, it is known that there is an advantage to synchronous pacing of the left atrium and the right atrium for patients with IAB, inter-atrial block. In a normal heart, atrial activation initiates with the SA node, located in the right atrial wall. In a patient with IAB, the activation is slow being transferred over to the left atrium, and as a result the left atrium may be triggered to contract up to 90 ms later than the right atrium. It can be seen that if contractions in the left ventricle and the right ventricle are about the same time, then left AV synchrony is way off, with the left ventricle not having adequate time to fill up. The advantage of synchronous pacing of the two atria for patients with IAB is disclosed at AHA 1991, Abstract from 64th Scientific Sessions, "Simultaneous Dual Atrium Pacing in High Degree Inter-Atrial Blocks: Hemodynamic Results," Daubert et al., No. 1804. Further, it is known that patients with IAB are susceptible to retrograde activation of the left atrium, with resulting atrial tachycardia. Atrial resynchronization through pacing of the atria can be effective in treating the situation. PACE, Vol. 14, April 1991, Part II, p. 648, "Prevention of Atrial Tachyarrythmias Related to Inter-Atrial Block By Permanent Atrial Resynchronization," Mabo et al., No. 122. For patients with this condition, a criterion for pacing is to deliver a left atrial stimulus before the natural depolarization arrives in the left atrium.
In view of the published literature, it is observed that in CHF patients improved pump function can be achieved by increasing the filling time of the left ventricle, i.e., improving the left AV delay, and specifically the left heart mechanical AV delay (MAVD); decreasing mitral valve regurgitation, (back flow of blood through the nearly closed valve) by triggering contraction of the left ventricle when and as it becomes filled; and normalizing the left ventricular activation pattern, i.e., the time sequence of left atrial contraction relative to right atrial contraction. More specifically, for a cardiac pacing system used for treating a CHF patient, the aim is to capture the left atrium; optimize the left AV delay so as to properly fill the left ventricle and provide a more normal AV delay; and activate the left ventricle as much as possible in accordance with the natural propagation path of a healthy left heart. Particularly, left ventricular timing with respect to the left atrial contraction is crucial for improving cardiac output. The mechanical closure point of the left, or mitral valve, is a crucial moment which needs to be adjusted by programming of the left AV delay. Correct programming of this variable is key for optimizing the filling of the left ventricle, and optimizing ejection fraction, or cardiac output (CO).
An observation which is important to this invention is that the exact timing of mechanical events are important for properly controlling pacing so as to optimize left ventricular output. Specifically, it is known that actual contraction of one ventricular chamber before the other has the effect of moving the septum so as to impair full contraction in the later activated chamber. Thus, while concurrent or simultaneous pacing of the left and right ventricle may achieve a significant improvement for CHF patients, it is an aim of this invention to provide for pacing of the two ventricles in such a manner that the actual mechanical contraction of the left ventricle, with the consequent closing of the valve, occurs in a desired time relationship with respect to the mechanical contraction of the right ventricle and closing of the right value. For example, if conduction paths in the left ventricle are impaired, delivering a pacing stimulus to the left ventricle at precisely the same time as to the right ventricle may nonetheless result in left ventricular contraction being slightly delayed with respect to the right ventricular contraction. As a consequence, it is important for this invention to provide a technique for measurement of mechanical events, such as a mechanical closure point of each of the ventricles, so as to be able to accurately program the sequence of pacing to achieve the desired dual ventricular pacing which optimizes ejection fraction, or cardiac output, for the individual patient.
In view of the above-noted importance of measuring mechanical events, such as mitral or tricuspid valve closure, and the importance of measuring cardiac output, it is necessary for the pacing system of this invention to employ sensors which can provide this information. It is known to use impedance sensors in pacing systems, for obtaining information concerning cardiac function. For example, reference is made to U.S. Pat. No. 5,501,702, incorporated herein by reference, which discloses making impedance measurements from different electrode combinations. In such system, a plurality of pace/sense electrodes are disposed at respective locations, and different impedance measurements are made on a time/multiplexing basis. As set forth in the referenced patent, the measurement of the impedance present between two or more sensing locations is referred to "rheography." A rheographic, or impedance measurement involves delivering a constant current pulse between two "source" electrodes, such that the current is conducted through some region of the patient's tissue, and then measuring the voltage differential between two "recording" electrodes to determine the impedance therebetween, the voltage differential arising from the conduction of the current pulse through the tissue or fluid between the two recording electrodes. The referenced patent discloses using rheography for measuring changes in the patient's thoracic cavity; respiration rate; pre-ejection interval; stroke volume; and heart tissue contractility. It is also known to use this technique of four point impedance measurements, applied thoracically, for measuring small impedance changes during the cardiac cycle, and extracting the first time derivative of the impedance change, dZ/dt. It has been found that a substantially linear relation exists between peak dZ/dt and peak cardiac ejection rate, providing the basis for obtaining a measure of cardiac output. See also U.S. Pat. No. 4,303,075, disclosing a system for measuring impedance between a pair of electrodes connected to or in proximity with the heart, and processing the variations of sensed impedance to develop a measure of stroke volume. The AV delay is then adjusted in an effort to maximize the stroke volume.
Given the demonstrated feasibility of four-chamber cardiac pacing, and the availability of techniques for sensing natural cardiac signals and mechanical events, there nonetheless remains a need for developing a system which is adapted to the cardiac condition of a patient with CHF, so as to provide pacing sequences which are tuned for improving cardiac output, and in particular for improving left heart function. It is a premise of this invention that such a system is founded upon accurate measurements of mechanical events, and use of the timing of such mechanical events to control and program pacing sequences.SUMMARY OF THE INVENTION
It is an overall object of this invention to provide a pacing system for multiple chamber pacing, and in particular, for pacing the patient's left heart in coordination with the electrical activation and mechanical events of the patient's right heart, so as to optimize left heart output. In accordance with this invention, there is provided a four-chamber pacing system, having leads carrying electrodes positioned for pacing and sensing in or on each of the four cardiac chambers. Additionally, the leads are connected to obtain impedance measurements from which accurate timing signals are obtained reflecting mechanical actions, e.g., valve closures, so that accurate timing information is available for controlling electrical activation and resultant mechanical responses for the respective different chambers. The impedance or mechanical sensing determinations are preferably made by multi-plexing through fast switching networks to obtain the desired impedance measurements in different chambers.
In a preferred embodiment, control of four-chamber pacing, and in particular left heart pacing, is based primarily upon initial detection of a spontaneous signal in the right atrium, and upon sensing of mechanical contraction of the right and left ventricles. In a heart with normal right heart function, the right mechanical AV delay is monitored to provide the timing between the initial sensing of right atrial activation (P-wave) and right ventricular mechanical contraction. The left heart is controlled to provide pacing which results in left ventricular mechanical contraction in a desired time relation to the right mechanical contraction; e.g., either simultaneous or just preceding the right mechanical contraction; cardiac output is monitored through impedance measurements, and left ventricular pacing is timed to maximize cardiac output. In patients with intra-atrial block, the left atrium is paced in advance of spontaneous depolarization, and the left AV delay is adjusted so that the mechanical contractions of the left ventricle are timed for optimized cardiac output from the left ventricle.BRIEF DESCRIPTION OF THE DRAWINGS
FIG. 1 is a schematic representation of a system in accordance with this invention, whereby four bipolar leads are provided, the leads being shown carrying bipolar electrodes positioned in each of the respective cardiac chambers.
FIG. 2A is a block diagram of a four channel pacing system in accordance with this invention, for pacing and sensing in each ventricle, and for obtaining impedance signals from the left heart and the right heart; FIG. 2B is a schematic representation of an arrangement in accordance with this invention for detecting left ventricular impedance for determination of cardiac output.
FIG. 3 is a block diagram of a four-chamber pacemaker with the ability to time multiplex impedance measurements, in accordance with this invention.
FIG. 4 is a block diagram of a system implementation in accordance with an embodiment of this invention for controlling left ventricular pacing in a patient with LBBB.
FIG. 5 is a flow diagram for a system implementation in accordance with an embodiment of this invention, for controlling left atrial and ventricular pacing in a patient with IAB.
FIG. 6 is a flow diagram of a routine in accordance with this invention for optimizing bi-ventricular pacing to provide maximum cardiac output.
FIG. 7 is a block schematic of a pacemaker in accordance with this invention for providing selectable four-chamber pacing and cardiac signal sensing, as well as impedance sensing between selected combinations of the four heart chambers.
FIG. 8A is a flow diagram of a process using inter-atrial or inter-ventricular impedance measurements for determination of existence of arrhythmias; FIG. 8B is a flow diagram illustrating a procedure for obtaining atrio-ventricular cross-impedance measurements for obtaining indications of heart failure.DESCRIPTION OF THE PREFERRED EMBODIMENTS
In the description of the preferred embodiments, and with reference to the drawings, the following designations are used:DRAWING DESIGNATION DEFINITION RA right atrium RV right ventricle RH RA and RV LH LA and LV LA left atrium LV left ventricle LAS left atrial sense RAS right atrial sense LAP left atrial pace pulse LVP left ventricular pace pulse RMAVD time interval between RAS and mechanical contraction of RV (as measured, e.g., by valve closure) LMAVD time interval between LAS or LAP and mechanical contraction of LV RAVD time interval between RAS and QRS in RV LAVD time interval between LAS or LAP, and QRS in LV
Referring now to FIG. 1, there is shown a schematic representation of a four-chamber pacing system, illustrating four pacing leads providing bipolar electrodes positioned for pacing and sensing in each of the respective heart chambers, and also for impedance measurements. Pacing lead 38 is positioned conventionally such that its distal end is in the right ventricular apex position. It carries bipolar electrodes 38a and 38b adapted for pacing and sensing; additionally, these electrodes can also be used for impedance sensing as discussed below. Likewise, atrial lead 36 is positioned so that its distal end is positioned within the right atrium, with bipolar electrodes 36a, 36b. Lead 34 is passed through the right atrium, so that its distal end is positioned in the coronary sinus for pacing, sensing and impedance detection through electrodes 34a, b, as shown. Likewise, lead 32 is positioned via the coronary sinus a cardiac vein, e.g., the middle or great cardiac vein, so that distal electrodes 32a and 32b are positioned approximately as shown for pacing, sensing and impedance detection with respect to the left ventricle. The pacing leads are connected to pacemaker 30 in a conventional manner. It is to be understood that each of the four leads can have one or more additional electrodes; however, by using time multiplexing techniques as discussed below and in the referenced U.S. Pat. No. 5,501,702, pacing, sensing and impedance detection can be accomplished with only two electrodes per lead. Referring now to FIGS. 2A and 2B, there is shown a simplified block diagram of a four channel pacemaker in accordance with this invention, having the additional capability of impedance detection to sense valve movement of the left and right ventricles. Although discussion of FIG. 2A is presented with respect to valve movement, it is to be understood that the impedance detection scheme may be altered to detect other mechanical events, such as ventricular wall contraction, in a known manner.
The system of FIG. 2A contains, in the pacemaker, a central processing block 40, indicated as including timing circuitry and a microprocessor, for carrying out logical steps in analyzing received signals, determining when pace pulses should be initiated, etc., in a well known fashion. Referring to the upper left-hand corner of the block diagram, there is shown signal amplifier circuitry 41, for receiving a signal from the right atrium. Electrode 36a is illustrated as providing an input, it being understood that the second input is received either from bipolar electrode 36b, or via an indifferent electrode (the pacemaker can) in the event of unipolar sensing. Likewise, a pulse generator 42, acting under control of block 40, generates right atrial pace pulses for delivery to electrode 36a and either electrode 36b or system ground. In a similar manner, right ventricular pace pulses (RVP) are generated at output stage 43 and connected to electrode 38a, and sensed right ventricular signals are inputted to sense circuitry 44, the output of which is delivered to control block 40. Also illustrated is impedance detector 45, which receives inputs from electrodes 36a, 38a, for delivering information corresponding to right heart valve closure, which timing information is inputted into control block 40. Thus, the system enables pacing and sensing in each chamber, as well as impedance detection to provide an indication of the timing of right heart valve closure, which represents the time of mechanical contraction of the right valve.
Still referring to FIG. 2A, there are shown complementary circuit components for the left atrium and the left ventricle. Output generator stage 47, under control of block 40, delivers left atrial pace pulses (LAP) to stimulate the left atrium through electrode 34a and either electrode 34b or system ground. Inputs from the left atrial lead are connected through input circuitry 46, the output of which is connected through to control block 40. In a similar fashion, output stage 48, under control of block 40, provides left ventricular stimulus pace pulses (LVP) which are delivered across electrode 32a and either electrode 32b or system ground; and left ventricular signals are sensed from lead 32 and inputted to input circuit 49, which provides an output to block 40 indicative of left ventricular signals. Also, dual inputs from the left atrial electrode 34a and left ventricular electrode 32a are inputted into left heart impedance detector 50, which provides timing pulses to block 40 indicative of the timing of left heart (mitral) valve closure. With this arrangement, the pacemaker has the basic timing and cardiac signal information required to program delivery of pace pulses to respective heart chambers in accordance with this invention. Block 40 contains current generators for use in impedance detection; microprocessor or other logic and timing circuitry; and suitable memory for storing data and control routines.
Referring to FIG. 2B, there is shown a diagrammatic sketch of an arrangement for detecting left ventricular impedance change, which is processed in block 40 to obtain an indication of cardiac output. As shown, a current source 52 provides a constant current source across electrode 53 in the right atrium, which suitably can be electrode 36a; and right ventricular electrode 54, which suitably can be electrode 38a. The current source can be pulsed, or it can be multiplexed in a manner as discussed below. Impedance sensors 57 and 58 provide signals representative of impedance changes therebetween, the impedance being a function of blood volume and valve closure, as discussed above. The outputs from electrodes 57, 58 is connected across impedance detector 56, which represents the microprocessor and/or other processing circuitry in block 40 for analyzing the impedance changes and making a determination of cardiac output. As is known, a measure of cardiac output can be obtained by extracting the first time derivative of cyclical impedance changes, dz/dt; a linear relationship exists between peak dz/dt and peak ejection rate.
Referring now to FIG. 3, there is shown a block diagram of a pacemaker 30 in accordance with a preferred embodiment of this invention, for multiplexing connections to electrodes so as to provide for pacing and sensing in any one of the four cardiac chambers, as well as for impedance determinations between respective different lead electrodes. Reference is made U.S. Pat. No. 5,501,702, incorporated herein by reference, for a full discussion of this circuit, and in particular the multiplexing arrangement carried out by switch matrices 68, 70. The pacemaker 30 operates under control of circuitry 62, which may include a microprocessor or custom integrated circuitry, as well as associated memory, in a manner well known in the pacemaker art. Circuitry 62 provides for processing of data, and generation of timing signals as required. Control circuitry 62 is coupled to pace/sense circuitry 64, for processing of signals indicating the detection of electrical cardiac events, e.g., P-waves, R-waves, etc. sensed from conductors which connect electrically to electrodes 32a-38b, as shown. The aforementioned leads are also coupled to a first switch matrix 68 and a second switch matrix 70. Matrix 68 establishes a selectable interconnection between specific ones of the electrodes of leads 32, 34, 36 and 38, and the current source 72, is controlled by circuit 62. In a similar manner, switch matrix 70 establishes a selectable interconnection between lead conductors corresponding to selected electrodes, and impedance detection circuit 74, for the purpose of selecting impedance measurements.
Still referring to FIG. 3, current source 72 receives control signals on line 73 from circuitry 62, and is responsive thereto for delivering constant current rheography pulses onto lead conductors selected by switching matrix 68, which in turn is switched by signals on bus 83. Impedance detection circuit 74 is adapted to monitor the voltage between a selected pair of electrodes which pair is selectably coupled by operation of switch matrix 70 which in turn is switched by signals on bus 80. In this manner, circuit 74 determines the voltage, and hence the impedance, existing between two selected electrodes. The output of circuitry 74 is connected through A/D converter 76 to control circuitry 62, for processing of the impedance signals and determination of the occurrence of mechanical events, such as left or right heart valve closure. The control of switch matrix 68 through signals on bus 78, and the control of switch matrix 70 through signals on bus 80, provides for multiplexing of different impedance signals.
It is to be understood that in the system arrangement of FIG. 3, pace/sense circuitry 64 may include separate stimulus pulse output stages for each channel, i.e., each of the four-chambers, each of which output stages is particularly adapted for generating signals of the programmed signal strength. Likewise, the sense circuitry of block 64 may contain a separate sense amplifier and processor circuitry for sensed signals from each chamber, such that sensing of respective wave portions, such as the P-wave, R-wave, T-wave, etc. from the RH and the LH, can be optimized. The pulse generator circuits and sense circuits as used herein are well known in the pacemaker art. In addition, other functions may be carried out by the control circuitry including standard pacemaker functions such as compiling of diagnostic data, mode switching, etc.
Referring now to FIG. 4, there is shown a logic control flow diagram for controlling the system of this invention to pace a patient with LBBB. The assumption is that the RH is normal, and that sinus signals from the SA node are being normally conducted to the LA; but that the LBBB is manifested by slow conduction to the LV, such that the LV does not contract when it should. As a consequence, there is mitral regurgitation, or backflow of blood through the valve because the LV does not contract when it is filled from the LA; and the contraction of the LV, when it occurs, is later than that of the RV, further contributing to decrease of LH output.
As seen at 101, the pacemaker monitors the RH, and gets a measure of RMAV. This is done by sensing right valve closure through RH impedance measurement, and timing the delay from the atrial depolarization (RAS) to valve closure. Then, at 102, the pacemaker is controlled to pace LV with an LAVD such that LMAVD is about equal to RMAVD. During this step, impedance measurements are made in the LV, and a measure of LMAVD is obtained. Based on this determination, the value of LAVD is adjusted to substantially match LMAVD with RMAVD. Note that normal conduction through the LV takes on the order of 50-60 ms, so it is expected that the LV should be paced in advance of the occurrence of RV valve closure, so that LV valve closure occurs at about the same time as, or even a bit before RV valve closure. Causing the LV to contract just before the RV might provide an increase of LH output which outweighs the small resulting RV dysfunction due to the septum being pulled toward the LV first. Thus, the timing of delivery of each LVP is adjusted to set LMAVD approximately equal to RMAVD. Then, at 104, the value of LAVD is further adjusted, while R and L valve closure is monitored, and LMAVD is adjusted relative to RMAVD. This adjustment, or variation of LMAVD, may be made by incrementally changing LAVD each cycle, or each n cycles, to scan relative to the value of RMAVD. Cardiac output is obtained through a left heart impedance measurement, and appropriate signal processing, for each setting of the differential between the right and left valve closures, and respective values of CO and LMAVD are stored at 105. The highest, or maximum value of cardiac output is determined, and LAVD is set so that the resultant MLAVD is at the differential compared to RMAVD to yield the highest cardiac output. In this manner, the timing of left ventricular pace pulses is set to produce substantial bi-ventricular mechanical synchronization for the greatest cardiac output. The determined value of LAVD and the corresponding LV-RV difference is stored.
Still referring to FIG. 4, at 106 the pacemaker proceeds to pace the LV with this established value of LAVD, providing mechanical synchronization. Of course, if the natural sinus rate varies, the pacemaker wants to follow; if the spontaneous RAVD varies, but the LAVD doesn't follow the change, the mechanical synchronization will be lost. Accordingly, at 107 the pacer monitors the natural sinus rate, or atrial pacing rate, and determines if there has been a significant change in atrial rate. If yes, at 109, the pacer adjusts LAVD accordingly to maintain mechanical sync for optimum output. Although not shown, the pacemaker can periodically go back to block 101 to re-determine the desired value of LAVD.
Referring now to FIG. 5, there is shown a flow diagram for pacing of a patient with IAB; such patient may have LBBB as well. Here, it is necessary to take control of the LA by pacing before atrial depolarization is conducted (late) to the LA. At 110, the pacemaker monitors the pattern of LA depolarization relative to RA depolarization, i.e., it determines the inter-atrial delay. At 111, it is determined whether the LA should be paced, based on the atrial depolarization pattern. If yes, the pacemaker sets an RA-LA delay at 112, which corresponds to a healthy heart, and which enables capture of the LA. At 114, the value of RMAVD is obtained, as was described in connection with FIG. 4. Then, at 116, LAVD is determined for a first setting of mechanical sync; this can be done by setting LAVD to produce LV contraction at the same time as RV contraction (valve closure), or earlier by a small time increment. Then, LAVD is varied, as shown at 117, and LMAVD and CO are determined corresponding to each value of LAVD. The value of LAVD is set to that value which corresponds to maximum cardiac output, and this value and the LV-RV mechanical relation, or mechanical sync value is stored for the chosen LAVD. At 118, the pacemaker paces LA and LV, in accord with the values that have been determined. In the event of significant change in atrial rate, LAVD is adjusted to compensate for the rate change, and to substantially maintain the LV-RV mechanical relationship previously found to correspond to maximum cardiac output, as shown at 120, 121. Although not shown, in the event of large changes in the sinus rate, or passage of a predetermined amount of time, determination of inter-atrial delay and LAVD can be repeated automatically.
Referring now to FIG. 6, there is shown a simplified flow diagram for a procedure in accordance with this invention for carrying out bi-ventricular pacing so as to maximize cardiac output (CO). This routine is adapted for patients who need right ventricular pacing, and who can benefit from synchronous left ventricular pacing as well. In this example, it is assumed that atrial pacing is not required, but if the patient requires atrial pacing, the routine can be adapted appropriately.
At block 130, a common value of AV delay (AVD) is first set. At block 132, both the left ventricle and the right ventricle are paced, initially with the previously set value of AVD, but then with a varying AVD. As AVD is varied, or scanned relative to the initial setting, the pacemaker makes determinations of cardiac output by processing impedance signals from the left heart, or left ventricle, in the manner discussed above. Values of CO are stored together with the different values of AVD, and the optimum value of a common AVD is determined corresponding to maximum CO. Then, at block 134, the value of LAVD is varied relative to RAVD, such that the left pacing pulse is delivered at differing times from the right pacing pulse. It is to be remembered, as discussed above, that for maximum cardiac output, it may be desirable to pace the left ventricle shortly before the right ventricle, and this step is a searching step to determine the time relationship between the two ventricular pace pulses which results in the best cardiac output. CO is determined as the ventricular sync relationship is varied, and the corresponding optimum LAVD is determined. When this has been obtained, the routine goes to block 136 and paces the patient at the determined values of LAVD and RAVD. Periodically, as indicated at 138, the pacemaker can determine whether a test is desired. If yes, the routine branches back to 130, to loop through the test and redetermine the optimum values of LAVD and RAVD. It is to be noted that the steps of blocks 132 and 134 can be done in a reverse sequence, i.e., step 134 first and then step 132.
Referring now to FIG. 7, there is shown an alternate block diagram of component portions of a pacemaker in accordance with this invention, for providing maximum flexibility in terms of pacing, cardiac signal sensing and impedance sensing. At least two electrodes are positioned in or proximate to each heart chamber, in the manner as discussed above in connection with FIG. 1, and connected in turn to block 150. As indicated in FIG. 7, block 150 is an output/input switch matrix, and interconnects with block 152 in the manner as described in FIG. 3. Thus, block 152 provides pacing pulses which can be connected through matrix 150 to each of the four chambers, and has sense amplifier circuitry for sensing signals from each of the four chambers. Block 150 further provides a multiplex switch array for switching a current source across selected pairs of the eight electrodes for impedance measuring purposes, again in accordance with the discussion of FIG. 3. The sensed impedance signals are suitably transferred from array 150 to digital signal processing circuitry 161, which is part of block 152. Block 152 is in two-way connection with the timing modules shown in block 154, for timing generation of pace pulses, current source pulses, and the generation of sensing windows. Blocks 150, 152 and 154 are further inter-connected by control bus 163. Data is transferred between signal processing block 170 and block 154 across data bus 157. Block 154 in turn is inter-connected with microprocessor 156, through household bus 151, data bus 153 and control bus 154. By this arrangement, impedance sensing can be carried out across any combination of the four heart chambers, e.g., right atrium vs. left atrium; right ventricle vs. left ventricle; right atrium vs. left ventricle; and left atrium vs. right ventricle. Impedance measurements between these combinations of chambers can be carried out in accordance with this invention, for purposes of analyzing and confirming arrhythmias, including fibrillation. Further, changes in conduction patterns, as seen in the morphology of such impedance measurements, can be monitored and processed for making determinations of progression of heart failure. Thus, cross-measurements of RA-LV and LA-RV can be useful in obtaining histories to determine changes indicating progression of heart failure.
Referring now to FIG. 8A, at block 160, the pacemaker first obtains impedance measurements either between LA and RA, or between LV and RV. These impedance values are processed at 162, and at 164 a determination is made as to whether the atrial or ventricular rhythms are regular or non-physiological. This determination can be made, for example, simply by sensing differences over time and comparing such differences to predetermined criteria. If a rhythm is determined not to be regular, then a determination of arrhythmia is made at 166. A suitable response is made at 168. Referring to FIG. 8B, at block 170 the pacemaker obtains cross-measurements of impedances, e.g., between RA and LV or between LA and RV. These measurements are stored and processed as indicated at 172, and evaluated at 174 to determined whether they indicate HF or progression toward HF. If yes, an appropriate response can be made, illustrated at 176, e.g., providing a warning which can be retrieved by an external programmer.
The scope of the invention extends to other conditions of CHF, in addition to the ones illustrated here. In each case, the condition of the patient must be responded to on an individual basis. However, in accordance with this invention, the system response includes a determination of mechanical events, e.g., valve closure, preferably in each side of the heart, and programming of pacing escape intervals based on consideration of the mechanical events and a determination of variations of cardiac output with variations of LAVD and/or mechanical ventricular synchronization. The system of this invention can be used in an implanted pacemaker system; or, the system procedures can be carried out with an external system, for determination of optimum programming of a pacemaker which is to be implanted or re-programmed.
1. A pacing system for providing pacing of a patient's left heart, comprising:
- first means for obtaining indications of mechanical contractions of the right ventricle;
- left ventricular pacing means for pacing the left ventricle; and
- LV control means for controlling the timing of said left ventricular pacing relative to indicated right ventricular mechanical contractions.
2. The pacing system as described in claim 1, comprising
- second means for obtaining indications of mechanical contractions of the left ventricle, and wherein said LV control means has means for controlling the timing of said left ventricular pacing so as to provide substantially synchronous left and right ventricular mechanical contractions.
3. The pacing system as described in claim 2, comprising left atrial pacing means for pacing the patient's left atrium; left AV control means for controlling the left AV delay between pacing the left atrium and the left ventricle, cardiac output means for measuring left heart output as a function of said left AV delay, and wherein said left AV control means further comprises maximizing means for adjusting said left AV delay to maximize left cardiac output.
4. The pacing system as described in claim 3, comprising means for sensing sinus signals, and left atrial timing means for timing delivery of left atrial pacing pulses relative to said sinus signals.
5. The pacing system as described in claim 1, wherein said LV control means has means for delivering a left ventricular pacing pulse just before the expected time of the next right ventricular mechanical contraction.
6. The system as described in claim 1, wherein said first means comprises an impedance measuring circuit for obtaining an impedance signal representative of impedance between the patient's right atrium and right ventricle, and processing means for processing said impedance signal to determine the timing of right heart valve closures.
7. The system as described in claim 1, comprising second impedance means for obtaining a left impedance signal representative of impedance change over the patient's left heart, and second processing means for processing said left impedance signal to obtain a measure of left heart output.
8. The system as described in claim 7, comprising third processing means for processing said left impedance signal to obtain filling signals indicative of the filling of the left ventricle, and wherein said LV control means comprises means for controlling timing of said left ventricular pacing signals as a function of said filling signals.
9. The system as described in claim 1, further comprising means for obtaining indications of left ventricular mechanical contractions, and wherein said LV control means comprises mechanical sync means for controlling said left ventricular pacing to achieve mechanical synchrony of said left and right mechanical contractions.
10. The system as described in claim 9, wherein said mechanical sync means comprises adjusting means for adjusting the timing of aid left ventricular pacing so as to maximize left heart output.
11. A four-chamber pacing system for providing pacing of a patient's left heart to improve cardiac output, comprising:
- RV means for determining the timing of right ventricular mechanical contractions;
- LV means for determining the timing of left ventricular mechanical contractions; and
- pacing sync means for pacing the patient's left ventricle; and
- control means for controlling said pacing means so as to substantially synchronize said left and right mechanical contractions.
12. The four-chamber pacing system as described in claim 11 comprising:
- LA means for determining the timing of left atrial depolarization;
- CO means for measuring cardiac output from the patient's left heart; and
- wherein said control sync means comprises LA VO means for controlling said pacing means to deliver pacing pulses to said patient's left ventricle at a left atrio-ventricular delay following left atrial depolarizations, and adjusting means for adjusting said left atrio-ventricular delay to correspond to maximum measured cardiac output.
13. A four chamber pacing system, having electrodes positioned in each of a patient's four heart chambers, comprising:
- impedance means for obtaining impedance measurements between a selected pair of said four chambers;
- processing means for processing said impedance measurements, and determining changes in said measurements over a period of time; and
- determining means for determining whether any said change occurs which indicates a physically abnormal heart condition.
14. The system as described in claim 13, wherein said determining means determines whether any such change occurs which is indicative of an arrhythmia.
15. The system as described in claim 13, wherein said determining means comprises means for determining whether said any such change occurs which indicates a heart failure condition.
16. The system as described in claim 13, comprising programmable selection means for selecting impedance measurements between any two of said four heart chambers.
|December 1, 1981
|Heilman et al.
|May 29, 1990
|March 26, 1996
|Plicchi et al.
|May 30, 2000
|Bakels et al.
|April 24, 2001
|Bakels et al.
|May 29, 2001
|Bakels et al.
- Daubert et al, "Simultaneous Dual Atrium Pacing in High Degree Inter-Atrial Blocks: Hemodynamic Results," AHA 1991, Abstract from 64th Scientific Sessions, No. 1804.
- Mabo et al., "Prevention of Atrial Tachyarrythmias Related to Inter-Atrial Block By Permanent Atrial Resynchronization," PACE, vol. 14, No. 122, Apr. 1991, Part II, p. 648.
- A. Cazeau et al., Four Chamber Pacing in Dilated Cardiomyopathy, PACE, Vo. 17, Part II, Nov. 1994, p. 1974-1979.
Type: Grant
Filed: Sep 6, 2001
Date of Patent: Jun 22, 2004
Patent Publication Number: 20020143368
Assignee: Medtronic, Inc. (Minneapolis, MN)
Inventors: Arnoldus Bakels (Simpelveld), Robert Leinders (Limbricht), Cobus de Roos (Landgraaf)
Primary Examiner: Jeffrey R. Jastrzab
Attorney, Agent or Law Firms: Girma Wolde-Michael, Michael C. Soldner
Application Number: 09/946,495
International Classification: A61N/1365;


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No matter how full the internet is with Metroid fan art, there's always someone topping it with something special. Here's an injured Samus Aran with some awesome coloring by DeviantART user muju. Could look at this all day.
Dayshot is an image-based feature that runs every morning, showcasing some of the prettiest, funniest game-related screenshots and art that we can find. Send us suggestions if you've got them.
Samus 2.0 by muju [DeviantART, via The Omega Nerd]
To contact the author of this post, write to: email@example.com

subset: commoncrawl


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Its really been quite awhile since I done this.Ah well.Today's best game character features vayne.Main character of the 1st mana khemia game,the sequel to the atelier iris series(which is an awesome series).Now then,why vayne?Well,he is in many ways likable as a good character.
Well vayne is a student to an alchemist school,being a very anti social and lonely boy that he was be fore he came to the school,he tries to avoid attention as much as possible.He is indeed an emo,even his voice sounds so.
I like his style in thinking things.He doesnt realy care and does not want any part of anything most of the time.He just wants to avoid trouble.Thats what of a person I am anyway.This is definetely a plus.Well when he 1st enters the school his only friend is sulfer the cat.He can somehow understand what he is saying.Weird.
Now on to my favourite part.The way vayne fights and his weapon is probably the most creative I have ever seen in the history of weapons and fighting.In battle,Vayne wields a claw,in which the nails are swords,and on his other hand there is an eye which scans the enemy I guess.The main arm,the one with the swords,can shapeshift into many different blade forms which suit the flow of battle.This is actually very cool.Seeing it on the PSP or PS2 is much better.
There may not be many good traits other people see in vayne,but this emo boy has actually much that makes him deserve this title.Mostly its his fighting style.Well peace for now.


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Leaking pipe is draining popular lake
Army Corps of Engineers officials said Monday that a leaking pipe is helping reduce the level of Big Creek Lake.
Workers were at the lake Monday morning working to try to stop the flow of water from the leaking valve.
The water level has been dropping significantly with no big rain for months. It's losing about a foot a month.
A slide gate that controls the outflow at the diversion dam has been inoperable since 1998.
Army Corps spokesman Jeff Rose said the Corps is required to release 3 cubic feet per second into the creek, but 8 cubic feet per second is being released.
To try to slow the discharge, the Corps lowered 40 sandbags into place more than 35 feet below the lake's surface. Rose said there is no danger to flood protection since the lake is primarily used for recreation.
Rose said the gate hasn't been repaired for years because Congress never approved the funding to fix it. Rose did not have an exact figure on how much it would cost to repair the problem.
The Corps has designed a new slide gate for the site, but officials said they are not optimistic about getting federal funds this year and they are hoping for rain to keep Big Creek from going dry.


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Page One
Occupy Holds Small Anniversary Protest at Berkeley
Occupy Cal visibly resurfaced on the UC Berkeley campus on Thursday, November 15, 2012 with a small encampment intended to mark the one year anniversary of the mass rally and protest that marked the high point of the campus Occupy Movement.
Occupiers had also rallied at the Regents meeting at UC San Francisco earlier on Thursday. On Thursday evening there were two tents on Sproul Plaza--one on the main plaza, and the other on the steps of Sproul Hall--as well as a number of banners--including a large "Welcome to the Open University" banner--signs, and protesters. The signs Thursday night were incongreuously juxtaposed with "Cal Philanthropy Day" banners and signs that had been put in place to encourage students to become alumni donors to the University.
On Friday morning before 8:00 am, as I headed for work, there were three tents in a cluster and two protesters visible, one holding a heart shaped sign in the periodic rain. They said that the University police had given them the "usual admonishments" last night about overnight lodging on University grounds, and protesters had taken down most of the banners and signs.
They expressed disappointment that that large numbers of people hadn't turned out but determination to continue with Occupy Cal actions during this academic year. The current tents will not remain up, but one further symbolic protest may be organized this semester, they said. Next semester, the focus will be on educating the campus community about "continued privatization" of the institution, including the agreement that brought money to the University from BP (formerly British Petroleum) to fund biofuel research.
By 9:45, when I passed through Sproul Plaza on a brief break, the three tents and the Occupy protestors were gone. I don't know if they had been asked to leave, or had voluntarily packed up the encampment after the one year anniversary commemoration.


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The transactions below and virtually all other student transactions with the University - are conducted online through the Student Payment Center (DU student login required).
Bursar Information
Payment, billing, and other Information about your student account are found on the Bursar's office web site (login required).
Panther OneCard
All students will receive a Panther OneCard, which is your student ID. If you have excess financial aid, the Panther OneCard also streamlines the refund process so that you receive funds electronically. As an admitted student, you will receive more information during orientation and/or through your admissions representative.
For Parents/Authorized Users
As a parent or authorized user, you have the option to add funds to your student's account and/or monitor the account directly. Because of Federal privacy laws (FERPA), the student is the only person who can grant access to his/her account. Click here to go to the Account Center (login required).
Tuition Refund Policy (for withdrawing from a class)
Sometimes students need to withdraw from courses. Davenport's policy for tuition refunds explains whether or not you might be eligible for a tuition credit. Often when you withdraw, the financial aid office is required by federal law to make adjustments to your financial aid. This calculation might result in some of your financial aid being sent back to the federal government. If this happens, then you will end up owing Davenport the resulting balance.
1098-T Tax & IRS Information
You will need the 1098T form (login required) to file with your income tax return if you've received financial aid during the calendar year.
How and when do I get my loan refund?
After the drop/add date for each semester, your financial aid award is disbursed (paid) to your account. Lenders generally send loan funds to Davenport approximately 3 - 4 weeks after the start of a semester.
The money is first used to pay:
- tuition charges
- fees
- books
- residence hall charges (if any).
After those payments, it is possible that you may have excess financial aid (or in other words, a credit balance). Davenport will send your excess financial aid to you via the Panther OneCard. Read more details about that process in the section about Excess Financial Aid.


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The coffeehouse and the corner bar are natural allies, but at times it's an awkward friendship. Together, coffee and spirits can occasionally make for an awesome combination—the eye-opening Italian tradition of the caffe corretto and the cream-topped Irish Coffee are notable winners—but because coffee and spirits are so different, with each offering its own, sometimes conflicting interpretation of buzz, booze and beans have long been at their best when sipped separately.
But things change. Yesterday's baseline of American coffee mixology may have been defined by a sharp jolt of bourbon to lend backbone to a bland cup of Folger's, but today the border dividing bartenders from baristas is growing increasingly vague. Los Angeles bartenders, such as David Kupchinsky at Eveleigh and Matt Biancaniello at the Hollywood Roosevelt Hotel, are giving coffee's usual soak-and-strain process a spirituous twist by substituting Italian vermouth or bitter liqueurs for the water; places such as Fort Defiance in Brooklyn and Liberty in Seattle, which operate as cafés by day and bars by night, are working micro-roasted coffees into the evening's drinks; and at a time when the delicate, floral character of cold-brew coffee is winning fresh converts, bartenders at Eleven Madison Park in New York are using its fruity brightness to flavor powerful spirit-focused cocktails.
At Anvil in Houston, Bobby Heugel recruited David Buehrer, owner of Greenway Coffee Co., to help create a weekend brunch menu that features coffee cocktails with a creative bent. Buehrer's contributions include drinks such as the espresso-fortified Occam's Razor; a Coffee Caipirinha made with cachaça, turbinado sugar and iced coffee; and a Coffee Old Fashioned, made with cold-brew coffee and chocolaty Demerara rum. For Buehrer, coffee is a natural match for spirits, but its delicate character and distinctive flavor require a thoughtful approach. While espresso has a robust edge that can add a solid spark to a drink, Buehrer notes it takes a skilled barista—and a bit of time—to pull shots worth matching with an ethereal aged tequila in the Occam's Razor. More bar-friendly is cold-brew coffee, which not only has a bright, lively flavor but is also more shelf stable, so a bottle can sit in a bartender's well all evening without the ingredient losing its appeal. "Coffee can add more body to a drink, and a deeper feeling and an edge," Buehrer says. "It can have such unique flavors that it works really well behind the bar."


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The Social Factor in Sustainable Architecture
Piazza del Campo in Siena, Italy. Photo: Edgar Barany/Flickr
I was recently struck by photographs of energy-efficient houses that were described as 'sustainable' — built mostly with natural or recycled materials and even finished with environmentally friendly paint — however, they looked like regular modernist buildings. Can modernist architecture be called sustainable, if only ecological techniques are used? Or, is there still something missing?
Sustainability is something more than just green. Yes, there are many definitions, and the term has been degraded over the years, however, have a look at this definition — the aim of sustainability is to improve quality of life while preserving biodiversity, the abundance of natural resources and social equity. If we assume that the aim of a sustainable design is to create pleasant environments that nourish human spirit, can this be achieved by modernist styling?
Can modernist buildings be described as harmonious, beautiful and nurturing the human soul? Do they create places where it is a pleasure to be in, where people like to sit on the bench and enjoy the surroundings? At least from my perspective — hardly, or not at all. The landscapes they create are mostly 'cold', 'artificial' and even 'dead'. And yet there are literally hundreds of places which are visited for their beauty and pleasant atmosphere which have traditional styles of architecture, be it Venice, Paris or Prague.
Contemporary office building in Gdansk, Poland. Would it help to create
a more enjoyable environment if it was made of recycled materials?
If you were to choose a square to spend an evening with your friends or to meet for a date, would you choose the square surrounded by modernist buildings made of glass, steel and concrete or the one that remind you of the traditional architecture of Tuscany in Italy or Provence in France? I don't have any scientific research to prove it, only a guess that most people would choose the latter. As such, since traditional architecture might be much better in creating enjoyable environments than the modernist approach, wouldn't it be accurate to conclude that modernism in architecture is a failed approach?
Traditional buildings of similar height in Sandomierz, Poland.
Photo: magro_kr/Flickr
I'm not saying that the solution for good design is to replicate the historic styles of architecture (which in some cases may be fine). My point is that a sustainable design should include the social factor, meaning it should aim to create an environment which is 'warm', 'alive' and beautiful — where people feel happy and where they like to spend time. If we try to design a building to meet these qualities, we may end up with something that looks like the buildings of the past. Would it actually be something bad?
Newly built residential complex in Sopot, Poland.
Many architects say that the style of architecture should reflect the present culture. However, since we live in the era the of consumer culture, is it really something worth reflecting? Why not design buildings that are timeless — buildings that will be perceived as beautiful and nourishing ten years from now, one years from now and two hundred years from now? A good contemporary design doesn't have look 'modern'. If it reminisces of historic architecture, so be it. The social factor is more important than the idea of 'modernity'.
Traditional architecture in Sopot (Parkowa Street).


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Follow RFF News on your cell phone. Text follow rff to 40404 you will receive txt messages with RFF News
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...Eric and Danielle's relationship did diminish...
I'm curious now too. Did I talk to Peach and not know it?
Geez--you guys are relentless!Lots more pictures to come from TES!Later on cause I'm off to a TAR lunch! Did I mention how much fun I'm having?
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Fridel Surname Ancestry Results
Our indexes 1000-1999 include entries for the spelling 'fridel'. In the period you have requested, we have the following 1 record (displaying 1 to 1):
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For those seeking solace and guidance during times of mental health and other struggles, libraries offer refuge and direction.
BIBLIOFILES: Libraries provide a safe place for those who need help
Leanne Myggland-Carter
This weekend marks the last three days to #GetLoud about Canadian Mental Health Association's Mental Health Week (May 6-12).
As annual participants in this important awareness campaign, public libraries across Canada are hosting programs and activities and promoting services and resources to remind their community members that libraries are a welcoming, safe and informed places to go any time of the year.
By definition, free public library service in Alberta includes access to the facility, use and borrowing of library resources, consultation with staff, and basic information service. In addition to serving as an essential link to local agencies and partner organizations, such as the Alberta Health Services Addiction and Mental Health office in Spruce Grove and Family and Community Support Services throughout the Tri-Region, libraries: greet patrons without bias and with respect; provide collections of materials ensuring intellectual freedom for all; listen to community members and respond to their diversity; treat everyone with dignity, courtesy, and compassion in their pursuit for knowledge.
For those seeking solace and guidance during times of mental health and other struggles, libraries offer refuge and direction. Refuge as a barrier and judgement free environment that embraces acceptance, appreciation, and recognition of all people in the community; direction with resources, services, and programs that will help them make sense of the world in a variety of ways.
Canadian Mental Health Association's website (mentalhealthweek.ca) also provides unlimited access to online support and information such as links that help people learn about mental health, a checklist to gauge your own state of mind, and articles that provide strategies to help you and those around you thrive. As they state on their homepage, "We can all have good mental health. It is about having a sense of purpose, strong relationships, feeling connected to our communities, knowing who we are, coping with stress and enjoying life. And it's never too early or too late to get there. But it's not just about what you do for yourself, by yourself — everyone needs healthy and supportive places to work, live and learn."
As healthy and supportive places, public libraries are so very proud to serve all people striving to work, live, and learn within the towns, cities, and counties that make up our province and our country. They provide people access to the information that will help them build the skills they need to find help, take control of their situation, and improve their life.
Because, quite simply, everyone has the right to feel well. Everyone.
Leanne Myggland-Carter is the marketing and fund development manager at Spruce Grove Public Library.


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The pre-entries were announced on Wednesday for the 2011 Breeders' Cup Ladies' Classic and I have included comments on all early entrants below.
At this stage it looks like nine horses will line up in the Friday feature. The pace figures to be provided by Ask the Moon and Plum Pretty.
Royal Delta continues to impress clockers at Churchill Downs as she attempts to rebound from a distant place finish behind Havre de Grace in the goo at Belmont.
Ultra Blend always runs her race and is a live contender if she brings her strong Southern California form to Kentucky.
Probable Starters:
Ask the Moon (Javier Castellano) – Dual G1 winner figures to attempt a wire job.
It's Tricky (Ramon Dominguez) -Two-time G1 winner always fires on fast dirt.
Miss Match (Garrett Gomez) -Back with female friends after failed tries in G1 Hollywood Gold Cup and G1 Goodwood.
Pachattack (Rajiv Maragh) -Back-to-back runner-up efforts in the G1 ranks.
Plum Pretty (Rafael Bejarano) -Exits big Parx win. Captured G1 Kentucky Oaks at CD.
Royal Delta (Jose Lezcano) -Which filly will show up Obvious threat if she runs back to Alabama.
Satans Quick Chick (Edgar Prado) -Spanked in G1 Beldame. Has dropped seven straight.
Super Espresso -Disappointed in G1 Spinster. Speed figs going the wrong way.
Ultra Blend – Gem of consistency became G1 winner at Del Mar Aug 6.
Unlikely Starters
Aruna -Failed to impress in recent Churchill work so she'll go in the F&M Turf instead.
Champagne d'Oro -Cross-entered in F&M Sprint and more likely to run in that spot.
Great Hot -G2 Raven Run winner probably goes in the F&M Sprint.
Havre de Grace – Horse of the Year candidate will take on the boys in the BC Classic.
Medaglia d'Amour – Likely to choose F&M Turf over this.
Switch – 2010 F&M Sprint runner-up is expected to go in that event again.


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One of MEV's best-selling luxe cotton maternity work pants - the Comfy Sateen Regular-Fit Pants in White is constructed with comfort, functionality and style in mind. Featuring a slim straight cut leg in stretch cotton, here's why it works so well with our pregnant and postpartum mommy fans: 1) Jersey knit waistband that may be worn be over the belly or rolled down to sit at the hips as desired. While the fully flexible waistband may be worn either way, we recommend that the best optimal use is to wear the waistband folded beneath the belly for support. 2) When folded-over, the waistband sits snug at the hips, giving subtle support at the under curve of the belly and around the lower back. The under-belly application will allow usage till full-term and beyond. Perfectly wearable postpartum as shown on our model! 3) Made with 97% cotton and a blend of spandex, these pants are designed for pure comfort. The touch of spandex allows the pants to stretch and conform for optimal fit as needed. 4) Sateen cotton finish which brings s very subtle sheen that works for office or anywhere smart casual. 5) Features faux front pocket details. Straight cut through the trouser leg, with a very subtle boot-cut at the hem for a balanced and flattering silhouette.
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The New Herbicides
With the massive amount of new information that becomes available every year for turfgrass managers to decipher, it is difficult for anyone to keep up. New herbicides and herbicide research is no exception. And the old saying "There is more than one way to skin a cat," applies directly to herbicides as well. With today's technologies, there is definitely more than one way to kill a weed.
The following is a review of new herbicides that have been introduced or relabeled for a new turfgrass use in 2005 or 2006. This review is not intended to eclipse the herbicide label itself, so in all cases, please consult the herbicide label directly before using any of these herbicides.
QuickSilver (carfentrazone-ethyl) is a broadleaf active contact herbicide that was introduced into the turfgrass market before 2005. However, in 2005 it received a supplemental labeling in selected states for niche use in the turfgrass market: moss control in bentgrass putting greens.
Moss, often referred to as silvery-thread moss (Bryum argenteum), is an increasing problem in bentgrass putting greens. It is thought to be a result of lower mowing heights and decreased fertility to satiate our need for increased green speeds. Such stressful condition severely inhibits the ability of the turf to recover from injury and moss can easily invade.
Past research has evaluated various micronutrients, nitrogen applications, fungicides and soaps. While some control was observed with such strategies, all were inconsistent and variable under different weather conditions.
QuickSilver has been evaluated by numerous researchers and has been observed to be a very effective product for moss control. Two applications of QuickSilver at 6.4 fluid ounces per acre applied two weeks apart quickly desiccates moss with no observable injury to bentgrass turf under normal conditions.
But remember, moss probably invaded due to the low competitive ability of the bentgrass. QuickSilver will kill the moss, but you must still increase the vigor of the bentgrass. Increasing nitrogen fertility and light verticutting, during the optimal time of the year, could potentially improve overall management of moss contamination.
While QuickSilver is great on moss, it is ineffective on algae. Many turfgrass managers group moss and algae together and why not, they are both weird spore producing weeds that don't fit the description of normal weeds we deal with. Evaluations at the University of Tennessee in 2005 have demonstrated that QuickSilver definitely knows the difference between the two species.
Lastly, QuickSilver also has specific wording on the label that allows for application to newly seeded or sprigged turfgrass areas. Due to its broadleaf activity, this is an excellent treatment for small seedling broadleaf weeds across the board and allows for an earlier application compared to traditional broadleaf herbicides such as 2,4-D.
Certainty (sulfosulfuron) is yet another herbicide in the growing list of sulfonylurea herbicides, which also includes Monument and Revolver, among others. Like Monument, it is very effective against sedge species, such as yellow nutsedge and green kyllinga. It also controls a select number of broadleaf weeds; however, this list is limited.
Unlike Revolver and Monument, Certainty is labeled for use on numerous turfgrass species other than bermudagrass and zoysiagrass. The addition of St. Augustine, centipede and kikuyu grasses adds more potential flexibility for those who deal with multiple turfgrass species on one golf course or landscapers who manage different home lawn grasses.
One unique characteristic is that Certainty can also be used to control rough-stalk bluegrass (Poa trivialis) in bentgrass turf. Rough-stalk bluegrass is the ugly cousin to annual bluegrass (Poa annua) and, due to its perennial nature, there are few herbicide options available for control, especially removal from cool-season turf. See label directions for specific recommendations.
Speaking of annual bluegrass, Certainty, while herbicidially active on annual bluegrass, provides only suppression with single applications. Small annual bluegrass plants can be controlled with Certainty, but larger plants will recover from the injury.
Surge (sulfentrazone + 2,4-D + MCPP + dicamba) is a new broadleaf herbicide that contains a new herbicide to the turfgrass market, sulfentrazone. Sulfentrazone is a protox-inhibiting herbicides that induces the formation of free radicals that destroy plant tissues. Translation: It burns the plant up really fast. Sulfentrazone primarily functions as a contact herbicide with little translocation.
As you can tell by the names, sulfentrazone and carfentrazone are in the same family of herbicides. But while carfentrazone has no activity on sedges, sulfentrazone is active on both broadleaf weeds and sedges.
While sulfentrazone is active on sedge species, there are potential limitations. Research has demonstrated that sulfentrazone controls yellow nutsedge very well and controls green kyllinga comparable to standard sedge herbicides. However, as a single application, Surge has not been researched. Sedge control with Surge, therefore, would be classified more as suppressing perennial species or controlling small annuals. Despite the reduced amount of sulfentrazone in Surge compared to past research, I have heard numerous reports of satisfied customers using Surge for sedge control.
Spotlight (fluroxypyr) is a new broadleaf herbicide for use on all major turfgrass species for control of broadleaf weeds. Spotlight contains fluroxypyr, an herbicide that is primarily active against broadleaf weeds. It acts in a similar fashion to triclopyr (Turflon Ester and also contained in Confront) and other broadleaf herbicides, such as 2,4-D, by functioning as an auxin-type herbicide inducing uncontrolled cell elongation and leaf and stem twisting.
Like most herbicides that primarily target broadleaf weeds, tank-mixtures are more beneficial because they broaden your spectrum of weeds controlled. However, research conducted in Tennessee indicates that Spotlight effectively controls many broadleaf species, such as white clover (Trifolium repens), ground ivy (Glechoma hederacea), and dandelion (Taraxacum officinale), when applied at 2 pints per acre.
Escalade (2,4-D + fluroxypyr + dicamba) is a mixture of the new herbicide fluroxypyr pre-packaged with 2,4-D and dicamba. Such a mixture can only increase the spectrum of broadleaf weeds controlled and the activity on more difficult to control broadleaf weed species. Two applications of Escalade at 1.5 quarts per acre applied 6 weeks apart controlled Virginia buttonweed (Diodia virginiana) 100 percent compared to less than 70 percent control from two applications of a traditional three-way (2,4-D, mecoprop, dicamba) herbicide.
Not a new herbicide, only a new name. Formerly named Manage (Monsanto), SedgeHammer (halosulfuron) is formulated and labeled for the exact same use. If you know Manage, you know SedgeHammer. Like all SU herbicides, remember to add the appropriate surfactant.
While these are some of the new herbicides that have become available recently, there will be many more in the coming years. Unique herbicides are being developed with safer toxicological properties and new modes of action. So get ready. With new herbicides come new possibilities for weed management.
Scott McElroy is an assistant professor and extension specialist in the department of plant sciences at the University of Tennessee (Knoxville, Tenn.).
Trade Name: QuickSilver
Supplier: FMC Corp.
Chemical Name: Carfentrazone-ethyl
Use Areas: Golf course, sports field, residential and non-residential turf.
Turf Safety: All major turfgrass species
Target Weeds: Broadleaf weeds, moss
Use rates: 6.7 fluid ounces per acre for moss in putting greens, 1.1 to 2.1 fluid ounces per acre for all other areas.
Trade Name: Certainty
Suppliers: Monsanto, Regal
Chemical Name: Sulfosulfuron
Use Areas: Golf course (except greens), athletic fields, sod farms, residential and non-residential areas.
Turf Safety: Bermudagrass, St. Augustinegrass, zoysiagrass, centipedegrass, kikuyugrass, bentgrass (under certain conditions)
Target Weeds: Yellow nutsedge, green kyllinga, select broadleaf weeds, Poa trivialis
Trade Name: Spotlight
Supplier: Dow AgroSciences
Chemical Name: Fluroxypyr
Use Areas: Golf course (except tees and greens), athletic fields, sod farms, residential and non-resi- dential areas.
Turf Safety: All major turfgrass species.
Target Weeds: Broadleaf weeds
Use rates: ⅔ to 2.5 pints per acre
Trade Name: Surge
Supplier: PBI/Gordon Corp.
Chemical Name: Sulfentrazone + 2, 4-D + mecoprop + dicamba
Use Areas: Golf course (except tees and greens), athletic fields, sod farms, residential and non-resi dential areas.
Turf Safety: Majority of turfgrass species except centipedegrass and St. Augustinegrass
Target Weeds: All broadleaf weeds, yellow nutsedge
Use rates: 2.5 to 4.0 pints per acre
Trade Name: Escalade
Supplier: Nufarm
Chemical Name: 2,4-D + fluroxypyr + dicamba
Use Areas: Golf course (except tees and greens), athletic fields, sod farms, residential and non-resi dential areas.
Turf Safety: All major turfgrass species.
Target Weeds: Broadleaf weeds
Use rates: ⅔ to 3.0 pints per acre
Trade Name: SedgeHammer
Supplier: Gowan
Chemical Name: Halosulfuron
Use Areas: Golf course, athletic fields, sod farms, residential and non-residential areas.
Turf Safety: All major turfgrass species.
Target Weeds: Sedges
Use rates: 0.67 to 1.3 ounces per acre
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403(b) Plans generally serve as voluntary supplemental retirement savings plans designed to supplement retirement benefits available from State pension plans and Social Security. The IRS provides a Summary of 403(b) Plan Basics page and a 403(b) Plan Brochure for Employees on its website.
Please visit the "Why Participate?" page for additional information on the benefits of utilizing the 403(b) plan.
403(b) Optional features are either included in, or excluded from, the Plan, as specified below and as further described in the parenthetically referenced sections in the Plan Document for Umatilla School District 6R. These options are listed here in abstract for convenient reference:
Umatilla allows Roth403(b) Contributions. Roth contribtuions are deferred from paychecks to investment accounts on an after-tax basis, as opposed to Traditional 403(b) which are deferred on a pre-tax basis.
Please note: Roth 403(b) accounts are available from select vendors, please review the information listed on the Umatilla 403(b) Vendors page for vendors that show "403(b) Roth Account Available" after the vendor name where applicable, then follow the Enrollment Steps to begin participation.
Please review the Eligibility and Limits Announcement for a full description of the employees eligible to participate and the contribution limits that apply. The 403(b) Enrollment Procedures for step-by-step instructions on how to start, change, and cancel contributions to a 403(b) Vendor under the plan. Additional information is available on our Choosing an Investment Product page.
To learn more about the transactions (including definitions and qualifying events), including how to obtain authorization for a transaction, visit the 403(b) Transaction Page.
Umatilla School District offers a 457(b) Plan in addition to the 403(b) Plan. Please visit the 457(b) Information page to learn more .
CCC serves as the third party administrator (TPA) of the 403(b) Tax-Sheltered Annuity Plan (TSA) and primary point of contact for
the Umatilla 403(b) Plan since 12/1/2007.
Page Last Modified: 8/4/2020 5:37:22 PM